AnnalsofSurgery1886 10000765

A N N A LS
SU RGERY
A M O N T H LY R E VI E W
E S U R G IC A L S C I E N C E AN D PR AC T IC
E DI TE D BY
LEWI S S P I LC H ER A M .
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M . D .
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OF BR OOK LY N ,
I R O F ES S O R O F C L I N I CA L S U R G R Y I N
E T H E N E W Y O R K P O ST G R A D U A T E I AL
M ED C SC H O O I
AN D
C HARLES K EET L E Y
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OF LO N DO N ,
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u b c t an o u inj cti o n o f 6 7
s u e s e , . ing for t rau m a tic 69 , 1 .
Alv olar ab c
e with th ro m bo i o f c a v
s e ss s s A m E xti rp a ti o n o f w h ol 2 5 5 5 3 0
r , e, , .
inu 1 7
e rn o us s s, 0. Ar t ry (
e al o a n u r i m m ning al
see s e s , e e ,
A m put a ti o n a t hi p 1 8 5 o f nti r m a nd , e e ar S c arp a ) C o m p r i o n o f inn o m in a t

, ess e,
s houl d r 5 5 5 3 ; o f for arm I n o cu la
e , 2 , 0 e , 33 ; cu r d b y p r
2 u r An u i m o f
e ess e, e r s
ti o n tu b r cu lo i a ft r 4 4 ; o f inv r t d
-
e s s e , 2 e e p o p l it al 333 ; Lig a tu r o f c o m m o n
e , e
p or ti o n o f ut ru b y th l ig a tu r 3 7 2 e s e e, . i l i a c 5 9 ; Lig a tu r o f u b c lavi a n u d r
, 1 e s , n e
A n a t o m y o f upp r xt r m ity R vi w o f e e e , e e c la ic l 4 7 ; p ro ducing uvu lar h m
v e, 2 ae or
ix
rh a c nding p h aryng al 5 ; T ra u
ge, As e e , 21 t ch ni q u d a ut o p i R vi w 1 3 8
e e es s es, e e 0 ,
0 .
m a tic a n u r i m o f f m oral 3 33
e s e . . B ra in ( al o c r bral t r p h ining ) C m
se e s e e e o
Ar t r ie in g o it r Lig a tu r f ff t 5 3 ;
es e, e o a e re n ,
2 p r i o n o f 6 7 ; O p ra tiv a tt a c k up o n
ess ,
1 e e s
S u rg ry f 47 6 7e 63 64 3 3
o 333 , , 1 . 1 , 2, ,
t h h u m a n 4 9 9 ; R m o v al o f tu m or o f
e , e ,
519 . I 7 1 , 49 9
A r nic al t r a t m n t o f al ig a n t tu m or
se e e m n s, BR I E S K Y on di a se se s o f th v ag n a e i ,
Re vi we
271 . o f 83 8 7
, 2 ,
2 .
t ro m a
A he Exti r p a ti o n o f 7 22
B ro nch o c l ( g o it r ) e e see e .
B ro nch u R m o v al o f t ra ch o t o y tu b
.
, ,
A ut o p i s e s, R vi w o f B o u r n vi ll
e ea nd e e
s, e e m e
Bri c o n
’
s m a nu al o f th t ch ni q u o f e e e ,
fro m 7 ,
2 .
3 80 . B W N I N W Ab t ra ct 66 6 7 6 8 7
RO G, .
, s s, , , , 0
80 .
81, 1 6 0, 1 79, 1 80 , 2 27,
2 38 , 3 3 1 , 33 5 , 3 5 1 , 4 2 2 , 4 2 4 , 4 2 7 . 444 ,
44 5 1 5 1 5 , 5 2 3 , 5 3 5 1 5 43 °
B on x a m in a ti o n o f th n o B r un o n fra ctu r R vi w o f 8 3 88 ;
s es, e e 2 2
B R vi w o f 3 78
A ER th e e e se,
, ,
e e
T ii b i g c o nt r i b uti o n R vi w f 8 3
n en s, e e o , 2 .
BULL W T La p aro t o m y for p r fora ting

.
,
B a ct r i al ci nc in i
e s e e ts s u rgic al r la ti o n e s, ,
. .
,
e
5 7, 1 50, 2 1 7, g un h o t w so und o f t h ab d o m n wit h e e ,
B A o n d for m iti R vi w o f 8
KE R e e s, e e 2 0
r c o v y 468 wit h d a t h 4 7 5
e er , ,
e ,
.
R a dic al cu r o f h yd ro c l
.
,
h o pit al r p or t R vi w 30 e e e,
B
.
AR D E N H E U E R , s e s, e e
o f 83 8 5 ; o n inj u r i o f upp r
2 2 es e ex
Bu r n b y l ct r ic la m p 60 e e ,
2 .
Bu r a t a E x o t o i 7 7
, ,
i i R vi w o f 8 4
t re m t e s , s s s s, .
2 ,
9 e e 2 0
BU T L E R G R R vi w o f T r v M a nu al
.
,
B M ANN B rl in c l inic R vi w o f 8 3
’
’ e e e es
ERG
. .
,
S e e e 2 ,
2 85
, , ,
o f S u rg ry 3 7 5 e , .
Butt o ck T ra u m a tic a n u r i m c a u d b y
.
Bi l i ary c al cu l u ( ch ol cy t o t o m y g all s, s ee e s ,
e s se
punctu r d w o und o f 33 3
,
ston ) es .
e ,
.
Bi l h arz i a h m a t ob i a in th vi c ra L
ae e s e , e
si o n c a u d b y th p r nc f gg a nd
s se e ese e o e s
m bry o of 35 35 /E CA L gi o n S u rgic a l r la ti o n of
C
e s , 0, 2. Re , e s
Bi m ut h for u l c r S u b i o did o f 5 45
s e s, e , . i le 0 5 29 .
Bla dd r ( e al o up ra pu b ic cy t o t o m y
see s s s , Cae s ar a n cti o n in h U nit d S t a t I
e se t e e es. n
l ith ola p a xy l ith o t o m y ) a nd v a gin a S t

, , a c r a ing m or t al ity f 5 5 6 ; A i m p ro v d
e s o ,
n e
t i ti
s o f fi tu la o f 3 7 ; Ch o ic o f o p r
cs s , 2 e e t ch ni q u in 5 5 4
e e , .
a ti o n for xt ra cti o n o f c al cu l i fro m 5 3 5

e , , C al c ar o u c o nc r ti o n o f p l u ra R
e s cti o n e e ,
ese
D igit al xp lora ti o n o f 5 3 ; D ra in a g o f
e , 2 e ,
o f r i b for 7 9 , 1 .
1 87 ; L i o n c a u d b y gg a nd m
es s se e s e C al cu l u ( bla dd r ch ol cy t o t o m y
s se e e , e s ,
b y r o f Bi l h arz i a h m a t ob i a in 3 5 ;
os ae , 0 g all t o n s up ra pu b ic ) fro m bla dd r
e, s e ,
Mod r m o di fi c a ti o n o f o p ra ti o n
e n s e s Ch o ic o f o p ra ti o n for xt ra cti o n f 5 3 5
e e s e o ,
for t o n in 5 43 ; T u m or o f 8
s e , s , 20 . M o d r n t ra n for m a ti o n o f o p ra ti o n
e s s e s
Bloo d T ra n fu i o n a nd infu i o n o f 3 3
, s s s , 1 . for 5 43 ; S u rgic al int r v nti o n in c r t a in
, e e e
Bo n es,E xp r i m nt al p ro ducti o n o f typ i

e e c a o f b i l i ary 339
ses ,
.
c al tu b r cu lo i f 79 ; S u rg ry o f 68
e s s o , e , , C a nc r ( e al o c ar cin o m t o n i llar tu
s ee s a, s ,
7 1 . 7 7, 79 , 8 1 , 8 2 , 8 3 , 84 , 1 2 3, 1 79, 1 85 , m r ) C ra t r ifor m u l c r a typ o f p i

o s , e e ,
e e
255, 26 1 .
2 6 2, 33 4, 33 5 . 35 1 , 3 62, th li l 3 5 7 ; o f c ar ti la g
e a , 35 ; o f h l au e, 0 t e ~
3 64, 3 73 , 4 1 7 , 42 4, 430 , 44 7 , 4 5 0 c e s, 3 88 ; o f l ip R u l t o f o p ra ti o n f , es s e s o r,
BO R EU N V I LL a n d m a nu al 7 3 ; f l ung P r i ar y 7 6 ; f o o p h a gu
’
E Bri c o n s de 1 o ,
m ,
1 o es s,
LVD E A .
G as tt o s t o t ru 36 7 3 7 n n o r u e s , 0, C ut a n o u i m p la nt a ti o n
e a n a dj unct t o
s as
n c ro t o m y 8
.
7 f ut ru
1: S tat i i c
O o f 37 ; fro m e s st s 0 e , 2.
t o m a 69
.
.
l un g t o pin E xt n i o n f 76 s e. e s o 1 C uti s, o ~
e ,
.
lab iu m m aj u c o m p l ic a t d
.
C l li
ar ro d D vic c for di tingui h ing
an e e s s y t fib s o- d ro r or s, e
b y p r gn a ncy 4 5 7
.
di ff r nt ol uti o n o f 5 6
e e s s 1 e ,
.
Cy t o t o m y ( c al cu l u li th t y up ra
.
.
C r cin m a r p ri ut r i S 5 ; o f larg i s se e s, o o rn s
a o Co o s e e n ,
al lora o o
.
t tin O p ra ti n for 47
es e e o s 2 p b i lu wit h dig i t c xp ,
ti n f th e e
bla dd r 5 3
.
.
C aro ti d T m i an u ri m o f i
a r t e rv , i au at c e s n e 2 .
,
Cy t ( i ) Int ra c a p u lar
t rn al 64
e 1
s s w hi see e ns , e c nococc ,
s
xti p a ti o n o f t hy ro id 7 4; o f l iv r H y
. .
C ar i la g ( C a nc r I th e r 1 e
t lm d e see c n rO e O e, , .
d a t rd , 7 3 .
t ti n in c a v n o u m y o fi b o m a o f th
C as ra o er s r e
ut u 3 7 e r
s . 0 . E F O R M IT I E S, R e vi w o f B ak r o n
e e ,
CA CA
TH C W A b t ra ctRT 33 9 44 . . .
,
s s, , 2, 2 80 .
D i lo c a t i o n o f fi b u la S i m p l 84 ; o f fi ng r
s ,
e, e s
C a v n o u inu A l v olar ab c with

er s s s, e s e ss up o n m t a c arpu B a ck w ar d 5 49 ; f h a d
e s, ,
o e
t h r m bo i o f 7
o s s , 1 0 . o f ra diu with fra ctu r o f upp r th i r d o f
s e e
C r bral (
e e bra in ) ab c u b q u nt t o
se e s e ss, s se e u ln a 6 ,
2 2 .
orb it al p r i o titi 3 34 T u m o u r e s s, . . 1 00 D i lo c a ti o n R vi w o f S t tt r o n r c nt
s s, e e e e e e
ca o f 5 ses . 10 . tra u m a tic 84 9 , 2 ,

2 2 .
C h nc r o f t o ngu
a th roa t
e 86 e, , e tc .
,
.
D i inf ct hi h a nd
s e H w h all th p h y i s s, o s e s
C h t S u r g ry o f 5 9
es , 74 76 7 7 79 e ,
1 ,
1 ,
1 , 1 , 1 . c i an , 66 .
Cli o lyc ys t e c to m y, 3 3 9 . D it s rm i um h ae m a t ob iu m .
3 50, 3 5 2 .
ol cy t o t o m y
Ch e s ,
1 8 3 , 1 84 ,
5 2 1 . D r ing for u l c r
ess e s, S u b i o did o f b i m u t h e s ,
C h o nd ro o t o id ar o m a o f -
s e s c th v r o id bo dy , 545
2 72 . D r i ll a ft r r cti o n N a i l a nd
s, e e se , s , 2 69 .
C h o n d ro s a i c t ma , D U NN H P Ab t ra ct , 7 7 .
, s s, 1 , 2, 1 61 , 33 4,
C LA R KE , W . b t r ct 9
R .
, A s a , 1 2 .
42 5
Re vi w o f M orr i o n u rgic al
e s s Re vi w o f B ab r o n x a m in a ti o n
e e e s
e a se s k idn y 8 of th e e , 2 2 . of n o 3 78 th e se, .
C la vic l E xci i o n o f a c ro m i l d o f with R vi w o f B o u r n vi ll a nd B i

’
e, s a en , e e e e r c on s
nti
e a nd ca pu la 5 5 5 3 ; L ig a tu r
r
e ar m s , 2 , 0 e m a nu l d t ch ni q u e d a ut o p i 3 8
e e e es s es, 0 .
o f b l i v l und r 4 7 ; S b
~
u c av a n esse s e , 2 u D u ra m a t r ( al o m ning al ) in bra in
e se e s e e
p i l
e r os ea i o f a n c ro d 3 7 3 re s e C
'
on e se , . tu m or C o nditi o n o f 5 s, , 10 .
C o c a i n in gyn c olo g y 3 68
e e , .
CO I I C A b t ra ct 3 6 5 3 6 6 3 6 7 3 6 8 AR S , T o r m o v for ign bo di fro m

E
P, . .
, s s, , , , , e e e es
3 6 9 3 7 0, 3 7 1 . 3 7 2
.
th e , 1 70 .
Re evi w f r c nt G rm a n u rgic al
e e e s c in o c o ccu o f l ung O p ra tiv t r a t m nt
E h s s, e e e e
pu bl i c a ti o n 8 7 s, 2 .
o f 7 7 ; o f ab d o m in al or g a n O p ra t i o n
,
1 s, e
C L C J A b t ra ct 8 5
O L E S, 66 77 47 . s s, , 1 , 1 , 2 , for 7 6 , .
33 6 . 3 4 1 , 344 , 4 5 7 .
E DW A D F S Ab t ra ct
R 87 88 9
S, . .
, s s, 1 , 1 , 1 0 .
C o lo tu m i ai l i ca
a , 3 45 .
T m t of t ictu r o f u r th ra
re a ' en s r e e
C o m p r i o n r m orrh ag 33
e ss f h ae e, 2, 333 . b y l ct rol y i 5 6 e e s s, 1 .
C o xi ti D i a gn o tic v al u o f r ct al
s , s e e e xa mi n U r t h ral f v r e e e ,
20 .
i in 8
at o ns , 0 .
E l ct ri c la m p S tunning a nd b u r n b y
e 6 , , 2 0
C ra ni m ( u bra in ) s
ee E l ct rol y i T r a t m nt o f u t h ral t r ict
e s s, e e re s
t i
r a e r zo r m lc r u e , ure . b) 1 56 .
E m bol i m a ft r fra ctu r e D a t h fro m
s e s, e m a to b i um , 352 .
t h ro m bo i a nd 2 6 1 s s ,
. F i bro id o f t h lab iu m m aj u c o m p li c a t e s e.
E m py m a o f a nt r u m O p ra tiv t r a t m e nt
e , e e e b y p r gn a ncy Cy t o 4 5 7 ; o f th k i n
e , s e s
o f, 33 5 3 5 8 ; tu m o u r o f ut r u P l vic b e s, e a sce s .
E n t e ro t for i l u 5 1 r m y e s, 2 . si m u la ting o ft 4 5 5 s ,
E pi l p y fro m ol d fra ctu r

e s e O f s k ull, 7 1 . F i bro m a t a o f th ab d o m in al w al l 3 6 ; e s, 0 0
E smh m i l it ar y u r g ry
av c
’
s s e , Re e vi w o f
, 2 8 4, th ut r u M y 3 5 ; o f th ut r u
e e s, o 0 e e s
29 1 . C a t ra ti o n in m y o 3 7
s 0 .
E VE , F S b ra ct 3 6 . .
, A st , 0 . F i bro ar c o m a o f th ab d o m in al w all 3 6
s e ,
0
E xci i o n for c h ro nic di a

s o f h o u ld r se se s e Fib m t
ro s a r c o tu m o u r 5 49 a o us s, .
j 7 ; o f h larynx 3 9 7 4 3 4 ; o f h
o rn t, 2 0 t e , , t e F i b u la S i m p l di lo c a ti o n o f 8 4
, e s ,
.
bo n o f h t ar u 9 3 ; o f h h i p jo in t
es t e s s. 2 t e -
,
Fm g up o n m t a c a p u B a ck w ar d d i
ers e r s, s
5 5 ; o f h kn
1, 4 0 j o int 3 64 4 7 t e e e- , . 2 . lo c a i o n o f t ,
E xt r m iti e S u rg y 8 5 3 46 3 5 9 3 6
es, er 0 1, 1 , , , 2, F i tu la C a
s o f g a t v a gin al 4 5 9 ; I t al
, se s
'
o
-
,
3 6 4 , 4 2 4, 444 , 5 3 0 i t a ti tic f i v a gin al 3 7 ; U

an s s s o ve s co - . 2 re
E xt r m ity
e , R e e vi w o f B d h on i ar en e ue r n th ro p rin al 46; i a n o C u r o f 3 6
-
e e , n- , e 1 .
j u ri i es o th pp r 84 9 ; R vi w f
e u e , 2 , 2 0 e e o F o t a ti o n La p aro t o m y f or
e ,
xt ra ut r in e -
e e
S
c h ii lle r s
’
u rgic al a n a t o m y o f upp r
s e ,
o tu i h or n o f a ut r u b ic or ni R F e s n o ne e s s, e
E xo to s C o ng nit al y mm t r ic al 3 6
se s, m o v al o f 3 7
e s e 2 . , 1 .
E xo to i b u r ata 77
s s s For r m
s I n o cu la ti o n tu b r cu lo i
, . a ft ea ,
-
e s s er
Ey es,E nuc l a ti o n wit h t ra n p la nt a ti o ne d a m put a ti o n o f 4 4 s an , 2 .
r i m p la nt a ti o n o f 7
e F ra ctu r B h a vi r f bo di l y t m p a tu r
,
1 2 . e, e o O e er e
u b cut a n o u 6 ; D a t h fro m th ro m In s e s, 2 1 e
A C E R vi w f T , d l b g on i e b i a nd m bol i m a ft r 6 ; o f h m
e o re n e en ur n os s e s e , 2 1 u e
j u r i a nd u rgic al di a o f h
es 6 8 ; P aral y i o f ra di al n r v follo w
s se ses t e, r us , s s e e
83 88 . 2 . ing 5 7 f p a t lla b y m t all ic utu r , 1 ; o e e s e .
F a ci al n r v t r tch ing o f
e e, s T r a t m nt o f 8 3 ; o f p a t lla N w
e , 1 .
e e , e , e O p e l"
F allo pi a n tu b ( py o al pinx ) ea ti o n for

see ; o f u l n a in upp r t h i r d
s . , 227 , e ,
F asci o f h n ck 9
m t e with d i lo c a ti o n o f h a d o f ra diu 6 ;
, 22 . s e s, 2 2
F a tty tu m o u r o f h k n jo in t 3 5 9 s f k ll 4 3 ; o f k u ll T r p h ining in p i
t e ee- , .
o s u , 0 s , e e
F a uc r ic al t r a t m nt o f m al ign a n t
es , S u
g l p y fro m ld 7 ; o f k u ll t r a t m n t f
e e e s O , 1 s , e e o
tu m o u r o f 3 8 8 s ,
c o m p o und 3 8 , 1 .
F m oral ar t r y T ra u m a tic a n u r i m o f
e e F ra ctu r ,
R vi w o f B r un o n 8 3 88 e s es , e e s , 2 , 2 .
33 3 ; v l a nd n r v in xti r p a ti o n f F ro n t al i T ra t o m a inu 68
es se s e e e o s, e s s, .
t ttm o f S c a p a t ri ang l 74
o urs
'
r
’
s e, 2
o f r ni a 5 3
.
F v r St no i
e e , fl y a ft r typ h o id ; 33 6 : G
e s s o
A N G R E N E ar
h nx e
e , 2 .
U r t h ral Ga nt g y R vi w o f 3 7 6
’
e 20 s s r er e
, .
e
F oo t P a infu l a ff cti o n f 5 3 ; S p o nt a n o u
, , .
, G all t o n e il u 8 5 ; I m p a cti o n o f
o , e s s e, e s, 1 0, 2 1
T u b r cu lar
,
p hl b g i l int r v n ti o n in
i k
e i f 3 46 ;
ac t e r e tas a O e
5 ; 2 1 ur ca e e
n
,
di a or h t ar u 9 3
,
se se t e s s, 2
339 .
F o ign bo dy (
re al o t ra c h o t o m y ) fro m Ga t ro t o m y for c a nc o f o o p ha gu
se e s e s s er es s,
h
t ar T r m o v 7 ; in o p h a gu
e e s, o
37
e e, 1 0 (es s, 2 .
C a t ro v a gin al fi t la C a o f 45 9 s
-
s u s e
G R S h or t ning o f ro und l ig a
.
, .
F WLO ER, .
G nit o u r in a y or g a n S u r g y o f
.
, e
3 e -
r s, er ,
20 , 0,
m nt s e , 42 .
1 8 7 , 1 88 , 2 5 6, 25 7, 2 5 9, 260,
F i bro a d n o m a o f th r ctu m p d d b y
-
e e e zo uc e
44 < f s< 4 38.
gg a nd m b y o o f di t o m u m h
.
th e e s e r s s ae
53 2
X li
GE R R I SH , F . H S u rg i c al ra
t e tm e n of t s iti o u o f , 7 4; T e s ticu lar a ff ct i o n a nd e s ,
m al ign a nt tu m o u r s fa uc 38 7
o f th e es, . 1 90 .
GE R S TER , A . G r ni al H yd ro c l o f
A dv a nt a g 59o f up ra es s He s ac. e e ,
2 .
pu b ic l it h o t o m y 9 8 H i p jo int Am put a ti o n a t
, 2 8 5 di a
.
-
, ,
1 ; se s e s,
Gla nd L i o n . c a u d b y gg d
es s D i a gn o ti c v al u o f r ct al x a m in a ti o n
se e s an em s e e e
b y r oso f B i l h arz i a h m a t ob i a in m n in 8 E xci i o n o f 5 ; in pu l m o n ary tu

ae ese , 0; s , 1
t r i 3 5 ; T b r cu lo i o f m a mm ary
e o, 0 b
u l i E xci i o n o f 4 5
e s s ,
e rc u o s s , s , 0 .
1 59 . H um ru E xci i o n o f h a d o f 5 5 ; P aral e s, s e , 2
G la nd r B a ct r i olo g y i
e s, 7 ; R vi w o f e
y i o f ra di al n r v follo wing fra c u r o f
o , 21 e e s s e e t e ,
K o c h o n p l nic f v r a nd 8 3 s 88 e 68 e e , 2 , 2 . .
Gli o m a 7 , 1 1 . H U T HI N N j J Ab t ra ct 86 8 7 3 7 3 C SO , r .
, .
, s s, , , ,
Glo tti ( E d m a o f 3 3 6
s, e
3 74 , .
G o i r b y l ig a tu r o f a ff r nt ar t r i
t e Op H yd a tid cy t o f l iv r 7 3
e e e e e s, s s e , .
e ra ti tr a tm n t o f 5 3
ve e
H yd ro c l o f h r ni al
e ,
5 9 ; o f tunic a
2 .
e e e s ac , 2
Go n orr h o a B a ct r i olo gy o f 5 ; b y m a n
e , v gin al i R a dic al cu r o f 3
e ,
1 0 e s
a s, e 0
o f g roo v d bo ugi T r a t n t o f ch ro n H yd ro n p h ro i T ra u m a tic 9
.
,
e es, e me e s s, 1 2 .
,
i 3 74 Hy t ct o m y for c a nc r Va gin al 3 6 7
.
c,
s e re e
A P Tr a nt o f a n u r i m 4 7
, ,
G UL
,
O D, e tm e e s
37 1
. . .
, ,
Gu mm a t a a t m ar gin f S yp h i l itic 8 7
.
o an u s , , .
Gun h o t w o und o f ab d o m n La p aro t o y

CT E R U S a cc o m p a ni d b y a g n ral
s e m
for p r fora ti ng with r c o v y 3 44 468 I rup ti o n o f l ich n E m o ti o n al 4 6

, e e e
e e er
, , , , e e 2
5 8 ; wit h d th 4 7 5 5 8 ; w o und o f
.
, ,
I l o c c al r gi o n S u r gic al r la ti o n of
2 ea 2 -
, , e ae e e s
pin H al d 44 7
, ,
S e, e e
5 9
.
, 2
Gyn c olo g y 4 8 5 3 6 5 3 6 7 3 6 8 3 69 3 7
.
Il u G all t o n
e 2, 0,
, , 8 5 , , , , e s, s e, 1 0, 2 1 .
37 4 5 5 4 5 6 4 5 7 45 8 I l iu m d ra ining p l vic ab c
1,
T
'
. , , , 0r e s e sse s , re
4 5 9, 5 5 1
p h i n i n g th e , 3 5 1 .
I l i a c ar t ry L ig a tu r o f c o mm o n for
e , e an
i
e ur s m o f xt rn al 5 9 e e ,
1 .
H E M AT O M AT A o f c ra ni al c a vity , I nc o ntin nc o f u r in in ch i l d r n
e 88 e e e ,
1 .
2 32 . I nfa nt F ra ctu r o f k u ll in a n 43
, e s , 0 .
H ae m orr h a g e a fte r uvu lo t o m y 5 2 1 ; int o , I nguin al h r ni a R a di c al cu r o f obl i q u

e , e e,
ab d o m in a l c a vi ty du r ing m n s t u a ti o n e r , 89 .
F a t al 4 5 6 ; M idd l m e ning al 2 3 2 5 1 2 ;
, e e
, I nj u r i es o f upp r x r m iti e e t e es, vi w o f
Re e
T ra n fu i n a nd infu i o n for 33
s s o s ,
1 . Bard e n h o n 84 9
aue r , 2 , 2 0; S u rg ry o f e ,
H a nd T u b r cu lo u
, yn o viti o f t ndi no u
e s s s e s 2 60 .
sh a t h o f 444
e s , . I nn o m in a t ar t y Co m p r i o n o f 3 3
e er , ess , 2 .
H ad
e u r g r y o f 68 7 7 6 7 6 9 7
, S e , , 0, 1, 1 ,
1 , 1 0, I n t r m nt A nti ptic u r gic al
s u e s,3 se s , 2 0 .
1 71, 1 72, 1 73, 227, 2 3 2. 3 5 5 , 3 8 8 , 4 30 I nt tin es C l t mi i l i a c a 34 5 ; gun h o t

e, o o o a , s
He a d ( al o bra in ) u m o u r o f
se e s ,
T s , 68
. w o und f with r c o v ry 344 468; o , e e , ,
H rni a G a ng r n o u
e , 5 3 ; in a p r gn a nt e s, 2 e with d a th 4 7 5 5 8 ; b t r uc i o n o f (
e , ,
2 O s t se e
w o m a n S t rangu la t d u m b i l ic al 44 ; I
,
e , 2 n al o i l u ) b y int r n a l t ra ngu la t d h
s e s e s e er
t i l ob t r ucti o n r l i v d b y lib
e st na s e e e e ra t ni a La p aro t o m y for 5 6; b t u
, ,
2 O s r o
ing h o m n u m fro m a n o m nt al 5 6
t e e t e , 2 ,
ti o n o f 5 7 ; b t r ucti o n o f fro m h r ni a
, 2 O s , e
in t o fora m n o f Win lo w S tra ngu la t d e s , e int o th fora m n o f Win lo w 44 ; h

e e s ,
2 O
int r n al 4 ; La p aro t o m y for int r n al

e , 4 2 e tr ucti o n o f r l i v d b y l i b ra ting th
s , e e e e e
tra ngu la t d 5 6 ; o f o m ntu m b y b

s e , 2 e a o m ntu m fro m a n o m nt al h r ni a 5 6;
e e e ,
2
d l w o und
om i n a 4 ; R a dic a l cu r of s, 2 0 e ob tr ucti o n o f S i g i fi ti o f c olla p d
s , n ca on se
ob li q u inguin al 89 ; S p o n t a n o u r o
e ,
e s en int tin in la p aro t o m y for 4 O p ra
es e , 2 0, e
INDE X . < i ii
>
ti o n for c ar cin o m a o f larg 47 ; R

s e, 2 esec La p aro t o m y ( al o C ar a n cti o n se e s ae s e se
i o n o f 344 ; S u rgic al r la ti o n o f i l o
,
r , e s e ch ol cy t o t o m y c h in o c o cci g
e s , e a s t ro s t o
c c al r gi o n o f 5 8
,
ae e . 2 .
m y h yd a tid v ar i o t o m y ) a nd l ig a tu o f
, , O re
I ntu ba ti o n o f lar ynx 7 3 ; a nd t ra c h o t o m y , e , c o mm o n i l i a c ar t ry 5 9 ; Di g i l e , 1 a no s t t ra ,
5 23 4 ; E xp lor tiv
2 0 84 for fi of a e, 1 , a e c t ro n s
il o e l r gi o n 5 9 ; for c ar cin o m a o f
-
cx c a e , 2
larg int tin 4 7 ; for int tin al ob t ru

e es e, 2 es s o
O I NT kn o u l d r tu b r o f c olla p d int tin
J ( s e e h ip
cu lo n s ) .
ee sh e e
in 4 ; for int r n al t rangu la t d h rni a

, 2 0 e s
se
e
es
e
e
Jo int u r g ry o f
,
s, S e , 5 1 , 8 0, 1 85, 22 7, 25 5,
5 6 ; for ob tr ucti o n f i
2 i 5 7 ; for s o n te s t n e , 2
2 6 2 ~ 2 6 5 , 2 6 9 , 2 70. 271, 3 59, 3 64 , 4 2 7 , p r fora ting gun h o t w o und o f b
e s a
d y 3 44 46 8 5 8 ; wit h d a t h
o m e n , r e c o ve r , , , 2 e ,
4 7 5 5 8 ; for p r ityp h l itic ab c

, 2
4
e s ess, 2 2,
2 4 3 ; for r t a in d fo tu in ut r u b ic orni
e e e s e s s,
W W tr tch ing o f fa ci al 3 7 ; in xt ra ut r in f t a ti o n 4 5 8 4 5 9 ;
K n v
E E N, . .
, S e 1 e -
e e oe .
,
er e, 1 . s u bl i m a t int o xic a ti o n in c a o f 5 5
e se , 1
b t ra ct
.
KEE TLEY , C B . .
, A s s, 1 76, 2 60 . L p ro y C o nt ag i o u n o f 3 4 ; N r v
e s , s ess , 2 e e
Os t o cla i 4 7
e s s, 1 . st r tch ing for a n th tic 5 7
e ae s e , 1 .
Re vi w o f B ak r o n d form iti
e e e e s, L ich n E m o ti o n al ict r u a cc o m p a ni d b y
e , e s e
a g n ral r upti o n o f 4 6
e e e , 2 .
vi w o f Th o m p o n o n up ra
Re e s s Lig a m nt S h or t ning f d 4 3 65
e s, e o r o un , 2,
pu b ic cy t o t o m y 7 7
.
s , 2 . Lig a tu r Am put a ti o n o f a n inv r t d ut r u

e, e e e s
K idn y ( e al o h yd ro n p h ro i ) E ti
see s e s s , x r b y th 3 7 ; o f a ff r n t ar t r i in g o it r
e , 2 e e e es e,
p ti a f 56on o 5 9; L i on c au d by
, 2 ,
2 es s se 5 3: f 2 i l i a c ar t ry 5 9
o c o m m on e , 1 .
egg a nd m bry o o f Bi l h arz i a h m t

s e s ae a o L ip R u l t o f o p ra ti o n for c a nc r o f
, es s e s e
b i a in 3 5 ; R t ro a nd I nt ra—
,
, p 0 t l e e rl on e a 1 73 .
inci i o n for tu m or o f 445 R vi w o f

s s , . e e L ip o m a o f k n 6 5 3 5 9 ee, 2 , .
M orr i o n th 8 ; R uptu r o f 9
s e, 2 1 e , 1 2 . L ith ola p a xy R a pid v a cu a t or for 5 7 , e
, 2 .
K o ch o n p l nic f v r d g la nd r R vi w
s e e e an e s, e e L ith o t o m y ( bla dd r c al cu l u y t \
ee e , s, c s to o
o f 83 88
, 2 , 2 . m y up ra pu b ic ) twic in fo u r t n
, s e ee
Kn jo int a ft r r cti o n N a i l a nd d r i ll
ee- , e ese , s s m o nth 8 7 s, 1 .
f fi x a ti o n o f
or 69 A rbor c nt l ip o m a , 2 : es e L ith o t rity ( bla dd r) see e .
o f 65 ; E xci i o n f th 3 64; E xti rp a ti o n

, 2 s O e, Liv r A b c f t h 3 4 ; L i o n c a u d
e , s ess O e, 1 es s se
o f yn o vi al m m bra n b h ind 4 7 ; in
s e e e , 2 b y gg a nd m b y o o f Bi l h arz i a
e s e r
h r dit ary
e e yp h i l i S yn o viti o f 8 7 ; s s, s h m a t ob i a in 3 5 ; T r a t m nt f h d i d
ae 0 e e o at
,
y ,
T r a t m nt o f w h it
e w ll ing o f 2 69 ; T
e e s e , u ~
cy t o f 7 3 ; wit h r c o v ry La p aro t o y
s s , e e , m
m ou r o f 359 s , . for p n t ra ting gun h o t w o und a ff cting
e e s e
th e , 5 28 .
LL O YD ,
S .
, O p ra tiv a tt a ck s o n
e e th e hu
A HI U M m aj u s c o m p l ic a t e d b y p r e g m a n bra in 49 9
L n a ncy , .
, Cys tro - fi b ro i d o f 45 7 , .
L u m bar ab c e s s r a t m nt o f 5 46 s s e , T e e ,
L ung ( tu b r cu lo u tu b r cu lo i ) O p
.
LA KE , R .
, Se rv o Bu l g ar i a n w ar fro a
-
m s ur s se e e s, e s s
g i c al p o int o f vi e w , 38 1 .
e ra ti t r a t m nt f hi
ve i of e
77 ;
e o ec n o c o cc 1
P r i m ary c a nc r o f 76
,
LAN GE , l inic al b r v a ti o n o n m y o
F C O se s e , 1 .
fib tu m or o f th ut r u 3 4
ro m a to u s s e e s, 0 .
Lupu T r a t m nt o f 6 ; vu l g ar i a nd tu
s, e e , 1 0 s
Larynx a ft r typ h o id f v r S t n o i o f 33 6
e e e , e s s ,
b e r c ulo s i s , 5 1 4
E xci i o n o f s I ntu ba ti o n o f 7 3 , , ,
Ly m p a ngiti a nd u bl i m a t i rr ig a ti o n
h s s e s
5 23 4 29 .
x iv
AC E \VE N , R a dic al cu r o f h e er Na i l a nd d ri ll a ft r r cti o n U o f

s s e ese , se ,
26 9
ni a . 89 . N c k A r i al tu m or
e , f i ep ar t o f s o a n te r o r , 23 5 .
M al l l i ab c e, in h 45
’
e v c s ess t e, 2 .
4 3 ; F a ci 1 a nd i f i l p a c s ae n te r a s c a s es of
'
M al ign a nt pu tu l Th r c a of 4 5 s e, ee ses ,
2 . 229 S u g ry o f 7 3 7 5
, 39 74r e , , ,
1 ,
1 , 2 29:
M a mm ar y g l d T b l i of 59 an s, u e rc u o s s ,
1 . 23 5
MA L A b t ra ct 6 8 7 3
R K, . , s s. ,
. c ro i o f c la vic l S ub p r i o t al r cti o
Ne s s e, e s e ese n
M T M (E
A R KO E , ph g for for . .
, so a o to m v for 3 7 3 ; o f ti b i a 8
, ,
2 .
i g bo di
e lo d g d in h tu b 9 3
n es e t e e, 1 . N c ro t o m y 8
e ,
2 .
M a a g T r a t m nt o f c ol i o i b
ss e, 66 e e s s s y, 2 . N p h r ct o m y 5 6 ; o n a p a ti nt 3 m o nt h s
e e , 2 e 2
M a xi llary inu O p ra tiv t r a t m nt o f

s s, e e e e o i d, 2
59 .
m py m a o 3 3 5
e e . p r iti a ft r la p aro t o m y a nd l iga tu r f
Ne h s e e o
M BU N Y C S y p ra ti o n c o m o n i l i a c F a t al 5 9
’
C R w ki E .
,
z m an o s s O e m , ,
1 .
a pp l i d t o h cu r o f u r th ro —
e p r in al t e e e e e N rve N u ral gi a o f in t r n al p la nt ar 5 7 ;
e, e e , 1
fi tu la 46
s 1 . follo wing fra ctu r P aral y i f d i l 68 ; e, s s o ra a ,
M di a n n r v
e U l n ar n r v g ra ft d up o n
e e, e e e ,
Val u o f nuc l a ti o n o f a n u ro m a w h ic h
e e e e
1 61 . m d t o d m a nd r cti o n o f a 5
see e e ese , 21 .
Me la n o tic wh it lo w 3 5 7 3 6 , ,
0 . N rve o f diff r nt functi o n c o n id r d in
es e e s s e e
Me ning al ar t ry H m orrh g fro m m id

e e , ae a e in i p h y i olo gic al a nd u rgic al r la
ts s s e
d le , 23 2, 5 1 2, ti o n U ni o n o f 6 ; O p ra ti o n o n 5 7 ;
s, ,
1 1 e s , 1
Me ningiti T ra u m a tic 4 3 s, , 0 . S c o nd a y utu r o f m di a n a n d u l n ar

e r s e e ,
Me n t ru a ti o n F a t al h m orrh a g int o b
s ,
ae e a 6 ; S u r g y o f I 66 68
1 1 6 44 7 er , , , , 1 1, ,
d m i ol c a vi ty du r ing 4 5 6
na ,
.
517 .
M nt r ic gla nd L i o n c a u d b y gg
e se e s, es s se e s Ner v t r tch ing e- s for a n th tic
e , 1, ae s e
an d m b y o o f B i l h arz i a h m a t ob i a in
e r s ae l p ro y 5 7
e s ,
1 .
th e , 35 0 . N rve utu r 6 e s e, 1 1 ,
M ese n t ry G un h o t w o und o f 468

e ,
s , . N u ral gi a o f xt n al p la nt ar n r v
e
5 7 e er e e s, 1 .
Me t a c ar pu B a c k w ar d di lo c a ti o n o f fi
s, s n N e t rr e c to m y, 5 t 7 .
g up o n 5 49
er , . Ne u ro m a, E e nuc l a ti o n o f a 5 , 21 .
M ic rob ( ba ct ri olo gy )
es se e e . N o s e, Re vi w o f B ab r o n x a m in a ti o n
e e e o f,
M i l it ary u rg ry R vi w o f E m ar ch
s e , e e s
’
s, 3 78 .
M I LL E R J ,
. S .
, T ro c ar for P ara c nt i e e s s ah
d o m ini 3 8 7 s, .
M orr i ( H n ry ) o n u r gic al di a
s o f k id
e s se ses
B S T R U CT I O N ( int tin )
y R vi w o f
ne ,
8 e e ,
2 1 .
O see es e .
MO I R T R u l t o f ti p t m th
R R S, . .
, es s an se rc e ( E d m a f g lo tti 33 6
e o s, .
d
o t r a t m t o f w o u d 48
s In e en n s, 0 . ( E o ph ago t o m y
s 93 ,
1 .
My ib ot t of h ut r u 3 5 ; C a t ra
ro m a a t e e s, 0 s ( E o p h a gu
s G a t ro t o m y for c a nc r o f
s, s s e ,
ion in 37
t ,
0 . 23 7 ; F or ign bo d y in 7 4 9 3 e , 1 ,
1 .
v —ar c o m a t o u t m or o f h ab d o m n
o s s u t e e , O G T O N A O p ra ti o n for v ar ic o c l
S ,
.
0 , e e e, 1 2 .
44 8 . O m ntu m Ab d o m in al w o und wit h h r ni a

e , s e
o f 4 ; fro m a n o m nt al h r ni a I n t
, 2 0 e e , es
ti mal b t r ucti o n r l i v d b y l i b ra ting

O s e e e e ,
5 26 .
O o p h o rap h y, 3 6 5
la n o tic wh it l o w alo ng
.
A I LS ,
Me th e
, O rb it al p r i o titi
e s s , Ce r bral ab c
e s e s s s ub s e
q u nt t o 3 34
e ,
.
IN DE X . XV
O hr t o p dic u rg ry e s e ,
2 66 , 269 , 2 70 , 27 1 , P ar i
o ci ty f u r g y a nd tu b r s s e O s er e
l
c u o us jo int di a 44 -
se se, 1 .
Os t o c la i 4 7
e s s, 1 . PI L H C L S La t ral p h aryng o t o m y for
ER, . .
, e
Os t iti o f k n
e s ee, T r a t m nt o f ar ticu lar
e e , xti rp a ti o n o f m al ign a n t tu m o u r o f t o n
e s
2 69 .
i llar r gi o n 3 9
s e ,
1 .
Os t o m a cuti 69
e s, . P l u ra R cti o n o f r i b for c al c ar o u c o n
e , ese e s
O v ar i o t o m y C o n r v a tiv 3 68 ; R m ar k
,
se e, e c r ti o n o f 7 9
e ,
1 .
on a ri o f ca o f 45 se es ses ,
2 . P o p l it al a n u r i m cu r d b y p r u r 3 33
e e s e e ss e, .
O v a y O p ra ti o n for p rola p d 3 6 5
r ,
e se , . P P FF P J A b t ra ct 3 3 7 34 5 349
O O ,
. .
, s s, 2 0, 2 , , ,
lab iu m m aj u P r gn a ncy C y t o fi b i d
e , s -
ro oi s
La p aro t o m y for c o m p l ic a t e d b y 4 5 7 ; ,
A LAT E C l ft 7 xt ra ut r in 4 5 8 4 5 9 ; La p aro t o m y for

P ,
e , 0 . e e e, ,
P a t lla b y m t all ic utu r T r a t n t o f tu bal 4 5 8; of v n y ar du ra ti o n 459 m e

, se e e s
’
, .
r a o a S t ra ngu la t d u m b i l ic al
e e s e, e
fra ctu r o f 8 3 N w o p ra ti o n for fra c P gn nt w m n e

, e
h ni a in 44
e , : e e
tu r o f 7 22
er , 2 .
ro a L o a b a
e
t t i n c u d y gg nd
.
,
P ara c nt i ab d o m ini A i m ro v d t ro P s e, es s se e s em
f B i l h arz i a h m a t ob i a i n
e es s s, n p e
b y
c ar for 3 8 7 ,
.
P ro t a t o t o m y
35
r os o ae , 0 .
P aral y i o f ra di al n r v ll w i g fra ct
s
t 5 3 , 2 .
ur e , 68
s s
P u tu l Th r
e
c a f m al ign a nt 4 5
e o o n
s e, ee ses O
, 2 .
A D I AL n r follo wing fra ctu r P

.
P ara p l gi a fro m c a nc r o f pin 7 6

e
R e S e, 1 e ve , e, a
ly i o f 6 8
.
P ara it in h d v lo p m n t o f c r t a in
s es t e e e e e ra s s ,
.
tu m or R ol o f 3 5 s, e R a diu in fra ctu r o f h upp r t h i r d o f l

,
2 . s e t e e u
P a t h olo gy o f tu m or 7 n a D i lo c a ti o n f 6
s, 2 2 .
, s o ,
2 2 .
P l
e v rc ab c D ra in a g o f 3 5 ; ab c
s e s s, R ctu m in c o xiti D i gn o tic v al u
e ,
of 1 s ess e s a s e ex
in h m al 4 5 ; ab c
t e i m u la ting o ft
e, 2 i i by h 8 L ion ca d
s e ss s s am n at o n s t e, 0 . es s us e
fi bro id tu m or o f h ut r u 4 5 5 b y g g a nd m b y o o f Bi l h ar i a h m a
t e e s, .
e s e r s z ae
P r in al fi tu la U r t h ro 46
e e s ,
t ob i a in 3 5 e 1 . , 2 .
P r in u m O p ra ti o n f c o m p l t la c ra
e e e R n al ( k idn y ) or e e e e see e .
cti o n N a i l a nd d r i ll for fi x a ti o n
,
ti o n f 3 66 o ,
R ese , s s
a ft r 69 ; o f a n c ro d c la vic l
.
P r i o titi C r bral ab c
e s s, ub q u n t t o
e e s e ss s b se e e ,
2 e se e, su
orb it al 3 34 .
p r i o t al 3 7 3 f i b , 79 e s e , ; o r 1 .
o f h ut r u b y a r c nt p
,
P r it o n al inci i o n for tu m or o f h k id
e e s R fi i s t e e t ro e x on t e e s e e O
R t ro a nd int ra i m t h o d T r a t m n t o f 3 69 e r a t ve e e e
ne y e 44 5 , , .
R vi w o f boo k
.
,
P r ityp h l itic ab c
e La p aro t o m y for 4 s e s s, 77 3 75 2 2 e e s s, 2 , ,
cti o n o f 79
, .
P r ity ph l iti 43
e s, 2 R ib R . , ese , 1 .
Ph ala nx up o n m t a c ar pu B a ck w ar d di A R CO M A C h o nd ro
e
3 5 9 ; F i bro or
s, s
lo c a ti o n i fi r t 5 4 O s ,
pind l c ll d 5 4 7 ; o f ab d o m n
0 .
s e-
,
e e e
Ph a y ng o t o m y for xti r p a ti o n o f al ign a nt , ,
44 8 ; o f k n jo i t 3 5 9 ; o f k in
e m
r
My o e e- n s
tu m or f i ll r gi o n La t ral 39
, ,
S pind l c ll d 3 5 8 ; o f t h y ro id bo dy
s o t on s ar e , e ,
1 .
e- e e
Ph l b e i k
a c te r ei o f foo t S p o nt a n o u ta s a
Ch d id 7
, e s,
on ro o s te o
~
,
, 2 2
,
346 S c al p E xti r p a ti o n o f w n in e s 22
PI L H
, ,
C J E 7 3 78 8 8 3 84 6 63 S c a pu la E xti r p ti o n o f nti r 5 5
E R, . .
, , ,
2, , , 1 1, 1 ,
, a e e, 2 ,
S c ar p a t r i a ng l E xti r p a ti o n o f tu m or o f
1 64 7 ,
1 1 , 35 4 2 , 2 0, ’
s e, s ,
2 4 2 , 24 3 7 2 4 5 , 2
5 7, 2 5 9, 2 60 , 269, 2 7 0;
2 74
2 7 1 , 2 74, 3 4 6 , 35 6 . 3 5 9 , 3 6 1 , 3 64, S c h ii lle r
’
s s u rgic al a n a t o m y , Re vi w o fe ,
5 1 9, 5 2 1 . 5 2 3 . 5 2 8 , 5 2 9 , 5 3 1 . 5 3 2 . 5 33 ,
S c ol i o i b y m a ag
s s ss e, T r a t m nt o f
e e , 2 66.
[ N O E /X .
Se r v o Bu l gar i a n w ar fro m a u rgical p o int S M W

-
o p ra ti o n a pp l i d t o cu r s ZY A NO SKI S
’
e e e
o f vi w 3 8 e . 1 . f u r t h ro p r in al fi tu la 46 o e -
e e s ,
1 .
S h a t h o f h a nd a nd w r i t T u b r cu lo u
e s S yp h i l i 8 6 8 7 3 7 3 s , e s s, , ,
.
s yn o viti o f t ndin o u 444 s e s, .
SH PH E F J E xci i o n o f h bo n
ER D, of. .
, s t e es
t h t ar u for tu b r cu lar di a
e s s 93 A R S U S E xci i o n o f h bo n
e
o f 93 se se, 2
T
.
s t e es 2
S h o u l d r jo int C h ro nic di a
, ,
e -
7 se se o i, 2 0,
,
2 7 1 . T AY L I I II Ab t a ct 69 7 45 5 OR, . s r s, 1 1 0,
S inu A l v olar ab c with th ro m bo i f

, ,
45 6
s, e s e ss s s O
c a v r n o u 7 E m py m a o f m a i lla y T langi ct a i a T r a t m nt f 66
e s, 1 0, e x r , e e s e e O 1
ro al ra o a
.
, ,
33 5 f nt i
; T t m 68 T m p ra tu
s, e in u b cut a n o u fr ctu r ,
.
e e re s e s a e s,
S k in ( al o cut a n o u cuti l ich n

se e s 6 e s, s, e , 2 1 .
lupu ) F i bro id o f h 3 5 8 ; T ra n p la n t a
s T nd o n o f w r i t a nd h a nd T u b r cu lo u
t e, s e s s , e s
ti o n f 7 8 o ,
. yn o viti o f h a th o f 444 s s s e s .
S k u ll ( bra in m ning al t r ph ining ) T ra t o m a inu fro nt al i 68

se e ,
e e , e e s s s, .
in bra in tu m or 5 ; F ra ctu r o f 43 ; T tic l a nd h rni a A ff cti o n o f h 9

s, 10 e , 0 es e e e s t e, 1 0
Tr at n t f p d fra ctu r o f 3 8 T t a nu in m a n E ti olo gy o f 4

.
,
e m e o c om o un e , 1 .
e s 22
, ,
.
S pin a b i fi d C u r o f 6 6 T h igh E xti r p a ti o n o f tu m or o f S c ar p a

’
a, e ,
.
, s s
S pin H al d gun h o t w o und o f 44 7 ; in

e, e e t r i a ngl o f 74
s , e ,
2 .
g o wt h o f a ni m al T or i o n o f 8 ; b y T H M P N W Ab t ra ct 3 3 3 3 3
r s, s ,
1 O SO ,
.
, s s, 2, .
m a a g T r a t m nt o f la t ral cu r v a tu r T h o m p o n o n up ra pu b ic cy t o t o m y R
ss e, e e e e s s s , e
o f , 5 22 . vi w o f 7 7 e 2 .
S p l nic f v r a nd g la nd r
e e R vi w o f
e Th roa t Ch a nc r o 8 6 e s, e e
, e ‘
, .
K o ch o n 8 3 8 8 ,
2 Th ro m bo i a nd
, 2 .
m bol i m a ft r fra ct r s s e s e u e,
S t a p h y lorrh a p h y 7 D a th fro m
,
0 6 ; o f c a v rn o u
.
inu e ,
2 1 e s s s,
St t
e ter o n r c nt t ra u m a ti c di lo c ati o n e Al v olar ab c
e with 7 s s, e s es s , 1 0 .
R vi w o f 8 4 9
e e ,
2 T h u m b up o n m t a c ar pu
, 2 2 .
B a c k w ar d d i e s, s
S t o m a ch a nd v gin a F i t la c o nn cti ng lo c a ti o n f 5 49
a , s u e , o , .
459 ° Th y ro id bo dy ( al o g o it r ) Ch o nd ro se e s e
S t r ic o f u r th ra b y l ct rol y i T r a t
t ur e e o t o id ar c o m a o f 7 ; I nt ra c a p u lar
e e s s, e s e s , 2 2 s
m e nt o f 5 6 ; S u b cut a n o u divi i o o f
,
1 xti rp a ti o n o f cy t o f 7 4 ; P a pi llary
e s s n e s s ,
1
u r t h ral 5 3 3
e ,
.
yli d c ll u lar a d n o m a o f 74 c n ro - e e , 2 ,
S u b c la vi a n ar t ry a nd v in L ig a tu r o f T o ngu Ch a nc r o f 86
e e , e , e, e , ,
4 72 . T o n i llary ab c 33 6 ; r gi o n La t ral s s e s s, e , e
S u bl i m a t in ob t t ic al i rriga ti o n U
e p h aryngo t o m y for xti rp a ti o n o f m al ig
s e r s, se e
o f 4 5 ; int o xic a ti o n in a c a f l p t
1 n a nt t m or o f 39 se o a a ro u s 1
l h a ngiti a nd 4 9
.
, ,
om y 5 5 ; y
,
m p 1 T or i o n in g ro wt h o f a ni m al 8 s , 2 .
s s, 1 .
S up ra pu b ic cy t o t o m y 3 49 5 3 5 5 43 ; A d sT ra ch o c l 35 , , , e e e, 2 .
v a nt a g o f 9 8 ; R vi w o f T h o m p o n T ra ch o t o m y (
es ,
2 al o intuba ti o n ) E
e e s e se e s , x
o n 77 ,
2 .
p lora t ory 7 5 ; E xtraor din ary c a o f 1 se s
S u r g ry R vi w o f B r un c o nt r i b uti o n
, ,
4 39 ; for laryng al t n o i fro m typ h o id

’
e e e s s e s e s s
,
t o c l inic a l 8 3 ,
2 f v r 3 36 ; in a ch i l d
.
y ar 33 6 ; e e , ac t . 1 e
S u r gic al c l inic o f univ o f B rl in C o nt r i

, ,
I ntu ba ti o n o f larynx a nd 5 3 ; tu b
.
in e , 2 e
b uti o n fro m 83 8 5
,
s th r igh t bro nch u

, 2 , 2 R m o v al .
f 7 e s, e o 2
S yn o vi al tu b r cu lo i 6 5 4 7 ; m m bra n
.
,
e T ra n fu i n a nd infu i o n 3 3
s s, 2 , 2 e e s s o s 1
b h ind k n jo int E xti rp a ti o n o f 4 7

, .
e ee - T ra n p la nt a ti o n o f y
,
7 , 2 .
s e e s, 1 2
S yn o viti in h r dit ary yp h i l i

.
f kn s o T ee d l b g o n in j u r i a nd u r gica l
e e s s, re n e en er es s
8 7 ; o f t ndin o u h a th e o f w r i t a nd di a o f fa c R vi w o f 8 3 88
s s e s s se ses e, e e 2 2
h a nd T u b r cu lo u 444
.
, ,
,
e T r p h ining for m idd l m ning al h
s, .
e e e e ae m o r
INDE X . xv ii
rh ag e , t ra u m a tic a p h a i a
232, 5 1 2 ; fo r s
Ul n ar n rv g ra ft d up o n m di a n 1 6 ;
e e e e 1
follo w d b y h m ip l gi a 69 ; in pi l p y
,
e e e , 1 e e s
S c o nd arye utu r o f m di a n n rv o u 6 s e e e s, 1 1.
fro m ol d fra ctu r o f th k u ll 7 ; th es e s , 1 e
U m b i l ic al h rn i a in a p r gn a nt w o m a n
e e
i l iu m for d ra ining p l vic ab c
,
35 e s e s se s, 1 .
S t ra ngu la t d 44 e 2
Tr v m a nu al o f u r g ry R vi w o f 3 7 5
, .
U r t h ra ( g o n orrh o a ) b y l c trol y i
’
e es s e e e
e see
.
, , e e e s s,
T r igg r fi g e M ch a ni m o f 444
-
n e r, e s , .
Tr atm n t e o f t r ict r o f 1 5 6 ; S b
e s u e u cu
T u b r cu lo i a ft r a m put a ti o n o f for arm
,
e s s e e
t divi i o n o f t r ictu r o f 5 3 3
an e o u s s s e
I n o cu la ti o n 4 4 ; B a ct r i olo gy o f 5 7
.
,
,
2 e , , U r th ral f v r
e e e 20
Ca o f u rgic al 5 9 ; i m p ro v d b y
, .
s es s , 1 e ex U r t h o p r in al fi tu la 46
e r -
e e s 1
o f h i p P u l m o n ary 4 5 ; Lupu
, .
i i
c s on , , 0 s U r in in c h i l d r n I nc o ntin nc o f 1 8 8
e e e e
vu l g ar i a nd 5 4 ; o f m am m a y gla n
, , .
s , 1 r d , Ut r b ic orni E xti rp a ti o n o f p r g a nt
e us s, e n
t
e c., 1 5 9 ; o f bo n E xp r i m n t al p ro e s, e e h or n o f a 3 7 ; b y a r c n t o p ra tiv 1 e e e e
ducti o n f typic al 7 9 ; S yn o vi al 6 5
,
o , ,
2 , m th o d T r a t m n t o f t fi i
e , of e e re ro e x on ,
42 7 3 6 9 ; b y m a n o f a l ig a tu r G ra du al
e s e,
T u b r cu lo u di a E xci i o n o f bo n o f
e s se se , s es a m put a ti o n o f a n inv r t d 3 7 ; C e e 2 as
t ar u for 2 93 jo in t di a 44 ; k n
,
s s , se se , 1 ee t ti ra in m y o fi b m t o f th 3 7 ; C
on -
ro a a e, ar
j o int di a 4 7 ; yn o viti o f t n din o u

se se, 2 s s e s i m
c no o f bo dy f 8 5 ; M y fi b m t
a o o- ro a o us
h a th f w r i t a nd h a nd 444
,
s e s o s , .
tu m or o f 3 5 ; di p la c m n t S h or t n
s 0 s e e e
T u m or ( al o a d n o m a a gi o m a a th r
, ,
se e s e , n , e ing ro und l ig a m n t for 4 3 6 5 ; E e 2, x

o m a c a nc c ar cin o a ch o nd ro
,
, e r, m , cer i i
c s on o f di a d p or ti o n o f c a nc ro u se se e s,
b l co m p r ion y t 3 6 7 ; P l vic ab c i m u la ting o ft

e ra t fib ess , c s , e xo s o se s, ro e s ess s s
g o it r gu mm a l i p o m a n u ro m a o v ary
e, , , e , , fi bro id tu m or o f 4 5 5 ; S t a ti tic o f c a n s s
o t o m a ar c o m a t ra ch o c l ) o f ab d o
,
s e , s , e e e cero f 3 70
ra pid g ro wth f m yx o ar c o m a
.
,
m en, o s U vu lo t o m y H m orrh a g a ft r 5
-
ae e e 21
t o u 44 8 o f bra in R m o v al f 7 499 ;
, , .
s, , e o ,
1 1 ,
o f ut r u P l vic ab c i m u la ting o ft
e s, e s e ss s s
A GI N A a inu t c a n al C a o f 4 59 ;
fi bro id 4 5 5
m e , se ,
T u m or s,
,
Ab d o m in al 4 5 8 4 5 9 ; A r nic al
.
Re vi w o f B i k y o n di a o f
e r es se ses ,
, , se
t r a tm n t o f m al ign a nt
e e C l inic al ,
a g n al fi tu la Ga t ro 4 5 9 fi tu la
V i S ta
g ro up o f 3 5 6 ; F i bro or pind l c ll d
s , s e- e e
ti i o f v ic o 3 7
s , s s ,
4 7 ; o f a nt r i or p ar t o f
s t cs es 2 .
s a rc o
e
m t a o-
n c k A r i al 43 o f bra in 49 9 ; o f
e
i s
,
:
. 1
e
V AN A A L W W Ab t ra ct 5 9
RSD E, . .
, s s, 1 ,
1 67 ,
, ,
fa uc M al ig a nt 3 8 8 ; o f h a d 68 ; o f 73 , 25 57
I 232 , 25 1 , 2 531
es, n , e
2 5 6,
,
2 6 1 , 2 62 , 2 6 5 , 2 66,
k idn y R t ro a nd int ra p r it o n al i
271 ,
2 72 ,
-
e , e -
e e n
i i
c s on for 44 5 ; o f k n jo in t F a tty a nd
. ee-
p r nt t a t o f k n o w l dg
O n th e
sar c o m a t o u 3 5 9 ; o f S c ar p a t r i a ng ls, s e,
in ba ct r i al ci nc in i t u rgic al r la
ese s e e e
E xti r p a ti o n o f 74 ; o f t o n i llar r gi o n
e s e e s s e
La t ral p h aryng o t o m y for xti r p a ti o n o f

, 2 s e ,
ti o n 5 7 5 s, 7 ,
1 0, 2 1 .
m al ign a nt 1 3 9 o f u r in ary bla dd r 8;

e
R vi w o f r c n t G rm a n
e e s e e e s ur
g i l pu bl ic a ti o n
, e 20
84 9
,
o f u t ru M y fi b m t 3 5 ; P
e s, o- ro a o us , 0 a
ca
T r a t m nt o f c o m p o un d fra ctu r
s, 2 4 2 1 .
th l g y o f 7 ; R ol o f p ara it in e e es
th
o o
d v lo p m nt o f c r t a in 3 5
, 2 2 e s es
o f th k u ll 3 8 e s ,
1 .
Var ic o c l O p ra ti o n for 1 ; T r a tm nt
e e e e e , 2 .
T yp h o id f v r S t n o i o f larynx a ft r e e, e , 20 e e
e e , e s s e ,
of 6 , 2 0 .
33 6 .
V in (
e c a v rn o u S D ) L ig a tu r o f
se e e s, c ar a e
u b c la vi a n und r c la vic l 4 7
s e e, 2 .
L CE R Cra t r ifor m 3 5 7 ; F la p t ra n V in S u r g r y o f
U p la nt a ti o n for 78 , e
, .
, s e s,
V r t bral c ol u m n (
e e
66 60 2 6
pin )
e , 1 20, 1
see s
,
e
2
.
,
1 .
U l c r S u b i o did o f b i m ut h for 5 4 5
e s, e s , . V ic al (
es bla dd r) see e .
U ln a in upp r t h i r d F ra ctu r o f 6 e , e ,
2 2 . V ic o v a gin al fi tu la S t a ti tic o f 3 7
es -
s , s s , 2 .
xv iii
VI N KE , H H . .
, E x ci s ion of th e jo in t
h ip - , th e foram n o f 44 e , 2 .
51 . W i r for a n u r i m I nt o ducti o n o f 4 7 63
e e s , r , 1 .
Wo und o f ab d o m n 4 344 468 4 7 5 e , 2 0, , , ,
A GS TAF FE , W W . .
, Re vi w o f
e 5 8 ; f li v r 4 7 8 5 2 8 ; o f i p
2 o e , H al d , s n e, e e
a nt u rg ry 3 7 6
G
’
s s e , . gun h o t 447
s , .
W n in c l p E ti p a ti o n o f 7
e s s a , x r , 22 . Wr i t T u b r c lo u y o vi ti o f t di
s , e u s s n s en no I S .
Wh itlo w M la n o tic 3 5 7 3 6
s, e , , 0 . s h a t h o f h a nd a nd 444
e s , .
Wi n lo w S tra ngu la t d int rn al h r i a int o

s , e e e n
A N N A LS O F S U R G E R Y .
ON N EP H RO LIT H O TO M Y WIT H ,
RE PO RT OF A
CA S E .
BY KE N D A L F R AN K S ,
F . R . C S . .
OF D U B LI N ,
S URG ON
E TO T H E A LAI
DE DE H O S P I TA L .
r e p o r ti n g t h e fo ll o w i n g c a s e a n d i n S h o r t l y d i s c u s s i n g
s o m e o f t h e c h i e f p o i n t s i n c o n n e c ti o n w i t h t h e O p e r a
t i o n I d o s o b e c a u s e t h e h i st o r y o f n e p h r o l i t h o t o m y is O f
,
s u c h r e c e n t d at e t h a t e v e ry c a s e o u ght t o b e p u b lis h e d in
w h i c h t h e o p e ra t i o n i s r e s o r t e d t o a n d a l s o b e c a u s e t h e p r e s
,
en t c a s e i s t h e fi rs t i n I r e l a n d i n w h i c h a s t o n e h a s b e e n e n
c i s e d fr o m t h e k i d n e y i n t h e l i v i n g s u bj e c t T h e t e r m me “
.
h ro l i t h otom y w a s p r o p o s e d b y S c h u r i g i u s as fa r b a c k a s t h e
p
e a r l i e r h a l f o f t h e e i g h t e e n t h c e n tu r y b u t t h e o p e r a t i o n i t s e l f ,
w a s p e r f o r m e d f o r t h e fi r s t t i m e b y M r H e n ry M o r r i s i n 1 8 8 0 .
,
a n d t h e d e t ai l s r e p o r t e d b y h i m t o t h e C l i n i c a l S o ci e t y o f L o n
d o n i n t h e s am e y e a r M r M o r ri s d e fi n e s n e p h r o l i t h o t o m y t o
. .
b e a n i n c i s i o n i n t o t h e s e c r e ti n g s u b s t a n c e o r p e l vi s o f t h e
“
k i d n e y wi t h t h e e x p r e s s p u r p o s e o f r e m o v i n g a c a l c u l u s t h e r e
,
fr o m ; a n d t h a t t o o a t a d a t e i n t h e p r o g r e s s o f t h e d i s e a s e
p ri o r t o t h e d i s o r g a n i z a ti o n o f t h e r e n a l s u b s t a n c e o r t h e ,
”
c o n v e r s i o n o f t h e r e n a l p e l vi s i n t o a l a r g e a b s c e s s c avi t y .
A l t h o u g h o f S O r e c e n t a n o ri g i n t h e o p e ra t i o n h as a l r e a d y ,
b e e n p e r fo r m e d a s u ffi c i e n t n u m b e r o f ti m e s i n E n g l an d i n , ,
A m e ri c a a n d o n t h e c o n t i n e n t t o S h o w t h a t i t i s n o t o n l y a
, ,
j u s t i fi a b l e p r o c ee d i n g b u t o n e fr u i t fu l o f t h e b e s t r e s u l t s
, ,
a n d fr e e fr o m ri s k t o a n e x t e n t h ar d l y t o b e a n t i ci p a t e d .
I t is r e p o r t e d t h a t t h e l a t e M r L aw r e n c e u s e d t o b e g i n o n e
.
o f h is l e c t u r e s t h u s “
T h e k i d n e y g e n t l e m e n i s fo r t u n a t e l y
, ,
”
b e y o n d t h e r e a c h o f t h e s u rg e o n .
1
T h a t d ay i s p a s t a n d t h e k i d n e y h a s c e a s e d t o o c c u p y s u c h
,
1
A s hh urs t
’
s I n t r n a ti o n al E ncyc lo p di
e ae a, Vo l V , . . p . 1 0 90 .
2 KE NDA L F R AN K S .
a d i s tin g ui s h e d p o s i t i o n T h e r e a r e fo u r w e ll r e c o g n i z e d
.
m e th o ds o f O p e r a t iv e i n t e r fe r e n c e w i t h t h e k i d n e y .
o r S i m p l e i n c i s i o n i n t o t h e k i d n e y w h e t h e r fo r ,
d i a g n o s ti c p u rp o s e s fo r t h e O p e ni n g o f a n a b s c e s s o r fo r
, ,
h y d r o n e p h r o s is . N ep /zr o r m p /zy d e s i g n e d f o r t h e p u r ,
p os e O f fi x i n g a m o v ab l e k i d n e y an d
.
N ap /1 72 5 10 770 o r e x ci s i o n o f t h e k i d n e y I d o n o t p u rp o s e .
i n t h e c o m p as s o f t h is p a p e r t o d is c u s s t h e s e v e r a l p r o c e d
u r e s b u t I S h a ll c o n fi n e m y s e l f t o t h a t o n e o n l y w h i c h i s i ll u s
,
t r a t e d b y t h e c a s e w h i c h I n o w d e s ir e t o r e p o r t .
J . H a m a n aet 2 8 by o ccup ati o n a s i l k we av e r was adm itt e d t o

.
, , .
, ,
th e A de l aid e H o s pi ta l in the autu m n o f 1 8 8 5 and fir s t ca m e under ,
m y car e o n th e sth o f Oct o b e r o f th e s a m e y e ar s uffe rin g fr o m lo s s ,
o f fl e s h increa s in g d e bi l ity and pain in th e l e ft s id e H is hi s t o ry was

,
.
a s follo ws : He had a l way s b e e n h e a l thy ti ll five o r s ix y e ar s a go ,
when h i s tr o ub l e s b e g an H e had b e en in th e h abit o f indu l gin g

.
l ar g e l y i n s ti m u l ant s with o cca s i o na l inter m i s si o n s s o m e ti m e s e xt e nd

, ,
in g t o a p e ri o d o f thre e m o nth s H i s drink wa s invariab l y a le

. In .
th e wint e r o f 1 8 7 9—8 0 durin g o ne o f h i s drinkin g b o ut s h e cau ght a

, ,
h e avy c ol d which c o nfined h i m t o be d fo r a fo rtni ght with s hiverin g s , ,
fe v e r and p ain s all o v e r the b o dy At t h e e n d o f th e fo rtni ght s u p

.
pre s s i o n o f urine cam e o n and l a s t e d fo r thr e e day s At th e e n d o f .
thi s ti m e it wa s a gain s e cret e d and wh e n p a s se d w a s b loo dy F o r

,
.
th e fi rs t day the b loo d was p a s se d in c lo t s s ub s equ e nt l y it ca m e m ixed ,
with th e urin e an d did n o t entir e l y di s appear fo r thr e e m o nth s

, D ur .
i n g thi s ti m e m icturi ti o n wa s n o t unu s uall y fre qu e nt n o r wa s t h e act ,
acc o m p anied by p ain Th e r e wa s n o v o m i tin g but th e b o we l s b e

.
,
ca m e c o n s tip at e d and s o m e ti m e s wo u l d n o t act fo r three day s Con .
curr e ntl y with the he m aturi a s e v e re and p ar o x y s m a l pain cam e o n I t

, .
b e g an in th e l eft gr o in and hip and s o m e ti m e s S h o t d o wn int o th e l e ft

,
t e s tic l e W h e n s ufficientl y w e ll t o m o v e ab o ut h e n o tic e d that the

.
,
p ain fr e quent l y shifted fr o m th e te s ticl e t o the cr e s t o f th e i l iu m and

up int o the l e ft s id e n e ar the s pin e T hi s p ain h a s c o ntinu e d m o r e o r
.
l e s s ev e r s inc e b ut s o m e ti m e s i t i s ab s ent fo r a fe w days

, .
T w o and a ha l f y e ar s l at e r he c o ntract e d a g o n o rrh oe a o f wh ich h e ,
h a s n o t b e e n cured The pa s s a g e o f a b o u gi e r e v e a l e d a s tricture

.
s i x inche s fr o m th e m eatu s which j u s t a llo wed a N o 7 E n g l i s h g au g e .
t o pa s s .
F o r s o m e ti m e previ o u s t o h i s ad m i s si o n t o h o s pi ta l he had b e e n
N E P H R O I TH O T OM Y L .
3
g radua ll y g e ttin g we ak e r D urin g th e pr e vi o u s w eek he had b een

.
l yin g up at h o m e unab l e t o e at o r d rink and v o m itin g wh atever he ,
t oo k P revi o u s t o thi s he h ad h ad n o v o m itin g

. The day after c om .
~
i n g int o the Ade l aide H o s pita l he wa s s eiz ed with r e t e nti o n o f urine ,
and a cathe ter had t o b e p a s s e d e very day fo r ab o ut a week At thi s .
ti m e he c o m p l ained o f s y m p t o m s whi ch s u gge s t e d v e s ica l ca l cu l u s ,
and acc o rdin gl y he was s o und e d o n t wo o cca s i o n s b ut n o thin g ab ,
n o r m a l c o u l d b e detected in th e b l add e r .
H i s fam i l y hi s t o ry wa s g oo d .
When fir s t h e c a m e under m y car e he wa s very an ae m ic H i s l ar g e .
dark eye s wi th c l ear b l ui s h c o nj unctiva h i s white lip s and c olo ur l e s s

, , , ,
p a s ty face wa s hi gh l y s u gg e s tive o f phthi s i s H i s l un gs h o wever .

, ,
w e r e s o und and h e had n o c o u gh

, H i s app etite w as fair l y goo d and
.
,
when n o t in p ain he s l ep t we ll , Wh e n e v e r he s t oo d o r wa l ked the

.
p ain in the s ide ca m e o n I t s o m eti m e s s eized h i m in the lo in s o m e

.
,
ti m e s i n the gr o in o r o ver th e i l iac cre s t b ut it n ever s h o t int o the te s

,
t i c le durin g th e wh ol e p eri o d th at h e was under o b s ervati o n H is .
p u l s e wa s 1 0 6 and th e te m perature n o r m al
, .
Th e urin e h e pa s s ed c o ntain ed p u s th e a m o unt o f thi s c o n s tant l y ,
varyin g S o m e ti m e s i t fo r m ed but a thin l ayer at the b o tt o m o f t h e

.
urine gl a ss and a g ain after t we l v e h o ur s s tandin g it wo u l d o ccupy

,
n earl y a third o f the c ol u m n o f fluid T h e s p ecifi c g ravi ty wa s 1 0 1 7

. .
T h e urine wa s a l way s aci d th o u gh s o m e ti m e s e x tre m e l y foetid

, Th e .
m icr o s c o p e revea l ed p u s c e ll s and cry s ta l s o f uri c acid but ther e were ,
n o pyrifo r m ce ll s and n o tub e ca s t s I was fir s t inc l in e d t o loo k up o n

.
the ca s e a s o n e o f tub e rcu l ar pye l iti s as o n acc o unt o f the c o n s tant

,
acidity o f th e urine and th e ab s ence o f a ll ve s ica l sy m p t o m s it was ,
evident th e p u s c o u l d n o t c o m e fr o m the b l add e r ; wh i l s t the cache e

t i c app e aranc e o f the m an w a s s u gge s tive o f tub e rcu l ar di s e a s e At .
m y reque s t Dr Wa ll ace Beatty o n t wo o cca s i o n s carefull y exa m ined

.
,
th e urinary d e p o s it s fo r b aci ll i but n o n e c o u l d b e det e ct e d

, .
He never p a s s ed any ca l cu l i o r grave l .
I kep t h i m under o b s ervati o n ti ll th e 2 7 th o f Oct ob er when h e l e ft ,
h o s pita l b ut attended o cca si o n a ll y a s an o ut patient

,
H e wa s treated -
.
at fir s t with b enz o ate o f s o da which m ateriall y di m ini s he d th e foet o r o f

,
th e ur i ne but did l itt l e g oo d o ther wi s e

,
Thi s was s ub s e quent l y .
ch an g ed fo r s a l icy l ic acid and s a l icy l ate o f s o da with the s a m e re s u l t ,
As trin g ent s o f vari o u s kind s incl udin g pyr o g a ll ic acid s ee m ed t o have

, ,
n o effe ct
» .
H e was r e ad m itted t o h o s pi ta l o n the r o th o f Ap ri l l a s t a s he was

-
,
d e cided ly lo sin g gr o und wa s o bvi o u s l y weaker and the pain s ee m ed

, ,
4 KB ND z: L
to b e g e ttin g wo r s e T h e uri ne had n o t i m pr o v e d and p us c o ntinued

.
,
to b e pa s s ed in l ar g e q uantiti e s I n o w ca m e t o t h e c o ncl u s i o n t h at
.
th e ca s e wa s o n e eith e r o f p uru l ent py e l iti s o f the l eft s id e o r o f r e na l

ca l cu l u s and th at i t wa s a ca s e in which an ex p lo rat o ry O p e rati o n
,
s h o u l d be p e rfo r m e d B e fo r e h o wev e r r e s o rt in g t o t h i s expedi e nt I

.
, , ,
a s k e d m y c oll e a g u e Dr Wall ace B e atty t o e xa m ine th e ca s e and t o

,
.
,
ive m e h i s O pini o n and I a m gl ad o f thi s O pp o rtunity o f a c k n o wl

g ,
e dgin g th e m at e ria l a s s i s tanc e and s up p o rt wh ich h e affo rd e d m e .
An e x a m inati o n o f th e ab d o m en and back rev e a l e d n o thin g a b n or

m al th e r e w a s n o fu l n e s s o r tu m o ur o r anythin g
,
T h e o n l y thin g .
e l icit e d by thi s e x a m inati o n was t e nd e rn e s s b e hind o n pre s s in g o v e r

the l a s t rib and b e lo w th e l a s t rib i m m edi at e l y e x t e rna l t o th e e r e ct o r
,
s pin ae .Th e r e wa s t e nd e rn e s s n o wh e r e e l s e T h e p ain wa s r e fe rr e d .
t o th e s a m e r e gi o n e x t e ndin g o v e r th e lo wer h a l f o f th e l e ft s ide o f

,
th e t h o rax and i n th e l e ft s ide o f the abd o m e n b e lo w th e l eft c o s ta l

,
arch It wa s o cca s i o nall y ab s e nt

. T h e p ain w a s d e s crib e d a s b urn
.
in g o r achin g H e c o u l d l ie wi th gr e ate s t c o m fo rt o n h i s back and

.
,
bett e r o n h i s l e ft s ide th an o n h i s back Lyi n g o n the ri ght s id e in

.
crea s e d th e p ain T h e character O f th e urin e wa s the s am e a s wh en

.
in h o spita l in Oct o ber .
Fr o m th e c h aracter and lo ca l iz ati o n O f th e pain fr o m th e c o nditi o n .
O f the urin e and fr o m ,

th e h i s t o ry o f the o n s e t o f t h e di s ea s e five o r
s ix year s pr e vi o u s l y Dr B e at ty c o n s idere d th at th e we i ght o f e vid e n ce

, .
wa s in fav o ur O f a rena l ca l c ul u s Und e r the s e circu m s tance s and

.
with t h e c o ncurrenc e o f m y c oll ea g u e s I O p erat e d o n th e 6 th day o f ,
M arch l a s t a s follo ws ,
The pati e nt was p l ac e d und e r th e in fl u e nce o f ether l yin g o n h i s ,
ri ght s id e in a s e m i pr o n e po s iti o n -
P i llo ws w e r e p l ac e d b e n e ath the
.
ri ght lo in and abd o m e n in o rd e r t o thr o w th e l e ft lo in we ll o ut and t o

,
s upp o rt th e kidney s o that i t s h o u l d n o t s l ip fo r w ard wh e n r e ached

, .
An inci s i o n w a s th e n m ade p ara ll e l t o th e t we l fth rib three quarter s o f ,

-
an inch b e lo w i t and b e ginnin g o v e r th e e x t e rna l b o rd e r O f th e e rect o r

,
s p i ne m u s cl e Thi s inci s i o n was fi ve inche s lo n g and e x te nd e d fo r

.
ward s t o a p o int a l itt l e s up e ri o r and p o s t e ri o r t o th e ant e ri o r s uperi o r

s pin e o f t h e i l iu m T h e m u s c l e s w e r e divid e d t o th e fu ll l en g th o f
,
the inci s i o n and th e n th e l u m bar ap o n e ur o s i s app e ar e d I t bu l ge d .
o ut int o th e inci s i o n and loo k e d s o l ik e t h e c olo n th at fo r a fe w m o

,
m e nt s I w a s und e cided a s t o i t s natur e By tracin g i t b ack ward s .

,
h o we v e r I fo und that it pa s s e d b e hind th e kidn e y and th e d o ub t

, ,
.
bein g thu s re m o v e d I divid e d i t fr e e l y T h e perir e na l fat at o nc e ca m e.
i nt o v i e w and w a s car e fu lly t o rn thr o u gh by m ean s o f fin g e r s and fo r

,
N E P H R OLI TH O T OM Y .
5
cep s thu s exp o s i n g the kidn ey which loo ked quite heal thy P a s s in g
, .
m y fin g e r b e hind it I br o ke d o wn s o m e adhe s i o n s and wa s th en e u

, ,
ab l ed t o e x p lo re i t s p o s teri o r s ur fac e th o r o u gh l y At i t s inner b o rder .
m y fin ge r i m pin g ed up o n a hard m a s s which at fir s t fe l t l ike the s p ine

, ,
but p a s s in g th e fin ger d o w n ward s i ts lo wer l i m it c o u l d b e fe l t I t .
app e ar e d t o b e ab o ut t wo and a ha l f t o three inche s lo n g An ex .
p lo ri n g ne ed l e was th e n p a s s e d thr o u gh th e s ub s tance o f the kidney ,
and a s i t reached th e in s id e o f the pe l vi s i t g rated a g ain s t a ca l cu l u s .
An inci s i o n a bo ut two in c h e s lo n g wa s m ade o n th e o uter b o rder o f

th e kidney d o wn t o the p e l vi s T h e h ae m o rrh a g e at fir s t was v e ry
.
bri s k b ut a fin g er p a s s ed thr o u g h the w o und s erved a s a p l u g and it

, ,
quick l y b e cam e checked The s t o ne was fri ab l e and chal ky b ut was

.
,
so fir m l y i m b edde d in th e p e l vi s th at i t had t o be cru s hed wi th a fo r
cep s and r e m o v e d pi e c e m e a l A l ar ge pi e c e o c c uyin g th e upper p o r

.
ti o n o f the p e l vi s I s ucc e eded in h oo kin g o ut with the fin ge r but m o s t ,
o f i t wa s re m o ve d wit h th e aid o f a l i th o t o m y s c oo p The ca l ice s .
o f the kidney s e e m ed t o c o ntain pr o ce s s e s fr o m th e s t o ne and I ex ,
p e ri e n c e d gr e at d i fficu l ty in e nuc l e atin g the m Wh e n I wa s s ati s fied

.
that a ll wa s c l e ar I irri g at e d th e w o und in the kidney wi th a weak

s ol uti o n o f c o rr o s ive s ub l i m at e t o wa s h o ut th e d e bri s By thi s ti m e .
th e bl e e di n g fr o m th e s ub s tance o f the kidney had near l y quite cea s ed .
A c c o rdin gl y I p l u gg e d th e w o und l i ght l y with s o m e s a l a l e m b r o th

,
-
g auz e wrun g o ut in weak carb ol ic lo ti o n A draina g e tu b e wa s p l aced

.
-
fr o m the de e p p art s o f the wo und extern a l t o the kidney and br o u ght

o ut at th e externa l an gl e o f the s kin wo und All divided ti s s ue s w ere .
s utured in s ucc e s sive l ayer s with cat g ut T h e wo und wa s dre s s ed

.
with s al a l e m br o th g auz e and a l ar g e thick p ad o f turf m o u l d wa s

-
,
p l aced o ver a ll and the p art s fir m l y b an da ged with a flanne l r oll e r .
D urin g th e wh ol e O p e rati o n which o ccupied j u s t an h o ur the pati e nt s

,
’
,
p u l s e re m aine d re m arkab l y goo d T h e s ub s equ e n t pr o gre s s O f the

.
c a s e wa s m o s t s ati s fact o ry .
T h e exter n a l wo u n d h e al e d by fir s t i n t e nti o n with th e excepti o n O f ,
th e track o f th e draina ge tub e which wa s n o t fin a ll y clo s ed ti ll b etween

-
t h e fo u rth an d fifth we e k . F o r th e fir s t fe w day s the dre s sin g s had t o

b e chan g ed two o r three ti m e s a day o win g t o their rapid l y bec o m in g
s aturat e d with b loo d s tain e d urin e b ut by de r e e s th e dre s sin s b e
g g
-
,
ca m e l e s s fre quent and by the fifth week we r e ab and o n e d a l t o gether

, .
Th e d ay after o p e rati o n I fo u n d h im l yi n g o n h i s ri ght s ide h is fav o r ,
i te p o s iti o n s ince th e O perati o n th o u gh pr e vi o u sl y he c o u l d n o t d o s o

,
o win g t o th e a g gravati o n o f p ain which it induc e d Mr Pi e ] the as . .

,
s i s t a n t t o t h e P r o fe s s o r o f Che m i s try in th e C oll e e o f Sur e o n s very

g g
6 KE ND A L F R AN K S .
kind l y analyz e d th e urin e pa s s e d day by day p e r m a m n a t u r a lem T he

’
e venin
g aft e r o p e rati o n it c o ntain e d a l ar e quantity o f b loo d b ut thi s
g ,
rapid l y di m ini sh e d and c e a s e d t o app e ar o n th e fo urth day On the .
tenth day th e p u s wa s s carc e l y n o ticeab l e in th e urine b ut s inc e th e n ,
i t h as reapp e ar e d th o u gh in m uch l e s s quantity As s oo n as the .
e x t e rn a l w o und h ad h e a l ed h e p a ss ed a n o r m a l quantity O f urin e
dai l y and th e a m o unt O f urea excreted varied fr o m o n e t o t wo and a

,
h a l f p e r c e nt .
T h e patient h a s n o w b e en b ack at h i s wo rk fo r s ev e ra l m o nth s He .
h as b e g un t o fi ll o ut and loo k s h e a l thy th o u gh s ti ll s o m e what ,
an aem ic The o th e r day I m e t h i m runnin g ha s ti l y d o wn s o m e s t e p s

.
very different in appearan ce t o what h e was in May l a s t Th e p ain in .
the s ide h a s c o m p l et e l y di s app e ared A g oo d dea l o f th e s t o ne wa s .
lo s t in the pr o c e s s o f wa sh in g away the d é bri s fr o m the p e l vi s o f the

kidn e y b ut a ll that wa s c oll e cted was carefu ll y wa s h e d and dri e d by
,
Mr P i e l wh o fo und that i t we i gh e d th e n
.
, g rain s I t i s c om .
p o s ed O i carb o nate o f l i m e ph o s phat e o f l i m e and a m m o ni u m m a g

,
n e s i um p h o s phat e .
Th e p e r a t i o n o f n e p h r o l i t h o t o m y h a s a l r e a d y ob t ai n e d a
O
w e ll e s t a b l i s h e d p o s i ti o n i n s u r g e r y
-
T h e s t a t is t i cs h i t h e r t o
.
h av e b e e n e x c e p t i o n a ll y g o o d U p t o t h e b e g i n n i n g o f t h e
.
p r e s e n t y e a r t w e n t y tw o c a s e s w e r e r e c o r d e d b y E n g l i s h a n d
-
A m e ri c a n s u r g e o n s O f t h e s e n o n e d i e d as a d i r e c t r e s u l t o f
.
t h e O p e ra t i o n T W O d i e d s h o r t l y aft e r w a r d s o n e fr o m m o r
.
,
p h i nis m u s
( P e p p e r ) a n d t h e o t h e r fr o m a c a l c u l u s b e c o m i n g
i m p a rt e d i n t h e u re t e r o n th e o p p o s i t e s i d e ( C u ll i n g w o r t h ) .
T h e o t h e r tw e n ty c as e s m a d e g o o d r e c o ve r i e s I n G e r m a n .
l i t e ra t u r e I c a n o n l y fi n d t w o c a s e s r e p o r t e d T h e fi r s t w as .
O p e ra t e d u p o n b y Ba r d e n h e u e r b u t t h e p at i e n t d i e d o f a n u ri a
1
, ,
a n d t h e au t o p s y s h o w e d t h a t a c a l c u l u s w a s i m p ac t e d i n t h e
O p p osi t e u re te r T h e s e c o n d c a s e was O p e r a t e d u p o n b y L a u
.
e n ste in i n J an u a r y l a s t a n d a l a r g e c a l c u l u s r e m o v e d t h e ,
p a t i e n t m a k i n g a m o s t s a ti s fa c t o ry re c o v e r y I t wo u ld th us .
ap p e a r t h at t h e d an
g e r o f n e p h r o l i t h o t o m y c o n s i s t s m ore in
o u r u n c e r t ai n t y as t o t h e p re s e n c e o f c a l c u l u s i n t h e s e c o n d
k i d n e y t h a n t o an y i n h e r e n t ri s k s i n t h e o p e r a t i o n i t s e l f T o .
ob vi at e t h i s M r K n o w s l e y T h o rn t o n o p e ra t e d fo r t h e r e m o v a l
.
1
Ce n tra lb la t t f C h. i ru rgi e, 1 882 , N o . 12 .
N E P H R OLI TH O T OM I .
7
Of r e n a l c a l c u l u s b y c o m b i n e d a b d o m i n a l a n d l u m b ar s e c ti o n s
i n M a rc h 1 8 8 5 w i t h c o m p l e t e s u c c e s s b u t i n t h i s I s c a r c e l y
, , ,
t h i n k h e w i ll fi n d m a n y t o fo ll o w h i s e x a m p l e a s fr o m t h e e x ,
p e r i e n c e a ffo rd e d b y n e p h r e c t o m y t h e a b d o m i
,
n a l O p e r a t i o n is
m u c h m o r e ri s k y t h a n t h e l um b a r a n d t h e a d d i t i o n a l ri s k i n
,
c u rr e d b y o p e ni n g t h e a b d o m e n i n a d d i ti o n t o t h e O p e n i n g i n
t h e l o i n m o r e t h a n c o m p e n s a t e s fo r t h e a d d i t i o n a l k n o w l e d g e
w h i c h m a y o r m a y n o t b e g ai n e d b y s o d o i n g .
T h e g r e a t d i ffi c u l t y h o w e v e r i n n e p h r o l i t h o t o m y w i ll a l
, ,
w a y s c o ns i s t i n t h e d i a g n o s i s We m ay fa i l t o r e c o g n i z e t h e
.
s y m p t o m s a s r e n a l a s i n a c a s e r e p o r t e d e l s e wh e r e w h e r e a
, ,
w o m a n i s s ai d t o h av e h a d b o t h o v a ri e s r e m o v e d b e fo r e h e r
t r o u b l e s w e r e fi n a ll y d i s s i p a t e d b y t h e e x t r a c ti o n o f a s t o n e
fr o m h e r k i d n e y O r w e m a y fe e l p e r fe c t l y c e r t a i n o f t h e e x
.
i s t e n c e o f a r e n a l c a l c u l u s a n d y e t a n e x p l o r a t o ry i n c i s i o n
,
m a y fai l t o r e v e a l i t T h i s h as h a p p e n e d a l r e a d y s e v e r a l
.
t i m e s a n d i n o n e c a s e r e p o rt e d i n t h e T r a n s a c t i o n s o f t h e
,
M e d i c o C h i r u r g i c a l S o c i e t y fo r 1 8 8 5 M r H e n r y M o r ri s h avi n g
-
,
.
,
fai l e d b y m a n i p u l a t i o n a n d b y t h e h e l p o f a n e x p l o ri n g
n e e d l e t o d e t e c t a ny s t o n e e x c i s e d t h e k i d n e y a n d s u b s e
,
q u e n t l y fo u n d a c a l c u l u s h i d d e n a w a y i n o n e o f t h e c a l i c e s .
H e r e c o m m e n d s t h a t i n fu t u r e i n s t e a d o f e x c i s i n g a n o t h e r w i s e
h e a l t h y k i d n e y a fr e e i n c i s i o n s h o u l d b e m a d e i n t o i t o p e n i n g
, ,
u p t h e c a l i c e s o n e a ft e r a n a n o t h e r u n ti l t h e s t o n e i s fo u n d .
T h e c a s e w h i c h I h av e n o w r e p o rt e d i ll u s t r a t e s t h e fa c t t h a t
w e c a n n o t r e l y a l t o g e t h e r o n t h e c l a ss i c a l s y m p t o m s o f s t o n e
i n th e k id n ey . T h e o n l y s y m p t o m s w h i c h a n e x a m i n a ti o n o f
t h e v a ri o u s c a s e s h i th e rt o p u b l i s h e d s h o w s t o b e p r e s e n t i n a ll
t h e s e c a s e s a r e p a i n r a d i a t i n g fr o m t h e p o s i ti o n o f t h e k i d n e y
i n t h e l o i n a n d t e n d e rn e s s o n p r e s s u r e o v e r t h e k i d n e y
,
Th e .
d i a g n o s i s i n e a c h c a s e h a s b e e n h e l p e d o u t b y o t h e r s ym p
t o m s ; i n m i n e fo r i n s t a n c e b y t h e a c i d i t y o f t h e u r i n e a n d t h e
, ,
us i t c o n t a i n e d b u t n o n e o f t h e s e a r e c o n s t a n t e x c e p t th e
p ,
p ai n a n d t h e t e n d e r n e s s o n p r e s s u r e .
TH E T R E A T M E N T O F T H E W O U N D A FTE R C A S
T R AT I O N .
BY W I LL I A M L . A XF O R D M ,
. D .
,
O F C H I C A GO .
N c u t t i n g O p e ra t i o n s o n t h e s c r o t u m s u c h as c a s t ra ti o n o r ,
a b l a t i o n O f t h e l o w e r p o r t i o n fo r v a ri c o c e l e t h e r e i s ,
a lw a y s a n u n p l e a s a nt p o s s i b i l i t y o f a r e c u rr e n t h a m o rrh a g e ,
i n t o t h e c a u s at i o n o f w h i c h t w o i m p o r t a n t fa c t o r s e n t e r : i n t h e
fi r s t p l a c e t h e d ar t o s v e r y v a s c u l a r a n d r e a d i l y c o n t ra c t i n g
,
u n d e r t h e s t i m u l u s o f t h e k ni fe a g ai n r e l a x e s w h e n t h e p a t i e n t
,
b e c o m e s w a r m i n b e d ; s e c o n d l y t h e p o s i t i o n a n d r e l a ti o n s o f
,
t h e s c r o t u m ar e s u c h t h a t t h e r e i s n o s a t i s fa c t o r y w a y o f c o m
p re s s i n g a n d s u p p o rti n g t h e w o u n d b y b an d a g in g .
A ra t h e r u n p l e a s a n t e x p e ri e n c e w i t h a r e c u rr e n t h ae m o r
rh a e a ft e r c a s t ra ti o n h as l e d t o t h e a d o p t i o n o f a m e th o d of
g
w o u n d t r e a t m e n t fo r w h i c h i s c l ai m e d s e c u ri t y fr o m a ft e r
,
h ae m o rr h a g e a n d a n i n c r e a s e d p r o b a b i l i t y o f p ri m a ry u n i o n .
I n a s m u c h a s t h e c a s e i s o n e o f c o n s id e ra b l e i n t e r e s t a b ri e f
r e p o r t m ay b e a c c e p t a b l e .
R . P c olo red ae t 2 6 Had b o th t e s tic l e s brui s e d in J u ly 1 8 8 2

.
, , . .
, .
P ain cau s ed in s en sibi l ity S we ll in g s ub sid e d in a fe w days and h e

.
,
a g ain r e s u m e d h i s wo rk as a c o a l h e av e n Ab o ut s ix m o nth s after he

-
.
n o tic e d that th e l e ft te stic l e was en l ar ge d and hard e ned Tri e d a ll .
s o rt s O f m e dica l tr e a t m e nt C a m e und e r m y car e at t he S o uth Side

.
Di s p e n s ary in J anuary 1 8 8 4 N O hi s t o ry o f s y p h i l i s T e s tic l e e m

, . .
larg e d and hard . S o m e fl uid in th e tu n ica va gina l i s c o rd m uch h y ,
p e rtro p h i e d but n o t r o u g h e n e d o r indurated E pididy m i s fr e e fr o m

.
di s ea s e T h e o t h e r t e s tic l e was appar e ntl y n o rm al I b e l i e v e d th e

. .
te s ticl e t o be th e s e at o f m a l i g nant di s e a s e a n d advi s e d c a s tra t i o n O p .
e ra ti o n was p e rfo r m e d in t h e u s ua l m ann e r s kin appr o xi m at e d with s i l k

,
s utur e a d rai n a g e t u b e p l ac e d in th e w o und and an anti s e ptic dr e

'
, , s s in g
app l ied I had l i g ated th e c o rd wit h s i l k e n m a s s e

. A s e v e r e recur
, .
(8 )
TR E A TM E N T OF W O UN D A F TE R CA S TR A YYOJV .
9
rent h ae m o rrha g e o ccurr e d wi t hin an h o ur and r e quir e d s typtic s t o c o n

tr ol E v e n t h e n i t wa s s t o pped wi th difficu l ty C o nva l e s cenc e th o u gh
. .
,
m uch r e tard e d by t h e accid e nt wa s uninterrup ted ,

The t e s tic l e was .
the s eat o f a gr o wth b e ginnin g at the ce ntre and inv ol vin g n e ar l y the
entire gl and Micr o s c o pi ca l e xam inati o n pr o ved it a s arc o m a
. .
In Oct o ber 1 8 8 6 h e a g ain pr e s ented hi m s e l f wi th e x actl y th e s am e

, ,
c o nditi o n O f affair s in the ri ght te s tic l e and a s ked m e t o O p e rate s ay

, ,
i n g that he had had n o c o m fo rt fo r a ye ar T h e te s tic l e had c a m.
m e n c e d t o e n l ar g e t wo m o nth s aft e r th e fir s t O p e rati o n Th e re wa s .
n o return O f di s e a s e in the l e ft gr o in Se e in g n o o t h er way O f re li e v

.
in g m y pati e nt o n O ct o b er 1 8 I a g ain O p e rated in a s m a ll r oo m and

, ,
under th e wo r s t hy gienic s urr o undin g s i m a ginab l e Aft e r sh avin g and .
s crubbin g th e fi e l d o f O p e rati o n the u s ua l inci s i o n wa s m ad e t h e t e s ,
ti ol e rapid l y e nucl eated and the c o rd tran s fixed and ti ed in ha l ve s

,
with fi n e carb ol iz ed cat g ut After the t e s ticl e wa s cut a way o ne o r t wo

.
b l e edin g p o int s were s ecured with th e cat g ut and a ll oo zin g c o ntr oll ed
by h o t wat e r Be ginnin g at th e lo we r end O f th e wo und with a s m a ll
.
,
g lo ver ’
s n eed l e ar m ed with N o 9 ir o n dye d s i l k at int e rva l s o f thr e e
.
-
,
fo urth s O f an inch s utur e s were pa s s ed at ri ght an gl e s t o th e l in e o f

,
inci si o n s o a s t o traver s e th e ti s s u e s underl yi ng th e wo un d s urface

an d extend c o m p l e te l y ar o und and b eneath thi s s urface m uch th e ,
s a m e a s in l acerat i o n o f the p e rineu m The s uture s we re vi sib l e o n l y

.
at the p o int s O f e n tranc e and exit Th e wo und wa s c lo s e d in thi s m an

.
n er up t o where the c o rd l i e s by the s ide o f the p eni s wher e i t wa s

fo und i m practicab l e A fe w int e rrup ted s uture s fr o m thi s p o int up
.
ward s and a fe w s up erfici a l s utur e s b et we e n the lo n g s utur e s c o m

p le t e ly c lo s e d th e w o und At the s id e O f th e p e ni s a s m a ll draina g e
.
tub e wa s intr o duced ; g auz e c o tt o n and a t rian gl e b an d a ge c o m p l et e d

, ,
th e o perati o n At the e n d o f t we nty fo ur h o ur s t h e draina ge tub e wa s

.
-
r e m o ved and a fre s h dre s sin g app l ied At th e e n d o f s ix day s i t wa s

.
fo und that pri m ary uni o n had o ccurred a lo n g th e entir e wo und e xc e pt

at a p o int wh e re t wo s utur e s that had b e e n t oo t i ght l y ti e d had cut
int o th e w o und cau sin g a s m a ll a m o unt o f s upp ura t i o n Th ere w a s
, .
a l s o s o m e p u s a lo n g th e trac k o f th e d e e p s uture s T h e p ati e nt c o n .

,
trary t o m y wi s he s had s pent a c o n s id e rab l e p o rti o n o f h i s ti m e o ut o f

,
b ed All s utur e s were r e m o v e d and a re s t O f a we e k enj o in e d th o u gh

.
,
practi ca ll y the m an wa s we ll I n a g ain o p e ratin g I s h o u l d u se a s e ptic

.
s uture s and h a d p e rhap s b etter s tat e th at in an o p e rati o n in th e inter

,
va l b etwe e n th e s e t wo I e m p lo yed s i iv e r wir e after thi s m e th o d b ut d o ,
n o t l ik e i t a s it cut s m o re t h an s i l k and cau s ed gr e at p ain o n re m o va l

, .
Th e t e s ticl e pr e s e n t e d m uch t he s am e app e aranc e a s did the fir s t th e ,
m icr o s c o p e a g a i n pr o vin
g it a s arc o m a .
10 WI LLI A M L . A X F OR D .
F r o m a p a t h o l o g i c a l s ta n d p o i n t t h e c a s e i s o f m u c h i n t e r e s t
'
s h o w in g t h e r e l a t i o n b e t w e e n t ra u m a t i s m a n d n e o p l as m a n d
,
m a y b e c i t e d i n s u p p o r t o f t h e t h e o r y t h a t s i n g l e i nj u ri e s a re
m u c h m o r e l i a b l e t o p r o d u c e s a r c o m a w h i l e c o n t i n u e d i rrit a
,
t i o n u s u a ll y r e s u l t s i n c a r ci n o m a . E x a c t l y w hy t h e d i s e a s e
d e v e lo p e d so m u ch lat e r i n o n e g lan d th an i n th e o t h e r is
p r ob l e m a ti c a l .P o s s i b l y t h e d i s e as e h a d s t a r t e d i n t h e s e c o n d
t e s ti c l e t h o u g h a t t h e t i m e o f t h e fi r s t o p e ra t i o n i t c o u l d n o t b e
,
d e t e c t e d t h e i r ri t a ti o n o f t h e s t yp ti c s e rv i n g t o i n c i t e i t t o
,
new a c tiv i t y .
I n c o n c l u s i o n : t o O b t ai n p ri m a r y u n i o n a n d a v o i d r e c u r r e n t
h ae m o r rh a g e a ft e r t h e o p e ra ti o n o f c a s t r a ti o n .
I O b s e rv e s t ri c t s u r g i c a l c l e a n l i n e s s
. .
I I L i g at e t h e c o rd w i t h c at g u t
. .
I I I Pu t i n a s e p t i c s u t u r e s a s a b o v e d e s c ri b e d b e c a u s e
.
,
a. I n t h e l o w e r a n d d an g e r o u s p o r t i o n o f t h e w o u n d a ll
o o z i n g w i ll b e c o n t r o ll e d a n d d r a i n a g e w i ll b e n e c e s s a r y .
é T h e w o u n d s u r fa c e s w i ll b e a p p r o x i m a t e d a n d s u p p o r t e d
.
,
p ri m a ry u ni o n fa v o r e d a n d r e c u r r e n t h m m o rr h a g e a v o i d e d
I V D ra i n a g e o n t h e s i d e o f t h e p e n i s a l o n e i s n e c e s s a r y
. .
C A S E O F W O U N D O F LA R G E I R R E G U LA R V EI N
T R U N K I N G R O I N D U R I N G A B LAT I O N
O F G LAN D U LA R T U M O R W IT H ,
C O N S E C U TI V E G R E A T CE D E
M A A ND D I S A B I LI T Y
O F LI M B .
G K L O TZ M D
‘
BY H E R M A N
‘
. . .
, ,
OF NE W YO R K .
S U R G O N TO TH E
E GE R M AN H P IT A L OS AN D D S E I P NSA R Y .
H E fo ll o w i n g c a s e t h e o n e b ri e fl y r e fe r r e d t o b y D r L
is . .
S P i l c h e r i n h i s fm e m o i r o n P r o p h y l a c t i c A r t e ri a l L i
.
,
A N N A L S O F S U R GE R Y F e b ru a r y
g a t i o n
, ( 1 8 8 6 p,
1 1 4 ) as cas e , ,
.
I I I i t h av i n g b e e n c o m m u n i c a t e d t o h i m b y D r W B r o w n
,
. .
ing . T h e fu ll d e s c ri p ti o n o f t h e c a s e a s s u bj o i n e d w i ll s h o w , ,
i t t o h a v e p o s s e s s e d s p e c i a l fe a t u r e s o f i n t e r e s t t h a t m a k e i t
w o r th y o f r e c o rd i n a d d i ti o n t o t h e l i g a t i o n o f t h e i n t e r n a l
,
s a p h e n o u s v e i n w h i c h a s w i ll a p p e a r
, ,
was n o t t h e m o s t im ,
p o r t a n t O f t h e t ru n k s l i g a t e d T h e c as e i s a s fo ll o ws
.
S cfi oezzem a n n ,Wm ; b o rn in G er m any l ith o grapher by

. ae t . 29 , ,
trade and s u fferin g fr o m g o n o rrh oea app l i e d fo r tr e at m e nt at the G er

,
m an Di s p e n s ary o f N e w Y o rk February 1 8 8 1
, , , .
H e pr e s e nte d hi m s e l f a g ain M arch 2 3 1 8 8 1 with an indurated , ,
chancr e o n th e inner s urfac e O f the prepuc e and by J une 1 8 di s tin ct , ,
s e c o ndary l e s i o n s O f s yphi l i s had deve lo ped ; an g ina r o s e ol a sto am , ,
titi s J u l y 6 an gin a s ti ll n o ticeab l e ; c o n siderab l e e n l ar g e m en t o f

.
,
l ym phatic gl a n d s in th e gr o in o n bo th s ide s and a cn e ifo r m e rupti o n O f

th e fac e . A u g u s t 9 in g uina l gl and s m uch l ar ge r ; ge nera l erupti o n o f
,
s m a ll pu s tu l ar s yphi l ide .
A u g u s t 1 0 the pati e nt wa s ad m i tted t o th e G er m an H o s pita l with a

,
p ap ulo pu s tu l ar s yphi l ide g enera l ind ol ent l y m phadeni ti s an acute

-
, , ,
p ainfu l s we ll in g o f t h e l y m pha t ic gl and s in th e ri ght gr o in After a .
vi g o r o u s c o ur s e O f anti s yphi l iti c tr e at m ent a ll direct sy m pt o m s o f

-
syphi l i s had di s appe ared by Sept e m b er 2 0 ; the b ub o e s o n b o th s ide s ,
(1 1 )
12 HE R M AN G [ ( . L O TZ .
h o wev e r had n o t b e e n fav o rab l y influenced b ut had incre a s e d i n siz e

, ,
with a tendency t o acut e s uppurati o n ; i t wa s therefo r e decided t o r e , ,
m o ve th e affe ct e d g l and s by O p e rati o n .
S e pt e m ber 2 2 th e gl and s o f th e ri ght side we re fir s t re m o ved in the

,
u s ua l m anner and with o ut any difficu l ty On th e l eft s ide the tu m e fi e d .
g l and s fo r m e d a s we ll in g fu ll y as l ar g e a s a hen s e g
’
g appr o achin g t h e ,
s p e r m atic c o rd v e ry c lo s e l y at th e upp e r and inner a s p ect o f the

wo und . T h e g l and s we re fir m l y adherent t o t h e s urr o undin g part s s o ,
that they c o u l d n o t b e s eparated e a s i l y with th e fin g er o r a b l unt i n

s tru m e nt ri ght b e lo w th e sp e r m atic c o rd the adh e s i o n s wer e fo und t o
b e particu l ar l y fi rm s o that it b e ca m e n e c e s s ary t o d e tach the glan d u
,
l ar m a s s by m e an s O f tracti o n and s h o rt c l ip s with a pair O f curved

s ci s s o r s durin g which m anipu l ati o n the pre se nce o f a l ar ge b loo d v e s
,
-
s e l w as di s c o ver e d in c lo s e pr o xi m ity t o the t hicken e d cap s u l e o f th e
UL A LA G S U P FI C I A L I N U I NA L V I N
F IG . 1 . IR REG R R E ER G E .
a Larg v in for m d b y —b I nt r n al a p h n o u v in ; I rr gu lar

. e e e z , e s e s e 5 . e m u cu lar
s
branch fro m o ut id o f t h igh a nd ; ci r cu m fl x i l i a c v in

s e ,
’
a e e .
P la c o f r uptu r f v in
e e O e .
D o tt d l in i d i te xt nt o f t m or
e n ca ln o e e u .
Li g a tur f
s.
gl and . Whi l e att e m ptin g t o g e t c l e ar o f thi s ve s s e l and pr o bab l y in ,
c o n s e qu e nc e o f undu e tracti o n o r m anipu l ati o n with th e clo s e d and

b l unt s ci s s o r s th e c o at O f th e b loo d v e s s e l g ave way and t h r o u gh a
,
-
ren t ab o ut 3 m i ll i m e tr e s wid e an i m m e n s e quantity o f v e n o u s b loo d

g u s h e d fo rt h and de l u g e d the fi e l d o f O p e rati o n A n atte m p t t o ch e ck .
th e fl o w O f b loo d by m e an s o f an art e ry fo rc e p s fai l e d o win g t o t h e de -

,
g e n e rat e d c o nditi o n O f th e wa ll s O f t h e b loo d v e s s e l Dire ct pr e s s ure -

.
by m ean s o f s p o n g e s was th e n app l i e d and fin all y a l arg e rubb e r ,

W O UN D OF TH E I R R E G U L AR I N G UI N A L VE I IV .
1 3
tub e adj u s ted ar o und t he t h i gh ab o ut t wo inch e s b e lo w Po up art s li g ’
a m ent s t o pp e d ci rcu l ati o n and h ae m o rrha g e e ffe ctua ll y N ow the re .
m ainin g attach m ent s o f t h e gl andu l ar m a s s were quick l y s e vere d and
the arran ge m ent o f th e v e in s was r e c o gniz e d t o b e a s indicated in the

acc o m panyin g dia gram T h e in g uina l v e s s e l pr o ve d t o be a l ar g e
.
vein fo r m e d by th e j uncti o n o f th e int e rna l s aphen o u s vein and an ir

r e g u l ar vein O f l arg e s iz e Th e fo r m er i n s t ead o f piercin g the fe m o ra l
, ,
fa s cia and d e s cendin g int o the fe m o ra l vein c o ntinue d a s uperficia l ,
c o ur s e whi l e the l att e r e m er g ed fr o m b et we e n the fa s cia l l ayer s di

,
r e c tly O ver th e fe m o ra l artery the p u l s ati o n o f which c o u l d b e p l ain l y

,
s e en and fe l t Fr o m th e p o s teri o r a s p ect o f the c o m m o n trunk

.
an o ther vein o f m e diu m s iz e c o u l d b e tr aced which wa s pr ob abl y th e ,
circu m flex i l iac vein The c o m m o n trunk c o ver e d o n l y by th e lym

.
,
phatic gl and s and th e s up e rficia l fa s cia t oo k an up ward c o ur s e and wa s ,
lo s t t o vi e w b en eath the s per m atic c o rd I t wa s th o u ght b e s t t o ap

.
p l y l i g ature s n o t o n l y t o th e trunk it s e l f b ut a l s o t o th e branche s n ear

their o ri gin ( as indicate d in th e dia gram by the l ine s acr o s s the ve s s e l s)
and after re m o va l o f th e rubb er tub e th e arre s t o f h ae m o rrha g e was
fo und p erfect The wo und was n ow dre s s ed with anti s ep tic p r e c au
.
ti o n the extre m ity s h o win g a s l i gh t l y b l ui s h c olo r b ut n o perceptib l e

, ,
lo werin g O f te m peratur e and t o av o id any di s turb ance o f the wo und

,
the p ati e nt was kept in th e O p e ratin g r oo m fo r s e vera l day s .
The fir s t chan g e t oo k p l ac e S e pt e m b er 2 6 o n acc o unt o f a s l i ght ri s e

o f te m perature and s l i gh t oe d e m a O f the l i m b T h e wo und s were .
fo und t o b e in g oo d c o nditi o n ; n o h ae m o rrha g e n o di s c olo rati o n The , .
oede m a w a s l e ss by S e p te m b er 2 8 and had e ntir e l y di s appe ar e d by
Oct o b er 1 6 when the wo und s o n b o th s id e s were fo und t o b e hea l in g

,
nice l y . Oct o ber 2 1 o win g t o inver s i o n o f the e d ge s o f th e s kin cica

, ,
t ri z a t i o n was s o m e what r e tard e d o ther wi se th e wo und s s h o we d a

,
he al thy appearanc e th e s a m e wa s o b s e rv e d Oct o b e r 2 9 On N o v e m .
b er 4 the wo und s we re hea l e d s o far th at th e y re quir e d b ut a s trip o f

adhe s ive p l a s ter a s a p r o te c ti o n Ab o ut thi s ti m e a m ark e d p o lyury
.
wa s ob s erved i n th e pati e nt wi th o u t i n c re a s e o f thir s t o r t h e pre s e nce

'
o f s u g ar in th e urine Thi s s y m pt o m had di s app e ar e d by N o ve m b e r

.
1 1
,
when t h e patien t wa s allo wed t o l e ave the b ed S oo n aft e r h ow .
,
e ver oede m a O f the wh ol e extr e m ity d e ve lo p ed di s tendin g th e l i m b up

, ,
t o th e hip whenever th e p atient r e m ain e d in the upri ght p o siti o n any

,
l en gth o f ti m e D urin g the n i gh t the s we ll in g w o u l d d e cr e a s e c on s id

.
e ra b ly ; m a s s a g e and th e rubb e r b anda g e had n o per m anen t g oo d
e ffe ct : At the expirati o n O f ab o ut s ix m o nth s the tend e ncy t o oed e m a

was s ti ll s o g reat that the patient wa s unfit fo r any r e g u l ar wo rk and ,
I4 H E R M AN G K
. L O TZ .
he th o u g h t h e wo u l d b e better O ff with o ut th e l i m b I had o cca s i o n .
t o s e e the p ati e n t o nce in that c o nditi o n b ut h ave n o t m e t h im since

, .
I di s tinct l y re m e m b er h o we v e r that aft e r s e veral m o nth s I was i n

, ,
fo r m ed by on e O f the r e sid e nt phy s ician s o f th e h o s pita l th at Sch had .
been e m p lo y e d ther e a s an a s s i s tant p o rter and that h e had b een ,
a b l e t o us e h i s le g fair l y we ll Thi s was c o n fi r m ed o n rec e nt inqui ry

.
by th e s uperintendent O f the h o s pita l and s e veral o ther partie s e m

p lo yed there As Sch h o wever was at n o ti m e up o n the l i s t o f re g
. .
, ,
ular e m p lo ye s o f the h o s pita l I wa s n o t ab l e t o a s certain the exact

,
ti m e when it happ ened .
I t b e c o m e s e v i d e n t fr o m a glanc e
t h e d i ag r am t h a t i n t h e
at
c a s e p r e s e n t e d w e h av e a n i r r e g u l a r d i s t ri b u ti o n o f t h e v e i n s
o f th e i ng u i n a l r e g i o n a n d w h i l e t h e r e is n o q u e s t i o n as t o
,
t h e i d e n t i t y o f t h e v e n a s a p h en a m a g n a i t m u s t r e m ai n u n c e r
,
t a i n w h e t h e r t h e s e v e r e d v e s s e l e m e r g i n g fr o m t h e d e p t h w a s ,
t h e fe m o r a l v e i n o r o n l y a n i rr e g u l a r b r a n c h o f i t a l t h o u g h I ,
a m i n c l i n e d t o t h i n k t h a t t h e l a t t e r vi e w i s t h e m o s t p l au s i b l e ,
a n d t h a t a fe m o ra l v e i n o f r e d u c e d s i z e a c c o m p a n i e d t h e fe m
o r a l a r t e ry i n its n o r m a l s i t u a t i o n A s t h e c a s e s t a n d s e s
.
,
e c i a lly i f w e t a k e i n t o c o n s i d e ra ti o n t h e e ffe c t o n t h e c i r c u l a
p
t i o n o f t h e l o w e r e x t r e m i t y i t h as t o b e ra n g e d b e t w e e n l i g a
,
t i o n o f t h e i n t e rn a l s ap h e n o u s a n d l i g a t i o n o f t h e fe m o ra l v e i n .
W h i l e t h e oe d e m a t h a t w as O b s e r v e d d u rin g t h e fi r s t w e e k
,
w as u n d o u b t e d l y d u e d i r e c t l y a n d s o l e l y t o t h e o c c l u s i o n o f
th e v e i n ,
I b e l i e v e t h a t l a t e r o n c i c a t ric i a l c o n t ra c ti o n a n d
p r e s s u r e u p o n t h e n e w l y e s t a b l i s h e d c i r c u l at i o n h a d t h e i r
s h a r e i n c au s i n g t h e m o r e p e r m a n e n t a n d s e v e r e s w e ll i n g I .
h a v e O b s e rv e d m o r e o r l e s s e x t e n d e d oe d e m a o f t h e l i m b a ft e r
e x t i r p at i o n o f t u m e fi e d l y m p h a t i c g l a n d s a n d i n c a s e s i n w h i c h
n o l ar g e r b l o o d v e s s e l s h a d b e e n i nj u r e d t h e oe d e m a a p p e a ri n g
-
,
a ft e r c i c at ri z a t i o n
.
T W O C A S E S O F O P E R A TI O N F O R R A D I C AL C U R E
O F H E R N I A W IT H U N U S U A L FE A T U R E S ,
.
CA S E O F C I R R H O S I S O F P E
NIS REMARKS . .
1
BY GE O R GE A . P ETE R S ,
M . D .
,
OF NE w Y O R K ,
S URG ONE TO TH E N EW YO R K , ST . M A R YS ’
A ND ST . LU K E S H O S P ITA L S
’
.
I C H AE L M G O WA N Ire l and was ad m itted int o St Luke s

’ ’
.
, ,
h o spita l May 4 1 8 8 5 with d o ub l e in g uina l hernia that up o n

, , , ,
the l eft s ide b ein g m uch th e l ar g e r O f the two T we l ve year s ago .

,
”
whi l e l iftin g a chi l d at ar m s l e n gt h h e fe l t s o m e thin g ive
’ “
g w a y , .
Th e r e wa s b ut l itt l e p ain a l th o u gh a s m a ll l u m p wa s o b s e rved in the

,
l e ft gr o in A phy s i cian wh o m he c o n s u l ted pr o n o unce d it t o b e her

.
ni a and dir e cted h i m t o we ar a tru s s which h e did fo r ab o ut t wo

, ,
year s after which ti m e a s he exp e ri e nc e d n o p ain o r inc o nvenience

, ,
and th e tu m o r was very s m all he di s c o ntinu e d i t s u s e Thr e e year s

, .
a g o whi l e l iftin g a he avy wei ght the tu m o r i m m ediat e l y b eca m e m uch

, ,
l ar ge r and wa s attend e d wi th sh arp p ain in the l u m b ar r e gi o n fo r

, ,
which h e re m ained in b e d fo r a w eek o r t wo s ince thi s ti m e h e h as
n ever b e e n a bl e t o h ol d up th e h e rnia l s we llin g wi th any tru s s which h e

c o u l d pr o cur e .
E i ght y e ar s a go he ca m e vi ol ent l y in c o ntact with a s harp c o rner ,
and a s m a ll b ub o n o ce l e app ear e d in the ri ght gr o in Thi s g av e h i m .
n o tr o ub l e unti l he l ifted th e heavy wei ght three y e ar s a go after which ,
ti m e b o th h i s herni ae b eca m e l ar g er and pain fu l F o r the year o r t wo .
p a s t h e h a s gr o wn very fle s hy Su m m in g up thi s i s h i s c o nditi o n o n

.
,
ad m i s s i o n t o h o spita l viz : On th e l e ft s ide i s a l arg e indirect in g uina l

, ,
hernia ea s i l y reduced excep t a s m a ll k nuck l e o f inte s tine app ar e nt l y

,
adher e nt t o the s a c The pi ll ar s o f th e rin g are readi l y defined and

.
very m uch s pr e ad ea si l y ad m i ttin g fo ur fin g er s On c o u ghin g o r

, .
s trainin g a l ar ge m a s s o f inte s tine c o m e s d o wn

, m e a s urin g three t o ,
s i x inche s .
1
Re a d b fo e re th e N ew Y ork S u r gic al S o ci ty e ,
N o v mb r 6
e e , 1 88 6 .
( I S)
I6 GE OR GE A . P E TE R S .
The i ng uina l rin g up o n th e ri gh t s i d e e a si ly ad m it s t wo fin ge r s and ,
th e e d g e s are s harp l y d e fin e d On c o u ghin g o n l y a s m all b ub o n o c e l e

.
,
c o m e s d o wn .
Fam i l y hi s t o ry an d g en era l c o nditi o n g oo d exc e pt that he had b een ,
drinkin g fre e l y O f s p i rit s fo r s o m e ti m e .
A s he s uffered s o m uch fr o m the s iz e O f th e tu m o r and the fact that ,
he c o u l d n o t we ar a tru s s I d e t e rm ined aft e r c o n s u ltati o n with m y

, ,
c oll e a gue s t o p e rfo r m Ban k s s O p e rati o n fo r the radica l c ure o f the her
,
’
nia in th e l eft gr o in .
On May 7 th the patient w a s p ut up o n the tab l e fo r o perati o n and ,
with m uch d e l ay br o u gh t under the influ e nce o f ether D urin g a l m o s t .
th e e ntir e ti m e o f the in h a l ati o n h e v o m it e d c o u gh e d and s tru g g l e d , , ,
so that it m ad e the o p e rati o n o ne O f g r e at difficu l ty

“
A fre e in ci s i o n was m ad e thr o u gh th e s kin c o m m encin g j u s t ab o ve ,
th e l ev e l O f t h e e x t e rna l abd o m ina l ri n g and th e di s s ecti o n carr i ed ,
car e fu ll y d o wn l ayer by l ay e r unti l th e s a c was exp o s e d and the pi ll ar s

, ,
O f th e r i n g w er e br o u gh t di s tinct l y int o vie w The rin g wa s v e ry l ar g e .
and patu lo u s ea si l y ad m ittin g fo ur fin g e r s Th e h e rnia was n o w r e

,
.
d u c e d by g e n tl e taxi s l eavin g th e c oll ap s e d s a c in the wo und

, The .
c o rd wa s fo und behind and we ll o ut O f th e way The s a c was n ow .
O p en e d and a knuck l e o f g u t w a s fo und c lo s e l y adh e r e n t t o i t s w a ll
j u s t at a l ev e l with the rin g I t was n o t d e e m e d prudent t o att e m p t

.
i t s s e parati o n and it wa s l e ft a s fo und

, The o penin g in t h e s ac was .
n o w carefu ll y and with m uch diffi cu l ty s titched t o the pi ll ar s thr o u gh
and thr o u gh with s t o u t cat g ut and th e rin g c lo s e d , .
O win g t o th e r e s t l e s s n e s s O f th e pati e nt under e ther and fre qu e n t

attack s o f v o m itin g th e b o we l s we r e fo rced d o wn in a l ar ge m a s s and
,
s pr e ad o ut u p o n the o ut s id e O f the b e ll y .
T h e pr o trudi n g b o we l was car e fu ll y g uard e d with t o we l s and s p o n g e s

we t with h o t w at e r Thi s s ta ge o f th e O p e rati o n was exce e din gl y diffi
.
cu l t an d pr olo n g e d I t wa s h o we v e r fina ll y acc o m p l i sh e d A great

.
, .
p o rti o n o f th e s ac wa s n ow di s s ected o ut two b o ne draina g e tube s ,

-
w e r e intr o duced and the wo und wa s c lo s e d with carb ol iz e d cat g ut and

,
an an ti s e ptic dre s sin g p l ac e d o ver a ll D urin g the e s cap e o f the b o we l.
t h e pu l s e s ank v e ry lo w and h e s uffe r e d v e ry m uch fr o m s h o c k b u t wa s

, ,
fina ll y r e s t o red by brandy e ther and di gita l i s hyp o d e r m ica ll y a d m i ni s

, ,
t e re d .
Th e p ati e nt s uffe re d v e ry m uch fr o m na u s ea pain and ty m panite s , ,
fo r a fe w day s aft e r th e O perati o n ; b ut the s e s y m pt o m s gradua ll y s ub

.
s ided . The wo und did n o t hea l thr o u gh o ut i ts wh ol e e x t e nt by firs t

int e nti o n b ut re m aine d O p e n at the t wo an gl e s gradua ll y fi ll in g up
, ,
with granu l ati o n s unti l J un e 1 7 1 8 8 5 wh e n h e wa s d i s c h are d cur e d

, ,
.
OP E R A TI ON F O R R A D I CA L C UR E OF H E R N I A .
1 7
A l ice S urm i n s k i
.
, Ir e l an d
arri e d w a s ad m itt e d int o St
, ae t .
50 , m , .
’
Luk e s H o s p i t al Ja n u ary 2 2 1 8 8 6 , Six year s a go after l iftin g a heavy
, .
,
w e i gh t s h e n o tic e d a s m a ll l u m p in t h e ri ght g r o in
, Findin g th at it .
di d n o t di s app e ar aft er a fe w day s s h e e nt e r e d R oo s eve l t H o s pital , ,
wh e r e sh e wa s treat e d fo r a s h o rt t i m e b ut n o O p e rati o n was d o n e ,

.
E v e r s ince that ti m e s h e h a s fe l t a w e akn e s s in th e ri ght gr o in and ,
o n ex e rti o n a tu m o r w o u l d a pp e ar which c o u l d b e r e duced She h as , .
nev e r wo rn a tru s s .
T e n d ay s a g o aft e r a s e v e re s train th e tu m o r app ear e d wa s p ainfu l

, , , ,
and incre a s e d i n s ize The b o we l s we r e c o n s tip ated and s h e s uffe r e d

.
,
s o m e what fr o m n au se a On ad m i s s i o n e xam inati o n r e v e al e d a tu m o r

.
,
i n t h e ri ght g r o in b e lo w t h e inn e r third O f Po upar t s l i g a m e nt glo b u l ar ’

,
in s hape ab o ut o n e inch in dia m e t e r e l a s tic t o the fe e l sl i gh tl y p ain

, , ,
~
ful o n pr e s s ur e and du ll o n p ercu s s i o n

, .
A p o rti o n r e s e m b l in g a p e dic l e e x t e nd e d d o wn t o w ard t h e fe m o ral

cana l B e fo re ad m i s si o n at t e m pt s had b e en m ad e t o r e duc e it by
.
taxi s but with o u t s ucce s s

, T h e at t e m p t w a s re n e w e d aft e r ad m i s s i o n
.
with n o re s u l t e xcept t o o cca s i o n lo ca l in fla m m at i o n and c o n s iderab l e

,
p ain S h e w a s o rd e red s trict d e cubi tu s and the c ol d c o i l was app l i e d

. .
The tu m o r w a s c o n sider e d t o b e an i ncarcerat e d fe m o ra l hernia ;

c o nt e nt s chi e fly o m e n tu m and after c o n s u lt ati o n I d e t e r m in e d t o p e r
,
fo r m Ba n k s s O perati o n h o pin g t o m ak e a radica l cur e

’
,
.
On F e bruary 5 1 8 8 6 s h e was put o n t h e tab l e e th e r was a d m in i s

, , ,
t e r e d and sh e wa s quick l y br o u g h t und e r i t s influenc e

, The i n t e gu .
m e nt o f the r o in and n i hb o rh oo d w haved s crubbed and re n

g e g a s s '
d ered a s e p tic An inci s i o n ab o ut t w o inch e s lo n g wa s m ad e o v e r the

.
c o nv e xity O f th e tu m o r and t h e di s s e cti o n wa s car e fu ll y m ade d o w n t o

w ard th e s a c T h e c o nn e cti v e ti s s u e s in thi s n e i ghb o rh oo d w e r e m at te d
.
t o g eth e r thicken e d and e x ten s iv e l y ad h e r e nt t o the s a c it s e l f The s e

, , .
adhe s i o n s w ere carefu ll y di s s e ct e d a w ay and t h e s ac wa s O p e n e d a llo w ,
in g th e e s cap e O f s o m e ye llo wi s h fl uid When br o u ght int o vi e w the .

,
c o n t e nt s o f th e h e rnia l s ac were fo u n d t o b e a s h eet O f o m entu m e n

v e lo i n
p g ab o ut three inch e s o f t h e v e r m ifo r m app e n di x the di s ta l p o r ,
ti o n o f which w a s d o ub l e d up on it s e l f allo win g th e knuck l e thu s ,
fo r m e d t o pr oj e ct ab o v e th e o m e ntu m r e s e m b l in g a gl and fo r w hich it , ,
w as ind e ed m i s tak e n unti l the unrave l in g O f th e ti s s u e s d e ter m in e d i t s

true ch aract e r Th e c o nt e n t s wer e adherent t o t h e s a c but we re d i s
.
,
s e c t e d fr e e and t h e v e r m ifo r m appendix and o m e n t u m w ere s eparat e d

,
d o wn t o th e rin g wh e re each was s ep arat e l y l i g a t e d wit h s t o ut cat g ut

,
and cut o ff Th e p o r ti o n o f the app e ndix v e r m ifo r m i s r e m o ved was two

.
inch e s and a h alf lo n g and O f ab o ut t h e s iz e o f a g oo s e qui ll , The - .

1 8 GE OR GE A P E TE R S . .
s ac w as ti e d o ff and with th e s tu m p which wa s l e ft j u s t at the

n ow , ,
fe m o ra l rin g wa s s titch e d t h r o u gh and thr o u gh with cat g ut

, A rub .
b e r draina g e tub e wa s n o w in s e rt e d t o t h e b o tt o m O f the wo und and

-
t h e s kin c lo s e d o v e r wit h fi n e cat g ut s uture D urin g the O p e rati o n th e .
w o un d wa s fr e qu e nt l y irri g at e d with a s ol uti o n o f bich lo rid e o f m e r

cury 1 t o ,
Th e dr e s s in g wa s i o d o fo r m g auz e and a s pica b an d
age .
The fir s t dr e s s in g wa s n o t di s turb e d unti l F e bruary r o th when the ,
draina g e tub e wa s r e m o v e d th e r e b e in g p e rfe ct uni o n e xc e p t wh e re

-
, ,
t h e tub e e m e r g e d D urin g th e pr o gr e s s o f th e cure a s m a ll c oll ecti o n

.
o f p us o ccurred which s o m e what d e l ay e d th e h e al in g .
S h e w a s di s char g e d cur e d Marc h 9 1 8 8 6 , .
E a rl y in May 1 8 8 3 a g e nt l e m e n Mr S ac t 6 5 pre s e nt e d hi m s e l f
, , , . .
,
with a c o nditi o n O f t h e p e ni s t o which I h ad n e v e r s e e n a para ll e l .
F o r m o r e t h an t wo ye ar s p a s t he had c o m p l ain e d o f p ain in that

o rgan and chan g e s in s tructur e h ad tak e n p l ac e which o cca s i o n e d
,
h i m m uch m e nta l wo rry and m ade h i m d e cid e d l y hyp o ch o ndriaca l

,
On e x a m inati o n I fo und th e gl an s and b o dy O f th e p e ni s fo r ab o ut

, ,
an inch fr o m t h e e n d h ard and unyi e l din g t o t h e t o uch The pr e puc e

, .
was v e ry hard t o t h e fe e l ine l a s tic and e m bracin g th e gl an s v e ry

-
, ,
c lo s e l y ; i t c o u l d n o t b e dra wn b ack s uffi ci e nt l y t o e xp o s e it T h e .
p o rti o n o f th e gl an s p e ni s which c o u l d b e e x p o s e d h a d the s a m e h ard

fe e l and wa s m o tt l e d w it h two o r three s m a ll r e d s m oo th s p ot s n o t
, , ,
u l cerat e d P ain a l th o u gh n o t s e v e r e had b e e n a c o n s tant s y m pt o m

.
, , .
Th e r e was a l s o m uch itc h in g and b urnin g .
H i s g e n e ra l h e a l t h had been c o n sid e rab l y affe ct e d b ut appar e nt l y ,
m o r e fr o m m e nta l a gi tati o n than fr o m actua l d i s e a s e T h e o rg an was .
n o t incr e a s e d in s iz e Th e r e wa s n o s yphi l itic o r g l andu l ar taint

. .
Fearin g that if l e ft un aided i t m i ght d e g e n e rate in t o e pith e l i o m a I

, , ,
d e ter m in e d t o a m putat e th e p eni s wh ich wa s d o n e May 9 1 8 8 3 , , .
T h e o p e rati o n was d o ne ab o ut o ne quart e r o f the di s tance b e hind

t h e c o r o na gl andi s with a circu l ar s we e p o f the knife T h e urethr a
’
wa s th e n di s s e cted o ut dra wn fo r ward and s titch e d with fin e s utur e s

, ,
t o t h e s kin in o rd e r t o pr e v e nt r e trac ti o n Th e wo und h e a l e d v e ry

,
.
kind l y and h e r e turn e d t o h i s h o m e in th e c o untry M ay 2 2 d t h irt e e n

, , ,
day s after th e O perati o n .
T h e s p e ci m e n wa s hand e d t o Dr Frank F e r g u s o n path olo gi s t wh o .

, ,
m ad e the follo win g rep o rt :

“
E xa m i n ati o n o f t h e p e ni s fr o m a m putati o n by Dr G e o r g e A . .
Pe t e r s o n May 9 1 8 8 3
, , .
T h e o r g a n was a m putat e d j u s t behind t h e c o r o na gl andi s th e pre ,

OP E R A TI ON F OR R AD I CA L C UR E OF H E R N I A .
19
p uc e b e in g a l s o re m o ved T h e m eatu s i s s m all ad m ittin g o n l y a N O

.
,
.
1 5 Fr e n ch s o und and the ti s s ue s ar o und it are an ae m ic and O f a p e

,
c u li ar tran s par e nt c olo r The urethra b e hind the m e atu s b e ar s the

.
n o r m a l r e l ati o n t o a p e ni s o f thi s s iz e T h e m uc o u s m e m bran e c o y

.
erin g th e gl an s and inn e r s urface O f the prepuc e i s n o r m a l Th e re i s .
a z o n e o f infla m m ati o n pr o duct s in th e pr e puce and gl an s thr o u gh o ut

th e ir e ntir e e xtent and a l th o u gh g enera ll y a c o n s iderab l e di s tanc e
, ,
fr o m th e s urfac e ( in th e gl an s a lo n g th e p e riphery o f th e c o rp u s cav e r

n o s um
) ,in p l ac e s ther e e xt e nd fr o m t h e infla m m at o ry z o ne l i m ited
area s which re ach the m uc o u s s urfac e Thi s z o ne i s c o m p o s ed o f .
s m a ll r o und c e ll s ( y o un g c e ll s i n p l ace s accu m u l ati o n s O f c o n s idera

)
bl e siz e ar e s e e n a s in th e fo r m ati o n o f ab s ce s s e s b ut n o wh e r e i s s e en
, ,
any t e nden cy t o br e ak d o wn S o m e o f the b loo d v e s s e l s in the nei gh

.
-
b o rh oo d O f t h i s z o ne o f y o un g ce ll s are fi ll ed with s i m i l ar s m a ll r o und

c e ll s whi l e th e ve ss e l s which p a s s u p thr o u gh the di s e a s ed p art s t o th e
,
m uc o u s m e m bran e are e m pty The ve s s e l s O f the c o rp o ra cavern o s a

.
are g e n era l ly di s t e nd e d w ith b loo d .
—I n fl a m m a tio n o f th e s ub m uc o u s ti ss ue o f the gl an s
p e n i s and prepuce .
“
N ata — 1 T h e infl a m m ati o n i s exten s ive i t s pr o duct s fo und at th e
.
,
l ine o f inci si o n in the a m putati o n .
“
2 .Th e re are n o e pith e l i a l c e ll s fo und in th e gl an s o r prep uce b e
neath the m uc o u s m e m brane n o r anythin g indicatin g carcin o m a o r
,
s arc o m a .
Ther s b een g en era l pre s s ure o n th e v e s s e l s and nerve s b y

“
3 . e h a
”
t h e infla m m at o ry pr o duct s .
O n p r e s e n t i n g t h e s e t w o c a s e s o f o p e ra t i o n fo r t h e r a d i c a l
C u r e o f h e r ni a I d e s i r e t o c a ll a t t e n ti o n t o c o m p l i c a ti o n s o c
,
c u rri n g i n b o t h O f t h e m I n t h e c a s e o f M c Go w a n w h o t o o k
.
,
e t h e r b a d l y o n O p e n i n g t h e s a c a l a r g e m a s s o f i n t e st in e s
, ,
w a s fo r c e d b y h i s e ffo r t s t o v o m i t t h r o u g h t h e d i s t e n d e d an d
, ,
fl a bb y rin g a n d w as a s o u r c e o f m u c h e m b a rr a s s m e n t a n d
,
c o n s i d e ra b l e d an g e r u n ti l i t w a s r e t u r n e d t o i t s h o m e T h e .
p ri n c i p a l a s s i s t a n t s h o u l d g u a r d v e r y c a r e fu ll y t h e o p e n ri n g
a n d h e a d O ff t h e fi r s t a t t e m p t a t e s c a p e T h e d a n g e r fr o m .
s h o c k w i ll b e m u c h l e s s e n e d i f t h e t r u a n t g u t i s k e p t c a r e fu ll y
p r o t e c t e d b y h o t we t s p o n g es .
I n t h e c a s e o f fe m o ra l h e r n i a a c o m p l i c a t i o n p r e s e n t e d
,
n a m e l y t h e a p p e n d i x v e r m i fo r m i s — w h i c h I d o n o t r e m e m b e r
,
20 GE GR GE A P E TE R S
. .
t o h av e s e e n i n a n y h e rn i a l s a c w h i c h I h av e o p e n e d In .
t h i s c a s e i t w a s w h e n fi r s t s e e n s u p p o s e d t o b e a g l an d b u t
, , ,
a s t h e m a s s w a s u n r o ll e d i t s i d e n ti t y w a s e s t a b l i s h e d As th e .
h e rn i a l m a s s w a s a d h e re n t t o t h e n e c k o f t h e s a c i t w a s d e ,
t e r m i n e d t o l i g at e t h e e n ti r e p r o t r u s i o n s o t h a t i t m i g h t a c t as
a p lug . O n e x a m i n i n g t h e a p p e n d i x a ft e r i t s r e m o v a l i t w a s ,
fo u n d t o b e p e rvi o u s d o w n t o t h e v e ry t i p b u t c o n t a i n e d n o ,
fae c a l m a t t e r T h e w o u n d o f O p e r a t i o n h e a l e d k i n d l y an d t h e
.
,
p r e s e n c e O f t h e d iv i d e d a p p e n d i x s e e m e d i n n o w a y t o r e t a rd
th e c ure .
O f a ll t h e m e th o d s w h i c h h a v e b e e n a d o p t e d fo r t h e ra d i c a l
c u r e O f h e r n i a t h e o n e d e s c ri b e d a b o v e a n d i n t r o d u c e d t o t h e
,
n o t i c e o f t h e p r o fe s s i o n b y B a n k s o f L iv e rp o o l i s t h e m o s t
, .
ra ti o n a l t o t h e s t u d e n t a n d c a p t iv a t i n g t o t h e s u r g e o n .
T h e e x p e ri e n c e w h i c h m o s t o f u s h a v e h a d w i t h t h e O p e r a
ti o n o f H e a t o n b y i nj e c t i o n a n d w i t h t h e n e e d l e s a n d w i r e h a s
n o t I w i ll v e n t u r e t o s ay b e e n s o s a ti s fa c t o ry a s t o c o n vi n c e
, ,
u s t h a t n o t h i n g b e t te r c a n b e d e v i s e d .
T h e m e t h o d s o f p r o c e d u r e a d o p t e d v a r y a c c o rd i n g t o t h e
t h e o ri e s o r e x p e ri e n c e o f d i ffe r e n t s u r g e o n s S om e use th e .
s i lve r wi r e ,
o t h e r s a s e p ti c s i l k t h r e a d a n d o t h e r s a g ai n c ar b o l
,
'
iz e d c a tg u t .Th e r e s u l t o f m y e x p e ri e n c e a n d O b s e rv a t i o n i n
c l in e s m e t o a d v o c at e t h e c a t g u t p r o p e r l y p r e p a r e d s o t h a t i t
w i l l n o t d i s s o lv e t o o r e a d i l y .
U ni o n b y fi r s t i n t e n t i o n i n t h e w o u n d i s n o t s o d e s i ra b l e a s
m ig h t a t fi rs t s e e m A s u ffi c i e n t a m o u n t o f i n fl a m m a ti o n t o
.
p r o c u r e a d e n s e t h i c k e n e d m a s s O f t i s s u e p r o vi d e d t h i s i s t h e,
r e s u l t o f s u p p u r a t i o n a n d g ra nu l ati o n a b o u t t h e ri n g an d
c a n a l i s t o b e p r e fe rr e d
,
.
T h a t t h e o p e r at i o n i s a r e a s o n a b l y s a fe o n e i s I t h i n k , ,
p r o v e d b y t h e r e s u l t s a l r e a d y O b t ai n e d W h e n th e c a s e s a r e
.
p r o p e r l y s e l e c t e d a n d t h e o p e ra t i o n i s d o n e w i t h a ll m o d e r n
p r e c a u t i o n s t h e p e r c e n t a g e o f r e c o v e ri e s i s a s l a r g e a s i n t h e
,
c as e s r e p o r t e d b y B a nk s a n d o t h e rs ab r o a d Ev e n wh e n s u ch .
p r e c a u t i o n s a r e n o t O b s e rv e d t h e s t a t i s t i c s s h o w a d e at h —
,
ra t e
o f o n l y o ne i n e ig h t .
I n c a s e s w h e r e t h e h e r n i a i s l a r g e a n d s u bj e c t s i t s o w n e r t o
m u c h p ai n a n d d i s c o m fo r t w h e r e i t c a n n o t b e e n ti r e l y re
,
OP E R A TI ON F OR R A D I CA L C UR E OF H E R N I A . 21
tu rn e d o r i f r e tu rn e d c an n o t b e k e p t in p la c e w i th a t russ
, , ,
t h i s o p e ra ti o n i s i n d i c a t e d
. Ev e n if i t s h o u l d n o t res u l t i n a
p e r fe c t c u r e t h e p a t i e n t W i ll b e s o m u c h i m p r o v e d a s t o b e
,
a b l e t o w e a r a t r u s s w i t h c o m fo r t a n d b e c o m e a g a i n a b r e a d
winne r .
T h e c a s e r e c o r d e d ab o v e i n wh i c h I r e s o r t e d t o am p u t a ti o n
O f t h e p e n i s is u n i q u e i n m
y e x p e ri e n c
. e D r .F e r g us o n a l so
s t a t e s t h a t i t i s t h e fi rs t O f t h e k i n d w h i c h h as b e e n b r o u g h t t o
h i s n o ti c e . T h e O p e r a t i o n i s t o m y m in d j u s ti fi e d b y t h e fa c t
t h at M r S i s n o w i n g o o d h e a l t h a n d t h e r e h a s b e e n n o e x
'
. .
,
t e ns i o n o f t h e d is e as e . T h e r e l i e f t o h is m e n t a l c o n d i t i o n
wo u l d i n i t s e l f s a n c t i o n t h e O p e r a t i o n
.
E D I T O R I A L A R T I C LE S .
T H E S U R GI CA L T R E AT M E N T O F P E R IT O N ITI S .
An i m p o rtant m o n o graph up o n the s urgi ca l tr e at m ent O f p e rit o niti s

by Dr H Truc o f Ly o n s h a s re centl y app eared I t s s c o p e i s m o r e
. .
, ,
l
.
ext e n s iv e than that O f the m e m o ir o f Miku l icz a l ready revie wed in ,

2
th e s e p ag e s fo r it inc l ude s a s tu dy o f a l m o s t every variety o f p e ri

,
3
t on i t i s c ollectin g the m any fact s s cattered thr o u gh the curr e nt p e ri o di

,
ca l s .
I t i s wri tten fr o m an unu s ual s tandp o int th e auth o r b e l ievin g that in ,
any ca s e th e perit o niti s i s the princip a l indicati o n fo r tr e at m ent ; if in ,
deve lo pin g o ur therap e utic attack we find th e cau s e O f the p erit o niti s ,
s ti ll e xi s tent w e s h o u l d treat that a l s o

, .
Truc r ej e ct s the di vi s i o n o f puru l ent p erit o niti s int o s e ptic and

a s eptic ; puru l ent p erit o nit i s i s m o re s eptic o r l e s s s eptic b ut it d o e s
“
,
”
n o t app ear t o b e s o m e ti m e s s e ptic s o m e ti m e s a s eptic B o th c l ini , .
ca l and exp e ri m ental s tudi e s s upp o rt thi s vie w givin g a g ra d uat e d ,
s erie s p u e rp e ra l p e rit o niti s and the fo r m s due t o feca l extrava s ati o n

,
bein g t h e m o s t s ep ti c o f a ll .
S i m p le w zfl zou t ef us zon s h o win g p ath olo gi ca ll y o n l y a

' ’
c o n g e s ti o n o f th e m e m bran e d o e s n o t enc o ura g e s ur gica l interference ,

.
K n o wsl ey Th o rn t o n wh o h a s Op erated t wic e in thi s c o nditi o n wi th o ut

,
s ucc e s s h ol d s that the O perati o n wi ll b e j u s tifiab l e o n l y when we can

,
by it in s o m e way di m in i s h the perit o ne a l c o n ge s ti o n .

4
T h e fata l ity o f p u r u le n l p e r ztom i zs i s t oo we ll kn o wn t o need the

' ' '
r e p e ti ti o n here O f K ai s er s s tati s tic s Th e s e ca s e s we r e fo r m erl y

’ 5
.
1“
T ra it e m e nt ch i r ur gic al e de la p é ri t o n it e. T h es e d e c o nc p o u r l a gré g a ti o n
.
’
,
P ari s , 1 8 86 .
2
ol a nn S l k l in Vor trag
V km ’
s am m . . e, NO . 262 .
3
A nn S u r g M y 8 86 p 3 86
. .
, a ,
1 , . .
4
B ri t M d J o u r 88 5 I 5 3 8
. e . .
, 1 , .
, ,
5
D t ch Ar ch f k li n M d
eu s e 8 76 . . . e .
, 1 , XVI I .
, 74 .
( 2 2)
S U R GI CA L TR E A T M E N T OF P E R I T ON I TI S . 23
treated by p un ctur e o r inci s i o n whe n they p o int e d as ab s ce s s e s Di s .
s ati s fi ed with th e r e s u l t s thu s O b tained t h e m o dern s ur g e o n prefer s

-
,
l apar o t o m y and ei ght s ucce s s fu l ca s e s o f thi s o perati o n fo r g enera l

,
s i m p l e p erit o niti s a re a l r e ady o n r e c o rd —th o s e O f Tait E l ia s , Stu 1 2

,
de n s k y K r On le i
,
n
3
Bert e l s o f S t P e ter s b ur g) Ca s e ll i 6
S,c h4
m i d t ( C e n ,
5
.
, ,
tr alb l f Chirur gie

. . 1 88 2 p 7 7 2 ) and Va le ran i ( ibid 1 8 8 6 p , , .
, . .
un l e s s th e l a s t i s t o b e c o n s idered a lo ca l perit o niti s Again s t the se .
are t o b e p l aced thr e e fai l ure s—th e ca s e s o f M orran t Bak e r Sa m ue l ,

T
W e s t and Wade 9 in a ll O f which th e O p e rati o n was und e rtaken with

,
8
,
the patient in c oll ap s e and d e ath o ccurred within t wenty fo ur h o ur s -

.
As Truc r e m ark s th e s e s tati s tic s ar e t oo inc o m p l e te an d the t o tal s t oo

,
s m a ll t o b e o f any va l ue ; b ut a car e fu l s tudy o f th e s ucc e s s fu l ca s e s
s h o ws th at i m m edi ate i m pr o ve m ent follo wed t h e O p e rati o n whi l e the ,
re s u l t c o u l d hard l y h av e been o ther than fata l had the di se a s e b een

l eft t o i t s n atura l c o ur s e Truc fo r m u l ate s h i s c o nc l u s i o n s thu s : Sup .
u ra t i on in the perit o nea l cavity s h o u l d b e treated l ike s upp urati o n in

p
the p l eura l o r articu l ar caviti e s ; th e re s u l t s wi ll c o rr e s p o nd t o the
pr o m ptne s s and th o r o u ghn e s s o f th e tr e at m e nt ; and l apar o t o m y i s the
be s t treat m ent fo r it a llo ws th o r o u gh e vacuati o n O f the p us careful
, ,
c l ean s in g o f the cavi ty th e de s tructi o n o f adh e s i o n s ( which m ay e n ,
cap s u l e s m a ll c oll ecti o n s o f p u s ) ; the r e m o va l o f e x udati o n and per

fe c t draina g e Lapar o t o m y m o re o ver allo w s th o r o u gh exa m inati o n
.
, ,
o f the wh ol e abd o m e n and m ay r e s u l t in the di s c o very and re m o val o f

the cau s e o f th e infla m m ati o n .
In s tudyin g p uer p er a l p e r ztom f zs we m u s t fir s t exc l ude the hyp er

' ' '
acute fo r m which t e r m inate s l ife in t w o o r thre e day s o r even in a fe w ,
h o ur s fo r thi s fo r m i s m e re l y a lo ca l m anife s tati o n o f a s evere g e neral

,
s epti c infecti o n and a llo ws O f n o tr e at m e nt F o rtunate l y in m o s t

, .
,
l
Bri t M e d
. J o u r 88 3 L 3 4 . .
, 1 , , 0 .
2
R ev d . ci n m ed ( H a y m ) 8 8
es s e c es . e 1 2, H .
, 68 2 .
3
C t lb l f C h i r
e n ra 88 6 p 72. . .
,
1 , . 1 .
4
Ar c h f k l in C h i r
. 8 8 6 XXX I I I 5
. . 1 , .
,
1 8 .
Quo t d by D p q i T h d Par i 88 5 , N O
5
e u a u e r, . e s, 1 . 233 .
6
L m i
e m dic al 8 a v r i l 88 6 p
a ne e e, 2 , 1 , . 1 79 .
7 La nc t 88 5 I I 9 5
e ,
1 , .
, 0 .
8
I b id .
9 La nc t 1 886 I 343
e , , .
,
.
4 E D I T OR I A L A R TI C LE S .
ca s e s o f p u e rpera l p e rit o niti s t h e p e ri t o n e u m b e c o m e s fir s t affect e d

an d ther e i s ti m e t o r e m o v e the dan ge r o u s m ateria l b e fo r e ab s o rpti o n
and ge n e ra l sy s te m i c infe cti o n o cc ur Truc divid e s th e m o dern tre at .
m ent o f pu e rp e ra l perit o niti s in t o thre e vari e ti e s— pr o phy l acti c p a l ,
li ati ve and curativ e T h e fir s t h a s acc o m p l i sh e d w o nd e r s and p u e r

.
,
p era l p e rit o niti s i s n o w an unc o m m o n di s e a s e The p a ll iative tr e at .
m e nt h o wever i s o f l itt l e i m p o rtance ; a n d curativ e that i s s ur gica l

, , , ,
tr e at m e nt g ain s gr o und dai l y in th e fav o r o f th e pr o fe s s i o n H e find s

, .
t wo indicati o n s fo r treat m ent—exce s s iv e ty m p anite s and effu s i o n int o
t h e p e rit o n e al cavity .
D e pau l fir s t s ucc e s s fu ll y tr e ated ty m p anite s by capi ll ary p un cture s

1
an d h i s ca s e entir e l y r e c o v e r e d T h e e x p eri e nce O f s ur g e o n s with thi s .
m e th o d h a s n o t b e e n e nc o ura gin g fo r the re l ief h a s b e e n o n ly t e m p o r ,
ary We w . o u l d add that it i s al s o a qu e s ti o n whether capi ll ary p un c

tur e s n o m atter h ow car e fu ll y the o perati o n i s d o n e i s s o fr e e fr o m
, ,
dan ger as Truc and the o th e r adv o cate s o f th e m e th o d wo u l d h av e u s

be l i e ve An e x tra o rdinary ca s e s h o win g th e g r e at advanta g e s t o b e
.
,
g ained by re l ievin g the ty m panite s in s o m e ca s e s i s th at r e p o rte d b y ,
R e ib e l o f which we give a s u m m ary as the o ri gina l acc o unt i s n o t

,
2
,
ea s y o f acce s s : A gir l ae t 8 wa s attack e d by g enera l p erit o ni ti s ,

.
, ,
and d e ath s ee m ed at hand wh e n o n the 1 9 th d ay O f her i ll n e s s R e ib e l, ,
p e rfo r m ed m ed i an l apar o t o m y b ut fo und n e ither p u s n o r gas in the ,
peri t o nea l cavity The inte s tin e s were adher e n t and an accid e nta l
.
wo und was m ade in th e gu t fr o m which i s s ued fe tid g a s and fe ca l m a t ,
ter The wo und wa s dre s s ed b ut n o t s utured T h e n e x t day i m

.
,
.
pr o ve m ent wa s m anife s t and a s t ool o ccurr e d S lo w rec o very t oo k ,

.
p l ace As Truc r e m ark s thi s wa s a happy c hance and the ca s e

.
, ,
t e ache s n o thin g e x c e p t th e i m pr o v e m ent O b tain e d by pr o vidin g fo r a

per m anen t e s cap e fo r th e g a s .
In thi s c o nnecti o n the follo win g rare ca s e ( o f which we wer e wi t

n e s s and which we pub l i s h by th e kind p er m i s s i o n O f the O perat o r s) i s
,
o f great int e r e s t : J u l y 3 0 1 8 8 4 Dr T G ai ll ard Th o m a s a s s i s t e d by, , . .

,
Dr J am e s B Hunt e r p e rfo r m e d l ap ar o t o m y up o n a wo m an ae t 3 5
. .
, , .
,
1
Gaz h op , P s, ar i 1 87 1 , p 33 5
p —q u o t d b y T r uc p
. . . .
2
G az m ed d e S . . t ra b u rg
s , 1 88 3 , . 2 e , .
75 .
S UR GI CA L T R E A TM E N T OF P E R I T ON I T I S .
25
fo r a fi b rO cy s t o f th e ut e ru s T h e cy s t wa s inci s ed the e d g e s o f th e
- .
,
o penin g s e we d t o th o s e o f th e abd o m inal wo und and a gl a s s draina ge ,
tub e in s erted in the cy s t cavity Carefu l t o i l e t o f th e perit o n e u m wa s .
m ad e the re s t o f the ab d o m ina l wo und c lo s ed with o ut dr aina g e and

, ,
a l i ght anti s ep tic dre s s in g app l i e d Dr Hunter th e n t oo k char g e o f . .
the ca s e T h e cy s t cavity was irri g ated dai l y and rapid l y c o ntracted

.
, ,
T h e te m perature at fir s t fe ll t o n o r m a l b y Au gu s t 7 ; the
, ,
pu l s e re m ainin g thr o u gh o ut at 1 1 0 t o 1 2 0 S o m e ty m panite s exi s ted .
fr o m th e b e ginn in g b ut o n Au g u t 1 0 after a s udden m o v e m en t by

,
.
the p ati ent i t b e g an t o i n cr e a s e rapid l y

, G reat dy spn oea and e ya .
n o si s ca m e o n and earl y o n Au g u s t 1 2 th e p atient l ay at th e p o int o f

,
death m akin g o n l y fo ur g a spin g r e s pirati o n s per m inute Dr H unter

, . .
th e n in s ert e d th e s m all nee d l e o f an a s pirat o r in th e m e dian l ine

ab o ve th e u m bi l i cu s and g av e i ss ue t o a s tr o n g j e t o f odor less ga s ,
which l a s t e d fo r an h o ur reducin g the en o r m o u s l y di s tended ab d o m en ,
t o n o r m a l di m e n s i o n s V ery fe tid fl atu s was s oo n after p a s s ed p er .
anu m The ty m panite s did n o t r e turn and s p e edy c o nva l e s ce n ce fol

.
,
lo w ed I t s ee m s al m o s t certain th at the ga s in thi s ca s e was c o n

.
t ai n e d in th e p erit o ne a l cavity and n o t in the int e s tine s .
T h e s e c o nd indi cati o n th e re m o va l o f th e p e ri t o nea l effu s i o n m ay , ,
b e m e t b y s i m p l e pun cture when the fluid i s s er o u s b ut m o re ener g etic ,
m e th o d s are n e eded when it i s s ani o u s o r p uru l e n t Truc h a s c ol .
le c t e d ei gh t ca s e s o f the puru l e nt fo r m tr eated by puncture o r s m a ll
inci s i o n ; o n e ca s e o f evacuati o n by the b i s t o ury thr o u gh D o u gl a s cu l

’
de s a c an d fi v e ca s e s o f l ap ar o t o m y—th o s e o f B one 1 K a l tenb ach

-
, , ,
2
Pl ayfair M olok e n d o ff and S o nnenb ur g

3
,
5
S onn e n b urg s ca s e can,
4
.
’
o nl y b e inc l ude d by a l itt l e fo rcin g a s the O perati o n wa s d o n e fo r a ,
g en era l p erit o ni ti s s e t up by a puerperal p eri m etritic e xudati o n On l y .
—
o ne death o ccurred in all fo urteen ca s e s M olok e n d o ff s and i t s ee m e d
’
,
t o b e due t o carb ol ic acid p o i s o nin g Truc then re l at e s th e hi s t o ri e s .
o f two hithert o u n p ub l i s h e d ca s e s o f l apar o t o m y fo r s ep tic p uerp era l

l
S ch m i d t
’
s Jah rb .
, 1 8 7 7 , C XXV , L . p . 1 73 .
g Gyn é c o lo g i e O p e ra to i r e , 1 885 , p .
41 2 .
3
B r it . Med . J our .
, 1 88 3 , I .
, 45 5 .
ci nc ( H ay e m ) 1 8 83 ,
4
R e v de . s e e s m e d. , II 2 66 .
5 A r ch T o c olo gi
. e, 1 88 5 , p .
38 1 .
26 E D I T OR I A L L
A R TI C E S .
perit o niti s d o ne by B o ui ll y at a m o r e acute s ta ge in the m al ady than

any ye t r e c o rded .
T h e pati e nt s deve lo p e d perit o niti s o n th e s e c o nd day aft e r n o r m a l
l ab o rs In spite o f th e us e o f intra uterine d o uch e s th e p atient s gr e w

.
-
wo r s e and l apar o t o m y wa s d o n e o n the fifth and s ixth day s ( r e s pect

,
i ve ly) aft e r t h e ir c o nfine m ent T h e p e rit o n e a l cavity c o ntained in o ne

.
”
ca s e s o m e y e llo wi sh vi s c o u s fluid and in th e o th e r a l ar g e a m o unt
“
, ,
o f s er o p uru l ent fluid and i n b o th ca s e s wa s irri gated with a we ak b i

-
,
ch lo rid e o f m ercury s ol uti o n D e ath o ccurred in o ne ca s e in fifteen

.
‘
h o ur s aft e r the O p e rati o n and in th e o ther in thre e h o ur s

, .
B o ui ll y think s that h i s O perati o n s wer e practic e d t oo l ate H e h ol d s .
that o ne s h o u l d n o t wait fo r th e fo r m ati o n o f p e rit o nea l e ffus i o n o r ,
fo r hi gh fe v e r b ut act as s oo n a s ty m panit e s gr e at i l iac o r pe l vic pain

, , ,
and a m ark e d sy s t e m ic r e acti o n are O b s e rv e d o nl y bearin g in m ind ,
th at the fir s t two s y m pt o m s ar e uncertain and m ay di s app e ar s p o n

t a n e o usly We ventur e t o s u gg e s t that in thi s difficul t s ituati o n an
.
i m p o rtant indicati o n a s t o o ur acti o n wo u l d b e furni s hed by th e e ffe ct

pr o duc e d by the i n tra ut e rine d o uch e If i t s e ffe ct i s de cid e d l y b e ne
-
.
fi c i al l apar o t o m y w o u l d b e unnece s s ary ; but i f l itt l e o r n o i m pr o ve

,
m e nt i s n o tic e d durin g the u s e o f th e d o uche fo r t wenty fo ur h o ur s it -

,
wo u l d b e e vid e nt that di s a s ter wa s i m pendin g and l ap ar o t o m y m u s t b e

,
r e s o rt e d t o as a fo r lo rn h o p e .
It s e e m s t o u s m o r e o v e r that thi s v e ry treat m ent o f p ue rp era l s e p

, ,
t i c ae m i a by intra ut e rin e inj e cti o n furni s h e s th e s tr o n g e s t ar g u m e n t by

-
analo gy in fav o r o f l apar o t o m y and perit o n e a l irri g ati o n in p u e r p era l

p erit o niti s We are cl inica ll y fa m i l iar with t h e wo nd e rfu l effect s o ften
.
pr o duc e d by the s e d o uch e s and in s pit e o f th e ri s k which att e nd s

,
th e m th e y are n o w univ e r s a ll y e m p lo y e d Why are we n o t j u s tified in

, .
a s s u m in g in s ever e r ca s e s the g re ater ri s k o f app lyin g s i m i l ar tr e at m e nt

t o th e perit o n e a l cavity ? We a gree th a t i t i s nec e s s ary t o re m o ve
/
fr o m t he ut e rin e cav ity a ll m ateria l which m ay by i t s pr e s enc e th e re

add t o th e s e ptic infe cti o n a l r e ady exi s tin g—wh e th e r we b e l ieve that
m ateria l t o c o ntain infectin g m icr o o r g ani s m s and th e s o i l they fl o uri s h
-
in o r h ol d s o m e m o r e intricat e th e o ry o f s e p tic infe cti o n A t a ll

, .
e v e nt s it h as be e n d e m o n s trat e d that the p e rit o ne a l effu s i o n c o ntain s

,
S UR GI C A L TR E A TM E N T OF P E R I T ON I TI S .
the s a m e m icr o o r g ani sm s and o th e r c o n s tituent s which ar e fo u nd in

-
th e ut e rine c o nt e nt s an d t h e c o nc l u s i o n lo gica ll y follo ws that th e peri

,
t on e al effu s i o n s h o u l d a l s o be re m o ved o r at l e a s t e x p o s ed t o t h e ,
acti o n O f the che m ica l s u s ed i n anti s e pti c inj e cti o n s Thi s s e e m s t o .
u s a far c lo s e r ana lo gy than the o ne s u g g e s ted by Truc— th e cure ttin g
o f the axi ll a in ca s e s o f s eptic l y m ph an giti s o ri ginatin g in the fin ger .
P a s sin g t o th e p e rit o niti s cau s e d by n on t r a u m a f zc p erf or a t i on o f th e

'
s t o m ach and inte s tin e w e find in thi s m e m o ir three ca se s hi th e rt o u n

,
p ub l i s h e d : R o b er t— p e ri t o n e a l ab s c e s s n e ar u m bi l icu s puncture and , ,
drain a g e rec o very ; R eyni e r—s y m pt o m s O f int e s tina l o b s tructi o n fo r

,
five day s l ap ar o t o m y p uru l e nt p e rit o ni ti s b ut n o O b s tructi o n fo und

. , , ,
de ath in s even h o ur s aut o p s y s h o wed p erfo rati o n o f c oecu m A Po n

,
.
cet—ca s e identica l with l a s t exc e p t that th e aut o p s y sh o wed g an gren e ,
o f th e v e r m ifo r m appendix with o ut any r e c o gniz ab l e perfo rati o n .
C o n fi n in g o ur s e l v e s t o the ca s e s treated by l apar o t o m y we find that ,
Truc h as c oll e ct e d thr e e b e s ide s the abo ve— th e ca s e o f Ch ap n ut and

Le F ort and th e tw o o f Kr On le i n
,
1
T o th e s e s h o u l d b e added the .
2
ca s e s o f Polai llon and Miku l icz m akin g a t o ta l o f s even In fi v e o f

3
,
4
.
th e s e ca s e s th e o perati o n was d o n e u nder t h e dia gn o si s o f inte s t ina l

O b s t ructi o n In fo ur the perfo rati o n wa s n o t fo und durin g the O p e ra
.
ti o n In a ll s e v e n th e o p e rati o n was p erfo r m ed aft e r a d e l ay o f fr o m

.
thr e e t o ten day s and t oo l at e t o b e o f s e rvic e un l e ss we h ol d t h at

, ,
s o m e m i ght h ave b een s av e d if the perfo rati o n had b e e n fo und B ut .
i t i s t hi s v e ry de l ay which render s th e pr o p er e x a m inati o n o f the ah

d o m i n al c o nt e nt s s o difficu l ty C e rtain l y if ther e i s anythin g t o b e .
,
l earned fr o m the s e ca s e s it i s the fact that int e rv e nti o n t o b e u s e fu l , , ,
m u s t b e und e rtak e n e ar l y Truc c o un s e l s a g ain s t l ap ar o t o m y i n ca s e s

.
o f typh o id dy s ent e ric and tub ercu lo u s u l c e r s o n acc o un t o f th e fe e b l e

, ,
c o nditi o n o f t h e p ati e nt u s ua ll y fo und in the s e m a l adi e s but the atti ,
tude Of Miku l icz app ear s t o u s th e c o rrect o ne— t o O p e rate i n every

ca s e o f p e r fo rative p erit o niti s if the pati ent i s n o t a l r e ady in a s tate o f ,
l
Pro gres m ed .
, 1 88 3 , p . 1 03 .
2
A r ch f K l i ch i r
. . n . .
, 1 8 86, XXXI I I .
, 5 14 —5 22 .
3 ’
L U ni on m ed .
, 1 88 4, XX XVI I .
, p . 1 4 .
4
S am m l . kl . V or t rag e, NO . 2 62 , p . 23 1 3 .
28 E D I T OR I A L A R TI C E S L .
c oll ap s e and at an e ar l i e r date than h a s as ye t b e e n the cu s t o m

,
.
In p e rit o niti s fr o m the m p zu r e of a és ces s es int o the p e rit o nea l cavity

‘
Truc qu o te s th e s ucc e s s fu l ca s e s o f Tait Tr e ve s and I sra el a n d we ,

1
,
2
,
s
m i g ht add t o the m the ca s e o f Burchard ( a l th o u gh in it th e ruptur e 4
t oo k p l ac e j u s t as t h e ab s ce s s wa s inci s e d and l apar o t o m y wa s d o ne ,
at o nc e) a ll s h o win g that l ap ar o t o m y and th o r o u gh c l e an s in g o f th e

,
p e rit o n e u m can s ave th e p ati e nt .
R uptur e o f o varian cy s t s and o f the foeta l cy s t in e x tra ut e rin e pr e g -
nan cy d e m and i m m e diat e l apar o t o m y b ut if d e l ay o ccur s and p e ri ,
t o n i t i s d e ve lo p s i t i s n o c o ntraindicati o n t o the o p e rati o n

, .
Of p e rit o niti s with s tran gu l at e d h e rni a Truc h a s fo und t wo ca s e s

—
tr e at e d by h e rni o t o m y and draina ge H or sle y s f lo ca l perit o niti s r e
’ )
,
c ove ry ; and Go d le e s
g en e ra l d e ath He g iv e s thr e e ca s e s tr e at e d
’
,
6
, .
by l apar o t o m y by C e ci I s ra e l and Ob e r s t ; t o which we w o u l d add

7
, ,
8 9
th o s e O f D e sn o s Fitz g eral d and Ha ll —s ix in a ll if w e ad m it I s ra el s

‘
,
10
,
11 2
,
’
ca s e In a ll the abd o m e n wa s O p e n e d by e xtendin g th e inci si o n fo r

.
,
h e rni o t o m y In I s ra el s ca s e the p erit o niti s wa s cau s e d by a p eri

.
’
typh l iti s s tran gu l ated h e rni a c o m p l icatin g— rec o very

,
D e s n o s and .
’
Ce c i s ca se s had p e rfo rati o n O f th e s m a ll int e s ti n e n o t di s c o ver e d

’
,
unti l aut o psy O b er s t fo und p erfo rati o n o f the s m a ll int e s tine an d

.
,
m ade an artificia l anu s—death Fitz ge ra l d fo und and s utur e d a p e r .
fora ti o n — death Hall fo und p e rtor a t i on o f th e ver m ifo r m a p p e ndix ;

.
and r e s ect e d the l att e r— rec o very Al th o u gh o n l y I s ra el and H a ll .
s aved th e ir p ati e nt s we m a fe ly d e d u c e fr o m th ese ca ses ( w i th

'
y s a ,
Truc ) th e nec e s s ity fo r an exp lo rati o n o f th e abd o m en w h e n e v e r in ,
I
Br i t M e d
. . J our .
, 1 88 3 , I .
, p .
3 03 .
2
La nc t e , 1 88 5 , L , 475 .
g S e m ai n e m ed .
, 1 8 8 4, p . 1
59 .
4
N Y Med
. Jour
. I L 73 . .
, 1 88 5 . , 1 .
5 M d Tim
e Lo nd 88 5 I L 43
. es, .
,
1 , , 1 .
6
M d T im
e Lo nd 8 8 5 I 6 7 8
. e s, .
, 1 , .. .
T
G az m d di R o m a
. e88 3 N .
7 93 ,
1 , o. 1 , 1 .
S
S m i
e m edic al 8 84 5 9
a ne e, 1 , 1 .
9
C t lb l t t f Ch i r u r gi
e n ra a 88 5 3 4 5 . e ,
1 , .
10
Bu l S A n a t d P ar i 8 7 9 LI V 5 7
. oc . . e s, 1 , .
, 1
ll
A t li
u s ra M d Jour 88 3 V
an 64 e . .
,
1 , .
, 2 .
12
N Y M d Jour
. . 88 6 I 66
e . .
, 1 . 2 .
S UR GI CA L TR E A T/VE N T OF P E R I I ON I I I S .
29
th e o p era ti o n herni o t o m y that cavity i s fo u n d t o c o ntain puru l e nt

Of ,
o r s e ptic fluid Thi s m ay b e d o n e by en l ar gin g th e inci s i o n up ward s

.
,
o r b y m e dian lap ar o t o m y T h e ca s e o f Ob er s t in which d e ath s e e m e d

.
.
,
t o b e d ue p art l y t o in n utri ti o n o n acc o unt o f th e artificia l an u s p art l y ,
t o th e e xi s t e nce o f m any sm a ll c oll e cti o n s o f p u s ency s te d b e t we e n t h e

fol d s O f th e p e rit o neu m e m pha s iz e s the n e c e s s ity o f th o r o u gh exp lo ra
,
ti o n o f th e abd o m e n which can o n l y b e carried o ut by m edian l ap a

,
r o to m
y B ut if ha s te i s n e c e s s ary a s in H a ll s ca s e h i s e xa m p l e
.
,
’
,
m i gh t b e follo w ed and th e adh e s i o n s br o k e n d o wn b y t h e hand in tr o

,
d u c e d up w ard s thr o u gh th e inci s i o n in th e i l iac re gi o n .
I t i s fo rtunat e that th e r e s u l t s o f l apar o t o m y fo r zzzles l zn a l oOs l r zze

' '
t i on are s o s ati s fact o ry c o n s id e rin g th e i m p o s s ibi l i ty o f di s tin g ui s hin g

,
i t fr o m p e rfo rati o n o f t h e int e s tine fo r o n e can o p e rat e at o nc e w it h ,
th e kn o wl e d g e th at th e tr e at m e n t i s s ui tab l e t o eith e r c o nditi o n and i s , ,
m o re o v e r curativ e fo r a p e ri t o ni ti s d e penden t up o n inte s tina l O b s tru e

,
ti o n . E v e n s e ptic p e rit o ni ti s i s n o t a c o ntraindicati o n In l ap a .
r o t o m y fo r int e s tina l o b s tructi o n a car e fu l t o i l et o f the p erit o neu m i s

,
nec e s s ary but draina g e m ay u s uall y b e di s p e n s e d with

,
.
In Truc fav o r s earl y o p e rati o n ( as s oo n a s p u s can b e

det e ct e d ) but n o t s o e a l y a s i s ur ge d b y Bu ll Fitz and o th er s T h e
,
r
,
1
,
2
.
m o dern t e nd e ncy s e e m s t o b e in the dir e cti o n o f e xp lo rative O p era
ti o n —e ven l apar o t o m y wi th o ut waitin g t o di s c o v e r p u s T h e inr o a d s

,
.
O f Tait s O p e r a t i o n u p o n t h e O ld th e o ri e s o f p e lv i c hav e
’
t h r o wn the p a t h olo gy O f that a fl e c ti on int o s uch an un c e rtain s tate a s

'
t o m ak e it i m p o s s ib l e t o r e ach any s ati s fact o ry c o nc l u s i o n s at pre s e n t ,
and o m ittin g Truc s vi e ws up o n it w e wi ll giv e h i s d e ducti o n s fr o m a

’
,
s tudy o f in ge n e ra l Th e y are bri e fly the s e .
S e r o u s o r h e m o rrha gi c cy s t s requir e tr e at m ent o n l y when th e y are o f

l ar ge s iz e o r when t h e ir c o nt e n ts b e c o m e p uru l e n t P uru l en t .
e ncy s t e d p e rit o ni t i s d e m and s pr o m p t e vacua t i o n O f the p u s t h e s m a ll e r ,
cy s t s adh e r e nt t o a cc e s s ib l e part s o f t h e abd o m ina l wa ll b e in g tr e at e d

by s i m p l e in ci s i o n ; t h o s e n o t s o p l ac e d t h e l ar ge c oll ecti o n s and a ll ,
1
N Y Med R e
. . . c ord 88 6
,
1 , I .
,
2 65 ( a nd d i s sc u s i o n ,
2
Am . Jour . Me d S ci nc
. e e s, 1 8 86 , I L , 3 2 1 .
30 E D I T OR I A L L
AR TI C E S .
ca s e s in which th e dia gn o si s i s unc e rtain b e in g tr e at e d by l apar o t o m y .
T e nd e ncy t o ext e rna l s p o ntan e o u s O p e nin g s h o u l d ha s t e n the

o p e rati o n bu t if di s char ge take s p l ac e int o any O f th e h ollo w o r g an s ,
t h e s ur ge o n m ay w ait h ol din g hi m s e l f read y t o O perat e at o nc e in ca s e

,
o f r e t e nti o n o f p us functi o na l di s turbanc e o f any kind o r d e teri o ra

, ,
ti o n o f t h e g e n e ra l c o nditi o n o f the pati e nt Thi s l a s t c o nc l u s i o n a d .
m it s o f s o m e critici s m fo r in m o s t ca s e s o f s uch int e rn a l O p e nin g the

, ,
dan g e r o f s e ptic infe cti o n i s s o gr e at that o n e wo u l d n o t b e di s p o s e d

t o b l a m e the s urg e o n wh o s h o u l d m ake an external inci si o n at o nce .
In p e r i le zzi t i s af ter s u rg i ca l op e r a l i ozzs up o n the abd o m e n the a d ,
m i t t e d tr e at m e nt i s t o at o nc e s upp l y fr e e i s s u e t o s e p tic o r puru l e nt
c oll e c ti o n s by draina g e and irri g ati o n thu s r e m o vin g a ll dan ge r o f g e n ,
e ra l infe cti o n But T e ri llon h a s s h o wn ( and we m i gh t in thi s c o nnec 1

.
”
ti o n a l s o r e fer t o E n ge lm an n s p ap e r o n In s idi o u s Septic ae m ia ) th at ’ “ 2
thi s p e rit o niti s o ften dev e lo p s with o b s cur e sy m pt o m s—v o m itin g ,
pain and e v e n an x iety b ein g fr e q u e nt l y ab s e nt ; ty m panite s i s th e m o s t

c o n s tant s y m p t o m Thi s o b s cure fo r m o f p e rit o niti s h o we v e r a fo rm
.
”
, ,
with o ut any effu s i o n int o the cavity d o e s n o t yie l d t o any tr e at m en t , ,
and i ts r e c o gniti o n i s a s ye t o f n o practica l i m p o rtanc e fo r the s ur ,
g e o n i s p o we r l e s s a ain s t it
g .
Truc s s tudy o f trau m at i c p e rit o niti s cau s ed by wo und o r ruptur e o f

’
s t o m ach o r inte s ti ne i s n o t very s ati s fact o ry H i s l i s t o f ca se s i s far .
fr o m c o m p l e t e and he ( and Miku l icz a l s o ) d o e s n o t at a ll c o n s id e r the

,
que s ti o n o f e x p lo r ative l apar o t o m y H e s ay s o f the s e ca s e s : Wh e n .

“
,
in th e ab s e nc e o f an externa l wo und the dia gn o s i s i s unc e rtain m e di , ,
”
ca l tr e at m ent i s a lo n e s uitab l e ad m ittin g s ur gica l interventi o n o n l y ,
when th e d o ub t h a s be e n r e m o ved by the d e v e lo p m e nt o f perit o niti s .
In m any ca s e s o f s i m p l e c o ntu s i o n o f th e abd o m en with o ut vi s cera l

inj ury the s y m pt o m s are as s e vere at fir s t a s in t h e ca s e s with rup ture
,
o f th e s t o m ach o r int es tin e s and the diag n o s i s i s i m p o s s ib l e unti l peri

,
t on i ti s deve lo p s E ven the lo s s o r p e r s i s t e nce o f du l ne s s o n p e r c us

.
s i o n o ver t h e l iv e r i s n o t a th o r o u h l y re l iab l e s i n In p e n e tratin g

g g .
gun s h o t and pi s t ol s h o t wo und s o f the abd o m en t h e s ucce s s fu l ca s e s

- -
l Bull. th era p .
, 1 8 83 , CI V , . p .
75
1 .
2
T ra n s. Am . G yn c ol e . S oc .
, 1 88 4, p . 259 .
S UR GI CA L TR E A TM E N T OF P E R I T ON I T I S .
31
a l ready o n rec o rd s h o w that the s ur ge o n i s j u s tified in p erfo r m in g l ap a

r o t o m y b efo re perit o niti s s et s in fo r he m ay b e c o nfid e n t that he wi ll ,
find a wo und o f th e s t o m ach o r inte s tine s in a l m o s t e ve ry ca s e The .
o n l y c o ntra indicati o n w o u l d b e the pr o b ab l e e xi s tence o f a w o und o f

-
the l iver with s ev e re h e m o rrh ag e .
I t i s true that th e s ucce s s fu l ca s e s o f B o ui ll y and Miku l icz ( a s w e ll 1 2
a s the n o n trau m atic ca s e s -

o f Kr o n l e in H all and o ther s a l ready , ,
g iven ) pr o ve that perit o niti s with fe ca l extrava s ati o n m ay b e s ucce s s

,
full y treat e d by l ap ar o t o m y But thi s i s s o m uch the excep ti o n that it .
s e e m s t o u s t o b e o ne o f th e ta s k s o f m o d e rn s ur g e ry t o g iv e exp lo ra
tiv e l apar o t o m y a tria l in certain ca s e s o f c o ntu s i o n o f th e a bd o m en

in o rd e r t o g ain fo r the s e ca s e s a l s o th e advanta ge s fo un d in perfo r m
i n g l ap ar o t o m y fo r g un s h o t w o und s o f the ab d o m en b e fo re perit o ni ti s
-
h as deve lo p ed .
D enni s indeed wo u l d app l y th e princip l e o f exp lo rin g the ab d o

,
3
,
m e n t o e v e ry inj ur y in which I t was p ro b ab l e th at inte s tine o r s t o m ach
h ad b een wo unded H e p erfo r m ed exp lo rativ e l apar o t o m y in o ne

.
ca s e o f p e netratin g s tab wo und o f the ab d o m en with o ut findin g any -

,
inj ury o f the vi s cera an d h i s p ati e nt m ad e an exce ll en t rec o very thu s

, ,
givin g th e the o ry th e s upp o rt o f o n e ca s e t o s h o w that t h e o perati o n

d o e s n o t nec e s s ari l y e ndan g er l ife .
Tr uc i s an e arne s t adv o cate o f e x p lo rative l ap ar o t o m y h o wever , ,
in ca s e s o f puru l ent p e ri t o niti s an d we m ay fi ttin gly c lo s e wi th h i s ,
o wn w o rd s T h e o penin g o f the ab d o m e n h a s lo s t m uch o f i t s

“
g ravity and , w e b e l i e ve th at w e hav e de m o n s trat e d that certain fo r m s
o f p erit o niti s can b e cure d by o pp o rtune and m eth o dica l s urg ica l
treat m e nt ; that i s e n o u gh t o c o nde m n s y s t e m atic refu s a l t o O p erate .
In s t e ad o f c o ntinuin g t o be a c o ntra indicati o n i t ( p e ri t on i -

,
t i s ) s h o u l d b ec o m e a p o s itive indicati o n D eath in th e ca s e s o f .

,
which we s peak i s certain We hav e s een that th e O perati o n m ay

, .
s ave the p atient Why h e s itate t o g ive th e l atter s o m e chance O f r e

.
c o v e ry ? B F A R Q U H AR C UR T I S
. .
1
Bu ll i r P ar i
S o c d e Ch. .
, s, 1 88 3 , I X .
, 698 .
2
S m m l k l in Vor t r ag N
a . . e, o . 2 62 , p . 23 1 5 .
3
M d N w Ph i l
e . e 886 I
s, ,
1 , .
, 2 25 , 253 .
32 E D I T OR I A L A R I I CLE S .
L
K U E M M E LL O N H I G H - Y I N G S T R I CT U R E S O F T H E R E CT U M .
A p aper o n t h i s s ubj ect r e c e nt l y r e ad b e fo r e th e Ha m b ur g M e dica l

S o ci e ty by Dr H e r m ann K fi m m e ll wi ll b e fo und in t e r e s tin g and i n
1
.
s tructiv e a s th e
,
s ubj e ct d e s e rv e s m o r e att e nti o n than i s u s ua ll y
acc o rd e d i t Und e r th e t e r m hi gh l yin g s tricture s o f th e r e ctu m
.
“ -
th e au t h o r d o e s n o t m e an g en e rall y s p e akin g a ll s trictur e s o f th e

, ,
upp e r p o rti o n o f th e r e ctu m cau s ed by th e pr e s s ur e o f intra p e l vic -
g r o w t h s o r infla m m at o ry pr o duct s o r br o u g ht ab o ut
, by di s p l ace m e n t
o r adh e si o n o f the r e ctu m t o o th e r o r g an s n o r s ten o s e s r e s u l tin g fr o m ,
m a l i gna nt o r b eni g nant n e o p l a s m s On the c o ntrary th e t e r m i s ap

.
,
p l icab l e o n l y t o a c e rtain gr o up o f cicatricia l s tricture s cau s e d by

u l c e rativ e pr o c e s s e s c o n s e qu e n t t o chr o ni c infe cti o u s di s e a s e s .
Stricture s s ituat e d lo wer d o wn in th e r e ctu m are as a ru l e e a s y o f , ,
dia gno s i s by m e an s O f s i m p l e di gita l e x p lo rati o n In thi s re s p e ct .
th o s e l yin g hi gh e r up diffe r gr e atl y n o t b e in g acce s s i b l e t o the s a m e

,
m ean s o f e xa m inati o n Th e au th o r inc l ud e s a l s o a m o n g the s e l att e r

.
s tricture s th o s e fo und in the s i g m o id fl e x ur e T h e lo we s t b o unda ry .
fo r th e s e hi gh l yin g s trictur e s s h o u l d b e p l aced at ab o ut 1 2 c t m ab o ve

- .
t h e ana l o p e nin g th e upp e r m o s t at ab o ut 3 5 c t m

, which w o u l d c o r .
,
r e s p o nd t o the j uncti o n with th e d e s c e ndin g c olo n ( c o untin g I 5 c t m .
fo r th e r e ctu m and 2 0 c tm fo r th e si g m o id ) P e rr e t c oll e ct e d 6 0 ca s e s

. .
o f s trictur e s e x a m in e d I n t he cadaver a n d it i s int e r e s tin g t o n o t e t he

, ,
r e l ativ e l y s m all nu m b e r o f hi gh l yin g s trictur e s a m o n g th e n u m b e r

- .
In 4 ca se s t he s trictur e s o r i ginat e d in th e anu s in 3 2 ca s e s be lo w 6 ,
c tm . in 3 ca s e s a t ab o ut 6 c tm in 7 b e t we e n 6—9 c tm in 5 ca s e s
,
.
,
.
,
o v e r 9 c t m ab o v e th e anu s a n d in 6 ca s e s th e p o int o f uni o n o f re c

.
,
t u m and c olo n was t h e s e at o f tr o ub l e In 4 ca s e s s e v e ra l s trictur e s

.
we r e fo und .
T wo chr o nic infe cti o u s di s e a s e s n a m e l y dy s e ntery and s yphi l i s a re

, , ,
th e chief cau s e s e t i olo gica ll y s p e akin g fo r thi s tr o ub l e ; catarrha l

, ,
u l c e rativ e pr o c e s s e s t h e m o r e s e l d o m But in rare in s tanc e s t ub e rc u

.
lo u s pr o c e s s e s m ay gi v e ri s e t o s trictur e s o f thi s kind a s d e m on s tra t t d ,
by th e aut h o r in a v e ry in te r e s t in g ca s e .
l
Vo lk m
’
an n s c oll cti o n o f c l inic al l ctu r
e e e s, No . 28 5 .
( Ch i r u r gi e , NO .
H I GH L YI N G S TR I C T UR E S
~
OF TH E R E C T UM .
33
Th e p ati e nt wa s a m an ae t 2 5 in wh o m th e s y m pt o m s o f a di s ea s e
,
.
,
o f the rect u m de ve lo p e d c o n s e cutive t o an o b s tinate catarrha l in fl am

m ati o n o f t h e int e s tine s . H eart and l un g s wer e n o r m al b ut o n e x ,
p lo rati o n o f th e r e ctu m with th e hand a s trictur e ab o u t 1 4 c t m abo ve

,
.
the anu s wa s di s c o vered T h e flat tu m o r like m a s s cau sin g the s trict

.
-
ure inv ol v e d ab o ut t wo third s o f the circu m ference o f th e int e s tine

,
-
and wa s adherent t o th e s acru m P atient was p l aced under anti s yph

.
-
ili ti c treat m en t and di l atati o n o f the s tricture b e g un b y m ean s o f

b o u gi e s Ijn p ro ve m e n t wa s s teady fo r s o m e three m o nth s when he
.
,
b e gan t o c o m p l ain o f increa sin g p ain in the lo in s A deep l y i n g Vi s i .

-
,
b l y fl u c t u a ti n g ab s ce s s o n bo th s ide s O f the s acru m wa s di s c o vered

-
an d i nci s ed r e l ea s in g a l ar g e quantity o f p uru l e nt m atter

, N e arl y the .
wh ol e o f th e p o s teri o r and the lo wer p art o f th e anteri o r s urface o f the
s acru m wa s cari o u s
. P ati e nt b e ca m e rapid ly we ak e r s y m pt o m s o f ,
g enera l tubercu lo s i s app earin g Death fift e

. e n m o nth s after c om
m e n c e m e n t o f th e recta l di s ea s e I n the aut o p sy the s trictur e was
.
fo und a l m o s t c o m p l ete l y di l at e d The cavity o f the s acr um was c oy

.
er e d wi th fi rm cicatrice s and nu m er o u s tubercu lo u s u l cer s the inte s ,
tine s b e in g fir m l y adher e nt t o the s a m e .
I t i s n o t a l way s e a sy b ut fo r therapeutic p urno s e s o f m uch i m p o rt

,
ance t o det e r m ine which o f th e two m e nti o n e d di s ea s e s i s the cau s a

,
tive e l e m ent in the s e ca s e s The auth o r fo r in s tance rep o rt s t wo

.
, ,
ca s e s where the p atient s wh o had in fo r m er ye ar s b o th c o ntracted s yph

i l i s r e s id e d fo r m any year s in the tr o pi c s E ach o f the m s uffered then
,
.
fr o m repeated attack s o f inte s tina l catarrh b ut n e ver wi th dy s ente ry , .
N o thin g re s u l ted fr o m anti s yphil itic treat m ent and th us n o thin g wa s

-
,
g ain e d fr o m an eti olo gi ca l p o int o f vie w Th e re l ative l y s m a.ll n um
b e r o f hi gh l yin g s trictur e s h o wever fo und in m o re n o rthern c o un

-
, , ,
trie s in c o n s e quence o f the infrequ e nt and l e s s m a l i g nant o ccurrence

,
o f dy s ente ry o n the o ne hand o n the o ther the fact that al m o s t with

, ,
o ut e x cepti o n the afflicted p e rs o n s h ave re sided fo r lo n g p eri o d s in the

tr o pic s and attribute th e c o m m e n c e m e n t o f their i ll ne s s t o their re s i
'
dence ther e and fina ll y the p o s iti ve ob s ervati o n s c o ncernin g the de

, ,
ve lO p m e n t o f thi s tr o ub l e dire c t l y follo wi n

, g an attack o f dy s ent e ry ,
wo u l d s ufficie nt l y pr o ve that the l atter di s e a s e i s the princip a l cau s a
tive influence fo r thi s fo rm o f s tr ict ure .

34 E D I T OR I A L AR TI C LE S .
In m o s t ca s e s s ay s the auth o r th e aut o p s y wi ll s hed n o li ght o n th e

, ,
pri m ary cau s e o f the tr o ub l e Ab o v e the s trictur e th e int e s tine i s u s u

.
ally m uch di s tended fr o m s ta gnati o n o f fecal m atter I n c o n s equen ce .
o f the frequ e n t e nerg e tic c o ntracti o n s hyp ertr o phy o f the m u s cu l ar ,
wa ll s take s p l ace and the s e lo s in g m o re and m o r e O f their e l a s tici ty

, ,
b ec o m e gradually very s tiff and ri gid If di l atati o n o f the o b s tr uct e d .
part i s n o t undertaken the irritati o n o f th e m uc o u s s ur face cau s ed by

,
th e i m pact e d fe c e s e tc wi ll s oo n l ead t o an u l cerated c o nditi o n an d

,
.
,
lo ss o f s ub s tance o f th e m uc o u s m e m brane The m u s cu l ari s wi ll b e .
c o m e inv ol ved the s er o s a under m ined and fina ll y fi s tulo u s pa s s a g e s

, ,
fo r m ed .
T h e s trictur e it s e l f i s s e en m o s t l y as a cicatricia l rin g s urr o unded

b y h ard c o nn e ctive ti s s ue S o m eti m e s it h a s b ut a very s m a ll o pen
.
i n g in o ther ca s e s we find it in the fo r m o f a m o re o r l e s s lo n g ri gid

,
tub e with a narr o w o r wide l u m en Occa si o nall y two o r thre e s trict .
u re s s eparated b y partia ll y hea l thy m uc o u s m e m bran e are m e t with .
The p atient s c o m p l ain o f a fee l in g o f pre s s ure and s en s ati o n o f b urn

i n g and s o rene s s in the re g i o n o f th e s t o m ach Lo s s o f appe tite .
,
flu s hin g i rre gu l ar heart acti o n draw in g s en s ati o n in the lo we r l i m b s

,
-
, .
n erv o u s irritabi l ity and o ften de e p hyp o ch o ndria s i s are s o m e o f the ,
chief s ym pt o m s O b s tinate diarrh oe a O ften exi s t s further m o re GraE

.
,
.
n a ll y the lo ca l s y m pt o m s b ec o m e m o re pr o m inent ; dra win p ain s in

g
the lo in s and frequent de s ire t o s t ool deve lo p s F o r th e s e hi gh l yin g .
-
s trictur e s th e s udden de sire t o s t ool o n a wakenin g in the m o rnin g i s a
charact e ri s tic s y m pt o m I n s tead o f fe ce s o n l y m uc o u s m atter i s

.
,
pa s s e d with m uch s trainin g The ribb o n l ike fo r m o f the fe ce s O ften

.
-
ive s a c l ue t o the di s ea s e in s tricture s near the a r ms b ut in s tricture s

g ,
s ituated hi gh up in th e rectu m the fec e s u s ua ll y have their n o r m a l

fo r m . They are s o m eti m e s h o wever s i m i l ar t o th o s e o f s h e ep s m a ll
, , , ,
h ard ba ll s T h e p atient rar e l y h as the fee l in g o f c o m p l et e evacuati o n

.
o f th e b o we l s The m uc o u s s ecreti o n b e c o m e s m o r e and m o r e ab un

.
d ant o b s tipati o n incr e a s e s I h the wo r s t ca s e s if n o di l atati o n o f

°
.
, ,
t h e s tricture tak e s p l ac e the s ta g nati o n o f t h e fe ce s l e ad s t op e rit o niti s

,
and d e ath A very i m p o rtant s y m pt o m appe arin g r e l ativ e l y ear l y in

.
th e c o ur s e Of the tr o ub l e and p o intin g t o i t s g rav e nature i s t h e rapid .

H I GH - L YI N G S TR I C T UR E S OF TH E R E C T UM .
35
w a s tin g a w ay o f the p atient the lo ss o f s tren g th and cachectic ap

,
p e a ran c e differin g s carce l y fr o m that o f th o s e afflicted with carcin o m a

, .
A car e fu l e x am inati o n p e r r e ctu m w i ll s h o w in m o s t ca s e s the rea l

nature o f the di s e a s e K u m m e ll advi s e s i n a ll ca s e s wh e re th e re i s
.
,
pr o tracted catarrh o f the l ar g e inte s tin e whi ch h a s re si s ted tre at

r
,
m ent and i s under m inin g the s tr e n g th o f the p ati ent that a carefu l
, ,
e x a m inati o n o f the rectu m b e m ade e ith e r di g i ta l o r in s tru m enta l , An .
o rdinary oe s o pha gu s s o und i s we ll s uited fo r the diagn o s i s o f hi gh l yi ng -
s tricture s Thr o u gh i t w ater m ay b e inj ected t o di s t e nd th e fol d s o f

.
m uc o u s m e m brane ob s tructin g i t s intr o ducti o n S o und s o f wha l e .
b o n e with ol ive shape d iv o ry head s are a l s o u s efu l in s tru m en t s fo r thi s

-
p urp o s e a s i s further m o re All in gha m s rub b er b a lloo n c o n s tructed fo r

,
’
a l ike o bj e ct Th e auth o r u s e s a wha l e b o n e s o und havin g a s p o n g e

.
-
attached t o it s further end the s p o n g e b ein g when intr o duced in a

, , ,
c o m pre ss ed s tate and gl idin g ea si l y thr o u gh the s trictured p art On

, .
withdrawin g the s o und m o re o r l e s s fo rc e m u s t b e exerted a s the ,
s p o n g e s woll en and m uch increa s ed in s iz e i s o b s tructed by the s trict

, ,
ure I n thi s m anner th e p o s iti o n and s iz e o f the l atter m ay quite w e ll

.
b e determ ined F o r th e dia gn o s i s and kn o wl ed g e o f th e re l ative

.
p o s iti o n s o f s evera l s tri cture s repeated exa m inati o n s m u s t b e m ade

, .
I n s o m e ca s e s it wi ll b e n ece s s ary t o di l ate the lo werm o s t s tricture b e

'
fo re anythin g p o s itive re g ardin g th o s e hi gher up can be arrived at .
E rr o r s in the dia gn o s i s o f th e s e hi g h l yin g s tricture s are fre quent l y -
m ade and nu m er o u s ca s e s o f thi s kind have b een rec o rded

,
Such a .
ca s e was p ub l i s hed b y Sy m e The o b s tructi o n t o the s o und o n i t s i n

.
t ro d uc ti on which w as s upp o s ed t o b e a s tricture wa s fo und in the

, , ,
aut o p s y t o have b een th e pr o m o nt o ry Wh en a s tricture i s pre s ent

,
.
,
i t s n ature s h o u l d b e if po s s i bl e deter m in e d
,
whether n a m e l y o f
, , ,
cicatricia l o ri gin o r ari s in g fr o m c o m pre s s i o n o f the rectu m by p ath o

,
lo gica l c o nditi o n s o f th e uteru s b l adder pr o s tate o r by exudati o n s o r

, , ,
tu m o r s in the s m a ll er p e l vi s etc I n s o m e ca s e s i t wi ll b e extre m e l y

,
.
diffi cu l t t o deter m ine whether the s tricture b e due t o a cicatricia l pr o

c e s s o r a m a l i g nant ne o p l a s m Thi s i s o f c o ur s e o f great i m p o rtance
.
, ,
in the treat m ent The follo wi n g ca s e o f th e auth o r s wi ll b e i n s truc

.
’
tive fr o m thi s p o in t o f V ie w : P atient a m an ae t 5 6 had experience d , , .

,
36 E D I T OR I A L A R TI C LE S .
a s udd e n l ar g e h e m o rrha ge fr o m th e rectu m follo wed h o we ver by n o , , ,
further s y mpt o m o f di s ea s e But gradua ll y pain s in the lo in s and .
l i m b s g e n e ral weakn e s s and d e bi l ity deve lo p ed cau s in g hi m t o s e e k

, ,
m edica l a s s i s tance Carcin o m a o f the re ctu m wa s s u s pect e d by h i s

.
phy si cian but di g ita l e xa m inati o n g ave ne g ative r e s u l t s

, On intr o .
d u c in g b o u g ie s h o we v e r a s tricture wa s fe l t ab o ut 1 3 ct m s ab o v e th e
, , .
anu s I t wa s pa s s ab l e fo r an in s tru m e nt o f 1 2 m m thickn e s s G rad

. . .
ua l di l atati o n was k e pt up the he a l th o f the pa t i e nt i m pr o vin g rapid l y

, .
When s een by the auth o r abo ut fo ur m o nth s after the h ae m o rrha g e,
had o c c ur e d h e did n o t at a ll pre s ent th e appearanc e o f an in va l id

,
'
Thi s fav o rab l e c o nditi o n h o we ver chan g ed s h o rt l y after ward s t he p a

, , ,
ti e nt sh o win g the a l m o s t un m i s takab l e loo k o f o ne affl ict e d with car

c in o m a Nine we ek s l at e r a di gita l exam inati o n d e tect e d th e e xi s t e nce
.
o f a carcin o m a R adica l extirp ati o n was follo we d by r e c o very In

. .
ca s e s o f d o ub tfu l diagn o s i s the p ati e n t sh o u l d b e k e pt und e r Ob se rv

ance for s o m e ti m e b e fo r e a p o s itive expre s si o n o f O p i ni o n i s given .
The ca se s are nu m er o u s and we ll kn o wn where s yphi l itic s tricture s ac ,
ce ss ib l e t o vie w and t o u ch have b een tr e at e d a s m al i gnant gr o wth s

,
.
F o r di l atin g hi gh l yin g s tricture s the s o call ed e l a s tic and wax

- -
b o u gi e s ar e th e b e s t They sh o u l d b e e m p lo yed h o wever with s o m e

.
, ,
care and are n o t s uffici e ntl y lo n g t o b e s e rviceab l e in a ll ca s e s Th o s e

,
.
o f Alli n gham are thick and h ollo w and c o m p o se d o f th e s a m e m at e ,
ri a l a s N el at o n s cathet e r s I f t hi s b o u g ie i s c o m pr e s s ed in the s trict

’
.
ure it m ay b e fi ll ed with water quick s i l ver fine s h o t e tc There are

, , , , .
,
fur th e r m o r e s ol id s o ft rubb er b o u gie s lo n g and e l a s tic with O l ive

, , ,
s hap e d p o int s Befo r e intr o ducin g a b o u gie the b o we l s s h o u l d b e

.
evacuat e d and th e rectu m irri g ate d with war m water The pati e nt l ie s .
o n a b e d o r s o fa with the br e ach pr o trudin g o ver the e d ge A grad

,
.
ual s lo w intr o ducti o n o f the we ll o i l ed b o u gie with fr e qu e n t int e r

, ,
m i s s i o n s wi ll e a s i l y o v e rc o m e any p ainfu l and di s a gr e e ab l e s en s ati o n s

,
in th e anu s c o ntracti o n s o f the s phincter s e t c I t i s n o t advi s ab l e t o

, ,
.
a llo w th e b o u gi e t o re m ain t oo lo n g as n o p er m anent dil a ta ti o n o f the ,
s tricture wi ll b e attained by thi s pr o cedure b ut t h e int e s tina l catarrh , ,
pr e s en t in all the s e ca s e s wi ll b e a ggravated Fiv e t o ten m inute s , .
wi ll s uffi ce fo r the de s ired e ffect N o r will it b e wi s e t o intr o duce.

H I GH - L YI N G S TR I C T UR E S OF TH E R E C T UIII .
37
m o r e than two di ffe rent in s tru m e nt s at o ne s ittin g At th e c o m m e nc e .
m e nt o f tr e at m e nt t h e b o u gie s s h o u l d b e intr o duc e d e very t wo t o

,
three day s l at e r o n wh e n di l atati o n h as pr o gr e s s e d c o n s id e rab l y l e s s

, ,
o ften E v e n aft e r all s y m p t o m s o f di s e a s e h av e di s app eared th e

.
,
b o u gi e s h o u l d b e o cca s i o na ll y e m p lo yed t o pr e v e nt if p o s s ib l e any , , ,
recurr e nce o f th e s trictur e Ab s ol ute rest wi ll b e nece s s ary in nerv.
o u s irritab l e an d an ae m i c individua l s e s p e ciall y at fir s t

, Sy m pt o m s o f ,
.
p e rit o niti s irritati o n painfu l fi s s ur e s etc m ay cau s e the treat m ent t o

, , , .
,
b e s u s p e nd e d at ti m e s fo r a whi l e Such incid e nt s happen in s pit e o f .
t h e gr e ate s t care The u s e o f a b o u gi e by the p atient hi m s e lf in th e s e

.
'
ca s e s o f hi gh l yin g s trictur e s s h o u l d th e refo re b e but s parin gl y a llo wed

-
,
and o n l y th e n in th e advanced s ta ge s o f the tr e at m ent and aft e r the

pati e n t h a s sh o wn h i s abi l i ty t o d o thi s Frori e p rep o rted a ca s e wher e .
th e in s tru m e n t s l ippin g fr o m th e pati e nt s gra sp p erfo rated the in te s

,
’
,
t i n al w a ll cau sin g death Tr o ub l e s m e sy m pt o m s s uch a s th e '
. o ,
,
catarrh etc sh o u l d b e re m o ved a s far a s p o s s ib l e

.
, Irri gati o n .
with war m ed s ol uti o n s o f a l u m tann i n c o rr o s ive s ub l i m ate , ,
o nce o r twice dai l y e s p eciall y after defe cati o n are b e ne , ,
fi c i al . In ca s e s where u l cerati o n s exi s t K o ni g advi s e s th e u s e ,
o f a weak s ol uti o n o f t h e ch lo rid e o f zinc which act s we ll o n ,
the u l c e rated p art s , but d o e s n o t affect th e n o rm a l m uc o u s m e m brane .
Burn in g s en s a ti o n s in th e r e ctu m t e ne sm u s e t c m ay b e r e l ieved by , , .

,
war m s itz b ath s s upp o s it o ri e s o f O piu m etc

, All i n gha m r e c o m m end s , .
in c as e s o f p ain a n d b urni n g in the pe l vi s and fo r th e inten s e n e ura l

gi a o ften fe l t ab o ut th e s acru m th e u s e o f an o int m ent c o m p o s e d o f ,
m o rphiu m and bi s m uth F o r i t s pr o p er app l icati o n t o th e m e m b rane

.
o f the re ctu m he h a s c o n s tructed a hard rubber bo u gie o n the p l an

,
o f a syrin g e Thi s i s p a s s ed c lo s e d int o the r e ctu m and i ts c o ntent s

.
, ,
t h e n e j e ct e d fr o m th e n u m e r o u s l atera l o p eni n g s Di s turb ance s o f th e .
di ge s tiv e o r gan s fr o m which the s e patient s in v ari ariab ly s uffe r wi ll r e

, ,
quir e suitab l e tr e at m e nt N o uri s hin g and ea s i l y di g e s tib l e foo d s h o u l d

.
b e gi v e n. F o r th e c o n s tipati o n l i gh t l axativ e s m ay b e e m p lo yed .
Di arr h oea o n th e o th e r h and gen e ra l ly re s u l ti n g fr o m irritati o n o f th e

, ,
hard i m pact e d fe ce s wi ll di s a pp ear u s ua ll y aft e r the in s tru m e n ta l

, ,
tr e at m e nt h a s b e gun P rep arati o n s o f bi sm uth n aphtha l in etc m ay

.
, , .
,
3 8 E D I T OR I A L AR TI C E S L .
b e e m p lo yed h o we v e r b ut th e u s e o f o pi ate s and s typ t ic a s h o u l d b e

, ,
g uarded a g ain s t I t wi ll
. b e ad v i s ab l e in th o s e ca s e s w her e the patien t ,
s h o ws t h e c o n s e quence o f lo n g s tandin g i n t e s tin a l o cc l u s i o n wi th

-
,
m ete o ri s m u s s y m pt o m s o f p e rit o niti s d e b i l ity e tc

,
n o t t o de l ay with , ,
att e m pt s at di l atati o n b ut t o pr o c e ed at o nc e t o th e e s tab l i s h m e nt o f

,
an artificia l anu s When the s e s y m pt o m s have di s app e ar e d and th e

.
hea l th o f th e patient per m it s treat m ent o f th e s tricture m ay b e under

,
taken and the atte m pt m ade t o b rin g ab o ut defecati o n in th e n o rm a l

,
way .
The pr o gn o si s wi ll b e fav o rabl e in th o s e ca s e s wh e n th e s tricture s

are acce s s ib l e t o tr e at m ent wi th bo u gie s and thi s i s n o t t oo lo n g de ,
~
l ayed As r e gard s the re s u l t s o f the treat m ent m uch wi ll depend o n

. .
the g reat e r o r l e s s e xtent o f th e de s tructi o n in the m uc o u s m e m brane ,
and o n the patience and e ner gy di sp l ayed by b o th p ati e nt and phy s i

c i an. K um m e ll g ive s th e hi s t o rie s o f two ca s e s which i ll u s trate th e
ab o ve m enti o n e d s y m pt o m s eti olo gy d i a gn o s i s and re s u l t o f tre at
-
, ,
m ent in a very characteri s tic m ann e r

, .
C A S E 1 Ma l e ae t 5 1 h as re s id e d fo r nine year s in the tr o pic s I n

.
,
.
,
.
1 8 7 3 h e c o ntracted s yphi l i s and s uffered in 1 8 7 9 fr o m an attack o f

dy s entery which gradua ll y a s s u m e d a chr o ni c fo r m re si s ti n g all tr e at
, ,
m ent . P ati e nt r e turned t o E ur o p e in 1 8 8 0 and a fter a m o nth s s o , ,

’
j o urn at a c ol d water b ath in g e s tab l i s h m e nt was di s char ge d cur e d A

-
, .
s h o rt ti m e afterward s h o wever the ol d s y m pt o m s o f di s e a s e r e turn e d

, , .
He c o n s u l ted a phy si cian bein g th e n very m u ch reduc e d in s tr e n gth

, ,
an ae m ic and c o m p l ainin g o f m uch p ain in the lo in s o cca s i o na l di ar ,
rh oe a and frequ e nt de s ire t o s t ool e s pe cia ll y o n ri s in

g in th e m o rnin g
,
.
On l y s o m e m uc o u s b loo dy m atter and s m a ll a m o unt o f hard fe ce s

,
wo u l d b e p a s s e d the p ati e nt o n l y findi n g r e l i ef after two o r three

,
m o ve m ent s o f thi s kind Di gita l e x p lo rati o n o f th e r e ctu m rev e al e d

.
n o thin g abn o r m a l On intr o duci n g a b o u gi e h o we v er an o b s tructi o n

.
, ,
was fe l t ab o ut 1 4 c t m ab o v e the anal o penin g

. B o u g i e intr o duc e d .
dai l y and l e ft fo r fift e en m inute s t o an h o ur After tr e at m ent in t hi s .
m anner fo r ab o ut e i ght m o nth s pati e nt wa s c ur e d all o bj e ctiv e and , ,
s ubj ectiv e s y m pt o m s h avin di s appear e d Fai l in h o w e v e r t o follo w

g g .
, ,
th e advic e o f havin g a b o u g i e in tr o duc e d fr o m ti m e t o ti m e t o pre ,

H I GH -
L YI N G S TR I C T U R E S OF TH E R E C T U M .
39
vent any p o s s ib l e return o f th e s trictur e t h e O ld tr o ub l e s r e appeared ,
in 1 8 8 4 t wo and a ha l f y e ar s l ater Wh e n s een by the a u th o r pati e n t

, .
,
wa s in g reat Sufferin g T h e s tricture was di s c o v e r e d 1 4 c t m

. ab o ve .
t h e anu s and was n o t pa s s ab l e fo r a m e diu m s iz e d s o und

, Sy m pt o m s -
.
o f perit o nitic irritati o n an d a p ainfu l fi s s ure o f th e anu s cau s ed fre

que nt int e rrup t i o n s in th e tr e at m ent The g en era l c o nditi o n o f th e
.
p atien t i m pr o ved h o wever a s t h e di l atati o n o f the s tri ctur e pr o

, ,
gre s s e d In the c o ur s e o f s ix t o s ev e n m o nth s the tr o ub l e s o m e s ym p

.
t o m s s ub s id e d and th e s tri cture ad m itted th e l ar g e s t s iz e d b o u gi e s

, .
D e fe cati o n w as n o r m a l and pain l e s s app etite exce ll e nt and g enera l ,
app earanc e hea l thy B o u g i e s are s ti ll e m p lo ye d ev e ry fi v e t o s ix

.
we e k s P atient i s we ll and s tr o n g eat s and di g e s t s th e h e arti e s t kin d s

.
,
o f foo d .
C A S E I I M a l e ae t 4 2 h as re s ided e l ev e n y e ar s in the tr o pi c s where

.
, .
, ,
he h a s s uffere d fr o m s evera l vi ol ent attack s o f diarrh oea b ut with n o ,
s y m p t o m s o f dy s entery Fr o m ti m e t o ti m e he h as b e en tr o ub l ed
.
with di s turbanc e s o f th e di g e s ti v e o r g an s and the s e b ei n g attri b uted ,
t o c l i m a t i c influ e n c e s pati e n t r e turn e d t o E ur o p e

, H e wa s treate d .
fo r a lo n g ti m e fo r ga s tric catarrh a s a ll the sy m p t o m s s e e m ed t o ,
p o int t o th e s t o m ach a s th e s e at o f h i s tr o ub l e F o r p a s t t wo y e ar s .
l ar g e quantitie s o f epid e r m i s l ik e m a s s e s and m ucu s have b een p a s s ed

-
in defe cati o n Th e fe ce s are s m a ll and hard

. P ati ent never h as the .
fe e l in g o f c o m p l e te e vacuati o n o f th e b o we l s aft e r defe cati o n Che s t .
o r g an s n o r m a l and di gita l e xam in ati o n o f th e re ctu m g ave n o r e s u l t

,
.
Catarrha l c o nditi o n o f th e m uc o u s m e m bran e o f r e ctu m On i n tr o .
d u c i n g an e l a s ti c b o u gi e an o b s tructi o n w a s fe l t ab o ut 1 3 ct m ab o ve
, ,
.
th e anu s A wha l e b o n e s o und wi th a m e diu m s e iz e d ol ive s haped

.
- - -
h e ad c o u l d b e p a s s ed thr o u gh th e s tricture and detected th e exi s t e nce ,
o f a s e c o n d s tricture ab o ut thre e t o fo ur c tm ab o ve th e fir s t Di l ata . .
ti o n wit h h eavy rubber b o u g i e dai l y In t w o m o n th s ti m e b o th s trict .

’
ure s we r e p a s s ab l e fo r very l ar g e s o und s A third s tri cture circa 3 .

,
c tm . in l e n g th wa s th e n di s c o vered l y in g ab o ut 2 1 c t m ab o v e the
,
.
anu s D i l atati o n o f th e l atter wa s difficu l t at fir s t b ut in th e c o ur s e

.
,
o f fift e e n m o nth s th e lo we r s tri ctur e s we re c o m p l ete ly re m o ved and ,
the upp e r m o s t was pa s s ab l e for the thicke s t in s tru m ent There was .
40 E D I T OR I A L A R TI C LE s .
s ti ll s o m e catarrh o f th e int e s tin e P ati e nt . i s we ll at p re s ent and e u

j o y s n o r m a l app e tite and goo d di g e s ti o n . A l ar ge b o u gi e i s intr o
d uc e d fr o m ti m e t o t i m e . C J C O LL E S
. . .
O S T E O CLA S I S .
l
(C ot
n i n ue d f r om Vol I V .
, p .
Colli n
’
s a pp
The fir s t in s tru m ent in v e nt e d by M C o ll in ( in
a r a t us . .
m ad e u se o f t h e l e vera g e o f t h e le g in o rd e r t o break th e fe m ur
1 8 79
) .
I t h ad c o n s equ e nt l y th e fau l t o f e x e rtin g i t s s tr e n g th o n th e l i g a m e nt s

o f th e kn e e and h as given p l ace t o an o th e r fo r m pr o duc e d acc o rdin g
.
,
t o Po u s s o n aft e r M C ollin had s e en h o w M R o bin h ad av oi ded thi s

,
. .
d e fect It i s therefo r e n o t n e c e s s ary t o d e s cribe C oll in s fir s t ap

.
, ,
’
paratu s in thi s arti cl e N e v e rth e l e s s v e ry g oo d r e s u l t s were O b tain e d

.
,
by thi s m achine inc l udin g th e s ucce s s fu l br e akin g d o wn o f a m al

,
united Po tt s fracture Po u s s o n giv e s an i ll u s trati o n o f the o s te o cl a s t

’
.
o f Tay lo r o f N e w Y o rk and c o m pare s i t with C oll in s fir s t ap

, ,
’
paratu s I t h o we ver o bvi o u s l y wo rk s wi th m uch l e s s l e vera g e and

. .
, ,
c o u l d b e m ade t o br e ak the fe m ur near e ith e r e xtr e m i ty with o ut s train

i n g the l i g a m ent s o f th e knee N o s tat e m e nt s are m ad e as t o i t s .
s a fe ty o r dan g er .
I t s gr e at m e rit i s that it r e duc e s t o a m ini

’
R ob i n s app a z a f us .
m um the l en g th of l evera g e r e quire d and thu s for e xa m p l e en ab l e s the , ,
s ur g e o n t o break t h e fe m ur j u s t ab o v e th e c o ndy l e s wi th o ut t h r o win g
th e s l i ght e s t s trai n o n the kn e e Th e re fo re in pr o ducin g h i s o s t e o .

,
cl a s t M R obin s olved the m ain pr o b l e m in c o nn e cti o n with i n s tru

, .
m enta l o s te o c l a s i s .
R o bin s apparat u s c o n s i s t s o f a w oo den p l ank t o s upp o rt t h e thi g h

’
( t h e pati e nt l i e s o n h i s back
) o f a m eta l p l ate t o l i e o n t h e fr o nt o f
,
the thi gh and th e r e fo re s l i gh t l y g utt e r s hap ed with the c o ncavity o n

,
-
th e lo wer s urfac e ( that which t o uch e s th e thi gh ) o f t wo s te e l b and s o r ,
h O O p s e g m ent s o f fo ur s cre ws o f a l eath e r c oll ar and a l e ver

-
, ,
.
l
De p ar le D o ct u r A l fr d P o u o n l ar i J B
e e ss ,
'
s, . . Bai lli e re et fi ls .
P ar i s , 1 88 6 .
OS TE O C A S I SL .
41
The p l ank i s p l aced o n th e tab l e i n s uch a way th at the wh ol e

l en g th o f th e fe m ur l ie s up o n i t th e p atient b e in g o n h i s b ack Thi s
,
.
di sp o s iti o n i s ab s ol ute l y nece s s ary fo r o ther wi s e a m o ve m ent o f r o ta

, , ,
ti o n and a c o n s e quent o b l iqu e fracture m ay b e expected at th e m o

m e n t o f o perati o n Th e p l ank i s in t wo p art s which can b e ap
.
p ro a c h e d o r s eparated s o a s t o adapt the app l iance t o thi gh s o f dif

fe re n t l e n g th s T h e p l ank i s p added w ith l e ather e s pecia ll y at the
.
,
upp e r and lo wer ed g e s The upp er ( s tee l ) p l ate o r g utter i s s i m i l ar l y

.
p added I t e m brace s the upper s urface o f the thi gh

. I t i s n o t m uch .
arched d o wn ward s at the Si de s l e s t it s h o u l d interfe re wi th the l atera l

,
exp an s i o n o f t h e s o ft p art s and i m pri s o n the l i m b t oo ti ght l y .
The s te e l h oo p s e g m ent s are p l ac e d acr o s s the s tee l p l ate o ne n ear

-
,
each end and are then s cre we d d o wn t o th e p l ank b y fo ur p e rp e n d i c u

,
l ar s cre ws In thi s wa y the thi gh i s fixed b etween th e woo d e n p l ank

.
b e lo w and the s tee l p l ate ab o ve The s cre ws are driven h o m e by a

.
key which h a s a s prin g near the hand l e s o arran ged a s t o indicate

,
when th e s cre w fo rce u s e d i s s uffici ent b ut n o t dan g e r o u s , .
I t I S a ésolzczely n ecess a ry to s cr ew th e p la i e fi r m ly dow n on fi l e M ig fi

‘
a a l as fi x Il
’
n iz
‘ ‘
ze la l ze r a ésola ze ly Other wi s e a n e at and preci s e frac
‘
.
,
ture at th e e x act sp o t de s ired cann o t b e expected .
T h e c o m pre s s i o n pr o ce s s ab o ve de s crib ed fo rce s th e artery and the
s ci atic nerve t o ward s the inner s ide o f the fe m ur and d o e s n o t c o m
pre ss either .
The kne e m u s t b e extended b efo re the s cre ws are ti ghtened o ther ,
wi s e the s kin wi ll b e dra gg ed o n .
The l e ath e r c oll ar i s p l aced o n the c o ndy l e s and i t s e xtre m itie s , ,
pier c e d wi t h e ye l e t h ol e s ar e b o ok e d o n t o th e runner o f th e l ev e r
-
,
.
The c oll ar s h o u l d b e sh o rt and the l ever th u s b r o u gh t a s near t o the

,
p ate ll a a s p o s sib l e .
The p o p l itea l v e s s e l s l i e s n u gl y b etween th e c o ndy l e s s afe fr o m ,
pr es s ure .
Havin g thu s adj u s ted each p ar t o f th e app aratu s th e s ur ge o n ,
s eiz e s th e l ever and pr o duce s a s uccu s s i o n ( s ec o u ss e c o ntin u o u s fo r a

) ,
f e w s e c o nd s rather th an vi ol ent fo r h e o ther wi s e m i ght exc e ed th e de

, ,
g ree o f fo rc e j u s t nece s s ary t o d e ter m i n e c o m p l ete fract u re .

42 E D I T OR I A L AR I I CLL S .
As oo n a s ever th e fractur e i s c o m p l e ted t h e l i m b m u s t b e freed

s .
A s i m p l e m e ch ani s m p re m i t s thi s t o b e d o n e in a m o m ent .
P a s s in g t o th e n e w o s t e o cl a s t s t h e au th o r g ive s a n u m b e r o f e xp e ri
,
m ent s ninete e n in a ll m ade by D e m o n s o f B o rd e au x and by hi m s e l f

, , , ,
up o n the fe m o ra o f adu l t s ubj e ct s with R o bin s apparat u s All the s e ,

’
.
tend e d s tr o n gl y t o pr o v e the pre ci s i o n s afe ty and hi gh va l ue o f th e ,
pr o cedur e It i s true o ne s eri o u s accident o ccurred n a m e l y tearin g

.
, ,
a way the ant e ri o r cruc i a l l i ga m ent fr o m t h e c o ndy l e But th e e xp e ri .
m enter b l a m e s h i s o wn in e xp e rienc e fo r thi s ( it wa s h i s s e c o nd e xp e r i
m ent and th e s erie s a s a wh ol e t e nd s t o s h o w that with e x peri e n ce

) , .
in th e u s e o f th e m achin e ca m e w o nderful preci si o n and n e atn e s s in

,
the p l ace and charact e r o f th e fractur e

F o ur experi m en t s o f fracture o f th e le g by R o bin s o s t e o c l a s t are ’
g iv e n The fir s t pr o duce d di s a s tr o u s re s u l t s th e s e c o nd wa s l e s s m i s
.
,
c h i e vo u s the third and fo urth were very s ucce s s fu l

, T h e auth o r a t .
tribute s th e s e vari o u s r e s u l t s t o the pr o p e r us e o f p addin g i n th e l atter

ca s e s and t o the ne gl e ct o f it in th e fo r m er
, .
Sati s fact o ry e xp e ri m e nt s o n th e lo we r end o f the radiu s are a l s o de

s crib e d .
A v e ry fav o rab l e acc o unt i s a l s o giv e n o f t h e re s u l t s pr o duce d b y
C oll in s o s t e o c l a s t ( h i s n e w fo r m ) Thi s chiefly c o ntra s t s with R o bin s

’
.
’
i n th at it act s s id e w ay s whi l e th e l atter break s fr o m anter o p o s teri o r l y -

.
Af te r t r ea lm en t s ega a la a n d a ccza’en ls o f t h e O p erati o n

'
-
.
,
M R o b in d o e s n o t r e ctify th e p o s iti o n o f the br o k e n b o n e unti l s ix

.
o r ei gh t day s aft e r o s t e o c l a s i s Durin g th e fir s t we ek a s p l int i s ap

.
p l ied m ol d e d t o th e l i m b in i t s d e fo r m ed s tat e b e fo r e O p e rati o n .
”
Thank s t o thi s m o de o f pr o c e e di n g we are t ol d rupture and s trip
“
, ,
pin g up o f th e p e ri o s t e u m a n d c o n s e qu e nt l y ge nera l and lo ca l re ac

, , ,
”
ti o n s ( fe v e r p ain swe ll i n g h yd rarthr o s i s) are av o id e d
, , , ,
.
Q uit e e xc e p ti o na ll y aft e r th e app l icati o n o f C oll in s apparatu s Mr

’
.
, ,
M R e c l u s G i ll e tte an d V e rneui l h ave o b s erv e d th e app e arance o f a

.
,
s m a ll g rayi s h and nu m b s p o t i n the s kin which h o wev e r n e ver m o rti

, , , ,
fi ed Bi l l r o th o nc e n o tic e d te m p o rary p ara l ysi s o f th e e xterna l p O p lit

.
e al .
Seri o u s inj uri e s t o th e j o int s ,

e .
g .
,
re l axati o n o f l i g a m e nt s ,
h yd rar
OS TE O C L AS I S .
t hro si s ,hav e o ccurred b ut le s s fre quent l y th an th e a bo ve r e l at e d ex

,
p e ri m e n t s o n the dead b o dy m i ght l e ad o n e t o exp ect .
I n a s m a ll m i n o ri ty o f ca s e s there i s a s l i ght fe bri l e re acti o n after

th e O p e rati o n .
M o difi cati o n s o f R o bin s m achin e can b e app l ied t o any p art o f any
’
o f the l i m b s .
Wh e n t h e kn e e i s anky lo s e d at a ri ght o r acute an gl e and i t i s de .
s ired t o b re ak the fe m ur j u s t ab o ve th e c o ndy l e s t h e l i m b i s p l ac e d o n ,
i t s o uter s ide and the o s te o c l a s t s pe ci a ll y m o difi e d fo r th e p urp o s e

, , ,
br e ak s i t fr o m wi th o u t in ward s .
S o m e exce ll ent ca s e s a re given o f t h e c o rrecti o n O f m al united -
Po tt s and C o lle s s fractur e

’ ’
.
Im
’
'
m ea za ze e
‘
f ecfs o f os teoc la s i s — A n a com i ca l les i on s zo /zi clz it ca uses .
The r e s u l t s o f M Ays ag u e r s nu m er o u s experi m e nt s o n m anua l o s t e o

.
’
c la s i s are t h u s s u m m ariz e d : I n y o un g chi l dr e n ab o ut 2 year s ol d the

b o ne s h av e s uch fl e x ibi l ity that c o m p l e te fractur e i s n o t g enerall y o b
tain e d . They b end and s trai ghten a g ain l ik e a fre s h branch o f a tre e ,
and there i s n o s ol uti o n o f c o ntinui ty i n th e p eri o s teu m Ther e i s .
”
“
infracti o n n o t true fracture Ab o ve 4 o r 5 year s o f a g e there i s
, .
a l m o s t a l wa ys rupture o f the peri o s t e u m and tru e fracture Thi s frac .
ture i s al way s s i m p l e ge n e ra ll y tran s ver s e s l i ght l y dentat e d The

, , .
p e riphera l s o ft p art s are c o n s tant l y un i nj ured pre s entin g neither ,
e cchy m o s e s n o r brui s e s T h e rupture o f th e b o ne ( the ti b ia) a l way s

.
take s p l ac e at the s p o t where th e thu m b s ( o n the kn e e if it b e u s e d ) ,
are app l ied I n ha l f the ca s e s th e fibu l a g ave w ay e xact l y at the s am e

.
l eve l a s th e tibi a In the o th e r s it was pr o duce d o n e o r t wo c e nti

.
m e t er s ab o ve o r b e lo w B ut the s e o b s ervat i o n s app l y t o o s t e o c l a si s o f

.
the diaphy s e s When the m anua l Or i s em erzt f or ce i s app l ied with a

.
vi e w to curin g g enu va l g u m the anat o m ica l l e s i o n s are very variab l e

and s o m e ti m e s c o n s iderab l e t o an a l ar m in g e xt e n t At a ll e vent s s uch .
,
i s t h e ca s e wher e t he o a t i e n t s a re pa s s e d t h e a ge o f chi l d h oo d M de . .
S anti e xp e ri m e nt e d o n s u bj e ct s b e t we en 1 8 a n d 2 2 y e ar s o f a g e and ,
i n 1 2 l i m b s th er e wa s n o e p ip h ys al s e parati o n b ut nine ti m e s rup

, ,
tur e o r d e tach m e nt o f t he e x tern a l l at e ra l l i g a m e n t and t wice a bi t O f ,
the c o ndy l e w a s t o rn a wa y with i t Once the c o n dy l e wa s br o k e n .
a w ay b o di l y m akin g a fr a ctur e int o the j o int

,
.
44 E D I T OR I A L A R TI CLE S .
C oll in s fir s t apparatu s wa s e ffe c tive in s eparatin g th e epiphy s i s e ve n

’
in ad ol e s c e n t s fr o m 1 4 t o 2 0 year s o f ag e b ut it pr o duc e d o th e r ,
l e s i o n s c o n s id e rab l e and ev e n al arm in g E v e n th e s e m i l unar carti l

, .
-
a g e s hav e b e e n di sp l ac e d by i t .
Th e r e i s n o t unfre quent l y inten s e p ain fo r fr o m t wenty fo ur t o fo rty -
e i ght h o ur s after the o p e rati o n I t o ft e n c o incide s with hydr arthr o s i s

. .
B o th s oo n di s app e ar .
B e fo r e the u s e o f the n e w o s t e o cl a s t s on e o r t wo v e ry s eri o u s ca s e s

o f arth ri ti s and p e ri o s titi s were r e p o rt e d Loo s e j o int h as al s o r e .
s u lt e d and even o ne p s eudarthr o s i s

, ( B o ecke l ) I n th e l a s t ca s e the .
par e nt s r e m o v e d th e s p l int s in th e fifth we e k an d m ay th e refo r e b e , . ,
b l am e d fo r th e e vi l r e s u l t .
Th e n follo ws an e x ce ll e nt chap ter c o ntainin g nu m er o u s s tati s tica l

fact s r e s p e cti n g th e app l icati o n o f o s te o cl a s i s t o m al unit e d fracture s -
.
Thi s chapt e r c o ncl ud e s h o we v er with a va l ue l e s s and narr o w c o m

, ,
pari s o n o f o s t e o c l a s i s with o s te o t o m y which fo r exa m p l e quite fai l s t o , ,
take int o acc o unt that o s t e o t o m y h a s o ft e n be e n o n l y und e rtak e n after

o s t e o c l a si s h a s fai l ed .
T h e nu m ber o f o s te o t o m i e s tak e n fo r c o m p ari s o n i s 3 7 o f the s e 7
wer e a tt e nded with abundant s uppura t i o n o r ery s ipe l a s .
I wi ll o n l y re m ark that I h ave m y s e l f d o ne e l e ven anti s e p tic o st e o t

o m i e s fo r m a l unit e d fractur e a n d s h o u l d hav e b e en g ri e v e d and s ur
-
,
pri s e d t o have s e en o n e s uppurat e .
V al u ab l e tab l e s o f ca s e s o f o s t e o cl a si s are added .
Os teocla s i s a pp li ed to t/ze t r ea lm en t of r a c/I i l i c ca r o a f a r es .
M Po u s s o n after di s cu s sin g the indicati o n s fo r o s te o cl a s i s in th e s e

.
,
affe cti o n s c o m p ar e s it with o s te o t o m y fo r th e s a m e di s e a s e s s o m e

, ,
what t o th e advanta g e o f the l att e r H e giv e s 9 8 o s t e o c l a s e s with

.
“
o ut a d e ath and inde e d with o ut any s e ri o u s c o m p l i cati o n

, , ,
.
M D e le n s wh o had gi v e n up o s t e o c l a s i s fo r M ac E we n s o s te o t o m y
.
,
’
,
h a s n ow aft e r s e ein g and u sin g C oll in s o s t e o c l a s t ( s e c o nd fo r m ) giv e n

,
’
,
up o s t e o t o m y in fav o ur o f m ach in e o s t e o c l a s i s E ven D e m o n s ( o f .
B o rd e au x ) th e French tran sl a to r o f M ac E we n s b oo k h as b e e n c o n ’
,
vert e d fr o m the adv o cacy o f o s te o t o m y fo r ge nu va l g u m t o t h at o f

o s te o c las i s .
os TE O CLA S I S .
45
That the o retica ll y p o ss ibl e accident arre s t o f gr o wth a s a c o u s e ,
u e n c e o f inj ury t o the e pip h y s ea l carti l a e h a s n o t o nc e be e n o b

q g ,
s erv ed .
There i s a d e arth o f o b s e rvati o n s m ade y ea r s aft er o s te o c l a s i s .
Lann e lo n g ue s a ys that ca s e s O perat e d o n in th e ol d wa y aft e r w ard s s uf

fe re d fr o m an e xtre m e s en s itivene s s in th e knee j o int t o chan g e s o f -
te m p erature and a t e ndency t o the fo r m ati o n o f o s te o phyte s at the l ine

o f fracture o r epiphy s ea l s e parati o n .
T h e durati o n o f treat m ent i s s o m e what lo n g after m anua l o s t e o ~
l a s i s o f adu l t s o win g t o the S prain e tc in flicted o n the j o int

, .
,
.
Th e fo rce required t o b r e ak a b o n e h a s by n o m e an s any fixed re l a

ti o n t o the age and s tre n gth o f th e p at ient .
The n e w m achine o s te o cl a s e s c o ntra s t with th e ol d n o tab l y in that

o n l y a sm all m in o rity o f th e fo r m er b ut th e l arg e m aj o r i ty o f the l at
,
t e r s uffe r fr o m l ive l y and pr olo n g ed pain s in th e n e i ghb o urin g j o int
aft e r o perati o n .
C o n s ol idati o n and b o ny uni o n tak e p l ace a s quick l y after the n e w

m o d e o f o s t e o c l a s i s a s aft e r a s i m p l e tran s ver s e fractur e cau s ed by
accident Age has a c o n s iderab l e infl uenc e o n thi s pr o ce s s The

. .
y o un g er the pati e n t th e m o re rapid th e uni o n .
T wo thre e o r fo ur week s m o r e g en e ra ll y s uffice fo r c o m p l e te r e c o v

, , ,
ery o f the s tr e n g th and s upp l en e s s o f th e l i m b .
I n c o m p arin g o s te o cl a s i s fo r ge nu va l g u m with M ac E we n s o s te o t ’
om y M ,
Po u ss o n r e gard s b o th a s ab s ol ute l y with o ut dan g e r H e
. .
p o int s o ut that a s o s t e o c l a s i s re quire s c o m p l icated apparatu s m any ,
s ur g e o n s e s p ecia ll y th o s e re s ident in re m o te di s trict s wi ll pr e fer o s t e

, ,
o t om y . H e c o nc l ude s fr o m a s tudy o f th e ca s e s rec o rded that c o n

, ,
v a le s c e n c e and c o m p l e te functi o na l r e s t o rati o n o f th e l i m b are n o tab l y
q u ick e r after o s te o c l a s i s by the n e w m achine m eth o d th an after

M a c E we n s o s te o t o m y’
.
f a nR
y los i s f
a nd o s om e oth e r
’
Os teocla s i s app li ea t o tfi e t r ea tm en t o
a r t i cu la r a fi ect i on s .
M Po u s s o n ana l yz e s 3 6 o s te o cl a s e s O f thi s c l a s s o f which 1 8 were

. ,
o f th e hip and 1 4 o f the kn e e He s ay s that the o rth o p ae dic re s u l t s

,
.
were
E D I T OR I A L A R I I CLE S .
P e rfect in
Sati s fact o ry in
T ol erab l y s ati s fact o ry in
Bad in
Th e o ri gin a l a ffe cti o n s l eadin g t o th e anky lo s i s we r e
Ti m es .
Trau m atic arthr i t i s

Tubercul ar
P uerpera l
Scar l atina l
Typh o id
E piphy s ea l
R heu m atic
Suppuratin g
Indeter m ined
In n o n e o f the s e ca s e s did o s te o cl a s i s pr o duce any r e l ap s e al th o u gh ,
in o ne ca s e o ri ginall y a trau m atic arthri ti s wh e re th e s p l int s etc

, , , .
,
w ere r e m o ved t oo ha s ti l y a vi ol ent infla m m ati o n r e s u l ted

, But .
t hi s did n o t attack the j o int i t s e l f o n l y th e s eat o f o s t e o c l a s i s

, T wo .
o r thr e e y e ar s h ad u s uall y e l ap s ed b et we en the d ate o f the o ri gina l

di s e a s e and that o f o perati o n All the patient s were ad ol e s cent s o r
.
m o r e o r l e s s y o un g adu l t s .
Wh e n an anky lo si s i s at a t oo acute an gl e fo r o ne o s te o c l a s i s t o
r e m e dy i t s ati s fact o ri l y R o bin s u g ge s t s t wo o n e ab o ve the o ther b e
, , ,
lo w th e j o int . T h e a l ternative i s a cuneifo r m o s te o t o m y .
M Po u s s o n s c o m pari s o n o f o s t e o cl a si s with o s te o t o m y in thi s cl a s s

.
’
o f a ff e cti o n s i s l ike h i s o th e r s i m i l ar c o m p ari s o n s very infe ri o r in va l ue

,
t o th e re s t o f h i s ad m irab l e b oo k H e cite s o n l y 2 2 l inear o s te o to

.
m i e s o f t h e hip w it h 2 d e ath s
, N o w I have m y s e l f d o ne 2 2 with o ut
.
,
any fatal ity and all with e x c e ll e nt r e s u l t and I e xpect that Vol k m ann
, ,
h as d o n e n e arl y a s m any th o u g h h e prefer s t h e we d g e o p e rati o n

, .
Wh e n o s t e o c l a s i s c o m e s t o b e d o n e every wher e in i s ol ated ca s e s by

s ur g e o n s wh o h ave had n o pr e vi o u s e xp erience o f the O p e rati o n we ,
m a y h ear o f s o m e m i s chi e f b e in g d o ne I c o n s i de r o s t e o t o m y o f t h e
.
hip t o b e a s s a fe a s t h at o f the fe m ur fo r g enu va l gu m when th e s ur ,

os TE O C LA S I S .
47
ge o n kn o ws h o w t o d o i t
. M Po u s s o n h o wever c o m e s t o the c o n
.
, .
e l u s i o n that it i s a very g rave b u s in e s s

.
I cann o t c o nc l ude thi s articl e wi th o ut fo r m all y o ffe rin g m y thank s t o

the auth o r o f th e b oo k under n o tice fo r the c o m p l ete lo gica l h o n e s t
, , ,
and a l t o g e ther e xce ll ent m anner in which he h as l ai d b efo re th e pr o

fe s s i o n an acc o unt o f wh at i s evident l y de s tine d t o b e a s ur gica l pr o
c e d ure o f hi gh va l ue and o f fre qu e nt app l icab i l ity . The wo rk i s b o th

practica l and s ch ol arl y . C B KE E T L E Y
. . .
INDE X O F S U R G I C A L PR O G R E S S .
G E N E R A L S U R GE R Y .
I . T reatm e n t o f E r y s i p e l a s By Dr W O TT O ( R ud ol ph H os
. . .
pital V ienna) In 1 8 8 3 Bar we ll r e p o rted five ca s e s o f e ry s ipe l a s ve ry

,
.
s ucc e s s fu ll y treat e d by e x c l u s i o n o f air F o r thi s purp o se h e u s ed

.
white l e ad p aint .Dr J Breuer re l ated t o th e auth o r a fav o rab l e ca s e

. .
s i m i l ar l y tr e at e d w ith l i qu o r g utta p e r c h ae a s an air e x c l uder

- Ott o -
.
u s e s a s ol uti o n o f 2 part s wa x 2 0 p art s dry e r and 1 0 0 l in s eed o i l

,
.
With thi s he m ake s r e p e ated app l icati o n s o ver t he affe cted p art and a
hand s breadth bey o nd Fiv e h o s pita l ca s e s a re d e s crib ed and fo ur
’
.
di s pen s ary p atient s m en ti o n e d In a ll the te m p e ratur e v e ry s oo n fe ll

.
,
th e pain s t o pp e d and n o furth er e x t e n s i o n o ccurred T h e fact that .
ery sipe l a s s pread s thr o u gh the upp er l ay e r s o f cuti s m ay p o s sib l y de

p end o u the acc e ssib i l ity o f ox y g e n [ Lo ca l app l icati o n s o f l e ad p aint
.
,
c o llo di o n va s e l in e s m e ared o n thick etc are e s t e e m e d by m any

, ,
.
,
Am erican practiti o ner s R ep t r ]

. Wi en M ea Woc/z 1 8 8 6 N o 4 3
. .
’
. . . . .
II . C o n t r i bu t i o n t o t h e P a th o g e n e s i s o f A c t i n o m y cos i s
A
of th e Lu ng . By Dr J I S R A E L ( B e rl in)
. . I srae l s pr e s e nt ca s e wa s
.
’
that o f a R u s s ian driv e r aet 2 6 wh o had u s ua ll y s l e p t o n s tra w o r in

,
.
,
h ay lo ft s and s o m e ti m e s drank fr o m th e s am e tr o u gh as hi s h o r s e
, .
A fter s o m e p ain in t h e l e ft s id e o f th e ch e s t in Oct o b er 1 8 8 6 ab , ,
s c e s s e s fo rm e d b e lo w th e l e ft nipp l e : th e s e in cr e a s ed in nu m ber and
dev e lo p e d u l cer s On ad m i s si o n in A u g u s t 1 8 8 5 there was m ark e d

.
, ,
e m aciati o n and c o n s iderab l e c o ntracti o n o f the l eft s id e o f t h e th o ra x
th e l atter c o ver e d wi th ab s ce s s e s and s o r e s wh o s e s e cr e ti o n c o ntain e d
ab undant acti n o m yc o s i s granu l e s T h e m uc o puru l ent sp u tu m i —

-
. at -
ti m e s tin ged with b loo d—a l way s c o ntained the s a m e De ath the e n d .
GE N E R A L S UR GE R Y . 49
o f M arch 1 8 8 6 fr o m diarrh oe a r e s u l tin g fr o m a m y lo id de g enerati o n o f

, , ,
th e ab d o m in al o r g an s .
A s in g l e fo ca l cavity in th e lo wer p art o f the l eft upp er p u l m o nary
lob e c lo s e t o the anteri o r s urface Fr o m thi s the pr o ce ss h ad fre e l y

, .
p e rfo rated th e fr o nt wa ll o f the che s t .
I n the actin o m yc o ti c pu l m o nary cavity wa s a l enti l si z e d fo rei gn -
b o dy which pr o ved m acr o s c o pica ll y m icr o s c o pica ll y and che m ica ll y ,
t o b e a fra gm ent o f a t oo th .
Thi s i s the fir s t p o s itiv e o f pr oo f o f th e V i e w which I had previ o u s l y .
adv o cat e d v i z that p u l m o nary actin o m yc o s i s d o e s n o t re s u l t fr o m

,
.
,
th e in spirati o n o f g e r m s in the air L b ut fr o m th e a s pirati o n o f g er m s

fr o m th e o ra l o r adj acent cavitie s cari o u s teeth evi dent l y b ein g o n e o f ,
the pri m ary s eat s .
In th e di s cu ss i o n R o s er ( M arb ur g) n o ted an acute and a chr o ni c

,
fo rm o f actin o m yc o s i s K o ni g ( GOtti nge n ) sp o ke o f s e ein g di s pen s ary

.
ca s e s frequent l y E sm arch h ad s een ten c a s e s wi th o n e death The

. .
p atient s are a l m o s t a l way s catt l e m e n Cen tél f Clzi rg 1 886 NO . . . . . .
24 . R ep o rt o f XV G er m an Sur gica l C o n gre s s A r c/z f Rli n Cfi i rg

. . . . . .
Bd 3 4 , H ft
. . I .
W . B R OW N I N G ( Broo k l yn ) .
III . A Cas e of Actin om

y c o s i s o f t h e Lu n g By A J . . .
O C H S N E R M D ( Chica g o )
, .
M a l e ac t 5 6 s t o ck rai s er b y o ccup a
.
, .
, .
,
-
ti o n A fter a hi s t o ry o f s evere p a i n In th e an tru m fo r s o m e m o nth s a

. ,
s p o ntan e o u s di s char g e o f p u s in t o the ph ar yn x with e s tab l i s h m ent o f ,
a p e rm anent fi s tu l a g ave r e l i e f— thi s in 1 8 7 8 S o m e o f the di s ch ar g e

,
.
find s entrance int o l arynx durin g s l eep excitin g s ev e re c o u gh I n , .
1 8 8 0 antru m was trephined fr o m t h e m o uth s craped and i rri g ated th e , ,
irri gati o n b ein g c o ntinued dai l y fo r two year s In 1 8 8 2 s i m u l tane o u s ly .

,
with cha n g e o f re s id e nc e N o rthern Me xic o and th e territ o ry b e , ,
t we en i t and C olo rad o the antru m c lo s e d and th e g e nera l hea l th wa s

,
m uch i m pr o ved I n 1 8 8 5 p u l m o nary sy m pt o m s c o n s i s tin g o f s uffoca

. ,
tiv e s en s ati o n s and c o u gh b e g an t o tr o ub l e h i m E xpect o rate s m ucu s .
and b loo d and in thi s s p utu m the ch aracteri s tic fun g u s o f ac tin o m y
,
c o si s i s readi l y fo und b y m icr o s c o pic exa m inati o n H i s p o s iti o n i s .

50 I N D E X OF S UR GI CA L P R O GR E S S .
s t oo pin g the ch e s t i s full in fr o n t and there i s a decre a s e o f m o ti o n

, ,
o n the l e ft s id e with du l ne s s r o u ghened r e s pirat o ry s o und s and nu m e r

, ,
o u s m uc o u s r al e s B e lo w the upper b o rder o f the fifth ri b and thr o u gh

.
,
o ut th e ri ght s id e the s o und s are n o r m a l .
The m an h as b e e n e n ga ge d i n rai s in g b uyin g and s e ll in g an d hand , ,
l in g l ar ge nu m b er s o f catt l e fo r m o re than fo rty ye ar s Am o n g the s e .
ani m a l s ther e were m any s ufferin g fr o m the di s ea s e kn o wn as l u m py

j a w , and it w a s the practice o f the p atient t o cure the ani m a l s thu s
affe cted b y free l y o penin g the ab s ce ss by crucia l inci s i o n extirpatin g

, ,
a s m uch a s p o s sib l e o f the l um p and intr o ducin g ab o ut on e drach m o f
p owdered ar s enic int o the cavity R epeatin g thi s o nce o r t wice .

,
u s ua ll y effecte d a perm anent cure — Cfi i cag o M ea f ou r a n a E x a m .

’
. .
’
.
Dec 1 8 8 6
. .
L S P I LC H E R ( B roo k l yn ) . . .
IV . A C as e Dr WM O N E I L L
of A c t i n o m yc o s i s . . .
’
”
A far m er ae t 5 0 had b een dre s s in g ca l ve s affected with what he
, .
,
”
ca ll ed rin g wo rm In a fe w week s h e wa s attacked with a pu s tu l ar
- .
erupti o n o n the left wri s t and fo rear m and a s l i ght appar e nt l y glan d u , ,
l ar s we ll in g under the ri gh t e ar When ( o ne m o nth after ward) h e .
fir s t c o n s u l ted Dr O N e i ll there were a l s o fo ur o r five sm a ll er s we ll

’
.
,
in gs in the nei gh bo rh oo d o f th e c l avicl e s and o ne in the l eft axi ll a .
I o dine and ar s enic given interna ll y citrin e o int m e nt lo ca ll y Skin , .
erupti o n a l m o s t di s appe ared in a fe w week s tu m o ur s s lo win g di m in ,
i sh in g But after two m o nth s o f treat m ent t o n s i ll iti s and aphth o u s

.
, ,
loo kin g s tate o f m o uth .
N ext m o nth m o uth better b ut t wo o r three n e w en l ar g e m ent s ap

, ,
pear ; s o m e o f ol d o ne s l ar g er The o ne b e lo w the ear was a s l ar g e .
a s a s m all hen s e gg s m oo th n ear l y pain l e s s e l a s tic and s l i ght l y m o v

’
, , , ,
ab l e Other sm a ll er swe ll in gs o ne b eneath chin o n e o n back o f

. , ,
head .
N o w s ub l i m ate and p o t i o d interna ll y i o dide o f a m m o n o int m ent

, . .
, .
e xterna ll y .
N ext m o nth appearance s m uch better b ut unfo rtunate l y s ev e r e

, ,
br o nchiti s s e t i n On i ts s ub sidenc e the tu m o ur etc are l eft m uch

.
, , .
,
wo r s e .
GE N E R A L S UR GE R I .
The tu m o ur s in the an gl e o f th e neck had ext e nd ed in all d ire c

ti o n s m o re e s p eci a ll y d o wn ward s I t had al s o s uppurated an d two o r
, .
,
thre e s inu s e s g ave exit t o a whiti s h p uru l ent fluid which fre quen t l y ,
c o ntained s m a ll ye llo wi s h p ar tic l e s The s o re g enerall y pre s ented a

.
reddi s h g ranu l atin g s urface b ut O cca si o na ll y dark c olo red s cab s wo u l d

,
fo rm o n it Severa l o f th e s m a ll er tu m o ur s o n the lo wer p art o f the

.
n e ck had near l y di s appeared b u t the o ne under th e chin wa s s ti ll l ar g e

,
en o u gh t o b e unc o m fo rtab l e an d th e tu m o ur o n the b ack o f the head

,
had b ec o m e a s b i g a s a wa l nut and a l th o u gh unu l cerated wa s s o

, , ,
p ainfu l that he c o u l d hard l y s l eep o n h i s b ack A s m a ll s we ll in g had .
”
a l s o fo r m ed und e r the l eft ear The incre a s e o f te m p erature and
.
p u l s e frequency l e s s than m i gh t h ave b een exp ected

- .
At thi s s ta g e i o did e an d br o m ide o f a m m o niu m w ere c o m m enced .
But th e tu m o ur s c o ntinuin g t o en l ar g e the O pini o n o f Mr A E B ar

, ,
. . .
ker was s o u gh t with a vie w t o s ur gical O p e rative tre at m ent ,

.
Dr O N e i ll fo und the m icr o o r g ani sm s s upp o s ed t o b e pecu l iar t o

.
’ “
”
the di s e a s e .
”
Speakin g o f th e ca l ve s with s o call ed rin g wo r m -Dr O N e i ll -
, .
’
s ay s ,
“
there are n o l u m p s at pre s ent under the j a ws o r in o r abo ut ,
their m o uth s R in g wo r m b e g an in th e m a s we ll a s in s ev e ra l o ther s

.
-
, ,
b y th e hair fall in g o ff a reddenin g o r infla m m ati o n o f th e s kin and

, ,
the fo r m ati o n o f a sh c olo re d s cab s m o re o r l e s s th i ck acc o rdin g t o th e

-
, ,
s everity O f the di s ea s e in the p art affe cted The di s ea s e i s cau s ed b y

.
a fun gu s which can b e de s tr o ye d by s u l phur o r b y m ercuria l prep ara

”
ti o n n o tab l y by c o rr o s ive s ubl i m ate
,
B ut Dr O Ne i ll h ad n o t up t o
’
. .
,
th e date o f h i s p ap er identified the fun gu s o f th e ca l f s di s ea s e with

,
’
that o f actin o m yc o s i s .
Up t o recent year s actin o m yc o s i s h as pr ob ab l y b een c o nfo unded

,
with s cr o fu l a and canc e r with the fo r m er in i ts ear l y s ta g e s and with

, ,
th e l atter in i ts u l cerate d s ta g e s .
Abo ut o ne ha l f o f the p ub l i s h e d ca s e s have b e en fata l

- The d is .
ea s e m ay attack a l m o s t any o r g an in th e bo dy .
O N e i ll think s that i o din e ar s enic and m ercury have s o m e p o wer

’
,
o ver th e di s ea s e i n i ts ear l y s t a g e s .
But after a ll where actin o m yc o s i s app ear s in the s hape o f externa ,

, ,
52 I N D E X OF S UR GI c A L P R O GR E S S .
tu m o ur s he think s that the m o s t e x pedi ti o u s and the b e s t t re atm ent

,
wo u l d b e r em ova l éy s u rg i ca l op er a t i on .
Actin o m yc o s i s appear s t o hav e b een fir s t di s c o v e r e d by I ta li an v e t

e rinary s ur e o n s and accurat e l y de s cribed by R ev ol ta in 1 8 68 B oll in
g .
g e r redi s c o v e red it and na m ed it in 1 8 7 7 and in th e follo win g y e ar

, , , ,
I s rae l d e s cri b ed the fir s t ca s e in m an .
C B K E E T L E Y ( Lo nd o n ) . . .
O P E R A T I VE S U R GE R Y .
I . N ew M e t h o d o f Am pu t a t i on at th e J iAnk l e
t By -
o n .
Pro f . A . C T A UB E R ( St P e ter sb ur g R u s sia)

. .
, . A fter havin g cri ticiz e d
FIG . 1 . S T U M P P R O D U C E D B Y T AU BE R ’
S M E TH O D .
th e m eth o d s o f o p erati o n at th e ank l e j o int intr o duced by Sy m e M a l

-
, ,
ai
g g n e ,R o ux S e d illo t Le F o rt and o th er s ur g e o n s P r o f T h as d e m
, , ,
. .
o n st r at e d in the fir s t c o n gr e s s o f t h e R u ss ian phy s ician s h i s o wn
m eth o d which i s a m o dificati o n o f P ir o g o ff s F i g 1 s h o ws a s tu m p

’
. .
m ade acc o rdin g t o T a ub e r s m eth o d H i s O perati o n P r o f T p er

’
. . .
fo r m s as follo ws .
OP E R A TI VE S UR GE R Y .
53
He b e gin s an inci s i o n at the attach m ent o f the tend o Achi ll i s ( A ,
F i g 2 ) and carri e s the knife fo r ward b elo w the m a ll e ol u s t o th e

.
, ,
Ch o p art s l ine ( B F i g
’
and then acr o s s t o the d o r s u m o f foo t
, .
,
F IG . 2 LI N E OE I N I I N AL N
C S O O G OU T E R SI D E OF A N L K E .
d o wn ( fr o m B t o C F i g
,
o n havin g reached the m idd l e li ne o n
, .
the p l antar s urface ( D F i g th e knife i s carried b ack war d t o the

,
.
he e l and then up ward t o the s tartin p o int ( D E A F i g I n thi s

g
r
, .
F IG 3 . . Li N E OF I N I I N AL N
C S O O G I NN ER S I DE OF A N KL E .
fi rs t o f o perati o n Dr T cut s the skin and o ther s o ft ti ss ue s t o

s tag e . .
th e very bo ne s .
S4 I NDE X OF S UR GI CA L P R O GR E S S .
I n the secon a s tag e P r o f T o pen s th e an k le joi n t in the u s ua l m an

’
. .
o
n er that i s he cut s l i gam ent s in thi s o rd e r li g fi b ulare ta l i p o s t li g

, , , .
-
.
, .
fi b ulare ca l cane u m and li g fi b ular e ta l i ant ; then ark r lig

,
.
-
and at . . .
,
l a st the de l t o id li g .
In the t/zi r a s tag e Dr T di s s ect s o ut th e a s tra g al u s and cut s O ff the

’
. .
foo t in the Ch o part l ine Whi l e an a s si s tant fir m l y h ol d s the os ca l c is

.
by fo rcep s Pr o f T s a ws o ff the e xt e rna l ha l f o f the b o ne in th e l ine

, . . ,
ou t fl o wt: /
F IG 4 . . THE F LA P CO M PLET ED .
c o rre sp o ndin g t o the:o ne fir s t m ade in the s kin ( B C F i g Thu s .
the interi o r flap o f the he e l c o ntain s a thick a l m o s t s quar e p art o f the ,
o s ca l ci s and the p o s ter tibia l artery n o t inj ured ( s e e F i g

. .
In the f ou r tlz s tag e P r o f T s a ws o ff the m all e ol i p ut s l i g ature o n

. .
,
the arterie s s evers and adj u s t s the two s urface s o f the b o ne s t o each
,
o ther which i s ea s i l y d o ne with o ut any exten s i o n o f the tend o A chi ll i s

, ,
as can b e s e en in F i g 4 La s t l y the w o und i s united with s uture s

. . .
N E R VO US AN D VA S C ULA R S YS TE M S . 55
Th e advant a ge s o f thi s m eth o d c o n s i s t s in th e follo wi n g p o int s

The p o s ter ti b i a l artery re m ain s intact s aved fo r the s tu m p ( s e e Fi g s
.
,
.
3 and 4 ) th e tend o A chi ll i s and b ur s a m uc o s a retr o ca l cane a re m ain -
uninj ured and the s urface s o f the b o ne s s a wn o ff Wi ll c o rre s p o nd

,
t o e ach Other ( se e F i g thu s fav o rin g the pr o ce s s o f o ss i fi c a

.
ti o n .
In 1 8 7 7 durin g the Turk o R u s sian war when there were m any s ol

,
-
,
dier s with fr o z en fee t P r o f Taub er tri ed h i s m eth o d with gratifyin g

,
.
re s ul t s He b e l ieve s th at in h i s m eth o d pre s e rvin g the p o s ter tibia l

. .
artery there i s far l e ss dan g er fr o m the necr o s i s o f flap s th an in the

o ther m eth o d s As t o the technique o f the O perati o n T aub e r s m e th o d
.
’
s e e m s t o b e l e s s c o m p l icated than th o s e o f the s ur g e o n s m enti o ne d
abo ve H o wever exp erience i s n eeded t o pr o ve all that Pr o f T c l ai m s

.
, . .
fo r h i s m e th o d Vr a tc/z ( St P e ter s b ur g)
. N o 5 J an 3 0 1 8 8 6
. . . . . , .
P J P O P O FF ( B roo k l yn ) . . .
VA S C U LA R S Y S T E M .
I . e n t o f S p o n t a n e o u s G l u t e al
La p a ro t o m y i n t h e T re a t m
a n d S c i a t i c An e u ri s m w i t h a R e p o rt o f T h r e e C a s e s i n ,
O n e o f w h i c h B o t h I n t e r n a l I l i a c A r t e r i e s w e r e T i e d at t h e
S a m e T i m e fo r D o u b l e G l u t e a l A n e u r i s m o f S i m u lt a n e o u s
D e v e lo p m e n t By F S D E N N I S M D ( Ne w Y o rk ) ( 1 ) Lap
. . .
, . .
,
.
a r o t o m y in n o w ay incre a s e s the dan g er s o f th e O p e rati o n o f l i g a

:
ture o f the in t e rna l i l iac art e ry ( 2 ) Lapar o t o m y pre vent s a s erie s 0 f
.
accident s which h av e o ccurred d urin g the p erfo r m ance o f the o pera

ti o n o f l i g atur e o f thi s artery by th e ol der m eth o d s Am o n g th e s e ac .
c i d e n t s m ay b e m enti o ned the divi s i o n o f the circu m flex and e i a s

p g
tric arterie s wo undin g th e v as deferen s incl udin g th e ureter in the l i g a
, ,
t ure p un c t ur e o f th e i l iac o r circu m flex ve i n s tyin g the g enita l branch o f

, ,
the g enit o crura l n erve s trippin g up and te arin g the p erit o neu m i n
-
, ,
j ury t o the s u b perit o nea l c o nnectiv e ti s s ue and o ther accident s o f a

l ike nature ( 3 ) Lap ar o t o m y enabl e s the s ur ge o n t o app l y the l i g a
.
t ure at a p o int o f e l ecti o n and affo rd s h im an o pp o rtunity o f O b tainin g

,
i nfo r m ati o n a s t o the exact extent o f di s ea s e in the m ain arteri a l trunk .
( ) ap ar o t o m y avert s the dan g er s which were l ike l y t o follo w l i g ature

4 L
56 I N D E X OP S UR GI CA L P R O GR E S S .
o f the i nterna l i l iac artery by th e ol der o p erati o n s am o n g which m ay ,
b e cited p erit o niti s re s u l tin g fr o m t e arin g up the perit o n e u m p o s te

r i o rl
y ce
,
ll u l iti s puru l en t oe de,
m a p e l vic ab s ce ss s e ptic ae m ia and p y
, ,
ae m i a .
( 5 ) Lap ar o t o m y o ccupie s m uch l e s s t i m e fo r i t s perfo r m ance
in o rd e r t o exp o s e th e interna l i l i ac artery th an was o ccupied t o reach
th e v e s s e l by the inci s i o n o f C oo per o r Ab ernethy A s gl utea l an .
e u ri s m a s a ru l e t o which ther e i s b ut o ne e x c e pti o n ( which i s d o u b t

,
fu l) pr o gre s s e s s teadi l y and rapid l y t o certain death fr o m h ae m o rrha g e

, ,
exp e ctant tr e at m e n t i s o ut o f the que s ti o n .
Other m e th o d s hav e n o t pr o ven e m inent l y s ucce s s fu l the o p erati o n ,
o f An ty ll u s g ivin g acc o rdin g t o H ol m e s fo ur r e c o v e rie s o ut o f fi ve ,
ca s e s ; that o f Ane l two rec o v e ri e s o ut o f fo ur ca s e s ; p e rch lo ride o f

,
ir o n in j e cti o n fo ur rec o verie s o ut o f s ix ca s e s ; pr o xi m a l c o m pr e s s i o n

,
o n the a o rta with dir e ct c o m pre s s i o n fai l ure ; l i g atur e o f th e interna l ,
I l iac by an inci s i o n para ll e l with Po up art s l i a m ent and p u s hin g b ack

’
g
the perit o neu m s ix rec o verie s in e l ev e n ca s e s I t b ein g rec o gniz e d
, .
,
h o w ever that the Hunterian m eth o d o f l i g ature o f th e m ain art e ry o n

,
the pr o xi m a l s ide give s th e b e s t re s u l t s par t icu l ar l y where e l a s tic c om ,
pre s s i o n i s inapp l icabl e a s in the pre s ent in s tanc e i t re m ain s t o find a ,
s ati s fact o ry way o f app l yin

g it ; fr o m the r e capitu l ati o n at the b e gin
nin g o f t h i s ab s tract l apar o t o m y wo u l d s e e m t o s upp l y the d e si de r
,
atu m .T h e auth o r re l ate s thre e ca se s t wo o f which o ccurr e d in h i s ,
o wn practice : A T h e fir s t ca s e o ccurr e d i n a wo m an ae t 6 0 wh o
.
, .
,
pre s ented pu l s ati l e tu m o ur s in b o th gl utea l re gi o n s th e tu m o ur s datin g ,
b ack a y e ar and a hal f and p ain in the re gi o n thre e y e ar s b ack The

, , .
externa l p art s b ein g th o r o u gh l y p urified an i nci s i o n in the m e dian ,
l ine fr o m the u m bi l icu s t o the sy m phy s i s pubi s wa s m ade th e p e l vic ,
vi s cera which w o u l d h ave hindered the o perati o n dra wn with o ut int o

, ,
war m m o i s t s p o n ge s and t o we l s th e interna l i l iac arterie s o f b o th s id e s

,
l i g atured in s ucce s s i o n with cat gut th e vi s cera r e turn ed th e external , ,
o p enin g c lo s ed and anti s e p tic dr e s sin g app l ied ; the pati e nt di e d with
s uppre s s i o n o f urin e and s l i g ht p arenchy m at o u s nephriti s o n th e third
day ther e after B The s ec o nd ca s e o ccurr e d in the practic e o f Dr

. . .
W L Che w o f Bir m in gham Ala and wa s a gl ut e al an e uri s m o f the

. .
, , .
,
ri ght s ide o f a m a l e ne gr o ae t 4 6 th e tr o ub l e datin g back s e v en

, .
,
N E R V0 US A N D L
VA S C U A R S YS TE M S . 57
m o nth s By a curved l atera l inci s i o n the ab d o m en wa s o pened o win g

.
,
t o the vi ol ent effo rt s o f the patient and the di ffi cu l ty o f m anip u l ati o n ,
a fe w c o i l s o f inte s tine dra wn o ut s tr o n g s i l k l i g ature app l ie d t o the

,
interna l i l iac th e p art s cl ean s ed the inci s i o n c lo s ed and anti s ep tic

, ,
dre s s in g app l ied P r o m p t adhe s i o n o ccurred with rapid di m inuti o n o f

.
the tu m o ur and cure C The third o ccurre d in a fe m a l e ac t 1 8 and

. .
, .
,
was a s s o ciated with an ane uri s m a l varix the l eft s ide b ein g a ffe cted ; ,
the tr o ub l e datin g b ack m any ye ar s Under care fu l anti s ep tic pre

.
cauti o n s th e ab d o m en wa s o pened the inci s i o n fina ll y extendin g

, ,
fr o m th e sym p h ys i s t o s o m e di s tance abo ve th e u m b i l icu s the inte s

'
tine dra wn o ut s ufficient l y t o p er m it the exp o s ur e o f th e ve s s e l ,
a d o u bl e t wi s t e d cat gu t l i g ature app l ied t o the l eft interna l i li ac th e ,
g ut s returned th e e xterna l inci s i o n c lo s e d and anti s eptic dre s s in g a p

,
‘
p l ied ; th e patient ra ll ied qui ck l y and th e bo we l s m o ve d n o r m a ll y o n
the fi fth d ay a s l i ght acute a l b u m inuria due t o c o n g e s ti o n o f th e kid
ney fr o m the l i g ature o f th e m ain trunk o f th e interna l i l i ac app eare d
o n the follo win g day b ut s oo n di s app eared The ane uri sm t o gether
, .
with the aneuri s m a l varix w a s p erfect l y cured Th e s e ca s e s wo u l d .
s ee m t o de m o n s trate s ati s fact o ri l y th e avai l ab i l ity o f thi s m eth o d o f
tre at m ent the o n l y rea l o b s tacl e t o the s ucce s fu l i s s ue o f th e o p erati o n

,
b e in g the o ccurrence o f ac ute a l b u m inuri a t o ward the preven ti o n O f ,
which the s tudy o f s ur g e o n s s h o u l d b e directe d —M eet I V eu/ s No v . . .
J A M E S E P I LC H E R
.
(U . 8 A . rm y) .
O p e r a t i o n fo r A n e u r i s m A rch
’
II B d or of th e of th e
'
. . as s s
A o rt a an d of e A n o n ym
By Dr J R O S E N S TIR N ( San Fran
th a . . .
ci s c o ) Thi s articl e c o ntain s detai l s and s tati s tic s n o t o n l y o f the

.
ca s e s c oll e cted by Pi l z and by K o ch ( v o n Lan g enb eck s Arch iv Vol s

’
.
,
.
I X and X) and n o tab l y b y Wyeth ( A m J o ur M ed Sci b ut . . .

,
al s o o f the s cattered ca s e s s ince p ub l i s hed b e s ide s a n e w o ne o f R s ’

.
and o n e fr o m G er s ter ( N e w Y o rk ) .
The o perati o n was d o ub tl e s s fir s t perfo r m ed b y M o tt in 1 8 2 0 th o u gh

the fir s t p ub li s hed ca s e wa s that o f Wardr o p ( Lo nd o n ,
On l y o f l ate year s h a s th e O p erati o n b een ad o p ted in G er m an y .
R h a s b r o u ght t o g ether a t o ta l o f 9 9 ca s e s
. The s e h e divide s as .
follo ws
L I G T RE
A U OF CA R TI
O D AND R I GHT S U BC L I N
AV A , 38 C AS ES
WI TH O U T A N TI S E P TI CS . WI TH A N TI S E P TI CS .
L I G A T RE U OF TH E S A E E SS E L S I TH N I N T ER L ET W EE N
M V \V A VA B ,
IO C ASES .
L I G T RE
A U OF TH E RI GHT CO M M O N CA R TI
O D, 31 C A S ES .
I s
l r
ll s
l -
l
L I G T RE
A U OF TH E RI GHT S U BC L IAN
AV , 5 CA SES .
l l
l l
ll l
l -
l
L I G T RE
A U OF TH E L E T F CO M MO N CA R TI
O D, I O C ASES .
Under the s e c o nd c l a s s S m ith s ca s e ( cure ) i s n o t inc l uded Be s ide s ’

.
the ab o ve there are fo ur o ther ca s e s .
a Sched e 1 8 8 4 l i g ature o f l eft c a r o tid and l ater o f l eft s u b cl avian

.
, , ,
with i m pr o ve m ent fo r a ti m e .
b Bu s ch 1 8 8 0 —
. 1 l i gature o f l eft car o tid and axi ll ari s D e ath thre e
, , .
d ay s p o . .
c. Wi l he l m 1 8 2 6 l e ft s ubc l avian vein m i s taken fo r the artery and

, ,
tied Death o n s eventh day

. .
’
a M o rri s 1 8 8 2 interna l j u gu l ar tied by m i s take in s tead O f the ri gh t
.
, ,
car o t i d D eath o n fo urte e nth day

. .
C o l i g ature o f l eft car o tid and s u b c l avian h as never b een perfo r m ed

-
,
a l th o u gh Bu s ch s ca s e ab o v e appr ox i m ated thi s

’
.
R s patient was a S we d i s h wo m an ae t 4 2 P re s ent tr o ub l e b e g an

’
.
.
, .
t wo and a h a l f year s b e fo re Other fo r m s o f treat m e nt unavai l in g . .
P u l s at i n g T u m o ur s iz e o f a hen s e gg di s p l acin g trach e a cau s in g

.
’
,
r e at p ain lo s s o f fle s h etc H e ti e d the ri ght c o m m o n car o tid and

g , , .
H E A D A N D N E CR .
59
th e s u b cl avi an N o ve m b er 2 6 1 8 8 3 in the G er m an H o s pita l at S F

, , . .
The s u b c l avi an was r eadi l y s ecured Whi l e freein g the car o tid the an .
t e ri o r m edia s tin a l s p ace was p un ctured and s o m e air dra wn in when
a c o m pre ss c lo s e d th e O penin g Si lk l i g ature s Draina ge tub e and

. .
s ti tche s re m o ved at s ec o nd chan e o f dre s sin g fo urteen day s l ater

g
.
The ri gh t radi a l pu l s e did n o t reappe ar unti l J anuary 2 0 the te m p o ra l ,
unti l M arch 1 8 8 4 Th e tu m o ur s lo wl y d i m ini shed th o u gh it i s s ti ll

, .
,
detectab l e P u l s ati o n at fir s t di m ini shed a l s o b ut o f l ate h a s re turne d

.
,
fn fu ll fo rce P atien t l a s t s een in Apri l 1 8 8 6 She wa s a g ain a bl e t o

.
,
.
fi ll her p l ace a s h o u s ekeep er and wa s fre e o f h e r fo r m er s u fferin g

, .
A tr o phy and w a s tin g o f th e ri gh t arm follo win g the O p erati o n w ere , ,
r e m e died b y e l e ctricity and m a ss a g e .
D e s pite the vie ws o f H ol m e s and Mar s h ( 1 8 8 5 ) and K u s ter R c o n , .
c lud e s fr o m a s tudy o f th e ca s e s th at c o l i g ature o f b o th ve s s e l s i s -
preferabl e t o t wo s ep arate O per ati o n s Li g a t i o n o f th e s ub c l avi an i s

.
certai n l y the m o re i m p o rtant p art I n s evera l o f the ca s e s s u b s e quent

.
aut o p s y s h o wed th e car o tid t o b e s ti ll p arti a ll y o pen After b riefly t e .
vie win g o th er m eth o d s o f treat m en t and their re s u l t s h e de ci de s that ,
l i g ati o n i s far th e m o s t s ucce ss fu l —A r clz f Rli n Cfi i rg 1 8 8 6 Bd

. . . . . . .
34 . H ft . I .
H E AD AND N E CK .
I . The F o rm i
at o n of a N ew
fr o m t h e N as al S k e l et on
F r o n t al B o n e By P r o f K ON I G ( Go ttin gen ) I n ca s e s where the
. . .
bo ny fram e wo rk o f the n o s e h a s b een de s tr o yed a ll atte m p t s heret o ,
fo re at rec o n s tructin g a pr o p er pr o fi l e have fai l e d .
I n vie w o f fo ur fair l y s ucce s s fu l ca s e s K h ere pr e s e nt s a m eth o d , .
which he h a s devi s ed Fir s t the s o ft p art s ( tip an d al ae) are m ade

.
,
m o bi l e b y a tran s ver s e cut thr o u g h the m o s t s unken s add l e p o rti o n

( )
o f the n o s e I f thi s lo wer p art i s then dr a wn d o wn int o i ts n o rm a l
.
p o s iti o n a b r o ad g ap i n g defect appe ar s Thi s i s fir s t b rid g ed o ver by

,
.
cuttin g a to c tm wide o b lo n g flap fr o m the fo rehe ad p e rp e n

.
di c ularly up ward s fr o m th e b rid g e o f the n o s e Thi s fl ap inc l ude s .
s kin peri o s teu m

, and c o rtica l l ayer o f fr o n ta l b o ne —the l atter b ein g
cut ar o und b y a chi s e l T he wh ol e i s then loo s ene d b y follo win g d o wn
.
thr o u gh the dip lo e with a chi s e l the exact wi dth o f the flap ; at i t s
lo wer end j u s t at th e b e ginnin g o f the n o s e it i s b ent s trai ght o ve r
, ,
d o wn ward s in fr o n t Thi s b rin g s the s kin s ide o f the fl ap t o face the

.
interi o r o f the n o s e and l eave s th e b o ne exp o s ed Of c o ur s e the s iz e .

,
o f thi s flap h as b e en s o ca l cu l ated that it j u s t c o ver s the ab o ve m en

t i o n e d defect At i t s fre e e n d i t i s s o s e wed t o the ap ex that the ( ex
.
t e rna l) cutane o u s b o rder o f the l atter re m ain s free T o thi s fre e edg e .
o f skin as we ll as ar o und the defect he n ow s e ws a c o ver fl ap Itak e n ,

-
l atera ll y fr o m th e fo rehead .
Hence the b o ne peri o s t skin flap c o n s titute s th e inner l inin g o f the

,
- -
n o s e The b o ny pr o fi l e o f the n o s e i s thu s g iven an a m p l e pr o m i

.
h ence S o m e l itt l e c o rr e cti o n s m ay s ti ll b e nece ss ary ab o ut t h e r oo t

.
o f the n o s e .
H i s 4 ca s e s inc l uded 2 fr o m syphi l i s 1 fr o m inj ury and 1 in a bo y , , ,
ae t. 1
5 fr o m necr o si s
, The g oo d re s u l t s have pr o ved l a s tin g
.
year s y e ar s and in t wo 1 year h ave p a s s ed s ince the O perati o n

, , , .
All h i s flap s even when a l itt l e l e ss than 1 c tm wi d e have pr o ven v i a

, .
,
b le .
I t i s b etter n o t t o O perate s o lo n g a s there i s o z oena fr o m n e

c ro s i s o r u l cerati o n W oo d cut s and l ith o graph s acc o m panyin g the
.
-
a rtic l e .
K s tate s that h e i s t ryin g thi s m eth o d in ca s e s o f t o ta l lo s s o f the

.
n o se . Rli n Gfi i r 1 8 8 6 Bd 3 4 H ft 1 . .
, ,
.
,
. .
II . On th e M e l i p a n d C l e ft P a l
or a t l i ty of O p e rat e d H ar -
at e By Dr A H O FF A ( WtIrz b urg) Thi s articl e add s 8 0 ca s e s fr o m

. . . .
vari o u s o perat o r s in Wurzb urg and Fr e ib ur g— I S 7 O t o 1 8 8 5 —t o pre

vi o n s s tati s tic s [ 71 A N NA L S 1 8 8 6 J an p 8 0 —8 . Of the wh ol e 8 0 , , .
,
.
,
24 have s ince died Of 6 4 under o ne year ol d 1 9 ( 3 0 died

.
,
befo r e the end o f that year T h e c oll e ctive s ta t i s tic s fo r the fir s t year .
give 3 7 3 ca s e s wi th 1 2 9 de ath s H o ffa endeav o r s t o deter

, .
m ine h o w far the fata l re s u l t s w e re due t o th e O p erati o n and h o w far ,
t o th e m a l fo r m ati o n it s e l f The n o r m a l death rate the fir s t year fr o m

.
-
an av era ge fo r vari o u s c o untri e s he g ive s as 2 l eavin g 1 0 % d ue t o ,
o ne o r b o th o f the cau s e s m enti o ned T o deter m ine b et ween the s e .

H E A D A N D N E CK . 61
he divide s the re spe ctive ca s e s o f F ritz s ch l G o tthe l f Ab e l and hi m s e l f , ,
int o three c l a s s e s acc o rdin g a s the chi e f defo r m ity wa s : I hare l ip ;

, ,
-
I I c o m p l ete fi s s ure ; I I I b i l atera l fi s s ure :

, ,
-
G r o up I . 1 1 4 ca s e s , wi th 2 7 d e ath s
II . 1 1 1 c as e s ,
wi th 4 3 death s
III .
41 ca s e s ,
with 2 4 death s
Fr o m th e s e fi gure s sh o win g pr o gre s s ive m o rta l ity as the tr o ub l e i n

,
crea s e s i t cann o t b e d o ub te d that the m a l fo rm ati o n it s e l f h as a gre at

,
influence o n the m o rta l ity Thi s c o nc l u s i o n i s O pp o s ed t o th at o f

.
G o tthe l f wh o bl am ed the s everer o p erati o n fo r the increa s in g m o rtal ity

, .
Th o s e o f the I I I c l a s s are u s uall y b o rn w eak and atr o phic and with ,
great tend e ncy t o re s pirat o ry and di ge s tive tr o ub l e s Th e re s pirat o ry .
tr o u bl e s are re m edied t o a far greater extent by th e o perati o n than are

the di g e s tive H end e av o r s b y o ther s tati s tic s t o furth e r e s tabl i s h h i s
. .
vie w o f the prevai l in g influence o f the m a l fo r m ati o n it s e l f rather than ,
the O perati o n o n the m o rtal i ty b ut deci s ive fact s are wanti n g

, ,
.
By addin g up 6 2 0 p ubl i shed ca s e s o f all a ge s h e find s th e m o rtal i ty ,
fo r the fir s t two we ek s p o t o have b een 6 0 ( 9 . fr o m the s e c o nd

.
week t o the en d o f the third m o nth in 4 3 9 ca s e s it w a s 6 7 Of
33 6 ca s e s 55 died b e t we e n the third m o nth and the end o f t h e
fo urth ye ar Of 3 9 ca s e s o f b i l atera l c l eft pa l ate with Os pr o m inen s

.
-
o pe rated under o ne y e ar o f a ge 2 5 died wi thin a c o up l e o f,
year s . By c o m p arin g two curve s o ne repre s entin g the n o r m a l death , ,
the o th er th at o f the o p erated chi l dren du rin g th e fir s t year h e find s ,
that th e s ec o nd t o th e s ixth m o nth in cl u sive i s the m o s t fav o rab l e ti m e , ,
fo r o p eratin g Denti ti o n whi ch th en b e gin s s h o ws a de l eteri o u s i n fl u

.
, ,
ence . A s an evidence o f the advanta g e o f o p e rati n g ear l y h e ci te s a

ca s e where the l ip was treated and at the end o f three ye ar s th e pre ,
v i ou s ly e xi s tin g a l v e ol ar an d ant e ri o r p alata l fi ss ure h ad c o m p l ete l y
hea l e d o u t — A r cfi f Rli n C /zi r 1 8 8 6 Bd 3 3 H ft iii

. . . . .
, . .
, . .
III C o n t r i b u t i o n s t o t h e T h e o ry o f Go i t re
. By Dr J . . .
S c H R AN z ( H o pfg art e n in T yrol)

’
A two year s exp erience with thi s .
tr o ub l e in a re gi o n where i t i s ende m i c furni s hed th e incentive t o an ,
artic l e o n certain p o int s in c o nnecti o n with g o i tre e s p eci a ll y o n the ,

62 I ND E X OF S UR GI CA L P R O GR E S S .
dep endence o f a l terati o n s in t h e cardiac acti o n o n v ol u m e chan g e s -
in the thyr o id gl and With the en l ar g e m en t o f th e thyr o id th e auth o r

.
h as fre quent l y o b s erv e d that ab n o r m itie s appear in o ther o r g an s o f the

b o dy— he art affe cti o n s b e in g o ne o f the s e .
H i s c oll ective ca s e s repre s ented 7 3 9 g o itre s a m o n g s t individ

u a ls l ivin g and dead— 7 5 0 pri vate p atien t s with 1 1 7 go itre s 5 5 7 ,
s ch ool chi l dren wi th 2 4 5 aut o p sie s at the Inn s bruck Pa th ologi

,
ca l In s titute with 3 0 8 and 2 2 7 in s ane at Hall wit h 6 8 g o itre s

,
.
All ca s e s even t h e l i ghter fo r m s are incl uded th o u g h in y o un g er

, , ,
p atient s it s o m e ti m e s s ub sid e s l at e r Th e s e fi g ur e s s h o w th at th e G er
.
m an Tyr ol i s a s m uch a flli c t e d by g o itre a s even th e w o r s t p art s o f

‘
S witz er l and . Sti ll cretini sm and deaf m uti s m i s rar e the tr o ubl e b e
,
-
,
i n g rather e xt e n s ive than s ever e .
In the upp er c l a s s e s in s ch ool i t wa s m o re fr e quen t than in the lo wer ,
in har m o ny Wi th Bircher an d o th e r s .
Of the 7 3 9 ca s e s o f g o itre 3 4 4 were a l s o the s u bj ect o f heart

,
tr o ub l e ; 4 7 o f the l att e r had va l vu l ar l e s i o n s th e b a l ance h yp e rtro ,
phy di l atati o n fatty o r o ther de gen e rati o n o r c l inica ll y ab n o r m a l

, , , ,
heart acti o n
- I n the s a m e re gi o n h e art affe cti o n s in the n o n go itr o u s
.
-
and phthi s i s are n o t very fr e quent e g o f 1 7 4 heart ca s e s a m o n gs t

, , . .
,
individua l s ( s ch ool chi l dr e n and private pati e nt s) 1 1 5 a l s o had ,
g o itr e H.i s s tati s tic s l ik e th o s e o f o th e r o b s erver s s h o w a s l i ght ex

, ,
ce s s o f fe m al e s a m o n gs t the g o itr o u s When the affe cti o n i s on e .
s ided i t h as a g reat p redi l ec t i o n fo r th e ri ght c oll ectiv e l y 9 2 r t o 1 9

, , .
l th e s eparate l i s t s a l s o b e arin g thi s o ut

.
,
.
Hi ll re s idence s l i ght l y tend s t o increa s e the nu m ber o f g o i tr o u s

a s m i ht a p r i or i b e e xp e cte d fr o m their reat e r phy s ica l train
g , , g s .
A s t o g e o gn o s tic c o ndi t i o n s ar gi ll ace o u s s l ate re g i o n s s h o wed a

,
m axi m u m o f go itr o us s and s t o n e a m ini m u m

, .
I n a tab l e are s h o wn the r e s u l t s o f exa m inati o n o f the drinkin g

water in the vari o u s di s trict s where th e s ch ool chi l dren l ived Fr o m .
the s e h o wever he i s unab l e t o draw any p o s itive c o nc l u s i o n s

, , .
T o return t o the influ e nce o n th e heart h e s ay s There i s n o ,

“
d o ub t that en l arg e m e nt o f th e thyr o id and abn o r m itie s o f th e he art

very frequent l y o ccur t o ge th e r A s t o the innate c o nnecti o n b et ween
.
H E A D A N D N E GR .
63
th e two vari o u s p o s sibi l iti e s have t o b e c o n s id e re d

,
Th e s y m pt o m s .
p o int t o a di s turb ed and e s pecia ll y a w eakened heart acti o n The re - .
turn o f b loo d t o th e heart i s i m ped e d p art l y by dir e ct pr e s s ure o n th e

vein s p artl y by c o m pre ss i o n o f the trache a and interfer e nc e with r e s
,
p i ra t i o n The intr
. o du cti o n o f a m o r e o r l e s s v ol u m in o u s va s cu l ar net
w o rk int o th e circu l ati o n a l s o direct l y increa s e s the s train o n t h e heart .
In th e o ne ca s e d i l atati o n in the o th e r o v e r acti o n an d hyp e rtr o phy

,
-
re s u l t and in b o th ca s e s fina ll y de generati o n o f the heart

, , , Thi s re .
s u l t ( hyp e rtr o phy o r di l atati o n Wi th o r with o ut fatty d e g e nerati o n ) i s

,
o b s erv e d in all a ut Op s i e s o f lo n g s tandin g ca s e s where th e g o i tre h as

'
exert e d pr e s s ur e In m any ca s e s h e art tr o ub l e i s certain l y cau s e d b y

.
g o itre b ut ther e are rea s o n s fo r thinkin g th at the rever s e a l s o o ccur s

, ,
a m o n g s t o ther s th e fact that in s e v e ra l ca s e s go itr e deve lo p e d i m m e

d i ate ly after o v e r acti o n o r hypertr o phy o f the h eart and repeate d l y
-
,
di s appe ared a g ain a s s oo n a s the heart tr o ubl e s ub sided .
That the en l ar g e m ent o f the thyr o id m ay in m any ca s e s b e th e re

s u l t o f a va s o m o t o r n eur o s i s s e e m s t o h av eb een fir s t s u gg e s ted t o h i m
b y th e follo win g ca s e : A gir l with a s m all g o itre b ut n o si g n o f h eart ,
tr o ub l e wa s attacked by a p ecu l iar a l m o s t c o ntinu o u s c o u gh for thre e

, , ,
day s and ni ght s with further s y m pt o m s ( a l m o s t i m perceptib l e radia l

,
p u ls e increa s ed s ec o nd p ul m o nary s o und dry rh o nchi fac e p a l e ex

, , , ,
t re m i t i e s c ool etc ) p o intin g t o s pa s m o f the va s o m o t o r s fo rcin g an

,
.
-
,
o ver quantity o f bloo d int o th e l un gs

- Mean whi l e th e g o itre .
b eca m e s m all er A h a l f ye ar l ater after an exhau s tin g

.
,
foo t t o ur an en o r m o u s go itre deve lo p ed within fo rty e i ght

,
-
h o ur s—th e cu s t o m ary c o u g h di s ap p e arin g e ntire l y the h eart actin g ,
s teadi l y face and extre m iti e s natura l

, Thi s w as the e xact o pp o s ite o f.
the ear l ier c o nditi o n S b e l ieve s i t t o have b een b ut the e xpre s s i o n

. .
o f a re l axed c o nditi o n o f the v a so m o to rs a s o m e what s i m i l ar re l axa ,
ti o n b ein g n o r m a ll y O b s erved after l ik e ex e rci s e Ag ain a bo y s u f .

,
fe re d an exten s ive b urn o f the f a ce D urin g exfol iati o n and s upp ura
.
ti o n a go itre deve lo p ed W h e n the wo u nd s hea l e d the g o itre dis ap

.
p e a re d Thi s S exp l ain s by the fact that irritati o n o f t h e s kin cau s e s

. .
a lo ca l an ae m ia follo we d by va s o m o t o r p aral y s i s F o r further c o r

, .
r o b o rati o n he m ake s a c o m p ari s o n with G rave s di s e a s e I n th e ear ly

,
’
.
4 I N D E a or S UR GI CAL P R O GR E S S
s ta g e s b r o m ide n o t i o dide 1 5 i n p l ace

,
When h o wever h yp e rp lasy
,
.
, ,
h a s re s u l ted the i o dide s are o f va l u e I n thi s a s in Grav e s di s

’
.
, ,
ea s e th o ugh l e s s o ft e n s i m i l ar cardiac c o nditi o n s o ccur

, , Sudden .
death i s c o m m o n t o b o th fo rm s .
P hy si olo gy teache s us m any a gencie s which depre s s the vas

c ular t o nu s—s trainin g wo rk o f any kind tire s o m e m arche s c l i m bin g , , ,
fo rced p l ayin g o n wind in s tru m e nt s di fficul t birth s rapid te m p erature , ,
chan g e s lo wered at m o s pheric pre ss ure u s e o f a l c o h ol etc

,
Th e re , ,
.
s ultin g c o nditi o n m ay in the s e ca s e s bec o m e p e r m anent The s e are .
a l s o the m o s t frequent cau s e s o f g o itre a s S s ca s e s s h o w Seac o a s t s

’
, . .
are a l s o fre e fr o m g o itre whi l s t the Al p s C o rdi ll era s and Hi m a l aya s

, ,
are i t s h o m e I n h i s re gi o n th e at m o spheric pre s s ure i s fr o m 4 0 t o 6 0

.
'
m m . H g lo wer than at the s e a l eve l

. A v ariety o f o ther fact o r s s uch .
,
a s te m p e rature chan g e s and greater phy s ica l s train c o m bined with the ,
lo wered at m o spheric pre s s ure in e l evated re gi o n s .
I n h ar m o ny with thi s the o ry i s the fact that go i tre o ccur s m o re fre

quent l y in y o uth and am o n gs t wo m en their va s cu l ar t o nu s b ein g m o re ,
m o bi l e .
The g o itr o u s tenden cy m i gh t b e graduall y deve lo ped where g enera

ti o n s c o ntinue und e r fav o rin g c o nditi o n s .
Thi s a l terati o n in the v a s om otors wo u l d exp l ain the heart tr o ub l e s

a s w e ll a s the g o itre The five drunkard s a m o n g s t the l unatic s were
.
a ll g o itr o u s and fo ur had a l s o cardiac affecti o n s

, .
A s t o the re l ati o n o f g o itre t o cretini sm cach e xia s tru m ipriva e tc , , .

,
h e m ere l y m ake s s u gge s ti o n s .
He re m ark s that any pr o ce dure requirin g narc o s i s o r in any way

s trainin g the heart i s in th e g o itr o u s e s pecia ll y dan g er o u s and that ,
t heir fate depend s o n th e heart —A r clz f Rli n C/zi r 1 8 8 6 Bd 34 . . . . .

, , .
,
H ft i . .
W
. B R OWN I N G ( Broo k l yn )
IV . (E de m at o u s L a ry n g i t i s . T r a c h e ot o m y . G lo s s i t i s
T e r m i n at i n g in Ab s ce s s . S e v e re H ae m o r r h a g e fr o m
T o n gu e . R e c o v e ry . By D H C H A R L E S M D
. . The patient , . .
wa s a heal thy m an aet , .

44 , wh o had had a s l i ght l aryn gea l infla m m ati o n
I I E A D AN D N E GR .
65
fr o m e xp o s ure t o c ol d a m o nth b efo re Thi s s ub s ided b ut recurred

.
,
s oo n aft e r and h e h ad s uffe re d m o re o r l e s s with h i s thr o at fo r three

,
we ek s pri o r t o the s e v e r e attack n o w de s crib e d .
H e wa s s udd e n l y attack e d whi l s t at wo rk with ur ge nt dy s pn oea

, , ,
a n d with difficu lty

go t h o m e S oo thi n g m e dicat e d inha l ati o n s d i a p h o
.
,
r e ti c s and a pur e w e r e at o nc e e m p lo y e d with b l i s t e rin

g g and h o t c o m
,
pre s s o v e r th e la r yn x When Dr Charl e s s aw h im two d a y s l at e r

. .
, ,
h e h a d all th e c h aract e ri s ti c sym pt o m s o f oe de m at o u s l aryn giti s ; and

the l aryn g o s c o p e s h o we d g re at redd e nin g and s we ll in g o f t h e epi
glo tti s and fa l s e c o rd s . The affe ct e d p art s were swab bed with nitrat e
o f s i l ver s ol uti o n ( g j: follo we d by gr e at and a l m o s t i m m e diate r e
l ief Ten h o ur s l at e r h e w a s s e ize d wit h urg ent dy s pn oea and a l m o s t
.
a s phy x iated .
La ryn g o trach e o t o m y w a s n ow perfo r m ed an d wa s follo we d b y i m

-
,
m ediat e r e l i e f O f a ll the a l ar m in s y m pt o m s He w s ur ro und e d b y

g as .
an at m o sphere o f s tea m vap o ur .
e xt m o rnin o as gr e at l y s woll e n and purp l i s h and pr o

5 N g t h e t n g ue w ,
t ru d e d be t w e e n th e teeth .I t wa s inci s ed in t wo p l ac e s F e d thr o u gh .
a tube .
N e xt day breathin g s ti ll ea s y
, The t o n g ue gre at l y e n l ar ge d
. .
S we ll in g and tendern e s s o f ri ght side o f neck fro m e ar t o c l avic l e .
T o n g ue a g ain inci s ed and o n e o unc e o f b loo d e s cap ed

, Thi s r e .
li e ve d h i m and t hr e e day s l ater th ere was c o n s iderab l e di s ch ar g e o f

,
fetid p u s fr o m the t o n g ue .
P ur u l ent m atter and b loo d c o ntinu e d t o b e di s char g ed fr o m the

m o uth durin
g the next t wo day s .
On the third day there we re s ix attack s o f h ae m o rrha ge the exact ,
s o urce o f whi c h c o u l d n o t b e a s certained S ol uti o n o f p e rch lo ride o f

.
ir o n app l ied o n l int t o ri ght s ide o f t o n g ue .
N ext day there was s e v e re h ae m o rrh a g e fr o m a ra gged cavity at

ri ght s id e o f r oo t O f t o n g u e which wa s s tuffed with l in t s o aked in
,
p e m i tra t e o f ir o n s ol uti o n Pl u g re m o ved t wo day s l ater Th e re were

. .
s li ght r e curr e nc e s o f h a e m o rrha ge o ne o n the day after the p l u g wa s

,
r e m o v e d a n d two s ub s e qu e n tl y but the p atien t pr o gr e s s ed fav o rabl y

,
a n d i s n o w quit e we ll , wi t h t h e e x cepti o n o f s o m e w a s tin g and lo s s o f

p o we r in th e ri ght sid e o f the t o n g ue Thi s h o wever i s g ettin g l e s s

.
, ,
.
In h i s r e m ark s o n the ca s e th e auth o r r e fer s t o th e m arked but o n l y

,
t e m p o rary r e l i e f affo rded by th e app l icati o n o f nitrat e o f s i l v e r He .
c o ntra s t s thi s wi th t h e c o m p l e te an d p e r m an e n t re l ief o f dy spn oea fol ,
lo wi n g la ryn g o trache o t o m y an d j u s tifi e s th e ch o ice o f thi s o perati o n

-
,
rath e r than trach e o t o m y o n the gr o und ( fir s t ) o f i t s b e i n g e a s i e r t o

p e rfo r m under unfav o rab l e circu m s tance s ( i e with l itt l e a s si s t ance . .
,
and in inc o nvenient p o s i ti o n ) and ( s ec o nd l y) fo r a rea s o n which i s l e ss

,
”
o bvi o u s t o keep the inci s i o n a s hi gh a s p o s s ib l e He c o n s ider s .
th e infla m m ati o n o f the t o n g u e a s an exten s i o n fr o m the epi glo tti s .
H e re gret s ( we think r i gh t l y ) n o t havi n g m ade m uch m o r e ext e n s ive

inci s i o n s in th e t o n gue Mi ght n ot the epi glo tti s and anteri o epi
.
-
g lo ttid e an fol d s h av e b e e n s c a ri fi e d in the fir s t in s tance ?
With r e ference t o th e h ae m o rrha ge s which o ccurred D r Char l e s , .
s peak s o f b e in g pr e par e d t o tie the externa l car o tid ( Wh y n o t t h e l in .
g ua l H e think s the w a s tin g and lo s s o f p o we r o f th e ri ght Si d e o f
the t o n gue due t o inflam m at o ry de g en e rati o n o f the m u s cu l ar ti s s ue .
Th e m o rta l ity o f th e affecti o n s which he give s acc o rdin g t o S e s tie r , ,
a s 1 5 8 o ut o f 2 1 3 and a s r e p o rted by Bay l e

, , 1 6 o ut o f 1 7 s ee m s e x ,
c e s s i v e . D urha m g ive s 1
9 o ut o f 3 0 —B r i t M ea
j ou r n a l N o v 6 .
’
.
,
.
,
1 88 6 .
B . WA I N E WR I GH T ( Lo n d o n ) .
V T w o Cas e s o f A cu t e Gl o s s it i s
. Dr T O T H E R I C K B o th . . .
ca s e s o ccurre d in the W ol verha m pt o n G enera l H o spita l .
C A S E I E R ae t 2 1 t o n gue c o vered by thick b r o wn fur hard

. . .
, .
, , , ,
i m m en s e l y s woll en tip pr oj ectin g ha l f an inch b ey o nd tee th i m m o va

,
b l y fixed G reat p ain and t e nd e rne s s o n pre s s ure Sal ivati o n pr o fu s e

. . .
Br e ath very o ffen s iv e D e gl utiti o n difficu l t H eadach e pu l s e in

. .
,
crea s ed and te m pe rature s l i ght l y rai s ed G radua ll y c o m p l ete ly re c o v

,
.
er e d .
CAS E I I J P ae t 2 7 s udd e n s we ll in g o f t o n g u e
. . .
,
.
, The c o nditi o n .
wa s exactl y s i m i l ar t o pr e cedin g ca s e S l i gh t a l b u m inuria Th e r e wa s

. .
s o m e s l i g ht s up erficia l s lo u ghin g under t o n g ue and g u m s In thi s ca s e .
an inci s i o n wa s m ade o n either s ide o f m edian l ine o f t o n g u e Made .
a g oo d rec o v e ry .
67
As a ru l e acute glo s s iti s end s in re s ol uti o n I t m ay h o wev e r extend

, .
, ,
back ward s t o the l arynx and render l aryn g o t o m y nece ss ary In a fe w .
ca s e s s uppurati o n o ccur s ; and s ti ll m o re rare l y p er m an ent thick e nin g ,
m ay b e l e ft The m o s t u s ua l cau s e fo r it i s s aid t o b e catchin g c ol d

.
,
and i t i s s upp o s ed by s o m e auth o ritie s t o b e catarrha l in i ts o ri g in .
L a n cet O ct 1 6 1 8 8 6
, .
, .
V I M a l i g n a n t Cy s t s o f N e c k
. Mr F T R E V E S The c l inica l . . . .
c o ur s e o f the thre e ca s e s o n which thi s paper was fo unded were a ll

.
s i m i l ar T e gr o wth s were c o n s i dere d t o b e cy s tic o n acc o unt o f their

. h
c o n tainin g a very s m a ll a m o unt o f s ol id m ateri a l One cy s t c o n .
t ai n e d p ure l y m ph i n the o ther t wo the c o ntent s we re m ucin o id

, One .
s p eci m en ( s ti ll a l ive a s s h o wn The fir s t ca s e wh e n s een wa s fi fty

) w .
thre e year s o f a ge The tu m o ur wa s s ituated in the l eft s ide o f the

,
n eck the s kin o ver b ein g red and bra wny I t c o m m enc e d a s a s m all
,
.
m a s s apparent l y b e neath the s tern o m a s t o id m u s c l e and wa s re g arded

,
~
a s a chr o nic ab s ce s s unti l an exp lo rat o ry p uncture g ave exi t t o a c l ear

, ,
g l airy fluid w hich

,
w as pr o n o unced o n ch e m ica l ana l y s i s t o b e m ucin .
The cy s t pr o ved t o b e deep l y attach ed I t di s char ged c o ntinu o u sl y .

,
w a s treated with inj e cti o n o f i o din e ; the d i s char g e b eca m e puru l en t ,
and fina ll y h m m orrh age t oo k p l ace and c lo s ed the s cene At the p o s t .
m o rte m there wa s an i m perfect cy s t wh o s e w a ll s were n o where m o re ,
than ha l f an inch thick The inner a s pect o f the w a ll s re s e m b l ed th e

.
c c lum na e carne ae o f the ventric l e s o f the h eart T h e s e c o nd ca s e wa s .
that o f a wo m an ae t 5 2 in which th e s ol id carcin o m a fo r m ed o ne s ixth

, .
,
-
p art o f the wh ol e m a ss Thi s cy s t was re m o ved durin g l ife the interna l

.
j u g u l ar vein wa s cut and the brachia l p l exu s exp o s ed ; p atient die d ten
,
day s afte r The cy s t c lo s e l y r e s e m bl ed the precedin g on e The t hird

. .
was epith e l i o m at o u s The p atien t in wh o m it o ccurred was 4 3 ye ar s o f

.
a ge and h ad b een O p e rated o n fo r e pith e l i o m a o f the ri g ht s ide o f the

,
t o n g ue . F o urte e n m o nth s after the tu m o ur appeared o n the l eft s id e

o f the neck The s kin o ver i t wa s red and bra wny and o n bein g
.
,
tapped yie l de d a fl uid che m ica ll y s i m i l ar t o l y m ph B l eedin g a l s o o c .
curred in thi s ca s e The cy s t wall wa s n o t m o re than a quarter o f a n

.
i nch thick in any p art N o s ec o ndary dep o s it s —La n cet 1 8 8 6 Oct 2

.
, , .
VII . A c u t e M y x ce d e m a y Sir
F oll ow ing T h yr o i d e c t o m .
W I LL I A M S T O K E S A wo m an ae t 1 8 wa s ad m itted int o the R ich

.
,
.
,
m o n d H o s pita l with exten s ive di s e a s e o f b o th lo b e s o f t h e thyr o id .
He al th goo d fre s h c o m p l exi o n w e ll n o uri s hed ; fa m i l y hi s t o ry g oo d

, ,
.
H e r chief tr o ub l e w as dy s pn oe ic attack s u s ua ll y at ni ght I t w a s de , .
cid e d t o r e m o ve the gl and Sir Wi ll ia m r e m o v e d i t by the m eth o d a d

.
v o c a t e d by K o cher H e m enti o n s the g reat difficu l ty h e exp e ri e nced

.
,
and the pr o fu s i o n o f th e he m o rrh a ge whi ch at ti m e s s e e m e d un c on .
t ro lla b le and thr e aten e d th e pati e n t s l i fe In th e end o n l y t he l e ft ’

.
lo b e was g o t a way : T h e patien t m ad e a g oo d rec o v e ry wa s r e liev e d ,
o f th e dy s pn oea and the ri ght lo b e s o m e what di m ini s h e d in siz e Thi s . ,
h o wever did n o t l a s t lo n g as the lo b e a g ain b e gan t o e n l ar ge and

, ,
dy s pn oea ca m e o n a gain With s ti ll gr e ater difficu l ty and dan ger the

.
lo b e was re m o ved Within fo urte e n day s p uffy s we ll in g was n o t e d

.
ab o ut eye l id s ba ck s o f wri s t s and o v e r m etatar s u s o f b o th feet Als o

, , .
s o m e m enta l t o rpidity She a l s o had fi ts ch aract e riz e d by gr e at l ivi l

.
,
ity o f face s tert o r o u s breathin g dy s pn oea qui ck p u l s e e y e s s tarin g

, , , ,
and pro trudin g pupi l s dil ated and car o tid s thr o bbin g e ndin g in c o p i
, , ,
o u s p er s pirati o n N o a l b u m inuri a All th e s e s ym pt o m s increa s ed

. .
,
and pu l m o nary infi l trati o n s uperv e ned She died nin e t e en day s aft e r .
the l a s t O p e rati o n Sir Wi ll ia m dra ws attent i o n t o t h e m arke d m yxoe

.
d e m a to u s s y m pt o m s and t o th e ir rapid o n s e t H e th en m e nti o n s t w o .
o th er ca s e s o f thyr o idect o m y d o n e by hi m s e l f in o n e o f which he p ar ,
t i ally r e m o v e d the gl and with p er m anen t l y g oo d r e s u l t I n the o th e r .

,
divi si o n o f the i s th m u s wa s follo we d by a s a ti s fa c t o rv i s s u e —B r i t .
M ea j ou r Oct 1 6 1 8 8 6
’
. .
,
.
,
.
V I I I O n t h e S u rg i c a l T r e a t m e n t o f C e r t a i n T u m o u r s o f
.
th e N e ck F R E D E R I C K B JE S S E T T F R C S M r le s s e t t a dv o
. .
, . . . . .
cate s a s o m e what b ol d e r s ur ge ry in d e a l in g with d e e p tu m o ur s o f t h e

n eck H e vie ws with very l itt l e fe ar l i g atur e o f b o th car o tid artery
.
and interna l j u g ul ar v e in E ven divi s i o n o f v a g u s s y m path e ti c

.
, ,
phrenic l aryn g ea l n e rve s have b e en divided wi th o n l y te m p o rary i h

,
”
c o nvenience .
I n o ne of the ca s e s o perated o n there wa s a l arg e gr o w th , which

69
had fo r m e d s lo wl y de ep l y s eate d and e x tendin g fr o m the e ar n e ar l y t o

,
th e c l avic l e and quite i m m o va bl e N o p ain b ut c o n ge s ti o n o f c o n

, . ,
ju n c tiva s o m e O p aci ty o f c o rn e a wi th a c e n tra l u l c e r a l s o p t o s i s Le ft

, , .
hal f o f face redder th an the ri ght and app ar e nt l y w ar m e r Tr e at m ent

,
.
l eft c o ndi ti o n o f e ve unaffe ct e d Th e gr o wth wa s then re m o v e d and

.
fo und t o c o n s i s t O f ca s e o u s gl and s The m an m ade a goo d rec o v e ry

.
,
and wi thin a we ek th e o cu l ar tr o ub l e s di s appe ared M r Je s s e t t g o e s . .
o n t o n arrate s e vera l ca s e s O f b o th inn o cent and m a l i g nant gr o wth s

which have been exti rpat e d wi th g oo d re s u l t s and s u m s up a s follo ws ,
( I ) All inn o cen t tu m o r s in th e s e r e gi o n s m ay b e r e m o ve d

. .
That m a l i g nan t gr o w th s m ay b e re m o ved when situate d in the tri

an gl e s o f the n e ck pr o vid e d they are free l y m o vab l e th at th e s ki n and
, ,
s uperfi ci a l s tructure s are n o t i m p l icat e d n o t wi th s tandin g th eir s iz e and

,
the p o s sibi l ity o f the l ar g e ve ss e l s b ein g i m p l icate d in th e gr o wth .
B r i t f li ed j ou rn O ct 1 6 1 8 8 5
. .
,
.
, .
IX . Aden oid G r o w t h s i n t h e P h ar y n x Sir W I L L I A M B . .
D A L B Y The s e gr o wth s c an b e re m o v e d by m any m eth o d s an d i f

.
,
d o n e th o r o u gh l y t h e re s u l t i s a l w ay s s ati s fact o ry I f the O p erat o r is .
p o s s e s s ed o f an e ffici e nt fi n g e r nai l n o thin g can b e b etter b ut a ll s ur

-
, ,
ge o n s fi n g er s a re n o t s uffi cien t l y adapted t o and s tr o n g e n o u gh t o t e

’
m o ve s o m e o f th e fi r m er kind s o f g r o wth I n th e s e ca s e s Sir Wi l

.
l ia m Da l by r e c o m m end s h i s arti fi cia l fi nge r nai l The in s tru m ent i s s o - .
m ade that th e s en s i ti v e tip o f the fin g er i s unc o vered and i s m o s t u s e ,
fu l in e s ti m atin g by t o uch what i s b e in g d o ne By thi s m e th o d a l s o .
the he ad can b e b ent fo r ward and by thi s m ean s the b loo d i s pre
,
vented fr o m runnin g d o wn ward s Then a g ain the artificia l n ai l

.
, ,
wo rk s s o th o r o u gh l y that a ll gr o w th c a n b e re m o ved at o ne s ittin g In .
chi l dren i t i s be s t t o e m p lo y an an ae s theti c B e s ide s the departure o f .

,
the three sy m pt o m s v iz the tend e ncy t o E u s tachian o b s tructi o n

, , .
the c o n s e quent de afn e s s ( which ge nera ll y direct s attenti o n t o the

t ro u ole and th e na s a l ob s tructi o n —which follo w s th e r e m o va l o f th e
) ,
aden o id g r o wth s th e r e are o ther advanta g e s t o b e reck o n ed s uch a s

, ,
the b e tter pr o s p e ct s o f re c o very in ca s e s o f diphtheri a o r s car l e t fe er v
o ccurrin g wi th an e m pty rather than a b lo cke d pharynx a s we ll a s the

, ,
b e tt er ch an ce s o f th e m idd l e e ar e s capin g de s tr ucti o n d urin g di s e a s e s

Th e i m pr o ve m e n t a l s o o f th e g enera l h e a l th with fr e e n a s a l breath ,
i n g as we ll a s di m ini s h e d t e ndency t o br o n chia l affecti o n s r e quir e o n l y

, ,
m e nti o n t o b e appreciate d — L a n cet Oct 2 1 8 8 6 , .

, .
H H T A Y L O R ( Lo nd o n ) . . .
X . Conge n i tal S t enosis T r a c h e a fr o m A b

of th e
n o rm a l C u rv at u r e o f t h e C art i l ag e R i n g s By Dr M . . .
S C H M I D T ( Cu x hav e n ) Fe m al e chi l d ae t 6 m o nth s w e ll d e ve lo ped

.
,
.
,
and n o uri shed had s in ce h er birth a l way s m uch difficu l ty in b reath

, , ,
i n g At ti m e s vi ol ent attack s o f dy s pn oea with acc o m p anyin g cyan o s i s

.
o f t h e l ip s and c ol d s weat s e s p e ciall y durin g the ni ght Lo ud in spira

,
.
t o ry s trid o r a l way s pre s ent N o s tri l s m uch di s tended e speciall y o n

.
,
in s pirati o n The de e p in spirat o ry drawin g in o f th e epi g a s triu m and

.
-
lo wer s ide s o f the th o r ax wh e r e n o t o nl y the interc o s ta l s p ace s b ut

, ,
l ar g e p o rti o n s o f the th o rax wall s w ere s unk e n in even very n o tice abl e
-
,
.
N o thin g abn o rm a l ab o ut th e neck n o r did a di gita l exa m inati o n o f the

,
o rifice o f the l arynx per 0 5 revea l anythin g that c o u l d cau se the sym p
, ,
t o m s ab o ve m e nti o n e d The in s pi rat o ry s t e n o s i s m ur m ur r e s e m b l ed

.
-
c lo se l y that o f l ary n g ea l cr o up and p o inted t o the l arynx a s th e p o int

,
o f Ob s tructi o n t o th e breathin g Trache o t o m y pr o p o s ed F o ur day s

. .
l at e r cric o tra che o t o m y perfo rm e d and a canu l a intr o duced Thi s had
-
.
n o b en e fici a l i n fluence w hatever o n the dy s pn oe a and t h e c o nditi o n o f ,
th e p a t ient re m ained uni m pr o ved C oll ap s e s oo n follo wed the pu l s e

.
,
b e ca m e weak and frequent and death en s ued the n e xt d ay At th e

,
.
aut o p sy i t wa s fo und that th e l arynx oe s o ph ag u s thyr o id and thy m u s , ,
gl and s were n o r m a l The trachea was di s s e cted free o f i t s s urr o und

.
in g s and n o thin g abn o rm al o b s erved wh e n in s pected p o s t e ri o rl y On

, .
O p e n in g i t h o wever in u ua l anner p o t ri o r l y in the idd l e

, ( t h e
, s m s e m
) ,
and s preadin g it o ut the upper carti l a g e rin gs yi e l ded e a s i l y t o th e

,
pre s s ure a s us ua l Lo wer d o wn o n the c o ntrary the l e ft s ide s o f the

.
, ,
rin g s were s tiff o ffer in g c o n s iderab l e re s i s tance t o the pre s s ure m ad e

,
o n th e m in thi s way an d turn i n g m o re slo wl y in ward When the wh ol e

, .
trach e a wa s s pre ad o ut it was s een that the curvature o f the upp er

rin gs was quit e flatten e d o ut whi l e the l e ft s ide s o f the lo wer rin g s
,
fo rm e d with th e ir anteri o r p o rti o n s a S harp an g u l ar crea s e Thi s .
cau s e d a veritab l e rid g e in the lo wer p o rti o n o f the trachea appearin g ,

H E AD A N D N E CK .
71
o n th e m uc o u s s urface o f the o r g an a s a vertica l l in e at th e b o undary

o f the ant e ri o r and l e ft l at e ral p art s Alo n g th e l ine t h e c ur vm g o f all .
t h e lo wer rin g s was br o ken by the an g u l ar b e nd in ward s I n the lo we r .
p o rti o n o f th e trach e a o n the l eft w a ll was a l s o a s o m e what c o ncave

i m pre s s i o n a s i f cau s ed by th e pre s s ure o f an e gg s h ap ed b o dy Thi s -
.
r e ach e d d o wn t o th e bifurcati o n ; th e an gl e where the l eft br o nchu s ,
j o in s the t ra chea appearin g in c o n s equence s o m e wha t r o und e d o ut

, ,
.
T h e l e n g th o f the affected p o rti o n o f th e trach ea fr o m th e bifurcati o n ,
up ward m e a s ur e d, cm the wh ol e len g th o f the trache a t o t h e cri

.
,
c o i d carti l a g e b e in g cm N o cau s e fo r the s ten o s i s wa s fo und

. .
Thi s d e fo r m ity o f th e trache a w o u l d s ati s fact o ri l y exp l ain th e phen o m

en a o b s e rv e d durin g l ife The s ten o si s wh i l e gre at en o u gh t o give
.
,
ri s e t o the dy spn oea and c o n tinued s trid o r had n o t b e e n s uffi cient l y ,
lar g e t o cau s e de ath C o m p l icati o n with the O perative trau m a was

.
follo wed by fata l r e s u l t s The o penin g m ad e in the trach e a b ein g s i t

.
u a te d ab o e the s ten o s ed p o rti o n and th e lo we r end o f the canu l a n o t

y ,
reachin g i t e ith e r o f c o ur s e n o b en e fi ci a l re s u l t t o th e p ati e nt c o u l d

,
tak e p l ace Infe ri o r trach e o t o m y a lo n e c o u l d h av e acc o m p l i s hed any

.
thin g Auth o r c o n s id e r s th e ca s e o ne o f c o n g enita l s ten o s i s o f the

.
trachea cau s ed by fau l ty curvatur e o f the carti l a g e H i s ca s e i s i n

, .
s tructive as de m o n s tratin g that in s i m i l ar ca s e s wher e trache o t o m y i s

,
indicat e d i t wi ll b e we ll t o d o thi s a s lo w d o wn as p o s s i bl e D eu tsc/z

, .
-
.
Ill ea Woc/Ien s c/zr if t NO 40 O ct 7 1 8 8 6

’
. . . . .
.
,
XI . x t i r p a t i o n o f t h e C r i c o i d C a r t i l a g e fo r E c
Is olat e d E
c h o n d ro m a By Dr A B O C K E R ( B erl in ) R ok i tan sk i rep o rte d ca s e s

. . . .
o f hyper o s t o si s and e xo s t o s i s o f th e o s si fi e d l arynx carti l a g e s b ut t o ,
V irch o w we are indeb t e d fo r o ur kn o wl ed ge o f ecch o ndr o m a o f th e

l arynx They are fo u n d a s diffus e and s m oo th gr o wth s al s o a s kn o tty
.
,
circu m s crib e d excre s cence s o n b o th the thyr o id and cric o id carti l a g e s

, ,
h avin g the g enera l t e ndency o f gr o win g in ward s int o the l u m en o f the ,
l arynx E cch o n dr o m a m ay b e ea s i l y m i s taken fo r p ol ypi b e in g c o y

.
,
ered with n o r m a l m uc o u s m e m b rane They are n o t O p erative fr o m .
ab o ve T h e nu m ber o f p ub l i s hed ca s e s 15 s m a ll Th o s e o f M a c ilvain

. .
( 1 8 3 1 ) and R y l and ( 1 8 3 5 ) s h o u l d n o t b e inc l ud ed as it i s s o m e what ,

pr o b a b l e th at b o th were ca s e s o f hyp e rp l a s ia o f the c o nnective ti s s u e ,
as we o ften s e e in s yphi l i s The fir s t authenticated ca s e i s th at o f

.
Fr o ri e p p ub l i sh e d in 1 8 3 4 The ch o ndr o m th e s iz e o f a wal nut wa s

, .
, ,
s ituat e d o n the inner s urface o f th e l arynx e x t e ndin far in t o t h e lu

g ,
m e n and re s tin g o n th e ri ght v o ca l ch o rd A s ec o nd ca s e wa s re .
p o rte d by Mack e nzi e in 1 8 8 0 The ch o ndr o m a a s l ar ge a s a h e n s

.
,
’
e gg ar o s e fr o m the cric o id carti l a ge gr o win g d o wn ward s and in fr o n t

, ,
o f th e ant e ri o r s urface o f th e trache a T ti rc k r e p o rt e d the fir s t laryn .

'
g o s c o p i c a l o b s ervati o n ( i e o n the l ivin g s

. ubj e ct ) o f. s uch
, a tu m o ur ,
in 1 8 6 3 and t o thi s m u s t b e added a ca s e o f St o rk in V i e nna o ne p ub

, ,
li sh e d by E hre n d or fe r and l a s tl y a ca s e r e p o rted by A s ch in 1 8 8 4

, ,
.
T h e auth o r give s th e follo win g ca s e s
Ca s e I M al e ae t 2 3 h e a l thy in app e arance and s h o win g n o t hin g

.
,
.
, ,
abn o r m a l ab o ut the neck Laryn g o s c o pica l e x a m inat i o n di s c lo s e d a

.
s m a ll tu m o ur t h e s iz e o f a b e an c o vered with n o r m a l m uc o u s m e m
, ,
bran e l yin g j u s t b eneath th e ri ght v o cal ch o rd quit e n e ar i t s ant e ri o r

,
attach m ent I t ar o s e fr o m the inn e r s urface o f t h e th yr o id carti l a g e

.
n e ar t h e a nt e ri o r l i n e o f uni o n The ant e ri o r e n d o f th e ri gh t ch o rd .
wa s rai s e d up wa rd s s o m e what and di s p l aced o ut ward l y by the tu m o ur .
T h e m e m bran e o f th e re s t o f the l arynx w a s n o r m a l E x a m inati o n .
with the s o und s h o wed the tu m o ur t o b e hard and kn o tty and fir m l y
a ttach e d to the l a m e ll a o f the thyr o id Att e m pt s t o g ra s p i t with a .
fo rcep s we re un s ucc e s s ful I t s e n tire r e m o va l wa s fina lly e ffect e d with

.
t h e h e l p o f a cuttin g fo rc e p s c o n s tructed o n the p l an o f th o s e o f Luer

,
.
The s p e e ch o f the patient wa s c o m p l e te l y re s t o red T he tu m o ur c o n .
s i s t e d o f hyal in e carti l a e
g .
Ca s e I I Mal e m t 6 2 o f m idd l e siz e p al e and s l e nd e r app e arance

.
, .
, ,
.
H ad had difficu l ty in breathin g fo r s o m e ti m e which had incr e a se d o f ,
l ate N o pu l m o nary catarrh A di s tinct s t e n o tic m ur m ur he ard

. .
durin g quick in s pirati o n Laryn g o s c o pica l e x a m inati o n

. Larynx .
s h o wed n o infla m m at o ry pr o c e s s On int o nati o n the v o ca l C h o rd s .
c lo s e d in the n o r m al m anner On in s pirati o n h o we ver a s o m e what .

, ,
r o und e d o va l tu m o ur was s een extendin g int o the l u m en o f the l arynx

,
fr o m i t s p o s t e ri o r wa ll j u s t b eneath th e p o s teri o r end o f t h e v o ca l

ch o rd s It ar o se fr o m th e wh ol e inner s urface O f th e l a m e ll a o f the
.
CH E S T A N D AB D OM E I V .
73
thyr o id and the nei ghb o rin g l eft arch o f the cri c o id carti l a g e reducin g ,
th e l u m en o f th e l arynx s o m u ch that b ut a S ick l e l ike aperture re -
m ained fo r br e athin g T um o ur h ad a s m oo th s urface b ein g ab o ut

.
,
th e s ize o f a haze l nut S wa llo win g e a s y E xtir p ati o n adv i s e d Tra

. . .
c h e o t o m y fir s t w ith divi s i o n o f the thre e upper rin s

, g Di g i ta l exa m .
i n a t i o n s h o wed the t u m o ur to b e i m m o vab l e i t s p l ac e o f attach m ent ,
b ein g th e s a m e a s de s cribed ab o ve A ta m p o n canu l a o f H ahn was

.
-
in tr o duced th e cric o id carti l a g e divid e d in the m edian l ine The cri

, .
c o i d w a s s o m uch inv ol ved in the ne o p l a s m that th e r e m o va l o f the

,
tu m o ur a lo n e was n o t p o s s i bl e The inci s i o n therefo re l en gthened

.
, ,
up ward s t o the hy o id b o ne and the wh ol e cric o id exci s ed I I ae m o r .

'
rh a e w as c o n s iderab l e W o und wa shed o ut with s ol uti o n o f c o rr o

g .
s ive s ub l i m ate and p l u gg ed wi th i o d o fo r m auz e N O fever follo we d

g .
the O p e rati o n . P atien t c o u l d e at and drink with o ut d iffi cu l ty o r

di s c o m fo r t A s ec o ndary h ae m o rrha g e o ccurrin g fi ve day s l ate r ex
.
,
h a u s te d the p ati e n t s o m e what b ut did n o t o ther wi s e affe ct h i s r e c o v

,
ery Di s char g e d cure d in five week s

. Th e tu m o ur had th e s tructure
.
o f hyal ine carti l a ge and s h o wed a r e gre ss ive m e ta m o rph o s i s o f th e ce l

lular e l e m ent s . V ari o u s chan ge s in th e l arynx o f th e p a tient t oo k
p l ace after r e m o va l o f th e cric o id T h e ch o rd s app ear e d s h o rtene d
.
and wabb l e d s o m e what o n int o nati o n The aryt e n o id carti l a g e s ap

.
p ro ac h e d nearer o ne an o th er an d o n in s pirati o n the ch o rd s re s ted

,
a g ain s t each o ther P atient wear s a can u l a c lo sin g i t wh e n sp eakin g

.
,
o r u sin g a s i m p l e venti l ated canu l a o f Brun s H i s v o ice i s di s tinct .
b ut h o ar s e an d r o u gh H e i s hea l thy and fe e l s w e ll and s tr o n g

. .
Brun s l ate l y o perate d a ca s e o f ecch o ndr o si s o f th e l arynx ari sin g fr o m ,
th e p l ate o f the cri c o id by chi s e l in g i t O ff The canu l a c o u l d o f

,
.
,
c o ur s e b e di s pen s e d w ith after ward s in thi s ca s e — D eu ts c/I M ed

,
. . .
Woc/zen N o 4 3 Oct 2 8 1 8 8 6
. . . .
,
.
C .
J . C o LLE s ( N ew Y o k)
r .
A B DO M E N .
I . C o n t r i b u t i o n s t o t h e T h e o ry o f H e r n i a By Pr o f E . . .
K U E S T E R ( Ber l in): B e s id e s th e h e rni a in guin o p rop e riton e ali s o f -
Kr o n l ein and the h in g uin o inter s titial i s o f Goyra n d ( v A N NA L S 1 8 8 6

.
-
.
, .
74 IN DE X OF S UR GI C A L P R O GR E S S
M arch P . K u s te r h e re m ake s o ut a third pr o b ab l y r e l at e d

.
fo r m which h e ca ll s hernia in g uin o s up e rfi c ialis T h e fir s t fo r m i s -

.
characterized by th e diverticl e which fo r m s th e h e rnia l s ac in the c o m

,
m o n e x t e rna l in g uina l rupture b ein g fo rce d in b e t we e n p e rit o neu m and

,
tran s ver s e fa s cia ; th e s ec o nd fo r m by the s ec o nd part o f the s ac l yin g in

fr o nt o f th e tran s ver s e fa s cia b et we e n the m u s cul ar l ayer s o f th e fr o n t
b e ll y wall ; whi l s t in t h e third variety here di s tin gui s h e d th e s ac c o m e s
-
, ,
o ut thr o u gh the anteri o r in guinal r i n g d o e s n o t s ink in t o the s c ro t un , .
o r o n l y partia ll y b ut turn s e ither up and o ut ward s under th e s kin O f

,
the abd o m en o r o ut and d o wnward s und e r th e skin o f th e le g o r

, ,
b ack ward s under the peri n eu m .
H e give s the hi s t o ry o f thr e e n e w i ll u s trative ca s e s t wo o f which ,
were o perated o ne o f the t wo givin g an O pp o rtun it y fo r a p o s t m ort e m

,
exa m inati o n .
The pecu l iaritie s o f the thr e e ca s e s are s u m m e d up a s follo ws

1
. Th e he rnia l s ack i s an o pen p e ri to nea l diverticl e in which l ie ,
te s ticl e and s per m ati c c o rd C o n s equent l y they are excl u s ive l y c o n

.
enita l in the en s e o f b e in g ex i s tent b ut n o t d e ve lo p ed The her

g ( s
) .
nia l O penin g i s wide and traver s e s the b e ll y wa ll dire ct l y fr o m fr o nt

,
-
back ward .
2
. The te s ticl e h as n o t de s cended int o th e s cr o tu m b ut i s in the ,
vicinity o f the externa l in g uina l rin g s o m eti m e s at a di s tanc e fr o m i t

,
b ut a l way s e c tOp i e d .
3 The te s tic l e i s a l way s atr o phic the s per m atic c o rd in m o s t ca s e s

.
,
t oo s h o rt .
4 In t wo ca s e s the sper m atic c o rd did n o t l ie o n the m edian s ide o f

.
the hernial s ack as i s o th e r wi s e th e ca s e in in g uina l hernia wi th o ut e x

,
c e p t i o n b ut o n the l atera l s ide

, .
5 The s ack i s c o vered exc l u sive l y by s kin and th e attenuated s u

.
p e rfi c i al fa s cia The infundibu l ifo r m fa s cia and cre m a s ter m u s c l e are

.
e ith e r entire l y wantin g o r b ut s l i ght l y de ve lo ped .
A fo urth d o ub l e s id e d ca s e he m enti o n s havin g s een and inc l ud e s

-
,
ab s tract s o f the fe w m o re o r l e s s c o rre s p o ndin g ca s e s t o b e fo und

in the l iterature .
K next c o n s ider s the O p e rative technique in hernia o f s uch vi scera

.
B ON E S , j oI N TS , OR TH OP AE D I C . 75
as are n o t wh oll y c o vere d by p erit o n e u m c oecu m c olo n e tc I n thi s , , ,

.
c a s e a w ide di s p l ac e m e nt o f the perit o n e u m m ay have dra wn the a t
t a c h e d inte s tin e a lo n g int o th e s ack S uch rup ture s are e ither c o n .
g e ni ta l o r at l e a s t ol d and l ar g e
, .
A vari e ty o f diffi cu l tie s m a y ari s e in O peratin g and a s n o d e finit e ,
p l an o f pr o cedure s e e m s t o have b een l aid d o wn K giv e s a ca s e t o ,

.
s h o w h i s m eth o d I t c o n s i s t s e s s entia ll y in preparin g b ack the s ack

.
an d adj acen t per i t o n e u m thu s a llo win g rep o s iti o n I n c o n g enita l

,
.
ca s e s thi s i s int e rfe r e d w i th b y th e fan l ike c o n s ti t u e nt s o f th e s per -
m ati c c o rd a s th e y c o ur s e o ver t h e s a c H o w ev e r s m all the te s t ic l e . .
i s u s uall y a trO p h i C I t can b e r e m o ved and th e radica l o perati o n c o m

.
p le t e d . leli n C/i i rg 1 886 Bd 3 4 .H ft I . . .

,
. .
W . B ROW NIN G ( B roo k l yn ) .
E XTR E M IT I E S .
I . T re atm ent I n gro w i n g T o e n a i l w i t h T a n n i n P H I L I P

of - .
M I ALL ( Bradfo rd)

A c o m m unicati o n fr o m S witzer l and in the B r i t i s lz
.
M ed i ca l j ou r n a l fo r Oct o b e r 2 3 r e c o m m end s th e lo ca l app l icati o n o f

p erch lo ride o f ir o n with re s t I hav e for m any ye ar s u s ed tannin fo r
.
'
the s a m e p urp o s e and d o n o t fin d re s t nece ss ary

,
A c o ncentrated .
s ol uti o n an o un ce o f p erfect l y fre h tannic acid di s s ol ved in s ix

( s
drach m s o f p ure water with a g ent l e heat ) m u s t b e p ainted o n th e s o ft

part s t wice a day I wo ca s e s r e c e nt l y had n o p ain o r l a m ene s s
'
after th e fir s t a pp l icati o n and w en t abo ut their w o rk i m m e diate l y

,
which they c o u l d n o t b e f o re Aft e r ab o ut thre e w eek s o f thi s treat

.
m ent th e n ai l h ad g r o wn t o i t s pr o per l en th and bread th and the cure

g ,
wa s c o m p l ete N o o th e r tr e at m ent o f any kind wa s u s ed th o u gh fo r

.
,
m er l y intr o duced l int under the in gr o win g ed g e in s uch ca s e s One o f .
the p atien t s wa s a m i ll gir l and the o th er a h o u s e m aid and bo th were

-
,
o n their feet m any h o ur s a day .
BO NE S , JO INT S , O R T H O P IE D I C .
I . E xc is i on of t h e E lb o w -
J oi nt w it h S u t u re of th e O le
c ranon t o t h e Low er E n d of t h e U ln a Mr C F P I C K E R I N G
. . . .
( Bri s t ol ) . A s tru m o u s girl , ae t . I

5 . Lo n gitudina l inci s i o n o ver b ack
o f j o int Tip o f O l e cran o n then cut O ff with a s harp chi s e l and j o int
.
,
thu s o p e n e d Di s e a s e d e nd s o f b o ne s were then re m o ved After

. ,
ward s tip o f O l e cran o n was united by a s tr o n g wir e s utur e t o the s a wn
s urface o f the u l na P ati e nt m ade a goo d r e c o ver y

. .
Op e rati o n was in F e bruary In S e p t e m b e r th e p o we r o f exten

.
,
“
sion is oo d b etter th an that o f fl e xi o n t h l atter h as b een de l ay ed

g , ; e
by the great l y wa s t e d c o nditi o n o f th e bic e p s ”

Wire l eft i n — La n . .
cet , Oct . 2, 1 88 6, p . 6 28 .
C . B . KEE T LE Y ( Lo nd o n ) .
II . F ive H dr e d an d S i x t e e n C as e s o f C o m p o u n d F ra c
un
tu re w i th P o i n t s o f E s p e c i a l I n t e r e s t O b s e rv e d in C on n e c
t i o n w it h t h e m By F S D E N N I S M D ( Ne w Y o rk ) In thi s
. . . . . .
,
.
p aper the auth o r s ta t e s t hat he h as m o dified h i s fo r m er O pini o n that

the dr e s s in g in c o m p o und fractur e s s h o u l d re m ain undi s turb e d durin g
th e entire p e ri o d o f repair and as a re s u l t O f certain unhappy e xp eri
, ,
e n c e s wh e re di s p l ac e m ent had taken p l ace under the dre s s in g and
m arked d e fo r m ity r e s u l t e d h e n o w in s pect s the fracture aft e r e i ght

day s and then a g ain aft e r ten day s aft e r which n o s e ri o u s devi ati o n ,
can o ccur He s tr o n gl y e m pha s iz e s the de s irabi l ity o f e ar l y a n ti s e p

.
s i s and advi s e s anti s eptic irri ati o n as s oo n a s the pati e nt i s s een and
, g
th e app l icati o n o f a te m p o rar y dre s s i n g b efo re the pati e nt i s r e m o ved
t o the h o s pita l I n a c a s e o f fracture o f the s kull wi th m enin g e a l

.
h ae m o rrha g e in which aft e r e xp o sin g the b l eedin g p o int with the

,
t re p h i n e h e w a s unab l e t o s eiz e it with artery fo rcep s o n acc o unt o f the

,
dura m ater r e c e din g befo re the m h e pa s s ed a tenacu l u m thr o u gh th e ,
dura in s uch a m ann e r a s t o inc l ud e the art e ry in i ts curve re l axin g ,
that p o rti o n o f the m e m brane s o that t he traditi o na ll y d i fli c ult m an os u

vre o f l i atur e o f th e m enin e a l artery c o u l d be p erfo r m e d with e a s e ;
g g
n o infla m m at o ry tr o ub l e e n s ued He a l s o re l at e s t wo ca s e s o f th e
.
fo r m ati o n o f a s urface c lo t r e s u l tin g fr o m epidura l h ae m o rrh a g e

,
by con tr e coup with o ut fractur e and re c o m m end s e x p lo rat o ry trephin

, ,
i n g in ca se s uch a c o nditi o n i s s u s p e cted After a fe w re m ark s up o n .
fatty e m b ol i s m and in s anity after fractur e o f the s ku ll he expre s s e s h i s ,
b e l i e f in the o ri gin o f certain ca s e s o f s arc o m a in fracture o f the

‘
B ON E S , j oI N TS , OR TH OR AED I C .
77
affected bo ne and re l ate s two ca s e s in which the g r o wth c o u l d b e

,
traced direct l y t o th at cau s ati o n ; epithe l i o m a m ay a l s o d e v e lo p in th e

tend o Ac h illi s th e ha m s trin g s o r any o th er t e nd o n s wh o se s ecti o n m ay
, , .
render reducti o n o r the m aintenance in reducti o n m o re s at i s fa c t o rv .
After a bri ef di s cu s s i o n o f th e gre ater infreq u ency o f a m putati o n

after c o m p o und fracture s in th e pr e s ent than in th e pa s t which he very,
c o rr e ct l y attri b ute s t o th e ad o p ti o n o f an ti s eptic m eth o d s o f tre at m ent

,
h e c o nc l ude s with a brief ana l y s i s o f h i s 5 1 6 ca s e s which m ay b e tab

,
ula t e d a s follo ws
78 I N D E X OF S UR G GA I L P R O GR E S S .
8 3
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2
7
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. n
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7 F ro m ex
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.
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e e
with w o und p r f ct e e
ly h a l d ( a nd
e e 2
F ro i p m rr e ar a
bl d a m ag to h
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t e lo ck o f a gun
b i n g d r iv
e e 11
th ro ugh h k u ll i t e s n
t o th bra in ed an
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,
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ba xi ting in th
se e s e
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.
, ,
Th ese di d se s e
fro c r bral o ft
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en ni g itu a t d a t a s e
di t a nc fro m h
s e t e
w o und Cau se
o f d a th n o t n o t d
.
e e .
Arm
F or ar
e m
Th igh
L g e
F ing r a nd t o
e s es
I nv ol ving h o u l d r s e
lbo w or W i t
,
e l S
jo int ( r u l t o f es ac
eid nt or o p ra
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ti o n
I nv ol ving h i p k n , ee
a n d a n k l jo int e
,
s . 2 . ro tu F m
b l m n ngi
e rc u o us e i
i
t s, follo wing o m s e
w k a ft r a r
ee s e ese e
ti o n o f h i p jo int -
C h r o n i c
.
2
B r igh t d i a ’
s s e s e
soo n a ft r w i r ing e
Inv ol ving c a r p a l h p a t ll
t e e a .
a n d m t a c ar p ale
t ar al a nd m t a
,
s e
t ar al jo int
s s
S up r i or a nd i f
.
e n e
r i r m a xi llary
O
bo n (4 r q ui r d
es e e
s utu r ing b y i l v r s e
wi r ) e
R i b a nd I a al
.
s s
bo n es
Il i
.
um
T o t al ,
GE N I T O- UR I N A R y OR GA N S .
79
E xc l udin g th e 4 8 ca s e s which t e r m i n a t e d fatall y duri n g fo rty ei gh t -
h o ur s th e 1 9 ca s e s which required pri m ary a m putati o n an d the 2

,
ca s e s wh i ch we re i m m edi at e ly tran s ferr e d fr o m th e h o s pita l at th e ir

o wn r e que s t and there re m ain 44 7 c o n s e cutiv e ca s e s o f c o m p o und
,
fractur e with o n l y 2 death s givin g a m o rta l ity o f l e s s th an

, if ,
n o w the 6 1 ca s e s o f c o m p o und fracture o f th e b o ne s o f the hand and

,
fe et b e e x c l uded as t oo in si gnificant in a cc o rdance with the cu s t o m ,
a m o n g all s ur ge o n s in th eir s tati s ti ca l rep o rt s o f ca s e s there s ti ll r e ,
m a i n s 3 8 5 ca s e s o f c o m p o und fracture with b ut a s in gl e d e ath g ivin g ,
a m o rta l ity o f l e s s than In c o m pari s o n wi th thi s attenti o n i s ,
ca ll ed t o the fact th at previ o u s t o the ad o pti o n o f anti s e ptic m e th o d s ,
the rate o f m o rta l i t y in th e b e s t o f tab l e s varied fr o m 2 0 t o 6 0

Add N ew s N o v 1 3 1 8 8 6
.
,
.
, .
J A M E S E PI LC H E R ( U S Arm y ) . . . .
G E N I T O - U R I N A R Y O R GA N S .
I O n t h e P a t h ol o g y o f H ae m a t o c e l e P R E C L U S ( P ari s) I n
. . . .
a lo n g artic l e o n th e p ath olo gy o f h m m at o Ce le M P au l R ec l u s b a s in g . ,
h i s re m ark s o n th e fact that i n fl am m a ti o n s o f s e r o u s m e m b ran e s are
s e c o nda ry t o th o s e o f t h e o r g an s th e y enve lo p s u gg e s t s the te rm ,
”
“
pachy va gina l iti s as giv m g an e x act n o ti o n o f the di s e a s e and re
-
l atin g it t o s i m i l ar l e s i o n s in the m enin g e s The cau s e i s n earl y a l way s .
an inj ury o r s o m e h abi tua l irritati o n s o s l i ght s o m e ti m e s as t o e s cap e

,
n o tice ; fo r e x a m p l e th e fr e que n t c o ntu s i o n o f the t e s te s o n th e p o m

.
m e l o f the s add l e in ridin g Th e gl and m u s t here s uffer m o re th a n the

.
s er o u s c o v e rin g I t b e c o m e s irritated th e circu l ati o n i s s l ack e ned a

.
, ,
s m a ll quan tity o f b loo d fi b r in e s pr e ad s o ut o ver the s er o u s m e m bran e ,
and thi s i s rep e ated s o that fre s h l ay e r s fo r m

, I t wi ll b e fo und that .
the epididy m i s b ein g m o re va s cu l ar and l e s s pr o tected than th e te s ti

c le which h a s i t s tunica a l bu gine a s u fl e r s m o re than th e l att e r and
'
, , ,
that th e diffe r e n t l ayer s o f b loo d have i t g enera ll y a s th eir c e n tr e th e ,
interna l o ne s bein g th o s e whi ch are thicke s t and m o s t rec e nt l y fo r m e d .
—G az . lzebd de M ed
. . et de C h i r .
, Sep t . 24 , 1 88 6 .
L . M A RK ( Lo nd o n ) .
80 INDE R OP S UR GI CA L P R O GR E S S .
I I A g a i n s t D i s t e n d i n g t h e B l a d d e r fo r E p i c y s t o t o m y
.
.
By Pr o f VO N D I TT E L ( V i e nna )
. La s t year Vo n D R e p o rt e d 4 0 0
. .
ca s e s o f o p e rati o n fo r ca l c u lu s ( v AN NA L S 1 8 8 5 O c t Pp 3 3 4 5 )
.
,
. . .
-
t o whi ch 5 0 l at e r ca s e s are n o w added .
H e fir s t cri ticiz e s the o f l at e fav o rit e p l an o f inj e ctin g th e b l add e r

b efo r e th e s upr a pubic Op erati o n In a fo rm er artic l e h e s u gg e s t e d th e
.
p o s s ib l e s uperi o rity o f air fo r s uch inj e cti o n a s i t w o u l d fir s t di s tend

,
th e cr e s t o f the b l add e r i n s t e ad o f the fundu s and m i ght cau s e l e s s ,
har m if i t ruptur e d thr o u gh int o th e ti s s u e s B ut t h i s l att e r a d van .
ta ge wo u l d b e s l i gh t un l e s s a s h e th e n s upp o s e d th e t e ar wa s in t h e
, ,
ant e ri o r w all E xperi m ent s o n t we nty cadav e r s have sh o wn a m o n g s t

.
,
o th e r thin gs that s uch i s n o t th e ca s e T h e quanti t y o f w at e r re qui

, .
s i te t o pr o duc e ruptur e o f th e b l adder r n g e d fro m 3 0 0 t o a g rm s .
in s ubj e c t s fr o m 2 t o 7 4 year s o f a e Of rupture fr o m inj e cti o n

( g ) 1
5 s .
with w ater 7 we r e thr o u gh th e ant e ri o r and 8 thr o u gh the p o s teri o r
w a ll . Th e e x act lo ca l iz ati o n o f th e t e ar d e p e nd s o n m any c o nditi o n s ,
a s the re m ain s o f previ o u s m o r b id pr o ce s s e s the reat variati o n i n th e

'
g ,
g en e ra l s h ap e o f the b l add e r and the arra n g e m e nt o f i t s detru s o r fibr e s ,
etc T h e e ffe ct o f s uch fi ll in g in rai s i n g the p e rit o nea l fol d in fr o nt

.
a l s o vari e s wid e l y As t o air o win g t o i ts c o m pr e s s ibi l ity m o r e i s t ol e r

.
, ,
ated Thr e e e x peri m e nt s g av e

. and cc re s p e ctiv e l y ; .
in a fo urth aft e r inj ectin g

, cc air it r e quired 3 0 0 gr m w at e r t o
.
, .
rupture ; in an o th e r wh e r e , cc air wa s b o rn e .
g rm wat e r ,
.
cau s e d rupture In t h e fir s t thr e e the t e ar wa s thr o u gh t h e p o s teri o r

.
wa ll .
I t m ay b e ur ge d that s uch quantiti e s are n o t requir e d in practic e .

,
th o u gh thi s d o e s n o t h ol d fo r thre e o f h i s e x p e ri m e n ts wh e r e 3 0 0 6 0 0 ,
and 8 0 0 gr i n s cau s ed rup t ur e M o re ov e r durin g l ife ca s e s are m e t

. .
with wh e r e th e b l add e r c o ntract s s o s tr o n gl y th at e v e n und e r deep
narc o s i s n o t h in g can b e inj e ct e d int o th e b l adder .
An y o p e rat i ve m e th o d m u s t b e d e cid e d b y c l ini ca l O b s e rvati o n and
thi s a l s o s h o ws t h e dan g er o f inj ecti o n s In a ca s e o f P r o f We i nle c h

. .
ner s o n a chi l d t h e hi gh o p e rati o n was d o n e after a s m a ll i nj e cti o n

’
int o t h e b l adder I t was fo und at the a u top sy t ha t a s m a ll diver t ic l e

.
near the inci s i o n had b ur s ted A l ike fata l r e s u l t in a 5 y e ar ol d b o y

.
- -
GE N I T O UR I N A R Y OR GA N S .
81
with a l ar g e cal cu l u s was r e p o rt e d by Vo n D in hi s previ o u s l i s t After . .
1 00
g r in s had b een inj e ct e d the re s i s tanc e di m ini s h e d
. Op e rati o n . .
D eath in t h re e d ays R up tur e o f p o s t e ri o r v e s ica l wa ll s tarti n g fr o m

.
,
a sm a ll div e rtic le An o ther ca s e o f We i n le c h n e r s o n a m an ae t 6 7

.
’
.
,
i s h e r e r e p o rt e d After w a s hin g o ut th e b l adder fo r a fe w day s 2 0 0

.
g r m s w e
. r e inj ecte d pr o vi s i o n a l t o o p e rati n g B loo dy fluid c a m e b ack .
fo r the fir s t ti m e pr o bab l y a s the aut o p s y indicated fr o m b e ginnin g

, , ,
rup ture th o u gh the m a n had a s trictur e A c ol p e urynt e r c o ntainin g .
2 00
grm s wa s intr o duced ( in t o t h e rectu m ) and 3 0 0 grm s fluid i n
. .
je c t e d int o the b l add e r ; 2 0 0 m o r e w er e needed b e fo re th e b l add e r

app e ar e d F l ui d tin g ed with b loo d in th e pr e v e s ica l ti s s u e s sh o wed
.
th at rup tur e had a l re ady o ccurre d D e ath in t wenty fo ur h o ur s Th e r e .

-
.
w a s an o b l iqu e circu l ar te ar thr o u gh m uc o u s m e m brane and s ubj acent
m u s cu l ar l ayer extendin g fr o m th e p o s t e ri o r w a ll ar o und o n th e l eft t o

,
anteri o r The m uc o u s m e m bran e was p ol yp o u s oe d e m at o u s inj ected

.
, , ,
and in wi de patch e s cicatricia l r e s e m b l in g a s e r o u s m e m brane A .
fo urth ca s e i s qu o ted fr o m G uy o n ( v A N N A L S 1 8 8 6 Apri l P 3 4 7 .

,
. . . .
He d o e s n o t d o ub t th at s o m e way o f av o idin g thi s dan g er w i ll b e

devi s ed b ut h ol d s th at fo r the pre s ent the m eth o d inv ol v e s t oo great a
,
ri s k [ I t wi ll b e n o tic e d t hat thi s articl e dea l s a l m o s t wh o ll y with th e

.
v ol u m e s inj e cted b ut give s n o e xact data a s t o pr e s s ur e ]

,
H i s l a s t 5 0 ca s e s inc l ud e I l atera l 1 m edian and 9 s uprap ubic o p ,
e ra ti o n s 2 l i th o trip s ie s and 3 7 l ith ol apaxi e s

, Of th e 9 e p i c ys to tom i e s 5 .
di e d 2 c e rtain l y fr o m the O p e rati o n 3 perhap s o n l y in p art ; in n o

, ,
ca s e did infi l trati o n o f urin e int o s u rr o undin g ti s s ue s o ccur The 3 9 .
O perati o n s by cru s hin g g a v e n o fata l r e s u l t s ; ditt o th e 2 p erine al o

p
e ra t i o n s . Wi en . M ed . Woe/zen . 1 88 6 . N o s 4 2 —4 6
. .
WM . B R O W N I N G ( B roo k lyn ) .
III . Use o f C o ca in eBy T J VD O VI K ov fo r L i t h o l a p a x y . . .
S K Y M D ( Ode s s a R u s s i a)
, . Havin g paid a glo win g tr ib ut e t o the
.
,
.
Am erican s ur ge o n s ( Bi g e lo w Oti s Weir etc ) wh o have b r o u g ht abo ut , , , .
a radica l refo r m in th e treat m ent fo r s t o ne in th e b l adder , Dr V d e . .
s crib ed fo ur ca s e s o f h i s o wn in which he u s ed c o cain e fo r l i th ol apaxy .
C A S E I N K m a l e m t 3 0 fo r s ix year s h ad the s y m p t o m s o f
. . .
, , .
,
s t o n e in t he b l adder ; was ad m itted t o th e h o s pita l o n January 1 1 :

32 OF S I R C I CA
‘
L P R O GR E S S .
1 85 6. H e ha d a s ot ne
diam e t er h ard m o vab l e ; als o
4
3
e rm . in , .
purul en t ca tar rh of t h e b la dd e r On Jan u ar y 2 0 li t h ola p axy wa s p er .
fo rm ed i n on e si m n H avin g w ash e d th e b la dd e r an d ur e thra

w i th so lu ti o n of bo ra ci c a ci d 2% s olu ti o n o f h ydr o chlo ra t e o f ,
co cai n e was inje c t e d in th e am o un t o f o un ce s A ft e r 1 2 m in ute s .
t h e lar ge li th o ui t e o f B ig elo w was in tr o duced th e s t o ne wa s s e iz ed at ,
on ce an d in nin e m in ut e s i t was cr ush ed 2 4 t im es By aspirati o n

,
.
m an y fragm en t s o f s t o n e w er e b r o u ht ou t Th en t he li th o tr it e o f g .
R eli qu e t wa s i n tr o d u c e d an d t h e lar g er fra g m e n t s o f s t o n e w ere

.
cr ush e d : agai n as p ira ti on Th en th e li th o tri te o f Th o m p s o n was

.
u s ed twi ce an d all th e frag m en t s o f s t on e w ere

. was h e d o ut T h er e .
wa s n o c on tra c ti on o f th e b lad de r at all The p ati en t b e gan t o feel .
a i n only 3 5 m i n u t es af te r th e c o m m en ce m en t o f t h e O p e r a ti o n No
p .
fever followe d t h e o p e rati on O n th e t hird day t h e tr a c e s o f b lo od .
in u ri n e di sap p e ar e d Carnrrh o f th e b ladder wa s cur ed i n t we l v e

.
CA SE II . M . P m al e . PE I. y ear s 20, wa s s ufi a i n g fro m st on e for 1 6 .
On e xam ina ti on a s t on e was fo un d 6 c t m lo n g hard s m o ot h an d , . , ,
m o v ab le .On Fe b r uar y 1 0 1 8 8 6 o p e rat i on F o ur p er ce n t s oluti o n

. . . .
m in ut es Bi g e lo w s l i th o
’
c o c ai n i m m i a t i c w as in j e c te d an d af t er I 5
i
tr i t e wa s i n t r o du c e d Aft er as p ir ati on th e li t h o trit e s o f R eli q ue t an d

Th o m p s on w ere us e d Th e o p er a ti o n las t e d 1 h o ur an d 5 3 m i nu t es .
m in u t e s th e p rud e n t b e gan t o fe e l p ain an d i n 4 0 m i nut e s th e

35 ,
e ffe c r o f c ocai n e s e e m e d t o h a v e p as s e d aw ay th e r e fo r e t h e s e c o n d ,
h alf o f th e O p erat i on w a p ai nf ul an d t owar d th e e n d of th e O per a ti on

s
,
t h e b la d d er b e g an to c on t rac t N o fe v er aft er th e O p erat i o n Ac e

. .
ca t arrh o f th e blad d er . Th e p at i en t left h o sp i t al cured Mar ch . 2 0,
III . V . Z m ale . in t. e n t er e d th e Mili t ar y H o s p i tal on
Marc h 1 2 . 1 8 86 . H e wa s s uf feri n g fr om th e s ron e for e i g h t ye ar s . A

st o n e wa s ro un d , 3
1
cm i n di am e t er . On A pril 3 Dr . V .
p er
foun d out c o c ai n e ha d n o e ffe c r on t e m pera t ure p uls e r es p i rat i o n

. ,
an d t h e p u p il of t he ey e s Th e op e r a t i on las t e d ab o ut half an h our ,

GE N I T O UR I N A R y 01? C A N S
-
.
83
and p ain l e s s ; n o c o ntracti o n o f th e b l add e r was n o tic e d O n

wa s .
t h e s ixth day th e pati e nt l eft t h e h o s pita l cur e d .
C A S E I V Dr I H ac t 5 9 fo r y e ar s wa s s ufferin g fr o m rheu m a
. . . .
,
.
,
~
t i s m a s th m a and s t o n e in th e b l adder ; h e wa s n e rv o u s and v e ry s en s i

,
tive t o p ain Dr Vd o vik o v s k y h ard l y c o u l d p er s uad e h i s c oll ea gue t o

. .
s ub m it t o t h e O p e rati o n The s t o n e wa s o n l y 2 c m in dia m eter but i t

. .
,
was h ard and s m oo th The o p e rati o n was p e rfo r m e d o n Apri l 2

. .
F o ur p e r c e nt s ol uti o n o f c o caine wa s u se d and Th o m p s o n s l ith o

.
’
,
trite T he O p e rati o n l a s t e d o n l y 1 2 m inute s was quite p ain l e ss and

.
, ,
the patient wa s v e ry m uc h s urpri s ed wh e n h e wa s t ol d that it was a ll

'
o ver The p atient wa s quite we ll o n th e fo urth day after the o pera

.
ti o n .
Dr Vd ovi k o vsk y
. c o m e s t o the c o nc l u s i o n that th e u se o f c o cain e
a lo ne i s quite s ati s facto ry wh en s t one i s n o t l ar g e and the o perati o n
can b e p erfo r m e d in ha l f an h o ur which i s the l i m it o f c o caine s e ffe ct
’
, .
I n ca s e s o f l ar g e s t o ne s ch lo r o fo r m i s preferab l e b ut eve n then if c o n , ,
tracti o n s o f the b l add e r are n o ticed c o caine i s pr o perl y indicated , .
Ves t m k ( St P eter s bur g) Aug 1 8 8 6

'
. .
, .
,
P J P O PO FF ( B roo k l yn ) . . .
'
IV C a s e s o f S u p r a p u b i c C ys t o t o m y By M C F
. Two -
. . . .
G AV I N M D and A T C A B O T M D ( B o s t o n )
, . .
, G avin s ca s e o c
.
’
.
, . . .
curred i nan ol d ex s ol dier o f di s s ol ute habit s ac t 5 2 with s tricture o f

-
, .
,
the urethra ( which c o ntaine d two fi s tulo us O penin gs the re s u l t o f fa l s e ,
pa s s a g e s in atte m ptin g cath eteri z ati o n ) and parti al anky lo s i s o f the ,
lo wer extre m iti e s b y whi ch li th ol ap axy and p erinea l l ith o t o m y we re

,
b o th rendered i m p o ssi bl e T he fi s tulae prevente d s ati s fact o ry di s ten .
ti o n o f the bl adder b ut after the inflati o n o f a b ag in the rectu m an

, ,
inci s i o n in the m e dian l ine fo ur inche s lo n g exp o s ed the b l adder which ,
wa s readily c au ght and O pened S o m e difficu l ty wa s experienced in .
s eizin
g the s t o ne s which were e ncy s ted in p o cke t s in the thickened
,
ve s ica l wa ll ; they we re finall y h o wever s ei z e d wi th l ith o t o m y fo rcep s , ,
o n b ein g pu shed up by an a s si s tant s fin g er in the rectu m

’
The p eri .
t on e um wa s n o t s een durin g the O perati o n .
Cab o t s ca s e o ccurred in a d ebi li tated m an se t 4 9 wh o had s uffere d

’
,
.
,
84 I N D E X OF S UR GICA L P R O GR E S S .
fr o m t o ne fo r a nu m b e r o f y e ar s ; a s trictur e a l m o s t o b l it e rat e d th e
s
l um e n o f the m e m bran o u s urethra Th e s t o n e w as fo und t o b e l ar g e .
an d the s trictured ur e thra c o ntraindicatin g l ith ol ap a x y t h e s upra pu b i c

, ,
-
o p e rati o n was decided up o n Aft e r intr o ducti o n o f s ixt e e n fluid

.
o unce s o f water int o th e b l adder the s upra p ubic r e gi o n wa s s ti ll tym ,

-
p a n i t i c o n percu s s i o n but b e ca m e du ll e r o n the di s t e nti o n o f th e rec

,
ta l b ag a l th o u gh i t n e ver reached flatn e s s

,
On inci s i o n th e p e ri .
,
t o n e um wa s s e e n t o ext e nd n e ar l y d o wn t o th e pubi s but after inci s in g ,
what appear e d t o b e a pr olo n g ati o n o f th e tran s v e r s a l i s fa s ci a b e lo w
i t it c o u l d be dra wn up o ut o f t he wa y T h e b l a dd e r wa s th e n i h
,
.
c i s e d and a very l ar g e h e art s hap e d s t o n e we i ghin g -

gra i n s re , ,
m o v e d wi th o ut tr o ub l e B o th pati e nt s r e c o v e r e d we d — B os ton M ed
. .
n No v
a nd S ur
g f a w . 1 1 1 886 ,
.
, .
V O b s e r v at i o n o n t h e M a l e U r e t h r a w i t h A p p l i c a t i o n s
.
t o E n d o s c o p y L i t h o la p a x y a n d C a t h e t e r i z a t i o n By O T I S K
,
. .
N E WE L L M D ( B o s t o n) The auth o r h as m ade a nu m b er o f ob s e r

,
. .
, .
v at i on s fo r th e purp o s e o f o b tainin g the l e n g th o f th e s h o rt e s t i n s tr u
m ent that can b e intr o duc e d thr o u g h t h e m a l e ur e thra int o the b l adder ,
an d find s that a s the pendu lo u s p o rti o n o f t h e urethra can b e fol ded

,
t o g ether s o that i t s lo n g axi s o ccupi e s n o t m o r e than fr o m to 2

inche s fo r s urgica l p urp o s e s the l e n g th o f th e ur e thra i s b ut 4 inch e s
, ,
in crea s ed in ca s e s o f hypertr o phy t o a p o s s ib l e s ix and an in s tru m ent ,
with a l en g th o f 5 inch e s o r m o r e i s s u fli c i e n t fo r any n o r m a l s ubj e ct .
Bearin g in m ind a l s o th e l ar ge si z e o f th e evacuat o r s u s ed in lith o la

p axy h e h as c o n s tructed an end o s c o pe havin g a 3 0 ca l ibre with th e
-
, ,
vi s cera l o penin g o b l ique e s p e cia ll y d e si gned fo r t h e in s p e cti o n o f the

,
b l adder and p erm ittin g what h as hithert o n o t b e e n d o n e th e i n tro d uc

, ,
ti o n o f i n s tru m e nt s thr o u gh i t s o that with s ui tab l e fo rcep s a fo rei g n

, ,
bo dy can be re m o ved with o ut o p erati o n thr o u gh i t The sh o rtne s s o f .
th e urethra j u s tifie s h i m in sh o rt e nin g th e di s tanc e b e t we en th e o rifice s

o f the tub e o f Big e lo w s evacuat o r fo r l ith ol apa x y fr o m
’
to 1 0
inche s by which he great l y s h o rten s th e peri o d fo r th e e vacuati o n o f
,
the c o ntent s o f the bl adder in that o perati o n ; the tub e i s s tai gh t ,
which al s o add s t o the re adine ss o f evacuati o n Th e auth o r c l ai m s that .

GE N I T O UR I /VA R Y OR C A N S .
35
th e m o dified e v acu at o r r e m o v e s fra g m ent s fo ur o r five ti m e s as rapid ly

a s Bi e lo w s in s tru m ent H e a l s o adv o cate s th e s h o rtenin g and i n
’
g .
crea sin g the dia m eter of the l i th o tri t e b e l i e vin g six inche s t o b e lo n g ,
e n o u h fo r any divu l s o r When a cathet e r o r tub e I S t o b e u s ed fo r

g .
w a s hin g o ut the v e s ical cavity i t sh o u l d b e a s s h o rt and o f a s l ar ge a ,
cal ibre a s p o s s i bl e s o a s t o b e s t ad m it the fre e pa ss a ge o f fluid s

, ,
thick m ucu s o r o th e r m atter a l th o u gh a lo n g er s iz e fo r c o nv e nienc e

, ,
o f m anip u l ati o n i s de sirab l e fo r o rdinary purp o s e s T h e i ll u s trati o n s

, .
o f h i s e nd o s c o p e d o n o t s h o w the in s tru m ent c l e ar l y and h i s d e sc rip ,
ti o n i s great l y w antin g in l uci di ty B os zon M ed a n d S u rg f ou r .

-
‘
. . .
N ov I I 1 88 6
.
,
.
VI . R ules fo r th e A p p licati on of E l e c t r o l ys i s in the
T r e a t m e n t o f U r e t h r a l S t r i c t u r e By R O BE R I N E W M A N M D .
’
, ,
( N e w Y o rk) In a cri ti ca l p ap e r sh o win g th e cau s e s o f fai l ure in

.
tre atin g s trictur e o f the ur e thra by e l ectr ol y si s t o be due t o ( r ) the i n ,
c o m pet e ncy o f the O p e rat o r ( 2 ) m i s m an a g e m ent o f the tre at m e nt ( 3 ) , ,
m i s taken dia g n o s i s an d ( 4) fau l ty in s tru m ent s t h e auth o r pre s ent s the ,
fol lo win g ru l e s as a s afe g uide t o practiti o ner s 1 Any g oo d g a l vanic .
b attery wi ll d o which h a s s m all e l e m e nt s and i s s t e ady ; th e t wen ty ce ll -
Dre s cher b att e ry carb o n and zinc i s an e xce ll en t in s tru m ent s u fficient
, , ,
particu l arl y fo r the b e ginn er z T h e fl uid fo r th e b attery o u ght n o t

,
. .
t o b e u s e d t oo s tr o n g 3 A uxi l iary in s tru m .e nt s a s g a

. l van o m e ter , ,
etc are i m p o rtant t o th e expert b ut n o t nece s s a ry fo r the b e ginn e r

.
, ,
.
4 . F o r the p o s itiv e p ol e a carb o n e l ectr o de i s u s e,

d c o vered w ith ,
s p o n g e m o i s t e ned with h o t w at e r and h e l d fir m l y a g ain s t the p atient s

’
,
hand thi g h o r abd o m e n

, 5 F o r th e ab s o rpti o n o f the s trictur e
. . th e ,
n e a t i ve p ol e m u s t b e u s ed 6 E l ectr o de b o u gie s are fi rm s o und s in

g . .
s ula te d with a hard b ake d m a s s o f rubb e r the p o int i s a m eta l b u l b

- .
eg
g s haped
-
w hich i s the actin
, g p art in c o ntact w i th the s tricture .
7 The curve o f th e b o u g i e i s s h o rt ; l ar g e curve s are m i s tak e s

. 8 . .
The p l ate s m u s t b e i m m er s e d in th e fl uid befo re th e e l ectr o de s are

i
p la c e d o n t h e p ati e nt an d rai s ed a g ain after t h

,
e e l ectr o de s hav e b e en
r e m o ved 9 All o p e rati o n s m u s t b e gin and end whi l e th e batt e ry i s
. .
a t z e r o incr e a s in
g and d e cr e a s in g t h e curr e nt s lo wl y and gradu a ll y by
,
86 I NDEX OF S UR GICA L P R O GR E S S .
on e c e ll at a ti m e av o idin g any sh o ck t o th e pati e nt 1 0 Befo re

,
. .
o peratin g th e s u s c e ptibi li ty o f the p atien t t o th e e l ec

,
tric curr e nt s h o u l d b e a s certain e d 1 1 The pr o b l e m i s t o ab s o rb the

. .
s tri cture n o t t o cauteriz e b urn

, o r d e s tr o y ti s s ue s
. 1 2 ,
Wea k eu r . .
r en ts a t lon In o t ca e a curr n t o f i x c e ll s o r
'
zn f er z/a ls m s s s e s
g 1 3 . .
,
fr o m t o s m i ll ia m p ere s wi ll d o th e wo rk but it m u s t b e r e gl i la t e d
, ,
acc o rdin g t o th e wo rk t o b e d o n e 1 4 Th e s é ance s sh o u l d b e at i h . .
t e rv als n o t t oo fr e quent l y in s ucc e s s i o n

, 1 5 T h e b e s t p o s i ti o n fo r . .
the p atient t o a s s u m e dur in g the o perati o n i s that which i s m o s t c o m

for tab le fo r hi m s e lf and th e o perat o r I pr e fe r the er e ct p o s ture b ut the .
,
recum b ent o r o ther s m ay be u s ed 1 6 An ae s th e tic s I l ik e t o av o id ;

. .
I wan t the p atient c o n s ci o u s s o that h e can te ll h o w h e fee l s 1 7 . .
F o rc e s h o u l d never b e u s ed ; the b o u gie m u s t b e g uid e d in the m o s t

g ent l e way ; the e l ectricity a lo n e m u s t b e a llo w e d t o d o the w o rk 1 8 . .
D uri n g on e s é ance two e l e ctrode s in s uc c e s s lon s h o u l d nev e r b e u s ed

,
.
1 9 . All s tri ctur e s are a m enab l e t o tr e at m ent by e l ec tr ol y s i s 20 P ain . .
s h o u l d nev e r b e inflicted by th e u s e o f e l ec tr ol y s i s t h erefo re i t s h o u l d

n o t b e app l ied when th e ur e th ra i s in ian acute o r e ven s ub acute i n
fl am m a to ry c o nditi o n I n c o nc l u s i o n h e r e m ark s that in every ca s e
, ,
that i s inte ll i g en t l y and j udici o u s l y und e rtak e n s ucce s s m u s t and wi ll ,
follo w In the s tri ct e s t s en se o f the wo rd ther e can b e n o fai l ur e i n

.
di s s ol vin g a way the den s e ti s s ue that c o n s titute s a s tricture fo r e l e c ,
tr olys i s i s ba s ed up o n a fix e d ch e m i ca l acti o n o f th e c o n s tant current
o n the s e ani m al ti s s u e s E l e ctr ol y s i s cann o t fai l but O p e rat o r s m ay

.
,
an d d o /V Y fi l ed R ee
.
-
. Se p t 2 5 1 8 8 6
. . . . , .
J E P I L C H E R ( U S A rm y ) . . . . .
W O U N D S —I N U R I EI S — A C C I D E N T S
J .
I S e v e r e I n j u r y fr o m D y n a m i t e A m p u t a t i o n o f F o r e
. .
ar m Ligat u re o f F e m o ral
. Arte ry G a n g r e n e o f Le g . .
A m p u t a t i o n o f T h i g h P y ae m i a S e v e r e R e a c t i o n a r y H a m
. .
o rrh ag e T r a n s fu s i o n o f B l o o d F o u r T i m e s
. R e cov ery . .
By M e s s r s A N NA N D A L E and J M C O TT E R I L L
.
J P se t 2 3 a quar . . . . .
, .
,
rym an was ad m it te d o n January 8 1 8 8 6 s uffe rin g fr o m t h e re s u l t s o f

, , ,
t h e e x p lo s i o n o f s o m e dy n a m i te cartrid g e s T h e pr o p e r app a ratu s fo r .

W O UN D S ,
[ N / UR I E S , A C C I D E N TS .
7
the purp o s e bei n g o ut o f o rd e r th e pa ti e nt had been war m in g s o m e o f

,
”
the e xp lo s ive in an o rdinary ir o n k e tt l e at a chaffe r wh e n th e dyn a ,
m i te e xp lo ded . Th e l e ft h and was c o m p l et e l y sh attered and the fo r e ,
a rm b ad l y l acerated b y the pie ce s o f m eta l ; the p o s teri o r a s p e ct o f the
l e ft thi g h was de e p l y ga s hed in a ll directi o n s th e fra gm ent s o f m etal

,
S p li n t e rin g th e lo we r en d o f the fe m ur and l yi n g in great quantity

,
a m o n g the deep s tructure s o f the thi gh T h e ri ght hand and le g wer e .
a l s o s evere l y inj ured but t o a l e s s ext e nt than th e l eft

,
Five h o ur s .
after the accident the h and wa s re m o ved by Mr C o tt e ri ll by a m o di .
fi e d circu l ar a m putati o n ab o ve t h e wri s t and l ar g e pi e ce s o f the kett l e

,
w ere extracted fr o m th e ti s s ue s o f the fo r e arm and thi g h Am puta .
ti o n of thi gh wa s o ut o f th e que s ti o n o win g t o th e e xtre m e weakne s s

,
o f the p ati ent cau s ed by th e lo s s o f bloo d and th e s h o ck

, Ch lo r o .
fo rm s ickne s s which s up e rvened after th e o p e rati o n wa s s ub du e d b y a

fe w fift e e n dr o p d o s e s o f a z o % s ol uti o n o f c o cain e .
T h e w o und o f the thi gh h avrn g s lo u ghed e x ten sive l y o n J anuary 1 0 , .
Mr Annanda l e ti ed the fe m o ra l artery at th e ape x o f Scarp a s trian gl e

.
’
s o a s t o l e s s en the ri s k o f s ec o ndary h ae m o rrha g e Thre e day s after .

~
w ard s s i gn s o f gan grene app e ared in th e ca l f o f th e l eft le g The .
te m p erature ran up t o 1 0 7 F in th e e venin g and the patien t beca m e

°
.
,
d e l iri o u s On th e follo wi n g day the g an gren e havin g s pread t o the

.
kn e e am putati o n thr o u gh th e upp e r third o f the thi gh wa s perfo rm e d

, .
On J anuary 1 5 at 1 A M a v e ry pr o fu s e r e acti o nary h ae m o rrha ge

, . .
, ,
fr o m a b ranch o f th e pr o funda artery havin g taken p l ace the pati e nt ,
was tran s fu s ed by Dr Dar l in g th e bloo d b ein g g iv e n by Dr Th o m s o n

.
, . .
F o ur o unce s o f b loo d we re inj ected t o geth er with two o unce s o f s ol u

,
ti o n o f ph o s phat e o f s o da and the c o ndi t i o n o f the patient at o nc e

,
b e g an t o i m pr o v e T h e p atient b ein g s ti ll ve ry w eak and at ti m e s

.
,
d e l iri o u s Mr Annandal e p erfo r m e d tran s fu si o n at m idday inj ectin g

, .
,
s i x o unce s o f b loo d with tw o o un c e s o f s a l in e s ol uti o n Marked i m .
pr o ve m ent a gain follo we d On J anuary 1 6 s y m pt o m s o f s eptic ab

.
s o rpti o n b ein
g pre s ent and the pati e nt pr o fo und l y weak tran s fu s i o n , ,
t o th e e x t ent o f si x o unce s o f b lo o d and two o f the s a l ine s ol u ti o n was

a gain p e rfo rm e d The gr e at i m pr o ve m ent which follo wed wa s m ain
'
t ai n e d fo r thirty si x h o ur s
- but o n January 1 8 th e re was a fa ll i n g off ,
88 INDEX OF S U R GI C A L P R O GR E S S .
and tran s fu s i o n wa s p racticed fo r t h e fo urth t i m e S e v e n o unc e s o f .
b loo d and t wo o f th e s a l in e s ol uti o n we r e inj e ct e d Ab o ut ha l f an h o ur .
aft e r t he O p e rati o n t h e pati e nt had a ri g o r and th e te m p e rature r o se ,
to but it rapid ly fe ll t o 9 9 and th e c o rpu s c l e s we r e fo und in

t h e evenin g t o hav e increa se d by per cub i c m i ll i m etre s ince th e
m o rnin g Fr o m thi s p e ri o d c o nva l e s cenc e s lo wl y be g an
. Sev e ral l arg e .
pyaem i c ab s c e s s e s fo r m e d and we r e o pened in vari o u s p art s o f th e b o dy

,
.
Th e p atient wa s di s char g ed in very g oo d h e a l th o n Apri l 9 .
T h e a ut h o r c o n s ider s that th e O perati o n o f tran s fu s i o n i s d e s tined t o
h ol d a far m o re pr o m inent p o s iti o n than it h a s hith e rt o d o ne o win g t o ,
the fact that th e m e th o d o f app l icati o n h a s b e e n S i m p l ifi e d and per

fe c t e d .I t i s s o m e what r e m arkab l e that th e u s e o f th e s a l in e s ol uti o n ,
in tr o duc e d by Dr B Hi ck in 1 8 7 8 h as n o t c o m e int o m o re gen e ral

. .
,
u s e a s i t c e rtain l y deprive s the o p erati o n

, a s u s ua ll y perfo r m e d o f
, ,
m o s t o f i t s difficu l ti e s and dan e r s

g .
Th e auth o r fir s t e m p lo y e d it in E dinbur g h ab o ut t w o y e ar s a go in a
ca s e o f s e v e r e h ae m o rrha ge fr o m g a s tr i c u l cer and wa s s truck with t h e ,
e a se and s afety o f th e m eth o d T h e s t e p s o f the O p erati o n w i ll b e

‘
.
fo und rec o rd e d in t h e B r i t t s /z M ed i ca l j ou r n a l o f A pri l 1 0 1 8 8 6 P

'
.
, .
6 9 7 t o which d e s cripti o n h e wi s h e s t o add th at t h e b loo d s h o u l d n o t

,
tak e m o r e than fi ve o r s ix m inut e s t o inj e ct th o u gh i t d o e s n o t c oa g u ,
late b e fo r e t wenty m inu te s at l e a s t in the m aj o rity o f ca s e s ; and t h at

thi s O perati o n l ik e all o th e r s s h o u l d b e d o n e with s uch anti s e p tic p re
, ,
cauti o n s as c o m m e nd th e m s e l v e s t o t h e c o m m o n s e n se o f t h e O p e ra to r .
M ed j e a n Oct 2 1 8 8 6
'
.
, , ,
.
H P E R CY D U NN ( Lo n d o n ) . .
G Y N IE C O LO G I C A L .
I . S ub s ero us P ap il lar y
C ys t o m a t a o f t h e O v a r y ; t w o
C a s e s t h e o n e b e i ng a T u b e O v ar i an C y s t O v a r i o t o m y
,
- .
i n b o t h C a s e s fo l l o w e d b y R e c o v e r y I n o n e C a s e fo r I n .
t e rn a l S t r a n g u l a t i o n L a p a r o t o m y fo u r M o n t h s l a t e r Re .
c o v e ry By Dr F LA N GE ( Ne w Y o rk )
. . . B o th o f the s e ca s e s h ad
.
thi s in c o m m o n that the tu m o ur wa s o f m o d e rat e s iz e s ituated o n t h e

, ,
ri h t s id e and r e s t e d w i t h br o ad b a s e b e t we e n t h e l ay e r s o f th e br o ad
g ,
G YALE c oz O GI C AL .
89
l i g a m e nt c o v er e d by p e ri t o n e u m wit h o ut in any w a y s h o win g th e fo r

,
m ati o n o f a pe dic l e .
In b o th the int e rn a l s urfac e o f th e s ac s h o we d p api ll ary fo r m ati o n s ,
whi ch in the o ne ca s e we re v e ry nu m e r o u s and we ll d e v e lo p e d s o th at ,
in s o m e p art s th e y g ave t o a l ar g e e x t e nt t o the inn e r s urfac e a p ap il

l ary a s pect B o th ca s e s we re O p e rat e d in s uch a way that th e tu m o ur
.
wa s g radua ll y s h e ll e d o ut o f i t s p e rit o nea l c o ve rin g under d u e c o n si d
c rati o n o f pr e v e ntin g he m o rrha g e by m a s s l i ature s In o n e ca s e t h e

g .
p e ri t o n e u m was thin and c o u l d o n l y inc o m p l ete l y b e pre s erved In

,
.
t h e o ther it was fa s ten e d t o th e lo w er p art o f the a b d o m i n a K wo un d and ,
t h e parieta l per i t o n eu m in s uch a way th at the p erit o n e a l cavity wa s
entire l y shut o ff In th e o th e r thi s p e rit o n e a l p artiti o n wa s inc o m p l e t e

. .
I n b o th ca s e s th e wo und s urface in th e d e pth o f the p e rit o neu m wa s

fi ll ed loo s e l y with i o d o fo r m g auz e which wa s re m o ved o n th e s e c o n d
-
,
o r thir a day t o b e r e p l aced by l e s s g auze and finally a drain a g e

tub e In thi s way gradua l di m inuti o n o f th e cavity t oo k p l ac e b ut in
.
,
o ne o f th e ca s e where th e c lo s ur e h ad b e en i m p erfect a fi s tu l a h a s
s , ,
re m ained thr o u gh which s o far s o m e c o ar s e s i l k s uture s h av e be e n d i s

,
char g e d and m o r a re t o c o m e o ut T h e patient m o v e s ab o ut with o ut

e .
m uch di s c o m fo rt T h e s p e ci m en o f thi s l atter ca s e pr e s e nt s the rar e

.
vari e ty o f tub o o varian cy s t the fa llo pian tub e b e in g in fre e c o m m uni

-
,
cati o n with th e in s id e o f th e cy s tic sa c I t s cana l w as fo und di l at e d

.
,
the m uc o u s m e m bran e hyp er tr o phi e d and th e c o nt e nt s a b loo dy m u

,
c us .Th e c o nt e nt o f th e cy s t it se l f at a puncture s e v e ra l m o nth s p re

vi o n s t o th e radica l O p e rati o n wa s c l ear ye llo wi s h and thin c o ntai nin g
, ,
a great dea l o f ch ol e s terin cry s ta l s .
The o ther ca s e had the fo llo wm g inter e s tin g hi s t o ry T h e p at i e n t .

,
after havin g rec o ver e d fr o m th e O perati o n s uffici e nt l y we n t t o th e Cat s ,
ki ll m o untain s She wa s th e n s uffe rin g fr o m un m i s takab l e t ub e rc u

.
lo s i s o f the l un g s Ab o ut fo ur m o n th s aft e r t h e o p erati o n s h e d e v e l

.
O ped s y m pt o m s o f o b s tructi o n o f t h e in te s tin e s udd e n l y app arent l y .
aft e r an indi ge s ti o n At th e e n d o f three day s wh e n fir s t s e en by Dr

.
, .
L the o b s tructi o n wa s c o m p l e te and s terc o race o u s v o m i tin g had O c

.
,
curre d rep e at e d l y With o ut m uc h de l ay th e patient w a s br o u ght t o

.
N e w Y o rk and aft e r th e s t o m ach p u m p and carb o nic a cid e ne m ata had

.
90 [ JVD E X OF S U R GI C A L P R O GR E S S .
b e e n tri e d wit h o ut s ucc e s s l apar o t o m y wa s d o n e o n t h e e v e nin g o f

,
S e p t e m b e r 1 7 T h e o b s tructi o n was d ue t o c o n s tricti o n o f a lo o p o f

.
int e s tine ab o ut t h e s iz e Of a duck s e gg by a sharp perit o n e a l b and ’
w h ich s pr e ad b e twe en two p o int s n e ar the attach m e nt O f th e m e s e nt e ry

t o t h e s m a ll int e s tin e Und e r thi s b and a c o il o f int e s tin e had appar
.
e n t l y s l ipp e d and w as s o
, ti ght l y s tran gu l ated that it loo ked al m o s t ,
gan gr e n o u s A r o und it there wa s a s m a ll g atherin g o f br o wn i s h b loo dy

.
fluid j u s t a s we find i t in ca s e s o f s tran g u l at e d h ernia Th e r e was n o

. .
c o nn e cti o n wi th th e o ri gin a l fi e l d o f O p e rati o n T h e p e rit o neal s a c re .

,
m ainin g aft e r th e o vari o t o m y had s hr unk t o a s m a ll h ard l u m p ,

Som e ,
.
adh e s i o n s o f t h e o m e ntu m t o it wer e r e m o v e d Nu m e r o u s tub e rc l e s .
w e r e fo und t o b e s pread o ver the perit o n e u m a l s o o n e l ar g e r ch e e s y .

,
n o du l e within th e o m e ntu m .
N O di s turb anc e follo we d th e O p e rati o n fr o m th e s id e o f th e abd o m
i n a l c a vi t v T h e functi o n o f t h e gut return e d ab o ut fo rty fi v e h o ur s

.
-
aft e r t he o perati o n and h a s s ince then re m ained n o r m al

,
.
Durin g the s e c o nd we e k h o we ver th e l un g tr o ub l e b e ca m e m o re

, ,
s e ri o u s and the fo r m ati o n o f a cavity in the ri ht upp e r lo be o f the

g
l un g c o u l d b e cl earl y m ade o ut The pre s e n t c o nditi o n o f th e patient .
n o w fo ur we e k s after th e o perati o n i s t ol e rab l y oo d t h o u h ther e is

,
g g . ,
n o d o ubt that fina ll y sh e wi ll di e fr o m tub ercu lo s i s —P r oee ed zng s N ew

°
Yo r ie S u rg S oc Oct 1 1 1 8 8 6
. .
, .
, .
11 . S ixC a s e s o f A b d o m i n a l S e c t i o n fo r P y o s a l p i n x o f
G o n o r r h aea l O r i g i n —By J O S E P H PR IC E M D ( Ph i l ade l phia)
. In ,
. . .
th e b e l i e f that th e y s h o w b e y o nd d o ubt t h e cau s a l r e l ati o n b e t we e n th e
di s e a s e d c o ndi ti o n o f th e tube s and o vari e s and a pr e v i o u s go n o rrh oe a ,
t h e writ e r pr e s e nt s t h e follo wi n g ca s e s 1 Hi s t o ry o f a pa s t attack o f .
go n o rrh oe a with pr e s e nt s y m pt o m s o f tr o ub l e in th e o v arian r e gi o n ; o n

e xa m in ati o n th e ri ht o v ary w as fo und t o b e e n l ar g e d aud it s tub e
g, ,
l ar ge di s t e nd e d t o rtu o u s and fir m l y adh e r e nt Abd o m i nal s e cti o n

, . .
r e v e al e d l ar ge ad h e r e nt o varie s and tub e s fi ll e d wi t h p u s and r e m o v e d

w ith gr e at diffi c ultv Th e y we re e nuc l e at e d and t h e pati e n t m ad e a
.
s p e e dy r e c o v e ry 2 C l ear hi s t o ry o f s p e cific tr o ub l e wit h o vari an

. .
pain and ge ne r a l d e bi l ity ; e xa m in ati o n s h o we d th e l e ft tube di s t e nd e d

G YN / ZCC OL O GI C A L .
91
and c lo s e ly attach e d by i t s lo we r b ord e r t o th e br o ad l i ga m ent ; the

'
o vary wa s l ar g e an d b o th it and th e tub e were e xten s ive l y adherent t o

,
the pe l vi c vi s cera On abd o m in a l s ecti o n a l ar g e tab e fi ll ed with p us

.
, ,
t o geth e r wi th a cy s tic o vary was re m o ved the p avi l i o n o f th e tube c o n

,
tainin g p u s s ac s fr o m which l eaka ge h ad pr o b ab l y o ccurred in t o the

p eri t o n eal cavity R ec o v e ry was rapid 3 A pr o s ti tut e in wh o m th e
. . .
uteru s wa s s m all and pu sh e d fo r ward by l ar g e t o rtu o u s and di s tended

m a s s e s s ituated p o s t e ri o r l y o n t h e ri g ht and l eft
, Abd o m ina l s e cti o n .
revea l ed a l ar g e tu b e c o nt ainin g puru l ent che e s y m att e r and m any ,
s tr o n g adhe s i o n s which rendered ir i m p o s s i bl e t o r e m o v e the ri ght

,
o v arv : a l th o u g h a m id the m o s t fi l thy s urr o undin g s the patient m ad e a ,
g oo d r e c o ve ry wi th the excepti o n o f a s m all s in u s pr o b ab l y l e adin g t o

, ,
p u s p o cket s c o nnected with th e o th e r tub e o r o vary 4 Hi s t o ry o f . .
a ctive g o n o rrh oe a an d s y m pt o m s o f o varian o r tuba l tr o ub l e ; exa m ina
ti o n s h o we d bo th o vari e s en l ar ge d with a t o rtu o u s irre gu l ar tub e d o wn

,
in the r e tr o perit o ne a l p o uch with extre m e tenderne ss s h o win g pr o b

~
. .
a b l y py o s a l pinx On ab d o m ina l s e c t i o n b o th tub e s we r e fo und fi ll e d

'
.
,
with p u s and bo th o vari e s cy s tic and were r e m o ved , The adhe s i o n s ,
were s tr o n g and inti m ate A t e ar o f a ll the c o at s o f th e inte s tine except

.
the m uc o u s m ade in detachin g the ri ght tub e and o v ary was s utured
, ,
a n d did n o t int e rfere with an unint e rrupt e d rec o very 5 Hi s t o ry o f . .
g o n o rrh oea exam in ati o n s h o win g the ri g h t tu b e and o v ary t o b e di s

.
e a s ed an d
g enera l p erit o niti s t o exi st Th e cy l indrica l
. t o rtu o u s and ,
s au s a g e l ike tu b e b o ggy t o
-
the t o uch wa s enucl eated with difficu l ty
, , ,
o win g t o the s tren gth o f th e adhe s i o n s and there we r e s m all necr o s e d

,
p o int s fr o m which c o n s tant l eaka g e had taken p l ace P atient did we ll .
fo r a whi l e but fin a ll y di e d o win g t o th e n e gl e ct o f h e r nur s e 6 C o n

,
. .
s tant di s ch ar g e and pe l vic p ain fo r a y e ar and o n exa m i n ati o n hard , , , ,
fi rm irre g u l ar b o di e s e xt e ndin g fr o m th e ri ght and l e ft p o s teri o r l y Ab

, .
d om in al s ecti o n s h o wed th e in l e t o f t h e p e l vi s ch o ke d by adhe s i o n s ,
and the tub e s and o varie s firm l y adherent t o th e s urr o undin g pe l v ic

vi s c e ra ; l eft tu b e t o rtu o u s and fi ll e d wi th p a s and b o th tub e s and o va
rie s r e quir e d c o m p l e te e nuc l e ati o n ; r e c o v e ry in a m o nth —JV Y M d . . .
j au n , Oct 2 3 1 8 8 6
.
,
.
JA M E S E . P I LC H E R ( U . S A
. rm y) .
R E VI E W S OF BO O K S .
H ow WE T R E A T W O U N D S T O D AY A tr e ati s e o n th e s ubj e c t o f anti

- .
s e ptic s ur g ery which can b e und e r s t oo d by b e ginn e r s By R O B E R T .
T M O R R I S M D Sec o nd editi o n 1 2 m o P 1 6 5
.
,
. . N e w Y o rk . . . .
and Lo nd o n : G P P utnam s S o n s . 1 88 6
.
’
. .
Thi s l itt l e b oo k h as e v id e nt l y b e e n wri t t e n w i t h a p urp o s e ; it i s

b o th a m i s s i o n ary tract and a pri m er o f anti s e ptic t e chnique Ther e .
i s witha l a bre ezy d o g m atic flav o r t o i t s s ent e nc e s that wi ll n o t fai l t o

, ,
attr act att e nti o n t o wh at i s s aid wh e th e r it c o m m and s a s s ent o r n o t

,
.
I t i s n o t an e l ab o rat e tr e ati se o n t h e tr e at m ent o f w o und s n o r a de ,
s cripti o n o f the m any varieti e s o f anti s e p tic t e chniqu e th at are in

v o g u e The auth o r i s very p l ain and detai le d in wh at h e d o e s s ay
.
,
and th e v e ry l i m itati o n o f h i s dir e cti o n s t o o ne l in e r e a ll y incre a s e s th e

va l u e o f h i s b oo k t o th o s e wh o wi sh t o kn o w j u s t what t o d o in o rder
t o c o nfo r m their wo rk t o th e de m and s o f th e m o s t appr o ved anti s ep s i s .
The m e th o d s d e tai l e d ar e th o s e which are t o b e fo und in the b e s t o f

th e G e rm an cl inic s at th e pre s e nt ti m e and which loo k t o th e o b tain ,
in g o f a s e ptic w o u n d s and infr e qu e nt dr e s s in gs Fu ll d e s cripti o n s o f .
all m ateria l s r e quir e d fo r thi s k ind o f w o rk h ow t o prepare th e m o r ,
wher e t o o b t ain th e m a s we ll a s h o w t o u s e th e m
, a r e g iven The , .
boo k wi ll d o m uch t o p o pu l ariz e th o r o u g h anti s e p tic wo und treatm e nt .
There i s so m uch o f s up e rfici a l s o ca ll ed anti s eptic wo rk b ein g d o ne

,
-
,
that s uch a c l e an cut p o s i t i v e detai l ed s e ttin g fo rth o f what c o n s ti

~
t ut e s r e a l anti s e ptic w o rk a s t hi s i s i s ca ll ed fo r
.
,
.
L S PI L C H E R . . .
D I E AS E P T I S C H E W U N D BE H AN D L U N G I N M E I N E N C H I R U R GI S C H E N PR I
VAT H O S PI TA LE R N
-
Vo n Dr G NE U BE R D o c e nt fri r Chirur gi e a d
. . .
,
. .
U n i ve rs i t at z u K i e l Ki e l Li p s i u s und Ti s ch e r 1 8 8 6 N e w Y o rk
.
,
. .
,
G . E S te c h e rt
. .
A s e ptic W o und Tr e at m e n t in m y P rivat e Sur gica l H o spita l s . By Dr .
G N E U BE R In s truct o r o f Sur ge ry at th e Univer s ity o f K i e l

.
,
.
In thi s pa m ph l e t o f 3 6 p a ge s th e fo r m e r a s si s tant o f P r o f E s m arch

, . ,
of K ie l re l ate s h i s e ffo rt s t o r e p l ac e t h e pre s ent m eth o d o f an ti s e ptic

,
tr eat m ent o f wo und s by si m p l e a s eptic treat m ent .
Be l i e vin g wo und di s ea se s t o b e cau s e d by th e acti o n O f g er m s he

-
,
s eek s t o av o i d th e ir pr e s e nc e by a g enera l i m pr o v e m e nt o f h o s pita l
hy gien e rath e r than b y lo ca ll y c o m ba ttin g th e m wi t h anti se ptic s ol u

,
t i o n s and m at e ri a l s .
[ VE U B E R 0 1V A S E P TI C DVO U N D TR E A T AI E N T 93
T h e wo rk i s o f int e r e s t a s i t i s t h e fir s t o ne o f i t s kind c o m in g fr o m ,
a G erm an s ur ge o n whi l e o ur o wn l it e ratur e o ffe r s a r e l ati v e l y l ar ge

,
nu m b e r o f s i m i l ar pr o p o s iti o n s N o r e s u l t s are a s ye t r e c o rd e d— th e
.
bui l din g s and interna l arran ge m e nt s havin g s carce l y been c o m p l e t e d .
A detai l e d d e s cripti o n o f the thr e e s e parate h o s pita l b ui l din gs and ac

c e s s o ri e s i s giv e n i ll u s trat e d by nu m e r o u s woo d cut s
,
and in t h e a c -
c o unt o f t h e o peratin g r oo m s m any hint s are int e r s p e r s e d which are ,
we ll w o rthy o f att e nti o n .
We n o tic e a fe w o f the m m o re p articu l ar l y Th e o p erati o n r oo m s .

,
which a r e s ituat e d o n the gr o und fl oo r a re fi v e in n u m b er ; a s e parate ,
r oo m b e in g u s e d fo r th e tr e at m e nt o f acute l y infl a m ed chr o nica ll y in ,

-
fla m ed and rec e nt w o und s inj uri e s n o t c o m p l icated w i th wo und s and

, ,
recta l and g e nit o urinary di s ea s e s r e s p e ctiv e l y E ach r oo m p o s s e s s e s

-
.
i t s o wn pr o p e r in s tru m e nt s and p a raph ernal ia .
T h e w a ll s cei l in g and fl oo r are a ll s m oo th and c o ated Wi th o i l p aint

,
-
,
s o a s t o b e ea s i l y c l e an s e d and m uch o f th e s tati o n ary furniture e tc

, , .
,
i s l e t int o the w a ll s .
The fl oo r S lo p e s t o a draina g e h ol e a t o ne s id e which l e ad s thr o u g h

-
,
a tub e dir e ct l y in t o th e o u t e r air Fr o m the e n d o f t hi s tub e th e wa s te

.
fluid s fa ll int o a receivin g funne l fr o m whenc e th e y a re c o nducted by ,
pipe s t o the s e wer By thi s arran g e m e nt the auth o r h o p e s t o e s cap e

.
the effe ct s o f s e we r g a s e s The o th e r w a s t e pip e s o f th e h o u s e are

-
.
-
s i m p l y trapped with water .
The air ad m itted t o the o p e ratin g r oo m pa s s e s fir s t thr o u gh a fur

nace and then thr o u g h a c o tt o n fi l t e r .
T h e auth o r intend s t o u s e o n l y s teri l iz e d w at e r fo r irri g ati o n s He .
p l ace s h i s in s tru m e nt s in a 1 % carb ol ic s ol uti o n aft e r b o i l in g the m ,
fo r fifteen m inut e s He giv e s th e gr e at e s t a t t e nti o n t o th e p er s o na l

.
c l ean l ine s s o f a ll the att e ndant s and h as a ll arti c l e s o f furniture a s

,
we ll a s th e apr o n s and b oo t s o f t h e s ur g e o n s s o aped o ff and c l ean s ed

wi th s ub l i m at e s ol uti o n ( 2 pr o T h e s p o n ge s aft e r havin g b een ,
th o r o u gh l y c l e an s ed ar e kep t in a 5 % carb ol ic s ol uti o n

, .
S e parate b ath tub s are pr o vid e d fo r p atient s affe ct e d with di ff e rent

-
di s e a s e s s eptic infe cti o n s b e in g pre v ente d fr o m a ll c o ntact with r e cent

,
wo und s . T h e s kin i s di s infe ct e d b e fo r e o perati o n s w ith s ub l i m ate so

lu ti on .
By s uch m e an s a s th e s e —th o u g h they can s carc e c l ai m th e tit l e o f

s i m p l e a s eptic as O pp o s ed t o an t i s epti c precauti o n s a s the auth o r ,
wo u l d have it Dr Ne ub e r h o pe s t o d o a way with the draina g e o f

, .
w o und s a l t o ge ther t o av o id chan gin g the dre s s in gs and t o e s cap e a ll

,
dan g er s o f p o i s o nin g b y an ti s ep ti c s ub s tance s .
W W VAN AR S D A L E . . .
P A T H O L O GI E T H E R A PI E D E R S E I T L I C H E N R U E C K G R AT S VE R K R U E M
U ND
M U N GE N Vo n Dr Ad ol ph Lo r e nz D o cent fur chirur gi e e t c Vi e n '
. .
, ,
.
na 1 8 8 6 Al fr e d H Old e r N e w Y o rk G E S te ch e rt ( P ath olo gy

,
. .
, . . .
and Treat m e nt o f Lat e ra l Curvatur e o f th e S pin e .
The b oo k app e ar s in l ar ge o ctav o c o ntainin g ab o ut 2 0 0 p a ge s o f ,
text and i s hand s o m e l y i ll u s trat e d by m e an s o f nin e l i th o graphi c and

,
e l even ph o t o graphic p l ate s .
Ab o ut o n e third o f the b u l k o f t h e b oo k i s d e v o t e d t o t h e p a th o lo g
-
ica l and th e o retica l a s p e c t o f th e s ubj e ct o f s c ol i o s i s and ab o ut o n e ,
fo urth each t o the c l inica l s id e o f th e s ubj e ct an d t o tr e at m en t .
The auth o r ad m it s a t o r s i o n o f the S pina l c ol u m n in s c oli o si s ( c o ntra

N i c o la d oni ) b ut d o e s n o t be l ieve th at s uch t o r s i o n i s pr o duced b y a
,
r e l ativ e r o tati o n o f the b o die s O f the vertebr ae up o n e ach o ther ( s ince

n o a l terati o n o f t h e artic ul ar s ur face s i s t o b e o b s e rved ) b ut m aintain s ,
that the c ol u m n i s r o tated a s a wh ol e .
The o rie s t o acc o unt fo r the m anner i n which the r o tati o n o ri ginate s ,
a s advanced by H v o n Mey e r B rach m ann Sch e nk and o ther s are

.
, , ,
refut e d The auth o r b e l i e v e s that when the b o di e s o f th e v e rtebrae

.
are fo rced t o o ne sid e in c o n s e qu e nce o f pre s s ure fr o m ab o v e the v e r ,
t e b r al arc s d o n o t partic ip ate t o the s a m e e xt e nt in the m o ti o n b ut ,
are a s it we re l eft b e hi nd
, ,
.
Anat o m ical chan g e s o ccurr i n g in t h e rib s the s t e rnu m t h e t h o rax , , ,
the pe l vi s the l i g a m e nt s and m u s c l e s o f s c ol i o tic individua l s are s e p

,
ara t e ly d e s crib ed .
A s t o the th e o ri e s o f t h e g e netic o ri g in o f s c ol i o s i s th e auth o r fi r s t ,
refut e s b o th anat o m ica ll y and c l ini ca ll y E u l enburg s th e o ry ( that th e

,
’
,
re l axati o n o f th e hyp e r e xtend e d m u s c l e s o n the c o nv e x s id e o f t h e

curve d s pin e cau s e th e di s o rd e r) and s harp l y critici se s H u t e r s hyp o
,
’
the s i s of the pre s s ure o f th e rib s durin g the g r o w th o f th e part s H e .
a l s o attack s o th e r l e s s re cent th e o ri e s re l atin g t o m u s cu l ar acti o n a s ,
we ll a s t hat o f Lo ri n s e r wh o b e l ie ve s s c ol i o s i s due t o s o m e in si di o u s
,
o s titi s Th e s o ca ll e d phy si olo gica l s c ol i o s i s h e be l ieve s t o b e an o p

.
-
tica l d e l u s i o n refe rab l e t o th e flatt e nin g o f the l eft ha l f o f t he b o di e s o f

the m iddl e th o racic vert e br ae .
T o R o s er and Vol k m ann he give s th e credit o f h avin g fir s t thr o wn

l i ght up o n th e s ubj ect o f s c ol i o s i s by adducin g s tatic m o m ent s an d, ,
thu s o ri ginatin g the the o ry o f pre s s ure by wei gh t in habitua l s c ol i o s i s ,
which he exp l ain s at l en g th .
In the cl inica l p o rti o n o f the wo rk we find chapter s o n t h e sy m p t o m

a t o lo gy o f typica l fo r m s o f s c ol i o s i s o n the re l ative fr e qu e ncy o f the s e
,
di fferent typ e s o n th e c l inica l c o ur s e o f the di s ea s e and o n th e m eth o d s

, ,
o f the cl inica l exam inati o n o f pati ent s A s t o the n o tati o n o f r e s u l t s o f .

L OR E N Z OIV L A TE R A L C U R VA T U R E OF S P L/VE .
95
s uch e x a m in a ti o n s the auth o r pr e fe r s the c o m binati o n o f ph o t o graphic

vie ws o f t h e b ack and t,h e data o btain e d with th e he l p o f Miku l icz s ’
m e a s uri n g apparatu s and th e l e ad wir e .
Chapt e r s d e s crip tive o f th e s tatic rh a c h i ti c and o th e r fo r m s o f s c ol i o

,
s i s are given and a practica l o n e o n th e

, pr o phy l actic tr e at m en t o f th e
d efo rm ity in which th e auth o r d e s crib e s a n o v e l s ch ool b ench -
.
Under th e h e adin g o f tr e at m e nt th e auth o r e x pre s s e s hi m s e l f a s n o t

,
in fav o r o f S we di s h m o v e m e nt s fo r s c ol i o s i s since h e d o e s n o t a gre e .
with E u l e nb ur g s m y o ge n e tic th e o ry Sayre s tr e at m ent i s exten s iv e l y

’ ’
.
c o m m ented up o n ; in the auth o r s O pini o n s u s p en s i o n a lo n e i s In s uffi

’
ci e n t t o c o rrect the e xi s tin g defo r m itie s an d ther e fo r e the c o r s et i s ,
t oo I neffective e s pecia ll y as it prev e nt s c o rr e cti o n o f the p o s iti o n o f th e

,
rib s Po r o p l a s tic fe l t i s c o nd e m ned a s n o t s uffici e nt l y e a s i l y app l icab l e

.
.
The anti s tati c m eth o d c o n s i s ti n g in the u se o f an inc l in ed s e at e t c

,
, .
,
i s n o t s uitabl e fo r the c o rrecti o n o f th o raci c fo r m s o f s c ol i o s i s ,
Th e auth o r s m eth o d o f treat m e nt o f l atera l curvature s o f t h e s pine

’
c o n si s t s in a c o m b inati o n o f fo rc e d c o rrecti o n s ( redre s s e m e nt ) o f th e

p o s iti o n o f th e part s t o g e th e r with the u s e o f a re m o vab l e p l a s ter o f
,
-
P ari s c o r s e t b et ween th e si ttin gs A cu s hi o n e d woo den cy l inder i s.
fixed h o riz o nta ll y at a hei ght c o rre s p o ndin g t o th e axi ll a o f the p atient
( s upp o s ed t o be s uffe rin g fr o m a deviati o n o f th e s pina l c ol u m n in its ,
th o racic p o rti o n t o th e ri gh t si de ) and o v e r thi s s upp o rt the pati e nt

, ,
bend s b ack w ard s and l at e ra ll y in s uch a m anner that t he cu s hi o n

,
pre s s e s up o n th e pr o m inent p o rti o n o f th e th o rax at a p o int wher e the

dia g o na l axi s o f th e ch e s t e m er ge s and in s u ch a p o s tur e that the s up
,
p o rt i s a t ri ght an gl e s t o thi s axi s The p ati e n t gra s p s a s trap attached

.
t o the fl oo r with h e r l e ft hand rai s e d ab o v e her h e ad By p u ll in g o n

, .
thi s s trap s h e can rai s e her fe e t fr o m th e fl oo r an d th e wh ol e we i gh t o f ,
the b o dy n o w re s t s o n the s upp o rt whi l e th e wei ght o f the lo we r e x ,
t re m i ti e s ( au gm e nted if ne ed b e by s uita bl e wei g h t s ) t e nd s t o c o rr e ct

, ,
th e c o m pen s at o ry curvatur e o f the l u m b ar p o rti o n o f t h e s pin e Thi s .
ex e rci s e he call s l atera l s u s pe n si o n In app l yin g the p l a s ter o f P ari s

. - -
c o r s et the auth o r e ndeav o r s b y p add in g it in certain p l ace s with

,
piece s o f fe l t t o c o m pre s s th e th o rax dia g o n all y s ufficient roo m b e

, ,
in g m aintained t o per m it a pr o p er exp an s i o n in a p l ane s itua t ed at

ri ght an gl e s t o th e o n e o f c o m pr e s s i o n Th e auth o r a l s o m ak e s an .
ext e n s iv e u s e o f n arr o w p l a s t e r of P ari s j acke t s o r b e l t s by m ean s

- -
,
o f which he endeav o r s t o o b tain a l at e r a l s hiftin g o f the entire upper

b o dy o n th e p e l vi s a s i t we re ,
.
The s e b anda g e s are app l ied whi l e th e p ati e n t a s s u m e s certain ap

p r Op ri a t e p o s iti o n s exten s i o n appar atu s l at e ra l tracti o n e t c
, b e in g, , .
,
fre quent l y m ade u s e o f .

9 6 R E VI E WS OF B O O K S .
In addi ti o n th e a uth o r giv e s a nu m ber o f h is ca s e s i ll u s trated ,

by
ph o t o graph s which it m u s t b e acc e d e d sh o w very goo d r e s u l t s
.
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.
W W
. . V AN AR S D AL E .
ON CA N CE R M O U T H TO N G UE A N D A L I M E N T A R Y TR A C T
OF TH E ,
.
T H E IR P A T H O L O G Y SY M P T O M S D I A G N O S I S A N D T R E A T M E N T
, , By .
FR E D E R I C BO WR E M AN JE S S E T E ng Sur g e o n t o th e Can
, ,
c e r H o s pita l Br om pt o n O ctav o pp 3 0 2
,
. Lo nd o n J and A . . . . . .
Church i ll 1 8 8 6. .
AS th e intr o ducti o n s tate s th e o bj e ct o f the auth o r in writin g thi s

,
b oo k i s t o c oll e ct th e m o r e re cent info r m ati o n o n th e s ubj ect s tr e at e d

o f and t o c o n tra s t th e exp e ri e nce o f o ther s urg e o n s with h i s o wn at
,
th e Can cer H o s pita l Br o m pt o n ,

Al th o u gh n o thin g n e w h a s b e e n a t
.
te m pt e d M r Je s s e t h as s ucc e e ded in pre s e ntin g a cl ear l y written and

, .
j udici o u s r é s u m é o f o ur kn o wl ed g e o f th e s ubj ect s which he h as under

tak e n t o di s cu s s Wher e s o m uch l iterature h a s t o b e r e ad o n every
.
s ubj e ct a r e l iab l e wo rk s uch a s th e pr e s ent i s o f m uch s erv i ce and

, , , ,
e nab l e s th o se in b u s y p ractice t o k e e p abre a s t o f th e advance s o f

th e day .
The c o ntent s a re divid e d int o nin e chapter s with th e follo win g

head s : Cancer o f th e Lip s ; Canc e r o f the G u m s and Antru m ; Can
cer o f th e J a ws ; Cancer o f the T o n gue ; C an c e r o f th e T o n si l ; Can .
c e r o f th e P harynx and ( E so pha g u s ; Cancer o f t h e St o m ach ; Cancer

o f th e Inte s tina l Can al and Cancer o f th e R e ctu m and Anu s
, .
I t i s unn e c e s s ary t o revi e w at l en g th th e c o nt e nt s o f e ach chap

ter a s it i s e qua ll y tru e o f th e m a ll t o s ay that they g iv e a fu ll and
car e fu l di ge s t o f the p ath olo gy s y m pt o m s dia gn o s i s and tr e at m ent
, ,
o f the canc e r o u s affe cti o n s in e ach cas e Stati s tical tab l e s o n que s .
ti o n s o f i m p o rtanc e are qu o t e d fr o m vari o u s writ e r s and S i m i l ar o ne s ,
h av e b e e n c o m pi l e d b y way o f c o ntra s t fr o m th e r e c o rd s o f the

th e Cancer H o s pita l Th e l att e r tab l e s h o we v e r d o n o t s e e m t o
.
, ,
diffe r in any e s s e ntia l way fr o m th o s e pr e vi o u s l y pub l i s h e d b ut in ,
s o far a s th e y c o nfir m th e m t h e y a re o f va l ue a s piece s o f c o rrob

o ra t i v e e vid e nc e .
A nu m ber o f i m p o rtant ca s e s a re narrated at l en g th at the end

o f the b oo k Th e s e h ave b een s e l e ct e d fr o m p ub l i s h e d r e c o rd s and
.
fr o m th e auth o r s ca s e b oo k and e x e m p l ify th e te x t

’
.
A g oo d ind e x m ake s a refe r e nc e t o any part o f th e c o ntent s at

a ll ti m e s e a sy .
T h e s p e ll in g o f K o cher s n a m e as K o c k e r i s a m i s tak e which h as

’
been carri e d thr o u gh o ut the boo k Thi s a lo n g with certain o ther .

,
typ o g raphica l e rr o rs wi ll d o ub t l e s s b e re m e died in a fu tur e editi o n

, .
T h e practica l exp e ri e nc e wide readin g and j udici o u s s e l ecti o n m an

, ,
i fe s t e d in thi s w o rk cann o t fai l t o b e appreciated .
C H A R L E S W C A TH C AR T . .
TH E R A D I C AL C U R E O F O B L I Q U E I N G U I NAL
H E R N I A B Y I N TE R NA L A B D O M I NAL P E R I
T O N E A L P A D AN D T H E R E S T O R A
,
TI O N O F T H E V A L V ED F O R M
O F T H E I N GU I N A L
C A NA L .
BY W I LL I A M M A C E W E N M ,
. D .
,
OF GL AS G O W ,
S U R GEO N T O T H E R O Y A L I N FI R M A R Y AN D L CT U R E R O N S Y ST E M A TI C A ND C L I N I CA L
, E
SUR G R Y IN TH
E R Y A L I N FI R M A R Y SC H O O L O F M D I C I N E
E O S UR GE O N TO
E .
TH H O S P ITA L F O R S I C K C HI L D R N
E E .
N th e n y O p e ra t i o n s fo r r a d i c a l c u r e o f h e rn i a a s a t
m a ,
p re s e n t p e r fo r m e d t h e s ac i s e i t h e r r e t ai n e d i n t h e c a n a l
,
( b e i n g d e a l t w i t h i n v a ri o u s w a y s
) o r a l i at u r e i s
g ,
p l a c e d o n
i t s n e c k a n d t h e r e m a i n d e r o f t h e s a c i s c u t o ff W o o d s op .
’
e rat i o n i s t h e t y p e o f t h e fo r m e r w h i l e t h a t w h i c h M r
,
Ba nks .
h as d e s c r i b e d m a y b e t a k e n a s i ll u s t r a ti v e o f t h e l a t t e r Th e .
t r e a t m e n t o f t h e s a c i n t h e o p e r a ti o n a b o u t t o b e d e s c ri b e d ,
d i ffe r s fr o m t h e s e i n a s m u c h a s w h i l e t h e s a c i s p r e s e r v e d i t i s
, , ,
c o m p l e t e l y r e t u rn e d b e y o n d t h e l i m i t s o f t h e c a n a l a n d fo r m e d
i n t o a p a d w h i c h i s p l a c e d o n t h e a b d o m i n a l a s p e c t o f th e c i r
c u m fe r e n c e o f t h e i n t e rn a l ri n g .
W h e n t h e s a c i s l e ft i n t h e c a n a l i t a c t s a s a p l u g P l u g s .
t e n d t o w i d e n i n s t e a d o f ob l i t e r a t i n g t h e c a n a l a n d p r e v e n t t h e
p i ll a r s fr o m c o m i n g i n d i r e c t a p p o s i t i o n O r g a n i c u ni o n i s
.
d i ffi c u l t t o s e c u r e b e t w e e n p o r ti o n s o f t i s s u e w h i c h h av e n o t
h a d t h e i r s u rfa c e s r e fr e s h e d s u c h a s t h e c a n a l w i t h i t s i n t e r
,
v e n in g s a c T o o v e r c o m e t h i s t h e w i r e s i n W o o d s O p e r a ti o n
.
’
a re t w i s t e d fi r m l y d o w n s o a s t o e x ci t e p l a s ti c e ffu s i o n w h i c h
i t i s h o p e d w i ll s u ffi c e t o m at t h e t i s s u e s t o g e t h e r T h i s i s u m .
d o u b t e d ly s e c u r e d i n m a n y i n s t a n c e s w h i l e i n o t h e rs i t i s n o t
,
a t t ai n e d . B o t h w h e n th e s ac is d e a l t w i t h i n t h is m a n n e r an d
w h e n i t s n e c k i s l i g a t u re d t h e r e r e m a i n s a fu n n e l S h ap e d p u c k
,
-
90 WI LLI A M M A CE WE N .
e rin g o f t h e p e ri t o n e u m t h e a p e x o f w h i c h p r e s e n t s i n o r a t
,
t h e i n t e rn a l ri n g W h e n t h e l i q u i d m o v e m e n t o f t h e i n t e s t i n e
.
as i t g l i d e s o v e r t h e p e r i t o n e u m is t h r o w n i n t o t h e fo r m o f a
w a v e b y t h e s u d d e n i m p u l s e o f s t ra i n i n g o r c o u g h i n g i t i s ,
c a rri e d i n t o t h i s p o u c h w h i c h g u i d e s i t i n t o th e c a n a l w h e r e i t
e x p e n d s i t s fo rc e I t t h u s a c t s a s a w e d g e w i d e ni n g a n d t e n d
.
ing t o o p e n u p th e c a n al .
W i t h t h e V i e w o f o b v i a t i n g t h e s e d e fe c t s t h e s a c i n t h e O p
,
e ra t i o n a b o u t t o b e d e s c ri b e d i s c a r e fu ll y s e p a r a t e d
,
not o n l y
,
fr o m t h e e n ti r e in g ui n a l c a n a l b u t a l s o fr o m t h e a b d o m i n a l a s
,
p e c t s o f t h e C i r c u m fe r e n c e o f t h e i n t e r n a l ri n g I t i s . com
p l e t e ly r e d u c e d fr o m t h e c a n a l i n t o t h e a b d o m e n b e y o n d t h e
i n t e rn a l ri n g t h e n t h r o w n i n t o a s e r i e s o f fo l d s c o n s ti t u t i n g a
, ,
a d w h i c h i s p l a c e d o n t h e p e ri t o n e a l s u rfac e o p p o s i t e t h e i n
p "
t e rn a l ri n g I t t h e r e c o n s t i t u t e s a b o s s o r b u l w a r k w i t h i t s
.
c o n v e x i t y p r e s e n ti n g b a c k w a r d s t o w a r d t h e a b d o m e n w h i l e ,
i t s b a s e r e s t s o n t h e a b d o m i n a l w a l l s s u rr o u n d i n g t h e c i r c u m
fe r e n c e o f t h e i n t e rn a l ri n g T h i s n o t o n l y p r o t e c t s t h e i n t e r
.
n a l ri n g b u t s h e d s t h e i n t e s ti n a l w av e b a c k w a r d s a w a y fr o m
,
t h e o p e ni n g .
H av i n g t h u s s e c u r e d t h e p e ri t o n e a l s u r fa c e s o m e s u r g e o n s
,
w o u l d b e i n c l i n e d t o l e av e t h e c a n a l a l o n e t h in k i n g w h e n t h e
,
fo r m e r i s a c c o m p l i s h e d t h a t t h e b u l w a r k b e h i n d r e q u i r e s l i t t l e
s t r e n g th e n i n g W h i l e a g r e e i n g i n t h e p r i m a r y i m p o rt a n c e o f
.
s e c u ri n g t h e p e ri t o n e a l s u rfa c e i t i s c o n s i d e r e d a d vi s a b l e t o
,
b ri n g i n t o ap p o s i ti o n a n d t o u n i t e p a r t s w h i c h a r e a b n o r m a ll y
w i d e g r e a t e r s e c u ri t y a n d r e s i s t i n g p o w e r b e i n g t h u s i m p a r t e d
,
t o t h e a b d o m i n a l w a ll T h i s i s e s p e c i a ll y t h e c a s e a s t h e
.
,
v a l v e l i k e f o r m a ti o n o f t h e c a n a l i s m o r e o r l e s s o b l i t e r at e d i n
h e r n i a t h e i n t e rn a l ri n g b e i n g w i d e n e d b y t h e p u s h i n g i n w a rd s
,
o f t h e c o nj o i n t t e n d o n s o t h a t t h e e Xt e rn a l a n d t h e i n t e rn a l
,
a p e rt u re s a r e p l a c e d m o r e d i r e c t l y o p p o s i t e e a c h o t h e r .
T h e c an a l h a v in g b e e n r e fr e s h e d b y t h e fi n g e r a n d t h e h an
d l e o f t h e s c a l p e l d u ri n g r e m o va l o f t h e s a c t h e r e fr o m i t s w a ll s ,
a r e b r o u h t i n t o d i re c t c o n t a c t T h i s m ay b e e ffe c t e d b y a n y
g .
o f t h e m a n y m e th o d s o f s t i t c h i n g T h e r e a r e h o w e v e r i n m o s t
.
, ,
o f t h e s e m e t h o d s t w o O bj e c t i o n a b l e p o i n t s w h i c h o u g h t t o b e
,
o b vi a t e d F i r s t t h e s ti t c h t h r o u g h t h e c o nj o i n t t e n d o n i s s i n
.
,
g le a n d i n c l u d e s t h e e x t e rn a l o b l i q u e t h e r e fo r e t h e a p p o s i t i o n
,
RAD I CA L C UR E OF OB LI Q UE I N G UI N A L H E R NIA .
91
o f t h e i n t e rn a l w i t h t h e o u t e r p i ll a r i s n o t s o e x t e n s i v e o r s o
e x a c t a s it w o u l d b e w e r e a d o u b l e s u t u r e p l a c e d i n t h e c o n
j o i n t t e n d o n a l o n e S e c o n d t h e c o nj o i n t t e n d o n i s a p p ro x i
.
,
m a t e d t o t h e o u t e r p i ll a r o f t h e e x t e r n a l ri n g t h e ab d o m i na l
,
w a ll s b e in g t h i n n e d t h e r e b y a n d t h e n a t u ra l v a l v e w h i c h t h e
c an a l fo r m s i s t o a g r e a t e x t e n t o b l i t e r a t e d I ns t ead o n e
.
,
o u g h t t o e n d e av o r t o b ri n g t h e c o nj o i n t t e n d o n i n t o c l o s e
p r o x i m i t y w i t h t h e o u t e r w a ll r e p r e s e n t e d b e l o w b y t h a t p o r
t i o n o f P o u p a r t s l i g am e n t o n a l e v e l wi t h t h e l o w e s t p a r t o f
’
t h e i n t e rn a l o p e n i n g a n d a b o v e b y P o u p a r t s l i g a m e n t t h e
,
’
,
t r a n s v e r s a l i s a n d i n t e r n a l O b l i q u e m u s c l e s a t a p o i n t c o rr e s
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u n y i e l d i n g l i g a m e n t o f P o u p ar t a n d t o u n i t e i t w i t h t h e t r a n s
v e rs a li s a n d i n t e rn a l o b l i q u e m u s c l e s I n o b l i qu e i ng u i nal
.
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o t h e r fo r m s o f a b d o m i n a l h e r n i a t h o u g h i n t h i s p a p e r i t s ap
,
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’
t h e h a i r o f t h e p u b e s a n d n e i g h b o ri n g p a r t s i s c l o s e l y S h a v e n ,
th e S k i n is w a s h e d w i t h s o a p an d w a t e r a n a i l b r u s h b e i n g e m
,
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u rp e n t i n e i s s m e a r e d
o v e r t h e p ar t s t o r e m o v e a n y g r e a s e w h ic h m ay r e m ai n a l i t t l e ,
m e t h y l a t e d S p i r i t c l e a r i n g a w a y t h e t u r p e n t i n e a n d l e a vi n g t h e
s k i n i n a g o o d c o n d i t i o n fo r o p e ra t i n g T h e p a rt s a re t h e n
.
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t i o n u n t i l t h e p a ti e n t i s p l a c e d u n d e r t h e i n fl u e n c e o f a n a n ae s
th e fic .
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,
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p l a c e d u n d e r t h e l a t t e r A n a s s i s t a n t s t a n d s at t h e o p p o s i t e
.
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.
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.
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,
92 WI LL I A M M A CE WE N .
o v a ri a n p e d ic l e s o r t h r o u g h m a s s e s o f o m e n t u m w h ic h a r e
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.
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p l o y e d fo r a ll t h e s u t u r e s e x c e p t t h e d o u b l e o n e i n t r o d u c e d
,
i n t o t h e c o nj o in t t e n d o n .
FIG . 1 . NE E D LE S , R I GH T AN D LE FT , USE D IN O PE R A T IO N F OR R AD
IC AL C UR E OF HE R N IA .
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e e ar e c o ntinu o u b ing m a d fro m
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.
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and its c o nt e n t s i s t h e n m a d e a n d t h e fi n g e r i n t r o d u c e d t h r o u gh
t h e c a n a l e x a m i n e s t h e a b d o m i n a l a s p e c t s o f t h e i n t e rn a l ri n g
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, ,
.
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FIG . 2 . SI TE OF I N CI S I O N .
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.
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p a ri e t e s o f t h e c an a l .
94 WI LLI A M M A CE WE N .
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, ,
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t h e c i rc u m fe r e n c e o f t h e ri n g (F ig . .
FIG .
3 . SE PAR A TI N G TH E PE R I T O N E U M .
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s e s C r m e e e e .
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is s
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ti o n s e v e ra l ti m e s t h r o u g h t h e s a c s o th a t w h e n p u ll e d u p o n
,
t h e s a c b e c o m e s fo l d e d u p o n i t s e l f l i k e a c u r t ai n ( F i g
,
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,
s k i n b e in g p u ll e d u p w ar d s o a s t o a ll o w t h e p o i n t o f t h e n e e d l e
R A D I CA L C UR E OF OB L I Q UE I N G UI N A L H E R /VI A .
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FI G .
4 . FO L D I N G TH E SA C .
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s e se es s .
t o p r oj e c t t h r o u g h t h e a b d o m in a l m u s c l e s w i t h o u t p e n e t r a t i n g
t h e s k i n ( F ig
. .T h e t h r e a d i s r e l i e v e d fr o m t h e e x t r e m i t y o f
FIG 5 . . SE C UR I N G TH E FO L D E D AB O V E .
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96 WI LLI A M M A CE
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.
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FIG 6 . . PAD C OV E R I N G AB D O M I N AL A PE CT
S OF I N T E R NA L RI NG .
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m
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.
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FIG 7. . THE T H R E A D E D H E R N I A N E E D L E M A K I N G D O UB L E P E N E T R A
T I O N O F CO N J OI N T TE N D O N .
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, ,
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b y t h i s t h r e a d a n d a l o o p l e ft o n i t s a b d o m in a l a s p e c t ( F i g .
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.
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FI G 8
. . LO O P ON AB D OM I NA L AS P C TE OF C O N J O I N T TE N D O N .
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,
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,
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an d w i t h d r aw n .
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,
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.
FI G 9
. . T H R E A D F R O M LO WE R B O R D E R O F C O N J O I N T T E N D O N B E I N G
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.
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.
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I OO WI LLI A M Ild A CE WE IV
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1 04 WJ LLJ AM M A CE WE N .
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R A D I CA L C UR E OF OB L I Q UE I N G UI N A L H E R N IA .
1 05
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1 19
THE O PE R AT I O N F O R VA R I CO C E LE ,
By A LE X O GS T O N c M
.
,
.
.,
O F AB E R DE E N ,
REGI U S P R O F E SSO R O F SU R G ERY I N T H E U NIV ER S I TY O F AB ER D EE N .
N o w h e re h as th e i nt r o d u c t i o n o f th e a n t i s e p ti c m e th o d i n t o
s u r g e r y e x e r c i s e d a m o r e m a rk e d i n fl u e n c e t h a n i n t h e e n c o u r
a g e m e n t i t h as g iv e n t o t h e p e r fo r m a n c e o f s u c h o p e r a t i o n s o f
c o n v e n i e n c e a s t h a t fo r V a ri c o c e l e F o rm e rl y l o o k e d u p o n
.
w i t h d i s fa v o r i f n o t a c t u a l l y c o n s i d e r e d u nj u s t i fi a b l e t h i s o p
, ,
e ra t i o n h a s s i n c e t h e a n t i s e p t i c d a y s b e e n a g a i n t a k e n up b y
s u r g e o n s e v e r y w h e re ,
and m o d i fi e d o r i m p r o v e d i n a c c o rd
a n c e w i t h a n t i s e p t i c p r i n ci p l e s Wh e r e th i s h as h a p p e n e d it i s
.
,
n o w p a r t o f t h e d a il y r o u t i n e o f p r a c t i c e a n d i s r e c o m m e n d e d
,
w i t h a s m u c h c o n fi d e n c e a n d p e r fo r m e d w i t h t h e s a m e s e c u r
,
i t y as t e n o t o m i e s a n d s u b c u t a n e o u s O p e r at i o n s
,
Im p ro ve d .
v a r i c o c e l e o p e r a t i o n s a re c o n t i n u a ll y a p p e a ri n g i n o u r s u rg i c a l
l i t e r at u r e a n d v a r i o u s p l a n s a re b e in g a d v a n c e d a s c l a i m in g
,
b o t h s a fe t y a n d s u c c e s s .
T h a t t h e o p e r at i v e t r e a t m e n t i s s o u nd a n d j u s t i fi a b l e s u r
g e r y c a n s c a r c e l y b e d e n i e d fo r a d v a n c e d c a s e s o f t h e d i s e a s e
,
a r e s o fr e qu e n t l y fo u n d t o p r o d u c e d i s t r e s s a n d d i s a b l e m e n t t o
a g r e a t d e g r e e t h a t a r e a s o n a b l y s a fe a n d c e r t a i n c u r e i s w e l
,
c o m e b o t h t o t h e s u ffe r e r a n d t h e s u r g e o n P a l li a t iv e .
m e t h o d s o f t r e a t m e n t s u c h a s W o r m a ld s r i n g t r u s s e s s u s p e n
’
, , ,
s o r y b a n d a g e s a r e s e l d o m o f a ny u s e
,
.
T h e m e t h o d o f o p e ra t i o n I h a v e e m p l o y e d d u r i n g t h e l a s t
e ight y e a r s e x c e l s i n s i m p li c i t y s a fe t y a n d c e r t a i n t y t h e
,
v a r i o u s p r o c e e d i n g s th at I h a v e s e e n r e c o m m e n d e d b y o p e r
a t o rs . I t i s i n d e e d s o s i m p l e th at I h a v e n o d o u b t m a n y
o t h e r s b e s i d e s m y s e l f h a v e h a d r e c o u rs e t o i t a l t h o u g h I h a v e ,
n o t o b s e r v e d i n m e d i c a l p e r i o d i c a l s a n y s t a t e m e n t o f i t s h a vi n g
b e e n ad o p t e d o r re c o m m e n de d .
I t c o n s i s t s i n a n a s e p t i c s u b c u t a n e o u s d e li g a t i o n o f t h e v e i n
b y m e a n s o f a n e e d l e a n d d i s i n fe c t e d t h r e a d .
( 1 20 )
TH E OP ER A TION FO R VA RI C O CEL E .
I ZI
I h ave p r e s e r v e d n o t e s o f s i x p a t i e n t s s o o p e r at e d o n t h e ,
e a r li e s t i n J a n u a r y 1 87 8 ,
T h e y w e r e a ll y o u n g m e n t h e s ub
.
,
o f a d v a n c e d v a r i c o c e l e o n t h e l e ft s i d e a n d t h e r e e x i s t e d
j e c t s ,
s o ft e n i n g o f t h e t e s t i c l e i n t w o o f t h e m I n a ll t h e o p e rat i o n
.
w a s c o n fi n e d t o t h e l e ft s i d e a n d w a s d o n e i n t h e s a m e m a n n e r
,
s a v e t h a t i n o n e o f t h e m a n ae s t h e s i a w a s n o t e m p l o y e d Th e y .
s u ffe r e d fr o m n o fe v e r o r c o n s t i t u t i o n a l d i s t u r b a n c e a ft e r t h e
o p e r a t i o n t h e l o c a l r e a c t i o n w a s c o n fi n e d t o t h e fo r m a t i o n o f
,
a fi rm i n d u r a t i o n a t t h e s i t e o f o p e r a t i o n w h i c h i n t h e c o u rs e
,
o f a fe w m o n t h s s l o w l y d i s a p p e a r e d T h e r e s u l t w a s i n e v e ry
.
i n s t a n c e s a t i s fa c t o r y a t t h e t i m e a n d m o s t o f t h e m I h a v e s e e n
,
o r h e a r d fr o m l o n g a ft e r t h e O p e r at i o n a n d t h e y h a v e fo u n d ,
t h e c u r e c o m p l e t e a n d p e rm a n e n t .
T h e o p e r a t i o n w a s c a rr i e d o u t as fo l l o w s : T h e p a t i e n t w a s ,
i n a ll c a s e s s a v e o n e p u t u n d e r t h e i n fl u e n c e o f c h l o r o fo r m o r
,
e th e r i n b e d an d ,
t h e s c r o t u m d i s i n fe c t e d b y a 5 p e r c e n t .
s o l ut i o n o f c arb o l i c a c i d T h e p a t i e n t w h o w a s n o t a n ae s th e
.
,
t i z e d w a s o p e r a t e d w h i l e s i tt i n g o n a c h a i r
,
A ft e r d i s i n fe c .
t i o n t h e l e ft h a l f o f t h e s c r o t u m w a s b y t h e u s u a l m a n oe uv r e
,
,
s i e z e d t h r e e q u a rt e r s o f a n i n c h a b o v e t h e t e s t i c l e
-
betwee n ,
t h e fo r e fi n g e r a n d t h u m b o f t h e l e ft h a n d a n d i t s c o n t e n t s
a l l o w e d t o s li p b a c k a n d e s c a p e u n t il t h e c o r d l i k e v a s d e fe -
re n s h a d s l i p p e d o ut o f g ra s p A t t h i s p o i n t t h e fi n g e r a n d
.
'
t h u m b s q u e e z e d t h e s k i n o f t h e t w o s i d e s o f t h e s c r o t um
t o g e t h e r t o s qu e e z e t h e v e in s a w a y fr o m t h e j u s t e s c a p e d v a s
, ,
an d a th re a d e d n e e d l e w as t h r u s t t h r o u gh t h e s c r o t u m at t h i s
s p ot
( F i g . I I ) A h a n d l e d n e e d l e w i t h a l a r g e e y e at i t s p o i n t w a s
.
e m p l o y e d a n d i ts t h r e a d w as t h e s t r o n g e s t s u rg e o n s s i l k dis
’
, ,
i n fe c t e d e i t h e r b y h a vi n g b e e n b o i l e d i n 5 p e r c e n t c a r b o l i c .
s o l u t i o n o r b y K o c h e r s m e t h o d o f t w e n t y fo u r h o u r s s o ak i n g
’
-
,
i n Ge rm a n o i l o f j u n i p e r t h e t h r e a d b e i n g a ft e r w a r d s k e p t i n a b s o
,
l u t e a l c o h o l T h e n e e d l e w a s d i s i n fe c t e d b y b e i n g w a s h e d fi r s t
.
,
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,
.
h a d i n t h r u s t in g t h e n e e d l e t h r o u g h t h e s c r o t u m t o a v o i d a t
, , ,
t h e p o i n ts b o t h o f e n t ra n c e a n d e m e rg e n c e o f t h e n e e d l e t h e ,
t u b u l a r s e b a c e o u s s c r o t a l g l a n d s fr o m w h i c h t h e h a i r s e m e r g e ,
a s th e
y a r e a l w a y s fu l l o f b a c t e r i a a n d th e i r d i s i n fe c t i o n i s a n
i m p o s s i b ili t y T h e n e e d l e w as t h e n u n t h r e a d e d a n d w i t h d r a w n
.
l e a v i n g t h e th r e a d i n i t s t ra c k T h e s k i n o f t h e fr o n t o f t h e
.
22 A LEX . O GS T OI V .
s c r o t u m w as t h e n s e i z e d b y t h e l e ft fo r e fi n g e r a n d t h u m b a n d
d r a w n fo r w a r d s i n a fo l d b e t w e e n t h e m u n t il t h e p u n c t u r e s
fr o m w h i c h t h e t h r e a d e m e r g e d w e r e d r a w n f o r w a r d o v e r t h e
d i l a t e d v e i n s t o t h e b a s e o f t h e fo l d s ( F i g I I I ) .Th e y w e re
.
t h e r e s q u e e z e d t o g e th e r a n d s t e a d i e d b y th e fi n g e r a n d t h u m b ,
a n d t h e n e e d l e t h i s t i m e w i t h o u t a ny t h r e a d
,
wa s o n c e m o re
,
p a s s e d th r o u g h th e s c r o t u m e n t e r i n g a n d e m e r g i n g b y th e
,
s a m e p o i n t s a s b e fo r e Th e e n d o f t h e th re a d e m e r g i n g b e s i d e
.
t h e n e e d l e p o i n t w a s t h r e a d e d i n t o i t s e ye a n d t h e n e e d l e w a s
w i t h d r a w n c a rr y i n g t h e t h r e a d w i t h i t s o t h a t b o t h e n d s o f
, ,
t h e th re a d e m e rg e d b y th e s a m e p o i n t w h e r e t h e n e e d l e w a s
fi rs t e n t e r e d ( F i g I V ) T h e n e e d l e h a vi n g b e e n d e t a c h e d t h e
. .
l o n g e n ds o f th e th r e a d w e re t i e d b y a s u r g i c a l k n o t a n d
t i g h t e n e d u p o n t h e v e in s a n d t i s s u e s t h e y e m b r a c e d w i t h t h e
u t m o s t s t r e n g t h t h a t c o u l d b e a p p l i e d A t ri p l e k n o t w a s
.
m a d e t h e e n d s o f t h e s i l k w e r e c u t o ff s h o r t a n d t h e k n o t p e r
,
m i tt e d t o s i n k i n t o t h e d e p t h o f t h e s c r o t u m Th e p u c k e r
.
i n g s i n w a r d o f t h e n e e d l e a p e r t u r e s d u e t o t h e fir s t a n d s e c o n d
,
n e e d l e t r a c k s n o t qu i t e c o i n ci d i n g i n t h e s u b c u t a n e o u s t i s s u e s ,
s e e F ig I V e r e fr e e d b y p u lli n k a r d s at t h e s e
( .
) .w g t h e s i n o u t w
s p o t s u n t il t h e i n c l u d e d fi b r e s g a v e w a y a n d al l o w e d th e ski n
t o fa l l i n t o i t s n a t u r a l p o s i t i o n e n t i r e l y u n c o n n e c t e d w i t h t h e
knot
A n o th e r e x a c t l y s i m il a r o p e r a t i o n w a s m a d e a n i n c h ( o r t w o
fi n g e r b r e a dth s a s th e c as e r e q u i r e d) h i g h e r u p t h e v e i n s an d
, ,
t h e o p e rat i o n w a s th e n c o m p l e t e .
T h e s c r o t u m w a s a g a i n d i s i n fe c t e d s u rr o u n d e d b y a s h e e t
,
o f s a l i c y li c w o o l a n d t h e p a t i e n t l a i d i n b e d w i t h t h e
,
t e ste s
e l e vat e d .
O n e o f m y p at i e n t s s u b m i t t e d t o t h e o p e r a t i o n w i t h o u t
a n ae s t h e s i a b u t a s a r u l e i t i s s u ffi c i e n t l y p a i n fu l
, ,
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t h e a d m i ni s t r a t i o n o f a n a n ae s t h e t i c a n d t h e c a r e fu l c a rr y i n g
,
o u t o f t h e d i s i n fe c t i o n a n d n e c e s s a r y s t e p s a r e m u c h fa c il i t a t e d
th e re b y .
A k n o t o f t h e s i z e o f t h e p o i n t o f t h e t h u m b a p p e a rs b e
t w e e n a n d a r o u n d t h e l i g a t u r e d p o i n t s a n d a s li g h t d e g r e e o f
,
s c r o t a l oe d e m a c a n b e d e t e c t e d l as t i n g fo r a fe w d a y s
,
Th e.
p a t i e n t s u ffe r s l i t t l e p a in a n d a s t h e n e e d l e p u n c t u r e s a re a g
,
g lu t i n a t e d a t o n c e fr e q u e n t d r e s s i n g i s n e e d l e s s .
FR A C T URES OF TH E L O WER E ND OF TH E R A DIUS .
A d a il y r e n e w a l o f t h e s a l i c y li c w o o l d u r i n g t h e fi rs t t h r e e
d a y s i s d e s i r a b l e a ft e r t h a t n o fu r t h e r d r e s s i n g i s r e q u i r e d
,
.
T h e k n o t a t t h e s i t e o f t h e op e r a t i o n s l o w l y d i s a p p e a r s a n d a t ,
t h e e n d O f t h r e e w e e k s th e p at i e n t c a n s a fe l y w a l k a b o u t ,
u s i n g h o w e v e r a s u s p e n s o r y b a n d a g e a n d b e i n g c a r e fu l t o
, , ,
a v o i d s t ra i n p re s s u re
,
o r fa t i g u e o f t h e p a r t
,
.
T h e d i s a p p e a r a n c e o f t h e l a s t t ra c e s o f t h e k n o t d e m a n d s a
m o n t h o r t w o fo r i t s a c c o m p li s h m e n t b u t e v e n t u a l l y n o t r a c e
,
r e m a i n s o f t h e o p e ra t i o n h a vi n g b e e n p e r fo r m e d .
T H E T R E T A M E N T O F F R A CT U R E S O F THE LO WE R
E N D O F T H E RA D I U S .
1
BY R I C H A R D JO H N H AL L M D ,
. .
,
OF NE W YO R K ,
’
SU R G E O N T O BELLEVU E , AN D T O ST . LU K ES
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H PI TA L
OS S .
T the o u t d o o r d e p a r tm e n t o f t h e R o o s e v e l t H o s p i t a l a n o t ,
i n c o n s i d e r a b l e n u m b e r o f fr a c t u r e s o f t h e l o we r e n d o f
th e r a d i u s p r e s e n t t h e m s e l v e s w h i c h h a v e a l re a d y b e e n s e e n
,
b y p h y s i c i a n s i n p r i v a t e p r a c t i c e a n d a ft e r t h e r e d u c t i o n o f
,
‘
t h e d e fo r m i t y a n d t h e a p p l i c a t i o n o f a n a p p a r a t u s hav e b e e n ,
r e fe rr e d t o u s fo r t r e a t m e n t b e c a u s e t h e p a t i e n t s a re i m p e c u
,
n i o u s ; o r w h i c h h a v e r e c e i v e d t h e fi r s t c a r e at s o m e o t h e r h o s
p i t a l o r d i s p e n s a r y a n d a re s e n t t o u s b e c a u s e t h e p a t i e n t s
,
r e s i d e i n t h e n e i g h b o rh o o d I n t h i s w a y a n d t h r o u g h c o n v e r
.
,
s at i o n w i th v a r i o u s s u rg e o n s a n d p h y s i c i a n s i n t h e c i t
y I ha ve ,
h a d o p p o r t u n i t y t o n o t e t h e d i ffe r e n t m o d e s o f t r e a t m e n t
a d o p t e d b y a g r e at n u m b e r o f s u r g e o n s and i n a num b e r of ,
th e h o s p it a l s i n th e c i t y .
I n t h e c l a i m o f a p a rt i c u l a r a p p a ra t u s a n d t h e t r e at m e n t O f ,
t h e fr a c t u r e t w o i d e a s s e e m t o m e t o h a v e s p e c i a l w e i h t w i t h
, g
1
R e ad b e fo r e th e N e w Y or k S urgi c al s o ci e ty M arch 2 3 , 1 8 86 .
1 24 RICH A R D j OH N H A LL .
Ne w Y o rk u rg e o n s
s F i rs t t h at b y l e a v i n g t h e w r i s t a n d
.
,
h a n d fr e e a n d a l l o w i n g i t t o fa l l i n t o a p o s i t i o n o f a d d u c t i o n
, ,
w e at o n c e re d u c e t h e d i s p l a c e m e n t o f t h e h a n d t o w a rd t h e
ra d i a l s i d e a n d p r e v e n t th e p art i a l a n k y l o s i s o f t h e w r i s t a n d
,
t h e r i g i d i ty o f t h e t e n d o n s a n d s m a ll j o i n t s o f t h e h a n d so ,
m u c h d r e a d e d i n t h i s fr a c t u r e ; a n d s e c o n d t h a t t o a v o i d t h i s , ,
l att e r c o n d i t i o n i t i s n e c e s s a r y a n d a d vi s a b l e t o c o m m e n c e p a s
s i v e m o t i o n a t a n e a r l y p e r i o d l o n g b e fo r e t h e c o n s o l i d a t i o n o f
,
t h e fr a c t u r e a n d t o c o n t i n u e t h i s d u r i n g t h e h e a lin g p r o c e s s
, .
A c o n v i c t i o n f o u n d e d o n b o t h t h e o r e t i c a l c o n s i d e ra t i o n s
,
a n d o n a c o n s i d e ra b l e p r a c t i c a l e x p e r i e n c e t h at b o t h t h e s e ,
v i e w s a r e in c o rr e c t i s m y o n l y e x c u s e fo r b r i n g i n g s o w e l l
,
w o r n a s u bj e c t t o t h e n o t i c e o f t h e S o c i e t y
I t w i l l p r o b a b l y b e a r e li e f t o t h e m i n d s o f m y h e a r e r s t o
, ,
k n o w t h a t I h a v e n o ne w a p p a r a t u s t o p r e s e n t n o n e w m o d e ,
O f t r e at m e n t t o p r o p o s e a n d t h at I d o n o t c l a i m , t o c u r e a ll
c a s e s w i t h o u t d e fo r m i t y o r a n k y l o s i s .
M y o nl y O bj e c t i s t o e x p r e s s m y c o n vi c t i o n t h at c e r t a i n p re
c a u t i o n s u s u a ll y c o n s i d e r e d n e c e s s a r y a r e n o t g e n e r a ll y s o ; ,
a n d t h a t i n t h e c a s e w h e r e t h e d a n g e r s fe a r e d a re r e a l t h e p r e ,
c a u t i o n s t a k e n a r e a t b e s t u s e l e s s a n d o ft e n i nj u r i o u s
, , ,
.
I n c l i n g in g t o t h e c o n v i c t i o n t h a t a d d u c t i o n o f t h e h a n d ,
m ai n t a i n e d e i t h e r b y i t s o w n w e i g h t as i n th e m e th o ds O f ,
C l in e a n d Bra s n b y C o o p e r o r b y t h e p i s t o l s h a p e d S p l i n t o f
,
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s in c e t h e fa c t t h a t t h i s t r e a t m e n t i s fo u n d e d o n a fa l s e V i e w O f
t h e n at u r e O f t h e d i s p l a c e m e n t a n d i s u s e l e s s t o o v e r c o m e ,
i t h as b e e n fu ll y d e m o n s t r a t e d b y t h r e e a t l e a s t o f t h e a u
, , ,
t h o r i t i e s m o s t fr e q u e n t l y c o n s u l t e d M a l g a i g n e ( Tra i te a es ,
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.
F ra c tu res p ,
.
F o r t h e p r a c t i c e o f l e a v i n g t h e w r i s t a n d h an d fr e e t o a l l o w ,
O f a c t iv e a n d p a s s i v e m o t i o n o r o f r e m o vi n g t h e a p p a r a t u s a t
,
s h o r t i n t e r v a l s d u r i n g t h e c o n s o l i d a t i o n fo r t h e s a m e p u r p o s e , ,
m u ch m o r e w e i g h t y a u th o ri t y c a n b e c i t e d I nd e e d a lm o st .
,
a ll t h e a u t h o r i t i e s i n s i s t u p o n t h e i m p o rt a n c e o f o n e o r t h e
'
o t h e r O f t h e s e m e a s u r e s A s in s t a n c e s m ay b e c i t e d M a l
.
g a i g n e ( o p c it
. t p .
,
w h o a l l o w e d t h e s p li n t s t o d e s c e n d
. .
FR A C T URE S OF TH E L O WER E ND OF TH E R A D I US .
o nly as fa r as th e fi rs t
c a r p a l b o n e s i n o rde r to b e ab l e
row o f ,
t o m ak e m o d e rat e m o v e m e n t s V P i t h a ( H a u a é a er a llg u u a
.
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.
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sp e c c /zi r
. B i l l r o t h a n d P i t h a Bd 4 A b t 2 S 1 0 2 ) a d v i s e s t h e
.
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s am e H am i l t o n ( o p
.
3 9)
0 s. e e m s t o a d v o c a t e c o m p l e t e
r e s t a s a r u l e b u t s t a t e s t h a t w h e n a fra c t u r e e x t e n d s i n t o t h e
, ,
j o i n t e a r l y p a s s i v e m o t i o n s m u s t b e m ad e t o p r e v e n t a n k y l o
,
s is . E r i c h s e n ( S c i e n c e a u a A r t of S u rg ery v o l I p 5 7 5 ) s a y s
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A ft e r t h e fi r s t w e e k i t i s w e ll e s p e c i a ll y i n e l d e r l y p e o p l e t o
, ,
l e a v e t h e fi n g e r s fr e e a n d t o e n c o u r a g e m o v e m e n t o f t h e m
, ,
l e s t t h a t p a i n fu l s t i ffn e s s r e s u l t w h i c h i s s o c o m m o n a r e s u l t
o f th e a c c i d e n t P a s s i v e m o t i o n O f t h e w ri s t j o i n t m a y h o w
.
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e v e r o ft e n b e c o m m e n c e d w i t h g r e a t a d v a n t a e t o t h e p at i e n t
, g
b e fo r e t h e u n i o n O f t h e fr a c t u r e m o r e p a r t i c u l a r l y w h e n i t i s
,
i m p a c t e d a n d p r e d i c t s v e r y t r o u b l e s o m e s t i ffn e s s i f t h e h a n d
,
a n d fi n e rs b e k e p t fi x e d d u ri n
g g t h e w h o l e t i m e P a c k a r d .
( A
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s h u rs t s I n te r /m t E u cy c lo ce a i a o
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g v o l i v p I 7 )
7 a d .
,
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v i s e s th at p a s s i v e m o t i o n s h o u l d b e m a d e o n l y i n e x c e p t i o n a l
c a s e s w h e r e t h e r e i s a s t r o n g t e n d e n c y t o s t i ffe n in g s u c h as ,
s o m e t i m e s o c c u r s i n o ld p e o p le o r w h e r e t h e v i o l e n c e p r o d u ci n
, g
t h e i nj u r y h a s b e e n v e r y g r e a t S t i m s o n ( O p c it . p 1 84 ) . .
,
.
r e c o g ni z e s t h e p r i n ci p l e t h a t i m m o b i l i z a t i o n i s i n d i c a t e d a s ,
a rule i n i nj u r i e s i n v o l v e d c l o s e t o j o i n t s ; b u t a dd s “
,
i n th e ,
s m a l l e r j o i n t s o f t h e h a n d t h e c a s e i s d i ffe r e n t T h e r e th e e x .
t e n d e d p o s i t i o n a n d i m m o b il i t y fa v o r s t i ffe n in g e v e n w h e n t h e ,
fr a c t u r e i n v o l v e s o n l y t h e fo r e a r m o r a r m ; a n d t h e r e fo r e , ,
s h o u l d b e l e ft fr e e o r d r e s s e d i n t h e fi x e d p o s i t i o n a n d m o v e d
,
e v e ry d a y A n d ag ai n ( p “
. t h e i n d i c a t i o n s a re o f t w o
.
k i n d s : t o i m m o b i li z e t h e fr a g m e n t s a n d t o a l l o w p a s s iv e a n d ,
v o l u n ta ry m o t i o n s O f t h e fi n g e rs i n o rde r t o p re v e n t o r d i m i n
i s h t h e i r s u b s e q u e n t s t i ffn e s s .
S c h e d e ( Zu r B e b a n d d e s t y p i s c h e n B r u c h e s d e r u n t e r e n
.
R a d i u s e p i p h ys e Ve r/za u a ’
. a er
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D e u ts c /ze u Ge s e ll .
f ur Ch i r .
,
1 88 2, p r e c o m m e n d s t h at t h e fi n g e rs s h o u l d b e l e ft fr e e
. 6 8)
a n d t h e p a t i e n t s e n c o u r a e d t o m a k e a c t iv e a n d p a s s iv e m o
g
t i o n s w ith th e m a n d t h a t t h e s p li n t s s h o u l d b e r e m o v e d e v e ry
,
e i g h t d a y s t o a ll o w O f p as s iv e m o t i o n r e m o vi n g t h e m fi n a ll y ,
i n t h r e e w e e k s T h e d i s c u s s i o n w h i c h fo l l o w e d t u r n e d r a t h er
.
O n t h e r e l a t iv e m e r i t s o f v a r i o u s s p li n t s e s p e c i a ll y as c om ,
p a r e d w i t h p l a s t e r o f P a r i s r at h e r t h a n o n t h e q u e s t i o n o f
,
1 26 R LCH A R D OH N H A LL
j .
ea rl y o t i o n ; b u t S ch u ll e r L a n g e n b e c k a n d B il l r o t h s t at e d
m , ,
t h a t t h e y a l w a y s u s e d p l a s t e r a s a p e r m a n e n t d r e s s i n g l e a vi n g ,
t h e fi n g e r s fr e e a n d w i t h o u t e v e r s e e in g s t i ffn e s s a s a r e s u l t
,
.
B i ll r o t h s t at e d t h a t t h e c a s e s i n w h i c h t h e r e w as a t e n d e n c y t o
a n k y l o s i s a n d m u c h s t i ffn e s s w e r e t h o s e d u e t o g r e a t vi ole n ce ,
t h e fr a c t u r e p e n e t r a t in g t h e j o i n t o r w i t h g r e a t e ffu s i o n O f ,
b l o o d a n d i n fl a m m at o r y p r o d u c t s .
I t w i l l b e o b s e r v e d t h a t s o m e o f t h e a u t h o ri t i e s q u o t e d a b o v e
a d v o c a t e e a r ly m o t i o n o n l y i n t h e m o r e s e v e r e c a s e s I f h ow , ,
e v e r t h e p r i n ci p l e w h i c h I a d v o c a t e i s c o r r e c t
,
t h at m o t i o n O f ,
a n i nj u r e d j o i n t a n d o f t h e p a r t s s u rr o u n d i n g i t w i l l o n l y in
c r e a s e t h e i n fl a m m at o r y p r o c e s s g i v e u s a g r e a t e r q u a n t i t y o f
,
p r o vi s i o n al c a l l u s a n d c a u s e m o r e e ffu s i o n i n t o t h e li g a m e n t s
,
a n d s h e at h s O f t e n d o n s w i t h c o n s e q u e n t g r e a t e r s u b s e qu e n t
,
r i g i d i t y i t fo l l o w s t h a t t h e w o r s e t h e c a s e t h e m o r e h a r m w i l l
,
b e d o n e b y d i s t u r b in g t h e p a r t s a n d t h e s t r o n g e r i n d i c a t i o n
,
W e h a v e fo r m o r e p e r fe c t a n d p r o l o n g e d i m m o b ili z a t i o n S o m e .
,
as S t i m s o n a d v o c a t e fi x at i o n o f t h e w ri s t b u t l e a v e t h e fi n g e rs
, ,
fr e e a n d c o n s i d e r a c t iv e a n d p a s s iv e m o t i o n o f t h e s e o f g r e a t
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- .
T h e u s ual pla n o f tr e a tm e n t was t o a dj u s t a p o s t e rior s pli n t a n d allo w

t h e li m b t o r e m ai n in a fix e d po s i tionfor a t l e a s t s i x w e e k s a t th e e n d
O f th a t t i m e Dr S a n d s t h oug h t t h e r e wa s n o t
. as a ru le a n y s t i ffn e ss
, ,
t o b e ob s e rv e d a t th e coxo fe m oral ar ticula t ion

-
H e h a d b e e n fre .
qu e n tly di s appoi n te d in a t te m p ting by m e an s O f p as s iv e m o t ion t o re

s t or e or pr e s e rv e th e m obili ty o f th e wri s t j oin t H e b e li e v e d th a t in
-
.
s om e ca s e s i m m obili ty i s in e vi tabl e H e h a d tr e a te d th e frac t ur e

.
FR A C T URE S OF TH E L O WER E ND OF TH E R AD I U S .
u n d e r con s i d e ra tio n in b o th way s th a t i s by co m pl e t e i m m obiliza t ion , ,
an d by r e s or ting t o e arly p a ss iv e m o t ion a n d by e ach m e th o d h a d o c ,
c as i o n a lly b e e n di s appoin t e d in t h e r e s ul t s w h e n th e acci d e n t occurr e d
in O ld p e r s o n s But w h e n th e co m p ari s on cam e t o b e m a d e b e tw e e n

.
th e r e s ul t s O b t a i n e d by th e t wo m e th o d s h e h a d n o h e s i t a t ion in s aying ,
th a t p a s s iv e m o t io n h a d b e e n r e s or te d t o m uch t o o O ft e n an d m uc h t o o
e arly . H e h a d fr e qu e n t ly n o t ic e d i n frac t ur e in th e n e ig h b orh oo d of

t h e e lb o w j oin t o ccurring in c h il d r e n th a t th e j oin t a ft e r th e frac t ur e
-
, ,
h a d uni t e d wa s v e ry s t i ff a n d th e t i s s u e s ab ou t i t m or e or l e s s th ick
.
e n e d an d th e con di t io n s s uch th a t all e ffor t s on t h e p ar t O f th e s u r

,
g e o n t o r e s t or e co m p le t e m obili ty by p a s s iv e m o tio n w e r e fu t il e ; b ut
h e h a d s e e n s o m e o f th e s e p a t i e n t s at a s ub s e qu e n t p e rio d an d h a d ,
b e e n b o th s urpri s e d a n d pl e a s e d at th e r e s ul t for th e infla m m a t ory ,
pro d uc t s h a d d i s app e ar e d a n d th e arm b e i n g l e ft t o p e r for m i t s

, ,
n a t ural m ov e m e n t s h a d b e co m e qui t e s uppl e At th e s a m e t i m e h e

, .
d i d n o t wi s h t o go s o fa r as a lw ay s t o con d e m n an e arly r e s or t t o p a s
s iv e m o ti on fo r h e h a d s e e n ca s e s i n w h ic h i t h a d b e e n th e m e an s o f
,
bri n gi n g ab ou t m obili ty wh e r e o th e rwi s e s uch m o tion woul d h av e b e e n

lo st But a s a g e n e ral rul e i t woul d b e b e tt e r t o le t na t ur e h av e h e r
.
, ,
own way ra th e r th an a t t e m p t t o forc e i t by e arly r e s or t t o p a s s iv e m o .
t i on an d s o far a s h i s e xp e ri e n c e w e n t h e was pr e p ar e d to e n d or s e th e
,
rul e a d vi se d by Dr H all . .
D R Y A LE s ai d th a t fro m h i s own e xp e ri e n c e prolong e d r e s t O f a

.
, ,
j oin t i s n o t pro d uc tiv e o f th e ankylo si s O ft e n a t trib u te d t o i t N ot o n ly .
wi th d i s e a s e s O f j oin t s b u t wi th frac t ur e s in th e n e igh b orh oo d i t h a d

, ,
b e e n h i s h abi t t o k e e p th e m in a fix e d p o s i tio n ra th e r a lo n g t i m e t h an
o th e rwi se an d h e h ad n o t b e e n tro ubl e d s ub s e qu e n t ly wi th a nkylo s i s
,
.
F ur th e r m or e h e h a d s e e n s o m e ca s e s in w h i ch i m m obiliz a tion h a d n o t
,
b e e n th e cau s e o f ankylo si s w h e n i t di d occur H e r e call e d on e ca s e .
in p ar ticular th a t O f an e l d e rly la d y wh o fe ll d own s o m e s t e p s an d

,
brok e h e r h u m e ru s T h e s plin t w h ich was appli e d fix e d th e e lb ow an d

.
s h o ul d e r j oin t s b u t t h e h an d w a s in t e n t ionally l e ft fr e e s o th a t i t sh oul d

-
,
n o t b e co m e ankylo s e d I n th e r e s ul t s th e e lb ow an d sh oul d e r j oin t s

.
-
w e r e fr e e v e ry m uch e arli e r th an w e r e th e j oin t s O f th e h an d wh i ch w e r e ,
n e v e r fix e d in a S plin t n or s u ffe r e d any inj ury H e was oblig e d t o .
work for s e v e ral w e e k s wi th p a s s iv e m o t ion b e for e s ucc e e ding in li m b

e ri n g up th e j oin t s O f th e h an d .
Dr L S PI LC H E R s ai d th a t h e wa s fully in accor d wi th th e i d e a o f
. . .
i m m obiliza tion i O i n t s as a r ule e i th e r wh e n th e y a re th e m s e lv e s th e s e a t

, ,
‘
O f an inj ury or wh e n th e p ar t s in th e i m m e d ia t e n e i gh b or h oo d h av e b e e n
,
i nj ur e d ; fo r i t h a d s e e m e d t o h im th a t in a tt e m p t s at e a rly m obiliz a
1 32 L . S . R I L CH E R .
t ion th e r e i s d ang e r o f incr e a s ing or prolonging irri t a tio n by th e m ov e

m e n t s o f th e frag m e n t s m ov e m e n t s cau se d by th e con trac t ion o f th o s e
,
m u s cl e s wh ich ar e i n s e r t e d in t o th e i m m e d i a t e n e ig h b or h oo d o f th e af
fe c t e d p ar t s th e s e con trac t ion s b e ing bo th volu n t ary a n d involun t ary

, ,
provok e d by p a s s iv e m o tio n T h e m ain r e a s on wh y p a s s iv e m o tion

.
s h oul d n o t b e u s e d woul d b e foun d in th e s e r e s ul t s an d n o t in any th ing ,
pro d uc e d in th e j oin t i t s e l f .
Bu t i n th i s i nj ury a t th e wri s t j oi n t th e r e i s a n e n tir e ly d i ffe r e n t con

-
di tion O f a ffair s ; in frac t ur e a t th e low e r e n d o f th e ra d iu s we d o n ot

by p a s s iv e m ov e m e n ts s e t in m o tion m u s cl e s wh ich are a tt ach e d in th e
i m m e dia t e n e igh b orh oo d O f th e a ffe ct e d p ar t Th e o n ly m u s cl e wh ich .
coul d b e broug h t in to m o tion i s th e prona t or qua dra t u s —all th e o th e r

m u s cl e s t e r m ina t e in t e n d on s w h ic h pa ss b e yon d th e a ffe c t e d p ar t s ,
wi th th e e xc e p tion O f th e s upina t or longu s w h ich i n th e or dinary m ov e

,
m e n t s o f fl e xi o n o f t h e j oin t i s n o t broug h t in t o u s e a t a ll Th e gr e a t .
m a sse s o f t h e e x t e n s or s a n d th e fl e xo rs ar e n o t s o r e la t e d to th e inj u ry
a s e i th e r volun t arily or in volun t arily t o pro d uc e m ov e m e n t s o f t h e
par ts wh ich m ay incr e a s e irri t a t io n w h il e th e m ov e m e n t s O f th e ar

,
t i c ular s ur fac e s upon th e m s e lv e s pro d uc e d by pa s s iv e m o t ion ar e i n
n ocuou s .
I t se e m e d t o h i m th a t in th e se inj uri e s th e gr e a t e s t d i fficul ty wi th

wh ich we h a d t o con t e n d an d th e e vil r e s u lt s o f w h i ch w e wi sh e d t o
,
avoi d was th e t e n d e n cy t o e ffu sion a n d s ub s e qu e n t a dh e s ion along

,
t h e s h e a th s o f th e t e n d on s a n d t h a t i n th e m ov e m e n t s prop e rly guar d e d

,
wh i ch m ay b e pro d uc e d a t a v e ry e arly d a te t h e for m a t ion O f th e s e a d

h e si o n s m a y b e pr e v e n t e d a dh e s ion s w h ich i f n o t pr e v e n t e d will pro
, , ,
d uc e a ft e r s t i ffn e s s O f th e p ar t s for a con s i d e rabl e p e rio d an d s o m e

-
,
t i m e s r e n d e r t h e j oi n t s u s e l e s s H i s own prac tic e d uring th e la s t

.
t w e lv e y e ar s h a d b e e n b a s e d upon th i s th e ory an d d uri n g t h i s t i m e h e,
h a d th row n a s i d e e n tir e ly s plin t s o f all kin d s A ft e r th e frag m e n t s.
h av e b e e n prop e rly r e plac e d h e s i m ply e n circl e s th e p ar t by a b an d o f

a dh e s iv e pla s t e r an i n ch an d a h al f wi d e w h ic h pr e t ty fir m ly bi n d s
,
t h e m t og e t h e r T h i s h e r e in forc e s by a roll e r b a n d ag e app li e d t o th e

.
h an d a n d fo r e ar m w h ich giv e s a s e n s e o f gr e a t e r s e curi ty an d d i m in

, ,
i sh e s th e t e n d e ncy t o fl uxi o n pr e s e n t in th e e arli e r d ay s O f th e inj ury .
In th i s way th e h an d an d th e fing e r s are l e ft t o th e na t ural m ov e m e n t s .
By th i s m e th o d h e h a d tr e a t e d pa ti e n t s o f all ag e s a n d th e r e s ul t h ad ,
b e e n uni for m ly s ati s fac t ory c e r t ainly m uch m or e s a ti s fac t ory as r e gar d s
,
func tional r e s ul t th a n th e r e s ul t s u s ually e xp e c t e d t o b e a t t ain e d by

s urg e on s . A s an i llu s t ra tio n O f th e m e th o d h e pr e s e n t e d a p a ti e n t a
, ,
wo m a n ae t 4 5 wh o a li ttl e m or e th a n t wo w e e k s pr e viou sly h a d fall e n

.
,
FR A C T URE S OF TH E L O WER E N D OF TH E R A D I US .
upon th e p av e m e n t an d s u s t ain e d in th e u s ual way frac t ur e o f th e low

e r e x tre m i t y of th e ra d iu s a t th e s a m e ti m e t e ari ng o ff th e s tyloi d pro
,
c e s s o f th e ulna als o .
H e fur th e r r e m ark e d th at 1 11 only two ca se s h a d h e appli e d any o th e r

d r e ss ing a fte r t h e r e c e ip t O f th i s inj ury a n d in b o th in s t anc e s i t wa s
'
d on e s i m ply t o s a t i s fy th e fe ar s o f e i th e r th e p ati e n t or th e fri e n d s In .
o n e c a s e a circular s t arch b an d ag e wa s u s e d w h ich co m pl e t e ly i m

’
m obiliz e d th e wri s t an d in th e o th e r Le vi s s m e t allic s plin t wa s u s e d
, .
O f cour s e h e appr e cia t e d t h e fac t th a t v e ry gr e a t d i ffe r e nc e s e xi t s in

,
t h e c h arac te r O f th e inj uri e s wh ich we a r e in t h e h abi t O f placing un d e r
th e g e n e ral h e a d O f frac t ur e O f t h e low e r e x t r e m i t y O f th e r a d iu s an d ,
th a t in c as e s o f s e v e r e co m m in u t io n O f th e low e r fr a g m e n t s p ar ticularly
i t m igh t b e d e sirabl e t o i m m obiliz e th e wri s t j oin t Bu t in th e or d i

- .
n ary ca s e s w h e r e th e low e r frag m e n t i s s i m ply t orn O ff wi th m or e or

, ,
le s s d i s plac e m e n t wi th ou t s uc h a d e gr e e o f inj ury o f th e p ar ts ab ou t

,
th e wri s t j oin t a s t o pro d uc e a v e ry se riou s co m plica ti on O f th e c ase i t

-
,
s e e m e d t o h im th a t in t h e s i m pl e r e t e n t iv e b an d ag e th e r e i s giv e n a
s u ffi ci e n t appara t u s fo r th e s ucc e ss ful m anag e m e n t o f th e s e ca se s an d ,
aft e r an e xp e ri e nc e o f th e s e y e a r s w h ic h h a s b e e n r e in forc e d by th e e x
,
p e ri e n c e o f m a ny o th e r s wh o h a d u se d t h e sam e m e th o d h e wa s r e a d y ,
t o b e li e v e th a t i t i s s u ffici e n t ly e ffici e n t an d th a t i t will giv e j u s t a s

,
goo d r e s ul t s as th e u s e O f s p lin t s In th e applic ation o f the b an d ag e

.
h e woul d s ay th a t i t i s alway s a m a tt e r o f fir s t i m por t anc e accura t e ly t o

r e d uc e th e frag m e n ts an d aft e r th a t a s i m pl e circular b an d ag e in th e
,
gr e a t m aj ori ty O f ca se s will b e foun d s uffi c re nt t o carry i t t o a s ati s fa c

t ory conclu s ion .
Dr C K BR I D D O N s ai d t h a t fo r m or e t h an e igh t y e ar s h e h ad a s e r
. . .
vic e i n th e Ne w Y ork Di s p e n s ary w h e r e th e r e w e r e t r e a t e d b e tw e e n

,
four an d fi v e h un d r e d frac t ur e s o f th e lo w e r e n d O f th e ra d iu s n e arly ,
all o f wh ich ca m e un de r h i s s up e rvi s ion In th e e arly p ar t o f th a t .
p e rio d t h e y w e r e t r e a t e d by i m m obiliz ation by t h e or d inary pi s t ol
S plin t a n d n o p a ss iv e m o t ion wa s u s e d u n t il a t th e e n d o f four or fi v e

,
w e e k s an d in a larg e p e rc e n t ag e o f th e se ca s e s fair r e s ul t s w e r e O b
,
t a in e d s t i ffn e s s r e m aining only for a s h or t p e rio d O f t i m e

,
In o th e r .
ca s e s tr e at e d by th e u s e O f th e d or s al in a d di tion to th e p al m ar s plin t
, ,
th e r e s ul t s w e r e un s a ti s fac t ory a s r e gar d s s ub s e qu e n t m obili t y o f th e
j oin t
.
H i s i m pr e s s ion h ad alway s b e e n th a t th e s t i ffn e ss wh ich follow s th i s

inj ury d o e s n ot d e p e n d s o m uch up on th e ch arac t e r o f th e t r e a tm e n t ,
or i m m obiliz ation or p a s s iv e m o t i on a s up on th e n at ur e o f t h e inj ury

, ,
i ts e l f I n th e s i m pl e fract ur e s v e ry goo d m o tion i s u s u ally ob t ain e d al

.
,
th oug h i n s o m e c a s e s th e r e i s s t i ffn e s s o f t h e fing e r s .

I 34 c H U T CH I S ON
j . . .
He c e r t ainly r e ach e d on e conclu s ion d uring h i s t e r m of s e r vic e an d ,
th a t wa s n o m a tte r wh e th e r th e ca s e wa s tr e a t e d wi th pla s t e r O f Pa ri s
,
- -
s pli n t or wi th a sh or t pi s t ol S plin t or o th e rwi s e a gr e a t d e al O f m i s

, ,
ch i e f was d on e by th e d or s al s plin t I n all th e la tt e r p ar t o f h i s s e r

.
vic e in th e di s p e n s ary h e n e v e r u s e d th e d or s al S plin t b ut e s p e cially ,
th e p a d s w h ich w e r e co m m only plac e d up o n i t an d al s o up on t h e

, ,
plan tar splin t in th e n e i ghb orh o o d O f th e frac t ur e H e h a d foun d th at

,
.
th e y pro d uc e d infla m m a t ion O f t h e s h e a th s o f t h e t e n d on s a n d th a t an ,
un d u e d e gr e e o f s ti ffn e s s r e m ai n e d F or a nu m b e r O f y e ar s h e h a d n ot
.
u s e d any p o s te ri or s plin t a t all b u t h ad si m ply e m ploy e d a cur t ai l e d

,
a n t e rior Splin t p a dding th e ra d ial a s p e c t o f t h e S plin t t o fi ll up th e con

,
cavi ty o f th e for e ar m a n d l e aving th e uhi ar p or t ion o f th e s plin t fr e e

, ,
a n d h e h a d ob t ain e d fair r e s ul t s .
H e th ough t th a t a goo d d e al o f th e d e for m i ty a n d O f th e s t i ffn e ss

wh ich r e m ain e d in th e s e ca se s wa s d ue t o th e fac t t h a t th e frac t ur e wa s
n o t r e d uc e d I t i s s o m e ti m e s e xc e e d ingly d i fficul t t o m ak e co m pl e t e
.
r e d uc tion a n d th a t di fficul ty d o e s n o t o ccur in b ad frac t ur e s b u t in

, ,
ca se s in wh ich th e l e sion i s m o d e ra te involvi n g th e b o n e s i m ply a n d

, ,
n o t t e ari n g a way th e fibrou s s t ruc t ur e s O f th e j oin t w h ic h co n tinu e u p ,
war d i n th e p e rio s te u m fo r a d i s tanc e abov e th e u s ual s i t e o f frac t ur e .
In th e ca se s in wh ich con s i d e rabl e d a m ag e i s d on e th e m obili ty O f th e

p ar ts i s s uch th a t th e y are e a s ily r e s t or e d I f th e r e for e gr e a t c ar e i s .
, ,
t ak e n t o r e d uc e th e frac t ur e co m pl e t e ly t h e frag m e n t s will b e r e t ain e d

,
in p o s i t ion wi th th e s i m pl e tr e a t m e n t d e vi s e d by Dr Pilch e r ; b u t .
w h e r e th e r e i s con si d e rabl e d a m ag e d on e t o t h e par t s ab ou t th e j oin t

h e b e li e v e d th a t t o d e p e n d upo n a s i m pl e r e te n tiv e ban d ag e woul d b e
liabl e t o b e follow e d by a goo d d e al o f m i s c h i e f a n d b ad r e s ul ts ; a t
le a s t t h a t h a d b e e n h i s p e r s onal e xp e ri e nc e as h e h a d t r e a te d s o m e ,
ca s e s n o t m a n y wi th th e s i m pl e r e t e n tiv e appara t u s an d th e sw e lling

, , ,
an d infla m m a t ion h a d gon e on incr e a s i n g a n d h e t h ou g h t t h a t t h e ,
s w e lli n g a n d infla m m a t ion w e r e con s e qu e n t upon th e m obili ty p e r m i t
t e d by t h e s i m pl e r e t e n t iv e d r e s s ing H e coul d n o t conc e iv e t h a t

.
,
w h e r e th e r e was m uch m obili ty o f th e par t s thi s s i m pl e r e te n tiv e b an d ,
a g e woul d an s w e r H e d i d n ot wi s h by any m e an s to con d e m n th e

.
m e th o d a d voca t e d by Dr Pilc h e r b u t s i m ply t o s t a t e th a t s uc h wa s t h e

.
,
r e s ul t in th e fe w ca s e s in wh ich h e h ad at te m p te d t o t r e a t th e frac t ur e
in th a t way ,
Dr . C H U T C H I SO N s ai d th a t fo r a nu m b e r O f y e ar s h e h a d tr e a t e d
.
frac t ur e s o f th e low e r e n d O f t h e ra di u s in th e m ann e r s h own on th e

p a ti e n t in tro d uc e d by Dr Pilch e r wh ic h i t wa s on ly fair t o s a y wa s
. .
, ,
brough t to th e at te n tion o f th e pro fe s s ion b y Dr Moor e o f R o ch e s t e r .

, ,
F R A C T UR E S OF TH E L O WER E ND OF TH E R A D I US .
1 35
in a p ap e r r e a d b e for e th e M e dical S o ci e ty of th e S t a te o f N e w Y ork

m any y e ar s ago in w h ic h h e e xpr e s s e d th e O pinion th a t t h e r e w a s wi th
,
th i s frac t ur e d i s loca t ion O f th e ulna in m or e t h an h al f O f th e ca s e s Dr . .
M oor e ci te d fi v e ca s e s w h i ch h e th ough t e st abli sh e d h i s vi e w T h e y .
w e r e all s e ve r e ca s e s a n d prob ably t h e r e wa s d i s loca t ion O f th e uln a

, .
H i s m e th o d con s i s t s in applyi n g a co m pr e s s ov e r th e low e r e n d O f th e

ulna wh i ch i s r e t ain e d in p o s i tion by s urro un ding i t wi th a dh e s iv e p la s
,
’
t e r s a s s e e n in Dr Pilch e r s c a s e
,
. S inc e th e n Dr H u t c h i s on h a d
. .
a d op te d th i s m e th o d al m o s t invari ably a n d wi th m o s t s a ti s fac t ory re

,
s u lt s .T h e r e h a s b e e n m uch l e s s s ti ffn e s s O f th e fing e r s l e s s ankylo s i s , ,
an d l e s s p ain th an in th e u se o f for m e r m e th o d s a n d th e t r e a t m e n t wa s ,
m up h l e s s t roubl e s o m e t o t h e s ur g e on th an a n y w h ic h h e h a d e m
pl oye d H e agr e e d e n t ir e ly wi th th e s t a t e m e n t m a d e wi th r e fe r e nc e t o
.
t h e s a t i s fac t o ry r e s ul t s ob t ain e d by t h i s m e t h o d o f t r e a t m e n t Of .
cour s e p e r fe c t r e s ul t s w e r e n o t t o b e e xp e c t e d in e v e ry ca s e by any
,
m e th o d O f t r e a t m e n t .
Dr PI LC H E R s ai d th a t in pr e viou s d i s cu s sion s o f th i s s ubj e c t h e h ad

.
cr e d i t e d D r Moor e wi th h i s s u gg e s tion co n c e rning th e p a th ology a n d

.
t r e a tm e n t o f th e se frac t ur e s a n d i t m i g h t n o t b e o u t o f plac e t o s t a t e
,
again th a t th e t urning O f hi s a tte n tion t o th e p o s sibili ty o f d oing away

’
wi th th e s pli n t was d ue t o Dr M oor e s origi n al p ap e r on th e s ubj e c t
.
,
p ubli s h e d in th e Tr a n s a ct i on s of t/ze M ed i ca l S oc i ety of t/ze S ta te of

N ew Yor k / or 1 8 7 0 f
S oon a ft e r r e a d ing i t a ca s e o f an aggrava t e d
.
ch arac t e r ca m e un d e r h is O b s e rva ti on i n w h i ch a gr e a t d e al O f d i sp la c e
m e n t pr e s e n t e d i t s e l f T h e r e w e r e all th e e vi d e nc e s O f th e con di tion
.
d e s cri b e d by Dr Moor e a s pr e se n t in d i s l o ca t ion o f th e e x te n s or carpi

.
uln ari s an d hi s m e th o d o f m anip ula tion a s appli e d by Dr Pilch e r was

,
.
s ucc e s s ful in r e s t oring th e p ar t s t o th e ir n a t ural con di t ion Dr M oor e s ’

. .
b an d ag e a s h e s uppo se d wa s t h e n appli e d T h e ca s e progr e s s e d t o

, ,
.
an e xc e ll e n t t e r m i n a t ion W h e n th e p a ti e n t was ab o u t t o b e d i s c h arg e d

.
fro m t r e a tm e n t Dr Pilc h e r fo u n d th a t in s t e a d o f placing h i s p a d un d e r

,
.
th e ul n a a s s tro n gly urg e d by Dr Moor e h e h a d plac e d i t u n d e r n e a t h

,
.
,
t h e ra d iu s T h e goo d r e s ul t n o twi th s t a n d ing le d h i m t o b e li e v e t h a t

.
,
th e e n tir e valu e O f t h e appara t u s wa s in th e r e t e n tiv e b an d a g e a n d n o t ,
in th e p ar ticular m o d e O f d r e s s i n g or in th e co m pr e s s an d fr o m th a t ,
t i m e h e h a d t h rown a s i d e t h e co m pr e s s an d h a d u s e d t h e r e t e n t iv e
b an d ag e wi th th e r e s ul t s alr e a dy st a t e d
,
.
Dr S AN D S s ai d h e th oug h t i t wo ul d b e in e xcu s abl e to m ak e t h e s ta t e

.
m e n t th a t th e r e s ul t s w e r e u n i for m ly go o d in th e t r e a t m e n t o f th i s frac
t ur e . H e w as s ur e h e h a d s e e n b a d r e s ul ts in O ld p e opl e w h ich w e r e ,
in e vi t abl e an d in a c e r t ain prop or tion o f ca se s in wh ich th e frac t ur e i s

,
1 36 A . G . GE R S TE R .
se ve re an d p at i e n t s O ld m or e or l e s s s ti ffn e s s wi ll b e th e r e s ul t
th e ,
.
H e d i d n o t b e li e v e a s Dr Bridd on h a d alr e a d y s t a t e d th a t th e tr e a t
, .
,
m e n t alon e wa s r e s pon s ibl e for s uch failur e s H e coul d h ar d ly b e li e v e .
t h a t an y m e th o d woul d pro d uc e u n i for m ly go o d r e s ul t s a n d h e d oub t e d ,
wh e th e r s uch a s t a t e m e n t sh oul d r e c e iv e th e e n d or se m e n t o f th e
S oci e ty .
Dr PI LC H E R s ai d h e h op e d th a t no t h ing wh ich h e h i m s e l f h a d s ai d
.
woul d l e a d t o th e s ugg e st ion wh ich Dr S an d s h a d e xpr e s s e d for h e .

,
h a d s i m ply s t at e d th a t in th e ca s e s pr e s e n t e d t o h i m an d t r e a t e d in ,
th i s way th e r e s ul t s h a d b e e n goo d
,
H e p e r h ap s h a d b e e n for t una t e
.
in n o t h aving h ad pr e s e n t e d t o h i m any ca s e s wi th th e con d i t ion s wh ich

Dr S an d s h a d r e fe rr e d t o an d h e woul d d i s lik e v e ry m uch b e ing
.
,
un d e r s t oo d a s s aying th a t th e r e w e r e n o ca s e s wh i ch woul d n ot r e s ul t
un s a ti s fac t orily no m a tte r wh at m e th o d was e m pl oy e d Wh a t h e h ad .
d e s ir e d t o e m p h a s iz e was s i m ply th a t in th e or d inary frac t ur e O f th e

low e r e x tr e m i ty o f th e r a diu s th e s i m pl e r e te n tiv e b an d ag e i s a s e ffe c tiv e
a s any o th e r m e th o d O f t r e a t m e n t .
Dr S AN D S s ai d th a t wa s th e e xac t p oin t ; h e was unab le t o s e e h ow

.
th e S oci e t y coul d s a fe ly e n d or se th e s t a t e m e n t th a t th e r e s ul t s are uni
for m ly goo d by any m e th o d O f t r e a t m e n t a n d h e was pr e p ar e d t o p ro ,
t e s t again s t i t .
Dr GE R S T E R s ai d th at in h i s s e rvic e d uring t h e la s t se v e n y e ar s a t th e
.
Ge r m an Di s p e n s ary th e n u m b e r O f fr a c t ur e s o f th e low e r e n d O f th e
,
ra diu s wa s qui t e con s i d e rab l e an d h e h ad d uring th e la s t fi ve y e ar s

, , ,
in a larg e m aj o ri ty o f th e se ca s e s e m ploy e d th e si m pl e dr e s s i n g pro

,
p o s e d by Dr Pilch e r H e h ad e m plo ye d i t wh e r e h e b e li e v e d i t woul d

. .
b e s u ffici e n t a n d a s a rul e i t h a d b e e n fou n d t o b e e ffi ci e n t in th e s e

. , ,
ca s e s . T h e r e s ul t s w e r e c e r t ain ly j u s t a s goo d a s th o se ob t ai n e d by
any o th e r m e th o d of t r e a tm e n t b u t e s p e cially b e tte r th an th o s e Ob
,
t ai n e d w h e r e S plin ts h a d b e e n e m ploy e d w h ich inclu d e d t h e m e t acarpo
p h alang e al j oin t s T h e m aj ori ty o f ca se s o f frac t ur e o f th e low e r e n d

.
o f th e ra d i u s w e r e s uc h in w h ic h s o fa r a s r e plac e m e n t o f frag m e n t s
, ,
w a s co n c e rn e d n o d i fficul ty was e xp e ri e n c e d a n d goo d r e s ul t s w e r e

, ,
gain e d I f h ow e v e r long s plin t s incl u di n g th e h an d w e r e e m ploy e d

.
, , , , ,
as wa s s e e n in a nu m b e r o f ca se s a dm i tt e d for a ft e r t r e a t m e n t a -
,
p s e u d o ankylo s i s o f th e t e n d on s an d o f th e s m all j oin t s O f th e fing e r s

-
wa s pro d uc e d by t h e prolong e d i n ac t ivi ty a m or e s e rio u s co n d i tion t h an ,
t h e frac t ur e i t s e l f e s p e cially in o ld p e opl e

, In th e ca se s t r e a t e d by
,
.
’
Pilch e r s m e th o d th e p a ti e n ts coul d al m o s t a t onc e r e s u m e t h e ir avoca
t ion s fro m th e t i m e wh e n t h e b on e s h a d uni t e d
, H e b e li e v e d th e m ov e .
m e n t s o f th e fi n g e r s afte r t r e a tm e n t by o t h e r m e th o d s we r e n o t as
, ,
F R A C T UR E S OF TH E L O WER E N D OF TH E R AD I US .
fr e e as th e y are se e n to b e pr e s e rv e d un d e r th s i i pl e r e t e n t iv e
s m
b an dag e .
H e s t a te d on th e o th e r h an d th a t i t i s a t r e atm e n t t o b e appli e d
, ,
only in th Os e ca s e s wh e r e th e r e plac e m e n t an d r e te n tion of th e frag

m e n t s a re e a s y T h e r e are ca s e s for t una te ly n ot v e ry n u m e rou s
.
, ,
wh e r e th i s r e t e n t iv e b an d ag e d o e s n o t s u ffic e I t m ay b e s ai d th a t .
th e s e d i ffi cul t ca s e s wi ll giv e p oor r e s ul t s un d e r an y for m o f t r e a t m e n t ,
b u t a larg e nu m b e r o f c a se s are s uch a s a dm i t O f e a s y r e plac e m e n t a n d

r e t e n tion o f th e frag m e n t s an d i n th e se ca s e s Dr Pilch e r s r e t e n t iv e
,
’
.
b an d ag e h ad prov e d v e ry s a t i s fac tory in d e e d .
Dr S T I M S O N s ai d wi th r e fe r e nc e t o rigi di ty o f th e fin g e r s following
.
,
i m m obiliz at ion th a t h e h e ar d wi th s urpri s e th e s t a t e m e n t m a d e by D r

, .
H all th a t i m m o b iliz ation O f th e fi n g e r s d o e s n o t e n d in rigi di ty H e wa s

, .
un d e r th e i m pr e s s ion th a t i t i s a fac t O f co m m on O b s e rva tion H e .
th oug h t al s o th a t i t i s a m a t t e r O f g e n e ral O b se rv at ion t h a t rigi d i t y o f

, ,
th e fing e r s occurr e d a s in th e ca s e m e n t ion e d by Dr Y al e

, w h e n th e .
,
li m b wa s i m m obiliz e d in th e tr e a tm e n t o f inj uri e s e v e n abov e th e

e lb ow H e h a d a c as e now un d e r ob se rva t ion in w hich al m o s t c o m
.
p le t e ri gi d i t y o f th e fin g e r s follow e d th e ir i m m obiliz a t ion for two w e e k s

i n th e t r e a tm e n t O f a s i m pl e u nin fl am e d inci s ion o f th e s kin o f th e
p al m .
H e agr e e d fully wi th Dr H all conc e rning th e ab s olu te valu e o f i m .
m ob iliz a t ion O f t h e wri s t A s t o t h e obj e c tion rai se d by Dr Hall

. .
,
th at p as s iv e m ov e m e n t s o f th e fing e r s are liabl e t o in cr e a s e th e i n
fla m m a t ion wi th in th e sh e a th s D r S ti m s on th oug h t th e d ang e r a re ,

.
m o t e o n e b e cau s e in th e fir s t pl a c e th e rang e O f m o t ion in th e fi n

, , ,
g e r s i s s o s lig h t an d s e con dly th e t e n d on s are s o w e ll pro t e c t e d fro m

, ,
s h ari n g in th e pri m a ry inj ury i n fron t by th e prona t or qua d ra t u s ,

be ,
h in d by t h e u s ually un t or n p e rio s te u m .
T h e r e s ul t in Dr H all s ca se s w h ich sh ow e d th a t in th ir ty o n e
’ -
.
,
c ase s no d e for m i ty wa s l e ft wa s by far b e tte r th an th e av e rag e a n d h e, ,
’
t h oug h t th a t i f Dr Ge r s t e r h a d h e ar d Dr H all s r e s ul t s h e woul d n o t
. .
h av e m a d e th e s t a te m e n t th a t th e r e t e n tiv e b an d ag e h a d giv e n r e s ul t s
s up e rior t o an
y o th e r .
Again th e p oin t rai s e d by Dr S an d s th a t s o m e c a s e s d o n o t affor d

,
.
goo d r e s ul ts h e th ough t an i m p or t an t o n e
,
In th e p a ti e n t pr e s e n te d .
by Dr Pilch e r i t s e e m e d t o h i m th a t th e d e for m i ty h a d n o t b e e n c o m
.
,
p le t e ly r e d uc e d an d th a t th e fing e r s w e r e n o t fr e e now
,
In th e s e .
ca s e s of fr a c t ur e of th e low e r e n d o f th e r ad iu s in w hich th e di s t al
frag m e n t i s S pli t in t o s e v e r a l p i e c e s th e ch anc e s are th a t r e cov e ry will ,
t ak e pl a c e wi th a li m i t a t ion O f m o t ion F ur th e r m or e th e r e are ca s e s .

,
R I CH AR D j OH N H A LL .
in wh ich th e in t e r m e dia te s p on gy p or tion O f th e b on e i s s o cru sh e d

th a t h e t h oug h t th e low e r frag m e n t s coul d n o t b e s a fe ly broug h t d own
wi th out ri s k O f failur e Of union ; s uch ca s e s ar e b e s t t r e at e d wi th ou t
m aking an a t t e m p t t o ov e rco m e th e sh or t e ning o f th e ra d iu s T h e re .
s u lti n g d e for m i t y i s n ot gr e a t an d i s n o t acco m pani e d by d i m inu t ion

,
O f func t ion .
Dr H A LL sai d h e e xpr e ss ly s t a t e d th a t i m m obiliz a tion in th e e x

.
t e n d e d p o s i t ion woul d b e follow e d by s ti ffn e s s acco m p a n i e d by d i s

,
co m for t to th e p a ti e n t H e n c e all th e ca s e s h ad b e e n tr e a t e d in th e
.
,
m ann e r d e s crib e d A ft e r e ffu sion h a s t ak e n pl ac e an d fib rin b e e n de

.
p o s i t e d i t s plac e i s t ak e n by organiz e d an d va s culariz e d ti s s u e s o

, ,
th a t in m aking m o t ion bloo d v e s s e l s ar e rup t ur e d w h ich giv e s ri s e t o ,
a fr e sh e xu d a tion th a t only incr e a s e s th e rigi d i t y o f t h e t e n d on s He .
sh oul d r e gar d Dr Pilch e r s ca s e a s o n e in w h ich th e r e w a s m ark e d d i s

’
.
plac e m e n t of th e h an d t owar d th e ra dial s i de wi th con s i d e rabl e li m i

,
t a t i o n o f m o t ion . H e h a d s e e n s e v e ral frac tur e s t r e a t e d in th i s m a n

n e r a n d o n e in wh ich Dr Moor e w a s s ai d t o h av e
,
. appli e d h i s o wn
app ara t u s a n d h a d n o t b e e n pl e a se d wi th th e r e s ul t s a s a rul e
, Dr . .
H all fail e d t o s e e h ow a s i m pl e b an d o f a dh e siv e pla s t e r ab ou t th e

wr i s t coul d h ol d th e frag m e n ts in po s i tion wh e n th e r e wa s a t e n d e ncy
,
t o r e curr e nc e o f th e d i s plac e m e n t on any m e ch anical th e ory w h a t e v e r

, .
Dr GE R S T E R s ai d h e d i d n o t wi sh t o b e un d e r s t oo d as s aying th a t t h e
.
r e s ul ts ob t ain e d by h i m in th e u s e o f Dr Pilch e r s r e t e n tiv e b an d ag e

.
’
w e r e b e t te r th an any O th e r s ; s i m ply th a t th e y w e r e fully a s go o d a s

th o s e O b t ain e d by any o th e r t r e a t m e n t .
Again h e t ook e xc e p tion t o th e e xplana tion giv e n by Dr Hall con

,
.
c e rning th e e ffe c t pro d uc e d by p a s s iv e m o tion on t h e sh e a th s O f th e

t e n d on s i n w h ic h e xu d a t ion h a s t ak e n pl a c e as h e d i d n o t b e li e v e th a t
,
p a s s iv e m ov e m e n t O f a sm o o th t e n d on woul d incr e a s e th e e xu d a tion

or pro duc e any a dd i tional a m oun t o f infla m m a tion nor di d h e b e li e v e ,
fro m a p r i or i r e as oning th a t s uch a r e s ul t was v e ry prob abl e .

ED I TO RI A L A RT I CLES .
O N LAT E R AL PH AR Y N GO TO M Y F O R TH E E XTI R PAT I O N OF MA

LI GNAN T T U M O R S O F T H E T O N S I LLAR R E GI O N .
Wh e n C h e e v e r of Bo s t on r e por te d h i s fir st ca se of O p e r ation for re

, ,
m oval o f a m al i gnan t t u m or O f th e t on s illar r e gion in 1 8 6 9 h e wa s abl e ,
t o fi n d b ut s c an t r e fe r e nc e in li t e ra t ur e t o th e s ubj e c t H i s c as e i n .
,
d e e d s e e m s t o h av e b e e n th e fir s t in wh ich an att e m p t wa s m a d e t o
,
m e th o dic ally an d r a d ic ally e x t irp a t e s uc h a t u m or fro m wi th ou t by l a te r al
p h a ryn go t o m y In h i s fir st op e ra t ion C h e e v e r d i d n ot divi d e th e jaw

.
,
b on e nor p e r for m a pr e li m ina ry t rach e o t o m y b u t b y m aking an i n

, ,
c i si o n fro m a poin t j u s t wi th in th e a ngl e o f th e j aw d ownwar d s fo r
inch e s p ar all e l t o th e st e rno cl e i d o m a s toi d m u s cl e follow e d by a

-
,
se con d inci s ion ,inch e s i n l e ng th along th e low e r b or d e r O f th e ,
jaw m e e t ing th e fir st inci s ion h e gain e d s u ffi ci e n t ro o m s o th at a fte r

, , , ,
h aving d ivi d e d th e d iga s tric s tylo h yoi d an d s tylo glos s us m u s cl e s an d

.
- -
,
h aving pick e d apar t th e fibr e s o f t h e s up e rior con s tric t o r O f th e

p h arynx h e wa s abl e t o e n ucl e a te th e affe ct e d t on sil wi th ou t inj ury t o
,
th e pillar s O f t h e fauc e s T h e t u m or th u s r e m ov e d i s d e s crib e d a s the

.
’
s iz e O f a h e n s e gg T h a t th i s op e ra tion was n o t s u ffi ci e n tly r adic al i s
.
e vi d e nc e d h ow e v e r by th e fac t th a t s p e e d y r e curr e nc e o f th e d i se a se
, ,
t ook plac e infil tra t ing th e s o ft p ala te

,
.
I n a s e con d ca s e r e p or te d by th e s am e s urg e on O p e ra te d in 1 8 7 8 , ,
th e j aw wa s sa wn th rough an d a pr e li m in ary t rach e o t o m y wa s d on e

, ,
an d th e grow th e asily e nucl e a t e d b u t wi th no b e tte r r e s ul t a s r e g a r d s

,
th e fu t ur e O f th e p a ti e n t for a t th e e n d o f t wo m on th s r e curr e nc e at
,
th e s i t e O f th e origin al d i s e a se h a d alr e a d y t ak e n plac e .
M e anwh ile a ddi tional con trib u t ion s t o th e li te ra t ur e o f th e s ubj e ct

h ad b e e n m ad e in p ar t icul a r a valu abl e m e m oir by Pol an d in th e Bri t
, .
an d F or M e d C h ir R e v
. . Ap ril 1 8 7 2 an d by Pa s s a qu ay ( Pari s 1 8 7
. .
, , , ,
S inc e th e p ublica tion O f C h e e v e r s s e con d ca se ( Bo s t on M e d an d

’
.
S urg J our Augu st 1

. . . th e no t e wor th y con trib u t ion s upon th e
,
( 1 39 )
1 40 E D I T OR I A L A R TI CLE S .
s ubj e ct wh ich h av e b e e n m a d e t o li t e ra t ur e ar e ch i e fly a s t at i s t i cal

p ap e r by D e lavan o f N e w Y ork on th e s ubj e c t o f Pri m ary E p ith e
, ,
li o m o f th e Ton s il ( N Y M e d Jour April

. . an e xh au s t iv e
. .
, ,
m e m oir involving s t a ti s t ical p a t h o logical an d op e ra t i v e fe a t ur e s by

, , ,
C as te x in th e R evu e a e Cfi i r u rg i e 1 8 8 6 a n d a clinical r e p or t by
,
’
, ,
Mikuli cz o f Cracow in th e D eu ts c/ze M ea Woc/zen s c/zr if t N 0 5 I O

, ,
’
.
, .
an d 1 1 , 1 886 .
Th e m o ir o f Ca s te x i s d e s e rving o f a full r e vi e w wh ich will b e giv e n

em ,
in a s u b s e qu e n t nu m b e r o f th i s j o urn al T h e r e m ain d e r o f th e p r e s e n t
.
a r ti cl e wi ll b e d e vo te d t o th e con trib u t ion o f Mikulicz .
T h e op e ra tiv e s t e p s o f M ar e a s follow s .
I n ci s ion in th e cu ti s fro m th e m a st oi d pro c e s s obli qu e ly d ownwar d s

t o th e gr e a t co rn u o f th e h yoi d b on e T h e s o ft p ar t s a r e d ivi d e d car e
.
fu ll y p ar tially al s o th e t i s s u e s o f th e p aro t i d glan d a n d th e e d g e o f

, , , ,
th e r am u s o f th e in fe rior m axillary b o n e e xpo s e d p o s t e riorly car e ,
b e in g tak e n to avoi d inj uring th e faci al n e rv e .
T h e p e rio s te u m i s th e n r e m ov e d wi th th e ra sp a t oriu m fro m th e e x
t e rnal an d i n t e rnal s ur fac e o f th e ra m u s upwar d s a s fa r a s p o ss ibl e an d ,
d own war d s a s far a s th e in s e r t ion s o f t h e m a s s e t e r an d in t e rn al

p t e rygoi d m u s cl e s T h e r am u s i s d ivi d e d s ubp e rio s t e ally
. to 1 cm .
ab ov e th e angl e a n d e nucl e a t e d Trac t ion i s now m a d e on th e jaw

,
.
d own war d s an d ou t war d s an d th e m a s s e t e r in t e rnal p t e rygoi d al s o

, , ,
th e d iga s tric a n d s tylo h yoi d d rawn t o o n e s i d e , T h e t on s illar r e gion .
wi ll b e fou n d t o for m th e b a s e o f th e woun d t h u s m a de By d ivi ding .
th e la t e ral wall o f th e p h arynx d ir e c t e n t ranc e i s ob t ain e d t o th e

,
p al at al arch e s b a s e Of t ongu e an d t o th e p o s t e rior p h aryng e al wall

,
up war d s in t o th e n a s o p h a ryng e al s p ac e -
I f th e d iga s tric m u s cl e b e.
fu rt h e r m or e d ivi de d th e e n t ranc e t o th e larynx will b e e xp o s e d

, Be .
for e b e gi n n i n g th i s O p e ra tion i t will b e a d vi s abl e t o p e r for m trac h e o t

,
om y . T h e au th or clai m s fo r t h i s O p e ra t i o n a gr e a t a d van t ag e ov e r
th a t o f Lang e nb e ck i n a s m uch a s by h i s m e th o d a t u m or involving th e

,
late ral p h aryn x w all m ay b e e xp o s e d f ro m ou twar d s an d th e wh ol e ,
O p e ra tion ca rri e d o ut ex t r a ca vu nz or i s et p /za ry ng i s

’
T h e au th or s .
m e th o d al s o p e r m i t s o f an an t i s e p tic t r e a tm e n t ( T am p ona d e wi th .
io do form gauz e ) - .
M A LI GN AN T T UM OR S OF TH E T ON S I LLAR R E C I OI V .
Miku licz giv e s th e h i s t ory o f four ca s e s op e ra te d by h i m s e lf in th i s ,
m ann e r .
Ca s e I Ton sillar carcino m a involvi n g th e po s t e rior p h arynx wall

.
,
.
th e b a s e O f th e t ong e an d th e s o ft p ala t e .
Pa ti e n t fe m al e act 6 5 h a d d i fficul ty in s wallowing for o n e an d a

, , .
,
h al f y e ar s A d iagno si s o f carcino m a o f th e l e ft t on sil wa s m a de s i x

.
m on th s pr e viou s t o th e O p e ra t ion Ph ary n go t o m y T h e in fe rior m ax

. .
i lla ry b o n e wa s n o t d ivi de d ab ov e th e angl e b u t c tm in fron t of ,

.
th i s ; con s e qu e n tly th e in se r ti on s o f th e m a s s e t e r an d in te rnal p t e rygoi d
m u s cl e s w e r e s e v e r e d R e m oval o f c a rcino m a T am p on ad e wi th
. .
i d o form gauz e Pa ti e n t n ouri s h e d by m e an s o f r ubb e r t ub e for t wo

.
w e e k s w h e n e dg e s o f woun d w e r e fr e sh e n e d up an d uni t e d by s u t ur e s
, .
In th r e e w e e k s th e e x t e rnal woun d h ad h e al e d a n d th a t o f th e ,
p h arynx co m pl e t e ly in s ix w e e k s Mov e m e n t O f th e j aw p e r fe c tly fr e e

.
,
als o th e ac t s of s wallowin g an d s p e aki n g Pa ti e n t r e m ain e d in th i s .
con di ti on for t wo y e ar s wh e n a fe w s u s picio u s l o oking ulc e ra ting spo ts

w e r e ob s e rv e d in th e ci ca trix an d a fe w m on th s lat e r th e r e lap s e wa s
,
co m pl e te .
Ca s e I I S arco m a o f th e t on sillar re gi on o c c up yi n g m o s t o f th e p h ar
.
,
yu x .
Pa t i e n t , m al e o tic e d a s w e llin g ab ou t th e angl e of th e

, ac t . 28, h ad n
j aw rig h t s i d e s o m e th r e e m on th s b e for e H e h as h ad con s i d e rabl e

, , .
t roubl e in s wallowi n g an d s p e aking fo r th e pa s t t w o m on th s an d di ffi
cul ty in br e a th i n g for o n e m on th At t i m e s s lig h t h ae m orrh ag e fro m .
m ou th .O n e xa m in at ion a s o ft t u m or s iz e o f goo s e e gg i s foun d on , ,
th e rig h t s i d e un d e r t h e a n gl e o f ja w A s o ft t u m or al s o s e e n in th e.
righ t t o n si llar r e gion i n vo lvi n g th e wh ol e m i dd l e p ar t of th e p h arynx

, ,
r e a ch i n g d own war d s t o th e larynx an d u pwar d s t o th e ch oan ae Pre .
v e n ti ve t rach e o t o m y Ph ar yn go t o m y accor di n g t o au th or s own ’

.
m e th o d T h e e xtip a t i on o f t h e wh ol e m a s s o f t u m or n e c e ss i t a t e d
.
O p e n i n g th e p h arynx T h e d e fe ct in th i s r e ach e d fro m th e ch o an ae t o

.
th e larynx Pa t i e n t n ouri sh e d by m e an s o f a rubb e r t ub e pa ss e d in t o

.
th e oes op h agu s an d fa s t e n e d by s u t ur e s t o th e e x t e rnal s kin Dr e s s .
ing s of io d o form gauz e C anula r e m ov e d fro m th e trach e a on th e

.
t e n th d ay th e t ub e fro m t h e oes op h a gu s on th e t w e l fth

, Di s ch ar g e d .
cur e d in fo ur w e e k s Br e a th in g an d s wa llo win g e n tir e ly fr e e an d

.
,
1 42 E D I T OR I AL AR TI CLE S .
voic e cl e ar Pa ti e n t d i e d thr e e m on th s lat e r s u d d e nly b ut fro m what

.
, ,
cau se was n ot a s c e r t ain e d .
Th e thir d ca s e i s th a t o f a carcino m a o f th e l e ft t on s il involving al s o ,
th e p ala t al arch e s an d e xt e n ding t o t h e h ar d p ala t e Pa t i e n t m al e .

, ,
act 6 1
. b a dly n ouri sh e d an d v e ry an ae m i c d i e d t wo an d a h al f h our s
, ,
a fte r th e op e ra tion fro m collap s e an d th e a s pira t ion o f bloo d Tra .
c h e o t o m y was n o t p e r for m e d in th i s ca s e T h e lo s s o f bloo d d urin g .
th e O p e ra tion was c o n s i d e rabl e .
T h e four th ca s e wa s a carcino m a o f t h e la t e ral p h ary n g e al wall .
M al e act 4 2 h ad O b s e rv e d a h ar d s w e lling a t th e a n gl e o f th e j aw le ft
,
.
, ,
s i d e fo r t wo m on th s
, F or s o m e t i m e th e d i fficul ty in s wallowin g an d
.
br e ath ing h a s b e e n v e ry gr e at T h e t u m or h a d i t s origin in th e l e ft .
t on sil a n d involv e d b o th p ala t al arc h e s th e ch oa n ae a n d fur th e rm or e , ,
th e la t e ral p h aryn x wall a n d r e ach e d d own war d s t o t h e lary n x

, Ph ar .
yn g o t om y wi th pr e v e n ti v e tr ach e o t o m y Th e w h ol e la t e ral wall o f th e .
p h a ryn x involv e d by th e d i s e a s e fro m th e e piglo tti s t o th e ch oan ae

, , ,
was e xci s e d fro m wi th ou t al s o th e p ala t al arch e s an d th e l e ft h al f o f

,
t h e s o ft p ala t e T h e ti s s u e s w e r e foun d infil tra t e d t o th e b a s e o f t h e

.
s kull Dr e s s ing s a s in Ca s e 3 O n th e s ix th d ay liga tur e o f th e c a

. .
,
r ot i d was n e c e ss ary t o con trol h ae m orrh ag e Canula r e m ov e d fro m .
t rach e a in t hr e e w e e k s a n d oe s o p h agu s t ub e in four w e e k s

, Pa t i e n t .
l e ft clin i c in s ix w e e k s th e e x te r n al woun d h aving h e al e d H e c om

, .
plain e d m uch o f s e v e r e h e a dach e s b e for e l e avi n g T h e m a s s o f t u m or .
le ft in th e na s o p h aryn g e al s pac e wa s foun d t o b e rapi d ly in cr e a s ing in

-
s iz e . Pa ti e n t wa s n o t s e e n again In r e gar d t o th i s la tte r ca s e .

,
Miku li cz r e m ark s th a t in h i s opinion m alig n an t n e opla s m s in th e up ,
p e r n a s o p h arynx d o n o t o ffe r any fi e l d fo r O p e ra t iv e t r e a tm e n t a s a

-
,
th oroug h e x tirpa t ion o f a d i ffu s e ly e x t e n de d carcino m a i s n o t po s s ibl e
in th i s plac e A car e ful e xa m ina t io n i n th e narco s i s sh oul d th e r e for e

.
b e m a d e b e for e op e ra ting I f e x tirpa tion o f th e t u m or b e i m p o s s ibl e

.
,
e nucl e a tion O f th e ra m u s o f th e j aw s h o ul d b e un d e r t ak e n as propo s e d ,
by K us te r in or d e r t o r e li e v e th e pa t i e n t a t l e a s t o f th e pain ful con di

,
t io n o f lock j aw I f th e in s e r tion s o f th e m a s s e t e r an d in t e rnal p t e ry

- .
g oi d r e m ain in t ac t th e ac t s o f ch e wing an d s p e aking will n ot b e in t e r

,
fe r e d wi th an d th e po s i tion o f th e t wo row s o f t e e th t o e ach o th e r

,
li ttl e i f any ch ang e d by th i s la tte r O p e r ation T h e u s e fuln e s s a n d in

, ,
.
M ALI GN A N T T UM OR S OF TH E T ON S I LLAR R E GI OIV
'
.
m any ca s e s n e c e s s i t y o f a pr e c e ding tr a ch e o t o m y i s s p e cially m e n

th e
ti o n e d .T h e d ang e r of n e gl e c ti n g th i s i s s e e n in Ca s e 3 wh e r e th e ,
coll a p se d an d an ae m ic p a ti e n t h ad n ot s u ffici e n t s tr e ng th t o e xp e c
t or a t e t h e bloo d wh ic h h a d e n t e r e d th e larynx p c io d o for
'
, 3 0 m . . .
gauz e wa s u s e d for d re s si n g s S y m p t o m s o f i o do form in t oxic ation

.
,
h o w e v e r app e ari n g in t h e fir s t ca s e on th e e igh t d ay 1 0 p c io d o

, , ,
. .
for m gauz e wa s s ub s t i t u t e d
-
As a r e s ul t o f h i s e xp e ri e nc e th e au th or
.
r e m ark s th a t s uch s y m p t o m s o f in t oxicati on app e ar e s p e cially O fte n in

ca s e s w h e r e th e s e cr e tio n s fro m larg e woun d s ur fac e s s a t ura t e d wi th ,
i o do for m e n t e r th e dig e st iv e t rac t As s o on as s uch sy m p t o m s ap

, .
p e a r h e r e m ov e s th e gauz e an d u s e s d r e s sing s o f m ull m oi s te n e d wi th

, ,
a s olu t ion o f ac e t a t e o f alu m e n T h e s e m ay b e con tinu e d fro m fou r

.
t o fi v e d ay s wi th ou t i nj ury t o th e woun d Th e in t ro d uct ion o f a rubb e r

.
t ub e in t o t h e oe s op h agu s at th e clo s e o f th e O p e ra t ion for fe e d ing th e ,
p ati e n t wa s al t og e th e r s a ti s fact ory an d s p ar e d th e p a ti e n t th e p ain

, ,
w h ich woul d h av e follow e d s uch a proc e d ur e l at e r on a ffor ding a l s o , , ,
t h e n e c e ss ary r e s t t o t h e woun d e d p ar t s .
R e gar di ng t h e d i ffe r e n t m e th o ds o f O p e ra t ing th e au th or h a s b ut ,
li ttl e t o s ay H e th ink s h ow e v e r th e s ub h yoi d p h aryngo t o m y e s p e

.
, ,
’
c i a lly a d ap t e d for t u m or s s i t ua t e d m or e an t e riorly K us t e r s m e th o d .
,
w h e r e t h e inci si on i s m ade thr ough th e ch e e k fro m th e angl e o f th e ,
m ou th t o th e an t e rior e d g e o f t h e s t e rno cl e i d o m as t oi d m u s cl e he - -
,
r e c o m m e n d s for t um or s ari s in g fr o m th e a lv e olar proc e s s an d m ucou s

m e m bran e o f m ou th I n conclu s i on th e a u th or giv e s s o m e in te r e s t ing
.
fa c t s co n c e rning t h e o ccurr e nc e an d cour s e o f c arcino m a o f th e t on s il s
an d la t e ral p h a ryn g e al wall H e h as ob se rv e d s e v e n c a s e s in t h r e e

.
y e ar s M ack e nzi e h a s a l s o r e p or te d s e v e n ca s e s O f th e l atte r fi ve

. .
w e r e m al e s a g e d r e s p e c t iv e ly 2 2 3 7 4 7 5 8 an d 6 7 y e ar s wh il st th e
, , , , ,
ag e s of th e two fe m al e s w e r e 3 4 an d 4 3 y e ar s r e sp e cti v e ly Of , .
’
Mikulicz s s e v e n ca s e s fi ve w e r e m al e s two fe m al e s wi th ag e s r anging
, , ,
fro m 4 2 t o 6 5 y e ar s K ust e r h a d two ca se s b o th m al e s ag e d 4 9 an d

.
, ,
6 1 ye ar s T h i s m ak e s a t o tal o f s ixt e e n ca se s t w e lv e m al e s an d four

.
,
fem al e s T h e l e ft t on s il wa s th e se a t o f th e di s e as e in s ix of th e
.
’
au th or s se v e n c ase s a n d in b o th o f th o s e o f K ust e r In th e se nin e
, .
ca s e s th e p al at al arch e s an d th e p alate w e r e inv ad e d in e igh t th e b ase ,
o f th e t o n gu e in fi v e th e p o s t e rior p h aryn x w all in four

, th e s upra an d -
,
1 4-4 E D I T OR I AL AR TI CLE S .
in fr a m axi llary b on e s in thr e e th e carcino m a e xt e n d e d t o th e larynx

,
i n thr e e an d upwar d s b e yon d th e ch oan ae in t wo ca s e s

, .
T h e fir s t s ym p t o m s o f t h e d i s e a s e app e ar e d thr e e t o fi ft e e n m on th s
b e for e con s ul t at ion b u t h ad e xi s t e d pr ob ab ly p rior t o th i s wi th ou t

,
b e ing r e m ark e d .
Pain in s wallowi ng O ccur s r e la tiv e ly la t e g e n e rally wh e n t h e carci ,
n o m a h as i nvolv e d th e p ala t al arch e s p ala t e t ongu e a n d j aw b on e T h e

, , .
d i a gno s i s will n o t b e d i fficul t wh e n th e t u m or h a s r e ac h e d th e s t ag e

,
o f ulc e ra t ion b u t a t t h e co m m e nc e m e n t o f t h e d i s e a s e w e a r e O ft e n in
,
d oub t as t o i t s t ru e na t ur e .
L S PI LCH E R . . .
T H E PA R I S S O CI E T Y O F S U R GE R Y A N D TH E Q UE ST IO N O F O P
BR A T I O N F O R T U BE R CU LO U S j O INT D I S E AS E .
At th e m ee t ing o f th e Pa ri s S oci été de c/zi r u rg i e fo r th e r o th o f F e b

r u ar
y la s t Dr C h auv e l r e por t e d in d e t ail upon a pap e r b y Dr Mab
,
. .
b oux of Lill e on th e qu e s tio n o f progno s i s a n d O p e ra tion in th e t u

, ,
b e r c ulo u s . T h e p ap e r o f M ab b o ux wa s b a s e d up on two ca s e s o f t u
b e rc u lo u s j oin t d i s e a s e ( 1 ) th e fir s t origi n a t ing in cari e s o f th e fo ur th

,
m e t a t ar s al bon e o f a you n g s ol d i e r wi t h r e s e c t ion O f t h e d i s e a s e wh i c h

, ,
was follow e d by s ynovi t i s o f th e p e ro n e al s h e a th a n d la t e r by s upp ura , ,
t ion o f t h e t ibio t ar s al ar t icula t io n an d conco m i t a n t p ul m o n ary t ub e r

-
c ulo s i s a ft e r th r e e m on th s all th e s ym p t o m s con t inui n g t o b e m or e

,
un favorabl e th e foo t was a m p u t a t e d an d rapi d cur e follow e d wi th

, , .
aba t e m e n t an d fi n al d i s app e aran c e o f th e pul m onary s y m p t o m s th e p a ,
t i e n t b e i ng i n t h e e nj oy m e n t o f rob u s t h e al th at th e t i m e o f th e wri t ing
o f th e pap e r ; ( 2 h con d ca s e wa s app ar e n t ly l e s s favorabl e t o t h e

) t e s e
th e o ry o f O p e ra t iv e i n t e rv e n t ion a corporal o f th e li n e se t 2 4 e n te r e d ,
.
,
th e h o spi t al a t Lill e in M ay 1 8 8 5 fo r ar th ri ti s O f th e l e ft kn e e co ms e c
, , ,
u t iv e t o a fall r e c e iv e d a m on th pr e viou s ly H e h ad h a d h aem op ty s i s .
in 1 8 8 4 b ut h a d b e e n w e ll S inc e th e n In spi t e o f i m m obi liz a tion an d

.
all o th e r m e th o d s th e d i s e a s e progr e s se d un t il Augu s t 1 5 w h e n th e

, ,
co n t e n t s O f th e j oin t w e r e foun d o n a spira ti on t o b e purul e n t in d ura

OP E R A TI ON F OR T UB E R C UL O US j OI N T D I S E A S E .
t ion at th eap e x o f th e l e ft lung was O b s e rv e d a n d th e p at i e n t was h ar

r a s s e d wi th a fr e qu e n t coug h Ar th ro t o m y was p e r for m e d on th e e 4 th
.
,
th e p u s e vacua t e d th e fungo s i ti e s r e m ov e d a n d th e d e nu d e d b on e
,
s crap e d Th i s wa s follow e d by r e d oubl e d s u ffe ring prob abl e m e n i n

.
,
gi t i s an d m or e pro n ounc e d pul m onary s y m p t o m s wi th th e for m a tion ,
o f e s ch ar s a t th e s acru m an d h e e l s In S e p t e m b e r th e p ain b e ca m e
.
,
a t rociou s an d th e e m acia ti on e x t r e m e t h e e xh au s tion co m pl e t e gan

, , ,
gre n e i m m i n e n t an d e arly d e a th c e r t ain In s pi te o f th e gravi ty o f th e

.
s i t ua tion a n d in d e fe r e nc e t o t h e wi sh e s o f th e m oribu n d pa t i e n t th e
, ,
th ig h wa s a m pu t a t e d in th e low e r th ir d Micro s copical e xam ina tion O f

.
th e kn e e s h ow e d th e l e s ion s o f t ub e rculou s ar th ri t i s in t he h ig h e s t d e
gr e e o f d e v e lop m e n t I m m e d ia t e ly a ft e r th e op e ra tion s l e e p r e turn e d

.
,
t o th e p a t i e n t p ain c e a s e d th e woun d cica t riz e d an d h e s e e m e d t o b e

, ,
s av e d b u t on t h e 8 t h o f O c t ob e r t h e fe v e r r e app e ar e d th e s t u m p u l
, ,
c e ra te d th e t ub e rculo s i s s e e m e d t o b e localiz e d in th e ab d o m i n al
,
vi s c e ra an d de a th e n s u e d on th e 1 8 th o f j anuary followi n g b u t wi th no
, ,
r e curr e n c e o f th e a t roci o us s u ffe rin g fo r w h i ch th e O p e ra t ion wa s p e r

for m e d . I n vi e w o f th e fac t th a t th e r e h a d b e e n n o th e rap e u tic or O p
e ra ti v e s ucc e s s — nor in d e e d was o n e e xp e c t e d— was th e O p e ra tion jus
t i fi ab le ? T h e au th or r e pli e d in t h e a ffir m a tiv e con s i d e ri n g th e r e li e f

,
fro m p ain an d th e c o n s e qu e n t e u th an a s ia t o b e ab un d a n t j u s t ifica t ion .
T h a t th e la t e r progr e s s o f th e t ub e rculou s d i s e a se wa s n ot d u e to th e
t rau m a t i s m o f th e O p e ra t io n i s e m p h a t ically s h own by th e m a ni fe s t
a m e li ora tion o f th e sym p t o m s d urin g t h e followi n g t w e n ty fi v e d ay s -

,
s h owing t h a t on t h e co n trary th e d i s e a s e w a s t e m p orarily r e li e v e d by

, ,
th e O p e ra t ion an d only r e s u m e d i t s r e g ular cour s e a ft e r th e b e n e fici al

,
e ffe c t s o f th e in t e rv e n t ion h a d b e e n e xh au s t e d .
M a b b o ux conclu d e s th a t ( 1 ) th e e xi s t e n c e o f p u lm ona ry t ub e rculou s

l e s ion s e v e n o f an a dvanc e d typ e i s n o t a co n train d ica tio n t o an am
, ,
pu t a tion of a m e m b e r a ffe c t e d wi th s uppura t iv e t ub e rculou s s ynovi ti s ,
wh e n th e la tt e r l e s ion pr e d o m i n a t e s th e p a th ological s c e n e a n d m e n
ac e s li fe . T h e op e ra t ion by s up pr e s s ing th e cau s e s o f e xh a us
,
t ion d u e t o th e ar ticular l e s ion can s t op t h e progr e s s o f t h e vi s c e ral

,
l e s ion t o th e e x t e n t o f r e placin g t h e lung s in a p e r fe c tl y nor m al s t a t e

, .
E v e n in ca s e s w h e r e t h e p h t h i s i s follow s i t s c o ur se a m p u ta ti o n o f ,
t h e d i s e as e d m e m b e r m a i m pro v e th e con d i t ion o f th e p a t i e n t i f only

y ,
1 46 E D I T OR I AL A R TI CLE S .
by r e li e vi n g th e in tol e rabl e p ain ; c on s e qu e n tly th e p olicy o f non in -
t e rfe r e n c e in ca s e s wh e r e a cura t iv e a c t ion can n o t r e s ul t s h oul d n o t ,
b e carri e d in t o th e t r e a t m e n t o f th i s a ffe c t io n .
M C h auv e l in co m m e n tin g u pon th e p ap e r r e fe rr e d t o th e diam e t

.
, ,
ri c ally oppo s i t e vi e w s h e l d by variou s s urg e on s wi th r e g ar d t o t h e pro
p ri e ty an d e x t e n t O f O p e ra t iv e in t e r fe r e nc e an d r e m ark e d th a t a pr e ci se ,
i n variab le rul e wi th r e gar d t o ac ti on coul d n ot b e lai d d own b ut th a t ,
e ac h ca s e m u s t b e t r e a t e d as an in d ivi d ual e n t i ty I f th e failur e o f Op

.
e r a ti o n s a n d th e pro m p t d e a th s a tt rib u t abl e t o s urgic al t rau m a t i s m i m
pr e s s u s we m u s t al s o n o t forg e t th e d e a th s slow e r p e r h ap s b ut c e r
, , , ,
t ai n ly m or e nu m e rou s wh ic h r e s ul t fro m non in t e rv e n t ion

,
-
T h e s e lat .
t e r are a t trib u t e d t o th e progr e s s o f an i n curabl e d i se a se b u t i s th e ,
p h y sici an any m or e j u stifi abl e in failing to in t e r fe r e th a n h e wou ld b e

in any o th e r o th e rwi s e incurabl e a ffe c tion s uch a s oe de m a o f th e glo t
,
t i s or s t ran g ula t e d h e rni a ?
O s s e ou s an d ar t icular t ub e rcular a ffe c tion s are n ot g e n e rally prop e r .
s ubj e c t s for inco m pl e t e in te rv e n t ion Pe rh ap s th e d ay i s n o t far d i s

.
t an t wh e n o s s e ou s an d ar t icu lar t ub e rculo s i s local t ub e rculo s i s wi ll b e

, ,
co n si d e r e d a s a n e opla sm th e m or e m alignan t fro m i t s t e n d e n c y t o

,
g e n e raliz a tion an d tr e a t e d un d e r th e s a m e rul e s a s s arco m a an d carci

,
n om a . Wh e n th e e x tirp a tion o f th e d i s e a s e i n plac e i s i m po s s ibl e or

wh e n th e a n a t o m ical con di tion s d o n o t p e r m i t th e co m pl e t e an d c e r
t ain ab la t io n o f all th e in fe c t e d t i s s u e s—con d i t ion s n ot rar e ly p r e s e n t
in o s t e i ti s an d synovi ti s—e arly a m pu t a tion i s in dica te d In th e ca s e s .
O f M ab b o u x h e t h oug h t th e O p e ra tio n w a s d e lay e d t o o lo n g in t h e
s e co n d ca s e i f n o t in th e fir s t
. .
A S s h ow n by th e se ca s e s t h e e xi s t e n c e o f pul m onary t ub e rcu lou s

,
le s io n s s h oul d n o t b e con si d e r e d a con t ra in d ica tion t o O p e ra t ion

-
.
Ca s e s of t e m porary cur e un de r th e s e con d i tio n s are co m m o n an d p e r ,
m an e n t cur e s a re n o t th e e xc e p tion T wo y e ar s pr e viou sly M C h au

.
,
.
v e l a m pu t a t e d t h e le g o f an o ld s ol d i e r a ffe c t e d wi t h t ub e rculou s d i s
,
e a s e o f th e t ar s u s wi th p u lm onary an d p e ri t on e al t ub e rc u lari z at i o n wh o ,
h a d b e e n b e d ri d d e n fo r two y e ar s an d lay in a s t a t e o f gr e a t e xh a u s
-
,
’
t i o n fro m fe v e r an d s uppura t ion Again s t th e s urg e on s j u d g m e n t a n d
w
.
in d e fe r e n c e t o th e pa ti e n t s i sh e s th e op e r ation wa s p e r for m e d a n d
’
, , ,
a ft e r r e p e a te d p e ri o dic al h ae m orrh ag e s fro m th e s t u m p i t cica triz e d , ,

OP E R A TI ON F OR T UBE R C UL O US OI N T D I S E A S E 1 47
j .
an d p a ti e n t fu lly r e cov e ri ng a ft e r a t e diou s conv al e s c e nc e was di s

th e , ,
ch arg e d co m pl e t e ly cur e d In clo s in g M Ch auv e l e m p h a s iz e d th e

.
, .
l e s s on o f M abb oux s s e con d ca se th a t on e o f th e in di ca ti on s for am

’ ’
,
p u t at ion in t ub e rculou s j oin t di s e as e m ay b e th e r e li e f o f p ain e v e n

-
,
wh e n th e cur e o f th e d i s e a se i s h op e l e s s .
M D e s pr e s al th ough con s i d e ri ng i t al m o s t u se l e s s wi sh e d t o pro

.
, ,
t e s t agai n s t th e b e li e f in th e th e o ry o f th e g e n e raliz a t ion o f t ub e rculo
s i s by th e prop aga tion o f a m i crob e T h e qu e s tion o f a m pu t a tion h ad

.
long b e e n un d e r di s cu s s ion a n d a s i t was s till on trial n o ab s olu te

, , ,
rul e s coul d b e e st abli sh e d for i t s app lica t ion H e h a d a m p u t a t e d th e

.
th igh of a pa t i e n t wh o h a d an ulc e ra t e d kn e e j o in t d i s e a s e an d h ae m op
-
tys i s. H e wa s cur e d b u t d i e d t wo y e ar s la t e r wi th t ub e rcular ulc e ra

,
t ion s on th e o th e r le g Tub e rculou s p a t i e n t s a ffe ct e d wi th non s up

.
,
-
u rati n g j oin t d i s e a s e sh ou ld b e t r e a t e d by i m m obiliz a t ion an d c o m

p
-
,
pr e s s ion A m pu t ation m ay b e of s e rvic e t o young m e n

. .
M Luca s Ch am pionn i er e con s i d e r e d th e O p e ra tion fo r th e r e li e f of

.
-
in te n s e p ain b u t wi th ou t h op e O f ulti m a te cur e t o b e j u s tifi abl e in

, , ,
S pi t e o f th e r e s ul ti n g d a m agi ng e ffe c t s up on th e s t a ti s ti c s o f t h e op e r a
t io n . T h e t ru e qu e s tion wa s w h e th e r an op e r ation fo r th e r e m oval o f
a t ub e rcular l e s ion in a t ub e rc ul ou s pa t i e n t wa s goo d tr e a tm e n t 01 .
h e r h a d sh own in a r e c e n t work th a t op e r at ion s e v e n p a rt i al on e s , ,
coul d b e s ucc e s sfully p e r for m e d on th e t ub e rculou s an d th a t in r e s e e ,
t ion s d i s e a s e d o sse ou s p ar t s coul d b e l e ft wi th ou t p r e v e n t ing a cur e ;

,
a n d a ft e r O p e ra t ion s th e p a t i e n t s grow fa t a n d ar e gr e a t ly i m prov e d in
p h y s ical con d i ti on N e w troubl e m ay s up e r v e n e la te r i t i s tr u e b ut

.
, ,
e v e n ra di cal op e r ati on s d o n ot pr e v e n t la t e r d e v e lop m e n t s H e wa s .
th e n an a d vo ca t e o f s urgical in t e rv e n t ion in th e t ub e rculo u s b ut un ,
lik e M C h a uv e l h e b e li e v e d i n th e u t ili ty o f p ar t ial abla ti on i n c e r t ain

.
,
c as e s .
M Ve rn e u i l b e li e v e d th at in t ub e rculo s i s a s i n canc e r th e s urg e on

.
,
s h oul d O p e ra t e for th e t e m p orary r e li e f o f s u ffe ri ng wi th ou t n e c e s s a rily

,
e xp e c t i n g any p e rm an e n t cur at iv e e ffe c t But in t ub e rculou s p at i e n t s

.
,
a ffe c t e d wi th s t ru m ou s s ynovi ti s O p e r ativ e in t e rv e n t i on wa s n e c e s s ary

,
only in ca s e o f th e e xi s te nc e O f s inu se s an d s upp ur at ion for m any ca se s ,
w e r e cur e d by co m pr e s s ion H e di d n ot p e rform m or e th an two o r

.
t hr e e am pu t ati on s a y e ar for t ub e rculou s a rti cul ar affe c t i on s an d st i ll

1 48 E D I T OR I A L A R TI CLE s .
fe w e r r e se c tion s R e s e c tion o f th e h i p j oin t alo n e h a s cau s e d m or e at

.
-
t ack s o f m e n i n gi ti s or rapi d g e n e raliza t ion o f t ub e rculo s i s th an all o th e r
op e ra tion s p e r for m e d in th e s e con di tion s .
M B e rg e r h a d in a pr e viou s d i s cu s s ion ci te d s o m e ca s e s o f rapi d

.
g e n e raliz atio n o f t ub e rculo si s a fte r am pu t a tion for ch ronic synovi ti s b ut ,
o n t h e o t h e r h an d h e h a d s e e n th e d i s e a s e cl e arl y d i m i n i sh in at l e a s t
,
o n e ca s e in w h ic h h e a m pu t a t e d t h e t h ig h o f a young m an in wh o m
,
u n e quivocal s ig n s o f t ub e rculariz a ti on e xi s t e d an d wh o a ft e rwar d s re ,
g a i n e d th e b e s t o f h e al t h An d i n an o ld m an i n w h o s e lu n g cavi t i e s
.
w e r e di s cov e r e d a n d wh o was in a s t a t e o f e x tr e m e d e bili ty h e s aw

, ,
ra di o carp al am pu t at ion follow e d b y an u n e xp e c te d r e cov e ry H e b e

-
.
li e v e d th a t inco m pl e t e r e s e c t ion s w e r e b a d prac t ic e i n th e t ub e rculou s ,
a n d th a t pri m ary u n ion m u s t b e s oug h t for o p e ra t i n g only in h e al th y ,
p ar ts .
’
M R e clu s h ad b e e n gr e a tly i m pr e s s e d by a ca s e in wh ich Li s franc s
.
d i s ar ticula tio n h a d b e e n p e r for m e d for cari e s O f t h e fir s t a n d s e con d

m e t a t ar s al b o n e s a n d in w h i c h pri m ary uni o n wa s O b t ain e d b u t a ft e r
, , ,
a fe w d ay s th e p a ti e n t d e v e lop e d a larg e fu n gu s i n a coun t e r op e ning

,
-
on th e pl a n t ar s ur fac e T h e s urg e on wh o s ucce e d e d M R e clu s in

. .
ch arg e o f th e ca s e was frig h t e n e d an d propo s e d a s e con d a m pu t a tion ;

,
th e p a t i e n t h ow e v e r r e cov e r e d wi th ou t fur th e r i n t e r fe r e nc e s o c o m
, ,
p le t e ly th a t a ca s t wa s m a d e o f th e s t u m p a s a typical r e s ul t o f Li s
’
fr an c s O p e ra tion .
M Pozzi d i d n ot th i n k th a t i t wa s i n d i s p e n s abl e t o O p e ra t e in h e al th y
.
p ar ts wh e n a m pu t a ti n g i n th e t ub e rculou s ; h e h a d m ad e an a m p u t a tion
in th e m i d d l e of th e le g o f a young fe m al e in th e m i d s t o f fi s tulo u s
s inu se s whlc h h a d t o b e s crap e d a n d e xci s e d t o r e fr e sh t h e fla ps a n d
.
,
h e ob t ain e d a v e ry b e au ti ful pri m ary union How e v e r h e con s i d e r e d

.
,
th a t all d i s e a s e d bo n e sh oul d b e r e m ov e d .
M R i c h e lo t h a d r e m ov e d on ly a par t o f th e gla n d s in a gr e a tly e m a

.
c i a t e d young m an wi th lar g e s uppura t ing g lan d ular m a s s e s a t th e n e ck ,
i n s pi t e o f wh ich u n ion was o b t ain e d an d th e gla n d s n o t r e m ov e d , ,
finally di s app e ar e d wh il e t ub e rculou s d i s e a s e o f th e e lbow wa s d e v e l

,
op e d .
M Po la illon r e c a ll e d th a t h e h ad two ye ar s pr e vi ou s ly pr e s e n te d a
.
, ,
p a t i e n t wh o s e wri st h e h a d r e s e c t e d fo r t ub e rcul o u s ar thri ti s wi th ou t

OP E R A TI ON F OR T UB E R C UL O US j OI N T D I S E A S E .
r e m oving all th e d i s e a se d p ar ts b u t wh o h ad r e cov e r e d ; h e h a d al s o

,
ci t e d se v e r al ca se s in wh ich a m p ut a tion h a d i m prov e d th e con di ti o n of

t ub e rculo u s p a t i e n ts .
M Le F or t b e li e v e d th a t s uppur at ion was n o t s o m uch t o b e fe ar e d

.
a fte r a m p u t ation as m igh t b e th o ugh t ; p a ti e n t s wh o b e ca m e gr e at ly

e m acia t e d b e for e O p e ra tion wh il e lo s ing b u t s m all quan ti t i e s o f p u s
, ,
o ft e n grow fat wh e n a fte r a m p u t a t i o n th e s upp ura ti on i s ab un d an t ; a

, ,
s m all a m oun t O f o s s e o u s s uppura ti on i s O ft e n s u ffi ci e n t t o gr e a t ly e x
h au s t p a ti e n t s . In h i s work on r e se c ti on s o f th e h ip h e wa s abl e t o
,
giv e th e la te r r e s u lt s o f th e O p e ra tion in a nu m b e r o f p a t i e n t s an d coul d

s e e th a t d e a th by m e ningi t i s wa s n o t by any m e an s s o fr e qu e n t as M .
Ve rn e uil a s s e r t e d . A ft e r r e s e ct ion s th e b o n e t ro ubl e wa s s o m e ti m e s

cur e d wh il e th e d i s e a se r e curr e d in th e s o ft p ar ts ; h e con s i de r e d th a t
,
inco m pl e te r e s e c tion s di d n o t giv e a s go o d r e s ul ts in g e n e ral a s th e

co m pl e t e In conclu s io n h e r e m ark e d th a t h e woul d con s i de r t ub e r
.
,
c ulo u s d i s e a s e wi th gr e a t d e bili ty con t ra in d ica t ion s t o O p e ra t ion in

-
ag e d b ut n o t in yo ung p a ti e n ts .
M Tr e la t b e li e v e d th a t in O p e ra ting u p on a t ub e rculo u s p a ti e n t all

.
t h e d i s e a s e d p ar t s sh oul d b e r e m ov e d ; i f pri m a ry union fail e d th e ,
m ini m u m o f s uppura t ion s h oul d b e s oug h t fo r H ow e v e r t h e t ub e r

.
,
culo n s p a t i e n t i s an in d ivi d ual a ffe c t e d wi th bacilli an d th e op e ra t or

,
c an n e v e r b e s ur e th a t h e h a s r e m ov e d t h e e n t ir e di s e a s e ; ca s e s o f O S
t e o m y e li ti s e xi s t for y e ar s wi th ou t b e co m i n g appar e n t ; th e r e was al

-
w ay s th e n a c e r t ain a m oun t o f ignoranc e up on th e par t o f th e s urg e on
an d a con s e qu e n t am oun t o f unc e r t ain t y a s t o th e r e s ul t i f a p a ti e n t

h a d b e e n co m pl e t e ly e xa m i n e d h ow e v e r b e for e d e ci d ing up on op e r a
, ,
t ion i t woul d g e n e rally b e n e fi t h i m

, . H e th oug h t th e r e w e r e go o d re a
s on s fo r h ol d i n g th a t a m p u t a t io n wa s pr e fe rabl e t o r e s e c t io n b u t i t ,
coul d n ot b e s ai d th a t t ub e rculariz a t ion invariably le d t o a m pu t a t ion

ra th e r th an r e s e ct ion T h e for m an d e x t e n t of th e l e s ion sh o uld alon e
.
d e ci d e th a t qu e s ti on .
TAM E S E PI L C H E R
. .
ON TH E PR E S E N T S T AT E O F K N O WLE D GE I N BA CT E R I AL
S C IE N CE IN ITS S U R GI CAL R E LAT I O N S .
( Co n ti n u e d fr o m p ag e
G GO N O R R H CE A
. .
T h e d i s cov e ry p cifi c organi s m o f gonorr h oea by A N ei sser

of th e s e .
in th e y e ar 1 8 7 9 i s on e o f th o se s ci e n tifi c ach i e v e m e n ts wh ich h av e

1
n o t a s ye t le d t o t h e prac tical th e rap e u t ical r e s ul t s wh ich s uch a d i s
c o v e ry m igh t w e ll h av e j u s t ifi e d u s in an t icip a ti n g Pe rh ap s t h i s i s th e .
ch i e f r e a s on wh y s o m any s urg e on s o f th e pr e s e n t t i m e h e s i t a t e to i n
e lu d e t h e gon ococcus —as t h e organi s m in qu e s t ion h a s b e e n d e s i gn a t e d
< ,
wi th m or e br e vi ty th an logic by i t s di s cov e r—i n th e ir ar ticl e s o f m e d

,
ical fai th O ur fai th h ow e v e r vari e s wi th our un d e r s t an d i n g an d i t i s

.
, , ,
wi th th e gonococcu s s o m e wh at a s B acon s ay s s p e aking o f A th e i s m , ,
a li ttl e l e arning inclin e th m an s m in d t o d oub t b ut d e p th in p h ilo s o

’
,
p h y again bring e th m e n s m in d s ab o u t t o b e li e f
’
.
T h e h i s t ory o f th e d e v e lop m e n t o f th e d oc trin e o f th e gonococcu s i s
in poin t o f fact s o m e wh a t s i n gular Di s cov e r e d as i t wa s co m p ara .

, ,
t i v e ly lo n g ago an d r e p e a t e d ly an d un e xc e p t ionally fo un d in a ll w e ll
,
m ark e d ca s e s th e r e i s a v e ry con s picuou s lack o f s ucc e s s ful cul tur e

,
e xp e ri m e n t s an d o f r e li ab l e inocula t ion e xp e ri m e n t s e v e n a t th e pr e s ,
e n t d ay T h e r e a s on for th i s i s t o b e look e d fo r on t h e o n e h an d in
.
, ,
t h e fac t th a t pro d ucing pur e cul t ur e s O f th e gonoco ccu s on s t e ri liz e d
s oil s i s a v e ry d i fficul t m a tt e r o f p e rfor m a nc e an d on th e o th e r h an d . ,
th e g e r m i s n o t on e th a t e a s ily prov e s i n fe c tiou s t o ani m al s a n d th e r e ,
i s a v e ry na t ural r e luc t anc e on th e p ar t o f e xp e ri m e n t e r s t o p e r for m ing

i nocula tion s up on th e m s e lv e s or o th e r s on accoun t o f th e m a n i fol d ,
d ang e rou s co m p lica tion s s o fr e qu e n tly a t tach ing t o th e d i s e ase .
We po s s e s s only t wo r e po rt s o f inocula tion e xp e ri m e n t s th at are
1
Ue b e r e i ne d e r G on orr h oe e i g e n th u m li ch e m i c ro c o c c u s fo rm . Vo r l a u f M i tth e i
.
'
u ng . C e n tralb l f ( 1 M e d \Vi s s
. . . . . 1 8 79 . No . 28 .
( 1 50)
BA C TE R I AL S CI E N CE I N I TS S UR GI CA L R E LA TI ON S .
1 51
wh olly s at i s fac t ory th e o n e by Ij oclefi a r a t th e o th e r by D u nn/z

,
’ ’
,
1
.
Inocu la tion wi th cul t ur e s on th e h uman s ubj e c t i t i s t ru e h av e b e e n , ,
p e r for m e d by o th e r s as w e ll— am on g w h o m are t o b e m e n tion e d

B ok ai Ch am e r on S te rnb e rg b u t th e fir s t o f th e s e h a s p ubli sh e d s uch
, ,
i nco m pl e t e a ccoun t s th a t th e y ar e n o t a d m i s sibl e for di s cu s s ion a n d ,
t h e la t t e r g e n t l e m e n as w e ll a s N e i s s e r h i m s e l f an d O pp e n h e i m
, were ,
n ot s ucc e s s ful in ob t ai n ing th e p ur e cul t ur e o f th e t ru e gono coccu s as ,
Bu m m h a s sh own ; s o th a t th e ir n e ga tiv e r e s ul t s lo s e all th e ir pow e r o f

c on v 1 c t 1 0n .
The ge rm i t s e l f—t o b e gin wi th

au th or s own r e v i e w o f th e s ub th e
’
3—
je c t i s d e s crib e d by N e i s s e r a s a m icro co ccu s alway s app e arin g in ,
coupl e s a s diploco cc u s th e s ingl e co cci ar e n o t p e r fe ct ly s p h e rical b u t ,
are fla t t e n e d a t o n e pol e t o s uc h an e x t e n t th a t th e ir s h ap e r e se m bl e s a
s e g m e n t O f a s p h e r e a n d th e w h ol e app e ar s n o t un lik e a br e ak fa s t roll

, .
T h e s ingl e co cci t urn th e ir fla tt e n e d p ol e s t owar d s e ach o th e r b u t a ,
narrow s p ac e s e p ara te s th e m an d th e r e i s n o con tac t , .
T h e se diplo coc ci m ul tiply by bipar t i tion e ach m icroco ccu s b e c om

ing d ivi d e d in t o t wo s o th a t group s o f 4 8 e t c are form e d b u t n e v e r
, , ,
.
, ,
ch ain s T h e h alving proc e s s of e ac h s ucc e s s iv e g e n e r ation occur s in

.
a lin e at rig h t a ngl e s t o t h a t O f th e for m e r g e n e ra t ion T h e s e group s o f .
p ai r s are alwa y s t o b e foun d in conn e c tion wi th th e p u s c e ll s an d only -

,
w h e n pr e se n t in gr e a t nu m b e r s are si ngl e p air s foun d fr e e in th e s e ru m .
T h e y ar e alway s pr e s e n t in gonorrh oe a e v e n in th o s e ca s e s O f six ,
t e e n m on t h s s t an d ing th oug h t h e y ar e n o t t h e n s o r e a dily foun d ; th e y

'
are n e v e r pr e se n t in o th e r s upp ura t ion s b u t th o s e o f gonorr h oe al o rigin ,

.
T h e y are m or e ov e r u s u ally th e only on e s pr e se n t in gonorrh oe al di s

, ,
ch arg e .
Thepr e s e nc e O f th e s e p e culiar organi s m s in gonorrh oe a wa s s oon

’
corrob ora t e d a fte r N e i s s e r s co m m un ica ti on by n u m e rou s ob s e rv e r s .
1 M B oc k /za r a t, B e i trag ’
z ur ZE ti o lo g i e un d Path o l ogi e d e s H ar n ro h re n tri pp e rs .
Vi e r t e ljah r s ch r f D e rm at o l. . . 11 . S yp h . 1 88 3 .
p 3
. . S i tz un g sh e r d p ys . . h . m ed . Ges .
z VVii i z b u rg S e p t 1 88 2
. . . .
2
D er M i k r o- O r g an i s m u s d e r g on orrh S c . hl eim h au t e r k r n k ung Wi e s b
a . ade n. 1 885 .
I F Be rgm
. an n .
3
D i e M i c ro c o c c e n d c r Go n orr h oe . R e fe ri r e n d e M i tth e i lun g D e u t . s ch . M ed . Wo c h
e n s ch ri lt . 1 88 2 . P
. 2 79 . I 3 M ay
. .
I 5 2 E D I T OR I A L A R TI CLE S .
B okai W e i s s Au fr e ch t E h rlich Bri e g e r G a ffky w e r e a m ong th e fir s t

, , , , , ,
t o publi sh a s s e n ting s t a te m e n t s a n d op h th al m ologi s t s s uch a s S a tt l e r ;

, ,
Le b e r Haab Hir s ch b e r g a n d o th e r s v e ry s oon t e s tifi e d t o t h e o ccur

, ,
r e nc e o f th e g e rm in gon o rrh oe al conj unc t ivi ti s Bo ck h ard t foun d th e m .
pr e s e n t in 2 5 8 ca se s of gonorrh oe a in 1 4 c a s e s o f v aginal bl e n n orrh oe a , ,
in 2 ca se s o f s upp ura tiv e c e rvical ca t arrh e t c Mor e r e c e n t ly Lun d , .
s tro m foun d th e m in all o f th e fi fty ca s e s h e e xa m in e d o n e o f wh ich

1
,
was o f two y e ar s s t an d ing— a n d e v e ry clinica l s t u d e n t h a s s inc e b e e n
abl e t o s a ti s fy h i m s e l f o f th e ir pr e s e nc e .
T h e s t aining i s b e s t d on e wi th m e th yl e n e blu e ; th e u s e o f w e ll col -
’
or e d pr e para tio n s an d o f Abb é s l e n s i s in di sp e n s abl e i n e xa m ining
th e puru le n t s e cr e t ion s w h ich s h ou ld b e d ri e d on t o cov e r gla s s e s in a
,
-
t h in lay e r a n d a ffix e d t o th e m by d ir e c t h e at .
I t wo uld h o we v e r b e e rron e ou s t o s upp o s e th a t th e sh ap e o f th e s e

, ,
d iplococci i s th e m ain ch arac t e ri s t i c p oin t in d iagno s i s Accor ding to .
Bu m m th e r e are no l e s s th an s e v e n d i ffe r e n t s p e ci e s o f diplococci

wh ich pr e se n t th e s a m e sh ap e in app e ar anc e an d grouping a s th e s p e c
i fi c gonococcu s T h e s e h ow e v e r can e a s ily b e d i s t i n g ui s h e d fro m th e
.
,
gonococcu s by m e an s o f cul tur e e xp e ri m e n ts sinc e no n e o f th e m grow ,
in th e s a m e m ann e r on th e s oil s .
O n th e co n t rary th e m ain d i ffe r e n tia t i n g fe a t ur e o f th e gonococcu s

i s i t s s i t ua tion in s i d e o f i t s c e ll th e lo d g m e n t i n t h e pro t opla s m a n d
, ,
i t s fur th e r d e v e lop m e n t b e n e a th th e s ur fac e o f th e l e ucocy t e Th i s .
abili ty o n th e p art o f th e m icro organi s m t o p e n e tra t e i n t o th e s ub -
s t an c e o f th e c e ll s i s no d oub t th e m ain r e a s on wh y t h e propo se d ab or
t iv e m e th o d s o f t r e a t m e n t o f go n orr h oe a h av e prov e d s o li t tl e s u c
c e s s ful .
Accor ding t o B u m m wh o h ad th e oppor tuni ty O f m icro s copically e x

,
a m i n i n g t w e n t y s i x ca se s o f O p h th a lm al bl e nnorrh oe a o f i n fan t s—a gon

-
o rrh oe al d i s e a s e acquir e d fro m th e m o th e r th roug h co n t agion d uring
rt u ri ti o n —th e g e r m s a c t iv e ly p e n e t ra t e in t o th e m uco u s m e m bran e

‘
Z
a
p ,
e n t e ring b e tw e e n th e e pi th e li al c e ll s a n d a dvancing s o far a s th e ,
1
S tud i e r o fn e r Go n o c o c c us . D I SS . He l si n
g fo r s . 1 88
5 .
2
O H aa
. b , D e r M i c ro c oc c u s de r B l e n n o rr h oe a N e o n a torum . Fe ts sch r i ft . Wi e s
b ad e n . 1 88 1 . s
C o r re p o n d f S c
. . h w iz e er Ae rtz e . 1 88 1 .
3, 4 .
B A C TE R I A L S CI E N CE I N I T S S UR GI CA L R E LA TI ON S .
1 53
p apil lary b o d y o f th e m ucou s m em bran e all

, th e wh il e incr e a s ing in
n um b er s .
I n co n s e qu e nc e o f th i s inva s i on l e ucocy te s app e ar in gr e a t quan ti ti e s ,
s upp ura t ion en su es th e e pi th e liu m

, b e co m e s p ar tly e l e v at e d an d
d e t ac h e d a n d e v e n t ually fi b rin o u s e xu d a ti on t ak e s plac e
,
.
The w h ol e proc e s s in ti m e co m e s t o a e n d p ar t ly b e cau s e th e m i ,
cro organi sm s p e n e t ra t e no d e e p e r th an th e papi llary b o dy an d prob

-
,
a bly al s o fo r t h e r e a s on t h a t t h e n u t ri t iv e s oil s ub s t a nc e o f th e p a rt s -
b e co m e s e x h au s t e d T h e l e uco cy te s th e n S i m ply conv e y t h e m icro

.
organi s m s t o th e s ur fac e an d t og e th e r wi th th e e pi th e li al c e ll s a s s i s t
, , ,
in r e buil ding th e d e s t roy e d t i s s u e s .
Bo c k h ardt h a s furni s h e d a r e por t o f m icro s copical e xa m in at ion s o f

1
gonorrh oe al infla m m a t ion o f th e ur e th ral m uco us m e m bran e H aving .
procur e d a pur e cul t ur e o f th e g onococcu s in th e four th g e n e ra tion fro m ‘
F e h l e i s e n h e ino cula t e d a p a ti e n t s u ffe ring fro m g e n e ral p araly s i s o f

,
th e in s an e by ur e th ral inj e c t ion o f a quan t i t y o f th e pur e cul t ur e an d ,
ob s e rv e d th e d e v e lop m e n t o f a typical gonorrh oe a a fte r th r e e d ay s O n .
th e t e n th d ay t h e pa t i e n t c h anc e d t o d i e in a p aroxy s m a n d t h e au t op s y
r e v e al e d th e following con di t ion s T h e r e was ab s c e s s o f th e righ t

.
ki dn e y hyp e r ae m ia o f th e m uco u s m e m bran e o f th e bla d d e r wi t h n e

,
c ro s i s o f m inu te p or tion s ; t h e m ucou s s ur fac e o f t h e ur e th ra wa s c o v
e r e d fo r a d i s t anc e o f 6 c e n ti m e t r e s fro m th e cu t a n e ou s orific e wi th
vi s cou s bloo dy e xu d a t e ; th e corpu s c a ve m o s u m o f th e ur e th ra was

s woll e n .
T h e s e cr e tion s o f th e m ucou s m e m bran e s a s w e ll as th e ki d n e y
flui d con t ain e d th e s p e cifi c cocci wh ich w e r e al s o foun d e nclo s e d i n

,
th e s ub s t a nc e o f th e w h i t e bloo d corp u s cl e s in th e m ucou s a n d s ub

-
m ucou s t i s s u e o f th e ur e th ra .
T h e ly m p h s pac e s an d d uc t s fur th e r m or e con t ain e d m icrococci an d

-
,
s o m e w e r e O b s e rv e d in s i d e o f th e w h i te bloo d corp u s cl e s in th e c ap i l -
la ri e s .
T h e se ana t o m ical d a t a m ak e i t e a s ily conc e iv abl e why i t i s th a t tru e

g onorrh oe a pr e s e n t s s o e x t e n d e d a cour s e an d th e m icro s copical e x ,
a m ina t ion con s e qu e n tly a d m i t s o f a d i ffe r e n t i at ion b e t w e e n tru e

g on
I S4 E D I T OR J A L A R I / CLE S
o rrh oea an d a n on s p e c i fi c ur e th ri ti s a s w e ll as o f a progn o si s as t o th e

-
,
ti m e o f d ura t ion j u s t as co n v e r s e ly a ur e th ri t i s wh ich run s i t s cour s e

, , ,
in a fe w d ay s p e r m i t s th e conclu sion th a t i t i s n o t d ue t o th e gon o

,
c o ccu s In s o m e of th e E urop e an clinic s no t ably at W urzb urg no case

.
, ,
o f gonorr h oe a i s d iagno se d u n t il th e gonoco ccu s h as b e e n foun d , The .
pr e s e nc e o f th e s p e cific g e r m i s al s o o f va s t prac tical i m por t ance in th e

d iagno s t ic e s t i m a tion o f gyn ae cological ca s e s— nor i s any gr e a t am oun t
o f s kill or t i m e r e quir e d fo r s uch e xa m ina t ion s wh ic h m ay e v e n b e e f ,
fe c te d b e for e th e p a ti e n t l e av e s th e e xa m i n ing ch air .
Inocula ti o n s o f go n orrh oe al p u s i t s e l f con t aining diplococci h av e , ,
fr e qu e n tly e nough b e e n ob s e rv e d t o call for th th e S p e cific d i se a se .
E v e ry pr a c ti t ion e r h as O ppor t uni ti e s o f wi t n e ss ing ino cula tion e xp e ri
m e n t s on th e conj unctiva i n h i s d aily prac tic e a n d th e e a rn e s t n e s s ,
wi th wh ich s urg e on s warn th e ir p a ti e n t s o f th e d a n g e r s o f s uch inocul a

t i o n s i s t h e b e s t argu m e n t in favor o f th e gonococcu s .
D e t ail e d accoun t s o f s uch inocula ti on s h av e b e e n p ubli sh e d by We l

an d e r wh o giv e s th r e e ca s e s o f s ucc e s s ful i n ocula t ion a n d S O call e d
1 -
, ,
con trol c a se s in wh ich inocula t ion wi th p us n ot con t aining th e org an

-
,
i sm s cau se d no infla m m a tion .
Bu m m h a s al s o sh own th at g on orrh oe al s e c re t i on w h ic h i s fr e e fro m
m icr o cocci d o e s n o t pro d uc e gonorrh oe al infla m m a tion All o f wh i ch .
t e n d s t o sh ow th a t i t i s in p oin t o f fac t th e gono co cc us w h ich i s th e
tr u e cau s e o f co n t agion .
An at o m ically th e gonococcu s h as b e e n d e m on s t rat e d up t o th e

p r e s e n t ti m e in go n orrh oe al a ffe c tion s o f th e m a le a n d fe m al e ur e th ra ,
th e b la dd e r th e ki d n e y s in p e ri ur e th ral ab s c e ss in gonorrh oe al
2 - 3
, , ,
bub o in gono rrh oe al goni ti s i n gonorrh oe al a ffe c tion s o f th e r e c

,
4 5
,
1
Q u e l qu e s rec h e rc h s
e s ur le s m i c ro b e s p at h o g en e s d e la bl e nn o r r h ag i e . Ga z e t te
M é di ca l e . 1 884 ,
p . 26 7 . N o rd M e d Arc
. . h . Vo l XVI . . No . 2 .
2
Bo ck h ar d t, l . c .
5 K a nznzér e r , U e b er g o n o r rh G e le n k e n t z un d u n g
. . C e n tr alb l f C i r . . h . 1 8 84 . No 4 . .
M . P et r o n e . Su ll a n a t u ra de ll ’
artri e bl e nn o rr h a
gi ca . Ri i vs ta C ir h . 1 883 . No, 2 .
B A C TE R I A L S CI E N C E I N I T S S UR GI CAL R E LA TI ON S .
1 55
’
t urn 1
c e r t ain ab s c e s s e s O f Bart olini s glan d s an d in
o f th e u te r u s , in
’
,
2
g o n orrh ae al conj un c t ivi ti s al th ough in t h e la tte r a ffe c t ion s o th e r m icro

,
o rgani s m s are fr e qu e n tly pr es e n t as w e ll .
A s r e gar d s th e cu ltiva tion o f th e g e r m r e liabl e cul t ur e s app e ar t o ,
h av e b e e n ac h i e v e d by Bu m m w h o s e s t at e m e n t s in th i s r e gar d a gr e e ,
wi th K rau s e Le i s tikow a n d LOffl e r th e cul tur e s b y o th e r e xp e ri m e n

, ,
t e r s b e i n g m or e or le s s o p e n t o O bj e c t ion .
T h e go n oco ccu s i t app e ar s can only b e cul t iva t e d on bloo d s e ru m

, ,
-
s oil s wh e r e i t d e v e lop s a s a v e ry fi n e s carc e ly p e rc e p tibl e fi lm o f gr e y

, ,
i sh y e llow color wh e n vi e w e d in d ir e c t ligh t

-
, T h e s ur fa c e o f th e .
co lony app e ar s sm oo th an d m oi s t ; i t s m argin s app e ar gra d ually di f

fu s ed i n t o th e s urrou n di n g par t s ; th e s e ru m s oil d o e s n ot b e co m e
liqu e fi e d T h e gonococci app e ar in group s d e v e loping in clo s e prox

.
,
i m i ty t o e ach o th e r .
T h e cul t ur e s th riv e b e s t a t a t e m p e ra t ur e o f 3 0 t o 3 4 C in a m oi s t ° °
.
a tm o s ph e r e T e m p e ra t u re s abov e 3 8 C d e s tr oy th e cul t ur e s T h e
.
°
. .
grow th progr e sse s v e ry s lowly an d t o ob t ain goo d cul tur e s i t i s advi s a

b le t o in ocula t e fr e sh s oil s a ft e r th e fir s t colony h a s d e v e lop e d for a
p e ri o d o f 2 4 h our s .
Wi th s uc h a pur e cul t ur e as th i s Bu m m p e rform e d h i s in ocula t ion

e xp e ri m e n t wh ic h e v e n i f i t i s only a s i n gl e o n e s till co m m a n d s a t t e n
, , ,
t i on s inc e i t an s w e r s e v e ry b ac t e riological r e qui s i t ion

, .
H e in tro d uc e d a m ini m al quan ti ty o f th e p ur e cul t ur e in t o th e
ur e th ra o f a h e al th y wo m an an d sh or tly a ft e r was abl e to Ob s e rv e th e ,
d e v e lop m e n t o f a s p e cific gonorr h oe a .
C o n s i d e ring th e d i fficul ty app ar e n tly atte n d e n t upon th e p rocu ring

O f pur e c ul t ur e s a n d th e s ci e n t ific s crupl e s conn e c t e d wi th th e inocula
t i on e xp e ri m e n t s on th e h u m an b o d y th e r e app e ar s t o b e no r e a s on ,
f o r n o t a cc e p t ing th e e vi d e nc e con t ain e d in th e two inocul at ion e xp e ri
m e n t s ab ov e d e s c rib e d nor for n o t a ccor d ing th e gonococcu s e qu a l ,
digni ty wi th th e t ub e rcl e b a cillu s a n d th e m icro org ani s m s O f s upp ura - -
t ion . W W VAN A R S D A L E . . .
1
Bum m , Arch i v . f Gyn ae c o l
. .
3 , p 339 . .
2
Bum m , l
. c . E . A r u i ng , U e b e r d as Vo r k om m e n v on l
Go n o c oc c e n b e i Ba rt o i n i
ti s . Vi e r te l jar s ch r ft f D erm . at . u . S yp h . 1 883 , p 37 1
. .
T R E AT M E N T OF S T R I CT U R E OF TH E U R E TH R A BY
E LE CT R O LY S I S .
It is to b e r e gr e tt e d th a t th e d i s cu s s ion on Dr S t e ave n s o n an d Mr
. .
Bruc e Clark e s pap e r on th e ab ov e s ubj e c t at a r e c e n t m e e t i n g of th e

-
’
R oyal M e d ical a n d C hirurgical S oci e ty s h oul d h av e t ak e n plac e s o la t e

in th e s e s s io n an d t o th i s an d t o th e la t e n e s s o f th e h our m u s t b e a ttri
,
b u t e d th e p auci ty o f sp e ak e r s .
T h e s ubj e c t i s o n e o f gr e a t in t e r e s t S ix ca s e s w e r e broug h t fo r
.
war d w h ich h ad b e e n tr e a t e d by th i s m e th o d in non e o f wh ich h ad r e

,
con trac tion t ak e n plac e th ough i t m u s t b e a dm i tte d th at a s u ffici e n t

,
in t e rval h ad n o t e lap s e d t o p e rm i t j u dg m e n t t o b e p a s se d as t o th e
p e r m a n e ncy o f cur e
.
I n th e fir s t ca s e rigor s o ccurr e d b ut th i s can s carc e ly b e won d e r e d

,
a t w h e n i t i s r e m e m b e r e d t h a t bo th g e n tl e m e n w e r e e m ploying th i s
m e th o d fo r t h e fir s t t i m e .
We r e gr e t th a t m or e d e t ail s w e r e n ot giv e n conc e rni n g th e n u m b e r ,
We no t e al s o th a t
'
s iz e po s i t io n a n d c h arac t e r o f th e
,
s t ric t ur e s .
,
a lth o ugh no r e co n t rac t ion I S s ai d t o h a v e t ak e n plac e i t d o e s n ot ap

,
p e ar th a t a th orough e xa m ina tion was m a d e wi th a b ougi e a b oul e ,
wi th ou t th e ai d of wh ich s lig h t co n s tric t ion s a re d i fficul t t o diagno s e .
T h e m o d u s op e ran d i e m ploy e d wa s as follow s : A g um e la s t ic or -
c e lluloi d bougi e wi th a wir e run ning d own t o th e c e n tr e t e r m in a t i n g in

a m e t al e n d for m s th e e l e ctro d e th i s b e ing conn e c te d wi th th e n e g a
, ,
t i v e pol e i s h e l d g e n t ly pr e s se d again s t t h e s tric t ur e a n d sh oul d b e o f

,
t h an i s t h e s t ric t ur e s calibr e To th e p o s
’
a s iz e larg e r by 2 or 3 m m
'
. .
i t i ve p ol e i s a t t ach e d a p ad e l e c tro d e w h ich i s plac e d ov e r t h e s acru m ,
t h e p a t i e n t lying upon i t T h e b a tt e ry u s e d i s S t oe h re r s 3 0 c e ll A ’
. .
c urr e n t s tr e ng th o f fro m 5 t o 8 m illia m p er e s i s foun d r e qui s i t e w h ich ,
i s gaug e d by m e a n s o f a galvano m e t e r .
I n ca s e s o f e cc e n tric s t ric t ur e a fu n n e ll e d e l e c tro d e can b e u s e d ,
p a s s e d ov e r a long ca t gu t b ougi e w h ich h a s pr e viou s ly b e e n pa s s e d

t h roug h t h e s t ric t ur e or fi li fo rm gui d e bougi e m ay b e pa s s e d t o wh ic h
, ,
i s s cr e w e d th e e l e c t ro d e . By th i s m e an s th e e l e c t ro d e can n o t fail t o
t rav e r s e th e prop e r cour s e .
TR E A TM E N T OF S T R I C T U R E OF TH E UR E TH R A .
_
1 57
A fte r th e pa s s ag e o f th e e le c tro d e th rough th e stric t ur e wh ich m ay ,
t ak e fro m t wo t o t w e n ty m inu t e s th e pa t i e n t go e s h o m e an d th e ur e th r a i s
,
le ft un t ouch e d for four t e e n d a y s T h e tr e a tm e n t can th e n b e r e p e a t e d i f

.
n e c e ss ary S p e aki n g g e n e r ally fro m t wo t o th r e e applica t ion s are r e

.
,
quir e d .
In th e d i s cu s s ion wh ich fo llow e d th e w ri te r o f th i s brough t forwar d

a ca se o f lo n g s t an ding s t ric tur e wh e r e e l e ct roly si s h ad s ucc e e d e d aft e r
-
t r e a t m e n t by d ila t a t ion h a d fail e d Al th ough on co m m e ncing e l e c

.
t r olys i s the s t ric t ur e o nly a d m i t t e d a N O 4 b ougi e o liv a ire a ft e r th r e e

.
,
app lica t ion s a N o 2 8 p a ss e d

. A m o n th a fte r th e c e s s at ion o f all
.
t r e a t m e n t a car e ful e xa m in a t ion o f th e ur e th ra wi th a 2 2 b ougi e a b oul e
fail e d t o d e te c t any t rac e o f s tric t ur e .
Mr B e rk e l e y Hill co m plain e d of th e wan t o f d e t ail s in r e cor de d

.
ca s e s H e h a d tri e d e l e c troly si s by m e an s o f a n e e d l e pa s s e d in t o th e
.
n e opla st ic t i ss u e
,th e r e s ul t b e ing th a t t h e s tri ct ur e g ot wor s e i n
s te a d o f b e tt e r
. Wh a te v e r goo d m ay h av e r e s ul te d fro m th i s plan o f
tr e a tm e n t h e b e li e v e d wa s d u e t o d il at a tion by m e an s o f th e e l e c
t ro d e a n d n o t t o e l e c tri ci ty an d in th i s Mr Bux t on Brown e a gr e e d . .

,
In th e pr e s e nc e o f th e nu m e rou s ca se s n ow on r e cor d we canno t b u t ,
t h i n k th a t e l e c t roly s i s i s capabl e o f cau s i n g s tric t ur e s t o d i s app e ar an d
prob ably o f e ffe c tin g a p e r m an e n t cur e Much h ow e v e r m u s t d e p e n d

.
,
up on th e way o f carrying o ut th e m e th o d I t a pp e ar s th at Mr F e n
. .
w ick h a s tri e d i t in a go o d m any c ase s at S t Pe t e r s Ho spi t al b u t .

’
,
wi th ou t m uch s ucc e s s On e r e as on of failur e b e ing th at only we ak

.
curr e n ts w e r e u s e d an d working wi th o u t a galv ano m e te r th e s e w e r e

, ,
n o t accura t e ly gaug e d Mr B Hill t ri e d a m e th o d al t og e th e r di ffe r

. . .
”
e n t a n d fail e d nor can th i s b e won d e r e d a t wh e n on e con s i de r s th e ,
plan h e p ur s e d .
In or d e r t o th orough ly inv e s tig ate th e e l e c tri cal t r e atm e n t o f s t ri e

t ur e i t i s n e c e s s ary th at ca s e s o f we ll m ark e d org ani c s tr ic t ur e ( an d fo r
,
pr e fe r e n c e th o se for wh ich dila t ation h a s b e e n fo un d t o b e in e ffe c t u al)

sh oul d in t h e fir s t plac e b e s ub m i t te d t o s o m e w e ll known s urg e on s -
,
conc e rni n g wh o s e p ow e r s o f diagno s i s th e r e can b e no qu e s tion T h e s e .
s a m e m e n sh oul d at t h e e xpira t ion o f t r e a tm e n t a n d p o s s ibly a g ain ,
a fte r t h e lap s e o f a y e ar e x am in e a n d r e p or t on th e se t e s t ca s e s
,
It .
1 58 E D 1 T 0R 1 A L A R TI CLE S .
se e m s t o u s th at only i n s om e s uch way as thi s can th i s qu e s ti o n b e

s a ti s fac t ori ly s e t tl e d
.
To furth e r th i s Obj e c t i t i s ann o unc e d th a t a t S t Pe te r s H o s pi t al for

.
’
S t on e a n d Ge n i to Urinary d i s e a s e s a s p e cial d e p ar t m e n t i s b e ing i n

-
s t i t u t e d for th e t r e a t m e n t o f s tric t ur e by e l e c t r o ly s i s t o th e prac t ic e o f

.
which all m e d ical m e n are invi te d . F S W I N F O R D E D WA R D S

. .
I N D E X O F S U R G I C A L PR O G R E S S .
GE N E R AL S U R GE R Y .
I . O n T u b e r c u lo s i s of th e M am m a ry G la n d an d S om e
O th e r R are C a s e s o f S u r g i c a l T u b e r c u l o s i s By Dr 0 H A BE R . . .
MAA S ( T ii b in gen ) To th e nu m b e r of affe c ti o n s wh ich are b e c om i n g

.
r e c o gniz e d a s t ub e rcular by th e m i cro s copical d e m on s tra tion o f t ub e r

c le bacilli co n t ain e d th e r e i n th e au th or a dd s m u s cular a n d m a m m ary
-
,
'
t ub e rcul o s i s illu s tra ti n g th e m wi th ca s e s a n d al s o giv e s t wo ca s e s o f

, ,
t ub e rculou s p r e p a t e llar bur s i t i s

-
.
A fte r r e vi e wi n g th e s ix r e liabl e ca s e s alr e a dy r e por te d th e au th or

a d d s t wo o f h i s own o f t ub e rculou s m a m m ary d i se a se an d proc e e d s t o ,
di s cu s s th e s ubj e c t
T h e a ffe c t i o n a tt ack s only fe m al e s b o th b e for e an d a fte r lac t at i o n ,
an d in d e p e n d e n t ly o f t rau m a t i s m s In m any ca se s o th e r t ub e rcul o u s

.
a ffe c tion s e xi st e d Th e c o ur s e o f d i s e a s e i s in s i diou s b ut n o t u n e x

.
,
c e p ti o n ally Th e d i s e a s e m ay a t t ack th e glan d pri m arily or s e co n d

.
ari ly .Bacilli w e r e foun d in b o th ca s e s o f th e au th or s Diagno si s i s

’
.
d i fficul t u n til s uppura tion e n s u e s Th e t r e a tm e n t i n dica t e d i s e x t irpa

.
t i on o f t h e e n tir e gla n d ; al th oug h circu m s cri b e d foci m a y b e r e m ov e d
by p ar tial e xci sio n .
Th e au th or s t wo ca s e s o f t ub e rculou s a ffe c ti o n of t h e p re p a te llar

’ -
b ur s a w e r e b o th ca se s o f pri m a ry sy n ovi t i s occurri n g in p e rfe c tly

h e al th y in d ivi d ual s .
T h e la s t ca se i s o n e O f m ul tipl e t ub e rculou s foci occu rri n g in de
e n tly in t h e m u s cl e s o f th e upp e r an d low e r e x tr e m i t i e s a n d o f t h e

p
bo dy in a m an 5 4 y e ar s o f age wh o wa s s u ffe ring fro m cari e s O f th e
,
fi fth d or s al v e r te bra Th e t u m or s va ri e d in s iz e fro m th a t o f a p e a t o

.
a h e n s e g g a n d w e r e S i t ua t e d in s i d e o f th e sh e a t h o f t h e m u s cl e s
’
.
,
Micr o s copically th e y c o n t ain e d t ub e rcl e b acilli T h e ca s e i s c on si d

-
.
e r e d a s on e o f d i sse m i n a t io n fro m th e v e r te bral fo c u s —B e i t r ag e z u r .
( 1 5 9)
1 60 i N DE X OF S UR GI CA L P R O GR E S S .
R/i n . C lzi r . zl/ i tf/z . a ns

’
o er c/i ir . A li n i R
’
. zu Tu b i ng en . II . Bd . 1 .
H e ft I I . .
W W . . VA N AR S D AL E ( New k)
Yor .
II . Th e T re at m e n t
By Pr o f T R E N D E LE N BU R O
of Lu p us . . .
I n d e s crib in g th e a fl e c ti o n th e au th or fu lly acc e p ts i ts t ub e rc ular
o ri gi n I t fo l lo ws th a t tr e a tm e n t t o b e p e rm a n e n tly s ucc e s s ful sh o ul d

.
s e e k t o d e s t r o y a ll t h e a ffe c te d ti ss u e .
F o rm e rly i n t e rn al r e m e d i e s w e r e m uch in V o gu e S w e a t cur e s a n d .
T ri ttrn a n n s d e coc ti o n ( s ar s aparilla) app e ar e d a t ti m e s t o pr o d uc e

’
so m e e ffe c t .
Cau s tic s h e lik e s b e s t i n th e fo rm o f p e ncil s an d ni t ra te of s ilv e r i s ,
pre fe rabl e to p o ta s h S inc e th e la tte r i s t oo d i ffl u e nt B e tte r th an th e s e .

,
h o w e v e r i s t h e ac t ual cau t e ry in th e conv e ni e n t fo rm o f th e p oin te d

,
t h e rm o cau t e ry -
T h e ac ti o n i s t h e n s tric tly l o ca lizab le
, I n Ge rm any .
a t le a s t t h e m e th o d m o s t in fav o r i s t h a t in t r o d uc e d by Vo lk m an n .
vi z .
, m e c h anical d e s truc ti on an d r e m o val o f th e n o du le s by m e a n s o f
t h e s h arp s p oo n T hi s p la n wh e n fol lo w e d by cau te riza ti o n wi th a

.
,
Pa q ue lin h e c o n si d e r s s p e cially c o m m e n d abl e

, Volk m an n s p unc t a .
’
ti on tr e a tm e n t i s o n ly a d ap te d t o lig h t ca s e s a n d d o e s n o t app e ar t o ,
b e v e ry c e rt ai n .
Va ri o u s m e th o d s s ucc e e d i f e ach ulc e ra t i o n e v e ry n o d ul e an d s u s ,
p i c i o u s s p o t i s in cl ud e d a n d t h e O p e ra tion — u n d e r n arc os i s o f c o ur s e
,
i s r e p e a te d a t t h e ri gh t t i m e In b a d ca s e s no si n gl e m e th o d pro t e c t s
.
a g ai n s t re lap se s Lupu s will al s o h e al o ut un d e r wa sh ing s wi t h

.
s o lu ti o n o f s ubli m a t e .
I n e xci s i o n wi th s ub se qu e n t pla s tic cov e ring i t i s w e ll t o wai t wi th
t h e la t t e r un til s o li d cica triza ti o n h a s t ak e n p lac e a n d t h u s av o i d ,
t aki n g away t o o m uc h or t o o li t t le Th e t ra n s p lan t e d flap i s n o t s a fe .
fr om i n fe c ti on d e s pi t e Hu e t e r s a s s e r ti on Tru e s uch an op e ra ti o n or ’
.
,
t h e re s u lti n g i n fla m m a t i o n s e e m s t o h av e a fav o rabl e i n flu e nc e o n t h e
cur e H e c o rr ob o ra t e s th e o ld ob s e rva ti on t h a t an e ry sip e la s a ls o h a s

.
a fav o rab le e fl e c t In cas e s wh e r e th e lupu s i s cl os e ly l o caliz e d t o a

'
wi n g o f t h e n os e a n d i t s c orr e s p o n ding m uc o u s m e m bran e h e O fte n

S p li t s t h e n o s e cl o s e t o th e s e p t u m , up t o t h e na s al b on e I t can b e ,
.
h e l d o p e n an d th e a ff e c t e d pa rt s tre at e d wi th th e S h arp s co o p an d th e
N E R Vo z/ S A N D VA S C U LA R S YS TE M S .
16 1
r
the m o - cau t e ry w h e n i t i s agai n s e w e d to g e th e r
, T h e fi n e s car .
is o f li t tle acc o un t d i s figur e m e n t b e i n g in e vi tabl e —D eu ts c/ze C/zi r

,
a rg i e L i ef
, .
3 3 H ae lft e
. 1 .
W . B RO W Ni N O ( Bro o k l yn ) .
N E R V O U S A N D V A S C U LA R S Y S T E M S .
I . S e c o n dary Su t u re o f t h e M e d i a n a n d U l n a r N e r v e s .
R e co very By Mr R H A R R I S O N ( Liv e rpo ol) T h e au th or narra te s

. . . .
t h e ca s e o f a m a n se t 2 1 wh o e ig h t e e n m o n th s b e fo r e a d m i s s i o n
.
, ,
fe ll ,
t h r o u gh a gr e e n h o u se s e v e r e ly cu t ting h i s wri s t
,
T h e r e was a m ark .
o f a d e e p c u t t ran s v e r s e ly acr o s s t h e wri s t j u s t ab o v e th e an te ri o r

,
a n n u lar liga m e n t T h e h an d was s ti ff an d u s e l e s s all th e m u s cl e s

.
,
we r e a t r o p hi e d an d s e n s a ti o n an d m o ti o n w e r e c o m p le te ly ab s e n t i n
,
t h e par t s upp li e d by t h e m e dia n a n d ulnar n e rv e s T h e au th or .
O p e n e d up t h e s car by a lo n g v e r tical inci s i o n a n d d i s s e c te d o ut th e ,
e n d s o f th e ulnar a n d m e d ian n e r v es th e s e w e r e fo u n d clubb e d a n d
i n c o rp o ra te d wi th th e s car ti s s u e T h e e n d s o f th e n e rv e s a fte r d i s
.
s e c t i o n o f t h e par t w e r e fr e s h e n e d wi th th e kni fe a n d br o ug h t t o g e th e r
as accur a t e ly a s p o s sib le wi th ca t gu t s u t ur e s T h e w o u n d was clo s e d .
a n d th e li m b plac e d o n a s plin t wi th th e h a n d sli gh tly fl e x e d Th e

, .
w o u n d h e a le d quickly A m o n th a fte r th e O p e ra ti on th e pa ti e n t was

.
a gain plac e d u n d e r e th e r wh e n th e s ti ffe n e d h a n d was s ubj e c t e d to

,
fr e e m o v e m e n t T h e a m o u n t o f s ti ffn e s s e s p e cially in s o m e o f t h e
.
,
p h alang e al j oin ts was s o gr e a t as t o occa si on c on s i de rabl e di ffi cu lty in

,
th o r o u gh ly e fl e c t in g w h a t was d e s ir e d F o r 4 8 h o ur s a ft e r th i s wa s
.
d o n e th e pa t i e n t e xp e ri e n c e d con si de rabl e pain in a par t th a t p re
v i o us ly h a d b e e n al m o s t in s e n s ibl e Sh o r tly a fte rwar d s th e pa ti e n t

.
wa s d i s c h arg e d i m pr o ving s l o wly b u t s te a dily

, W h e n h e was s e e n .
a fte r the e xpira ti o n o f ab o u t e ig h te e n m o n th s i t wa s fo un d th a t s e n s a ,
t i o n wa s e v e rywh e r e c o m p le t e w h e r e i t h a d b e e n d e s tr o y e d e xc e p t in ,
t h e li t tl e fi n g e r a n d t h e r e c o v e ry o f m u s cu lar p o w e r h ad b e e n s uc h
,
t h a t h e h a d b e e n abl e t o r e s u m e h i s e m pl o y m e n t .
H . l ’
. D U NN ( Lo n d o n ) .
II U n i o n o f N e r v e s o f D i fl e re n t F u n c t i o n C o n s i d e r e d i n
’
i t s P h y s i o l o gi c a l a n d S u r g i c a l R e la t i o n s By M GU NN M D . .
,
. .
,
( C hica g o) A fte r an ac c o un t o f c e r tai n circu m s t anc e s whic h le d to

.
162 I N D E X OF S UR GI CA L P R ooR E S S .
th e c o n clu si on th a t th e d i ffe r e n c e b e t we e n m o t o r an d s e n s ory n e rv e s

i s n o t in tri n s ic b u t d e p e n d e n t up o n t h e orga n iz a t i o n a t th e e n d o f th e
n e rv e r e fe rri ng i n par t icular t o th e inv e s tiga tio n s o f R awa

, s h o wi n g
,
t h a t ( a ) t h e c e n tral n e rv e app ara t u s i s e n abl e d t o i n n e rva t e organ s
wh ic h d o n o t b e lo n g t o i t a s s o o n a s t h o s e o rgan s ar e ar tifici all y
broug h t in c o n n e c tion wi th i t ; ( 1 ) th e c e n t ral n e rv e appara t u s i s th e

7
chi e f n ouri sh ing a g e ncy for th e p e rip h e ral e n d ( o f t h e e n t i r e corr e c t

n e s s O f wh ic h h o w e v e r th e r e i s s o m e d o ub t a n d ( c) fo r t h e r e e s t ab
, , )
li sh m e n t o f func ti o n i n th e p e rip h e ral e n d o f a d ivi d e d n e rv e w h ich ,
h a s b e e n uni t e d t o th e c e n tral e n d o f any o th e r n e rv e fr o m s ix t o s i x ,
t e e n m on th s t i m e i s r e quir e d h e d e t ail s c e r t ai n e xp e ri m e n t s upo n d og s

,
wh i ch fi n ally we n t S i m ply t o Sh o w th a t an e n tir e s o l ut io n o f con tinui ty
o f th e n e rv e o f t h e for e le
g h a d n o e ff e c t t h e r e b e i n g s o fr e e a d i s t al
-
,
a n a s t om o s i s a ffor di n g a r e trogra d e rou t e fo r th e n e rvou s forc e an d

, ,
b e cau s e o f wh ich i t i s n e c e s s ary t o awai t th e O pp o r t u n i ty t o i n s t i t u t e

e xp e ri m e n t al op e ra t i on s i n m an T h e e xp e ri m e n t s o f R awa s h ow e d
.
th a t t h e fu n c tion c o ul d b e e s t abli s h e d w h e r e t h e n e rv e t runk s w e r e
la i d S i d e by s i de a s w e ll a s e n d t o e n d s h owi n g an e l e ctiv e p ow e r in
,
na t ur e by wh ich th e corr e s p o n d i n g filam e n t s m ay b e broug h t in t o h ar

m o n i o u s co nj unc t ion T h e O ppor t uni t y for an e xp e ri m e n t al op e ra tion
.
pr e s e n t e d i t s e l f i n D e c e m b e r 1 8 8 5 wh e n h avi n g t o r e s e c t b e tw e e n
, , .
t h r e e a n d four i n c h e s o f th e ri gh t u l n ar n e rv e for th e r e m oval o f a

n e uro m a t h e au th or proc e e d e d t o gra ft th e di s t al p or t ion
, o f th e di
v i d e d n e rv e upo n th e t ru n k o f t h e m e d ian d e n u d i n
g th e t run k o f t h e
,
la tt e r of i t s s h e a th an d layi n g th e broa dly ch a m fe r e d d i s tal e n d of th e

ulnar upon th e d e n u d e d s i d e O f th e m e d ia n t o wh ich i t w a s fa s t e n e d ,
by thr e e fi n e ca tgu t s u tur e s H e ali n g wa s c o m pl e t e on t h e e i gh te e n th

.
d ay . I m m e dia t e ly a ft e r th e O p e ra ti on t h e r e wa s c o m pl e t e paraly s i s o f
m o t ion an d s e n s a t io n in th e par t s s uppli e d by t h e u ln ar n e rv e on th e
e ig h t e e n th d ay e xa m ina t ion s h o w e d a S lig h t r e t urn o f s e n s a t io n al on g
,
th e ul n ar s i d e o f th e ri n g fi n g e r an d i n fl e xi n g th e h an d upon th e wri s t
, ,
t h e r e s e e m e d t o b e con t rac t ion i n th e fl e xo r carpi u ln ari s b u t in t h e ,
a tt e m p t t o fl e x th e fi n g e r s th e r e wa s no r e s p on s e i n th e t e r m i n al
,
p h ala n g e s o f th e ri n g a n d li tt l e fi n g e r s thr e e m on th s a ft e r th e O p e ra
ti on t h e r e wa s m ark e d i n cr e a se o f s e n s a t io n o n th e ul n ar s i d e o f th e
,
ring fi n g e r b ut no se n s at ion i n th e li ttl e fi n g e r an d no i n cr e a s e i n th e

,
N E R VO US A N D VA S C ULA R S YS TE M S .
1 63
rang e o f m o tion ; a m on th lat e r th e p ati e n t co ul d fe e l a ligh t t ouc h o n

th e ulnar s i d e o f th e ring fing e r ; th e r e wa s n o s e n s a t ion t o t o uc h in
th e li t tl e fin g e r b u t th e r e was a li ttl e fe e ling o f war m th in i t w h e r e a s

, ,
h e r e t o for e i t h ad fe l t a n d h a d b e e n c o l d th e r e wa s incr e a s e d m u s cular

p ow e r an d th e p at i e n t coul d n o w a dd uc t th e h an d wi th co n s i d e rabl e
,
vigor b ut a s ye t h a s no pow e r ov e r th e t e rm inal p h alan g e s

,
Th e .
au th or al s o quo t e s a ca s e o f D e p re s i n wh ic h th e m e d ian wa s e n gra ft e d

’
upon th e ulnar by s e para ting th e fila m e n ts o f th e la tt e r an d in t e r

w e avi n g th e fring e d fila m e n t s O f th e d i s t al m e dian e n d a m o n g th e m ,
wi th th e r e s ul t o f par tially r e s t oring th e func tion s in t h e par ts s uppli e d

by th e m e d ian n e rv e a t th e d a te o f th e r e por t fi fty four d ays a ft e r t h e
, ,
-
op e ra tio n —M ed N ew s 1 8 8 6 M ay 8
. . . .
III . A C as e of A o rt i c A n e u r i s m T r e at e d b y t h e
I n s e rt i o n
o f W i re By J R AN S O H O FF M D ( Cinci n na ti ) In a color e d m a n
. .
, . .
,
. .
ac t 3 5 an a n e uri s m o f th e a s c e n d ing aor t a r e s ul ting fro m ov e r e x e r t io n

.
, ,
-
in rowi n g ab ou t two m o n th s pr e viou s ly h ad b e e n t r e a t e d i n e ffe c t u allv

,
by i o d i d e o f po t a s s iu m an d s ub cu t an e ou s inj e c tion s o f e rgo tin e Pi .
nally a s tr aigh t h o llow n e e dl e wi th th u m b s cr e w a t t ach m e n t wa s pu s h e d -
in t o th e an e uri s m fro m th e righ t s i de a n d th rough i t wa s p a s s e d ni n e ty

s i x inch e s o f fl e xibl e s ilv e r wir e T h e p ain e xp e ri e nc e d wa s v e ry
.
s lig h t an d d uring th e in tro d u c t ion o f t h e fir s t for t y e ig h t i n c h e s o f W i r e

,
-
th e pul s e r e m ain e d unc h ang e d b ut i t th e n s u dd e n l y b e ca m e al m o s t

,
i m p e rce p tibl e an d v e ry rapi d th e pa ti e n t b e ca m e v e ry fain t a n d d e a th

,
app e ar e d t o b e i m m i n e n t; s t im ulan t s h o we ve r o ve rc a m e th e s yncop e a n d

, ,
th e r e m ain d e r o f th e wir e wa s in t ro d uc e d wi t h ou t in t e rrup tion O n th e .
au t op sy t he s yncop e wa s fo un d to h av e b e e n d u e t o t h e pa s s ag e o f a
,
loop o f wire b e yo n d th e n e ck o f th e s a c a n d in t o t h e aor t a w h e r e i t ,
was prob ably d e fl e c te d by th e aor tic v alv e s T h e r e wa s n o b l e e d i n g .
d uring th e O p e ra t io n nor i m m e d ia t e ly a ft e r th e wi th d rawal o f t h e
n e e d l e An a m e lioratio n o f th e s y m p t o m s c o n ti n ue d fo r t wo we e k s
.
afte r th e O p e ra t ion b u t th e n a c h ang e fo r th e wor s e s up e rv e n e d

, gr e a t ,
oe d e m a o f t h e righ t s i d e o f t h e fac e a n d t h e rig h t a rm b e ing d e v e l o p e d ,
an d in h op e o f con s oli d a t i n g t h i s par t o f th e s ac

, nin e ty e ig h t i n c h e s ,
-
o f wir e w e r e i n s e r t e d in t o th e s t e rnal por tio n ; s o m e i m prov e m e n t s u
p e rv e n e d b u t th e p a ti e n t di e d s u dd e nly e i g h t d ay s la t e r fro m rup t ur e

, ,
1 64 j N DE X OF S UR GI CA L P R o C R E S S .
o f th e s a c Au top s y sh ow e d th e for m a ti o n o f c lot s ab ou t th e l o o p s o f

.
w ir e . F r o m h i s e xp e ri e nc e in th i s ca s e an d an an aly s i s o f fo ur t e e n
O th e r s th e o p e ra t o r c o nclu de s th a t in b ut th ir ty e r c e n t o f th e ca s e s
,
p .
c a n d e a th b e a t t ribu t e d t o t h e O p e ra t i o n an d e xc e p t in p e rip h e ral v e s ,
s e ls w h e r e s o m an y s a fe r m e th o d s are at our c o m m a n d th e prac t ic e i s ,
w o r th y o f fur t h e r t ria l prac tic e d as a la s t r e s o r t i t h a s un d o ub te dly ,
le n g th e n e d li fe an d i t i s far fro m i m pr o b abl e th a t i f o ft e n a d op te d a

, , ,
p e r m a n e n t r e cov e ry w ill o cca si o nally b e o b t ai n e d i n ca s e s th a t w o ul d

b e h o p e l e s s wi th ou t i t —M ea N ew s 1 88 6
. May 2 9 ’
. . . .
IV . i c A n e u r i s m o f t h e I n t e r n al C a r o t i d A rt e ry
T ra u m at .
By T F PR E W I TT M D ( S t Loui s M O ) A bull e t e n t e r e d th e ch e e k
. .
, . .
,
.
,
.
ov e r th e m alar b on e ran ging b ack war d th e inj ury b e i n g fo llow e d by

, ,
i m m e d ia t e an d pr o fu se h wm orrh a ge c o n troll e d by c o m pr e s si o n fr o m ,
t h e w ou n d o f e n t ran c e — th e r e b e i n g n o woun d e xi t—an d fr o m th e e a r
t h e la tt e r r e curring s e v e ral t i m e s A gra d ually i n cr e a s i n g s w e lli n g a p

.
p e ar e d wh ich t h r e e m o n t h s la t e r pr oj e c t e d i n t o t h e p h aryng e al cav

, , ,
i t y a n d r e s t e d again s t t h e uvula e x t e n d i n g e x t e r n ally fro m th e a n t e ri o r

,
p e tr o u s por tio n o f th e te m p o ral t o th e h yoi d b o n e a n d h a d a ll th e '
s y m p t o m s o f an a n e uri s m o f th e in t e rnal caro ti d ar t e ry t og e th e r wi th ,
s ym p t o m s i n d ica t i n
g inj ury o f th e glo s s o p h aryn g e al an d po s s ibly th e
-
, ,
p n e u m o ga s tric n e rv e s Th e c o m m o n car o t i d ar te ry was th e n liga

.
t ur e d a n d th e pu ls a t io n arr e s t e d fo r a t i m e b u t s oon r e t urn e d As a .
a e r n i er r es s o r t b e e x te n d e d t h e i n ci s i o n upwar d in th e h O p e o f b e i n g
’
,
abl e to lay op e n th e s ac an d apply a liga t ur e t o t h e di s t al s i d e ; d i s

s e c t i o n h ow e v e r r e v e al e d th a t th e sac fill e d all th e s pac e b e t w e e n t h e
'
, ,
m a s t o i d proc e s s a n d th e co n dyl e an d ra m u s o f th e j aw a n d e x t e n d e d ,
t o t h e S kull t o wh ic h i t w as cl os e ly a dh e r e n t a n d t h a t fur th e r a t t e m p t s
, ,
t o r e ac h i t i n th a t d ir e c ti on w e r e u s e le s s a n d d r e s s i n g s w e r e appli e d ,
.
S e c o n d ary h ae m orrh ag e s e t i n s om e d ay s la t e r b ut wa s c o n tr o ll e d by
“
c o m pr e s s ion W i th pl e d g e ts o f i o d o form i z e d lin t th ru s t i n t o th e s ac ; e p i

le p t o i d c o nvul s ion s i n v o lvi n g th e facial mu s cl e s a n d th e fl e xo r s o f th e
,
a rm a n d h an d s e t i n t e n d ay s la t e r an d c o n tinu e d a t i n t e rval s u n t il
d e a th on th e t w e n ty n in t h d ay T h e d iagn os i s was c o n fir m e d by th e
- .
au t o p s y th e ball b e ing foun d in th e po s te rior p ar t o f th e s a c I n c on

,
.
n e c t i o n wi th th e ca s e th e wri te r call e d a tt e n tion t o th e e x t r e m e ra ri ty

,
VA S C ULA R S YS TE M S I65
fl
N E R V0 US A N D .
of t rau m a tic a n e uri s m o f th e i n t e rnal caro ti d an d b e li e v e d th i s ca s e .
r e s u lt i n g fro m a g u n sh o t wo un d t o b e uni qu e i n s urgical li t e ra t ur e

,
.
W T B R I GG S M D ( N a sh vil le T e nn ) r e m ark e d th a t h e h a d r e
. .
, . .
, , .
p or te d a ca s e o f traum a t ic an e uri sm o f t h e in te r n al caro ti d th e r e s ul t ,
o f a s t ab w o u n d O p e ra t e d upo n s ucc e s s fully i n 1 8 7 1

-
,
At fir s t S ig h t . ,
h e co n s i d e r e d i t t o b e a s m all an e uri s m o f o n e o f th e bran ch e s o f th e

e x t e rnal car o t i d b u t an e n larg e m e n t o f t h e woun d sh ow e d h i s e rr o r
,
.
Li ga t ur e o f th e co m m on caro t i d fail e d t o con trol th e h ae m orr h ag e a n d ,
th e in t e rn al caro ti d w as d i s s e c t e d o u t un t il th e poi n t o f inj ury
r e ach e d th e s a c op e n ed a n d liga t ur e s appli e d ab ov e a n d b e low i t th e

, ,
p a ti e n t ob t ai n ing a p e r m an e n t r e cov e ry .
D H
. .
( Ph ila d e lp h i a
) r e p or t e d a ca s e o f a wo m an
,
wi th a t u m o r as larg e a s an orang e j u s t b e n e a th a n d b e h i n d th e angl e

,
O f t h e j aw proj e c t ing al s o in t o t h e p h arynx ; i t h a d grown s l o wly fo r

,
e ig h t m o n th s a n d w a s a t t ribu t ed by th e p a t i e n t t o a blow on t h e s i d e
o f th e h e a d T h e t u m or wa s m a t e rially r e d uc e d in s iz e by p r e s s ur e
.
o n t h e i n t e rnal caro ti d ar t e ry h a d a d i s t i n c t pul s a t io n an d brui t a n d

, ,
h e co n s i d e r e d i t t o b e an a n e uri s m o f th e i n t e rnal caro ti d ; h e liga t ur e d
t h e co m m on caro t i d i m m e d i a t e ly abov e th e om o h yoi d b u t al t h o ug h -

, ,
t h e p ul s a t ion wa s d i m i n i s h e d i t coul d s t ill b e fe l t a fac t a t tribu t abl e t o

, ,
i t s co m m unica t io n wi th t h e e xt e rn al caro ti d a n d th e e x t e rn al t hyroi d ,
a n d li n gual ar t e ri e s w e r e t i e d s t oppi n g all p ul s a t ion

,
A ft e r ab ou t a .
w e e k th e pul s a t ion r e app e ar e d a n d co ul d b e con troll e d by pr e s s ur e up o n

th e caro t i d o f th e O pp o s i t e s i d e an d th e co m m on caro t i d o f t h a t s i d e
,
wa s al s o t i e d T h e wall s o f th e t u m o r we r e v e ry th in a n d d uring a
.
,
t e m p ora ry ab s e nc e o f th e O p e ra t or yi e l d e d t o ulc e ra t ion cau s i n g h ae m

, ,
o rrh a g e in t o t h e fauc e s ; t h i s w a s con t rol le d by plugging t h e s a c but ,
t h e pa t i e n t d i e d o f s e p tic poi s o n i n g a fe w d ay s la t e r He h a d in t e n d e d .
,
i n ca s e o f s uc h an acci d e n t t o d ivi d e th e j aw e xpo s e t h e t u m or a n d

, ,
app ly liga t ur e s t o bo th e n d s th i s la t te r O p e ra t ion s h oul d b e a pri m ary

o n e ,wi t h o u t wai t ing fo r o t h e r m e th o d s t o fail .
A VA N D E R VE E R M D ( Albany N
.
, . .
,r e la t e d a c a s e of an e uri s m
,
.
o f t h e i n t e r n al caro ti d appar e n tly cur e d by co m pr e s s ion t h e p a ti e n t ,
d yi n g n o t long a ft e r o f s e e m i n g ap op le xy —
, , P r oceea i ng s A m S ur e.
’
.
Ass
’
n . 1 886 .
J . E . I LCH E R
P (U . 8 Arm y)
. .
1 66 I N D E X OF S U R GI CA L P R o C R E S S .
V . n t o f T e l e a n g i e c t a s i a By Dr BO E i N t :
O n t h e T r e at m e . .
N rd i n g e n ) T h e fo l lo wi n g e th o d o f t r e a t ing t e l e angi e c t a s ia i s
( e . m
r e co m m e n d e d by t h e au th or wh o h as appli e d i t in a nu m b e r o f ca s e s ,
wi th a s t o ni sh i n g s u cc e s s T h e t u m or inclu di n g th e s urroun di n g s ur
.
fac e fo r abou t 2 m m i s p ai n t e d on c e d aily fo r four con s e cu t iv e d ay s

.
,
wi th a 4 p c s olu t io n o f s ubli m a t e collo diu m un til a wh i te lay e r abou t

. .
-
,
1 m m th i ck h a s for m e d
. .
Ca s e I A n gio m a in th e m i dd l e of th e l e ft inn e r e dg e o f th e s cap

.
u la 1 5 m m
,
lo n g an d 1 1 m m wi d e d ark brown a n d e l e va te d abou t
. .
,
m m ab ov e th e h e al thy s ki n
. Two applica tion s w e re m a d e On . .
t h e s ix th d ay th e collo d iu m lay e r h a d loo s e n e d i t s e l f abou t th e p e ri
h e ry an d w a s r e trac t e d l e avi n g a s uppura t i n g ri n g ab ou t 2 m m in

p , .
wi dth Two d ay s la t e r th e s cab wa s r e m ov e d wi th ou t pai n O n th e

. .
s uppura t i n g granu la t ing s ur fac e th u s e xp o s e d no s i g n s o f an y d ila t e d

, ,
v e s s e l s w e r e s e e n Dr e s s ing s o f b o r am ylum
. Ci ca triz a tion co m p le t e .
in s e v e n d ay s T h e p a t i e n t wa s a d e lica te b oy o f 7 m o n th s o f ag e
.
,
b u t S h ow e d n o r e act ion fro m th e t r e a tm e n t .
In a s i m ilar m ann e r th e au th or tr e a t e d an a n gio m a 2 4 m m lo n g 1 5 .

,
m m . br o a d a n d e l e va t e d 3 m m ab ov e th e niv e au o f th e S ki n si tua te d .
,
i n th e m i ddl e of th e th ir d S pinal v e r t e bra in a ch il d 9 m on th s o f age , .
F o ur applica t io n s w e r e m a d e R e s ul t s a t i s fac t ory in e v e ry way

. In a .
th ir d c a s e b u t t w o applica t i o n s w e r e m a d e th e an gio m a t h e s iz e o f a ,
i o c e n t pi e c e abou t
-
b e i n g si t ua t e d in th e m i ddl e o f th e for e h e a d
, .
Cica triz a ti o n follow e d in four t e e n d ay s wi th ou t r e action T h e four th .
ca se wa s an a n gio m a on th e e d g e o f th e righ t larg e labiu m in a girl 6

m on th s o f age T h e tr e a t m e n t wa s m uch c o m plica t e d h e r e by t h e
.
c o n s t a n t w e t ti n g o f th e p ar t s wi th urin e r e n d e ring th e h e alin g proc e s s ,
sl ow . T h e r e s ul t h ow e v e r was e n t ir e ly s a t i s fac t ory a s wa s al s o t h a t

, , ,
i n t h e au th or s fi fth ca s e
’
.
T he c o n trac tion of th e cicat rix i n th e s e ca s e s wa s v e ry s ligh t wh ich ,
fac t s h oul d r e co m m e n d t h i s m o d e o f t r e a tm e n t e s p e cially in ca s e s o f
an gio m a o f th e fac e By th orough ly co v e ring th e s u rroun di n g s ur fac e

.
o f s ki n by collo d iu m b e for e t h e s olu t io n i t s e l f i s appli e d li t tl e or no ,
pai n wi ll b e pro d uc e d i f car e b e t ak e n Th e s olu tion u s e d was th e

,
fo ll o wi n g : R H ydrarg b ic h lor cor , c o llo di i . Fo r cl e an s . .

,
H E AD AN D N E C R .
167
i ng an d pr e s e rvi n g th e bru s h e s e th e r sh oul d be u se d —D eu tscfi . M ea ’

.
Woc/zen . NO . 1 7 . April 2 9 1 8 8 6 , .
C . CO LL E S ( N e w Yor k) .
H EA D AND N E CK .
I . On C o m p re s s i o n By Pro f E R N S T VO N
of th e B rai n . .
B E R G MANN ( B e rlin ) I n th i s ar ticl e th e d i s tingui sh e d e xpon e n t o f th e

.
s ubj e c t of tr au m at ic in tr a cranial pr e s s ur e vi n di ca t e s h i s th e ori e s

again s t c e r t ain m o d e rn au th or s wh o ar e e n d e avoring t o ov e r th row th e
old t e n e t s—m or e e s p e ci ally again s t A d a m ki e wicz o f Cracow .
R e fe rring ca s ually t o th e prac t ical r e s ul t s r e c e n t ly ob t ain e d by a d
h e ring t o th e o ld d oc trin e a s in s t anc e d in t h e publica t ion o f Wi e s

,
m ann ( A NNA L S Vo l I I , P wh e r e i t i s S h own th at t w e n ty o u t o f

. . .
th e t w e n t y two ca s e s w e r e s av e d by ti m e ly O p e ra t iv e in t e r fe r e nc e th e
-
.
a u th or proc e e d s t o d i s cu s s th e p h y s ical p oin t s b e aring upon th e qu e s
t ion O f brain pr e s s ur e .
A d a m ki e wicz h ad a s s e r te d th a t th e brain was c om pr e s s ibl e a n d th a t

co m pr e s s ion o f i t s s ub s t anc e pro d uc e d th e s y m p to m s o f in tracranial
pr e s s ur e To th i s th e a u th or m ak e s th e following r e ply
. .
T h e brain s ub s t anc e prop e r po sse s se s p h y s i cally s p e aking a c o m , ,
p r e s s i b i li t
y av e raging b e t w e e n t h a t o f wa t e r a n d t h a t o f gla ss wh ich ,
s o m e wh a t approxi m a t e s t o t h a t o f a 4 6 m illion th p ar t o f i t s origin a l -
volu m e But to e ffe c t a co m pr e s sion e v e n in th i s d e gr e e a far gr e a t e r

.
, ,
a m ou n t o f forc e woul d b e n e c e s s ary t h an th e cranial cavi ty coul d wi th

s t an d .
I t was n o t p e r m i s s ibl e t o con foun d co m pr e s s ibi li ty in i ts p h y s ic a l

se n s e wi th e xpr e s s ibili t y a s A d a m ki e wicz h a d d on e w h ic h la t te r wa s
, ,
prop e r ty b e longi n g to s pong e s an d s h ar e d by th e brain .
W h e n th e bloo d con t ain e d in th e capillari e s o f th e brain i s d riv e n

o ut by pr e s s s ur e a s th e wa t e r i s forc e d o ut o f t h e p or e s o f a s a t ura t e d
,
s po n g e by s qu e e zin g t h e brai n lo s e s i t s nouri s h m e n t a n d i t s func t ion

,
b e co m e s i m p air e d T h e e ffe c t o f s uch i m p airm e n t o f nu tri tion upon the

.
n e rv e c e n t r e s i s fir s t irri t a tion a n d s ub s e qu e n t ly p araly s i s

-
.
Th u s th e p ul se fo r in s t anc e i s fir s t r e n d e r e d l e s s fr e qu e n t in
, ,
co m pr e s s ion o f th e brain by irri t a tion o f th e pn e u m o ga s tric n e rv e

,
-
,
a n d s ub s e qu e n t ly i t b e co m e s m or e fr e qu e n t w h e n para ly s i s O f th e vagu s
occur s .
r6 8 I N D E X OF S UR GI CA L P R O GR E S S .
The ch anical ac tion in co m pr e s s ion o f

m e th e brain th e r e for e d o e s
, ,
not ac t ually d i ffe r fro m progr e s siv e an ae m ia of t h e brai n i n d uc e d b y

,
o th e r con di tion s .
A d a m ki e wicz obj e c ting t o th i s th e ory th a t th e t e n s io n o f th e li quor ,
c e r e bro s pi n ali s coul d n o t b e incr e a se d b e yon d i ts n a t ural low t e n s ion

-
,
b e cau s e in th e fir s t plac e i t wa s o f th e na t ur e o f a t ran s u d a te an d

, ,
‘
coul d n o t acquir e a h igh e r pr e s s ur e th an e xi s t e d in th e capillari e s fro m

wh e nc e i t tran s u d ate d an d s e co n d ly th e e xi t s a ffor d e d t o th e c e r e bro
, ,
S pinal liquor w e r e alway s availabl e — th e au th or r e fu t e s b o t h t h e s e
propo s i tion s at l e ng th quo ting N a un yn an d S ch r e ib e r a n d Lan d e re r in

,
s upp or t of hi s a s s e r tio n s .
Dir e c t m e a s ur e m e n t s o f th e e xi s ti n g pr e ss ur e i n s i d e o f th e S pac e O c
c up i e d by th e c e r e bro s pi n al liquor prov e d th e t e n s ion t o b e gr e a t e r
-
th an th a t o f t h e capillari e s T h e e xp e ri m e n t s w e r e p e r for m e d upon a n

.
in fan t s u ffe ring fro m S pi n a b ifi d a .
By co n ti n u e d forcibl e m anual co m pr e s s ion o f th e t u m or i t w a s i n ,
fac t po s s ibl e t o ob t ain t h e co m pl e t e s e ri e s o f s y m p t o m s oc c urring i n

,
’
t rau m a t ic co m p r e s s io n o f th e brai n inclu di n g S t ok e s r e s pira t ory p h e
,
nom e non .
Al th oug h g ivi n g A d am ki e wicz d ue cr e d i t for h i s e xp e ri m e n t s on

localiz e d pr e s s ur e by th e in tr o d uc tion o f la m i n ari a t e n t s in t o th e
cranial cavi ty t h e au th or p oin ts o u t th a t h e n e v e r d e ni e d local al t e ra
,
t ion s in t rau m a tic co m pr e s s ion s o f t h e brain b u t a s se r t s t h a t t h e g e n ,
e ral s y m p t o m s ar e pro d uc e d by m e a n s o f g e n e ral p r e s s ur e T he e x .
e ri m e n t s o n v e nou s pr e s s ur e p e r for m e d by A d a m ki e wi cz a r e cri tici s e d

p ,
a n d th e opp o s i t e r e s ul t s O b t ai n e d by Cra m e r a n d Mo s s o up h e l d
, , .
As for t h e a s s e r tion th a t th e c e r e bro S pinal liquor h a s s u ffici e n t o u t

-
l e t s t o pr e v e n t a high t e n s ion occurring i t i s r e fu te d by th e au th or by ,
analogy wi th hyd roc e l e a s ci t e s e tc in wh ich ca s e s th e in t e rnal pr e s s

, ,
.
,
ure i s h ig h a n d t h e ly m p h a t ic s ys t e m o f d rainag e i s pa th ologically
al t e r e d .
The p ap e r r e pr e se n t s a valuabl e a dd i tio n t o th e for m e r w e ll known -
work s o f th e au th or on th e s ubj e c t an d an e s p e cially in te r e s ting o n e in

, ,
s o far a s i t co n t ai n s r e fe r e nc e s t o th e la te s t a d vanc e s in clo s e ly r e la t e d

H E A D A N D N E CR 1 69
s ubj e c t s — A r é ezt en a us K on ig ] Un i o er s B e r li n
’ ’
o e r cb i r K li n i k
. . o er . . .
I . Th . I .
W W . . VA N A R S D AL E (N ew Yor k) .
II . T ra u m at ic A ph as i a
b y H e m ip le gia , F ollow e d
T re p h i n i n g : D e ath By Pro f R FR ASE R Pa ti e n t a publican
. . . .
, .
ac t 44 fe ll i n t o a c e llar a n d r e c e iv e d a s e v e r e b low on l e ft S i d e o f for e

.
,
he ad S t un n e d for t e n m i n u t e s an d wa s t h e n carri e d h o m e
. Le ft .
fro n t al r e gi o n m u c h b rui s e d an d an inci s e d woun d O v e r le ft e y e brow ,

.
S p e e ch i n d i s ti n c t Walk e d o u t on th e se con d d ay b u t r e turn e d h o m e

.
,
unab le t o s p e ak an d vo m i te d O n th e follo wing d ay h e coul d s p e ak

, . .
b u t w a s gi ddy D uri n g n e x t s e v e n w e e k s s u ffe r e d fro m fr e qu e n t p ain

.
in le ft S i d e o f for e h e ad an d h a d m a n y a t t ack s o f s u dd e n fain tn e s s an d

,
gi d di n e s s S p e e ch o fte n i n di s ti n c t M e m ory fo r wor d s b e ca m e gr e a tly

. .
i m p air e d N O h i s t ory o f syp hili s On a dm i s s ion t o R oyal Infi rm ary h e

. .
co m plai n e d o f s lig h t pain in l e ft fron t al r e gi on an d di s t inc t t e n d e rn e s s , .
In di s tinc t ci ca trix ov e r l e ft e ye bro w N O paraly si s T e m p Un . . .
d e r s ta n d s e v e ry th i n g s ai d t o h i m a n d an s we r s s e n s ibly Ca n no t na m e ,
.
a r t i c le s pr e s e n t e d t o h im b u t r e cogniz e s th e ir n a m e s Can wri t e b ut

, .
,
”
S p e lli n g i s e n t ir e ly a t faul t T h u s h e ca ll s a kni fe a nob a n d th e n .
, ,
” ”
wri t e s i t s otp a W h e n a sk e d t o wri t e I will co m e h e wro t e I f
.
“
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h ay h goo d th e n s t opp e d S h ook h i s h e a d an d s ai d i t w as wron g
, , , .
Can copy corr e c tly an d u n d e r s tan d s wri tte n la n guag e D e ci d e d im

, .
p air m e n t o f ri gh t s i d e ca m e on Co m p lai n e d o f pin s a n d n e e dl e s .
in righ t h an d M e m ory fo r n a m e s qui te ab s e n t

. .
H e m ipl e gi a b e ca m e al m o s t co m pl e t e Pupil s un e qu al— e vacu ation s .
pa s se d involun t arily O p ti c d i s c s p al e Con tr ac tur e o f fl e xor s o f righ t

. .
e lb ow B e ca m e s e m i co m a t o s e
.
- .
H e was now t r e p h in e d ov e r l e ft i n fe rior convo lu tion O n op e ning .
d ura m a t e r n o th in g abnor m al coul d b e se e n no S ign s o f infla m m a t ion

, ,
o f t h e m e m br an e s an d n o a ccu m ul at ion o f p u s or o th e r fl ui d
,
A fi ne .
ca t arac t kni fe wa s in tro d uc e d in t o brai n s ub st anc e in th r e e dir e c t ion s ,
b u t no p u s wa s foun d Woun d clo s e d an d d r e s s e d an ti s e p t ic ally N o

. .
i m prov e m e n t in con di tion T e m p e ra t ur e ro s e t o 1 0 7 th r e e d ay s a ft e r .

°
op e ra ti on an d p a ti e n t di e d N e crop s y M e m bran e s o f brai n h e al th y

, . . .
Co n volu t io n s e s p e cially on l e ft s i d e fl atte n e d Tr e p hin e woun d i m

, ,
.
I 7O I N D E X OF S UR GI CAL P R O GR E S S .
m ed ia te ly ov e r co m m e n c e m e n t o f S ylvi an fi s s ur e B e n e a t h woun d .
w e r e s e v e ral s m all e cc hy m o se s o f r e c e n t origi n th e s urrou n d i n g brain ,
t i s s u e b e ing p al e an d appar e n tly abnor m al O n r e m ovi n g th e brain

.
,
th e l e ft h e m i s p h e r e b u t e s p e cially t h e t e m poro s p h e n oi d al lob e wa s

,
-
,
p al e an d s woll e n an d d e ci d e d ly larg e r th an th e righ t T h e la te ral

, .
v e n tricl e s w e r e d ila t e d an d co n tain e d an e xc e s s o f cl e ar s e ro us fl ui d .
On se c tion i m m e d ia t e ly th roug h c e n tr e o f t r e p h i n e wou n d th e w h ol e O f

th e t e m p oro s p h e n oi d al lob e wa s s e e n t o b e o ccupi e d by a larg e glio m a
-
a n d s urroun d i n g s o ft e ni n g ; th e t u m or s e x t e n d e d b ackwar d s a s a uni
for m infil t ra t io n as far as t h e li m i t o f t h e po s t e rior b on e o f t h e la te ral
v e n tricl e I t h a d inva d e d Broca s convolu tio n an d th e a dj ac e n t par t s

.
’
,
'
o f t h e a s c e n d i n g fron t al an d p ari e t al convolu t ion s I m m e d i a t e ly b e .
n e a th th e s up e rficial e cch y m o s e s in Broca s convol ution th e r e wa s a ’
r e c e n t h ae m orrh ag e ab ou t th e S iz e of a walnu t A s m all n o d ul e o f t u .
m o r o f a s i m ilar na t ur e a n d a s big as a c h e rry was s i t ua t e d in t h e

, ,
righ t h e m i s p h e r e a t th e m i dd l e thir d o f th e a s c e n ding pari e t al c o nv o lu

t io n — La n cet Feb 2 7 . 1 886 . . .
111 . T o R e m o v e F o re i g n B o d i e s F r o m t h e E ar s By JO .
NA TH AN H U T C H I N S O N Mr H u t c h in s o n r e co m m e n d s th a t a
, .
s ilv e r wir e loop s h oul d b e u s e d in s t e a d o f e i th e r forc e p s or s co op

-
He .
s ay s h e n e v e r u s e s e i th e r o f t h e la tt e r in s tru m e n t s h a s al wa y s f oun d ,
th e wir e loop m o s t s ucc e s s ful

-
I t i s i m p o ssibl e fo r i t t o inj ur e th e
.
m e m bran e or ca n al A fte r h aving p u t th e p a ti e n t un de r an an e s th e tic

.
,
th e loop i s in tro d uc e d g e n tly in t o th e e a r an d t urn e d abo u t till i t i s b e
li e v e d t o b e b e h in d th e for e ign b o dy T hi s o fte n r e quir e s a li ttl e ti m e

.
an d p a t i e n c e — B r i t M ea j ou r n April 1 0 1 8 8 6
’
. . . . . .
IV . Al ve o lar Abs ce s s W ith T h r o m b o s is of C a v e r n o u s

S inus By PE A R CE GO U L D
. Pa t i e n t a wo m an ae t 5 7 was
, ,
.
,
a dm i tt e d in t o th e T e m p e ranc e H o s pi t al wi th th e m ou th a n d t e e t h i n a
foul s t a t e a s lough y op e n i n g wa s s e e n in c e n tr e o f rig h t c h e e k An .
inci s ion was m a de in t o th e ti s s u e s o v e r th e j aw fro m th e ou ts i d e w h e r e ,
fl uc tuation wa s d e t e c te d ov e r th e lo we r par t o f m a s s e t e r t h e s we lling

’
o f fac e s ub s i d e d a li t tl e a ft e r th i s b u t th e p a ti e n t s g e n e ral co n di t i o n
,
r e m ain e d v e ry un s a ti s fac t ory S ix m olar t e e th w e r e e x trac te d a n d a

. ,
H E A D A N D N E CR 1 7I
“
prob e p a s s e d th rough e x te r n al O p e ni n g d e t e c t e d b ar e bon e F o ur d ay s .
a fte r th e e x trac tio n o f t e e th an ab s c e s s app e ar e d ab ov e e x te rnal angu

lar pro c e s s o f orbi t a n d a n o th e r in po s t e rior t ria n gl e O f n e ck b u t e x ,
t e rn al j ugular wa s n o t th ro m bo s e d Pa t i e n t b e ca m e d row s y ; gr e a t .
oe d e m a o f th e orbi t wi t h s o m e p t o s i s o f rig h t an d l e s s o f le ft A s th e nia .
incr e a se d S o m e rigor s conj unc tiv ae y e llow a n d m o ti on s colorl e s s

.
, , .
B e ca m e c o m a t o s e d an d di e d N e crop sy— s e v e ral glob ular ab s c e s s e s

.
w e r e fo un d in lun g s wi th d e n s e wall s an d n o s ign s O f a dj ac e n t i n fl am ,
m a t ion Liv e r e nlarg e d a n d fa t ty ki d n e y s h e al th y

. N e cro s i s o f o u te r .
p ar t o f righ t S i d e o f low e r j aw ; t e m poral m u s cl e di s color e d b ut n ot ,
act ually purul e n t Ly m p h was d e t e c te d alo n g b a s ilar pro c e s s o f o c c ip

.
i t al b on e an d s e lla Turcic a R igh t cav e rnou s s inu s gr e a tly d i s t e n de d

.
,
an d con t ain e d gr e yi s h y e llow brok e n d own p us a n d clo t s ; ri g h t o p h

-
th a lm i c v e in S i m ilarly a ffe c t e d an d th e circular s inu s wi th th e s up e rior

,
p e tro s al on th e ri g h t In fe ri or p e tro s al an d la t e ral s inu s e s h e al th y

. .
Le ft cav e rn ou s s inu s con t ain e d a clo t o f w h ich th e inn e r par t was ye l ,
low — La n cet M arch 2 7 1 8 8 6

. . .
H H T AYLO R ( Lon d o n ) . . .
V . R em o val T u m o r of t h e B ra i n
of a By O H I R S C H . .
F E L D E R M D ( S an F ran c i sc o) A m an act 3 2 ab ou t e igh te e n m on th s

,
. .
,
.
,
.
,
pr e vi ou s ly b e gan t o s u ffe r fro m p ain in th e h e a d in th e e arly m ornin g

,
h o ur s wi th occa s ional d izzin e s s d uring th e d ay ; n e x t S ligh t b u t pro ,
g r e s s i v e lo s s o f pow e r i n t h e l e ft le g a n d arm ; th e e y e s ig h t gr e w d im
an d a m auro s i s b e ca m e n e arly co m pl e te ; h ad occa s io n al e pil e p ti for m
s e iz ur e s irr e gular in o ccurr e n c e d uring wh i ch h e r e m ain e d con s cio u s

, ,
a n d w h ic h b e gan ab ou t th e s a m e t i m e a s th e h e a d ach e s wi th s p a s m s ,
an d j e rking s o f t h e m u s cl e s o f t h e l e ft s i d e Ph y s ical e xa m i n a t ion .
s h ow e d t h e le ft lab i o na s al fol d ob li t e ra t e d a n d th e l e ft a n gl e o f th e
'
m ou th d rooping w h e n clo s e d a n d m or e on s h owing t h e t e e th

, , p ar e ,
S i s o f b o th upp e r e x t r e m i t i e s wi th s t r e ng th o f l e ft h a n d s lig h tly d i m in

,
ish e d an d lo s s o f m u s cular s e n se i n l e ft upp e r e x tr e m i t y a n d l e s s in

,
t h e low e r ; S lig h t an ae s th e s ia o f th e t e rm i nal branc h e s o f t h e trig e m inal
n e rv e on th e l e ft S i d e b u t s e n s a t ion nor m al in upp e r an d low e r e x tr e m

i ti e s of b o th s i d e s t e n d on r e fl e x incr e a s e d on b o th S i d e s e sp e cial ly th e ,
l e ft s triking b e low e i th e r p a t e lla c a u s ing c on trac t ur e o f th e m u s cl e s on

,
1 72 I N DE X OF S UR GI CA L P R O GR E S S .
th e oppo s i te s i d e ; h e t o tte r e d on s t an d ing wi th th e e y e s clo s e d Th e .
e y e s pr e s e n t O p t ic n e uri t i s wi th a t rop h y th e ar t e ri e s b e ing v e ry s m all

,
a n d t h e rig h t e ye l e s s a ffe c t e d th an th e l e ft wi t h h o we v e r black pig , , ,
m e n t in th e c e n t e r o f th e m acula lu t e a T h e h e a d ach e v e r tigo vo m i t

.
, ,
i n g unila t e ral p araly s i s a n d a t rop h y o f th e O p t ic n e rv e s poin t e d t o a

,
n e opla sm wi th in th e cranial cavi ty ; th e e pil e p t ic an d e pil e p t i for m s e iz
ur e s occurri n g wi th ou t lo s s o f con s ciou s n e s s poin t e d t o a cor tical s e a t ,
for th e grow th i t wa s e vi d e n t t h a t t h e m o t or c e n t e r s abou t th e s ulcu s
o f R olan d o o f th e rig h t s i d e m u s t b e th e s e a t an d fro m t h e fac t th a t th e
fac e arm an d le g c e n t e r s app ar e n t ly w e r e a ffe c t e d th e m i dd l e por ti on

, ,
was s uppo s e d wi th c e r t ain ty t o b e involv e d i t h avi n g b e e n foun d th a t
th e se a t o f s e n s a t ion e xi s t s i n th e p ari e t al lob e s o f t h e brain th e a n ae s ,
th e s i a o f th e l e ft h al f O f t h e fac e i n d ica t e d th a t th e n e opla s m w a s lo
c a t e d in th e m i d d l e O f th e gyr u s p o s t c e n t rali s S yp h ili s b e ing e xclu de d .
by h i s t ory an d t r e a tm e n t thr e e b u tt on s o f b on e w e r e r e m o v e d wi th th e
,
tre p h in e an d un d e r t h e d ura m a t e r wa s foun d a gh o m a wh i c h pro t ru d e d

, ,
ab ou t on e h al f inch an d wa s r e m ov e d in p ar t i t b e ing d i fficul t t o s e p ,
ara t e i t e n tir e ly fro m th e h e al th y brain ti s s u e T h e s y m p t o m s w e r e .
S ligh t ly am e liora t e d by th e O p e ra tio n b u t th e p a t i e n t gr e w wor s e a n d

, ,
s e v e n d ay s la t e r d i e d T h e au th or a ttrib u t e s t h e un favorabl e r e s ul t
.
t o th e fac t th a t th e s o ft glio m a wa s co n t inuou s wi th t h e a dj oini n g brain
t i s s u e s o th a t i t s co m pl e t e se p ara t ion was i m p o s s ibl e wi th o u t t h e d e
s t ruc t io n o f a l arg e por t ion o f th e c e r e bru m H a d i t b e e n a h ar d t u

.
m or th a t coul d h av e b e e n r e a d ily i s o la t e d i t i s v e ry probabl e th a t t h e

,
p a ti e n t woul d h av e r e cov e r e d —P a c ifi c M d a n d S u rg f ou r 1 8 8 6 . . . .
April .
VI n u cl e at i o n w ith T ra n s p l a n t at i o n an d R e i m p l a nt a
. E
t ion of E y e s By C H M AY M D ( N e w Y ork ) A ft e r a running

. . .
, . .
,
.
h i s t ory o f th e op e ra tion a s appli e d t o th e h u m a n b e i n g S h owi n g fo ur ,
o ut o f fi v e ca s e s t o h av e b e e n failur e s t h e wri t e r proc e e d s t o giv e a

,
de t ail e d accoun t o f t we n ty four e xp e ri m e n t al op e ra t ion s up on rabbi t s

-
,
fro m wh ic h h e conclu d e s th a t th e O p e ra t io n i s a p e r fe c t ly fe a s ibl e o n e ,
all th o s e ca s e s i n wh ich a b an d ag e coul d b e k e p t o n th roug h ou t th e

t r e a t m e n t b e ing s ucc e ss ful a s t o s iz e c on for m i ty a n d t e n s ion t h e cor
, , ,
n e a r e m ai n i n g h azy h o we v e r — I V Y M ea R ec May 2 9 ’
, . . 1 886 . . . . .
[AM E S E . Pi LC H E R , (U . 5 . A rm y) .
H E A D AN D N E CK .
1 73
VI I . i n a l R e s u l t s o f t h e O p e r a t i o n fo r C a n c e r
O n th e F
o f t h e Li p By Dr A W O E R N E R ( T ubing e n ) In th e T ubing e n
. . . .
S urgic a l Clinic n o l e s s t h an 2 7 7 op e ra t ion s for labial canc e r s h av e b e e n
p e r form e d o f all o f wh ich th e au th or h as b e e n abl e t o ob t ain r e c e n t

,
h i s t ori e s T h i s s ubj e c t m atte r h e m ak e s u s e o f for s tati s ti cal c on s i d

.
-
e ra ti on s in th e pr e s e n t p ap e r T h e t o t al n u m b e r o f ca s e s o f labi a l
.
canc e r a dm i tte d t o th e h o s pi t al a m oun t e d t o 3 0 5 b u t 2 8 of th e s e w e r e ,
inop e r abl e .
The e n t ir e nu m b e r o f ca se s i s con de n se d in t abul ar for m an d ,

oc
c u p i e s fi ft y th r e e p ag e s — m or e t h an h a lf o f th e nu m b e r cov e r e d by
- th e
e n t ir e ar ti cl e .
S e v e ral sm all e r abular syn op s e s r e pr e s e n ting di ffe r e n t s t a ti s tical

t
poin t s o f in t e r e s t a re di s t rib u t e d t h roug h o u t t h e p ap e r an d ch ar ts ,
b e ar wi tn e s s o f th e d ilig e nc e wi th w h ic h th e s t a t i s t ic s h av e b e e n c o m
pil e d.
A fe w o f th e fi gur e s giv e n m a y b e m e n t ion e d h e r e .
Nin e ty an d o f t h e nu m b e r e ffe c t e d w e r e m al e s T h e m o st .
fr e qu e n t a g e wa s b e t w e e n 6 5 a nd 7 0 Ni n e ty p e r c e n t w e r e e xpo s e d t o
. .
inj uri e s a n d th e incl e m e n ci e s o f th e w e a th e r Of 6 9 m en 5 1 w e r e .
m e n tion e d a s s m ok e r s 1 8 a s non s m o k e r s
,
Inj uri e s w e r e b e li e v e d
-
.
t o cau s e t h e m a la d y in 1 1 ca s e s .
O f th e 3 0 5 ca s e s 2 8 9 canc e r s w e r e S i t ua t e d on t h e un de r li p a n d
,
-
,
only 1 6 or 5 2 % on t h e upp e r on e
,
. .
T h e O p e ra t ion g e n e rally co n s i s t e d in cun e i for m e xci s ion o f th e t u m or
2 2 4 ca s e s la i c p ra ion w r p r or ix y nin i
( ) P s t . O e t s e e e f m e d s t e t m es - .
O f th e 2 7 7 ca s e s O p e ra t e d upon in th e clinic 1 1 1 in divi d ual s w e r e

a tt ack e d by r e curr e nc e s o f th e di s e a s e an d s o m e r e p e a t e d ly , Th e s e .
r e curr e nc e s g e n e rally t o ok plac e wi th in th e fir s t y e ar .
As r e gar d s th e r e s ul t s o f th e op e ra tion th e m or t ali ty a m oun te d t o

p e r c e n t O nly t h r e
. e o f t h e s e ca s e s h ow e v e r b e lon g t o t h e a
,
n ,
t i se p t i c p e ri o d M o s t o f th e d e ath s w e r e d u e t o a d vanc e d ag e an d
.
se v e r e s urgical op e ra t i on s s uch a s th e r e m oval o f th e m axilla

,
.
T h e a v e rag e l e n g t h o f t i m e th a t t h e p a ti e n t s con t inu e d t o liv e a ft e r
r e co ve ry wa s y e ar s Six p a ti e n t s liv e d t o b e ov e r 8 0 .
Taking th r e e y e ar s a s an a m pl e p e rio d for r e curr e nc e s t o d e v e lop ,

1 74 I N D E X OF S UR GI CA L P R O GR E S S .
1 06 ca se s w e r e co m pl e te ly cur e d or p e r c e n t o f th e w h ol e
, .
nu m b e r .
T h e au th or finally a dd s s t a t i s ti c s ob t ain e d fro m th e e n tir e nu m b e r
o f O p e ra t e d labial c an c e r s h e r e t o for e p ubli sh e d wh ic h i s 8 6 6 , .
T h e r e s ul ts o f th i s co m pari s on a r e v e ry s i m i lar t o th o s e ob t ain e d
fro m th e T ii b in g e n Clini c —B e i t r ag e z u r K li n C/zi r M i tt/z a us de r . . .
cfi i r K li n i R z u Tub i ng en I I Bd 1 H e ft V
’
. . . . . . .
VI I I I n t r a c a p s u l a r E x t i r p at i o n o f T h y r o i d C y s t s
. On .
By Dr E U G E N M U E LL E R ( Tubing e n) T h e a u th or publi sh e s e igh t

. .
ca s e s in which Pro f Brun s o f T ubi n g e n e nucle a t e d th yroi d cy s tic

.
, ,
t u m or s th i s m e th o d o f O p e ra t ion b e i n g pr e fe rr e d s i n c e th e in tr o d uc tio n
,
O f th e an ti s e p t ic m e th o d t o inj e c t ion O f t inc t ur e o f io d in e an d t o i h ,
c i s i on O f th e cy s t .
Th e op e ra t ion con s i s t s i n inci s i ng th e cap s ul e o f th e gla n d a n d t h e n
d i s s e c ting o u t th e cy s tic t u m or wi th i ts s a c e n tir e by m e an s o f b lun t ,
in s tru m e n t s an d wi th ou t i nj uring th e s a c T h i s O p e ra t ion can b e p e r

, .
for m e d ih fi ft e e n m i n u t e s an d fr e qu e n t ly no v e s s e l s e xc e p t th o se d i
,
v i d e d by th e fir s t inci s ion h a e t o b e liga t e d v .
T h e au th or co m p ar e s th i s O p e ra t ion wi th th e ol d e r on e s o f i nj e c ti o n
an d inci s ion an d p oin t s o u t i ts a d van t ag e s ; i t i s th e l e a s t d a n g e rou s

,
m o s t c e r t ain an d quick e s t m e th o d o f t r e a t i n g cy s t s o f th e th yroi d T h e

,
.
cr e d i t o f h avi n g r e co m m e n d e d i t i s giv e n t o j ulliar d .
T h e O p e ra tion i s n e x t d e s crib e d in d e t ail a n d a r e vi e w o f th e r e s u lt s

‘
h i th e rt o ach i e v e d by m e an s o f th e e n u e le a ti on m e th o d by j u lliar d ,
Bu c kh ard t Wo lff an d Br un s giv e n

, ,
.
In th e th ir ty th r e e ca s e s co n s i d e r e d th e t u m or s vari e d in S iz e fro m
-
th a t o f a pig e on s e g g t o a c h il d s h e a d T h e woun d s h e al e d m o s tly

’ ’
.
by fir s t in te n ti on wi th ou t any ou t war d occurr e nc e a n d on th e av e r

, , ,
a ge in th ir te e n d ay s —B ei t r ag e z u r K li n C /zi r IlI i tt/z o u r a e r

, . .
/ .
’
cb i r [ ( Z i n iR z u Tizb i ng en I I Bd 1 H e ft I II
'
. . . . . . .
W W VA N A R S D A LE ( N e w Y o k ) . . r .
CH E S T AND ABD O M E N .
I . o re i g n
F B o dy in t h e CE s o p h a g u s . By A . G GE R S. TE R , M .
D .
, ( N e w Y ork) . A ch il d , 1 2 m on th s o ld , pr e se n t e d no h i s t o ry of
C H E S T A N D A B D OM E N .
1 75
h avi n g wa llow e d an y for e ign b o dy b ut s u ffe r e d fro m incr e a s ing di ffi

s .
cul t r e s pira tion wi th occa s ional aggrava t e d p aroxy s m s o f d y s pn oea

, ,
c h i e fly e xpira t ory—th e r e b e i n g b u t li ttl e di fficul ty in in s pira t ion—o f

S ix m on th s d u r a tion An e xplora t ory trach e o t o m y fail e d t o i m prov e
.
th e r e s pira t io n a n d on e xplora t i on wi th a s o ft rubb e r ca th e t e r th e

, ,
tr ac h e a an d th e bronc h i s e e m e d t o b e cl e ar I t w a s ob s e rv e d t h at th e .
i n tro d uc ti o n o f a ca n ula in t o th e tr ach e a incr e a s e d th e di fficul ty of

r e s pir at ion b u t th e br e a th i n g b e ca m e e a s i e r wh e n th e m ou th o f th e
,
c an ula wa s occlu d e d by th e fi n g e r F ur th e r e xplora tion w as po s t .
p on e d b u t th e n e x t day pn e u m o n ia s e t in t e r m ina ting fa t ally in th r e e

'
, ,
d av s . O n a ut op s y a t rian gular d e fe c t o f th e t rach e a w

, a s foun d a li t
t le low e r th an m i d way b e tw e e n t h e cricoi d car tilag e a n d th e bi furca
t i o n o f th e t r a ch e a wi th a corr e s po n d ing d e fe c t ab ou t 1 c e n ti m e t e r i n
,
d ia m e t e r in th e oes op h agu s T h roug h th e s e O p e ning s a fl a t bra s s b u t

.
,
to n a c e n ti m e t e r an d a h a lf i n di a m e t e r proj e c t e d in t o th e t r a ch e a
, ,
ab ou t 3 m i lli m e t e r s ; t h e for e i g n b o dy w a s e m b e dde d in th e ti s s u e s

b e t we e n th e t rac h e a an d th e oe s op h agu s b e in g h e l d in p o s i ti on e x ,
ac tly lik e a p i c t ur e by i t s fra m e T h e ulc e ra tion h a d e vi d e n t ly t e r m i

.
h a t e d by co m pl e t e cica triz a t ion n o a c t iv e infla m m a t ion b e ing foun d

,
a t th e t i m e o f d e a t h a lt h oug h t h e t i s s u e s w e r e co n s i d e rably th i ck e n e d
,
by th e form e r i nfla m m a t ory proc e s se s T h e slowly progr e s s iv e ch ar .
ac t e r O f dy s p h agi a w as d u e t o t h e a d vancing cica t rici al con tr a c t ion o f
th e par t s T h e d i fficul t e xpira tio n a s co n t ra s t e d wi th th e co m p ara t iv e ly

.
,
e a s y in s pira t ion wa s d u e t o t h e s l an ti n g p o s i tion o f th e for e ign b o dy

, ,
givi n g i t th e ac t ion o f a valv e ; th e s tr e a m o f air ru sh ing up fro m b e low

h a d th e e ffe c t o f r ai s i n g up th e proj e c t in g e d g e o f th e b u tt on an d th u s
r e n d e ri n g i t m or e t ra n s v e r s e t o th e axi s o f th e t rach e a Al th ough th e .
u s e O f a m e t allic prob e i n s t e a d o f a s o ft ca th e t e r in e xploring th e ,
t rac h e a woul d h av e d e t e c t e d th e for e i gn b o dy i t coul d n o t h av e b e e n ,
e x t rac t e d fro m th e oe s op h agu s o n accoun t o f th e r i m , o f th ick e n e d t i s
s u e w h ich h e ld i t a n d h e d oub t e d w h e t h e r i n s t an t d e a th fro m

,
s u ffo c a
t i o n woul d n o t h av e b e e n pro d uc e d by an a t t e m p t a t r e m oval th ro ug h
th e t rac h e a —P r oceed i ng s I V Y S u rg S oc . 1 886 .Ap ril 2 6 . . . .
j A M E s E PI LCH E R ( U S Arm y) . . . .
I 76 I N D E X OF S UR GI CAL P R O GR E S S .
II . P rim r y C a n c e r o f L u n g —E xt e n s i o n
a to th e V e rte
b r al C o lu m n —P a r a p le g i a By M P M U S E LI E R . . . . T h e p a ti e n t in
thi s a d m i t te d i n t o L H Op i ta l N e ck e r
’
rare c as e was a wo m an , ae t .
75,
Aug .
4, 1 885 .
F or e igh t m on th s
u ffe r e d in te n se p ain s appar e n tly n e uralgic in
sh e s , ,
th e righ t arm a n d Sh oul d e r for wh ich v ariou s m e d ical m e n h a d p re

,
s c rib e d variou s r e m e d i e s ih vain .
Ab ou t e igh t d ay s b e for e sh e ca m e un d e r th e car e o f M Mu sc li e r sh e .
h a d h e r s e l f d i s cov e r e d a s m all s w e lling in t h e p o s te rior t ria ngl e o f t h e
n e ck T h i s was appar e n tly gl an d ular an d clo s e t o th e brac h i al

.
pl e xu s .
A S i m ilar b u t s m alle r t u m or e xi s t e d on th e o t he r s i d e
, , S lig h t .
p ain s w e r e occa sionally fe l t in th e Sh oul de r o f th a t ( th e l e ft) S i d e .
E igh t d ay s b e for e e n t e ring h o s pi t al S h e h a d cou g h e d up an e xp e c ,
t ora t i on w h ic h s h e h e r s e lf co m p ar e d t o re d curran t j e lly -

.
Au s cul tation r e v e al e d a z on e in th e m i d dle o f th e righ t ch e s t p os

t e ri orly wh e r e t h e r e s pira t o ry m ur m ur wa s ob s cur e
, .
On e w e e k a ft e r a dm i s s ion p ain s w e r e fe l t in th e l e ft ar m an d sh oul

d e r al m o s t a s s e v e r e a s th o s e in th e righ t T h e s a m e nig h t co m pl e t e .
paraly s i s b o th m o tor an d s e n s o ry a tta ck e d th e low e r e x tr e m i ti e s An

, , .
ae s th e s ia r e ach e d as h ig h a s th e s e co n d a n d fo ur th ri b s B o th p a t e llar .
r e fl e x e s s oon di s app e ar e d an d wi th in t w e n ty four h o ur s o f t h e p araly

, ,
-
ti c att ack a l a rg e s acra l b e d s or e for m e d

, T hr e e d ay s a ft e r ward s S h e
-
.
die d .
Au t op sy C anc e rou s no dul e s in th e upp e r a n d po s t e rior p ar t o f th e

.
ri gh t lung ; th e ir s iz e fro m th at o f a n u t to th a t o f an e g g ; th e ir n um
b e r fi ve or S i x
, Lung s ub s t anc e aro un d in t e n s e ly cong e s t e d
.
,
.
N o no d ul e s in th e l e ft lung Mo s t c ar e ful e xa m ina tio n o f th e oth e r

.
vi s c e ra r e v e al e d no th ing .
S pinal cor d e t c A t t h e l e v e l o f t h e j unc tion o f th e s e v e n th c e rvi cal

, .
v e r te bra wi th th e fir s t dor s al S ligh t a dh e s ion o f th e d ura m a te r to th e

,
in te rv e r te bral car tilag e T hi s car tilag e proj e c t e d s li g h tly in t o th e m e d

.
ullary canal Th e n e igh boring v e r te br ae a re e a s ily c u t wi th t h e kni fe

. .
Spinal cor d h ar d e n e d a t th e l e v e l o f th e c e rvical e nlarg e m e n t O ne O f .
th e a dj ac e n t v e r te bral b o d i e s was i nfil tra t e d wi th canc e r T h e s upra .
cl avicular t u m or s w e r e app ar e n tly c anc e rou s a n d on t h e rig h t s i de , , ,

CH E S T A N D AE D OM E N .
1 77
th e n e rv e s of th e br ach i al p le xu s w e r e in i mm e di ate con tact wi th the
u or
t m .
Th e u th or i s of opinion th at th e canc e rou s gl an d on th e righ t s i d e

a
e xci te d t h e p ain s in th e arm th at th e p arapl e gi a an d b e d s or e w e r e du e

,
-
t o pr e s s ur e of th e c an c e rou s no d ul e d e v e lop e d in th e v e r t e b r al b o d y
ac t in g s u dde nly on a S pin al cor d n ot pr e p ar e d for i t .
[ T h e se vi e w s s e e m a li ttl e d oub tful Gr e at p ain follow e d by p ara .
pl e gi a i s u s ual wh e n canc e r atta ck s th e v e rt e br al colu m n wh e th e r th e ,
affe c t e d n e rv e s are pr e ss e d on by glan d s or n o t I n th i s ca s e t o o th e .

, ,
righ t glan d wh ich wa s s uppo s e d t o b e pr e s s ing on th e n e rv e s e x e rci s e d ,
n o pr e ss ur e on th e n e igh b ori n g v e s s e l s T h e r e was no oe d e m a o f th e.
a rm ,an d th e pul s e s w e r e e qu al I t i s t o b e r e m e m b e r e d th a t th e p ai n s
.
h ad e xi s t e d e i gh t or nin e m on th s Mor e ov e r th e l e ft arm an d Sh oul de r

.
a t la s t b e ca m e a ffe c t e d lik e th e rig h t a n d th i s wa s follow e d i m m ed i a te ly

,
by th e p arapl e gi a I t will s carc e ly b e di s pu te d th e r e for e th at th a t

.
, ,
p ain wa s of s pinal origin an d d ue d ir e c tly t o th e s pinal canc e r If t h e .
l e ft why n ot al s o th e righ t ? Th e s i t ua tion o f th e canc e rou s v e r te bra

wa s al s o e xa c tly in corr e s pon de nc e wi th th e origin o f th e p ain ful n e rv e s .
R ep ] — Ga z IlI ed de P a r i s
. . 1 886. Ap ril 3 . . .
C B K E E TL E Y ( Lo n d n ) . . o .
III . O n t h e O p e rat i v e T r e at m
n t o f E ch i n o c o c cu s o f t h e
e
Lu n g s By Dr . I S R A E L ( B e rlin ) O p e ra tiv e tr e a t m e n t fo r e ch in
. .
o c o c c u s o f th e lung s h as b e e n rar e ly un d e r t ak e n T h e d i ffi cul t y in .
m aking a d iagn o s i s th e s pon t an e ou s r e cov e ry by e xp e c t ora t ion o fti m e s

,
ob s e rv e d an d finally th e d r e a d o f O p e ning a h e al th y pl e ural ca vi ty an d

,
c au s i n g p n e u m o th orax ; h av e b e e n th e ch i e f r e a s on s fo r th i s th e rap e u
t i c i d l e n e ss Th e au th or i s i n favor o f m or e ac tiv e th e r ap e u t ic m e as
.
ur e s a s s o m any ca s e s l e ft to th e m se lv e s p e ri sh in con s e qu e nc e o f
, , ,
p e r fora tion in t o th e bronc h i A ca s e o f e ch ino coccu s o f th e conv e xi ty

.
o f th e liv e r wa s r e por t e d by th e a u th or in 1 8 7 9 wh ich h e h a d s ucc e s s ,
fully r e m ov e d by op e ning th e pl e ural cavi ty an d d i vi d ing th e d iap h rag m .
T h i s an d si m ilar e xp e ri e nc e s h av e sh own h i m th a t O p e n ing th e pl e ural

c avi ty for a sh or t p e rio d an d clo s i n g i t un d e r s tric t an ti s e p tic p re c au
t io n s i s n o t n e c e s s arily follow e d by s e riou s r e s ul t s
, T h e e n tr a nc e o f .
ai r o f cour se S h oul d b e r e s t ric t e d a s m uc h as p o s s ibl e

, , Au th or giv e s .
IN DE X OF S UR GI CA L P R O GR E S S .
t w o m e th o ds op e ra ting T h e o n e con s i s t s i n e x te n d e d r e s e c tion O f

of .
t h e rib s an d inci s io n o f th e cy s t a ft e r uni ti n g th e lu n g t o t h e co s t al

,
p le ura by s u t ur e s T h i s m e th o d woul d b e in dica te d in s uch ca s e s

.
wh e r e p o si t iv e p r e s s ur e e xi s t s in th e cavi ty o f th e t h orax a s i s th e ca s e ,
wh e r e larg e e c h i n ococcu s s ac s li e d ir e c t ly again s t t h e ch e s t wall

-
Un .
d e r s uc h co n di tio n s th e p le ura m ay b e inci s e d wi th ou t fe ar o f th e e n
t ranc e O f air t h e t e n s e cy s t pr e ss i n g clo s e ly in t o th e woun d

, Wh en .
t h e cy s t i s n o t l a rg e a n d t e n s e e noug h t o c h a n g e th e nor m al in t ra
th oraci c n e ga t iv e pr e s s ur e in t o a p o s i t iv e o n e t h e n t h e s e co n d op e ra
,
t iv e m e th o d woul d b e i n d ica t e d T h i s i s a s follow s : Ab ov e an d b e

.
low th e prop o s e d lin e o f i n ci s io n h ook s are p a ss e d th rough th e co s t al

p le ura wh ich h as b e e n e xp o se d by r e s e c tion o f th e rib s T h e pl e ura i s .
t h e n i n ci s e d a t i n t e rval s an d only d uring e xpira t io n pi e c e s o f i o d o ,
for m g auz e b e i n g pr e s s e d i n t o t h e c u t followi n g th e kni fe s t e p by s t e p

, ,
t h u s e ffe c tually clo s i n g th e woun d b e for e th e n e x t i n s pira tio n t ak e s
p la c e W h e n th e inci s io n i s fi n i s h e d in i t s e n tir e le n g th th e gauz e i s

.
,
pr e s s e d i n t o th e pl e ural op e n i n g a s t h e e d g e s are s e para t e d T h e cy s t .
i s n o t inci se d un til th r e e d ay s la t e r w h e n th e lu n g an d ch e s t wall h av e

,
b e c o m e a dh e r e n t A u th or r e por t s th e following in te r e s ti n g ca s e Pa
.
ti e n t w o m an ac t 2 5
, . F o r pa s t e igh t w e e k s p ai n s in ch e s t an d s i n c e
.
,
t wo m o n th s d i fficul ty in br e a th i n g acco m pani e d by coug h wi th occa s
i o n a l bloo dy S pu t u m T h e r e i s a con s i d e rabl e b ulging in th e low e r

.
par t of th e rig h t s i d e o f th orax b e gi n ni n g at t h e th ir d rib an d ov e r

, ,
w h ich th e r e i s ab s o lu te d uln e s s on p e rcu s sio n No r e spira t o ry m u r .
m u r or vocal fr e m i t u s Abov e s e con d rib co n di t io n s n or m al D uring

. .
d e e p i n s pira tion th e low e r b oun d ary O f t h e lu n g s ou n d r e ac h e d t o th e

four th rib w h ic h fac t di sp e ll e d all i d e a o f th e pr e s e nc e o f a pl e uri tic e x
,
u d a t i on . I t wa s de ci d e d t h a t t h e pr e s e n c e o f a t u m or in t h e lu n g ( as
S h o wn by th e bl o o d y S pu t u m cau s e d t h e bu lgi n g m e n t io n e d a b ov e
) .
A spira tion wi th Prav az s yri n g e d r e w o ff th e ch arac te ri s ti c e c h in o c o c

’
c u s li qui d a l s o p ar t ic le s o f co m pr e s s e d lu n g t i ss u e
,
T hi s proc e d ur e
-
.
wa s fo llow e d by vio le n t c o u gh i n g wh ic h r e s ul t e d in th e e xp e c t ora tion

,
o f s om e 1 5 0 0 c c m O f th i n . fro th y flui d e vi d e n tly c o m i n g fro m th e

, ,
e ch i n oco ccu s s a c Pa ti e n t b e ca m e wor s e h e r t e m p e ra t ur e r e ac h ing

.
,
A s pira ti on o f th e e ch i n ococcu s fl ui d cau s e d d ifl u s e bronc hi ti s o f

th e le ft s i d e an d p le uri t ic pai n s s e t in on t h e rig h t si d e in co n s e qu e n c e o f
, ,
I 79
w h ich th e d y s pn oe a b e cam e alar m i n g O p e ra t ion two d ay s la t e r R e. .
s e c ti on o f 6 c t m o f t h e se v e n t h an d e ig h th rib s
. On inci s ing t h e cy s t .
th e r e e s cap e d a v e ry l arg e par e n t v e s i cl e an d se v e ral s m a ll e r on e s wi th

-
a qu an ti ty o f aqu e ou s t ran s p ar e n t fl ui d T h e low e r p ol e of th e s ac .
w a s a dh e r e n t t o t h e d iap h rag m T h e lung t i s s u e co m p o s ing s a c wall

.
-
wa s c tm in t h ickn e s s a t th e plac e o f inci s ion Con tra in ci s ion for

. .
-
d rain ag e b e h in d a n d b e low Two d rainag e t ub e s 1 6 c tm long in t ro

.
,
.
,
d u c e d in t o t h e lung cavi ty Woun d di s in fe c t e d wi th s alicyla te d wa t e r

.
a n d d r e s s e d wi th io d o for m gauz e T h e fur th e r progr e s s o f th e p ati e n t

.
wa s co m plica t e d by a v e ry s e v e r e a tt ack o f bronch o pn e u m oni a o f th e -
l e ft lung d oub tl e s s cau s e d by th e a s pira t io n o f th e e ch inococcu s fl ui d

,
- .
Dy s pn oe a v e ry g r e a t a n d incr e a s e d by th e pn e u m o th orax o f th e righ t

si d e. Ve n e s e c t ion gav e m uc h r e li e f Pa t i e n t m a d e th e n a rapi d re
.
c o v e ry a fi s t ula h ow e v e r r e m ai n i n g
, , , T h e la t t e r i s now clo se d
. Thi s .
ca s e woul d d e m on s tra t e th a t th e ri s k o f a ra d i cal O p e rat ion i s r e ally

s m all co m par e d t o t h e d a n g e rou s con se qu e nc e s o f an e xplora t ory
p un c t ur e I t wa s un d o ub t e dly th i s la tte r th at le d t o th e b ur s ting o f

.
th e cy s t in t o t h e bronc h i an d th e d a n g e rou s s t a t e o f th e p a ti e n t s ub se
q u e n tly In a S i m ilar ca s e o f S ch e d e an d al s o in o n e o f C om il an d
.
Gibi e r d e a th fro m s u ffo ca t ion was cau se d in th i s m ann e r P unc t ur e .
sh oul d only b e u n d e r t ak e n w h e n th e r e fl e x irri t abili ty h a s b e e n all ay e d
b y m orp h in e i nj e c tion s or ch loro form narco s i s Au th or r e co m m e n d s -

.
th e la tt e r par ticular ly i f o n e i s in th e po s i t ion t o un d e r t ak e t h e ra d ical

,
O p e ra t i on at onc e — D eu ts c/z M ed Wocfi . N o 1 9 May 1 3 1 8 8 6

.
, . . . .
C J C O LL E S ( N e w Y o k ) . . r .
IV . c t i o n o f R i b fo r C a l c a r e o u s C o n c r e t i o n o f
R ese
P l e u ra By Dr A BO N i ( Pavi a) Th e p a ti e n t a p e r s on ac t 60
. . . .
,
.
,
h a d r e c e iv e d a blow s o m e t i m e pr e viou s ly T h i s h ad b e e n follow e d by.
p l e uro p n e um onia an d a pul m o n ary cavi ty d e v e lop e d

-
, T h rough a .
fi s t ulo u s S inu s s o m e th i n g s i m ula t in g cariou s b o n e coul d b e m a d e o ut .
T h e p a ti e n t b e co m in g m or e a n d m or e d e bili t a te d h e r e m ov e d 5 c t m , .
fro m th e fi fth an d s ix t h rib s a t abou t th e m a m m a ry lin e on th e l e ft
s i d e t og e th e r wi th a fragil e concr e t ion

,
.
Cl e a n s i n g wi th d i s in fe c t an t d raina g e io d o for m Co m pl e te re s t ora .
t ion o f g e n e ral h e a lth T h e r e m ai n i n g fi s t ula S h ow s a t e n d e ncy t o

.
1 80 I N D E X OF S UR GI C AL P R O GR E S S .
cica t riz e — Ga zz t d Osp i ta li

. . . . 1 88 5 . No .
38 .
( R e port of M e d ico
C h irg S oc ty o f Pavia
. . .
V O n G a lls t o n e I l e u s By P
. W I S I N G T h e au th or i s abl e
. .
,
fro m an ob se rva tion o f h i s own a n d fi fty o th e r s w h ich h e h as coll e c t e d ,
t o giv e a d e t ail e d accoun t o f a t roubl e w h ic h h a s r e c e iv e d l e s s c o n si d
e ra t i on th an i t se e m s t o d e s e rv e A m ong s t ca s e s of il e u s col
.
le c t e d by Le i ch t e n s t e rn 4 1 w e r e o f th i s for m
As a rul e il e u s i s only cau s e d by an e xc e e dingly larg e s t on e ; a

,
s m all e r o n e coul d only cau s e incarc e ra t ion w h e r e t h e r e wa s pr e vio u s
con trac tio n o f th e gut or w h e r e i t h ad b e co m e e nlarg e d by d e p o s i tion

,
o f fae cal m a t t e r Incarc e ra tio n o f ga ll st o n e in th e v e r m i for m app e n

.
dix r e la tiv e ly n o t S O v e ry rar e i s n o t inclu d e d by t h e au t h or

, ,
.
G all s t on e s p a s s i n g th e na t ural way th rou gh th e c h o le d o c h i c d uc t ,
u s ually n o t ov e r 1 c t m in d ia m e t e r d o n o t a s a rul e play any par t

.
, , ,
in ob struc ting th e g u t O b t ura ting s t on e s u s ually p a s s thr ough a

.
fi s t ula ; th i s m ay b e cau s e d by th e s t o n e in d uc in g an ulc e ra t ion O f th e

b la dd e r wall local a dh e s iv e p e ri t oni t i s an d finally a p e r fora t i n g ulc e ra
-
,
t ion o f th e in t e s t in e or th e co m m un ica t ion m a y r e s ul t fro m a lo c al can

,
cer . Th e O p e ni n g m ay b e in t o t h e s t o m ac h colo n or d uo d e nu m th a t ,
in t o th e s t o m ac h i s rar e s t th oug h Cruv e i lh e i r foun d a s t on e th u s in

,
t ran s i t a n d i n o th e r ca s e s larg e s ton e s h av e b e e n vo m i t e d up

,
S m all .
s t o n e s a ft e r t aking th e na t ural wa y i n t o t h e d uo d e nu m m ay d oub tl e s s

, ,
b e fo rc e d in t o th e s t o m a c h by e ffo r t s a t vo m i ting A s t on e pa s s e d d i .
re c t ly in t o t h e s t o m ach h a s n e v e r b e e n k n own t o e n t e r t h e in t e s tin e an d
cau s e il e u s .
R ar e ly th rough m o r e fr e qu e n tly th an in t o th e s t o m ac h th e s t o n e fi n ds
, ,
i t s way in t o th e colo n In th e nin e s uc h ca s e s —Murc h i s on s i x w e r e o c

.
c a s i o n e d by canc e r a n d in t h r e e o f th e s e th e r e wa s al s o a c o m m un i c a
,
t ion b e tw e e n ga ll bla d d e r a n d d u o d e n u m
-
A s a rul e n o incarc e ra tiv e .
,
s y m p t o m s ari s e in th e colon a t m o s t t h e s t on e s t o p s abov e th e anu s

,
an d m ak e s t roubl e in d i s c h argi n g Th e u s ual way fo r S t o n e s t oo larg e

.
fo r th e gall d uc t i s by a fi s t ula t o th e d uo d e nu m
, Murc h i s on g ath .
e r e d 3 4 s uch ca s e s m o s t ly fa t al , Y e t r e c ov e ry i s n o t i m po s s ibl e
. .
A m ong s t W s 5 1 ca s e s in 2 4 o f whi ch t he co n di tion o f th e gall bla dd e r

’
,
-
i s s p e cifi e d th e p e r fora tion wa s in t o t h e i n t e s tin e in 1 8

, In only 3 o f .
CH E S T A N D A E D OM E N .
I 81
th e 24 does a larg e st on e app e ar to h a v e t r a v e r s e d th e c h ole d o c hi c
d uc n
The p oin t o cclu s ion vari e s in d i ffe r e n t in divi d ual s accor ding t o
of
t h e s iz e O f th e s t on e an d t h e wi dth o f th e i n t e s t in e E v e n in th e d uo d e
.
n u m t h e s t on e m ay c a u s e a co m pl e t e clo s ur e a n d b e m i s t ak e n fo r
pyloric s te no s i s— a s h as r e ally h ap p e n e d Co m m o n ly h ow e v e r th e
.
, ,
occlu s ion t ak e s plac e far th e r d own i n t h e j ej unu m or il e u m T h e au th or .
foun d in opp o s i t ion t o th e s t at e m e n t s o f F r e rich s th a t gall s t o n e s u s u

,
ally lo d g e i n th e j e j un u m a n d o f Le ic h t e n s t e rn t h a t th e y m o s t fr e qu e n t
,
ly lo d g e in th e low e r p ar t o f th e il e u m a m o n g s t 3 3 ca s e s th e ob t ura
,
t ion t w e lv e t i m e s in t h e j ej unu m a n d t w e n t y o n e in th e il e u m -
in ,
t h e la tt e r t wi c e in th e m i dd l e s i x t i m e s in t h e upp e r t w e lv e t i m e s in
, , ,
t h e low e r h al f H ow e v e r r e cov e ri e s are n o t inclu d e d an d i n th e m

.
, ,
prob ably th e c oe cal valv e was th e poin t o f ob tura tion T h e g ut i s a s a .

,
rul e gr e a tly di s t e n d e d ab ov e th e lo d g m e n t collap s e d b e low

, , I t m ay .
b e m or e o r l e s s al t e r e d at th e S p o t o f c lo s ur e e v e n gan gr e nou s
,
.
Ab ov e th i s i t i s s o m e ti m e s hyp e r ae m ic a n d ulc e ra t e d s up e rfi ci ally or

d e e ply . A fe w ti m e s circu m s crib e d or m or e g e n e ral p e ri t o n i ti s wa s
pr e se n t .
A s t o clinical s y m p t o m s d i s r e gar d i n g th e r ar e ca s e s w h e r e t h e s t on e
t rav e r s e s th e d uc t cau s ing gall s t on e colic a n d ic t e r us or w h e r e a t t i m e s ,
in trav e r sing th e d uo d e nu m i t co m pr e s s e s th e d i v e r t c l y a t e ri — th e p e r .
fo r a t i o n o f th e s t on e fro m th e ga ll bla dd e r in t o th e g u t i s fa r fro m

-
a lway s acco m p a ni e d by s e v e r e s u ffe ri n g O n ly in a th ir d o f th e ca s e s

.
d o e s s e v e r e p ain in th e h e p a ti c r e gion wi th v o m i ti n g app e ar t o h av e
b e e n pr e se n t .
S o m e t i m e s no illn e ss pr e c e d e d th e il e u s ; in o th e r ca s e s only d ig e s
t iv e d i s t urb an c e s ob s tip a t ion an d p ain in th e liv e r r e gion are m e n
,
t i on e d I c t e ru s c e r t ainly d o e s n o t b e lon g to th e r e gul ar a c c om p ani

.
m e n t s o f th e p e r fora t ion ; i t i s s p e cifi e d only e ig h t t i m e s in th e 5 1
ca s e s A fte r th e s t on e h as e n t e r e d th e in te s ti n e il e u s v e ry s oon se t s
.
in b u t i t pr e s e n t s n o ch arac te ri s tic s t o d i s ti n gui sh i t fro m il e u s fro m

o th e r cau s e s All t roubl e d i s app e ar s on th e s t on e e n t e ri n g th e colo n
. .
I n s oli t ary ca s e s th e s t o n e d i s te n d s th e gut wall t o a d iv e r ticulu m

-
wh e r e i t m ay b e carri e d a lo n g t i m e wi th o u t an y di fficul ty .
A s r e gar d s se para t e s ym p t o m s th e p ain m a y b e v e ry u n e qual n ow

, ,
1 82 INDE X OF S UR GI CA L P R O GR E S S .
m or e d i s s e m i n a te d or agai n m or e localiz e d T h e c h aract e r o f th e .
vo m i te d m a t e rial an d th e pr e se n c e o f m e t e ori s m d e p e n d upon t h e s e a t

o f th e s t on e w h e n thi s i s low d own fae cal vo m i ti n g d o e s n o t app e ar
, ,
u n til la te .
I n o n ly 5 o f th e 5 1 ca s e s coul d a t u m or b e fe l t .
T h e following m a tte r s d e s e rv e con s i d e ra ti on in m aki n g t h e d i a g n o

s e x o f th e p a t i e n t e 4 4 w h e r e th i s i s s t a t e d
( )
1 T h e O f t h . 1 1 ,
w e r e m al e s an d 3 3 fe m al e s ( 2 ) Th e ag e O n e was 2 7 y e ar s wh il e
. .
,
3 6 w e r e 4 0 y e ar s o ld a n d m o s t o f t h e m ov e r 5 0
, ( 3 ) Pr e c e ding ab e r .
ra tio n s i h h e al th S inc e t h e s t on e d o e s n o t u s ually trav e r s e th e n a t ural

.
way j aun d ic e an d co lic a re only valuab le a s i n d ica ti n g th e for m a tion

,
o f s t on e . O n th e o th e r h a n d pr e viou s m or e or l e s s d e fini t e s ym p t o m s
,
o f circu m s crib e d p e ri t o n i t i s i n t h e gall bla dd e r r e gio n a re t o b e h e e d e d

-
,
a t th e s a m e r e m e m b e ri n g th a t s ub j e c t i v e s y m p t o m s o f th e p a s s ag e o f
th e s t on e m a y b e wa n ti n g ( 4 ) T h e a tt ack o f il e u s m a y a ffor d s o m e
.
h e lp ,
Vo m i ting u s ually b e gin s e arly e v e n w h e n th e s t o n e i s in t h e
,
il e u m . T h e s i d e s o f th e ab d o m e n a re g e n e rally l e s s di s t e n d e d U n d e r .
narco s i s th e s t on e m ay po ss ib ly b e fe l t w h e r e th e ab d o m i n al wall s a re
t h i n ; in th e au th or s ca s e t h e p ari e t e s we r e t oo th ick for thi s I f i t i s s u s
’
.
p e c t e d t h a t a d i s cov e rabl e t u m or i s cau s e d by a ga ll s t on e It w oul d b e
prop e r t o in tro duc e a fi n e n e e dl e b e for e laparo to m y .
R e g ar di n g progno s i s 3 8 o f th e 5 1 d i e d ; b ut pr e s u m ably m or e fa t al
,
ca s e s a n d e s p e ci ally th o s e o f au top s y w oul d b e publi sh e d All d an .
ge r i s in m o s t ca s e s p a s t a s s oon a s th e s t on e i s d i s c h arg e d b y th e
na t ural ou tl e t ; s till in s o m e ca s e s al te ra tion s in th e g ut— e g ulc e ra tion . .
a n d cica t ricial s t ric t ur e —m a y h av e b e e n i n d uc e d w h ic h la t e r l e a d s t o ,
wa s ting or d e a th O f 2 5 fa t al ca s e s 1 4 e n d e d b e tw e e n th e S ix th and
.
e ig h t d ay s o n e fro m
, , acu te p e ri t oni ti s i n th e fir s t 2 4 h o ur s an d on e ,
a ft e r t h r e e d ay s laparo t o m y h aving b e e n p e r for m e d I n 9 1 3 1 5 2 6

, .
, , , ,
a n d 2 8 d ay s r e s p e c t iv e ly a d e a t h occurr e d
,
wh il s t o ne follo we d p e r
,
fo ra tiv e p e ri t o n i ti s a t th e e n d o f two m on th s .
In d ivi d ual ca s e s pr e s e n t i n g th e m s e lv e s u s ually a s in te s ti n al o c ,
e lu s ion o f unc e r t ai n cau s a tio n h av e s o m e t i m e s b e e n t r e a t e d a t fir s t

,
wi th purga t iv e s t o w h i c h a n y favorabl e r e s ul t w oul d th e n b e a t tr i

,
b u te d . T h e u s ual t r e a tm e n t fo r il e u s— h ig h inj e c t ion s opi a t e s e t c , ,

.
h a s b e e n r e p e a t e dly a d op t e d fo r t h e m o s t p ar t un s ucc e s s fully

, In o n e .
CH E S T A N D A B D OM E N .
1 83
c as e th e s t o n e was pa ss e d a ft e r m a s s ag e o f th e b e lly an d in tw o a ft e r ,
th orou gh p alp a t ion i n e xa m ining All four ca se s in w h ic h la p aro t o m y

.
wa s d on e — b e tw e e n th ir d a n d s e v e n th d ay—prov e d fa t al I n one o f .
t h e s e t h e s t on e co ul d n o t b e fo un d i n th e o th e r th r e e i t wa s r e a d i ly
fe l t th e g u t wa s op e n e d a n d a ft e r r e m oval o f t h e s t on e w a s s e w e d
, , ,
up D e a th r e s ul t e d in 8 h our s 2 4 h our s a n d S ix d ay s r e s p e ct iv e ly
.
, .
A p urga tiv e i s a d v i s e d a t th e b e g in n ing b ut sh oul d n o t b e con ti n u e d , .
K u s s m a ull s s t o m ac h wa s h in g h e th ink s will prov e u s e ful Hig h i h

’
.
i ar e t o b e t ri e d s i n c e th e y a r e h ar m l e s s ir ri t a t iv e cly s te r s a r e t o
j e c t o n s ,
b e avoi d e d h ow e v e r N u tri tiv e e n e m a s m ay pr e s e rv e th e p a ti e n t s ’

.
,
s t r e n g th .
Laparo t o m y i s c e r t ainly j u s ti fi ab le b ut sh oul d n o t b e d on e t o o e arly .
W s ca s e was t h a t o f a wo m an of 7 5 y e ar s S h e s u ffe r e d fro m ob s ti

’
. .
pa tiou an d occa s i o n al ab d o m inal colic la te i n th e s u m m e r S e p t e m , .
b e r 5 th th e b o we s woul d n o t m ov e T h i s co m pl e t e ob s truc tion wa s .
follow e d in a fe w d ay s by s e v e r e vo m i t i n g th a t s oon t o ok on a fe c ula n t

ch arac t e r ; ab d o m e n a li t tl e s e n s i tiv e b ut s lig h tly d i ste n de d N O t u m or , .
coul d b e m a d e o u t e i th e r t h ro ug h th e an te rior wall s or p e r r e c t u m

S lig h t ic t e ru s on th e r o th Morp h in e cro t on oil a n d h igh inj e c ti on s
.
,
d i d n o t cl e ar t h e O b s truc tion A council on th e 1 6 th d e ci d e d again s t

.
a n y O p e ra tion D e a th on th e 1 9 th An e gg sh ap e d s t on e 7 c tm
. .
-
, .
long by t e n aroun d block e d a loop o f t h e upp e r h al f o f th e il e u m j u st

,
b e low t h e n av e l S ign s o f b e ginning p e ri t oni t i s

. G all bla dd e r .
-
s h runk e n ulc e ra t e d a n d pr e s e n t ing a p e rfora t ion in t o th e a d h e r e n t

,
d uo d e nu m ab ov e th e m ou th o f t h e c h o le d o c h i c d uc t T h e r e wa s al o .
s
a s m all O p e ni n g in t o th e colon a dh e ri n g to th e un d e r s urfac e o f th e

liv e n — N or d M ed A r R Vo l 1 8 N o 1 8 ( a s ab s trac te d in C e n tb l
. . . .
,
. .
f C h irg
. 1 886
. NO . .
W BR O WN I NG ( B o o k l yn ) . r .
VI C h o l e c y s t o t o m y By C T PA R K E S D D ( C h icago ) R e
. . . .
,
. . .
p or t s t wo u n s ucc e s s ful ca s e s sh o wing th a t O b s truc tion o f t h e gall d uc t

,
-
i s n o t alway s a m e nabl e t o s urgical t r e a t m e n t a n d illu s tra t ing t h e d i ffi ,
c ult i e s th e s urg e on h a s t o d e al wi th w h e n th e bla d d e r i s a t rop h i ed or ,
w h e n i t i s n o t in a s t a t e o f d i st e n s io n Th e fir s t o ccurr e d in a wo m an .
,
wh o h a d s u ffe r e d fro m gall s t on e s wi th fr e qu e n t coli c fo r s ix y e ar s an d

-
1 84 I N D E X OF S UR GI CA L P R O GR E S S
wh o s e gall b la d de r flacci d an d clo s e ly a dh e r e n t t o th e un d e r s ur fac e

-
,
o f t h e liv e r w as foun d wi th con s i d e rabl e d i fficul ty

, I t w a s finally .
loo s e n e d fro m i t s a t t ach m e n t t o th e li ve r an d brough t t o vi e w s u t ur e d ,
t o t h e ab d o m inal i n ci s ion op e n e d an d for ty th r e e calculi r e m ov e d

,
- .
T h e pa ti e n t e n d ur e d th e an ae s th e tic b a dly an d n e v e r ralli e d The se c .
on d occurr e d in a gr e a t ly e m aci a t e d m an a n d was e xplora t iv e in ,
ch arac te r s inc e n o g all st on e s h a d e v e r b e e n di s cov e r e d Clo s e to th e

,
-
.
locali ty wh e r e th e gall bla dd e r sh ou ld h av e r e s te d lay a larg e cy s t

-
,
w h ich wa s t oo n e ar th e v e sse l s t o p e rm i t o f r e m oval An au top s y th e .
following d a y sh ow e d a m uch a t rop h i e d a n d e m p t y gall bla d d e r wi th a -

,
s t on e co m p le t e ly ob s truc t in g th e pa s s ag e th roug h th e d u c t a n d a s m all ,
ab s c e s s i m m e d ia te ly by th e s i d e o f th e d uc t accoun ti ng fo r th e cy s t ,
th a t h a d b e e n fe l t .
W H CAR M ALT M D ( Ne w Hav e n Co n n ) r e p or te d a ca se o f a

. .
,
.
, ,
rob u st wo m an wh o ca m e to h i m wi th a h i s t ory O f O p e ra ti o n upo n th e

righ t ki dn e y in B e rl i n clai m i n g a r e cu rr e nc e o f th e s y m p t o m s for wh ich
,
t h e O p e ra t ion h a d b e e n p e r for m e d a n d d e s iri n g t h e r e m oval o f th e v i s

,
c us t h e r e wa s a t u m or cl e arly m ark e d on in s p e c t ion a n d p alpa t ion

, ,
a n d n o h i s t o ry o f any biliary t ro ub le ; on l aparo t o m y t h e t u m or w a s ,
d i s cov e r e d t o b e a gall b la dd e r gr e a t ly d i s t e n d e d wi th in s pi s s a t e d m u
-
,
c u s an d calculi T h e s e w e r e r e m o v e d th e ab d o m e n w as clo s e d an d
.
,
th e pa ti e n t proc e e d e d t o rapi d conval e s c e nc e — P r oceed i ng s A m S u rg . . .
Ass n . 1 88 6 May 8 . .
VII . x p lo r a t i v e L a p a r o t o m y w i t h C o n s e q u e n t C h o
E
le c y s t o t c m y By j C H U T C H I S O N M D ( Bro ok lyn N Y ) A
. . .
,
. .
,
. .
wo m an wt 4 0 h a d b e e n s u ffe ring fro m p aroxy s m s o f ab d o m inal pain

,
.
,
fo r tw e lv e y e ar s w h e n a t u m or w a s O b s e rv e d e x t e n d ing fro m a lin e on

,
.
a le v e l wi th th e u m bilicu s a n d an inch t o th e l e ft o f i t acro s s t o th e ,
ri g h t lu m b a r r e gion a n d d ownwar d t o wi th in two i n ch e s o f Poup ar t s

'
li ga m e n t i t wa s irr e gularly roun d e d fluc tua t e d d i s t in c tly was m ova , ,
b le fro m s i d e t o s i d e a n d p ainl e s s Cy s t ic t u m or o f th e ovary w as .
d i a g n o s e d a n d i t s r e m o val by ab d o m i n al s e c tion a d vi s e d Wi th s o m e .
d o ub t h ow e v e r r e s ul t i n g fro m a la t e r e xa m ina t ion as t o th e corr e c t

, , ,
n e s s o f th e d iagno s i s an inci s ion wa s m a d e e x t e n d i n g t wo a n d a h al f

,
i n c h e s d o wn w ar d fro m an i n c h b e low th e u m bilicu s ; a troc ar d r e w

E X TR E M LT/ E S . 85
fro m th e pr e s e n ting t u m or a pi n t of lau d abl e p u s con t aining no ch ol e s ,
t e ri n e c ry s t a l s or o th e r e l e m e n t s t o s h ow th a t i t ca m e fro m th e gall
b la d d e r ; a biliary calculu s wa s h ow e v e r foun d in th e s ac an d on, , , ,
fur th e r e xplor at ion ano th e r wa s foun d p oin t e d on o n e s i de th e p oin t

, , ,
fi t tin g in t o th e o ri fi c e o f th e cy s t ic d uc t an d c o m pl e t e ly o ccl ud ing i t ,
w h i ch e xplain e d th e ab s e n c e o f j aun dic e clay color e d s t o ol s or bil e ,

-
pig m e n t in th e urin e T h e s ton e s w e r e r e m ov e d th e s ac e xplor e d an d

.
,
cl e an s e d an d th e e d g e s o f t h e O p e ning in t o i t s ti t c h e d t o th e lip s o f th e
ab d o m in al wo un d ; th e e d g e s o f th e p e ri t on e u m w e r e clo s e d by a con
'
t i n uo u s ca t gu t s u t ur e a n d th e r e m ain d e r o f th e ab d o m i n al t i s s u e by i n
t e rru p t e d c a rb oliz e d s ilk s u t ur e s carri e d d own t o th e p e ri t on e u m b u t

,
n o t th roug h i t a gla ss d rainag e t ub e w a s k e p t in t h e gall b la dd e r fo r -
p urp o s e s of d rainag e a n d irriga tion a n d th e p a ti e n t p a s se d on t o a s a t

,
i s fa c t ory r e cov e ry T h e wri te r con s i d e r s s u t uri n g th e O p e ni n g in th e

.
g all bla dd e r t o th e ab d o m inal w all s an d e s t abli sh ing a bilia ry fi s tul a

-
pre fe r abl e to s e win g i t up an d l e avin g i t in th e ab d o m in al cavi t y ( 1 ) ,
b e c a u s e th e r e i s l e s s d an g e r o f e s cap e o f bil e in t o th e p e ri ton e al c a vi ty

an d ( 2 i f h e c a l culi can n o t b e foun d a t onc e th e y m ay b e s e arch e d
) t
fo r s ub s e qu e n t ly or b e s p on t an e o u s ly d i s c h arg e d th roug h th e fi s tulo us
O p e ning ; th e fi s t ul a u s ually h e al s in a fe w w e e k s — P r oceed i ng s I V Y

'
. .
S u rg S oc. 1 886
. April 2 6
. .
E XT R E M I T I E S '
1 . o u r C a s e s o f A m p u t a t i o n a t t h e H i p J o i n t By T A
F -
. . .
M C GR Aw M D ( D e troi t Mich ) T h e fir s t ca se occurr e d in 1 8 7 2 in

, . .
,
.
a m an o f low p h y s ical con di tion wt 4 8 for a m ix e d s arco m a por tion s

, .
, ,
o f wh ich w e r e m yxo m a t ou s o f t h e rig h t th ig h affe c t ing b on e a n d s o ft

, ,
.
p ar t s T h e wo un d h e al e d kin dly an d th e p a t i e n t was d i s ch ar g e d in

.
n o t m or e th an s i x w e e k s Two O p e ra ti on s w e r e p e r for m e d d u ring th e

.
followi n g y e ar for r e curr e n t t ro ubl e in t h e cica t rix th e l as t on e e x t e n d ,
ing up nn de r Poupar t s liga m e n t th e ac e t ab ulu m b e ing goug e d o ut

’
,
wi th a ch i s e l A ft e r th ir t e e n y e a r s th e p a ti e n t i s s till livin g in goo d

.
h e al th al th oug h wi th a s u s pici ou s t u m or of o n e arm

,
.
Th e s e con d ca se wa s in a b oy wt 1 0 s u ffe ring fro m a s e v e r e b urn .

,
involvin g th e wh ol e t high fi ve m on th s a fte r th e in j ury T h e h wm or

,
.
1 80 I N D E X OF S UR G I CA L P R O GR E S S .
rh a co n troll e d by pr e s s ur e on th e co m m on iliac wi th a s t a ff in
g e was
t h e r e c t u m ; th e b urn b e ing e x t e n s iv e b ut a s i n gl e flap wa s ob t ain e d
,
fro m th e unburn e d ti s s u e s on th e ou t s i d e o f th e li m b T h e pa t i e n t .
ralli e d w e ll b ut t e t anu s d e v e lop e d a n d d e a th follow e d in o n e w e e k

. , .
T h e t h ir d ca se was a larg e roun d c e ll e d s arco m a involving n e arly t h e

-
wh ol e th igh origina ting in th e ci ca t rix o f an o ld g un sh o t woun d o f th e

,
-
kn e e ; th e fe m ur was d i s ar ticula t e d th roug h an in ci s i o n on th e ou t e r

a s p e c t o f th e h ip a n d a lo n g an t e rior fl ap fo r m e d by tran s fi xi on th e n
, ,
a S h or t po s t e rior fl ap a n d t h e ar t e ri e s w e r e
, s e cur e d m o rrh a g e .
was con t roll e d by m e an s o f a long pi e c e O f rubb e r t ubing p a s se d

'
a roun d th e t h ig h a n d th e b o d y i n s uc h a m ann e r a s to cro s s b o th t h e
fe m or al an d glu t e al ar t e ri e s th e fl ap s w e r e s e iz e d in t h e h a n d th e m o
m e n t t h e y w e r e c u t ; an d t h e d igi t al co m p r e s s io n t h u s a dd e d t o th a t o f
t h e t ubing . T h e p a t i e n t ralli e d w e ll a n d was di s c h a r g e d fro m th e h o s
pi t al thr e e m on th s la te r th e woun d al m o s t h e al e d b ut d i e d t wo m on th s
, ,
t h e r e a ft e r fro m a s e con d ary p ul m onary d i s e a s e .
T h e four th ca s e occurri n g in a m an wt 3 7 wa s al s o for roun d c e ll e d

. .
,
-
s arco m a o f th e t h ig h h wm o rrh a e b e ing con t rolle d by a pl an s i m ilar

, g
t o t h a t follow e d in t h e pr e c e d ing ca s e An e x t e rn al cu t an e ou s fl ap
.
w as c u t by an inci s ion b e ginning a li t t l e b e low Poup ar t s liga m e n t a n d

’
,
j u s t in si d e of th e an t e rior in fe rior iliac S pin e e x t e n d in g in a curv e t o a ,
p oin t on th e o u te r a s p e c t o f th e th igh s i x inch e s b e low th e s u m m i t o f

,
t h e t roch an t e r an d th e nc e t o a poin t a li tt l e a n t e rior t o an d abov e t h e

,
g lu t e al fol d. an in t e rnal s kin fl a p b e ing c

-
u t t o corr e s pon d T h e m us .
cl e s in se r t e d in t o an d ab ou t th e t roch an t e r s w e r e th e n d ivi d e d th e ,
j o i n t e xpo se d th e b on e di s ar ticula t e d an d th e r e m aini n g s truc t ur e s di

,
v i d e d by o n e s w e e p o f th e kni fe T h e w oun d wa s clo s e d wi th car e ful

.
a n ti s e p tic pr e cau tion s b ut th e p a ti e n t d i e d s ix ty h our s la te r app ar e n t ly

,
o f s uppr e s s ion O f urin e al th o ug h t h e r e was n o urwm i c co m a

,
.
T h e wri t e r c all s a t t e n t ion t o th e rapi d a n d e x t e n s iv e involv e m e n t o f
t h e b on e by s arco m a an d e xpr e s s e s h i s b e li e f th a t a s arco m a e v e n ,
t h ough s m all an d a t th e low e r e n d t h e fe m ur d e m an d s a m p u t at ion at ,
t h e h ip b e li e ving th a t t h i s plan woul d gr e a t ly d i m ini s h t h e m o r t ali t y o f

,
th e d i s e a s e . H e con s i d e r s th a t th e d ang e r s o f th e O p e ra t ion in c o m
p a r a t i v e ly h e al th y s ubj e c t s m a y b e gr e a t ly ov e rr a t e d by t h e pro fe s s ion .
T h e d ang e r fro m h wm o rrh a ge i s n o t v e ry gr e a t e xc e p t i n v e ry fa t ,

GE N I T O- UR I N A R Y OR C A N S .
I 87
h e avy an d ata i a n wm i c s ubj e c t s a n d t h e bl e e d ing can b e

th e s m e t m e ,
r e a dily con troll e d by th e m ean s d e s crib e d H e woul d h ow e v e r in .

, ,
s i st upon th e d i s ar t icula t ion O f t h e fe m ur b e for e an

y o f th e larg e r v e s
s e l s ar e d ivi d e d —I V Y M ed R ec 1 88 6 .May 2 2 . . . . .
j E PI LCH E R ( U S A m y) . . . . r .
G E N I T O - U R I NA R Y O R GA N S .
I . O n D r a i n age of t h e B la d d e r w i t h
p e c i a l R e fe r e n c e S
t o a P o s t P r o s t at i c O p e r a t i o n
-
By E H H O W L E TT F R C S . . .
, . . . .
T h i s O p e r ation i s p e r form e d in th e s a m e m ann e r as H arri s on s pro s

’
t a t i c punc t ur e w h ich in d e e d i t wo ul d b eco m e w e r e t h e pro s t a t e h y

, , ,
e r trO p hi e d
p .
Th e p a ti e n t b e ing in th e li th o t o m y p o si t ion th e bl a dd e r i s fill e d i f ,
e m p ty T h e for e fing e r o f th e l e ft h an d i s p a ss e d in t o th e r e c t u m a n d
.
k e p t th e r e wh il s t a troc ar an d canula o f th e S iz e O f a N O 1 2 ca th e t e r
, .
( E ngli s h ?
) i s th ru s t th roug h t h e s kin a b ou t o f an inch in fron t o f
t h e anu s an d s lowly pu sh e d on till r e s i s t anc e i s fe l t t o h av e d i s ap
p e are d A fte r m ain t aining th e s ilv e r canula for s o m e d ay s an i n di a

.
rubb e r ca th e te r i s s ub s t i t u te d .
Two c a s e s are r e la t e d in w h ich th i s punc tur e was prac ti s e d I n th e .
fir s t a ca s e o f e pi s p a d ia s fo r th e p urp o s e o f k e e pin g s o m e fi s t ulw fr e e

, ,
fro m u rin e an d in th e se con d t o e s t abli s h a p e rm an e n t d rain in a c a s e

, ,
o f a t ony o f S lig h t pro s t a t ic e nlarg e m e n t .
F or ch ronic cy s ti t i s e nlar g e d pro s t a te a t ony p araly t ic r e t e n t ion

, , , ,
rup t ur e d ur e th ra i m p a s s abl e s tric t ur e an d m alignan t di s e a s e o f th e pro s

, ,
t a t e or b la dd e r wh e r e con t inuou s d r ainag e o f th e bla dd e r i s in d i ca t e d ,
t h e au th or r e co m m e n d s th e p o s t pro s t a t i c p unc t ur e — B r i t M ed f ou r
- . . .
F eb .
II . A Cas e w h e re L it h ot o m y w as T w i ce P e fo r m e d
W i t h i n F o u r t e e n M o n t h s w i t h R e m a r k s By R E G I NA LD H AR .
R ISO N T S wt 6 2 wi th st on e in th e bla dde r ( m ul tipl e ) an d e nlar g e d

. . .
, .
,
pro s t a t e was s ubj e ct e d t o l a te ral li th o t o m y as Mr H arri s on h op e d t o , .
i m prov e th e pro st a t ic ur e th ra by a s e c ti on o f th e glan d ( vi d e H arri s on

“
O n t r e a t m e n t o f c e r t ain ca s e s o f pro s t a ti c O b s truc tion by a s e c t i o n O f
1 88 I N D E X OF S UR G/ CA L P R O GR E S S .
”
th e glan d Tran s In t e rna tional M e d Congr e s s Cop e nh ag e n
.
. . .
A bl ad de r dr ainag e t ub e wa s in s e r te d a fte r th e op e ra tion an d r e tain e d

fo r S i x w e e k s Th e pa t i e n t l e ft th e h o s pi tal sh or tly a fte rwar ds wi th a
.
fi s t ulo u s t r a ck unh e al e d T h e calculi r e m ov e d w e igh e d n e arly gi ij

. .
Th ough th e p a ti e n t r e t urn e d t o work th e bla dde r n e v e r qui te r e c ov ,
e r e d i t se l f th e woun d d i d n o t clo s e a n d h e h a d fr e qu e n t a t t ack s o f c s

, y
t i ti s . O n s oun d i n g th ir t e e n m on th s a fte r th e Op e ra tion a s t o n e was d e
t e c t e d wh ich wa s r e m ov e d b y li th o t o m y in th e lin e o f th e old inci s ion
a m on th s ub s e qu e n tly T h e o p e ra tion wa s e a s y acc e s s t o th e bla d de r

.
,
b e i n g gr e a tly i m prov e d for on th i s occa sion th e larg e st s t a ff coul d b e

,
r e a d ily pa sse d T h e calculu s w e igh e d gj an d th e au th or conclu d e s

.
,
was ov e rlook e d a t th e fir s t op e ra t ion e v e n in s pi t e O f all th e p r e c a u ,
t ion s wh ic h th e s t a t e o f th e pro s t a t e pro m p t e d Th e p a ti e n t rapi dly .
g o t w e ll an d m e n tion i s m a d e o f th e fact th a t th e r e wa s n o w no pro s

,
t a t ic b ar nor r e s i d ual urin e .
[ B e for e th e fir s t op e ra tion th e e nlarg e d pro st a t e i s s ai d t o h av e i m

p e d e d th e e a s y in t ro d uc t ion o f th e in s tru m e n t s ]
Mr Harri s on co n s i de r s th e r e for e th a t th i s op e ra t ion h a s th e a dv a n
.
, ,
t ag e o f s upra pubic li th o t o m y in ca s e s o f pro s t a tic e nlarg e m e n t fo r by

-
,
th e la t te r al th ough t h e s t on e m ay b e r e m ov e d th e ob s truc t ing p ro s t a t e

, ,
i s l e ft in t ac t —B r i t Ill ed f ou r
. F eb 1 3 1 8 8 6 . . . .
,
.
111 . R em a rk s o n I n c o n t i n e n c e of U r i n e i n C h i ld r e n By .
WM H DAY M D A ft e r m e n tioning th e
. .
, . . variou s cau s e s o f e n ur e si s
th e follo wing ca se in conn e c tion wi t h ch r o nic albu m i n uria i s re
la te d
S M wt 9 incon t in e nc e bo th by d ay a n d n ig h t
. .
, .
,
At 6 y e ar s o f a g e .
h a d s carl e t fe v e r follow e d by drop s y A y e ar a ft e r r e cov e ry coul d

,
.
only pa s s u rin e in drop s A ft e r two m on th s urina t e d e v e ry te n m in .
u te s wi th ou t pain Was s oun d e d for s ton e on accoun t o f p ain an d th e

.
occa s ional pr e s e nc e of bloo d in th e urin e .
O n a d m i s s ion urin e h igh ly albu m i n o u s wi th a fe w ca s t s , .
Tr e a tm e n t—Con fi n e m e n t to b e d lying for a par t o f th e day i n th e ,
pron e po s i ti o n Milk d i e t an d a m ix tur e O f b e lla donn a iron and nux

.
, ,
v o m ica .
GE N I T O UR I N AR Y OR GA N S .
1 89
A ft e r s ix w e e k s t r e a t m e n t th e i n con tin e n c e h ad alm o s t e n tir e di s ap

p e ar e d th e b oy r e t urn i n g h o m e m uch r e li e v e d
,
.
C ase 1 1 A girl wt 7 N e rvou s an d e xci t abl e

.
, . . Mi tr al di se a se . .
N e v e r h a d s carl e t nor rh e m atic fe v e r .
E nur e si s e v e ry nigh t Urin e p al e copiou s 1 0 2 0 aci d con t ai n e d

.
, , , ,
p h o s p h at e s .
r e a t m e n t—A s olu t ion o f arg e n t n i t 9 i

j t o gj was appli e d to th e
. .
n e ck O f th e b la dd e r a n d a m ix t ur e o f b e ll a d on n a an d iron was giv e n

, ,
’
b ut wi th n o g o o d e ffe c t E le c trici t y by m e an s o f S t oe h re r s sm all e s t in
.
d uc tion app ara t u s ( in t e rrup t e d curr e n t) wi th o n e c e ll was now u s e d for

t e n m inu t e s d a ily o n e sp o n g e b e i n g p lac e d ov e r th e s acr u
,
m an d th e
o th e r ov e r th e pub e s A fte r fi v e w e e k s o f th i s tre a tm e n t sh e l e ft th e

.
h o s pi t al cur e d .
Ca s e 1 1 1 Y R wt 7 I n co n tin e n c e for e ig h te e n m on th s U ri n e
. . .
, . . . .
pal e an d con t ai n e d a fe w p h o s ph a t e s aci d , .
Tr e a t m e n t—Milk di e t wi th m e at onc e a d ay F aradiz a tio n d aily

,
.
‘
for t e n m inu t e s A m ix t ur e o f b e lla don na an d iro n H e l e ft th e h os

. . .
pi t al cur e d a ft e r si x we e k s t r e a tm e n t h aving o n ly w e tte d h i s b e d fi v e

’
,
t i m e s s inc e a d m i s s ion .
Ca s e I V A p al e an d irri t abl e b oy wt 8 Troubl e d wi th e nur e s i s

.
, . .
fro m bir th . Pa s s e d larg e quan t i ti e s o f h i gh color e d o ffe n s iv e u ri n e -

,
con t aini n g m uch uric aci d Tr e a tm e n t a s in t h e la st ca s e e xc e p t th at

.
,
h e was or d e r e d s trych n in e an d p h o s p h oric aci d on a ccoun t o f th e u rin e ,
a n d b e lla d o n n a was pu s h e d t o i t s p h y s iological e ffe c t T h e p a ti e n t .
’
was gr e a t ly b e n e fi te d th ough n o t qui t e cur e d a ft e r th r e e m o n th s
, ,
tr e a tm e n t .
Ca s e V A girl wt 9 S u ffe r e d wi th e n ur e s i s o f a y e ar s d ura t ion

.
,
. .
’
.
All tr e a tm e n t h ad faile d t o r e li e v e h e r T h e u s e o f th e b a t te ry and .
t h e iro n an d b e lla d o n n a m ix t ur e w e r e pr e s crib e d A ft e r s ix w e e k s p a .
t i e n t wa s w e ll b u t th e b a t t e ry g e tt i n g o u t o f or d e r e nur e s i s t o a s lig h t
, ,
e x te n t r e t urn e d .
A s an a dj un c t t o t h e tr e a tm e n t e m ploy e d in th e s e ca s e s Dr D ay .
r e co m m e n d s col d s pon gi n g in th e m orn ing In de e d h e a ttrib u t e s on e .

,
cur e to th i s m e an s a lon e T h e col d or e v e n for d e lic ate ch il dr e n

.
, ,
t e pi d s pongi n g Sh oul d b e follow e d by vi gorou s fric tion In th i s way .
i t br a c e s up th e n e rvou s s y s t e m —B r i t M ed f ou r F eb 1 3. . . . . .
1 90 I N D E X OF S UR GI C A L P R O GR E S S .
T e s t i c u l a r A ffe c t i o n s By M VE R N E U I L W h e n
an d H e rn ia . . .
h y d roc e l e i s acco m p ani e d by t ub e rcular e pi di dy m i t i s th e a u th or r e c o m
m e n d s th e inj e c t ion o f io d in e a s in th e or d inary ra d ical cur e fo r h y dr o
c e l e for i t app e ar s t o e x e rci s e a b e n e fi cial influ e n c e o n th e di se a s e d

e pi d i dy m i s H e al s o p oin ts o u t th a t h y droc e l e m ay b e d ue t o th e
.
pr e s s ur e o f an e piploc e l e on th e v e in s o f th e cor d i n wh ic h ca se i nje c ,
tion i s c o n t rain d ica t e d — Ga z ette d es H op i ta u x Marc h 2 1 8 8 6 ‘
. .
,
V . On S u p ra- P u b i c Lith o t o m y T h e th r e e foll o wing con .
t ri b ut i o n s on th i s s ubj e c t w e r e r e p o r te d a t th e R oyal M e d C h ir S oc . . .
on Marc h 3 0 1 886
,
Ca s e
. s I an d I I By R I C H A R D B A R W E LL
. F R , . .
C . S .
Ca s e 1 R o s e A wt 9 s ubj e c t o f v e s ical calculu s o f larg e s iz e To

. .
,
.
, .
avoi d th e ri s k of a v e s ico vagin al fi s t ul a s upra p ubi c li th o t o m y wa s p e r

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p e r for m e d th e bl add e r b e ing fir s t d i s t e n d e d T h e r e c t al b ag wa s

, .
n ot u se d T h e bl ad d e r wall was s u t ur e d a fte r e x trac t ion o f th e s t on e

.
,
a n d t h e ch il d w a s w e ll in for tnig h t T h e s t on e w e ig h e d . ounc e s .
Ca s e 11 A m an wt 6 0 wi th a m e diu m S iz e d s t on e pro st a tic e n

.
, .
, ,
larg e m e n t an d h wm a turi a T h e s upra p ub ic O p e ra t ion w a s s e l e c t e d

.
-
n o t only an acco un t o f th e con d i t ion o f th e pro s t at e b u t al s o a s i t wa s ,
th oug h t th a t th e h wm o rrh a ge m ig h t p oin t t o a v e s ica l grow t h .
T h e r e c t al b ag wa s again d i s car de d b u t t h e bla d d e r wa s d i s t e n d e d

,
wi th §xvi b orO glyc e ri d e s o lu ti on

-
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T h e au th or conclu d e d h i s p ap e r by s t a t ing th a t d i s t e n tion O f th e
r e c t u m h ad a v e ry s m all e ffe c t on th e an t e rior p e ri t on e al fo ld .
Ca se 1 1 1 A c a s e o f ve s i c a l calculu s o f unu s ually larg e S iz e r e m ov e d

.
,
by s upra p ubic cy s t o to m y By W A L T E R R i vi N GT O N M 8 M an wt
-
. . . .
, .
61 .Calculou s s y m p to m s for S ix te e n y e ar s .
F e bruary 2 4 1 8 8 5 E x t e rna l ur e th ro t o m y fo r purpo s e o f e xp lo ra t i o n

, . .
A larg e s t on e was di s cov e r e d w h ich was al m o s t i m m ovabl e wh e n

,
gra s p e d wi th forc e p s S upra pubic li th o t o m y was n o w p e r for m e d T h e

.
- .
s t on e w as brok e n up by m e an s o f a c h i s e l a n d m all e t a n d e x t rac t e d
pi e c e m e al .
T h e woun d in th e bla dd e r a nd t h a t i n th e s o ft par t s w e r e s e para t e ly

GE N I T O UR I N A R Y OR GA N S
-
. 191
s u t ur e d wi th i n se r tio n o f a drainag e t ub e an d a s ilv e r t ub e wa s pl a c e d

in th e p e rin e al woun d .
O n March 2 1 th e p ati e n t was allow e d up fo r o n e h o ur

, .
O n April 1 7 th e pa ti e n t wa s w e ll wi th th e e xc e p t ion o f a fi s t ula in

,
p eri n e o .
T h r e e m on th s afte r th e p e ra tion th e p ati e n t s uccu m b e d t o a

O re
n e w e d att ack o f cy s ti t i s . S uppur at iv e n e p h ri ti s was foun d a t th e
au t op s y .
Th e pi e c e s o f cal culu s t og e th e r w e igh e d 2 3 ounc e s avoir d up oi s .
Al th oug h n o t ab s olu t e ly t h e l arg e s t calculu s r e m ov e d d uring li fe i t ,
a pp e ar s t o b e so wi th r e cov e ry o f th e p a t i e n t fro m th e i m m e d ia t e e f
fe e t s o f th e O p e ra ti on .
Ca s e I V By W H A J A C O BS O N M B F R C S A lad wt 1 9
. . . .
, . .
,
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, .
,
h a d sym p t c m s o f s t o n e fo r fi ve y e ar s A li th o tri te di s cov e r e d m ore

.
t h a n o n e s t on e .
O n J a nu a ry 3 0 h ypoga s t ri c li th o t o m y wa s p e r fo rm e d th e bla dde r

, ,
h aving b e e n inj e c te d wi th 3 x o f wat e r an d th e r e c ta l b ag in tr o d uc e d .
T h e p e ri t on e um wa s n o t s e e n O n e s t on e only was foun d at th e t i m e

.
o f t h e O p e r a t ion t h e o th e r t wo e s caping a fo rt nig h t a ft e r th e O p e ra t ion

,
th roug h th e woun d .
I t i s s uppo s e d th a t th e s e w e r e m i s se d owi n g t o th e m i s t ak e o f k e e p
,
ing th e bla dde r d i s t e n de d wi th flui d d uring th e S e arch N O s u t ur e s .

,
d r a inag e t ub e n or ca th e t e r w e r e e m ploy e d a fte r r e m oval o f t h e calculu s .
T h e p ati e n t wa s w e ll in fi v e w e e k s conval e s c e nc e h aving b e e n r e t ar d e d

,
by an att a ck o f pn e u m oni a .
T h e larg e s t c alculu s only w e i g h e d 3 0 0 grs s o th at as th e a u t h or r e .

,
m ark s all m ig h t h a v e b e e n d e al t wi th by li th o tri t y

,
Mr J acob s on con . .
ci n d e s h i s p ap e r wi th th e s e propo s i tion s r st T h a t t h i s O p e r at i o n .
woul d b e foun d o f gr e at valu e by th o se wh o only h ad t o d e al wi th s t on e

occa s i onally m or e e s p e ci ally i f th e s t on e s w e r e l arg e an d in th e ad ul t
,
s ubj e c t . 2d T h at wh il st i t coul d n e v e r con tr a s t in b rilli ancy wi th

.
l at e r al li th o t o m y i t woul d in i t s i m prov e d form giv e b e tte r r e s ul t s in

, , ,
a d ul t s wi th s t on e s n o t s ui t e d t o li th o tri t y 3 T h at a t pr e s e n t i t woul d
. .
b e wi se r n o t t o a tt e m p t t o clo s e th e bla dd e r woun d wi th s u t ur e 4 . .
Th at in r e vi e wing an ab an d on e d op e r ati on th e se t wo qu e s ti on s c all e d

I 92 I N D E X OF S UR GI CA L P R O GR E S S .
fo r an an s w e r a D i d we s t an d in a b e t t e r p o s i ti on t owar d s th e O p
. .
e rat i o n th an our pr e d e c e s s or s h a d d on e 2 T h i s qu e s tio n coul d b e

an s w e r e d in th e a ffir m ativ e a fte r th e work d on e by Dr G ar s on Pro f .
, .
Pe t e r s o n an d Sir H e nry T h o m p s o n 5 O n wh a t g roun d s wa s th e op

. .
e rat i o n ab a n d on e d ? T h e s e th e au th or e nu m e r at e d —B r i t M ed f ou r . . .
April 3 1 8 8 6 ,
.
F . S wi NFO R D E D WA R D S ( Lo n do n ) .
VI . C a s e o f R u p t u r e o f t h e K i d n e y By Mr E A L E S A
A . . .
colli e r was brough t up fro m a co al m in e s u ffe ring fro m collap se th e ,
r e s ul t o f a cru sh o f th e righ t S i de fro m a fall o f co al H e p a s s e d s o m e .
bloo d wi th h i s urin e b ut afte r a few h our s th i s s t opp e d

, H e c om .
plain e d of gre a t p ain in th e right fl ank H e d i e d 4 8 h our s a fte r th e.
inj ury .
A p os t m or te m r e v e al e d th e fact th a t th e righ t ki dn e y was d i s plac e d

-
in t o th e i liac fo s s a an d rup t ur e d wh il s t th e r e wa s a larg e accu m ula t ion

,
o f bloo d b e h in d th e p e ri t on e u m Th e qu e s t ion i s rai s e d a s t o wh e th e r

.
an y op e ra tion s h oul d h a v e b e e n p e r for m e d —La n cet March 1 3 .

,
1 88 6 .
VII . T rau m at i c By J O H N LO W E M D A
H yd r o n e p h r o s i s .
,
.
ca s e was r e la t e d in wh ich s o m e bloo d h ad b e e n e ffu s e d fro m an inj ur e d

ki d n e y giving ri s e t o a s ac p ar t o f wh ich was fo rm e d fro m th e p e lvi s
, ,
o f th e ki dn e y an d par t fro m th e s urroun d ing ti s s u e s .
Th e di sc u s s ion wh i ch r e s ul t e d t urn e d p ri n cip a lly on th e qu e s tion o f
t r e a t m e n t by inci s ion an d al s o on t h e propri e t y o f s uc h a t e r m a s

,
t rau m a t ic h y dr on e p h ro s i s wh e r e th e s ac wa s un d oub t e dly n o t d u e

,
s ol e ly t o a d ila t e d ki d n e y p e l vi s as i s th e ca s e in or d inary h y dron e
p h r o s i s — La n ce t
. April 1 0 1 8 8 6 Vol 1 p 6 8 9
.
,
. .
, . .
W B CLA R K E ( Lo n do n ) . . .
CE S O PH A GO T O M Y F O R F O R E I GN B O D I E S L O D GE D
I N T H E T UB E .
1
BY T H O MAS M MAR K OE M .
,
. D .
,
O F N E W YO R K .
S U R G E ON TO TH E NEW Y
OR K H PI TAL
OS .
H E fo l l o w in g c a s e s n e i t h e r o f w h i c h h as b e e n p u b li s h e d
, ,
fo r m t h e fo u n d a t i o n o f t h e r e m a rk s I h a v e t o O ffe r t o t h e
c o n s i d e r a t i o n o f t h e s o c i e t y o n t h e s u b j e c t O f O p e n i n g t h e oe s o
p h a g u s fo r t h e r e m o v a l o f fo r e i g n b o d i e s l o d g e d i n t h e t u b e
C A S E I —Ha rri e t J on e s wt 3 wh il e playing wi th s o m e iron j ack s

.
,
.
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s uc h a s c h il d r e n n ow u s e in p lac e o f th e o ld fa sh i on e d j ack s t on e s
go t
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o n e o f t h e m in t o h e r m ou th a n d s wallow e d i t T h e alarm wa s i m m e .
di a t e ly giv e n by h e r s i s t e r wh o was playing wi th h e r an d wh e n th e

, ,
m o th e r ran t o h e r s h e s e e m e d t o b e c h oking Th e m o th e r p u t h e r .
fing e r b ack in t o th e fauc e s an d d i s tin ctly fe l t th e for e ign b o dy b ut

, ,
only s ucc e e d e d in pu sh ing i t far th e r d o wn an d o ut o f h e r r e ach A .
d oc t or in t h e n e igh b or h oo d s a w h e r wi th in a fe w m inu t e s a n d p a s s e d ,
a prob an g wh ich h e th ough t h ad gon e d own t o th e st o m ach H e

, .
gav e th e ch il d a pow d e r wh ich h a d th e e ffe ct o f m aking h e r vo m i t

,
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a n d th e vo m i ti ng con t inu e d d uring th e w h ol e nigh t T hi s o ccurr e d on .
S un d ay Ap ril 2 5 1 8 7 5
, T h e n e x t d ay Sh e s e e m e d s ick an d pro s
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t rat e d woul d n o t willingly t ak e foo d e vi de n t ly on a ccoun t o f p ain in ,
th e a c t o f s w allowing Sh e wa s abl e t o s wallow liqui d s b u t br e a d or

.
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o th e r S li ds woul d go d own for a c e r t ain d i s t anc e an d th e n b e re

o , ,
je c t e d Th e r e was a li t tl e coug h n o d y spn oe a an d n o e vi d e nc e th a t

.
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t h e ch il d fe l t any local p ai n Th i s con tinu e d till T h ur sd ay th e 2 9 th

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wh e n I fir st s aw h e r s h e in th e m e an ti m e b e ing con s t an t ly up in th e
,
m o th e r s a rm s v e ry w e ak an d m o s t o f th e t i m e wi th h igh fe v e r
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I ex .
am in e d t h e fauc e s wi th m
y fi n g e r S h e b e ing un d e r th e in flu e nc e o f
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.
y for e ign b o dy nor coul d I d i s cov e r a n y ,
s w e lling or an
y abnorm al con di tion o f th e p ar ts wi th in m y r e ach .
C ar e ful e xplor ati on of th e n e ck e x t e rn ally di d n ot r e v e al any tum e fa c

1R
e ad b e fore th e N e w Yor k S urgi c al S o ci e ty, Ap ri l 1 2 , 1 8 86 .
1 94 TH OM A S M . M A R R OE .
t io n or any o th e r in dica tion of th e pr e s e nc e o f th e in tru d e r 1 th e n

, .
pa s s e d in t o th e oe s oph agu s a lar g e l e a d e n prob e wh i ch s truck a m e ,
t allic b o dy a ft e r i t h a d pa s s e d ab ou t fi v e i n c h e s 1 e s ti m a t e d i t s po s i .
t io n t o b e a li t tl e b e low th e cricoi d car t ilag e b ut r e n e w e d e x t e rnal p al ,
p a t i o n fail e d t o r e v e al i t s pr e s e nc e I th e n pa s s e d d ow n a pair o f lo n g
.
,
cur v e d forc e p s wi th wh ich I coul d e a s ily t o uch th e j ack ; b ut a ft e r r e

, ,
p e a t e d e ffo r t s wi th i n s t ru m e n t s o f vari e d for m a n d s iz e I cou ld n o t .
s ucc e e d i n g e t ting a h ol d on i t Al th o ugh as g e n tl e as po s s ibl e in all

.
our m anipula tio n s a s m all quan ti ty of bl o o d y m ucu s Sh ow e d m e th a t

,
s o m e d a m ag e wa s b e in g d on e t o th e m ucou s m e m bran e an d I d es i s t e d ,
a ft e r t ryin g a larg e bougi e wi th wh ich I th ough t I m igh t p u sh th e

for e ig n b o dy d own i n t o th e s t o m ach I n th i s h ow e v e r I di d n o t s u c
.
, ,
c e e d th e in s tru m e n t only p a s s ing a s b e for e ab o u t fi ve i n ch e s a n d b e

, , , ,
i n g th e r e fir m ly arr e s t e d .
T h e n e x t d ay F ri d ay th e 3 o th h aving provi d e d m y s e l f wi th o th e r
, , ,
applian c e s a n d h avi n g a sk e d Dr G e org e A Pe t e r s Dr T T S abi n e

, . .
,
. . .
,
a n d Dr M c Burn e y t o a s s i s t m e w e all m e t wi th Dr R ann e y i n wh o se

.
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care th e ca se originally was an d th e m anip ula ti o n s of th e d ay b e for e

,
w e r e r e p e a te d an d vari e d in e v e ry way wi th ou t any s ucc e s s i n d i s

,
lo d gin g th e pi e c e o f iro n I t coul d e a s ily b e t ouch e d a n d s e v e ral

.
,
t i m e s w a s fairly s e iz e d by t h e forc e p s b u t th e y coul d n o t b e m a d e t o ,
k e e p th e ir h ol d F e ari n g fur th e r a t t e m p t s woul d o n ly incr e a s e local

.
m i s ch i e f on co n s ul t a t io n we d e ci d e d t o proc e e d a t o n c e t o oe S O p h a o t
, g
o m y for wh ic h w e h a d th e co n s e n t o f t h e p ar e n t s
, .
An inci s ion wa s m a d e ab o u t m i d way b e t w e e n th e tr ach e a an d t h e

s te rno m a s t oi d m us cl e co m m e nc in g o ppo s i t e t h e m i d d l e o f th e th yr oi d
-
,
ca rt ilag e an d e x t e n di n g t o wi th in l e s s th a n an inch o f th e t op o f th e
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s t e rnu m Pa s s i n g d own b e t w e e n th e s t e r n o m a s t oi d an d s t e rno h yoi d

.
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m u s cl e s an d pu sh ing th e o m o h yoi d ou t war d we ca m e d ow n t o t h e

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l e v e l o f th e caro t i d sh e a t h wh ich w a s al s o p u sh e d ou t war d an d fro m

, ,
th i s p o i n t th e d i s s e c t io n w a s m ainly con d uc t e d by t h e h an dle o f t h e
s calp e l Car e fully d i s placing th e loo s e co n n e c tiv e t i s s u e we ca m e

.
,
d own upon th e S i d e o f t h e oe s op h agu s al o n g w h ich coul d b e d i s t in c t ly ,
s e e n t h e in fe ri o r laryn g e al n e rv e a t t h i s poi n t givi n g O ff a co n s i d e rab le

,
lat e ral branch t o th e t rach e a Th i s n e rv e w a s car e fully pu sh e d fo r

.
war d an d i t wa s n o tic e d th a t e v e ry t i m e i t wa s pr e s s e d upon by th e

,
fing e r or th e c urv e d s pat ula th e ch il d sh ow e d s ign s o f m ark e d laryn

,
g e al d i s tr e s s O n e o f t h e p air s of lo n g curv e d forc e p s we h a d b e e n

.
u sing wa s th e n pa ss e d d own clo s e d in t o th e oe s op h agu s an d by i t

, , ,
t h e oes op h agu s w a s br o u gh t in t o r e li e f i n th e wou n d A lo n gi t u dinal .
i n ci s io n O f ab ou t th r e e quar te r s o f an i n ch in le n gth wa s th e n m a d e
-
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o p e n i n g in t o t h e t ub e bri n gi n g i t s cavi t y v e ry d i s t inc t ly in t o vi e w

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$ S OP H A G O T OM Y F OR F O R E I GN B OD I E S I N TH E T UB E .
195
Drawi n g th e lip s o f th e oes op h ag e al O p e ning w e ll ap ar t th e po si tion of ,

.
th e for e ign b o d y was p lai n ly r e v e al e d An O p e ning h a d b e e n m ade . .
o f cour s e on th e l e ft s i d e
, O ppo s i te t o th e O p e ning th e r e for e on th e
.
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righ t wall o f th e t ub e wa s s e e n on e li m b o f t h e j ack proj e c ting i n t o th e

,
t ub e wh il e th e m ain b c dy O f th e j ack wa s e n t ir e ly ou t s i d e o f th e t ub e
, ,
wh ich i t m u s t th e r e for e h av e p e r forat e d fro m wi th in ou t war d H ow .
th i s irr e gularly sh ap e d b o dy coul d h av e t rav e r s e d t h e wall o f th e oe s o
p h a gu s w h e t h e r forc e d th r ough by m u s cular con trac tion t e n d ing t o

,
clo s e th e t ub e up on i t or w h e th e r i t was p u sh e d th rough by th e s pong e

,
proba n g or by th e r e p e a te d h a n dli n g s of i t wi th th e forc e p s coul d n o t

, ,
now b e a s c e r t ai n e d ; th e fac t wa s plainly vi s ibl e t o all T h a t i t wa s .
pu sh e d th rough by m e ch an ical forc e an d n ot by a proc e s s o f ulc e ra ,
t ion s e e m e d e vi d e n t fr o m i t s b e i n g s urroun d e d a n d h ugg e d by s oun d

,
t i s s u e s s o clo s e ly th a t I h a d t o c u t a p ar t of th e oe s op h ag e al wall in
or de r t o g e t th e b o dy b ack i n t o th e t ub e an d th a t t h e r e was n o in dica ,
t ion o f infla m m a t ion ulc e ra t ion or s uppura t io n in th e ni d u s

, , fro m ,
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on e o f th e b uri e d iron poin t s th e w h ol e w a s e a s ily roll e d o ut o f i t s b e d

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a n d r e m ov e d I t wa s e vi d e n t th at th e b o d y o f th e j ack m u s t h av e lain
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ou t si d e o f th e oe s oph ag e al t ub e an d b e tw e e n i t an d th e caro ti d sh e ath

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upon wh ich i t m u s t alr e a d y h av e b e g un t o pr e ss .
T h e woun d wa s broug h t t o g e th e r in i t s upp e r th r e e q uar t e r s by fi n e -
s ilk s u t ur e s th e low e r four th b e i n g l e ft op e n

, In t o th i s O p e n p or tion .
o f th e woun d a S ilk t e n t w a s in s e r t e d fo r d rainag e N o a tt e m p t wa s .
m a d e t o clo s e t h e wou n d s o f t h e oes op h agu s No v e ss e l h a d b e e n

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woun d e d wh ich r e quir e d a li ga t ur e T h e woun d was d r e s se d ligh t ly

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b ut Of cour s e wi th ou t t h o s e an t i se p ti c pr e cau t ion s wh ich w e r e th e n

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b ut i m p e r fe c t ly un d e r s t oo d Th e p ar e n t s w e r e d ir e c t e d n o t t o allow
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t h e ch il d t o s w allow any th ing a n d an e n e m a o f b e e f t e a or m ilk wa s

,
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or de r e d t o b e giv e n e v e ry th r e e h our s We w e re in for m e d th a t fro m .
th e v e ry fir st th e c h il d h a d b e e n v e ry av e r s e t o s wallow any th ing an d ,
in con s e qu e nc e h a d gr own v e ry th i n a n d fe e b l e .
M ay 1 —Pas s e d a r e s t l e s s nigh t wi th ou t s l e e p E n e m at a r e t ain e d

. .
only for ab ou t an h our O r de r e d th r e e drop s o f l au danum wi th

.
e ac h .
May 2 — Gr e at th ir s t ; e m acia tion v e ry e vi d e n t v e ry fe e bl e woun d

.
look s w e ll no tr oubl e ab ou t throa t N o s w e lling of n e ck . .
May 4 —H as b e e n allow e d t o s wallow w ate r fr ee ly I t s e e m s to

. .
giv e co m for t th ough i t all co m e s o ut Of woun d a s a s c e r t ain e d by

, ,
m e a s ur e m e n t Sh e s wallow s e a s ily
. S ti t ch e s all r e m ov e d th e
.
wou n d gap s fr e e ly E n e m a t a are r e t ain e d long e r by th e h e lp o f th e

.
lau d anu m S h e i s lo s i n g fl e sh rapi dly

. N o cough an d r e s pira tion .
,
e a sy .
1 96 TH OM A S M . M AR H OE .
May 8 — S e e m s t o b e nou ri s h e d v e ry i m p e r fe c tly by th e e n e m a t a

.
.
th ou gh t h e y are giv e n fai th fully T h e woun d d o e s n o t granula t e

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all a dh e s i on s h av e br ok e n up a n d i t s e e m s t o b e incapabl e O f r e para

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t iv e ac ti o n S o m e li ttl e m ilk i s foun d by m e a s ur e m e n t t o g o d o w n

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, ,
t o th e s t o m ac h b u t o n ly a t rifli n g qua n ti t y
, S o m e bro n ch i ti s fr om .
con s t an t we t ti n g o f th e ch e s t T h ir s t n o t so gre a t ; v e ry r e s tl e s s an d
.
s l e e pl e s s .
May 1 0 —E n e m a t a h av e b e e n giv e n by th e l o ng t ub e an d in lar ge r

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quan ti ty wi th a li ttl e bran dy Sh e lo o k s a li ttl e b e t te r a n d he r pul s e

, .
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i s s t r on g e r A pa t ch o f e ry s ip e la s sh ow e d i t s e l f on th e n o s e O r
. .
d e r e d th e pa t ch t o b e pai n t e d wi th t inc t ura fe rri c hlori di a n d t o a dd ,
o n e grain o f qui n in e t o e ach inj e c t ion w h ich are n o w pr e t ty w e ll re ,
t a in e d .
May 1 1 S e e m s brig h te r b u t e ry s ip e la s h a s S pr e a d o n th e for e

.
-
,
h e ad . S h e r e t ain s th e e n e m a t a b u t sh e i s poorly n o uri sh e d

, I h av e .
ab s tain e d fr o m pa s s ing a t ub e th r o ug h th e oe s op h agu s on acc o un t o f ,
i t s v e ry d a m ag e d c o n d i ti o n B e s i d e th e wou n d m a d e i n o p e n i n g th e
.
t ub e on t h e l e ft S i d e t h e r e i s a n o th e r larg e O p e n i n g o n th e rig h t s i d e
,
m a d e fo r t h e e x t rica t io n o f t h e for e ign bo d y an d t h e r e i s a ls o wi th o ut ,
d oub t m uch lac e ra tion o f t h e m ucou s m e m bran e cau s e d by o ur p e r

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s i s t e n t e ffo r t s a t s e izin g i t wi th th e fo rc e p s I fe ar th a t th e pa s s ag e o f
.
an i n s tru m e n t fro m th e m o u th m igh t d o m uch m i s ch i e f an d m igh t i n .
cr e a s e fu t ur e troubl e sh oul d th e p a ti e n t r e cov e r Th e pu ls e i s m uch

,
.
b e tt e r ; n o r e para tiv e ac tion in th e w o u n d .
May 1 2 — A s u d de n c h ang e t ook plac e a ft e r m y vi s i t y e s t e r d ay

. .
T h e ch il d s e e m s now dyi n g o f m e r e inani t ion th oug h t h e e n e m a t a are ,
giv e n r e gu larly an d are m o s tly w e ll r e t ain e d I i m m e dia t e ly in tro .
d u c e d a t ub e i n t o th e s t o m ac h a n d th r e w in four o unc e s O f war m m ilk

p unch I t was t o o la t e T h e ch il d ral li e d for a li ttl e ti m e an d di e d
. .
,
ab ou t th r e e h our s afte r .
CA S E II — R ich ar d Gh e n t ag e d t we n t y four a p ain te r by tr a de was

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,
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a dm i tt e d i n t o th e N e w Y ork Ho spi t al January 2 2 1 8 8 6 Ab o u t fi ve ,

.
w e e k s b e for e a dm i s s ion w h il e e a ting s upp e r a pla te c o n tai n in g fo ur

, ,
ar tificial t e e th br ok e in h i s m o u th an d th e p ala te p or ti on wa s s wall o w e d

,
.
H e m a d e a t t e m p t s i m m e dia t e l y t o vo m i t a n d tri e d t o d i s l o d g e t h e ,
plat e b u t d id n o t s ucc e e d H e s ay s th a t s e v e ral s urg e on s h av e m a d e

,
.
a tt e m p t s t o r e m ov e th e pla te b ut h av e n ot s ucc e e de d T h e pa ti e n t i s .
a m a n in fair c o n di ti o n o f h e al th a n d vig o r an d d oe s n ot s e e m t o h av e ,
s u ffe r e d m a t e rially fr o m failur e o f n u t ri t io n T hi s i s d ue t o th e fac t .
th a t t h o ug h h e h a s n o t b e e n abl e t o s wa ll o w s oli d fo o d h e h as b e e n
, ,
abl e t o s wallow flui d s wi th c o m para tiv e c o m fo r t H e s ay s h e c an fe e l .
d i s ti n c t ly th e S po t wh e r e th e fo r e ign b o dy h as l o dge d a n d i n d ica te s a ,

( E S OP H A G O T OIII Y F OR F OR E I GN B OD I E S I N TH E T UB E .
I 97
p oi n t j u s t b e low th e larynx b u t s ay s i t giv e s h i m no p ain nor i s th e r e

, ,
a n y t e n d e r n e s s t o b e d i s cov e r e d i n th e r e gi o n w h e r e h e s ay s h e fe e ls i t .
A lar g e No 1 2 oe S O p h a g e a ls t ub e d e t e c t s an ob st ruc tion j u s t b e low th e

.
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cricoi d car tila g e abou t e ig h t inch e s fro m th e t e e th ; a s m all o n e N o

, , .
4 pa s s e s e a sily in t o th e s t o m ach
, .
J an uary 2 9 — A t te m p t s w e r e m a de t o r e m ov e th e pla te an d it was

.
,
foun d n o t di fficul t t o s e iz e i t wi th th e coi n ca t ch e r b u t w h e n s o s e iz e d -

,
i t wa s fo un d s o i m m ovab ly fix e d t h a t th e forc e t h a t we th oug h t i t s a fe

t o e m ploy d i d n o t c h a n g e i t s po s i tio n in th e l e a s t A larg e s t o m ach .
'
p u m p t ub e wa s th e n p a s s e d d o wn to th e for e ign b o dy an d an a tte m p t ,
m a d e t o forc e i t d o wnwar d i n t o th e s t o m ach wi t h th e s am e r e s ul t , .
F ro m th e lo n g t i m e w h ich h a d e lap s e d fro m th e ti m e o f l o dg m e n t an d ,
fro m th e fi xe d n e s s o f th e b o dy I fe l t qui te s ur e th a t i t h a d par tly ui

,
c e ra t e d i t s way o ut O f th e t ub e an d th a t th e r e for e any un d u e forc e in

,
e x trac tion woul d w h il e i t wa s u n availing prov e d i s a s t rou s t o t h e oe s o

, , ,
p a g us an d t o t h e par t s ar o u n d i t
h R e a s o ni n g th u s we r e co m m e n d e d
.
,
t h a t ano t h e r a t t e m p t s h ou ld b e m a d e un d e r e th e r an d i f n o t s ucc e s s , ,
ful th a t oe s op h ago t o m y s h oul d b e p e r for m e d

, .
F e bruary 9 — T h e p a ti e n t w a s plac e d fu lly un d e r th e influ e nc e o f

.
e th e r a n d agai n th e for e ig n b o dy wa s s e iz e d wi th th e coin ca t c h e r b ut

,
-
,
t h e co m pl e t e r e laxa t ion pro d uc e d by th e an ws th e ti c h a d n o t loo s e n e d
in th e s lig h t e s t d e gr e e th e gra s p o f th e oe s op h agu s an d th e O p e ra tion ,
was proc e e d e d wi th An i n ci s io n four i n ch e s an d a h al f i n l e ng th wa s

.
'
m a d e e x te n d i n g fro m
, th e t o p o f th e t h yroi d car tilag e n e arly t o th e
clavicl e alo n g th e in n e r b o r d e r o f th e s t e rn o m a s t oi d m u s cl e pa s s i n g
,
-
,
obliqu e ly s o t h a t th e upp e r e n d o f th e i n c i s i o n wa s h al f an inch in t e rnal

t o t h e e d g e O f th e m u s cl e w h il e th e low e r e n d ov e rlapp e d i t n e arly a s
,
m uc h T h e o m o hyoi d wa s divi d e d an d th e n pa s s ing d own b e tw e e n

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th e s t e rno m a s t oi d an d t h e s t e rno h yoi d m u s cl e s a n d pu sh ing th e t h y

- -
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roi d b o dy inwar d th e s i d e o f th e oes op h agu s wa s e a s ily r e ach e d by

,
s e para t i n g t h e lo o s e ar e olar t e xt ur e s wi th th e fin g e r a n d th e h an d l e o f
th e s ca lp e l T h e r e curr e n t laryng e al n e rv e wa s n o t s e e n an d no ve s
.
,
s e l was c u t o f a s iz e r e quiri n g liga t ur e Th e oe s op h agu s was now m a d e

.
t o bulg e i n t o th e woun d by pa s s i n g th e larg e s t o m ac h p u m p t ub e d own -
t o th e p o in t o f ob s truc ti on an d th e n pr e s s i n g wi th t h e fing e r s d e e ply
o n th e rig h t s i d e o f t h e t rac h e a T h i s broug h t th e s i d e o f th e oeS Op h a

.
gu s fully in t o vi e w an d e nabl e d u s v e ry e a s ily t o m a k e a longi t u d inal

inci s i o n i n t o i t abou t an i n ch long op e nin g th e t ub e j u s t abov e th e
,
p o in t o f l od g m e n t a n d bri n gi n g i n t o vi e w th e fo r e i gn bo dy wh ich was ,
s e e n t o occupy a p o s i tion parall e l wi th th e axi s o f th e oe s op h agu s a n d
ab ou t a t a righ t a n gl e t o th e m e d i an plan e o f th e bo dy I t was s e iz e d .
wi th a d re s s ing forc e p s b ut wa s fo un d a s i m m ovabl e as e v e r I t wa s

,
.
198 TH OM A S M M A R H OE
. .
n ot ill th e i n ci sion wa s prolong e d d ownwar d s o as t o c u t th roug h t h e

t ,
oes op h ag e al wall w h ic h e m brac e d t h e pla t e s o fir m ly th a t i t coul d b e ,
s t irr e d fro m i t s b e d I t wa s th e n e a s ily r e m ov e d

. I t woul d n a t urall y .
b e e xp e c t e d th a t s uch fi rm i m pac tion d uring s o long a p e rio d woul d

h av e b e e n acco m pa n i e d by s o m e ulc e ra ti o n o f th e s ur fac e s agai n s t
wh ich th e for e i g n bo dy h ad s o long b e e n pr e s s i n g A car e ful i n sp e c .
t io n wi th a goo d lig h t e nabl e d u s t o fe e l pr e t ty s ur e th a t v e ry s lig h t
abra s ion o f th e s ur fac e h a d t ak e n plac e a n d th a t th e r e a s on why th e ,
pla te wa s s o fir m ly h e l d was th a t th e t ub e h a d con t rac t e d S O fir m ly

ab ov e th e poin t of d i s t e n sion a s t o r e s i s t a ll our e ffor ts at d i s lo d g e m e n t .
A s o ft rubb e r t ub e wa s n o w in tr od uc e d t hrough th e w o un d an d p a s s e d
-
,
in to th e s t o m ach an d l e ft i n s i t u Car e ful an ti s e p tic d r e s sing s w e r e

, .
appli e d fro m w h ich th e t ub e wh ich h a d a funn e l sh ap e d e x tre m i ty

, ,
-
,
was allow e d t o proj e c t I t wa s e x t r e m e ly e a s y t o p a s s flui d s th rough

.
th i s t ub e in t o th e s t o m ac h u s ually by m e r e ly p ourin g th e m S lowly in t o

,
t h e funn e l t h oug h occa s ionally i t was n e c e s s ary t o forc e t h e m t h rough

,
wi th th e s t o m ach p u m p -
Th e r e wa s v e ry li t tl e infla m m at ory r e ac t ion afte r th e Op e ra t ion Th e .
t e m p e ra t ur e s carc e ly ro s e abov e a n d t h e w o un d b e h av e d in a
m o s t s ati s fac t ory m ann e r T h e t ub e gav e no p ain or un e a s in e s s an d

.
,
a ffor d e d th e m o s t co m for t abl e po s s ibl e m e an s o f ali m e n t a t ion H i s .
g e n e ral co n di t ion wa s w e ll m ain t ain e d an d h i s nu tri tion p e r fe c t O n,

.
th e 1 9 th a s th e woun d wa s granulat ing fin e ly a n d looki n g p e r fe c tly

, ,
h e al th y an d r e a d y t o h e al th e t ub e wa s r e m ov e d , B e for e i t wa s t ak e n .
o u t h ow e v e r a s i m ilar t ub e wa s in tro d uc e d in t o t h e l e ft no s t ril an d

, , ,
.
,
a s t h e fir s t t ub e wa s r e m ov e d th e s e con d wa s S lipp e d by th e wo un d
,
in t o th e s t o m ach Th i s again prov e d an e a s y a n d co m for t abl e way o f

.
fe e ding th e t ub e th rough th e n o se giving ri s e o nly t o a li ttl e s or e n e s s

,
in th e m e at u s thr oug h wh ich i t p a s s e d b ut n ot e nough t o cal l for ,
tr e a t m e n t Th i s s e con d t ub e wa s u s e d wi th a vi e w o f pr e v e n ting any

.
m a tt e r s g e tting o u t o f th e oe s op h ag e al woun d i n th e ac t o f d e glu t i tion
in t o th e ye t unh e al e d fi s tu lo u s t rack l e ft by th e r e m oval o f t h e origi n al

t ub e I t s e e m e d t o a n s w e r i ts purp os e p e r fe c tly th e wou n d clo s ing
.
,
pro m p tly a n d h e alin g s o w e ll th a t on th e 2 6th th e na s al t ub e wa s re

m ov e d a n d th e p a ti e n t was allow e d t o s wallow s o ft fo o d wi t h ou t t e
,
s tric ti on N 0 fur th e r in te rrup tion t o th e h e ali n g occurr e d an d th e p a

.
,
t i e n t was w e ll by th e i 5 th o f Marc h .
Th e p e r a t i o n o f w S O p h a g o t o m y fo r t h e r e m o v al o f i m p a c t e d
O
fo r e i g n b o d i e s i s n o w o n e o f u n iv e r s a l a c c e p t a n c e As a le g it .
i m at e s u r g i c a l r e s o u r c e h o w e v e r i t w a s S l o w i n a c h i e v i n g
, ,
t h i s p o s i t i o n a n d wa s r e c e i v e d w i t h m u c h d i s t r u s t a n d h e s i t a
,
G S OP H A G O T OM Y F OR F OR E I GN B OD I E S I N TH E T UB E .
19
9
t i o n t il l c o m p a r a t i v e l y r e c e n t p e r i o d M r A r n o tt
w i th i n a . .
,
s u r g e o n o f th e M i d d l e s e x H o s p i t a l w r i t in g i n 1 8 3 3 s a y s : I n“
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g g
a n o p e r a t i o n w h i c h h a s r a r e l y b e e n p e r fo r m e d I t i s s t at e d t o
.
h a v e b e e n t wi c e e x e c u t e d i n Fr a n c e a b o u t a c e n t u r y a g o a n d ,
o n c e a g a i n l a t e l y b u t I c a n fi n d n o r e c o r d o f i t s h a vi n g b e e n
,
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d o n e i n En g l a n d S i n c e t h e o c ca s i o n s fo r i t s p e r fo r m a n c e
.
m u s t h av e b e e n q u i t e a s fr e q u e n t i n f o r m e r t i m e s a s t h e y a r e
at p r e s e n t i t i s n o t q u i t e e a s y t o e x p l a i n t h e t i m i d i t y o f o o d
, g
a n d o th e r w i s e b o l d s u r e o n s i n r e g a r d t o t h i s o p e r at i o n I t
g .
s e e m s li k e l y t h at t h e d e p t h o f i n ci s i o n i n t h e n e c k n e c e s s a r y t o
r e a c h t h e oe s o p h a g u s a n d t h e i m p o r t a n t o r g a n s a m o n g w h i c h
,
t h at i n c i s i o n m u s t p as s d e t e rr e d s u r g e o n s fr o m a tt e m p t i n g
,
oe s o p h a g o t o m y i n c as e s w h e n w e s h o u l d n o w c o n s i d e r i t
_
c l e a r l y i n d i c at e d P e rh a p s a l s o t h e fa c t s t h a t t h e o c c as i o n s
.
fo r i t s p e r fo r m a n c e w e r e s o r a r e t h a t n o o n e s u r g e o n c o u l d
e v e r h o p e t o a c q u i r e a l a r g e e x p e r i e n c e i n i t i s a g o o d r e as o n
w h y b u t fe w h a d t h e c o u r a g e t o r e s o r t t o i t T h at t h i s i s t r u e
.
i s s e e n b y s t at i s t i c a l t a b l e s w h i c h S h o w t h at o u t o f e i g h t y two -
c a s e s w h i c h h a v e b e e n c o l l e c t e d u p t o d a t e o nl y fi v e m e n
, ,
h av e h a d m o r e t h a n tw o c a s e s : a n d o f t h e s e fi v e o n l y t w o h a d
, ,
a n e x p e i e n c e e m b r a c in g fi v e c a s e s
. Bu t p r o b a b l y t h e m o s t
.
p o t e n t r e a s o n fo r n o t d o i n g oe s o p h a g o t o m y w a s fo u n d i n t h e
i l l u s i v e h o p e t h a t t h e fo r e i g n b o d y w o u l d b e s p o n t a n e o u s l y
dis l o dg e d T h i s h o p e h a s b e e n I fe e l q u i t e s u r e e n c o u r a g e d
.
, ,
b y t h e fr e q u e n c y w i t h w h i c h fo r e i g n b o d i e s h a v e b e e n s p o n
t a n e o u s ly e x p e l l e d fr o m t h e a i r p a s s a g e s a ft e r a l o d g m e n t o f
-
m o n th s a n d e v e n y e a rs I n c r e a s i n g e x p e r i e n c e h as s h o w n
.
t h at t h e p h y s i c a l a n d v i t a l c o n d i t i o n s are n o t t h e s a m e i n th e
two s e t s o f c a s e s . h a i —
I n t e r p as s a g e s w e h a v e a n o p e n t u b e ,
a c o l u m n o f a ir t o a c t u p o n t h e fo r e i g n b o d y a n d a ll t h e ,
p o w e r o f t h e n u m e r o u s a n d s t r o n g m u s cl e s e n g a g e d i n t h e e f
f o r t o f fo r c e d e x p i r a t i o n I f i t w e r e n o t fo r t h e s p a s m o d i c r e
.
s is t a n c e o f th e
g l o tt i s e v e r y fo r e i g n b o d y n o t t o o fi r m l y fi x e d
, ,
b y s i z e o r s h a p e w o u l d b e e as i l y e x p e ll e d t h r o u g h t h e l a r y n x
, .
N o s u c h p r o vi s i o n e x i s t s i n t h e oe s o p h a g u s a n d i f t h e i n , ,
t r u d e r c a n n o t b e d i s l o d g e d b y fo r c e p s o r p r o b a n g a n d c a n ,
n o t b e p u s h e d i n t o t h e s t o m a c h t h e r e s e e m t o b e h a rd l y a n
, y
m e a n s a n d t h e r e fo r e
, , l i tt l e h o p e o f s p o n t a n e o u s e x p u l s i o n
,
2 00 TH OM A S M M A R K OE .
Th e c o n s e q u e n c e s O f s u c h u n d i s t u r b e d l o d g m e n t are n o w u m
d e rs t o o d t o b e d i s a s t r o u s i n e v e r y c a s e a n d fat a l i n a fr i g h t ,
fu ll y l a r g e p r o p o r t i o n T h e s e c o n s e qu e n c e s a re fa m ili a r t o u s
.
a ll a n d a r e y e a r l y i ll u s t r a t e d b y
, fa t a l c a s e s p u b li s h e d i n t h e
j o u r n a l s O n e o f t h e s e w a s r e l a t e d b y D r W T B u ll a t a
. . . .
,
r e c e n t m e e t i n g o f t h e s o c i e t y i n w h i c h a h o r s e c h e s t n u t lo d g
,
-
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in g n e a r t h e c a r d i a c e x t r e mi t y O f t h e p y l o r u s h a d p r o d u c e d a ,
p e r fo ra t i o n o f t h e p l e u r a w h i c h w a s fi ll e d w i t h a m i x t u r e o f
,
v ari o u s i n g e s ta i n a s tat e o f d e c o m p o s it i o n t h e l u n g its e l f ,
b e i n g c o l l a p s e d M r B ry a n t q u o t e s s e v e ra l c a s e s o n e i n
. .
,
w h i c h a fi s h b o n e c a u s e d d e a t h b y p e r fo r a t i o n o f t h e h e a r t a n
-
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o t h e r i n w h i c h t h e a o r t a w a s e r o d e d b y a s h a rp s p i c u l u m O f
b o n e a n d a n o t h e r i n w h i c h fa t a l i n fl a m m at i o n o f t h e S p i n a l
,
c o r d w a s p r o d u c e d as a c o n s e q u e n c e o f u l c e r at i o n O f t h e i n t e r
v e r t e b r a l s u b s t a n c e fo l l o w i n g t h e a r r e s t o f a p i e c e o f b o n e i n
t h e oe s o p h a g u s M r B r y a n t a l s o a ll u d e s t o t w o c a s es r e p o r t e d
. .
b y M r E r i c h s e n i n o n e o f w h i c h a p i e c e o f g u t t a p e r c h a fo r m e d
.
,
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fo r i t s e l f a b e d i n t h e w a l l O f t h e oe s o p h a g u s fo r u p w a r d o f s i x
m o n t h s a n d d e s t r o y e d li fe b y u l c e r a t i o n i n t o a l a r g e v e s s e l a n d
, ,
c o n s e qu e n t h w m o r rh a g e ; a n d a s e c o n d i n w h i c h a fat a l r e s u l t
w as b r o u g h t a b o u t b y a h a l f c r o w n u l c e rat i n g i t s w ay i n t o t h e
-
O n e v e ry i n t e r e s t i n g c as e o c c u rr e d t o M r B e n n e tt
'
a o rt a . .
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, ,
n al i m p a c t i o n d a n e r o u s r e s u l t s m a b e ap p re h e n de d I t oc
g , y .
c u rr e d i n a c h i l d 7 y e a r s o ld fr o m w h o m h e r e m o v e d b y oe s o p h
, ,
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,
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y e a r s a n d a h a l f b e fo r e I t h a d u l c e r a t e d t h r o u g h t h e oe s o p h
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ag u s an d o p e n e d th e ri g ht b r o n ch u s a n d w as l y i n g p art l y ,
i n t h e b r o n c h u s a n d p a rt l y i n t h e w S O p h a g u s M r M ay h a d . .
t h e g o o d fo r t u n e t o s a v e h i s p a t i e n t b y h i s o p e r a t i o n M an y .
o t h e r fat a l r e s u l t s o f oe s o p h a g e a l i m p a c t i o n m i g h t b e c i t e d ,
b u t fr o m t h e c u r s o r y g l an c e I h a v e b e e n a b l e t o t a k e o f t h e
,
l i t e r a t u r e O f t h e s u b j e c t I fe e l qu i t e s u r e t h at i t w o u l d b e d i ffi
,
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c u l t t o fi n d a m o n g a ll t h e r e c o r d e d c a s e s a s m a n y o f S p o n
, ,
t a n e o u s r e c o v e r y a s I h a v e h e r e g iv e n a s h a v i n g a fa t a l i s s u e .
T h e s e c o n s i d e r at i o n s e x p l a i n a t l e a s t i n p a r t t h e s l o w p r o g
, ,
r e s s o f t h i s o p e r a t i o n i n p u b l i c fa v o r a n d a t t h e s a m e t i m e ,
t h e y p o i n t o u t t h e i n d i c a t i o n s fo r i t s p e r fo r m a n c e Th u s it .
m a y b e s t a t e d t h a t w h e r e a fo r e i g n b o d y h a s l o d g e d i n t h e
Q QS OP H A G O T OM Y F OR F OR E I GN B OD I E S I N TH E T UB E .
20 1
oe s o p h a g u s a n d c a n n o t b e r e m o v e d b y fo r c e p s o r s n a r e fr o m
,
th e m o u th a n d c a n n o t b e p u s h e d i n t o th e s t o m a c h it s h o u l d
, ,
b e r e m o v e d b y oe s o p h a g o t o m y p r o v i d e d i t h a s l o d g e d a t a
,
p o i n t a c c e s s ib l e t o t h e s u r g e o n s k n i fe a n d t h at t h e o p e r a t i o n
’
s h o u l d n o t b e d e l a y e d in th e h o p e o f s p o nta n e o u s e x p u l s i o n .
O f c o u r s e b e fo r e p r o c e e d i n g t o s o s e r i o u s a n O p e r a t i o n t h e
, ,
d i a g n o s i s s h o u l d b e c e rt a i n a n d t h i s u s u a l l y p r e s e n t s n o d iffi
,
c u l t y T h e h i s t o ry O f t h e a c c i d e n t t h e s e n s at i o n s o f t h e p a
.
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t i e n t t h e b e h a v i o r i n r e g a r d t o s w a ll o w i n
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g a n d a b o v e a ll t h e
, , ,
p o s i t i v e e vi d e n c e a ffo r d e d b y t h e b o u g i e u s u a l l y l e a v e n o ,
d o u b t i n t h e m i n d o f t h e s u r g e o n b o t h a s t o t h e fa c t o f i m
p a c t i o n a n d o f t h e p r e ci s e s p o t at w h i c h i t h a s o c c u rr e d I t .
S h o u l d b e n o t e d h e r e t h a t e x t e r n a l p a l p a t i o n ra r e l y i v
g e s a ny
as s ista n c e i n a s c e r t a i n i n g t h e p r e s e n c e o f a fo r e i g n b o d y
l o d g e d i n t h e oe s o p h a g u s T h e t u b e l i e s s o d e e p b e h i n d t h e
.
t r a c h e a a n d b e l o w a ll t h e m u s c l e s o f t h e n e c k t h a t t h e h a r d e s t ,
a n d m o s t i rr e
g u l a r s u b s t a n c e s l o d g e d i n i t c a n v e ry r a r e l y b e
a p p r e c i a t e d b y e x t e r n a l e x a m i n at i o n O f th e O p e r a t i o n i t s e l f
.
,
n o t h i n g n e e d s t o b e s a i d t o t h i s s o ci e t y T h e p l a n o f i t i s S i m
.
p le an d th e e x e c u t i o n e as
y ,
r e q u i ri n
g o n l y d e l i c a c y a n d c a r e
fu l n e s s i n i t s p e r fo r m a n c e . I t s h o u l d b e d o n e o n t h e l e ft s i d e ,
a s t h e oe s o p h a g u s i n c l i n e s t o t h at S i d e a n d it s h o u l d b e c o m
,
e
m e n c e d b y a v e r y li b e r a l i n c i s i o n o f fr o m fo u r t o fi v e i n c h e s i n
l e n g t h i n o r d e r t o g iv e a c h a n c e t o c o n d u c t t h e d e e p e r m a
,
n i u la t i o n s a s fa r a s p o s s i b l e
p , ,
b y t h e s e nse of si ht
g .
I t i s m o r e p a r t i c u l a r l y t o t h e m a n a g e m e n t o f t h e c as e a ft e r
o p e r at i o n t h a t I w i s h t o d i r e c t t h e a t t e n t i o n o f t h e s o c i e t y .
V a r i o u s p l a n s h av e b e e n s u g g e s t e d b y v a r i o u s o p e rat o rs a s t o
t h e t w o p r i m e p o i n t s w h i c h p r e s e n t t h e m s e lv e s t o t h e s u r g e o n
a ft e r h e h a s c o m p l e t e d h i s o p e r a t i o n .F i rs t t h e h ea li n g o f t h e
,
w o u n d w i t h t h e l e a s t r i s k o f w o u n d c o m p li c a t i o n s ; a n d s e c o n d , ,
n u t r i t i o n o f t h e p at i e n t n o t m e r e l y w i th th e v i e w o f s u s t a i n i n g
,
l i fe b ut a l s o o f m a i n t ai n i n g r e p a r a t iv e p o w e r a t a p o i n t a t
,
w h i c h i t w il l p r o v e i t s e l f c a p a b l e o f h e a li n g a l a r g e d e e p a n d ,
d i ffi c u l t w o u n d I fe e l t h a t it w a s a fa i l u r e o n m y p a r t t o a p
.
p r e c i a t e t h e i m p o r t a n c e o f t h i s l a tt e r p o i n t w h i c h c a u s e d t h e
u n f o r t u n at e r e s u l t i n m y fi r s t c a s e a n d I d e t e rm i n e d s h o u l d
'
, ,
a n o t h e r c a s e b e p l a c e d i n m y h a n d s t h at m al n u tr i t i o n s h o u l d
,
n o t c a u s e i t s fa i l u r e i f i t c o u l d b e p r e v e n t e d ; O f c o u rs e i t i s ,
20 2 TH OIII A S III . III A R K OE .
u n d e r s t o o d t h a t s w a l l o w i n g o f fo o d i n t h e u s u a l w a y c a n n o t b e
p e r m i t t e d fo r t h e o b vi o u s r e a s o n t h at s u c h s w a l l o w in g w o u l d
,
p re v e n t th e h e a l i n g o f t h e w o u n d e d g u l l e t w o u l d a l l o w th e e s ,
c a p e o f fo o d i n a m o r e o r l e s s s e p t i c c o n d i t i o n i n t o t h e c a vi t y
o f t h e w o u n d o u t s i d e a n d t h u s i n fl a m m at o r
, y c o m p l i c at i o n s o f
t h e m o s t s e r i o u s n a t u r e w o u l d a l m o s t n e c e s s a r i l y s u p e rv e n e .
T o m a i n t a i n t h e n u t r i t i o n o f t h e p a t i e n t t h e n e i t h e r fo o d m u s t
, ,
b e t r a n s m i tt e d t o t h e s t o m a c h b y t u b e s p a s t t h e w o u n d e d
p o i n t o f t h e oe s o p h a g u s o r e l s e r e li a n c e m u s t b e h a d o n r e c t a l
,
a li m e n t a t i o n
. R e c t a l a l i m e n t a t i o n h o w e v e r a ffo r d s u s o nl y a
, ,
l i m i t e d re s o u r c e i n n u t r it i o n T h o u g h i t m ay s e r v e u s w e l l
.
d u r in g t e m p o r a r y i n t e rr u p t i o n o f g a s t r i c d i g e s t i o n fr o m a n y
c a u s e ye t l i fe c a n n o t l o n g b e s u s t a i n e d b y i t a n d w h e n s u s
, , ,
t a i n e d t h e n u t r i t iv e c o n d i t i o n s c a n r a r e l y b e k e p t u p t o t h e
,
h i g h r e p a r a t i v e p o i n t n e c e s s a r y fo r t h e h e a l i n g o f a l a r g e O p
e ra t i o n w o u n d . T h i s V i e w o f th e l i m i t a t i o n o f re c t a l a l i m e n t a
t i o n h as b e e n g r o w i n g s t r o n g e r i n m y m i n d e v e r s i n c e m y a t
t e n t i o n w a s c a l l e d t o t h e s u bj e c t b y t h e c o n s p i c u o u s fa il u r e t o
s e c u re p r o p e r n u t r i t i o n i n th e fi rs t c a s e I h av e n a rr a t e d ; a n d
I b e l i e v e t h at i f I h a d fu ll y a p p r e c i at e d j u s t h o w li t t l e r e l i a n c e
,
w a s t o b e p l a c e d o n i t m y li tt l e p a t i e n t m i g h t h a v e b e e n a liv e
,
a n d w e l l at th i s m o m e n t It is t r u e t h at i n t h i s c as e t h e c o n d i
.
t i o n s w e r e u n fa v o r a b l e fo r t h e p a s s a g e o f a t u b e t h r o u g h e i t h e r
t h e m o u t h o r t h e w o u n d T h e e x t e n s i v e l y d a m a g e d oe s o p h a g u s
.
m a d e i t h i g h l y p r o p e r t o a v o i d a n y fu r t h e r i nj u ry if i t c o u l d i n ,
a n y w ay b e a v o i d e d a n d t h i s m u s t b e t h e e x p l a n a t i o n
,
if n ot ,
t h e j u s t i fi c at i o n o f th e c o u r s e p u rs u e d
,
Bu t h a d I a t t h a t t i m e
.
t h e s a m e c o n v i c t i o n s I n o w e n t e r t a i n w i t h r e fe r e n c e t o r e c t a l
a l i m e n tat i o n,
I s h o u l d a t a ll h a z a r d s h a v e p a s s e d a t u b e
t h r o u g h e i t h e r t h e m o u th o r t h e w o u n d a n d t h u s h a v e s e c u r e d ,
t h a t f u l l r e p a r a t iv e n u t r i t i o n w i t h o u t w h i c h i n m y c a s e a ll re , ,
p a i r b r o k e u p at t h e w o u n d e r y s i p e l as s e t i n a n d th e p at i e n t
, ,
s u n k s o r a p i d l y t h a t w h e n a t u b e w a s i n t r o d u c e d a n d p l e n t i fu l
,
n o u r i s h m e n t w a s s u p p l i e d i t c a m e t o o l a t e t o s a v e t h e l i fe
,
w h i c h I h a d b e e n fo r s o m a n y d a y s b l i n d l y t r u s t in g t o a m o s t
u n r e l i a b l e s u p p o rt e r .
T h e m a n a g e m e n t o f t h e s e c o n d c as e s e e m s t o m e t o p r e s e n t
a m u ch b e t te r p ro s p e c t o f s u c c e s s D e t e rm i n e d t o s e c u r e g a s
.
t r i c a l i m e n t a t i o n t h e c h o i c e o f m e a n s la y b e t w e e n i n t r o d u ci n g
,
G S OP H A G O T OI V
I Y F OR F OR E I GN B OD I E S I N TH E T UBE .
20 3
a t u b e th ro u gh o u t h o r w o u n d w h e n e v e r it wa s n e c e s s a r y
th e m
t o g i v e n o u r n i s h m e n t o r l e a v in g a t u b e
,
p as s e d t h r o u g h t h e
,
m o u t h o r w o u n d c o n s t a n t l y i n s i ta
, t h u s p e rm i t t i n g n o u r i s h
,
m e n t b e in g g i v e n w h e n e v e r d e s i r e d .I c h o s e t o l e a v e the t u b e
i n t h e w o u n d fo r s e v e r a l r e as o n s .F i r s t I t h o u g h t t h at t h e
,
t u b e w o u l d i n s u r e t h e d r a i n a g e fr o m t h e b o tt o m o f t h e d e e p
w o u n d ; s e c o n d l y th at i t w o u l d t e n d t o p r e v e n t t h e e n t r a n c e o f
,
a n y m a t t e r s r e g u r i t a t e d fr o m t h e s t o m a c h ; a n d l a s t l y
g I w as , ,
c o n fi d e n t t h at t h e t u b e t h r o u gh w o u n d w o u l d b e m u c h l e s s
d i s t r e s s i n g t o t h e p at i e n t t h a n a s i m i l a r t u b e p a s s e d t h r o u g h
t h e m o u th o r th e n o s t ri l I e n t i r e l y r ej e c t e d t h e i d e a o f t h e
.
fr e q u e n t i n t r o d u c t i o n o f t h e t u b e b e c a u s e I fe l t c o n vi n c e d t h a t
,
s u c h a p r o c e d u r e w o u l d n o t o n l y s e ri o u s l y d i s t u r b t h e h e al i n
g
p r o c e s s b u t w o u l d b e s u c h a d r e a d a n d a t r i a l t o t h e p at i e n t
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a n d s u c h a t a x o n t h e s u rg e o n th a t t h e r e s u l t w o u l d b e t h at
,
th e t u b e w o u l d b e i n t r o d u c e d as ra re l y a s p o s s i b l e a n d w h e n , ,
i n t r o d u c e d t h e s t o m a c h w o u l d b e d i s t e n de d w i th as m u c h
,
fo o d a s i t w o u l d h o l d i n o r d e r t o p r e v e n t t h e n e c e s s i t y o f e a r l y
,
r e p e t i t i o n o f t h e t r o u b l e s o m e p r o c e d u r e —a c o n d i t i o n o f t h e
s t o m a c h b y n o m e a n s c o n d u c iv e t o c o m fo r t o r t o g o o d d i g e s
tio n . I n a ll t h e s e r e s p e c ts t h e c a s e a n s w e r e d m y b e s t e x p e c
t at i o n s . Th e t u b e i n t h e w o u n d c o m i n g o ut t h r o u g h t h e d re s s
i n g w a s a l w a y s a v a il a b l e fo r u s e a n d s m a l l q u a n t i t e s o f n o u r
,
i sh i n g fl u i d w e re c o n s ta n t ly s u p p l i e d b y t h e h a n d s o f th e
n u rs e w i t h o u t p a i n a n d w i t h o u t t r o u b l e a n d w i th o u t a ny o v e r
,
t a x i n g o r d i s t re s s i n g o f t h e d i g e s t i o n ; a n d r e g u rg i t at i o n w h i c h ,
r a r e l y o c c u rr e d t o o k p l a c e t h r o u g h t h e t u b e w i t h o u t a t a n y
, ,
t i m e a p p e a ri n g a r o u n d o r t h r o u gh t h e d re s s i n g s The w o u n d .
w a s p e r fe c t l y d r a i n e d a n d g r a n ul a t e d h e a l t h fu l l y fr o m t h e b e
,
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2 04 TH OM A S M . M AR K OE .
w h o l e n u m b e r o f p e r s o n s o p e r a t e d u p o n u p t o d at e i s 8 2 O f .
t h e s e c a s e s 6 3 w e r e s u c c e s s fu l a n d 1 9 fo l l o w e d b y d e a t h ,
Of .
t h e 8 2 c a s e s t h e fo r e i g n b o d y w as fo u n d a n d r e m o v e d i n 7 4 ,
a n d o f t h e s e 5 7 r e c o v e re d a n d 1 7 d i e d T h e fo r e i g n b o d y w a s .
n o t f o u n d i n 7 c as e s a n d i n o n e c a s e i t w a s fo u n d b u t s l i p p e d
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i n t o t h e s t o m a c h a n d p a s s e d p e r ( mu m I n o n e o f Bi llé s c as e s
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t h e fo r e i g n b o d y s l i p p e d i n t o t h e s t o m a c h a n d w as t h e n c e re ,
m o v e d b y g a s t r o t o m y t h e p a t i e n t d y in g o f p e r i t o n i t i s
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c as e o f c o u r s e t h e fa t a l r e s u l t s h o u l d n o t b e c r e d i t e d t o t h e
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t h e t i m e a t w h i c h o p e r a t i o n w a s p e r fo r m e d a ft e r t h e i m p a c t i o n .
I fe e l c e rt a i n t h a t d e l a y w o u l d b e a c c o u n t a b l e fo r a v e ry
g r e at l y i n c re a s e d d e ath rat e I n t h i s c o n n e c t i o n i t m ay b e
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w e l l t o c a l l a t t e n t i o n t o t h e e vi l e ffe c t s o f d e l a y e v e n i n t h o s e ,
c a s e s w h e r e t h e fo r e i g n b o d y c a n b e d i s l o d g e d w i t h o u t oe s o
p h ag o t o m y I n th e s e c a s e s t w o c a u s e s c o n t r i b u t e t o m ak e
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d e l a y dis astr o u s F i r s t t h e t e n d e n c y o f t h e fo r e i g n b o d y p a r
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t i c u la rly i f i t i s h a r d a n d r o u g h t o m a k e i t s w ay o u t o f t h e ,
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p o rt e d a n d s e c o n d ly b y t h e c o n t ra c t i o n o f t h e c i r c u l a r fi b re s
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m o r r o w s o b u r i e d it s s h a r p p o i n t s i n t h e m u c o u s m e m b ra n e ,
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g o t o m y h as b e c o m e t h e o n l y r e s o u r c e ; a n d t h e h o rs e c h e s t n u t
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d i s l o d g e i t a n d fi n a ll y c a u s e d t h e d e a t h o f t h e p a t i e n t
,
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Fr o m t h e s e c o n s i d e r a t i o n s I w o u l d d e d u c e t h e s u r g i c a l r ul e
T o a tt e m p t t h e r e m o v a l o f fo r e i g n b o d i e s i m p a c t e d i n t h e
oe s o p h a g u s a s s o o n a s p r o p e r i n s t r u m e n t s c a n b e p r o c u r e d ,
G S OP H A G O T OM Y F OR F OR E I GN B OD I E S I N TH E T UB E .
20 5
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p a s t win t e r h e s aw a wo m an t w e lv e d ay s a fte r sh e h ad s wallow e d a

pla te wi th on e t oo th wh ich h ad lo d g e d t wo inch e s b e low th e cricoi d .
A gr e a t m any a t te m p t s h a d b e e n m a d e for a w e e k by t wo or t h r e e
s ur g e on s t o r e m ov e i t b u t wi th ou t s ucc e ss
, Dr Abb e wa s abl e to g e t . .
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t ru di n g fro m th e m o u th fro m t h e fir s t T h i s fac t was d e m on stra t e d

,
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in s o m e ca s e s r e c e n tly r e p or t e d in E ngli sh j ournal s in wh ich th e p a ,
t i e n t t ol e ra t e d th e t ub e fo r a n u m b e r o f d ay s wi th co m p ara t iv e c o m
for t.
D R M AR K O E s ai d h e h a d n o t s e e n t h e r e p or t s r e fe rr e d t o by Dr
. .
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. . .
t h e con t in uou s u s e o f t h e e la s t ic t ub e for th e p urp o s e o f a lim e r t a t i o n .
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t ion wa s o u t o f th e qu e s t i on th e t ub e wa s s t ill in ( th e six t e e n th d a

, y
a ft e r th e O p e ra t ion an d al im e n t a t ion w a s k e p t up wi th a gr e a t d e al o f
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t h roug h th e s t u m p o f t h e t ongu e in or d e r t h a t t h e s ub se qu e n t in tro
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2 06 TH OM A S M . M A R K OB .
b ut wh e n ub e was r e m ov e d on th e fi fth d ay a n d an a t t e m p t wa s
th e t ,
m a d e t o fe e d th e pa t i e n t in t h e a ft e rnoon i t cau s e d s o m uch e xci t e ,
m e n t th a t t h e t ub e wa s r e plac e d an d foo d wa s in t ro d uc e d a s b e for e .
H e wa s a n xiou s to r e m ov e th e t ub e a s i t wa s o f E ngli s h m ak e h ar d , ,
a n d w e bb e d a n d was liabl e
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ri n gs t o pro d uc e a s or e Bu t s uch an e ffe c t did n o t t ak e plac e T h e

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t ub e wa s r e m ov e d onc e in th r e e or four d ay s fo r t h e p u rp o s e o f cl e an
s i n g an d r e placing i t by a n e w o n e i f i t h a d b e co m e ro ug h By n our .
i s h in g th e pa t i e n t th ro ug h th e oe s op h ag e al t ub e th e y h a d b e e n e nabl e d
t o carry h i m th roug h an a tt ack o f ca t arr h al pn e u m o n ia wh ic h d e v e l
O p e d t h e th ir d d ay a ft e r th e op e ra t ion .
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. .
H o s pi t al up on a m a n ab ou t 4 0 y e ar s o f a ge wh o h ad swallo we d a p la te
wi th s e v e ral t e e th s o m e t i m e b e for e a d m i s s i on b ut e xac tly h o w lo n g ,
h e cou ld n o t r e call Pr e vi ou s t o a d m i s s ion s o m e s urg e on s h ad m a de

.
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in e ffe c t ual a t te m p t s to wi th d raw t h e for e ign bo dy w h ich was s i t u a te d ,
n e ar t h e e n t ra n c e t o th e s t o m ac h Dr La n g e fail e d u n d e r an ae th e s ia
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a n d th e n p e r for m e d oe s op h ago t o m y t hinking h e wou ld th u s b e e n ab le d

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t o g e t a s a fe r gra s p on t h e for e i g n b o dy H e w as h ow e v e r s t ill u m .

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ab le t o e x trac t i t or t o p u sh i t d own un til finally i t w e n t d o wn in t o

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t h e s t o m ac h un d e r v e ry s lig h t pr e s s ur e T h e fur th e r fa t e o f t h e fo r .
e i gn b o d y wa s u n k n own ; th e m an w a s d i s c h arg e d a ft e r s o m e w e e k s ,
cur e d an d h a d n o t b e e n h e ar d o f s i n c e Wi th r e gar d t o th e t r e a t m e n t
,
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o f th e woun d h e clo s e d th e wall s o f t h e oe s op h agu s wi th ca t gu t

, in ,
s e rt e d o n ly a fe w s u t ur e s in th e e x t e rnal woun d l e avi n g i t par tially ,
op e n an d m aking fr e e d rainag e T h e m a n s wallowe d fro m th e b e gin .
n i n g t h e fir s t d ay s r e c e ivin g on ly s m all qu a n t i t i e s o f wa t e r a n d m ilk

,
a d m ini s te r e d cau tiou s ly Pri m ary u n ion t ook plac e th e wo un d clo s ing
.
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qui ckly Dr Lang e th oug h t s uc h tr e a t m e n t woul d b e j u s tifi e d in

. .
ca s e s in w h i ch th e t i s s u e a t t h e oe s op h ag e al O p e ning wa s h e al th y ; h e
di d n o t know th a t i t wo ul d b e prop e r i f s uppura tio n h a d t ak e n plac e
a t th e p oi n t o f O p e ra t iv e in t e r fe r e nc e I n th i s ca s e th e t r e a t m e n t was
.
qui t e s a ti s fac t ory ; no fo o d app e ar e d a t th e e x t e rnal woun d .
D R I\I A R K O E s ai d th a t s ucc e ss d e p e n d e d e n tir e ly up on clo s ur e o f

.
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t h e oes op h ag e al wou n d a n d i f t h i s coul d be

, s e cur e d
, t h e m e th o d .
a d op t e d by Dr Lang e wa s un d oub te dly t h e b e s t Bu t i f union fail e d

. .
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t o t ak e plac e a t any p oin t in th e li n e O f inci s io n s e p ti c m a t e ri al w oul d ,
b e lik e ly t o e n t e r i t e s p e ci ally d uring th e a c t o f s w allowi n g foo d Mor e

, .
r e c e n t wri te r s h e b e li e v e d w e r e al m o s t unani m ou sly o f th e O pinion

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t h a t th e woun d s h o ul d n o t b e clo s e d .
T h e PR E S I D E N T r e m ark e d th a t i n th e c a s e O f th e c h il d wh o s e h i s t o ry
,
Dr M ark o e h a d r e la te d i t woul d h av e b e e n v e ry unwi s e to clo s e th e

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p ag u s .
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. . though t th a t w h e n i t b e c am e n e c e s s ary t o
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in tro d uc e th e oe s op h ag e al t ub e t o n ouri sh a p a t i e n t i t woul d b e m uch

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m or e conv e ni e n t t o t h e s urg e o n a n d m or e c o m for t abl e t o t h e p a t i e n t

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t o i n t ro d uc e i t th rou g h t h e n o se . S uch h a d b e e n h i s e xp e ri e n c e a ft e r
e x t irp a tion o f t h e t o n gu e a n d in o th e r c a s e s
, . H e h a d ob se rv e d th e
s am e d i ffi cul ty r e fe rr e d t o by th e au th or o f t h e p ap e r w h e n th e t ub e
w a s in tro d u c e d th roug h t h e m ou th— n a m e ly fauci a l irri t a t ion
, He
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a n d t h e n t o cl e a n s e i t a n d s ub s ti t u ting a n e w o n e i f i t b e ca m e roug h
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ON T U M O R S O F TH E U R I N AR Y BLAD D E R AN D T H E I R
T R E AT M E N T .
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th olo gy an d th e rapy o f t u m or s o f th e urinary bla dd e r al th oug h m any ,
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p ubic an d la t e ral cy s to t o m y an d Po dra z k i did n o t r e co m m e n d th e m

e i th e r .
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p e ar e x tr e m e ly dang e rou s Progr e s s i n th e righ t dir e c ti on coul d only

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b e m a de by an i n cr e a s e o f our d iagno s ti c r e s ourc e s an d th e m e ri t o f ,
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t i o n ab ly t o G S i m on wh o in 1 8 7 5 fir s t d e m on s t ra te d th a t th e fe m al e
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bo th diagno st ic an d th e rap e u tic m e as ur e s Th e m e th o d wa s afte r .
1 No . 2 69 - 2 68 . ( C h i rurgi e N .
T UJII OR S OF TH E UR I N A R Y B LA D D E R .
2 09
w ar d s a d op te d for O p e ra tio n s in th e m al e ur e th ra a n d bla dde r by R .
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no s i s o f a larg e m yo m a o f th e bla d d e r S i m on s m e tho d h ow e v e r .
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ca m e in t o g e n e ral u s e only a ft e r i t h a d b e e n p e r fe c t e d by S ir H e nr y
T h o m p s on in 1 8 8 0 1 8 8 2 - .
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p ar ts h a s n o t k e p t e qual p ac e wi th th a t o f our th e rap e u tic m e an s an d ,
we a r e s t ill far fr o m p o s s e s s i n g a de qua t e knowl e d g e o f t h e p a th ology
o f th e s e t u m or s .
N e opla s m s o f th e bla dd e r d e v e lop a s pri m ary gro wth s th e y e xte n d .
t o i t fro m o th e r n e ig h boring organ s or app e ar th e r e th r o ug h m e t a s t a s i s

,
fro m n e o pla s m s in r e m o t e ly s i t u at e d organ s T h e t wo la t te r for m s o f

.
d e v e lop m e n t b e long e xclu s iv e ly t o m alignan t grow th s a n d h av e con , ,
s e qu e n tly b u t a li m i t e d in t e r e s t fo r th e s urg e on
, T h e pri m ary t um or s .
a r e foun d i n t h e fe m al e only in th e wall o f t h e bla dd e r b ut in t h e m al e ,
s ubj e c t al s o in th e pro s t a t e glan d T h e s e la t te r are cli nically s e l d o m

.
d i s t ingui sh abl e fro m th e for m e r b o th pro d ucing ab o u t th e s a m e s ym p

,
t o m s e tc ,
a n d m u s t b e con s i d e r e d h e r e a s b e longi n g t o t h e s ubj e c t
.
,
b e for e u s .
T h e au th or giv e s u s th e follo wing cla s s ifi ca t io n o f t u m or s o f th e
urinary bla dd e r
.
—
A N E O P L A S M S O F T H E PR O S T A T E I F zb m a a m om a ( K l e b s) ; 2
’
.
’
-
,
jV
Iy om a ; 3 , C a r c i n om a .
B N E O P L A S M S O F T H E B L A D D E R WA LL —I N e opla s m s ari sing fro m

.
-
. .
t h e m ucou s or s ub m ucou s conn e c t iv e t i s s u e .
B ap zllom a ( K ra m e r) F zb r om a p ap i lla } ? ( Virch o w) Th i s i s b y

'
'
I
. , .
far th e m o s t fr e qu e n t o f all t um o r for m s o f t h e b la dd e r an d app e ar s

-
,
s ingly or in group s A s s ingl e gr o wth s t h e y a re m or e o ft e n m e t wi th

.
in th e fun d us th e n in th e t rigon um a n d la s tly in th e la te ral wall s o f

,
th e bla dd e r n e ar t h e o rific e s o f th e ur e t e r s O nly ve ry rar e ly h a v e .
th e y b e e n foun d in o th e r p ar t s o f th e bla dd e r a n d t h e n m os t ly i n ,
gro up s s e v e r al s m all on e s clu s te ring a r ou n d o n e larg e p olyp K us te r

, .
g iv e s u s an e lab ora t e d e s crip t io n o f th e s e p apillo m a gro up s th e ir m i ,
c ro s co p i c a l a pp e aranc e e t c T h o m p s on h as d e s crib e d a tr an s i t io n
, .
for m o f p apillo m a i e t o a m alig nan t gro wth an d wh ich h e s ay s i s

,
. .
, , ,
ch arac t e riz e d by i ts rich va s cularity a n d c e ll i n fi lt ra ti o n in th e t i s s ue s -

IO E D I T OR J A L A R I I CLE S
ab ou t ba s e T h i s la t te r i s wi th ou t d o ub t owi n g t o i n fl a m m a t ory ir
i ts .
ri t a t i o n h ow e v e r ,
T h e villi are v e ry d e lica t e ly c on s t ruc t e d th e cur
.
,
r e n t o i th e uri n e d uri n g m ic t uri t ion b e i n g o f s u ffici e n t s tr e n g th t o te ar

th e m o ff a n d c au s i n g c o ns e qu e n t ly fr e qu e n t h aem o rrh a g e s
, T h e d e li ,
.
ca t e c on s tru c tion o r th e ina de qua te ly s uppor te d w a ll s o f th e bloo d v e s -
s e l s in th e s e vi lli a r e o ft e n a ls o t h e cau s e o f h ae m o rrh ag e s E v e ry con .
t rac ti o n o f th e b la dd e r m u s c le s m u s t c o m pr e s s t h e bloo d v e s s e l s a t th e
-
b a s e o f th e villi p rod u c i n g c o n s e q u e n tly h yp e r aem ia of th e se an d le a d

, , , ,
in g e a s ily t o th e rup t ur e o f bl o o d v e s s e l s T h e s e for m a tio n s by b e - .

,
c o m i n g i n c ru s t e d wi th th e uri n al s al t s m ay d e c e iv e o n e a s t o th e ir r e al ,
n a t ur e a s th e y are O ft e n t ak e n fo r v e s ical calculi

,
Papi llo m a ar e m or e .
fr e qu e n tly m e t wi th i n m al e s th a n in fe m al e s A m o n g 1 5 ca s e s r e .
por t e d by Th o m p s on th e r e we r e b u t t wo wo m e n an d in S p e rling s 4 2
, ,
’
ca s e s 2 9 w e r e m al e s Th i s gr e a t di ffe r en c e i s n o d oub t o wi n g t o th e
.
fr e qu e n t irri t a ti o n t o wh i ch th e m ucou s m e m bra n e o f t h e bla d d e r i s e x

p o s e d i n m al e s by th e e x t e n sio n of infla m m a t ory proc e s s e s fro m th e
,
ur e th ra e t c al s o t o th e gr e a t e r di fficul ty in uri n a ti n g i n m e n o f m i d
,
.
,
d le a ge S upp or t i n g t h i s la t t e r th e o ry we fi n d t h a t m o s t ca s e s ar e b e
.
t w e e n th e a g e s o f 3 0 an d 6 0 y e ar s s e l d o m e arli e r ,
.
E zé r ous P olyp i a n d Myx om a — Th e s e are t o n gu e l i k e or b ulb

'
2
.
/ .
-
s h a p e d fo r m a t i o n s a n d ar e fo u n d i n t h e r e gi o n O f th e n e ck o f t h e bla d
d e r an d it s ba s e n o t in group s a s th e p apillo m a b ut s pr e a d o u t as i t
, , ,
w e r e o v e r an e x t e n t o f th e m ucou s s ur fac e T h e s e grow th s s e l d o m

,
.
cau se h aem orrh ag e s on accou n t o f th e ir ra th e r t ough struc t ur e an d are

, ,
foun d m o s tly in ch il dr e n .
S a r com a —Ve ry rar e ly s e e n b u t fi v e ca s e s h avi n g b e e n t h orou h

3.
g ,
ly d e s crib e d an d r e cor d e d n a m e ly by S e n ftl e b e n Marc h an d S i e w e r t , , , ,
H e i m Vogtli n an d S c h le gte nd al
-
, O th e r l e s s car e ful O b s e rva tio n s .
h av e b e e n m a d e by H e a d H ue T h orn t on a n d S okolow T h e gr e a t e r
, , .
n u m b e r a r e fo u n d in fe m al e s ubj e c t s al s o a ll o f th e fir s t m e n t io n e d ,
fi v e ca s e s .
I I N e o pla s m s ari si n g fr om th e m u s cular lay e r o f th e bla dd e r

. .
4
. A ly o m a — Th e fir s t ca s e r e cor d e d i s on e o f R ob K n ox in 1 8 6 2 . .
O th e r s a s A R j ack s on Ge r s un y a n d Gu s s e n b a u e r h av e ob s e rv e d
,
. .
, ,
th i s form o f n e op la s m b ut Vo lk m a n n i n 1 8 7 6 wa s th e fir s t wh o
, , ,
th or o u gh ly d e s crib e d a ca s e o f un d o ub t e d m yo m a o f th e bla dde r Th e .

T U M OR S OF TH E UR I N A R Y B LAD D E R .
21 1
u or was s i t ua t e d at a c o n s i d e rabl e s pac e away fr o m th e pro s ta t e

t m ,
wh ich e xc lu d e s th e p o s sibili ty O f i t s h avi ng b e e n in any way conn e c te d

wi t h th e la tt e r a d oub t e vi de n tly e xi s ti n g i n all c ase s publi s h e d p rior
,
t o th i s S inc e th e n a fe w n e w ca s e s h av e b e e n r e cor d e d
. Be lfi e ld .
( 1 8 8 1
) fou n d a m y o m a o f t h e b la d d e r i n t wo d e a d s ubj e c t s by acci ,
de n t . Th e s t ruc t ur e o f th e s e t u m or s r e s e m bl e s i n m o s t p oin t s v e ry
c lo s e ly t h a t o f u t e rin e m yo m a .
I II N e op la sm s O f th e e pi th e liu m a n d g lan d ular struc t ur e s o f th e

.
lfl a d de n
5 . A den om a .
6 . C a r ci n om a —Clinically carcino m a t a bla dd e r are n o t di s

of th e
ti n gu i sh ab le fro m th o se o f th e pro s t a t e so th a t th e la tt e r will h av e t o

,
b e con s i de r e d in th i s gr o up Car e ful s t u dy only o f th e m icro s copical

.
s t ruc t ur e will r e v e al t h e r e al s t ar tin g p oi n t o f t h e t u m or

-
T h i s la tt e r .
is o f i m por t anc e n o t only fro m a p a th ol o gical a n at o m i c al s t an dp oin t -

,
b u t als o as r e gar d s th e di agno s i s a n d th e th e rap e u ti c m e a s ur e s t o b e

un d e r t ak e n As th e au th or j u s tly r e m ark s i t woul d b e o f va s t i m p or
.
,
’
t anc e i f K l e b s a s s e r tion prov e d t ru e accor d i n g t o wh i ch n a m e ly all
, , ,
carcino m a t a of th e bla dd e r ori gina te in th e pro s t a t e glan d c on s e qu e n tly ,
a pri m ary t u m or foun d i n th e fun du s o f th e b la dd e r in a fe m al e s ub

j e c t,
coul d n o t p o s s ibly b e a carcin o m a W h e n th e s e n e opla s m s a
.
p
p e ar i n th e r e gion o f th e n e ck of th e bla d de r i n m al e s ubj e c ts s u sp i c ,
i o n a s t o th e ir origin woul d b e e xci t e d Al th ough d oub tl e s s m any o f

.
, ,
t h o s e ca se s d e s crib e d a s carci n o m a o f th e b la d d e r h av e r e ally ori g i ,
ma t e d in th e pro s t a t e i t ca n no t b e d e n i e d on th e o th e r h an d th a t carci
, , ,
n o m a o f th e bl a d d e r i t se l f d o e s occur d e v e loping i n th e e pi th e liu m o f

, -
t h a t organ I t woul d b e s ay s K u s t e r v e ry r e m arkabl e i f th e e p i th e

.
, ,
liu m on a m uco u s s ur fac e s o fr e qu e n t ly e xpo s e d t o irri t a tion s e t c , .

,
sh oul d di ffe r s o e n t ir e ly in th a t r e s p e c t fr o m o th e r m ucou s m e m bran e s
o f th e b o dy B o de s tr e a ti s e on th e s ubj e c t ( 1 8 8 4) sh ow s th a t p ri
.
’
m ary carcino m a t a o f t h e bla dd e r in wo m e n ar e n o t s o v e ry rar e a s we ,
fi n d a m ong th e 3 0 c as e s coll e c t e d in h i s r e por t 1 4 fe m al e s T h e for m , .
o f carcino m a m o s t fr e qu e n t ly m e t Wi th h e r e i s th e pa p illary al th oug h ,
th e m e d ulla ry form i s n o t s e l d o m s e e n ca se s o f th e la t t e r h aving b e e n

,
r e cor d e d by M ar ch an d an d o th e rs T h e cancroi d form h as b e e n o fte n

.
-
ob s e rv e d by T h i e r s ch Pa e t Winck e l an d T h o m p s on an d t h e a lv e o
g , , , ,
lar carcino m a wi th i ts s i n gular t e n d e ncy t o colloi d d e g e n e ra tion i s al s o

,
occa s ionally foun d All th e s e for m s o f c arcin o m a inclu ding al s o th e

.
,
g lan d ular f or m occuring i n t h e pro s t a t e d e v e l o p fir s t as fl at circular ,
pro t ub e ranc e s on th e m ucou s s ur fac e or as m or e d e e p ly lying l um p s

W i th a s m oo th s ur fac e i m m ov abl e ov e r th e t u m or Variou s ch an g e s
,
.
i n t h e ir app e aranc e s o on occur in co n s e qu e nc e o f t h e ir ri t a t io n t o

,
wh ich th e y ar e m or e or l e ss e xpo s e d H ae m orrh ag e s s oon follow b ut .

,
in m an y ca s e s pr e c e d e th e d e v e lop m e n t o f a canc e r T h e s ur fac e .
e pi th e liu m b e co m e s n e cro t ic a n d fall s o ff allowi n g t h e u ri n e t o co m e ,
d ir e c tly in t o con t a c t wi th t h e b a d ly nou ri sh e d canc e r b o d y wh i ch i s -
pron e t o r e gr e s s iv e m e ta m orp h o si s Pu t ri d d e co m po s i tion o f th e urin e .
follow s pro d ucing rapi d n e cro s i s o f larg e r or s m all e r p or tion s o f th e

,
t u m or k e e pi n g th e for m e r in s pi t e o f fr e qu e n t m ic t uri t ion in a d e

, , ,
co m po se d s t a t e Ca t arrh o f th e bla d de r i s th e r e s ul t an d th e h yp e r
.
ae m i c m uco u s m e m bran e i s con s e qu e n tly pron e t o h a e m orrh ag e s The .
m u s cular lay e r o f th e bla d de r i s s oon a tt ack e d i t s h yp e r t rop h i e d con ,
di tio n h ow e v e r g e n e r all y pr e v e n t ing rapi d p e r fora t ion

, , T h rough e x .
t e n s ion o f th e purul e n t infla m m a t ion upwar d s t h e ki d n e y s b e co m e i n
volv e d a n d d e a th s oon in t e rv e n e s e n ding th e s u ffe ring s o f th e p a

, ,
ti e n t .
7 . D e r m o za Cy u m — T h e y are foun d b o th a s O p e n an d clo se d sac s

’
’
.
Mar tini in 1 8 7 4 p ubli sh e d h i s ob se rva tion s on on e of th e la tt e r foun d

, , ,
in a n e wly b orn m al e c h il d T h e b la dd e r was clo s e d n e ar th e ur e th ra

-
.
,
th e urin e h aving b e e n pa s s e d th roug h th e u m b ilicu s N o anu s e x .
i s te d a co m m unic at ion wi th t h e in te s tin e h ow e v e r b e ing foun d

, Th e , , .
po s te rior h al f o f th e bla dd e r co n s i s te d o f a p or tion o f cu t i s cov e r e d wi th

h air s T h o m p s on r e cor d s a ca s e o f op e n d e r m oi d cy s t in a wo m an 3 0
’
ve ar s o f a g e .
R e gar d ing th e iol o gy o f t u m or s o f th e urin ary bla dd e r K u st e r

ae t ,
s t a t e s no th ing o f m uch i m p or t anc e b e yon d w h a t i s g e n e rally known , .
F oet al pr e d i s po s i tion h e r e as e l se wh e r e in th e b o d y h as un d oub t e d ly ,
m uc h t o d o wi t h t h e d e v e l o p m e n t o f t h e s e n e opla s m s a s h a s fur th e r ,
m or e p a th ological irri t a t ion G on orrh oe a o f long s tan d i n g h yp e r trop h y

.
,
o f t h e pro s t a t e cau s ing s t a gna t io n o f p ar t o f th e bla d d e r con t e n t s -

,
li th ia s i s o f long d ura t ion e tc are all cau s a tiv e influ e nc e s o f th i s s t a te

’
.
, ,
0 irri t a t ion Conc e rni n g th e s t a ti s tic s o f t u m or s o f th e urin ary bla d

‘
.
T LrlI OR S
'
OF TH E UR I IVA R I/ B LA D D E R .
21 3
we fi n d th a t , fro m May 1 8 7 1 t o j anuary 1 8 8 5 o f

, ,
ca s e s tr e a t e d
, ,
in th e s urgical d e p ar tm e n t o f th e Augu s t a Ho s pi t al in B e rlin 3 0 5 h a d ,
d i s e a s e s o f th e uri n ary p a s s ag e s A m ong th e la tt e r w e r e

1 0 ca s e s wi t h t u m or s o f t h e bla d d e r z e of th e n um b e r a d
'
.
, .
,
m itt e d o r , o f t h o s e a fflic t e d wi th d i s e a s e s o f t h e urinary p a s
s ag e s .
O f fur th e r in t e r e s t i s th e fac t th a t d uri n g t h e s am e p e ri o d

,
pa ti e n t s wi th t u m or s w e r e a d m i tt e d th e 1 0 wi th t u m or s o f th e b la dd e r
,
m akin g th e r e for e
, , o f th i s w h ol e nu m b e r G urlt p ubli sh e d in .
,
1 8 8 0 s ta t i s t ic s o f
, ca s e s o f t u m or s coll e c t e d fro m th e r e p or t s o f
,
th r e e larg e Vi e nna H o s pi t a ls In 6 6 ca s e s o f th i s nu m b e r th e bla d d e r

.
,
w a s th e s e a t o f d i s e a s e , R e gar ding t h e se x o f th o s e a ffe c t e d
wi th t h i s troubl e we fi n d th a t in Gurlt s 66 ca s e s 4 6 w e r e m al e s 2 0
,
’
, ,
fe m ale s ; in S p e rling s 1 1 4 ca s e s 7 8 w e r e m al e s 3 6 fe m a le s ; i n
’
. ,
T h o m p s on s 2 0 ca s e s 1 8 w e r e m al e s 2 fe m al e s Willy M e y e r giv e s 2
’
, ,
.
ca s e s b o th m al e s ; Pou s s on 3 5 ca s e s o f wh i ch 1 5 w e r e m al e s 2 0 fe
, , ,
m al e s ; a n d fi n a lly 1 1 o f K u s t e r s 1 2 ca s e s w e r e m al e s T h i s would
’
.
m ak e a t o t al o f 2 4 9 ca se s 1 7 0 o f wh ic h w e r e m al e s an d 7 9 fe m al e s
, ,
.
Tu m or s o f th e urin ary bla d de r d e v e lop in v e ry m any ca s e s wi th ou t

m ark e d s y m p t o m s T h e ir e xi s t e nc e wi ll b e s u s p e c t e d wh e n bloo d y
.
,
u ri n e i s s u d d e n ly p a s s e d by an in d ivi d ual un til th e n to all app e ar ,
a n c e s p e r fe c t ly h e al th y T h e s e h ae m orr h ag e s h ow e v e r m u s t b e di s
.
, ,
ti n g ui sh e d fro m t h o s e cau s e d by o th e r l e s ion s in th e urinary t rac t .
In h ae m orrh ag e s fro m th e ki dn e y s th e urin e i s g e n e rally e v e nly m ix e d

wi th b loo d b ut th i s m a y al s o b e th e ca se w h e n s ligh t h m m orrh a ge s
,
o f th e bla d d e r h av e t ak e n plac e an d th e b loo d r e t ain e d lo n g e noug h
t o h av e b e co m e d i ffu se d in th e uri n e I t i s o th e rwi s e in ca s e s o f t u

.
m or s o f th e bla dd e r a t l e a s t in t h e e arli e r s t ag e s o f th e ir d e v e lop m e n t

,
.
I n m ic t ur i t ion th e s tr e am o f urin e i s a t fir s t qui t e cl e ar b e co m in g ,
gra d ually blo o dy an d con s i s ti n g finally o f app ar e n tly qui t e p ur e

bloo d .
A s e con d v e ry i m p or t an t s y m p t o m i s th e p a s sing o f p ar t icl e s o f th e

n e opla s m wi th t h e urin e T h i s t ak e s plac e a t ti m e s t o qui t e an a st on
.
i sh in g d e gr e e s urpri s i n gly larg e quan t i ti e s b e i n g p a s s e d wi th in a s h or t

,
ti m e. F ro m a m i cro s copical e xa m ina t ion o f th es e p ar t icl e s a di a gn o
s i s o f th e e xi st e nc e a n d ch arac t e r o f a t u m or m a b e m a d e O t h e r
y .
2 14 E D I T OR I A L A R TI C LE S .
s ym p t o m s con s i s t in d i s t urba n c e s in urina ting an d pain in s o m e ca s e s , , ,
i n t e n s e ; in o th e r s h ow e v e r v e ry sligh t T h e p at i e n t s co m plain fre

, ,
.
qu e n tly o f a h e avy b e aring d own s e n s a tion i n th e p e ri n e al r e gion an d

,
-
,
o f a fr e qu e n t d e s ir e t o s t o o l Ca t arrh o f th e bla dd e r i s n e v e r ab s e n t
.
in t h e long c o ur s e o f th e di se a se a dd i n g m uch t o th e g e n e ral dis c o m

,
for t o f t h e p a t i e n t by t h e acco m p anying ch ill s an d h ig h fe v e r .
T he g e n e ral for m a n d con s i s t e n cy o f a t u m or o f th e bla dd e r m ay b e
u s ually d e t e r m in e d by p alpa tion abov e th e s y m p h y s i s a n d th roug h th e

r e c t u m in wo m e n th roug h th e vagin a T h e in tro d uct ion o f in s tru
, .
m e n t s s h oul d b e un d e r t ak e n wi t h car e a s ca t arr h o ft e n r e s ul t s

. fro m
t h i s proc e d ur e Th oroug h di s i n fe c tion o f th e ca th e te r s e tc u s e d

.
,
.
,
wi th a 5 % s olu tion o f carb olic aci d i s a d vi s abl e al s o a care ful cl e an s

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wo m e n b e for e in tro d uci n g any in s tr u m e n t s T h e au th or e m ploy s a
, .
ca th e t e r o f hi s own co n s t ruc tio n h aving a long o p e ning n e ar i t s e x

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t re m i ty on th e un d e r s i d e H e u s e s th i s lik e a s coop pu lli n g o ff por

.
,
t i o n s o f th e n e opla s m fo r m i cro s copical e xa m i n a t ion .
H ae m orrh ag e sh oul d n o t b e fe ar e d fro m i t s u s e as i t i s s lig h t i f i t

, ,
occur s a t all A fur th e r m e an s o f d iagno s tic valu e i s e n d o s copy o f

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t h e bla dd e r or cy s t o s copy o f wh ic h t h e r e ar e t wo m e t h o d s
,
By th e .
o n e th e ol d e r m e th o d t h e lig h t i s d ir e c t e d fro m wi th o u t t h roug h s ui t

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a bl e t ub e s in t o t h e bla dde r ( D es or m e aux Gri i n fe ld ) I n th e o th e r

'
.
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m e th o d t h e s o urc e o f lig h t ( a pla t inu m wi r e k e p t gl o wi n g by m e an s o f

,
an e l e c tric curr e n t) i s ca rri e d dir e c tly i n t o t h e bla dd e r O f all m e th o d s . .
o f e xa m ina t ion h o w e v e r th e m o s t i m por t an t i s th e d igi t al e xplor a t ion

, , ,
fo r th e kno wl e d g e o f w h ic h we a r e in d e b t e d t o S i m o n s m e t h o d o f d il ’
a ta ti o n o f t h e fe m al e ur e th ra m e n t ion e d ab ov e Th e in t ro d uc tion o f .
th e fing e r in t o th e bla dd e r in fe m al e s a ft e r d ila t a tion o f t h e ur e th ra h as

,
b e e n acco m pli s h e d pr e s e n t s no gr e a t di fficul ty b ut in m al e s th e ca s e

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i s d i ffe r e n t. We are oblig e d h e r e t o O p e n th e ur e th ra in th e m e m bra

n ou s p or t i on a n d d ila t e th e pro s t a t ic por t ion s o a s t o pa s s t h e fin g e r
i n t o th e bla dd e r S o m e op e ra t or s a s Vo lk m an n u se t h e fi n g e r as a
.
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d ila t or in s t e a d o f th e in s t ru m e n t s con s truc t e d fo r t h a t purp o s e The .
au th or u s e d Si m on s s p e cula m o difi e d s o m e wh a t Al th o u gh p alp a

’
, .
t ion i s wi th o u t d oub t our b e s t m e a n s o f e xa m ina t ion s t ill e v e n th i s a t ,
ti m e s m i s l e a d s u s K us t e r giv e s t h e h i s t ory o f a ca s e w h e r e th e con

.
T U III OR S OF TH E UR I N A R Y B LA D D E R .
21 5
c e n tri c ally h yp e r trop h i e d bla d d e r wall le d hi m to b e li e v e in th e pr e s

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e nc e o f a carcino m a t h e a u t op s y h o we v e r
. s h o wi ng th e ca s e t o h av e
, ,
b e e n o n e o f purul e n t cy s ti t i s T h e irr e gular fo s s ae b e tw e e n th e t r a

.
b e c u la gav e th e fe e ling o f a d e e p irr e gular d e s t ruc t ion o f th e ti s s u e s .
I f w e t ak e a r e tro s p e c t iv e V i e w o f all t h e d iagno s t ic m e an s a t o ur
d i s po s al we s h all se e th a t no s ingl e o n e o f th e se i s in i t se l f s u ffici e n t t o

,
e nlig h t e n u s co m pl e t e ly a s t o th e n a t ur e o f th e t roubl e in all c ase s , ,
b ut th a t a co m bina t ion o f s e v e ral will b e n e c e s s ary fo r th i s p urp o s e .
S inc e b e n ig n an t n e opl a s m s in th e bla dd e r wi th h ar d ly an e xc e p ,
ti on th r e a t e n t h e e xi s t e nc e o f th e p a t i e n t t h e ir r e m ov al i s th e r e for e
, ,
d e s irabl e Tu m or s a tt ach e d by m e an s o f th in p e dicl e s are r e m ov e d in

.
v ariou s way s Volkm ann t wi st e d th e t u m or in o n e c ase K o ch e r u s e s

.
a s c o o p p a s s ing i t in t o t h e bla dd e r along wi th th e fing e r

, T h o m p s on .
a d vi s e s in ca se s wh e re th e p e dicl e i s th ick a n d larg e t o t e ar i t away or

, ,
b i t e i t o ff wi th th e forc e p s F o r th i s p urpo s e h e h a s con s tr u c te d a

.
forc e p s wi th d e n ticul at e d e d g e s s i m ilar t o t h o se u s e d for t h e e x trac

,
t ion o f s t on e s fro m t h e bl ad d e r Th e u s e o f th e in s tru m e n t r e quir e s

.
t h e gr e a t e s t car e th e d ang e r o f i nj ury t o ot h e r p ar t s b e ing con s i d e ra

,
b le. At t i m e s i t wi ll b e po s s ibl e t o d raw d own th e t u m or ( e s p e ci ally

in fe m al e p a ti e n t s) far e nough t o ge t a cl e ar vi e w o f th e p oin t o f i t s
,
a tt achm e n t t o th e bl add e r w h e n i t can b e e a s ily r e m ov e d by th e kn i fe

,
a n d t h e bla d d e r wall s clo s e d wi th s u t ur e s t h u s e ffe c t ually pr e v e n t ing

,
h ae m orr h ag e W h e n th e t u m or i s favorably s i t uat e d th i s proc e d ure

.
,
m ay b e s ucc e s s fully carri e d o u t in m al e s by d ila ting t h e ur e th r a in t h e
pro s t a tic por tion a fte r th e inci si on in th e m e d ian lin e .
I f th i s m ann e r o f r e m ov al i s n o t p o s s ibl e e i th e r o n accoun t o f t h e

,
larg e s iz e or p o s i t ion o f th e t u m or th e bla dde r m u s t b e op e ne d ab o ve

,
t h e s y m p h y s i s in fe m al e s al s o th roug h th e vagin a
, .
Colpocy s t o t o m y wa s fir s t r e co m m e n d e d an d i m prov e d by S i m on ,
b u t h i s m e th o d s e e m s n e v e r t o h av e fo un d m any follo we r s The a u .
t h or giv e s b ut t h r e e ca se s wh e r e t u m or s w e r e r e m ov e d in t h i s m ann e r ,
o n e o f K al t e nb ac h a s e con d o f Li n d e m ann t h e th ir d o f S c hle t e n d al

. ,g .
E picy s t o t o m y i s wi th o ut d oub t t h e b e s t o f a ll m e th o d s o f r e m oval
in bo th s e xe s an d giv e s th e m o st co m pl e t e s urv e y o f t h e in te rior o f

,
t h e bla d d e r Un til r e c e n tly th e d e v e lop m e n t o f th i s O p e ra t ion h a s

.
b e e n ra th e r r e t ar de d owing principally t o th e fe ar o f inj uring th e p e r

,
i t o n e u m d uri n g th e o p e ra ti on , an d to pr o d uci n g infil tra tion of uri n e in

th e p e riv e s ical ti s s u e s .
To av o i d th e for m e r o f th e s e d ang e r s th e b la d de r sh oul d b e fi ll e d

,
wi th s o m e a n ti s e p tic flui d b e for e th e op e ra t i o n or t h e inci s ion sh oul d b e ,
m a d e s lo w ly a n d c ar e fully th e t i ss u e s b e i n g divi d e d lay e r by lay e r

,
.
Pe t e r s e n fi lls th e b la d d e r wi th 4 0 0 t o 6 0 0 gra m m e s o f s o m e a n ti s e p t ic
flui d an d i n tr od uc e s a c olp e uryn te r co n t ai n i n g s o m e 4 0 0 gram m e s o f

,
w arm e d flui d in t o th e r e c tu m By th i s la tte r m e a n s t h e bla d d e r i s

.
for c e d up o v e r th e e dg e o f th e sym p hy s i s r e n d e ri n g i nj ury t o t h e p e r

,
i t on e um a lm o s t i m p o s sibl e I n fil tra tion of th e urin e i n to th e s urr o un d

.
in g t i s s u e s will tak e plac e o n ly w h e n th e urin e i s allow e d t o coll e c t in

la rg e qu a n ti ti e s i n th e bla dd e r an d flow o u t t hr o ugh t h e w ou n d Th i s .
i s b e s t pr e v e n t e d by drai n a g e a go o d m a n n e r o f acco m p li s h ing w h ich

,
i s t o pa s s a rubb e r t ub e h avi n g la t e ral ap e r t ur e s th roug h t h e wou n d

,
an d o u t th roug h th e u r e th ra ; at t h e s a m e t i m e pluggi n g up t h e ab d o m
in al wo un d wi th pi e c e s o f i od o form m u ll Guyon u s e s th e t h e rm o .
c a u t e ry for r e m ovi n g th e n e op la sm s of th e b la dd e r cau t e rizi n g th e ,
w o un d s ur fa c e aft e rwar d s Th e au th or h ow e v e r d o e s n o t r e co m m e n d
- .
, ,
th i s m e th o d e s p e cially in ca s e s o f larg e r grow th s

, as th e woun d t h u s ,
l e ft will b e lo n g in h e ali n g an d a con s t an t cau s e o f ca tarrh H e pr e fe r s .
an e llip tical c u t a r o un d t h e t u m o r un i t i n t h e e d g e s a ft e r w ar d s wi th
g ,
ca t gu t s u t ur e s .
F o r th e e x tirpa ti o n o f d e e p s e a t e d t u m or s in th e fu n d u s o r trigonu m , ,
Tr e n d e l e n b u rg s m e th o d for dir e c ti n g t h e li gh t o n t o th e fi e l d o f op
’
e r a ti o n m ay b e e m p lo y e d wi th a dvan t ag e T h i s co n si s t s in s u s p e n d
.
in g t h e pa ti e n t h e a d d own war d s by h i s le g s ov e r th e b ack o f an at

, ,
t e n d a n t an d t ur n e d t o war d s t h e lig h t s o th a t t h e la tt e r sh i n e s d ir e c t ly
,
i n t o th e b la dd e r wh e n th e wo u n d e d g e s are s e para te d- Th e bla dd e r .
a n d i n t e s ti n e s s i n k d own war d s a n d p ar t s h i dd e n b e h i n d th e s ym p h y s i s
co m e in t o vi e w
O f v a s t i m p o r t a n c e fo r t h e o p e ra ti on an d a ft e r tr e a tm e n t woul d b e -
t h e p o s s ibi li ty o f k e e pi n g t h e b la dde r fr e e fr om uri n e d uri n g t h i s wh o le
p e ri o d. T h i s w o u ld on ly b e po ss ib le b y i n t r o d uci n g ca t h e t e r s in t o t h e
m e te r s an d allowi n g t h e m t o r e m ai n th e r e fo r a c o n s i d e rabl e s pac e o f
ti m e. Th a t s uch a pr o c e dur e m ay b e carri e d o u t wi th ou t grav e r e

s u lt s w e h a v e s e e n i n a c ase o f S c h e d e wh e r e th e c a th e t e r r e m ain e d
, ,
B A C TE R I A L S CI E N CE I N I TS S UR GI CA L R E LA TI ON S .
21 7
in th e ur e te r fo r s e v e n d ay s B y prop e r ly i llu m ina t in g th e i n t e ri or o f

.
t h e b la dd e r th e O p e ni n g s o f th e ur e t e r s a r e e a s i ly s e e n an d t h e in t ro
,
d uc t ion o f in s t ru m e n t s n o t d i fficul t T h e au th or u s e s for th i s purp o s e

.
t h i n e la s t ic b o ugi e s a s h e co n si d e r s th e u s e o f S i m on s m e t al ca th e t e r s
’
, ,
t o o d a n g e rou s .
Th e t r e a t m e n t o f m a lign a n t t u m or s o f th e uri n ary bla dd e r h a s con
s i s t e d fo r th e m ai n p ar t u n til th e pr e se n t i n s crapi n g away p or ti on s o f

, ,
t h e m an d cau t e rizi n g th e s ur fac e i n or d e r t o r e t ar d i f po s s ibl e t h e ir , ,
rapi d grow th .
R a d ical tr e a t m e n t h a s b e e n only un d e r t ak e n in ca s e s w h e r e t h e car
c i n o m a w as favorably S i t ua t e d fo r e xa m pl e on th e a n t e ri or wall o f th e
, ,
bla d d e r S ucc e s s ful op e ra tion s fo r carcino m a in o th e r par t s o f th e

.
b la d d e r sh oul d n o t b e con s i d e r e d i m po s s ibl e if th e li m i t s o f th e m u ,
cou s m e m bran e h av e n o t b e e n p a s s e d fo r w h ich o f cour se an e arly

, , ,
d iag n o si s o f th e d i s e a se will b e n e c e s s ary .
I n co n cl us io n K us t e r th i n k s t h a t th e th e rapy o f t u m or s o f
,
t h e bla dd e r far fro m b e i n g s o h op e l e s s a s for m e rly t h ough t h a s

, ,
i m prov e d so m uch th a t th e larg e r n u m b e r o f th o s e s u ffe ring fro m th i s

t e rribl e m ala d y m a y b e al m o st d e fini t e ly cur e d by a ti m e ly an d prop e r
op e ra t i on . C J C oLLE s . . .
ON TH E PR E S E N T S T A T E O F K N O \VLE D G E IN BAC T E R I A L
S C I E N CE IN S U R G I CA L R E LA IONS
T
IT S .
( Co n c l u d e d fr o m p a g e
A C T I N O MY C O S I S — T AN T H R A X— G L AN D E R S
The u dy o f th o s e bran ch e s of b ac t e riology wh ic h h av e d ir e c t b e ar

st
in g upon v e t e ri n ary s urg e ry a n d p ublic e co n o m y h as b orn e m ore p r a c

t ical frui t th an a n y o th e r d e par t m e n t o f th e s ci e nc e l e a ding a s i t h a s , ,
d on e t o a n e arly a n d co m p ara t iv e ly co m pl e t e knowl e d g e o f c e r t ain

,
z o o n o ti c s a s i n s t an c e d a t l e a s t in E urop e by t h e s ucc e s s ful e n forc e

, ,
m e n t o f pub lic an d priva t e m e a s ur e s b y l e gi s la t iv e b o d i e s a n d ca t t l e
far m e r s fo r th e p urp o s e o f pr e v e n ti n g th e o ccurr e n c e a n d s pr e a d o f

s uch d i s e a s e s An d o ut o f th e s e i n v e s t iga tion s o f s uc h prac tical valu e
.
,
E D I T OR 1 A L A R TI C LE S .
to v e t e ri n ary s urg e ry a m at e rial a dvanc e in our th e or e t ical knowl e d g e

,
o f t h o s e s ur g ical i n fe c t io u s d i s e a s e s in m a n h a s s r un w h i c h o w e t h e ir
p g ,
origin t o c o n tagi o us con t rac te d fr o m a n d g e n e rally r e s tric te d t o th e

low e r ani m al s .
Al th ough o ur knowl e d g e o f th e s e di s e a s e s app e ar s m e r e ly in th e

li gh t o f a s i d e i s s u e of v e te ri n ary b ac te riol o gy ( a s ubj e c t wh ich we can
'
n o t h e r e e n t e r up on a n d h as r e c e iv e d b ut r e la t iv e ly li tt l e a d vanc e
) ,
m e n t by th e m o s t r e c e n t inv e s tiga t i o n s t h e d i s e a s e s th e m s e lv e s s t ill ,
o ffe r s u ffi ci e n t in t e r e s t—an in te r e s t e v e n e nh anc e d by th e co m para tiv e

rari ty o f th e ir occurr e n c e — t o d e s e rv e a bri e f c on si d e ra t i o n in th e s e
p ag e s .
O f th e d i s e a s e s r e fe rr e d t o a cf zn om ym s zs i s s till th e m o st ob s cur e
' '
.
,
T h e g e n e ral i m pr e s s ion i s th a t i t i s v e ry rar e ; b ut i t i s u n qu e s t ionably
o ft e n n o t r e cogniz e d wh e n pr e s e n t a n d i t i s probabl e th a t i t w o ul d b e
, ,
m or e fr e qu e n t ly diagno s e d i f th e d i s e a s e w e r e b e tt e r k n own
, .
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i ts e l f by th e app e aranc e o f a s o ft wh i ti s h t u m or fr e qu e n t ly s i t u a te d
on th e low e r j aw or in fron t o f th e s pinal colu m n an d c onn e c t e d wi th ,
t h e b on e A s e c tion th roug h th e t u m or sh o w s a gr e a t nu m b e r o f
.
s o ft e r fo ci o f th e color o f s ulp h ur wh i c h s t a n d w e ll o u t again s t t h e m o r e

,
r e ddi sh groun d .
In th e cour se o f t i m e th e t u m or br e ak s d o wn a n d an ab s c e s s i s
for m e d T h e p u s v e n t e d by inci s ion or s p o n t a n e ou s ulc e ra tion c o n
.
t ai n s nu m b e r s o f s ulp h ur y e llow m iliary bo d i e s o f s o ft con s i s t e n c e a n d

-
fa t ty fe e l wh ich ar e fr e qu e n tly uni t e d t og e th e r i n clu s te r s r e s e m bli n g

,
m ulb e rri e s By pr e s s ur e th e s e clu s t e r s are e a s ily s e p ara t e d in t o th e ir

.
e l e m e n t s wh ic h prov e w h e n vi e w e d un d e r th e m icro s cop e t o

, ,
c o n si s t ,
o f i n t e r t win e d fu n gu s m yc e lia
-
t h e s ingl e th r e a d s o f w h ic h app e ar
-
,
ra d ially arrang e d arou n d th e ir c e n te r s e ach on e i n cr e a s ing i n di a m e ,
t e r t owar d s t h e p e rip h e ry w h e r e t h e y pr e s e n t b ulb o u s t e r m ini

,
Inoc .
u lat i o n e xp e ri m e n t s prov e t h e s e fu n g us m a ss e s t o b e th e cau se O f th e
d i s e a s e ; h e nc e th e n a m e A pr o p e r cla s s ifica t io n o f t h e para s i t e h o w

.
,
e v e r h a s n o t ye t b e e n acc o m pl i s h e d t h e prob abili t i e s b e ing t h a t i t b e

, ,
long s t o th e cla s s o f fun gi prop e r .
Actino m yc e s in m an w e r e fir s t d e s crib e d by Le b e r t b ut w e r e n o t ,
1
1
T r ai té d ’
an a to m i e p at h l o og i q u e I p 5 4,
. . I S S7 . R e fe r re d t o b y F i rk e r t . l . c
B A C TE R I A L S CI E N CE I N I TS S UR GI C A L R E LA TI ON S .
2 19
r e cogniz e d a s para s i te s un til B o lling e r p ubli sh e d h i s c e l e bra te d p a th o

'
l ogical tr e a ti s e o n th e s ubj e c t t we n t y y e ar s la te r T h e e tiology o f th e .
d i s e a s e i s s t ill qui te ob s cur e a lth oug h th e fr e qu e ncy o f th e d i s e a s e in ,
ox e n h a s o fte n s ugg e s t e d th e p o s sibili ty of i n fe c tion by th e c on s u m p

t io n o f raw b e e f— a s upp o s i t ion w h ich woul d accoun t fo r th e gr e a t e r
‘
co m para tiv e rari ty o f th e d i se a s e in E nglan d a nd th i s coun try .
T h e lo caliz a t ion o f th e d i s e a s e i n m an m ay b e variou s .
I s ra e l i n hi s m o n ograp h o f th e d i s e a s e in w h ich h e giv e s an accoun t ,
o f 3 8 ca se s d ivi d e s all ca se s in t o fo ur cla s s e s o s e in wh ic h th e

( ) h
1
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p ara s i te gai n s e n tranc e th rough a ca ri ou s t oo th or a woun d i n t h e oral

cavi ty a n d l e a d s t o an a ffe c tion o f th e j aw ( 2 ) th o s e th a t pr e s e n t a f
,
fe c t i o n s o f t h e r e s pira t ory t rac t—wh ich fr e qu e n t ly s pr e a d t o t h e pl e ur ae
a n d s pinal colu m n ; h o in w h ic h h in inal canal i pri m arily

3) t se t e t e s t s
a ffe c te d ; an d ( 4 ) th o s e o f d o ub t ful origin Ca se s o f ac tino m yco s i s o f .
th e F allop ian t ub e s s pr e a di n g t o th e p e ri t on e u m h av e lik e wi s e b e e n r e
p or t e d s ugg e s ting an e n t ranc e th rough th e g e ni t al t rac t

1
.
In 1 8 8 4 O I s ra e l c lai m e d t o h av e cul t iva te d ac tin o m yc e s in p ur e

.
cul t ur e s on ox bloo d s e ru m a n d s t a t e d th a t th e ir grow th w a s s low

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.
T hi s la tt e r s t a te m e n t w o u ld v e ry w e l l corr e s pon d wi th t h e cl i nical a s

p e e t s o f th e d i s e as e w h ich sh ow s th e ac ti v e s uppura t iv e proc e s s e s t o
,
b e m uch m or e s luggi sh e v e n t h an in t ub e rculo u s d i s e a s e Bu t t h e .

3
d e s crip tion o f th e cul t ur e s s o lack s co m pl e te n e s s a n d luci di t y t h a t h i s ,
s t a t e m e n t s h av e n o t b e e n
g e n e rally a c c e p t e d by b ac t e riologi s t s O th e r .
cul t ur e e xp e ri m e n t s w e r e co m m e nc e d by j a h n e b u t w e r e n e v e r e n ,
4
t i re ly co m pl e te d To th e knowl e d g e o f th e pr e s e n t wri te r n o s a t i s fa c
.
t ory cul t ur e s o f t h e fungu s h av e b e e n publi s h e d up t o th e pr e s e n t
ti m e .
I n ocula tion s wi th th e ac tino m yc e s g e r m s h av e b e e n s ucc e s s fully p e r -
for m e d by Po n fi c k 5 J a h n e 6 an d J I s ra e l , ,
. .
7
l
Z em am z . Ue b
di e A c ti n o m yc o e d e s Ba u c fe l
er s h ls u . d e r Bau c h e i ng e w eide b eim
Men s ch en, Wi e n M e d Jah rb 1 88 3 , p 47 7

. . . . .
2
Ue b e r di e C ulti v i rb a rk e i t d e s Ac ti n o m yc e Vi re s . h . Arc h Vo l 9 5
. . 1 8 84 .
3 F i r /i fi t .
’
L Ac ti n o m yc o s e d e l
’
h om m e e t de s an i m a u x . Pa r i s . F eli x A l can .
1 8 84 .
4
D e ut sch . Z e i ts c hr f T hi e rm . . ed . 1 88 1 . Vo l 7 , p
. . 15 5 .
5D
i e Ac ti n o m yc o e s . Be rli n . H ir s c h w al d . 1 88 1 .
6 en
C tralb l f d m e d . . . , Wi ss . 1 880 . No . A8
IB
e rli n M e d S oc i e ty
. . 13 j un e . 1 88 3 .
2 20 E D I T OR I A L A R TJ CLE S .
S t aining ac tin o m yc e s can b e e ffe c t e d by an y anilin e dye in

o f th e ,
t h e s a m e m ann e r a s th a t o f or d inary fu n gi Th e s t ai n i n g will h o w .

,
e v e r again wa s h o ut in wa t e r
, Pi lo c ar m i n s t ain s th e m y e ll o w In . .
s e c tion s th e y m ay b e s t ain e d a d i ffe r e n t color fro m th e s urrou n d i n g
t i s s u e s wi th t h e h e lp o f a n ilin e d y e s or t h e s e c t i o n s m ay b e color e d in ,
O r s e il le fo r o n e h o ur wa sh e d o ff in a lco h ol a n d the n s t ain e d wi th g e n ,
t ian viol e t ( We ig e r t
)
1
.
R e c e n t ca s e s o f th e d i s e a s e h av e b e e n p ubli s h e d by Z e m a n n ( 5 2
ca s e s) C hi a ri M dd e d o rp ff ( 2 ca s e s) Mull e r an d M agnu s s e n ( 4
,
i l ,
3 5 6 4
,
ca s e s) an d in E ngla n d by Tr e v e s a n d S c h a t to c k
, , ,
7
.
8
T h e progno si s o f t h e d i s e a s e i s g e n e rally u n favorabl e i f th e in fe c t ion ,
h a s i n any way s pr e a d Ti m e ly s ur gical i n t e r fe r e n c e m a y e ffe c t a cur e . .
N o t le s s th an th ir t e e n ca s e s o f r e cov e ry h av e b e e n r e p or t e d The .
t r e a t m e n t co n s i s t s in inci s io n o f th e ab s c e s s an d s crap i ng o u t o f th e -
cavi ty T h e a ffe c tion i s fr e qu e n tly t ak e n for s cr o fulou s di s e a s e

. .
A zzzfi m x or m alignan t pu s t ul e a s th e d i s e a s e i s cli n ically call e d in

‘
, ,
i t s s urgical a sp e c t— c h a rb on s pl e nic fe v e r wool s or t e r s d i s e a s e an d

’
H -
, ,
i n t e s tinal m yco s i s b e i n g o th e r syno n ym e s— h a s alway s b e e n o f gr e a t

in t e r e s t t o bac te riol o gi s t s fo r th e r e a s o n th a t i t was t h e fir s t m yco tic
d i s e a s e di s cov e r e d in m an a n d o n e owi n g t o th e e x t r e m e facili ty o f , ,
cul tiva ting t h e viru s wh i ch wa s e sp e cially a d ap te d for inocula ti on a n d ,
d i s i n fe c ti o n e xp e ri m e n t s .
T h e b acilli o f an th rax w h e n in con t ac t wi th a s ui t abl e s oil s uc h a s , ,
po t a t o slic e s g e la tin e roo ts o f plan t s alkalin e uri n e or variou s n e u t ral

-
, , , ,
i n fu s i o n s a n d at a t e m p e ra t ur e o f 3 6 C s o o n gro w t o long fila m e n t s i n °

.
, ,
w h ic h a ft e r a sh or t t i m e s m all o val tran s par e n t bo di e s app e ar at re g

, ,
1 Vi rc h w s A hiv s
o
’
rc e . 1 88 1 . Vo l 8 4, p
. . 2 45 .
2
L . c .
3
Ue b er p ri m a r e D arm -
a c ti n o m
yc o se des Me ns c h en . Pr a g . Med . Wo c h . S c hr .
1 8 84 No . 10 .
4
E i n B e i tr a g z ur K e n n t n i s s d e r A c ti n o m yc o se D e ut s ch . M e d VVo c h . . seh r.
N os . 1 5 a n d 16 .
5
B B r zm
. s . M i tth e i lung e n a is der ch i r . K i ni l k . zu b
T u inge n . b
T u i ng e n
H . Lau pp .
(3 H e ft ) .
6
Be i t rag e z ur D i ag n o s ti k u . C a s ui s ti k d e r A c t i n o m yc o se . Di ss ert a ti o n .
1 88 5 .
7
La n c e t . Vo l I . . 1 88 4 , p . 1 07 .
8
Lan c e t . Vo l I . . 1 88 5 , p 80 8 . .
BA C TE R I A L S CI E N C E I N I T S S UR GI CA L R E LA TI OI VS .
22 1
ular in te rval s wh ich r e frac t th e li g h t in a gr e a t e r d e gr e e th an th e s ur

,
roun di n g p ar ts a n d s urviv e long a fte r th e ori g inal fila m e n t s h av e b e

co m e d e s troy e d T h e s e oval b o d i e s are th e s p or e s an d a g ain d e v e lop
.
u n d e r s ui t abl e circu m s t a n c e s in to b acilli W h e n tr e a t e d wi th ch e m .
i c als th e y prov e v e ry r e s i s t an t ; s o m uch s o i n fac t th a t i t i s v e ry ge n , ,
e rally a s s u m e d th a t a n y li n e o f t r e a tm e n t w h ic h s u ffic e s t o d e s t roy t h e
vi t ali ty o f an th rax s por e s i s m or e th an s u ffici e n t t o kill all o th e r g e r m s

,
wh ich th r e a t e n i n te r fe r e n c e i n th e tr e a tm e n t of wou n d s .
Th e m ann e r o f t e s ti n g th e e fficacy o f an t i s e p t ic s olu tion s wi th
an th rax s por e s i s v e ry s i m pl e S ilk th r e a d s a r e i m pr e gna t e d wi th ah .
th rax b acilli i n cul t ur e s a n d w h e n t h e s por e s ar e for m e d a r e d ri e d T h e

-
, ,
.
ch e m ical s ub s t anc e t o b e t e s te d i s m ix e d wi th th e cul t ure s oil in any

giv e n propor tio n a n d a pr e p ar e d th r e a d i s lai d upon i t
,
I n th i s m a n .
n e r i t w a s s h o wn by K oc h th a t corro s iv e s ubli m a t e s olu tion o f th e -

,
s t r e ng th o f 1 in s u ffic e d t o kill th e an th rax s por e s ; a s olu t ion -
c on ta i n ln g o n e p ar t in p ar t s o f s oil s e rv e d t o e x e r t an i nh ib i
t ory i n flu e nc e up o n th e ir d e v e lop m e n t ; th a t i s t o s ay th e s p or e s coul d
n ot d e v e lop a s long a s th e y r e m ain in con t ac t wi th th i s s oil ; b ut t h e y
w e r e n o t kill e d fo r on b e ing prop e rly wa sh e d o ff wi th s t e riliz e d wa te r

,
a n d t ran s fe rr e d t o o th e r s oil s n o t; d i s in fe c t e d t h e y r e a d ily d e v e lop e d ,

.
T h e s e qu e s tion s h av e b e e n m a d e th e s ubj e c t o f e xp e ri m e n t an d pa p e r s ,
by F rank an d Pe rronci t o th e for m e r s t u dying th e e ffe c t o f an ti se p t ic s

1 2
upon an th r a x afte r K och fro m wh o s e r e s ul t s in r e gar d t o figur e s h e ,
fr e qu e n tly d e via te s— an d t h e la t te r e x t e n d in g h i s r e s e arch e s t o t h e e f
fe e t o f h e a t a n d d i s in fe c t ion upon th e g e r m s .
In tro d uc e d in t o th e blo o d o f m an or ani m al s th e b acilli d o n o t for m

s por e s by m e an s o f long fila m e n t s b u t m ul tiply by d ivi s ion in s uc h a ,
m ann e r t h a t th e b loo d ve s s e ls in th e cour s e o f a fe w h our s b e co m e , ,
crowd e d wi th b acilli an d d e a th e n s u e s .
T h e d i s cov e ry o f th e n a t ur e o f t h e d i s e a s e i s conn e c te d wi th th e
na m e s of Polle n d e r Bran e ll a n d D a a e
3
v i n ,
5 4
.
1
Ueb di Wi k g i
er e r un e ni g e r A n ti s e p ti c a au t d as M i lz b r an d c o n t ag i u m . I n a ug .
D i s s e rta
t D p 8 83
o r at 1
b di T i tat d lz b v b
. . .
2
U e er e e n ac es Mi r an d i ru i n e i n e n s s ei d en G e s ta lt e n a ls S p o re un d
ll s
Bac i u An t rac i h s
R e vue fur T h i e rh e ilk 1 8 8 3 , N o
. . . 11 .
3
l h
Vi e r te j a r f g e r M e d Vo l 8 1 8 8 5
h w
. . . . . . .
4
Vi rc o s A rc h Vo l 1 4 1 8 5 8
’
. . . .
5
Co m p t re n d Vo l 5 7 1 8 6 3 ; v ol 77 1 8 7 3
. . . . . . .
22 E D I T OR I AL A R TI CLE S .
Mor e r e c e n t d e s crip ti o n s h av e b e e n furni sh e d by K o c h wh o t h or ,
ou ghly i n v e s tiga te d th e di se a s e in variou s s e ri e s of e xp e ri m e n t al r e

se arc h e s a n d e x t e n d e d h i s e xp e ri m e n t s t o t h e qu e s t io n o f a t t e nua
1
,
t ion o f th e cul t ur e s .
’
F o llowing o u t Pa s t e ur s d i s cov e ry th a t c e r t ain cul t ur e s o f a g e r m
pr o d ucing ch ol e ra in ch ick e n s m i g h t b e s o t r e a t e d th a t th e viru s b e ,
c om e s a tt e n ua te d an d n o t o n ly fail s t o pro d uc e th e di se a s e wh e n inoc

,
ula t e d b ut ac t s i n a m an n e r pr e v e n t iv e o f s ub s e qu e n t in fe c t ion s anal

, ,
o g o u s t o vacci n a t ion for th e pr e v e n t ion o f s m all p ox Tou s s ain t wa s - 2

,
ab le in lik e m a n n e r t o a t t e nua t e cul tur e s o f a n th rax by s ubj e c ting

th e m t o h e a t o f 5 5 C fo r a s p ac e o f t e n m inu t e s An d Pa s t e ur h i m
" °
. .
s e lf s ub s e qu e n t ly foun d th a t i f th e an th rax b ac i lli w e r e cul tiva te d -
t h roug h o u t a t a t e m p e ra t ur e rangi n g fro m 4 2 t o 4 3 C t h e organi s m s

° °
.
b e ca m e a tt e nua te d an d coul d b e e m ploy e d fo r pr e v e n tiv e vaccina

t ion .
3
K och , an s w e r t o Pa s te ur a ft e rwar d s prov e d th a t t h e s e s t a te

in his 4
,
m e n t s n e e d e d t o b e s o m e w h a t r e s t ric te d a n d s h ow e d t h a t i m m uni t y ,
fro m th e d i s e a s e coul d b e ob t ai n e d in th i s m an n e r only in sh e e p an d

ox e n an d th a t o th e r ani m al s a s w e ll as m an coul d n ot b e b e n e fi te d by
,
s uc h vacci n a t io n m e th o d s T h e m a t e rial u s e d fo r vaccina t ion ( s ec “

.
”
an d va cc i n e ) wa s m or e o v e r by n o m e an s h ar m le s s a n d cau s e d t h e
, ,
d e a th o f 1 0 t o 1 5 p e r c e n t o f th e h e al th y ani m al s ; nor d i d s uch vac

.
c i n at i o n e n s ur e i m m uni ty fro m s po n t an e ou s in fe c ti on— th e u s ual

m e a n s o f acquiring S pl e nic fe v e r t h roug h s por e s t ak e n in t o th e in t e s
t i n al t rac t wi th th e fo dd e r— b u t on ly agai n s t ar tifici al i n ocula tion .
Th e s e obj e c tio n s wh i c h b an i sh e d th e h op e o f th e u se o f vaccina ti on

m e th o d s i n th e s urgical tr e a t m e n t o f h u m an an th rax Pa s te ur coul d n o t ,
r e fu t e h i s an sw e r b e i n g r e s tric t e d t o vin d ica ti n g h i s p e r s onal s ci e n tific

,
po si ti o n an d ach i e v e m e n t s wh ich K och h a d n e v e r in te n d e d t o i m

,
p e ach al th ou gh h e h a d cri ti ci s e d h i s m e th o ds o f i n ocula ti n g wi th s e
1
C o/ m
’
s Be i tr a g e z ur Bi o l o
g i e d e r Pfl , p . . 277 . M i t th e il . a. d . K ai s . Ge s - Am t .
Vo l I , p 49
. . .
Q
R ec h e rc h s
e p e ri m s u r la m a a d i e
ex . l c h b ar s
o nn e u e . Pari s . 18 79 .
3
Bu ll . de
’
l Ac a d 1 8 80 2 8 C o m p t
. . . . r end. Vo l 9 2
. . 1 8 8 1 , e tc .
4
Ue b er di e M i lz b r an d i m p fun g ; e i n e e n t g e g n un g auf den v on s
Pa te ur i n G e n f g e
h a lte n e n Vo r tr ag . Ca ss le u n d Be r i n l
1 88 2 . .
B A C T E R I A L S CI E N CE I N I T S S UR GI CA L R E LA TI ON S
’
c re t i o n s fr o m t h e m ou th an d no s e , wh ic h ab ou n d in m icro orga ni s m s -
,
in s t e a d u s i n g pur e cul t ur e s
of .
T h e c orr e c tn e s s o f Pa s t e ur s pri n cipl e in pro t e c ti n g sh e e p fr o m

’
ch arb o n by vacci n a ti o n wa s fu lly conc e d e d by Ge r m an b ac t e riologi s t s .

1
T h e d u ra t ion o f acquir e d i m m uni ty o f th e d i s e a se by inocula tion i s

giv e n by F e tz a t se v e n te e n t o e igh t e e n m on th s fo r rabbi ts An e x .
2
o b e li e v e d h e cou ld c h an g e an th rax b acilli

’
p e ri m e n t o f Bu c h n e r s w h ,
3
in t o ano th e r s p e ci e s o f inn o cu o u s g e r m s th e s o call e d b acilli o f h ay ,

-
i n fu si on wa s r e fu t e d by K och an d i t was prov e d th a t h e h ad s i m ply

, ,
pro duc e d an att e nua t e d for m O th e r m e th o d s o f a t te nua t ion w e r e .
s ub se qu e n t ly publi s h e d by A C h auv e au a n d C h a m b e rla n d a n d R oux 5.

4
,
b u t s i n c e t h e s e a n d fur th e r p ubli ca t ion s are o n ly o f a v e t e rinary i n t e r

e st we m ay fo r t h e pr e s e n t p a s s th e m ov e r
, , , .
A fur th e r proo f o f th e a d va n c e m e n t of our knowl e d g e of an thrax

ov e r th a t o f o th e r s p e ci e s o f b ac t e ria i s t o b e foun d in th e e x t e n s iv e
c h e m i cal a n al yt ical r e s e arc h e s con d uc t e d wi th a n th rax—a s t e p as h as ,
b e e n b e for e r e m ark e d w e ll calcula t e d t o fur th e r d e v e lop our un d e r

,
s t an d i n g o f t h e e t iology o f p ara s i t i c d i s e a s e s .
N e n cki ch e m ical ly a n alyz e d cul t ur e s o f a n th rax s p or e s an d foun d

6
,
t h a t t h e a lb u m e n o f w h ic h th e y a r e con s t i t u t e d d i ffe r e d fr o m th a t o f
p u tr e fac tiv e g e r m s i n t h a t i t wa s n o t s o lubl e in aci d s b ut only in a l

.
,
kali e s w h il e th e o th e r was s o lubl e b o th in wa t e r alkali e s an d d il u t e

, ,
aci d s N e i th e r co n t ai n s s u lp h ur
. .
S z p i lm an n foun d th a t oz o n e kill e d p u tr e fac t iv e b ac te ria b ut did n o t ,
d i ffe r fro m o xyg e n in i t s ac tion up on an th rax b a c i lli a fac t wh ic h h as - fi
b e e n a d duc e d t o e xplain th e m o rb i fi c action o f th e g e r m s .
1
Km Gaj flt y a n d Locfi c r
, E xp e r i m e n t e e S tud i e n
’ ’
. ll u b er d i e K u n s tl . Ab
s c h e w ac h un
g d e r M ilz b ran db a c i lle n , e t c M i tth e il a d K ai . . . . s . G e s Am t . . Vo l I I , p . .
1 41 . 1 8 84 .
s ci e n c e s s
'
2
Acad de s . d e Par i . S é a n c e d u 4 A ou t . 1 88 4 .
3
Ue b er di e e xp e ri m . E r z e n g un g d e s M i
d e n H up i lz e n M un i c lz b r an d c o n ta g . aus . h .
1 8 80 D i e U m a n d un g d e r M i
. w l lz b
r a n d b aci lle n i n u n s c u rll Ba c t e ri en , n d e n tg e g . . .
’
n u n g K oc fi s a n B a s f c zcr Vi r c o
’
A rc 1 88 3 Vo l 9 1 , p 40
. h ws h . . . . .
4 ’
C o m p t re n d d e l a c d e s c i e n c e
. .M ay, 1 88 0 i i d Vol 9 6 N o s
. s 11 s . . b . . . .
-
.
5
C o m p t r e n d Vo l 9 6 N o 1 5
. . . . . .
6
b
U e e r d as E i w e i der M il ss zb r an d b a cille n . Be r d e r d e u t Ch e m
. . . Ge s . 1 8 84 . H .
1 6, p . 2 60 5 .
2 24 E D I T OR I A L AR TI CLE S .
No t wi th s t an d i n g th e gr e at a m oun t o f goo d work d on e o n an th rax ,
th e luci d i t y o f th e s ubj e c t i s s t ill ob s cur e d by t h e app e aranc e e v e n a t ,
t h e pr e s e n t t i m e o f s t a t e m e n t s di s s e n ting fro m th e g e n e ra lly acc e p t e d

,
fac t s an d th e ori e s o f bac t e riology .
T h u s 0 5 0 1 h a s la te ly p ubli sh e d a con trib u t ion t o th e s ubj e c t wh ich

1
canno t b e m a d e t o a gr e e wi th our pr e s e n t s y s te m s o f m y cology Tak .
ing th e blo o d o f h or s e s an d sh e e p th a t h a d di e d a ft e r inoculation wi th

a n th rax bacilli h e s t e riliz e d i t by boiling f o r fro m
-
, 3 t o 1 4 h our s fi l ,
t e re d i t w h il e h o t a n d r e p e a t e d th i s pr o c e s s o n c e or t wic e a dd ing a
, ,
li ttl e wa te r e ach t i m e an d fi n ally h e pour e d th e liqui d in t o b o t tl e s

, , ,
wh i ch h e clo s e d wi th co t ton plug s an d again bro ugh t th e con t e n t s t o a
b oil T h i s li qui d h e b e li e v e d t o b e p e r fe c tly s te riliz e d a s h e coul d n ot

.
,
pro d uc e an th rax i n ani m al s by inocula tion o f m i n u t e quan ti ti e s to
1 c c m ) o f i t nor coul d h e in fe c t s ui t abl e cul t ur e s oil s wi th i t

.
, But on -
.
i nj e c ting larg e r qua n ti t i e s o f th i s flui d in to th e ab d o m e n o f 1 7 m ic e 1 6 ,
rabbi t s an d 3 sh e e p h e s ucc e e de d—i n 7 m ic e 8 rabbi t s an d 2 sh e e p ,
in ob t ai n ing t ru e an th rax wi th bacilli an d all th e pa th ol o gical s ym p

,
t o m s o f th e d i se a s e wh ich cau s e d th e ir d e a th
, S o m e fur th e r ani m al s .
,
rabbi t s an d 5 m ic e al s o d i e d in t h e blo o d o f w h ich no b acilli

5 , ,
coul d b e foun d b ut th e bloo d o f th e s e con t ain e d s m all b o d i e s high ly ,
r e fr a c t iv e t o ligh t r e s e m bling s por e s wh ich in fi ve ca s e s d e v e lop e d on

, ,
s ui t abl e s oil s t o ch arac t e r i s t ic an th rax bacilli an d in all ca s e s kill e d -

. , ,
t h e ani m al s inocula t e d wi th th e m T h r e e rabbi t s fi ve m i c e an d on e

.
,
s h e e p r e m ain e d h e al th y But w h at was m or e s urpri s ing t wo rabbi t s

.
, ,
an d th r e e sh e e p w e r e s h o wn t o h av e b e e n r e n d e r e d cap abl e o f r e s i s t ing
inocu la t ion wi th tru e an th rax by s uch inocula tion s wi th t h e fil te r e d

,
s t e riliz e d flui d .
O s ol b e li e v e s t o h av e th u s d e m on s t ra t e d th e e xi s t e nc e o f a ch e m ic a l
an th rax poi s on an an th rax p t o m ai n e
,
-
.
E v e n i f th e s e s t a t e m e n t s d o n o t concur wi th our pr e s e n t knowl e d g e
o f th e s ubj e c t ar e in d ir e c t O ppo s i t ion t o all e xp e ri m e n t s th a t h av e

,
h i th e r t o b e e n s o o fte n r e p e a t e d by t h e h igh e s t au th ori t i e s an d m u s t , ,
th e r e for e fro m our pr e s e n t poi n t o f vi e w b e cri t ici se d a s i n s o m e m an

, ,
n e r faul t y ( th e e xp e ri m e n t s giv e t h e i m pr e s s ion o f inocula tion s wi th i n
1 x s
E p e ri m e n te lle U n t e r uch ung e n u e r d as An th raxg i ft I n a ng b . . D i s s e rtat . D o r p at
.
188 5 . bs s h
Vi d e a tra c t, F o r t c ri t te d e r M e d Vo l I V, p 2 44 . . . .
B A C TE R I AL S CI E N CE I N I T S S UR GI CA L R E LA TI ON S . 225
s u ffi ci e n tly s te ri liz e d s p or e s ) i t woul d b e un fair t o ov e rlook th e m un til

, ,
t h e e xp e ri m e n t s h av e b e e n r e p e a t e d an d t e s t e d by o th e r r e liabl e e x
e ri m e n t e r s fo r b e i n g p e r for m e d wi th an org a ni s m s o w e ll s t u d i e d a s
p ,
a n th r a x t h e y m a y co n t ai n th e fir s t s t e p s o f an a d v anc e in our knowl

,
e d g e o f i n fe c t iou s d i se a se s ul t i m a t e ly l e a d ing t o s o m e n e w s ci e n t ifi c
,
a cqui s i tion w h ich w e h a v e n o t d r e a m t o f in our b a c t e rial p h i lo s o

,
phy .
T h e t r e a tm n t o f m alignan t p u s t ul e th a t form o f an th rax ( th e inoc

e ,
ula ti on o f a woun d wi t h th e g e r m w h ic h h e s urg e on i s u s u a lly call e d

) t
upon t o a tte n d an d e a sily r e cogniz e d by th e circu m s crib e d in fl am m a

,
t ory oed e m a e ncircling t h e d i s color e d gangr e nou s c e n t e r wi th i t s ch ar
ac t e ri s ti c s e rou s d i s ch arg e sh oul d b e in a ccor d an c e wi th th e g e n e ral

,
sy m p t o m s I f fe v e r i s pr e se n t i t i s a s i gn th a t th e viru s h as e n te r e d
.
,
th e circul at ion an d no local tre at m e n t wi ll b e o f any av ail

, Th e p a .
t i e n t sh oul d b e at on c e p u t t o b e d an d k e p t at r e s t un til th e fe v e r h a s
d i s app e ar e d ; th e e xci t e m e n t inci d e n t t o e n e rg e tic loc a l appli c ation t o

th e woun d i s b e s t avoi d e d T h e pr e s e n t wri t e r h ad oppor tuni t i e s for
'
ob s e rvin g th e b e s t r e s ul t s afte r th i s tr e a tm e n t in s e v e ral ca s e s wh e r e ,
inocula ti on s o f an i m al s wi th th e s e rou s di s ch arg e of th e pu s t ul e t e

v e al e d all th e virul e nc e o f typical an th rax I f no fe v e r sy m p t o m s h av e .
app e ar e d i t h a s b e e n ad vi s e d by Dr K arg o f Le ip s ic to s urroun d th e

, .
, ,
pu st ul e wi th h ypo d e r m i c inj e c tion s o f m e rcuric bich lori de a s m uch as ,
h al f a grain o f wh ich m ay b e giv e n wi th i m p uni ty .
G la n a cr s Ge h e i m ra th S t ruck ann o unc e d th e d i s cov e ry o f th e

’ 1
.
s p e cific b acillu s o f glan d e r s by Dr Lo e ffl e r a n d Pro f S ch u e t z on th e

. .
2 0 th o f D e c e m b e r 1 8 8 2 in th e D czczscfi e Wocizcm cs zf t
’
‘
.
, ,
T h e b acillu s v e ry m uch r e s e m bl e s th a t o f t ub e rculo s i s b ut d o e s n ot

, ,
p o s s e s s i t s sp e cial s taini n g r e ac tion ; i t m ay b e s tain e d wi th m e th yl e n e

blu e in wa t e ry s olu t i on wh il e i t lo s e s th e s t aini n g ob t ain e d in anili n e
,
wa te r wh e n tr e ate d wi th wa t e r con t ai n i n g a li ttl e a c e tic a ci d

, .
2
F ollowing th e s p e ci al m e th o d s o f K oc h i ts d i s cov e r e r s fir s t m icr o

s c 0p i c all
y e x am in e d th e t ub e rcl e s foun d in ani m al s s u ffe ring fro m
1
Vorlaufi g e M i tth e ilu n g u b er di e E n td e c ku n
g d es R o tz c o ntagi um s im k ai s . Ges .
Am te .
H ue p p e , M e t
2
h o de n d e r Bac t-F o r s ch . Wi e s b ad en . 1 88 5 , p 67
. .
glan d e r s , an d h e r e fo u n d th e
b acil li i n qu e s tion alway s pr e se n t Th e y .
n e x t cul tiva te d th e g e r m in pur e cu ltur e s on s te riliz e d sh e e p s bloo d ’
t h roug h s ucc e s siv e g e n e ra t io n s a n d fi n ally inocula t e d rabbi t s fi e ld , ,
m ic e a n d g uin e a pig s wi th cul tur e s o f th e four th or fi fth g e n e ra t io n

-
( r e pr e s e n t i n g a cul t iva tion p e rio d o f 1 or 1 / m on th s ) an d th u s s u c 1

2
c e e d e d in pro d ucing b o th l o cal a n d g e n e ral i n fe c t io n s T h e y finally .
a ls o i n oculat e d t wo h or s e s wi th pur e cul t ur e s on e ori gina lly ob t ain e d ,
fro m a h or s e s u ffe ri n g fro m glan d e r s an d th e o th e r fro m an inocula t e d ,
guin e a pig th e fir st h or s e d i e d in t wo w e e k s t i m e
-
’
.
Ve ry fe w d ay s aft e r th i s p ublica tio n Bouch ar d Ca p i t on an d C h arri n , ,

1
cl aim e d t o h av e foun d th e s p e cific organ i sm o f glan d e r s an d in a c o m ,
m un i c ati on in th e Bull e t in d e l Ac a d é m i e d e M ed icin e Vulpi an a n d

’ ?
Boul e y clai m e d priori ty o f th e d i s cov e ry for th e s e g e n tl e m e n T h e ir .
d e s crip tion h ow e v e r r e fe r s t o rou n d or ovoi d m ovabl e b o d i e s an d

, , ,
n o t t o b aci lli s o th a t i t i s prob abl e th a t t h e ir cul t ur e s w e r e n o t pur e

,
on e s ye t th e y m u st h a ve con t ain e d s o m e e l e m e n t s of th e s p e cific g e r m s

,
a s th e ir ino cula t io n e xp e ri m e n t s w e r e s ucc e s s ful T h e d i s cov e ry o f th e .
Oa czllz i s th e r e for e a ttribu t e d t o th e G e rm an s ci e n ti s t s

' '
Mor e r e c e n t cul tur e e xp e ri m e n t s h av e b e e n p e r for m e d by K i tt on

- 3
po ta t o s oil s an d on bloo d s e ru m an d h av e s e rv e d t o co rrob ora t e th e

- -
,
s t a t e m e n t s o f Lo e ffl e r an d S c h ii tz b e s i d e s d e m on s t ra t i n g th e prop e r ty
’
,
C a d e gre e o f h e a t
°
o f th e b acillu s t o d e v e lop a t a t e m p e ra t ur e o f 2 5 .
,
nor m ally ob t aining in m o d e rat e d cli m at e s an d calling a tte n t ion t o th e ,
e xi s t e nc e o f s por e s m or e r e si s ta n t t o d e s truc t iv e ag e n t s th an th e
,
b a cilli .
T h e d i s e a s e in m an i s v e ry rar e r e c e n t ca s e s h a v e b e e n d e s c rib e d
by Buc quoy E s se r a n d S ch u tz an d Ballanc e i n wh ich e i th e r th e
’
5
4 6
, ,
b acilli w e r e foun d or i n ocu la tion s p rov e d s ucc e s s ful .
W W VAN A R S D A LE . . .
1
S u r la c ultu r e , e t c . Bu ll . d e l Aca d
’
. de M e d. . No 5 1
1 88 2 . . .
“ ”
2
No 41 O c tob 1 88 3 S ur un e n o t e c om m un i qu é e , e tc
. .
30 . . .
3
Ve r s u c h e ii b e r d i e Z ii ch tu n g ( le s Pr o tz p i lz e s .
j ah r e s b e r . d . M u nc h . T h i e r ar z
me i c s h . 1 8 8 3 - 84,
p 56 . .
4
Bu ll e ti n
’
d e l A ca d . 24 j un i , 1 88 4 .
5
R o t z ii b e rtragu n g a uf M ensc h en. A d M i tth e il
. . . a . d p . k . reu ss . Ve te ri n ar-S an i
s
ta t -Be r 18 8 2 -83. . Ar c h . f Wi. ss . u .
p ri v . T h i e rh e ilk . Vo l X I , p 9 2. . .
“La n c e t Vol 1 1 88 5 , 200

, . .
p . .
I ND EX O F S U RGI CA L PR O G R E S S .
O PE R AT I VE S U R GE R Y S U R G I CA L ANAT O M Y S U R GI CAL I N S T R U
M E NT S AN D AP PA R AT U S .
I S i m p li fi e d T e c h n i q u e fo r E x t i r p a t i o n o f A t h e r o m a
. .
By Dr C LA U E N S T E I N ( Ha m burg) T h e a t te nua te d s kin ov e r w e n s

. . .
i n th e s calp m ak e s i t d i fficul t t o p e e l o ut th e cy s t afte r th e u s ual cro s s ,
inci s ion wi th o u t rup t ur e T h e c u t s kin al s o b e co m e s r e lax e d an d s o

,
.
r e tar d s i t s s e para tion .
L m ak e s a 1 t o 1 / c t m long ra d i al inci s ion t h rough th e s kin a t

.
1
2 .
th e low e s t po i n t o f th e li ttl e t u m or p u sh e s in th e s m all h an dl e o f th e

,
s calp e l on t h e fl a t an d by la t e ral s t rok e s quickly s e p a ra t e s Off th e s kin

, .
A clip wi th th e s ci s s or s th e n s u ffici e n tl y l en g th e n s th e i n ci sion t o fi n

No 26
'
i sh r e m o val C cn t r a lb Cizzrg
. 1 886 . . . . .
W BR O WN I NG ( Bro o klyn ) . .
II . A N e w O p e r a t i o n fo r F ra ct u re of th e P a t e lla . S ub
c u t a n e ou s P a t e lla r S u t u r e w i t h S i lv e r By Pro f A N T O N W i re . .
C E C I ( Ge nna) A fte r p oin ting out th e m ain d i s t urb anc e s inci d e nt t o

.
fr a ct u re o f t h e p a t e lla th e a u th or fir s t conci s e ly r e vi e w s th e di ffe r e n t

,
m e th o d s o f t r e at m e n t h e r e t o fo r e r e co m m e n d e d a n d prac ti s e d for th e
i nj u ry S u t ur e h e b e li e v e s h ar dly e n couraging in th e fac e o f th e e x

.
,
i s tin g s t a ti s tic s ; ye t applianc e s an d b an d aging fr e qu e n tly in h i s O pinion

cau se anch ylo si s a n d h ar dly e v e r e ffe c t goo d con s oli d ation T h e au
, .
t h or th e r e for e propo s e s th e fol lowing m e th o d o f t r e a tm e n t w hich h e ,
b e li e v e s e qually s e rvic e ab le in r e c e n t c ase s an d in th o s e of long s t an d ing ,
a s w e ll a s in ca s e s wh e r e a l e ng th y fibro u s callu s h as b e e n for m e d
wi th ou t any fe ar o f anch ylo s i s ob taining ; h e al s o r e co m m e n ds it a s a

pro p h ylactic m e a s ur e in r e curr e n t fract ur e s .
B e for e O p e ra ting th e e ffu s ion in to th e j oin t sh oul d b e r e m ov e d by

,
( 2 27)
228 IN DE X OF S UR GI CA L P R O GR E S S .
a s piratio n e s p e ci ally i f i t b e larg e an d th e j oin t wa sh e d o ut a fte rw ar d

, ,
or a s p lin t m a y b e appli e d an d th e op e ra tion d e fe rr e d for ab ou t th r e e

d ay s un til ab s orp t ion h av e b e e n co m p le t e d
,
.
T h e O p e ra t ion i s p e r for m e d wi th th e h e lp o f a drill ; th i s i s d e s crib e d

a s a s m all cylin d rical r o d o f plia b l e s t e e l 2 m m in dia m e t e r a n d ab ou t
,
.
8 c tm in l e ng th th e e n d o f w h ich r e s e m b le s a fi n e ra s p a t ory an d i s
.
,
p e rfora te d wi th an e ye T h i s e n d sh oul d b e broa d e r th an th e r o d

. .
An a s si s t a n t h ol ding th e li m b o f th e co m pl e t e ly n arco t iz e d p a ti e n t in
h yp e r e x t e n si on approxi m a t i n g th e t wo frag m e n t s o f th e pa t e lla a n d
,
m ovi n g th e s kin in fol d s t owar d s t h e c e n tr e o f t h e pa t e lla ; th e o p e
ra t or pi e rc e s th e s kin wi th th e dri ll u n d e r th e pa t e lla an d forc e s i t wi th

s lig h t ro t a t ory m ov e m e n t s d iago n a lly th roug h th e s ub s t an c e o f th e p a
t e lla k e e pin g i t p arall e l t o th e larg e r s ur fac e s o f th e b on e

,
an d t ran s ,
fi xi n g i t in an obliqu e dir e c t io n fro m t h e inn e r par t b e low upwar d s an d ,
ou tw a r d s T h e poin t p a s s e s o u t th rough th e s ki n abov e H e n ow

. .
t h r e a d s th e e ye wi th a s ilv e r wir e a n d r e trac ting i t pull s th e wi r e

, ,
t h roug h th e pa t e lla an d o ut a t t h e fir s t poin t o f in s e r tion H e th e n re .
p e a t s th e O p e ra t ion in th e o th e r d iago n al lin e o f t h e pa t e lla in l ik e ,
m ann e r b u t a t righ t an gl e s t o th e fir s t p e r fora t ion

, h avi n g pr e vio us ly
,
p a s s e d t h e wi r e un d e r t h e s kin aroun d t h e l e w e r m argi n o f th e p a t e lla
t o t h e la t e ral a s p e c t o f th e bo n e H e th e n again pa s se s th e e n d o f
.
t h e wir e un d e r th e s kin abov e t h e upp e r m argin o f th e pa t e lla a n d fi n ,
ally twi st s th e two e n d s th u s approxi m a te d tigh tly t og e th e r an d b uri e s ,
t h e twi s te d par t T h e a s s i s t an t m u s t h ol d th e frag m e n t s in appo si t ion

.
un m ov e d th rough ou t th e op e ra tion an d car e m u s t b e t ak e n n o t t o ge t

,
t h e wir e t an gl e d or t wi s t e d in t o loop s T h e s kin h aving b e e n m ov e d

.
o ut o f plac e d uri n g th e d ri lling t h e p e r fora t ion s are r e m ov e d fro m t h e

,
Wir e wh e n th e t e n sion i s r e lax e d .
T h e wir e li e s t o a gr e a t e x t e n t e m b e dd e d in t h e s ub s t a n c e o f th e p a
t e lla in th e sh ap e o f a figur e 8 T h e w h ol e proc e d ur e i s t o b e carri e d

.
o u t un d e r s tric t an t i s e p t ic pr e cau tion s a n d m ay b e s p e e d ily

, p er
f orm e d .
Th e in dica tion s for th e O p e ra tion are giv e n a s follow s

( )
1 P a t e llar
frac t ur e o f r e c e n t occurr e nc e
( p e r fe c t a d ap ta tion b e ing alway s po s s ibl e
i n narco si s
) ( 2 ) F rac t ur e s o f long e r s tan din g ; fr e sh e ning up of th e
.
e d g e s i s unn e c e s s ary s inc e th e irri t a t i on cau s e d by t h e wir e alo n e s u ffi c e s

GE N E R A L S UR GE R Y .
2 29
to pro d uc e th e r e quir e d c allu s ( 3 ) R e curr e n t frac t ur e s for wh ich

.
,
th e O p e ra tion i s a prop h ylac t ic m e as ur e .
Th e au th or h a s t wic e p e r for m e d th e O p e ra t ion wi th e xc e ll e n t r e s u l t s .
—D cutsc/z Z ei tsch f C/zzr . Bd 2 3 . N os 3 a n d 4

'
. M arch 1 0
. . . . .
1 88 6 .
III . On the F a s c i ae an d I n t e r fa s c i a l S p a c e s of th e N e ck .
By Dr KR PO U L S E N ( K op e nh ag e n) Variou s a u th or s v e ry wi de ly
. . .
di ffe r in th e ir O pinion s as t o t h e d e s crip t iv e an at o m y o f th e c e r vi c al

fa s ci ae T h e r e as on for th i s li e s in th e fac t th a t th e fa s ci ae o f th e n e ck
.
d o n o t corr e s p on d t o th o se o f th e e x tr e m i ti e s A conn e ctiv e ti ss u e .
only m or e or l e ss s p aringly i n t e r s p e r s e d wi th fibrou s e l e m e n ts t ak e s ,
th e plac e o f fa s cia in th e n e ck T h e r e s ul ts o f di ss e c t ion s th e r e for e

.
, ,
m ay va ry on e an at o m i s t fi n d ing t w o la m in ae wh e r e ano th e r fin ds non e

,
a t all accor d ing t o t h e d e v e lop m e n t or th e l e ann e s s o f th e s ubj e c t an d

,
th e t e ch nical s kill o f th e d i s s e c t or .
H e nk e i n de e d wh o e x am in e d th e ana t o m y o f th e n e ck wi th th e
, ,
h e lp o f art ificial lo c al inj e c t ion s cam e t o th e conclu s ion th a t in r e ali t y

,
n o con tinuou s fa s cia of th e n e ck e xi s t e d .
Vi e win g th i s conclu s ion s o m e wh a t s k e p tically th e au th or followe d a ,
d i ffe r e n t m o de o f inv e s t iga tion H e fir st froz e hi s s ubj e c t by m e an s o f

.
s al t an d i c e an d th e n m a d e a s e ri e s o f s e c ti on s t h ro ug h th e n e ck wi th
,
a s aw A fte r h ar d e nin g th e s e c t ion s in alco h ol for o n e m on th h e

. ,
coul d e a s ily p e rc e iv e an d t rac e o ut th e conn e c tiv e ti s s u e an d th u s ob

t ain s ui t abl e s p e ci m e n s fo r d e m on s t ra t ion t o a i d h i m in h i s s ub se qu e n t
e xp e ri m e n t s .
F or w h e r e v e r h e d i s cov e r e d i n t e rfa s c i al s p ac e s h e inj e c t e d colo r e d ,
m a s se s an d th u s e n d e avor e d t o sh ow th e ir configura t ion an d in t e r r e l a -
t ion , an d t o d e m on s t r at e up on a b a s i s o f s ur gic al an at o m y t h e tr u e
, ,
con di tion s favo ring th e d e s c e n t o f ab s c e s s p u s along th e fas ci ae -

.
Th e s e e xp e rim e n ts w e r e p e rfor m e d on 64 ca d av e r s ab ou t 1 0 0 s e p ,
a ra t e inj e c t ion s b e ing m a d e wh i ch a re giv e n in d e t ail

,
Up on th e r e .
s ult s ob t ain e d th e au th or b a s e s h i s d e s c rip t ion o f th e fa s ci ae o f th e n e ck
a n d th e s pac e s b e t w e e n th e m ; h e poin t s o ut h ow e v e r t h a t t h e cour s e , ,
wh ich ab s c e s s e s fo llow in th e ir d e s c e n t m ay va ry fro m th e cour s e t ak e n

2 30 I N D E X OF S UR GI CAL P R O GR E S S .
by hi s i nj e c ti on s owi n g ,
t o th e r e a di n e s s wi th wh ich p u s de s tro ys ti s
sue .
Ain on g th e p ac e s m inu t e ly d e s crib e d a re th e following : ( a) s upra

s
s t e m al s pac e ; ( b in fe rior c e rvical t ria n gl e c

( ) r ov i s c e ral a n d
( )
d
) r e t ,
p r ev i s c e ral s p a c e ( e ) th e s pace s inclo sing th e ar te ry an d th e v e i n ; ( f)

th e s ub m axillary r e gion ; ( g ) th e paro t i d ; ( h) th e s t e rno cl e i d o m a s - -
t o i d r e gion an d ( i ) th e la t e ral r e gion o f th e n e ck

,
.
Two h an d s o m e color e d li th ograp h ic pla te s a cco m p any th e ar ticl e .
D cu ts clz Z e zts cfi f C/zzTg M arch 1 8 8 6

' '
. Bd 2 3 H ft 3 4
. . . . .
,
. . .
W W VAN AR S D ALE ( N e w Y o k ) . . r .
IV . A n t i s e p t i c S u rg i c al I n s t ru m e nts By Dr T H H E I D
. . .
E NR E I CH ( Mo s cow , R u ss ia) . In th e s urgic a l s e c t ion o f t h e Congr e s s
F IG . 1. L I GATU R E lA R . S h wi
o s
n g c o n tr uc ti o n .
o f R u s s i an ph y sician s h e ld l as t J anuary in S t Pe t e r s b urg Dr H e i d

,
.
,
.
” f
e n r e i ch r e a d a a
p p e r on “
An t i s e p t ic S urgical in s t ru m e n t s u s ing or ,
dem on r
s t at ion th e in s t ru m e n t s m anu fac t ur e d by t h e fi rm S h v a b e o f ,
M o s cow Dr l l h ol ds th a t in ord e r t o b e a n ti s e p tic th e in s tru m e n ts

. . .
u a d f a h ar d a rial w h ic h coul d t b cra t c h e d an d in

m st b e m e o m t e n o e s
wh ich n o cr e vic es coul d b e form e d T h e m a te ri al m u s t r e s i s t ch e m .

GE N E R A L S UR GE R I .
23 I
ical or th e r m ic influ e nc e s an d m u s t n o t ru s t aft e r h aving b e e n tr e a te d

,
wi th an an ti s e p ti c flui d T h e in stru m e n t s m u s t b e m a d e o f a s ingl e

.
s oli d pi e c e o f m e t al or a t l e a st t h e y m u s t b e e a s ily t ak e n ap ar t wi th ou t
,
h e lp o f any t ool s All p ar t s o f th e in s tr u m e n t s m u s t b e s m oo th an d roun d

.
,
a dm i t ting n o sh arp e d g e s corn e r s or blin d h ol e s S te e l an d gla s s a re

, .
t h e only m a t e ri al w h ic h can b e k e p t a s e p tic th e for m e r b e ing nick e l ,
pla t e d or galvaniz e d .
In 1 8 7 9 S hvab e for th e fir s t ti m e pr e par e d th e an ti s e p tic ca s e s o f i n

s tru m e n t s fo r th e p h y s ici an s wh o w e r e t o b a tt l e aga i n s t th e plagu e in
FIG . 2 . L I G A T U R E JA R . R e a dy fo r us e .
s ou th R u s s ia . ca s e s prop e r w e r e m a de o f p oli sh e d wo o d cap a

T he ,
b le o f a th orough d i s i n fe c ti o n ; n o s ilk or ve lv e t wa s u s e d in t h e m S inc e .
th e n Sh v a b e h a s t ri e d t o ob se rv e th e principl e s lai d d own ab ov e an d ,
wi th s ucc e s s .I n hi s fa ct ory h e h a s d i s car d e d co m pl e te ly w oo d b on e ,
an d e v e n vulca n iz e d rubb e r m aki ng h i s in s t ru m e n t s o f s oli d s t e e l

,
.
T hi s e xa m pl e i s now follow e d b y m any m anu fac t ur e r s in Ge r m any

a n d Au s t ria .
I t i s o f gr e a t i m por t anc e fo r s urg e on s t o h av e d i s in fe c t e d silk a t
h an d . Sh vab e m ak e s a s p e ci al j ar for th a t h ol ding fi ve nu m b e r s of ,
s il k h e r m e t ica lly clo s e d an d

, ye t e a s ily acc e s s ibl e ( g
F i T h i s ja r .
con s i s ts o f th e following par ts sh own in th e illu s tra tion : a roun d j ar

( )
c con t ain s an axi s wi th fi v e groov e s t o w h ic h corr e s pon d a s m a ny,
gr oov e s in th e j ar i ts e l f In th e s e groov e s are plac e d s pool s ( a ) m a d e

.
’
o f a d ull gl as s s ilk i s wo un d on t h e s e s p ool s A fl at li d o f gla s s ( 5 ) .
cov e r s th e jar ; i t h a s a larg e h ol e in th e c e n tr e co rr e s p on d in g t o i t s ,
a xi s an d fi v e s m all h ol e s m ark e d by figur e s fro m 1 t o 5 a n d d e s ign e d

, , ,
for p a s s ing th e e n d s o f s ilk fro m t h e s p ool s T h e li d can b e .
li fte d by m e an s o f two b u tt on sh ap e d h an d l e s -
Th e e x te ri or li d h e r .
m e t i c ally cov e r s th e j ar ; i t i s provi d e d wi th a h an d l e As all th e .
p ar ts o f th e j ar are m a d e o f gla s s th e y can b e th orough ly di s in fe c t e d

,
.
T h e s am e j ar s are m ade fo r wir e Ves t m é

’
( St
. . .
Pe t e r s b urg) M arch 1 8 8 6
.
,
.
P .
J . PO PO FF ( B o k l yn)r o .
H E AD AND N E CK .
I . O n T r e p h i n i n g fo r H o rr h a g e fr o m t h e M i d d l e M e
ae m
n i n g e a l A rt e ry i n t o t h e C lo s e d C r a n i a l C a v i t y By Pro f . .
K R O E N LE I N ( Zurich) T h e s ub s t anc e o f th i s p ap e r r e a d b e for e th e

.
,
5 8 th co n v e n t ion o f Ge r m an S ci e n ti s ts an d Ph y s ician s a t S tra s s bourg

in S e p t e m b e r la s t for m s a co m pl e m e n t t o Wi e s m an n s ar ti cl e on th e
,
’
s am e s ubj e c t th e au th or e x te n ding t h e conclu s ion s d rawn fr o m t h e

1
,
ob se rva tion o f ca s e s a t th e Z uric h clini c up t o th e pr e se n t t i m e ,

.
Wi th in th e l ast th r e e y e ar s i t app e ar s th e au th or h a d occa s ion t o

, ,
t r e p h in e four ti m e s for rup t ur e o f th e m i dd l e m e ning e al ar t e ry th e 0 p
e ra ti o n h ow e v e r on ly prov e d s ucc e s s ful in t wo o f th e ca s e s

, , a n d th e ,
fat a l t e r m ina tion o f th e o th e r t wo wi th fth e ir p o s t m or te m e vi d e nc e

,
-
,
fir s t s ugg e s te d th e plan o f O p e ra t iv e p roc e d ur e s e t for th in th e pr e s e n t

p ap e r .
Two o f th e s e c a s e s h av e alr e a dy b e e n giv e n by Wi e s m an n t o wh ich ,
th e au th or a dd s t wo n e w on e s an d r e fe rring t o W in all p oin t s o f

, ,
.
s ym p t o m a t ology a n d d iagno s i s —s o fully d o e s h e e n d or s e h i s a ss i s t a n t
—proc e e d s to a sk in wh a t m an n e r we sh all a c t wh e n th e d iagno s i s o f ,
b rai n pr e s s ur e r e s ul ting fro m rup t ur e o f th e m e ning e al ar t e ry h as b e e n

-
arriv e d at by m e an s o f c e r e bral s y m p t o m s alon e a n d wh e n n o m ark s ,
1
Vi d e ANNA LS OF S U RGE RY . Vo l . 2, p 502 D e c
. . . 1 88 5 .
H E A D A N D N E CK .
233
of e x te rnal viol e nc e in dica t e th e poin t o f l e s ion In th e s e ca s e s W

. .
h ad prop o s e d t o apply th e t r e pan a t d i ffe r e n t poin t s a t r an d o m b e ing ,
le d by a t t e m p t s at lo caliz a t ion of th e c e r e bral s y m p t o m s But th e .
pr e s e n t au th or propo s e s t o a d vanc e m e th o dic ally in all ca s e s accor d

ing to a fix e d plan o f ac tion d e d ucibl e fro m th e following con s i d e r a
,
t ion s.
All h aem a t o m at a r e s ul ting fro m rup t ur e o f th e ar te r m e nin g m e d . . .
or i t s b ran c h e s th o ugh in divi d u ally varying wi th i n c e r tain li m i ts in for m

, ,
m a y b e r e d uc e d t o c e r t ain typ e s—a t l e a s t w h e n group e d accor d ing t o
th e s y m p t o m s o f d iagno s t ic i m por t anc e O n e group th e d i ffu s e h aem

.
,
a t o m at a m ay e x t e n d Ov e r t h e inn e r s ur fac e o f an e n t ir e h al f o f th e
,
s kull e x t e n d ing fro m th e in t e rn al occipi t a l pro t ub e ranc e t o th e fron t a l

,
t ub e ro s i ty an d fro m th e falx c e r e bri d o wn t o t h e pl anu m orbi t al e th e ,
flo or of th e te m poral cavi t y an d th e t e n t oriu m c e r e b e lli r e s p e c tiv e ly .
Ano th e r group th e circu m s crib e d h ae m at o m a ta b e i n g m or e s h arply

, ,
d e fi n e d th an t h e d i ffu s e on e s a n d r e pr e s e n t ing a circl e or an oval in

,
ou tlin e an d a l e n s in s h ap e ( as b e ing o f gr e a t e r th ickn e s s in th e c e n

,
tr e th an a t th e m argin ) m a y b e s ub divi d e d accor d in g t o loca t ion .
T h e m o s t fr e qu e n t for m s are th o se s i t ua t e d ov e r th e m i dd l e c e r e bral
cavi ty an d b oun d e d in fron t by th e m argin o f th e l e sse r wing o f th e

,
p te rygoi d at th e b a ck by th e e d g e o f th e p e tro u s pyr am i d ( on accoun t

,
o f t h e fir m e r a d h e r e n c e o f t h e d ura m a t e r t o th e b on e a t th i s p oin t
) ,
b e low by th e r e gion of th e fora m e n s pino s u m a n d ab ov e by p oin t s

, , ,
b e yon d th e s q u a m o u s s u t ur e or s i t ua t e d a s far up as th e m argin o f th e

,
s e m icircular plan e .
Le ss fr e qu e n t for m s o f circu m s crib e d h ae m a t o m a ta occupy only th e

re gion b e low th e p ari e t al tub e ro si t y an d d o n o t e n cro ach upon th e m id
d le c e r e bral cavi t y T h e y e x t e n d upwar ds to th e falx p o s t e riorly t o
.
,
th e in te rn al occipi t al pro t ub e ran c e an d d own war d s a s far a s th e

c e r e b e llar te n toriu m .
T hi s for m th e au th or cal ls h ae m a to m a p o s t e riu s s p ari e t o o ccipi t al e

.
-
.
Th e l e a s t fr e qu e n t a re th e h ae m a t o m a t a an t e riora s fron to t e m p o rali a ;

.
-
th e s e are s i t u at e d b e n e a th th e fron t al t ub e r an d e x t e n d d own war d s t o
th e planu m orbi t al e fro m p ar t o f wh i c h th e d ura m ay b e t orn aw ay

, ,
a n d b a ckw ar d s t o th e s u t ur e cruci a t a .
2 34 INDE X OF S UR GI CAL P R O GR E S S .
The varia tion in th e s i t e s of th e se t u m or s i s du e t o va ria tion s in th e

poin t o f rup t ur e wh ich again d e p e n d s upon th e lo ca tion an d d e s c ri p
,
tion of t h e tr a u m a ti s m T h e t runk or th e larg e r or s m alle r branch e s

.
o f th e ar te ry m ay rup t ur e G e n e rally s p e aking rup t ur e o f th e an t e rior

.
,
branch o f th e an t e rior d ivi s ion o f th e ar te ry cau s e s th e an te rior h ae m

a t o m a wh il e th e po s t e ri or o n e i s cau s e d by rup t ur e o f th e po s t e rior
,
branch b e yon d th e po in t wh e r e i t p a s s e s t h e pyra m i d .
Th e t e m poro p ari e t al for m

-
t h e fir s t o n e m e n t ion e d
,
e n s u e s a ft e r
,
rup t ur e o f on e of th e v e s s e l s s i t ua te d in th e t e m poral cavi ty In ca s e .
t h e h ae m orr h ag e i s s lig h t th e circu m s crip t vari e t y r e s ul t s o th e rwi se a ,
di ffu se h ae m a t o m a i s for m e d T h e s e for m s a re in o s t fr e qu e n t for th e

.
r e a s on s th a t th e t e m poral r e g i on i s v e ry vuln e rabl e an d th a t th e lar ,
g e s t v e s s e l s are h e r e m e t wi th .
Varyi n g loca t ion o f th e s e h ae m a t o m a t a un qu e s t ionab ly pro d uc e s a

d i ffe r e nc e i n th e s y m p t o m s a ccor d ing t o th e s e a t a n d e x t e n t o f th e
,
le s ion an d i t s local e ffe c t upon th e p s ych o m o t or cor t ical provinc e s —in
s o m e ca s e s con trala t e ral p araly s i s o f th e upp e r e x t r e m i ty alo n e in ,
o th e r s of th e faciali s alon e again in o th e r s p araly s i s o f t h e upp e r an d

low e r e x tr e m i ty co m bin e d r e s ul ti n g
, But fr e qu e n t ly th e ca s e s are n ot
.
s uc h s i m pl e on e s a n d co m plica t ion s s uc h a s concu s s ion

, con t u sion o f ,
t h e brai n a n d ap opl e c ti c foci e xi s t a n d t h e pa t i e n t m ay b e in t oxi ca t e d

, ,
s o t h a t th e s urg e on i s s a t i s fi e d i f a t all h e can d iagno s e rup t ur e o f t h e

,
ar t e ry an d d e ci d e up on wh ich s i d e i t i s s i tua t e d .
T h e qu e st ion th e n a s t o th e p oi n t wh e r e th e t r e p h in e i s t o b e a p
,
pli e d i s t o b e an sw e r e d in th e fo llowing m a n n e r : By p e r fora ting th e

,
s kull in t h e t e m poral r e gion w e gain acc e s s t o th e ar e a o f b o th th e

,
d i ffu s e th e t e m poro pari e t al a n d th e fron t o t e m p oral h ae m at o m a a n d

,
- -
,
can th u s r e m o ve th e e x trava s a t e d bloo d al th ough we h e r e d o n ot

,
m e e t t h e trunk b u t only th e m ain a n t e rior branc h o f th e m i d d l e m e

,
n i n g e a l ar t e ry
. But s inc e th e circu m s crib e d p ari e t o occipi t al h m m at o m a
-
i s n o t acc e s s ibl e a t th i s poin t if th e fir s t p e r fora tion prov e o f no av ai l

, ,
a s e co n d O p e nin g sh oul d b e m a d e i n th e occipi t al r e gion t o m e e t th e

vi t al in dica ti on .
A s e co n d O p e ning o f t h i s s or t i s in fac t a d vi s ab le in ca s e s o f di ffu s e

, ,
h ae m a t o m a t o p e r m i t t h e m or e th oroug h r e m oval o f t h e coagula an d
e n s ur e co m pl e t e d rai n ag e .
235
As xact localiz a tion of th e poin t s a t wh ich t o apply th e

t o th e e
t r e p h in e t h e a u th or giv e s th e fo llo win g d ir e c tion s : Draw a lin e par

,
all e l t o th e h orizon t al li n e o f th e s kull ( wh i ch run s th rough th e in fe rior

orbi t al m ar g in t o th e e n tran c e o f t h e au di tory m e a t u s) th roug h th e
s up e rior orbi t al m argi n Bo th p oin t s are s i t ua t e d upon th i s lin e th e
.
,
an te rior on e 3 t o 4 c tm b e h in d th e zygo m a tic proc e s s o f th e fron t al

.
bo n e ; th e p o s t e ri or on e a t th e p oi n t o f i n t e rs e c ti on of th i s lin e wi th a
v e r tical on e carri e d upwar ds dir e c tly b e h in d th e m a s t oi d proc e s s .
T h e loca liz a tion o f th e variou s for m s o f h ae m a t o m a t a an d o f th e
p oin t s s e l e c te d for t r e p h inin g i s i llu s tra t e d by di agra m s —D eu ts clz .
Z cztscfi r f C/zzr N o s 3 an d 4 M arch 1 8 8 6

' '
. Bd 2 3
. . . . . . . .
W W VA N A R S DA LE ( N e w Y k ) . . or .
II .C a s e o f T r a ch e o ce l e
A By G D AR E M BE R G M D ( M e n . .
, . .
t o n ) a n d A VE R N E U I L M D ( Pari A wh h a d long
. s
) , m a n ae.t 7 3 o . .
,
.
,
h a d a d ry w h e e zi n g cough a si de fro m w h i ch h i s h e al th h a d alw ay s

, ,
b e e n e xc e ll e n t pr e s e n t e d i n 1 8 8 4 a s m all t u m or on th e l e ft o f th e
, , ,
t rac h e a w h ic h i t s e e m e d t o co m pr e s s wi th a prolo n ga tion b e h in d t h e

, ,
clavicl e th e t u m or b e i n g app ar e n tly lo c aliz e d in th e corr e s pon ding lob e

o f t h e t h yroi d glan d T h e r e wa s sligh t cough wh e e zing an d s u ffo c a
.
,
ti on o n a tt e m p t ing t o a s c e n d s tair s wi th s o m e varia tion s un d e r vario u s

m e th o d s o f t r e a t m e n t t h i s t u m or con t inu e d t o d e v e lop un t il in N o v e m
,
b e r 1 8 8 5 th e n e ck h a d un d e rgon e a gr e a t incr e a s e in i t s t o t al vol

, ,
u m e wi th ou t an y cu t an e ou s oe d e m a infl am m a t ory r e dn e s s nor an y

, ,
v as cular dila ta t ion e xc e p t in t h e s upra clavicular triangle wh e r e th e -
v e in s w e r e s woll e n ; th e m o e m e n t s o f th e larynx in d e glu t i tion a n d

v
r e s pira tion w e r e nor m al th e t rach e a wa s d e vi a te d sligh tly t o th e righ t ;

d e glu t i ti on h a s b e e n d i fficul t b u t n o t pain ful for a ye ar a l th ough th e ,
i n g e s tion of c e r tain m a tt e r s h a s cau s e d p aroxy s m s of s u ffo ca tion O n .
th e le ft si d e o f th e n e ck wa s t h e t u m or w h ic h woul d app e ar s u d d e nly ,
an d d i s app e ar a s quickly ; a t fir s t o f s m all s iz e i t now fill e d th e e n t ir e ,
s pac e i n clu d e d b e tw e e n th e low e r j aw a n d th e clavicl e a n d b e t w e e n ,
th e m e d ian lin e an d t h e p o s t e rior b or d e r o f th e s t e rn o m a s t oi d m u s cle ; -
i t s app e aranc e i s provok e d only by cough in g alth ough cou gh d o e s n ot ,
n e c e ss arily pro d uc e th e t u m or ; i t m a app e ar fro m fi v e t o fi ft y t i m es

y
a d ay ; i ts p e r s i ste nc e i s no l e s s variabl e ; s o m e ti m e s th e pro t ru s ion
2 36 I N D E x OP S UR GI C A L P R O GR E S S .
a pp e ar s an d di sapp e ar s wi th th e p aroxy s m o f cough ing lik e a b all oo n , ,
t o b e infl a t e d a n d collap se d by e xp i ra t i on an d in s pira t ion ; at o th e r
t i m e s t h e d i s t e n s ion la s t s fro m t e n s e con d s t o a m inu t e an d a h al f ; i t

,
m ay d i m ini sh in par t t h e n s t op fo r a fe w se con d s a n d th e n collap s e in

, ,
an in s t an t ; d uring d i s t e n s io n i t i s e l a s t ic ty m pani t ic a n d con s ti t u te d

,
e vi d e n tly by r e t ain e d air fo r th e s t e th o s cop e r e ve al s no r e s pira t o ry

,
m ur m ur ; pr e s s ur e wi th th e h an d h as no e ff e c t upon r e d uc t ion wh ich ,
i s a s si s t e d by m ov e m e n t s o f d e glu t i tion or by inclining th e h e a d s ud

d e nly t o th e l e ft sh oulde r B e s i d e th e t u m or on th e l e ft s i de a s i m il ar
.
,
s m all e r pro m in e n c e w h i c h n e v e r b e ca m e l arg e r th an a walnu t w a s d e

, ,
ve lO p e d l at e r in th e rig h t s upr a cl avicular t riangl e b e h in d th e b or d e r o f

-
,
t h e s t e rno m a st oi d m u s cl e
- T h e th e ory th a t th e origin al t u m or wa s a
.
goi tr e o f th e l e ft lob e o f th e th yr oi d glan d was e vi d e n t ly un te nabl e as

w e ll a s th a t o f a va s cular t u m or al th o u gh th e r e e xi s te d a no t abl e t ur
,
g e s c e n c e o f th e v e in s o f th e n e ck ; a n d th e d iagno s i s finally s e tt l e d
upon an a e ri al t u m or call e d a e ri al goi tr e or tr ach e oc e l e an d ch arac te r
, ,
i z e d by s u dd e n app e aranc e a n d d i s app e aranc e in d ol e nc e th e ab se nc e , ,
o f infla m m a t ory s y m p t o m s s onorou s r e s onanc e th e r e la tion t o cough

, ,
a n d co e xi s t e nc e o f t roubl e s o f r e s pira t ion p h ona t ion a n d d e gl ut i t ion

,
.
T h e m o s t prob abl e t h e ory o f th e cau s a t ion o f th e t u m or i s th a t th e r e ,
b e ing a con st ric tion o f th e tr ach e a ( a s s h own by th e wh e e zing ,
th e m e m br a nou s wall o f th e p a s s ag e b e ca m e d ila t e d a t a circu m s crib e d
poin t in th e for m o f a s ac a s occur s in c e r tain ane uri s m s an d s ynovi al

,
cy st s ; or th e s o fte n e d inflam e d a n d th inn e d wall yi e l d e d d u ri ng

, ,
th e pr e ss ur e o f e xpira t ion th e p a s s ag e b e ing i m p e d e d by a m a s s o f

,
m ucu s a n d a s ac was gra d ually d e v e lop e d in t h e loo se i n t e r tr ac h e o

,
-
oe s op h a g e al an d d e e p c e rvical conn e c t iv e t i ss u e by th e s a m e m e c h an ,
i s m a s i s ob se rv e d i n th e for m a tion o f p n e um o c e le s o f t h e cr aniu m .
Th e d an g e r i s e vi d e n t ly in se con d ary l aryng e al t roubl e s m ani fe s t e d by ,
th e paroxy s m s o f s u ffoca t ion I t was t h oug h t b e s t to po s tpon e s urgi

.
cal in t e rfe re nc e an d th e p a ti e n t fi n ally d i e d in April 1 8 8 6 s upp o s ably

, , ,
fro m a rapi d ly d e v e lopin g a d e no s arco m a o f th e p e ri trach e al gla n ds

-
,
th e r e b e ing a fa m ily h i s t o ry o f c anc e r —R ea u c a’ e . 1 88 6 .
M ay .
E PI LC H E R ( U 5 Arm y)
I
. . . . .
2 37
CH E ST AN D ABDO M E N .
I . G as t r o s t o m
y fo r C a n c e r o f t h e ( E s o p h a g u s By A D . . .
K N E E M D ( Mo s cow R u s sia ) . . In 1 8 8 0 in M o s cow Dr Kn e e

, .
, ,
.
foun d e d a pri v a t e clinic o f h i s o wn s p e ci ally fo r s urgical ca s e s He ,

.
h a s n ow 1 6 b e d s F or t h e la s t four y e ar s Dr Kn e e h a s t r e a t e d 2 7
. .
ca s e s o f canc e r o f th e oe s op h agu s T h e p a ti e n t s w e r e 2 5 m al e s an d .
only t w o fe m al e s In th e clinic w e r e t r e a t e d 1 7 p a ti e n t s o f wh o m 6
.
,
w e r e lo s t s igh t of Ga s tro st om y h a s b e e n p e rfor m e d in 1 3 ca s e s o f

.
,
wh ic h in 1 0 th e r e s ul t was favorabl e an d in 3 un favorabl e .
T h e ca s e s wi th favorabl e r e s ul t w e r e a s follow s
N o 1 M a le ae t 4 9 sick 1 5 m on th s ; ga s tro s t o m y p e rfor m e d J an

. .
,
.
, .
2,
1 8 8 2 : liv e d a ft e r O p e ra tion 9 m on th s ; cau s e o f d e a th canc e rou s ,
m e ta s t s s a i .
No . M al e ae t 4 8 s ick four m o n th s ; ga s tro s t o m y S e p t 6 1 8 8 2

2 .
,
.
, . ,
wa s aliv e 2 m on th s s inc e b ut was lo s t s ig h t o f , .
N o 3 M ale ae t 6 2 s ick 5 m on th s ; ga s tro s to m y J an 2 1 1 8 8 3 ;

. .
,
.
, .
,
liv e d a fte r O p e ra t ion 5 m o n th s a n d 2 8 d ay s cau se o f d e a th pl e u ri sy , .
N o 4 Mal e ae t 4 0 s ick 6 m on th s ; ga s tro s t o m y Au g 3 0 1 8 8 3 ;

. .
,
.
, .
,
wa s s e e n aliv e in D e c e m b e r 1 8 8 3 b u t wa s lo s t s ig h t o f a ft e rwar d s , , .
N o 5 M al e ae t 5 0 s ick 8 m on th s ; g as t ro s t o m y O c t 2 1 8 8 3 ; liv e d
. .
,
.
, .
,
5 m on t h s ; cau s e o f d e a th pn e u m onia .
N o 6 M al e ae t 5 0 sick 8 m on th s ; ga s tr o s t o m y O c t 2 1 8 8 3
. .
,
.
, .
,
liv e d a ft e r O p e r ati on 8 m on th s an d 1 7 d ay s ; cau se o f d e a th p n e u ,
m oni a .
N o 7 M al e ae t 6 2 s ick 5 m on th s ; g a s tr o st o m y J an 1 3 1 8 8 4 ;
. .
, .
, .
,
liv e d 9 m on th s cau s e o f d e a th canc e rou s dia th e s i s , .
N o 8 M al e ae t 4 1 s ick 7 m on th s ; ga s tr o s t o m y F e b 7 1 8 8 4 ;
. .
,
.
, .
,
li v e d 9 m on th s an d 6 d ay s c a u se of d e a th pn e u m oni a , .
N o 9 M al e ae t 5 9 s ick 4 m on th s ; ga s tr o st o m y April 1 4 1 8 8 4 ;
. .
,
.
, , ,
w as s e e n aliv e J uly 1 1 1 8 8 4 b ut a ft e rwar d s was lo s t s ig h t o f

, , .
N o 1 0 Mal e ac t 5 6 s ick 5 m on th s ; ga s tro s t o m y July 3 1 8 8 4 ;

.
'
, .
, ,
wa s se e n a liv e N ov e m b e r 6 1 8 8 4 b ut a ft e rwar d s wa s lo s t s igh t o f , , .
Ca s e s wi th un favor abl e r e s ul t :
N o 1 Mal e ae t 6 2 s ick 1 2 m on th s ; g a s tro s t o m y N ov 1 1 1 8 8 1 ;
. .
, .
, .
,
d i e d wi th in 3 6 h our s cau se p e r fora t ion in t o th e l e ft bronch i al t ub e , .

2 18
w
I N D E X OP S UR GI CA L P R O GR E S S
No 2 Mal e ae t 3 9 s ick 6 m on th s ; ga s tr o s t o m y D e c 2 8 1 8 8 3 ;
. .
,
.
,
.
,
d i e d on 8 th d ay fro m bl e e d i n g , .
N o 3 Mal e ae t 6 1 s ick 8 m on th s ; ga s tro st o m y N ov 1 5 1 8 8 4 ;

. .
,
.
,
.
,
d i e d on 1 2 th d ay fro m e xh au s t ion , .
In E ur op e th e r e are known 5 6 c a s e s of ga s tro s t o m y ( e xc e p t th o se

o f Dr K n e e wi th favorabl e r e s ul t
) . .
Dr K n e e pro te st s e m p h a tically again s t t r e a tm e n t wi th b ougi e s or

.
prob e s in ca s e s o f can c e r o f th e oe s op h ag us for fe ar of p e r fora tion in t o ,
t rach e a or bronch i a n d al s o o f pr e m a t ur e O p e ning o f t h e canc e rou s

,
t u m or N o cica triza tion c an b e h op e d for in s uch ca s e s O ut o f 1 3

. .
p a ti e n t s o f Dr K n e e 6 h ad a co m pl e t e s tric t ur e o f th e oe s op h agu s an d
.
, ,
7 coul d p a s s only s m all quan t i t i e s o f fl ui d T h e op e ra t iv e t e ch ni qu e .
a d op te d by Dr K i s a s follow s : A pri m ary in ci s ion in th e ab d o m inal

. .
wal l fro m 6 t o 8 c m long fro m th e 8 th rib alo n g th e m argin o f rib s

,
.
, ,
.
T h e p e ri t on e u m h aving b e e n inci s e d h e a t t ach e d th e p e ri t o n e al co a t ,
t o th e e d g e s o f woun d T h e n h e e x trac t e d a p or tio n o f t h e s t o m ach

.
a n d a t t ach e d i t t o e d g e s o f woun d by fro m 1 t 2 0 Le m b e r t s u t ur e s

5 o ,
t aking car e th a t s u t ur e s sh oul d pa s s only t h roug h t h e s e rou s coa t o f
t h e s t o m a ch O n h aving fini sh e d th i s fir s t p ar t o f op e ra t ion ( lap ar

.
h e wou n d i s d r e s s e d a n d th e pa t i e n t i s or d e r e d t o t ak e i c e a n d
o tom y
) t ,
opiu m F our nu tri tiou s cly s t e r s p e r d ay

. T h e woun d wa s dr e s se d .
a gain on 6 th d ay Th e s t o m ac h wa s op e n e d on 8 th or 9 th d a y an d a
.
,
t ub e fro m 5 t o 6 m m in tro d uc e d A t fir s t only li qui d fo o d ( m ilk wi n e

. .
, ,
e gg) wa s in t ro d uc e d th rough th e fi s t ul a a n d a ft e r war d s s crap e d raw ,
m e a t a n d e ve n roa s t e d m e a t S o m e p a ti e n t s t ook by fi s t ula abou t s ix .
poun d s o f foo d p e r d ay In o n e ca s e th e r e was an ob s tina t e vo m i ting .

,
wh ich d i s app e ar e d only gra d ually Co m pl e te ci ca triza tion t ook plac e .
on fro m 1 8 t o 2 0 d ay s a ft e r laparo t o m y ; th e r e for e Dr K n e e r e m ov e d .
s u t ur e s only at th e e n d o f a for tnigh t Ves t /”R .
e t e r sb urg ) January 886

( S t P . . 1 .
P . PO P O FF ( Broo k l yn ) .
II . I n t o x i c a t i o n a ft e r L a p a r o t o m y
O n S u b lim at e By Dr . .
H K U E M M E LL ( H am b urg) K wh o was s o in s tru m e n tal in i n tro

. . .
,
d u c in g bich lori de a s an an t i s e p t ic n ow r e por t s hi s unpl e a san t e xp e ,

2 39
ri e n c e wi t h i t By li m i ti n g th e u s e o f th i s s olu tion an d e m ployi n g prin

.
c i p ally s t r e n g th s o f 1 t o 5 h i s fir s t 1 7 0 m aj or op e ra tion s wi th i t
s h ow e d b u t o n e ca s e o f p oi s oning l as t ing a fe w d ay s ; t h i s o ccurr e d in
a v e ry fa t s ubj e c t afte r a m p u t a tion of th e m am m a .
Wi th in a fe w m on th s h ow e v e r h e h a s h a d two ca s e s o f poi s oning

, ,
a ft e r p e ri t on e al op e ra t ion s H i s fir s t nin e l aparo t o m i e s wi th i t p a s s e d

.
o ff w e ll .Th e n ca m e a fa t al ca s e o f p oi s o n in g in a wo m an o f 3 0 y e ar s .
S h e w a s o f s l e n d e r b uil d an d v e ry an aem ic fr o m pro fu se u t e rin e

,
h ae m orr h a g e s I n t e r s t i t i al m yo m a o f u te ru s : lap aro t o m y ( O p e ra t io n

.
la s ti g 1 4 h our s) Cun e i for m e xci s ion o f t u m or s ligh t lo s s o f bloo d

n
1
.
war m s ubli m a t e s olu tion n o t s trong e r th a n 1 t o 5 6 0 0 0 wa s u s e d ; v o m

,
-
i ting r e p e a te d d uring th e nigh t diarrh oe a s e t in n e x t day th e p a s s a g e s ,
s oon con t aining bloo d ; no fe v e r Sh e b e ca m e progr e s s iv e ly w e ak e r

.
,
a n d d i e d four d ay s a ft e r t h e O p e ra t ion .
N e i th e r in tr a vi t am nor a t th e a u t op s y wa s th e r e an y in dica tion o f

infla m m a tion ab ou t th e u te rin e woun d In th e m ucou s m e m bran e of .
th e a s c e n d in g an d tran s v e r s e colon w e r e s e v e ral d e fe c t s wi th s h arp
e dge s .
T h e s e con d ca s e wa s th a t o f a ra th e r an ae m ic b ut fairly n ouri sh e d

wo m an o f 2 5 Papillo m a ( s iz e of a b aby s h e a d) o f righ t ov ary wi th
.
’
a larg e e ncap s ula t e d a s ci t e s T h e l e ft o vary al s o d i s e a s e d wa s re

.
, ,
m ov e d a t t h e s a m e t i m e op e r ati on at fir s t w e ll bo rn e ; vo m i ting d ur
ing th e d ay an d s e v e r e collap s e in th e e v e ning ; s ti m ulan t s hyp o d e r
m i c ally ; e x t r e m e e x h a u s t ion th e followin g d ay vo m i ting h ad s t opp e d ,
b u t th e pa s s ag e s b e c am e bloo d y I nj e c tion o f 1 5 0 0 grm

. . s al t .
s o lu t ion in t o th e l e ft b a s ilic v e in wi th gr e a t i m prov e m e n t in th e p ul s e ;

,
i t h ow e v e r cau se d a s ubj e c t iv e fe e ling o f gr e at fe ar l a s t in g all d ay

, , , .
T h r e ate ni n g s y m p t o m s h a d s ub s i de d by th e n e xt d ay th ough bloo dy ,
p a s sag e s co n t inu e d a fe w d ay s an d gu m s an d oral m ucou s m e m bran e

w e r e ulc e ra te d at m any p oin t s F inal r e cov e ry N o r e lap s e up t o
. .
s e v e n m on th s p 0 . F ro m form e r p ublic a tion s an d th e two h i s t ori e s

.
j u s t giv e n I b e li e v e we c an d raw th e conclu s ion th a t in l aparo t o m y on

,
p at i e n ts n o t to o m u ch r e d uc e d s ubli m at e s olu tion s of 1 t o 5 6 0 0 0 m ay

,
-
b e u se d ; th at h ow e v e r i n h igh ly a n ae m ic w e ak e n e d in divi d ual s an d

, ,
240 I I VD E X OF S UR GI CA L P R O GR E S S .
o
th s e wi th ki dn e y a ffe c tion s it is s a fe s t to avoi d s ubli m a t e al t og e th e r .
f No
'
Gen i aI . . C/zzTg . 1 886 . . 22 .
WM . BR O WNI NG ( B r oo k lyn )
III . nt of R e ce nt Ab d om i n al W o u n ds w ith H e r
T r e at m e
n i a of th e O m e nt u m By H H A R T MANN M D ( Pari s )
. Th e
.
,
. .
,
.
wri te r call s a tte n tion t o th e fac t th a t a lth ough F r e n ch s urg e on s h av e ,
a d op t e d a d va n c e d vi e w s wi th r e gar d t o ab d o m inal s urg e ry in g e n e ral ,
t h e y s t ill h ol d t h e m e th o d o f a l lo wi n g o m e n t u m pro tru d ing fro m an ,
ab d o m inal woun d t o cur e i t s e l f by s loug h ing o ff an d th e n pro c e e d s

, ,
t o giv e a d e t ail e d cri t ici sm o f th e au t h o ri ti e s fo r t h i s m e th o d sh owi ng ,
th e cru d e n e s s o f th e ir r e a s oni n g a n d t h a t th e failur e s o f t h e m e th o d o f

,
liga t ur e a n d r e t urn t o th e ab d o m in al cavi t y w hich cau se d i t s for m e r

’
,
r e pu dia t io n w e r e d u e n o t t o any d e fe c t in th e m e th o d i t se l f b u t to
,
fau lt s o f i t s applica t i on an d r e ci t e s th r e e s ucc e ss ful ca s e s t o s h ow th e

,
p e r fe c t s a fe ty o f liga t uring th e pro tru ding p ar t an d d ropping i t back

in t o th e ab d o m inal c avi ty all un d e r car e ful an t i s e p tic pr e cau tion s by
, ,
w h ich a s ur e r m or e r api d an d m or e g e n e ra lly s a ti s fac t o ry cur e was

,
ob t ain e d th an wa s p o s sibl e by th e e xp e c tan t pla n —R evu e a c C/zzr u r ’

'
g ia. 1 886 M ay . .
IV . T h e S ign i fi C o l l a p s e d I n t e s t i n e i n La p a
can ce of
r o t o m y fo r I n t e s t i n a l O b s t r u ct i o n By J E M I C H A E L M D . . .
, . .
( Bal ti m or e ) R e fe r ri n g to a s t a t e m e n t th at a d ila te d in t e s tin e woul d

.
in dica t e th a t th e c au s e of th e ob s truc tion i s low e r d o wn wh il e a col ,
lap se d in te s t in e can only b e e xp e c t e d on th e p e rip h e ral s i d e o f th e oh

s truc tion th e wri t e r quo t e s t w o ca se s w h ic h h a d co m e u n d e r h i s o b
, ,
s e rva ti on in w h ic h t h e s m a ll in t e s tin e wa s collap s e d w h il e th e r e w a s an

,
ob str u c tion a t th e s ig m oi d fl e xur e t o sh ow th a t th e prop o s i ti on i s n o t ,
s t ric t ly corr e c t or i n variab ly tru e — I ll ca I Vew S May 2 9 ’

1 886 . . . .
V . D i agn o s t i t i al By C J O H N S O N M D ( Bal
Lap ar ot om y . .
, . .
m or e ) .T hi s pap e r d i s cu s s e s th e s ubj e c t in a g e n e ral w ay an d i s in

accor d a n c e wi th pr e va le n t vi e w s on th e s ubj e c t ca lling a t te n tion t o ,
t h e fac t t h a t a ll i n tra ab d om inal O p e ra tio n s a re t o a c e r t ain e x t e n t e x

-
CH E S T A N D A B D O M E N .
24 1
p lor a t i ve A s i de fro m th i s h e d i vi de s ca s e s d e m an ding l ap aro t o m y

.
,
i n to two cl a ss e s ( 1 ) ca s e s in wh ich a d iagno s i s c an n o t b e m a de wi th

,
o ut i t s a i d a n d ( 2
) ca
,
se s in wh ic h a d iag n o s i s h a ving b e e n m ad e n o , ,
d e fini te lin e o f op e ra t ion can b e m ark e d o u t a n d no ab an d on m e n t of
a c tiv e m e as ur e s e n t e r t ain e d or j u s t ifi e d T h e d iagn o s i s o ug h t t o b e .
e s t abli sh e d in e v e ry ca s e a n d t h e o p p or tu n i t y o ffe r e d by lap aro t o m y

,
s h o ul d n o t b e d e lay e d t o o long .
A VA N D E R VE E R M D ( Alb a n y N
.
,s p e akin g approvingly o f
. .
, .
l ap aro t o m y a s a d iag n o s ti ti a l m e th o d r e vi e we d t h e p oin ts up on w h ich ,
s ur g e on s are a t varianc e e xpr e s s ing h i s approval o f e arly op e ra t ion s ,
am ong t h e b e s t s urroun d ing s a n d wi th all an t i s e p t ic pr e cau t ion s The .
inci s ion s h o ul d b e i n th e m e dian lin e w h e n th e i nte s tin e s a re in fl a te d

a n d roll o ut o f t h e op e ning h e a d vi s e s pricki n g th e m o s t pr o m in e n t ,
lo op t o p e r m i t th e e s ca p e o f ga s a n d s e cur e t h e coll ap se o f t h e g u t .
H e woul d clo s e th e ab d o m e n by t h e d e e p t h ro ug h a n d t h ro ug h s u
t ur e in pr e fe r e nc e t o t h e m e t h o d o f s u t uring e ac h lay e r s e p ar a t e ly .
J E M E AR s M D ( Ph ilad e lp hi a) w o uld a dop t t h e follo wing or d e r o f

. .
,
. .
,
t r e a t m e n t ( 1 ) e x te rnal m anipula tion ( 2 ) i n t e rn al e xa m in at ion w h e r e

, , ,
.
i t i s p os s ibl e t o b e m a d e t hro ug h e x p lora tion o f th e p e lvic ca vi ty ( 3 ) ,
a s pira tion a n d ( 4 ) lap ar o t o m y t h e m o s t s e riou s o f all a n d t o b e r e ,
s or t e d t o a fte r th e failur e o f a ll o th e r m e t h o d s H e d e pre ca te d ra sh .
n e s s b u t approv e d o f ab d o m inal s e c tio n in in t e s t inal o b s truc tion a n d ,
in gun sh o t woun d s o f t h e ab d o m e n h e th oug h t th e r e co ul d b e no qu e s

t ion o f i t s p ropri e ty H e b e l i e v e d t h a t t h e con di t ion o f th e p e ri t on e u m
.
h a d m u c h t o d o wi th th e i m m uni ty o f op e ra t iv e pro c e d ur e s a n d t h a t ,
o n e w h ich h a d b e e n accu s to m e d t o th e pr e s e nc e o f a t um o r wo uld
e n d ur e O p e ra t ion m uc h b e t t e r th an a p e r fe c t l y h e al th y o n e .
C T . . PA R K E S , M D ( C hicago ) b e li e v e d t ha t t h e l e ng th
. .
, of th e in
c i si on li ttl e in fl ue n c e o n th e r e s ul t o f th e op e ra tion al th ough

h a d b ut ,
h e h a d obse r v e d th a t i n t h e ca s e s i n wh ic h i t b e ca m e n e c e s sary t o e x
,
t e n d th e i n f s i o n ab o v e th e u m b ili c u s c o n v ale s c e n c e wa s s o m e wh a t
r
,
m or e prolong e d H e al s o w a s O p p o s e d t o th e s u t uring t h e d i ffe r e n t

.
ab dom inal lay e r s a n d clo s e d th e inci s i o n by s u turing th e lip s o f t h e

,
wo un d en m a ss e A ca s e w hich h ad b e e n v e ry in struc tiv e t o h i m i n

.
conn e c tio n wi th th e d ang e r o f op e ning th e ab dom e n was th a t o f a wo

242 I N D E A OF S UR GI CAL P R O GR E S S
'
m an wh o h a d b e e n h ook e d by a cow th e ab d o m e n ripp e d O p e n an d ,
th e b ow e l s cau s e d t o pro tru d e ; t h e se w e r e cl e an se d a n d r e t urn e d an d ,
r e cov e ry fo llow e d pro m p tly wi th o u t e v e n a loca liz e d p e ri t oni ti s H e

, .
th ough t d e lay in ca se s o f i n t e s t in al ob s t ruc t ion wro n g an d quo t e d ca s e s
in s uppor t of th i s vi e w .
.
J F T H O M P S O N M D ( W a sh i n g ton D
.
,
. . r e p or t e d two ca s e s in
, .
wh ich lap aro to m y h ad b e e n p e r for m e d fo r d i a gn o s ti ti al purpo s e s In .
th e fir s t th e p a t i e n t h a d b e e n s u ffe ri n g for s e v e ral y e ar s fro m a t u m or

, ,
r e s e m blin g an ovarian t u m or i n m any r e s p e c ts e xc e p t th a t i t h ad two ,
s inu s e s le a d i n g fro m i t an d O p e ni n g i n t h e groin s ; th e ab d o m inal e n
larg e m e n t wa s as gr e a t a s a t t h e fi fth or s ix th m o n t h o f g e s t a tion fol

-lowi n g up o n e o f t h e Sinu se s in t o t h e c avi ty o f th e ab d o m e n a l arg e
,
t u m or pr e s e n t e d b u t th e flow o f p us coul d n o t b e e xplain e d ; t h e t u

,
m o r b e i n g app ar e n tly e m b e dd e d in th e ab d o m inal wall i t was th oug h t ,
b e st t o clo se th e woun d wi th ou t fur th e r op e ra tion ; a t th e au t op sy fi ve ,
m on th s la te r th e t u m or wa s foun d t o b e an e nlarg e d an d d i sloca t e d

,
s pl e e n
. T h e s e con d c ase was fo r a t u m or w h ich b e ing foun d on O p e n ,
i n g th e ab d o m e n t o b e an e x te n s iv e c arcino m a involving t h e m e s e n ,
t e ry t ran s v e r s e colon a n d l i v e r was l e ft un di s t urb e d a n d th e p at i e n t

, ,
r e cov e r e d r e a d ily from th e op e ra t ion H e di s approv e d o f th e s i m pl e

.
co n tinuou s s u t ur e in clo s ing th e ab d o m e n b e li e vi n g th at e ac h lay e r ,
s h oul d b e s u t ur e d s e para t e ly so th a t t h e in t e rn al p e ri t on e al lay e r m ay
h av e u n i t e d s u ffici e n tly t o pr e v e n t th e e n tranc e o f p u s b e for e s upp ura
t ion s h all h av e b e e n e s t abli s h e d .
F ur t h e r r e m ark s w e r e m a de by o t h e r s p e ak e r s ca s e s b e i n g quo te d in ,
wh ich an e xplora t ory O p e ra tion woul d h av e prob ably s av e d li fe th e ,
t r e n d o f O pinion b e in g in favor o f t h e m or e fr e qu e n t applica tion o f th e
op e ra tio n —P r oc A m S a rg A ss n 1 8 8 6
. . . . .
V I A S u c c e s s fu l C a s e o f L a p a r o t o m y fo r P e r i t y p h li t i c
.
Ab s ce s s . By J L H O MAN S M D ( Bo s t on Ma s s ) A b oy ae t 1 1
. .
, . .
, , .
,
.
,
h a d s u ffe r e d fro m p ain an d t e n d e rn e s s in th e righ t iliac r e gion for fi ve
d ays ; d u ln e s s wa s fou n d on p e rcu s s ion an d th e t e m p e ra t ur e a n d p ul s e .
ra te w e r e h i gh an d incr e a si n g In pur s uanc e o f th e policy o f e arly

.
i n te r fe r e nc e an inci s ion wa s m a d e ab o u t inch e s lo n g wi th ou t

, ,
pr e vi ou s a s p i ra ti on ov e r th e m o s t it e n d e r poin t an d th e p e ri to n e u m ,
IE N
CH E S T A N D AB D OIP .
24 3
op e n e d ; h e al th y in t e s tin e pr e s e n t ing was p u sh e d asi d e an d b e n e a th i t ,
w e r e foun d loop s of in t e s tin e b oun d t og e th er by a r e c e n t pla st ic pro

c e ss an d by p oking ab ou t wi th th e fin g e r an ab s c e s s wa s t orn op e n
, ,
e v a cua tin g t wo ounc e s or m or e o f foul u s A d o ubl e d rainag e t ub e

p .
wa s in s e r t e d a n d th e woun d c lo se d th e p a ti e n t m aking a pro m p t t e

,
c ov e ry .
E s p e cial a tte n t ion was call e d to th e e arly p e ri o d a t wh ich th e O p e r a

t ion w a s p e r for m e d o n th e fi fth d a y o f t h e s ickn e s s a n d th e s e con d a ft e r
b e in g s e e n by a m e d ical m an — B os ton M ea a n a S zcrg f ou r

. 1 886
’
.
’
. . .
April 2 9 .
VII . P e r it y ph l it i s
By H B SAN D S M D ( Ne w Y ork ) Q uo t e s
. . .
, . .
, .
s ix ca s e s o f p e ri typ h li t i s wi sh in g t o e m p h a s iz e t h e n e c e s s i ty o f ab s o
,
lu te r e s t in th e tr e a tm e n t o f th i s a ffe c ti on T h e fir st wa s th e c as e o f a
.
p h y s ician wh o wa s d oing fairly we ll b u t wh o wh il e th e d i s e a s e was in

, ,
progr e ss w a s allow e d t o t ak e s e v e ral ca th ar tic m e di cin e s e ach o f

, ,
wh ich only aggr a v at e d th e t roub le an d fi n ally a ft e r a copiou s p a s s ag e

, ,
pro d uc e d by an e n e m a h e fe ll in t o collap se a n d di e d wi th n o c a u s e
, ,
fo r t h e e xi s ti n g p e r for at i on o f t h e app e n dix vi s ibl e on a u t op s y I t wa s .
e vi d e n t i n th i s c a s e t h a t t h e d i fficul t y h a d b e e n confin e d wi th in n ar
row li m i t s for a w h il e a n d un d oub te dly a b e tt e r ch anc e for r e cov e ry

,
wo ul d h av e b e e n a ffor d e d i f th e p a ti e n t h a d b e e n k e p t ab s olu te ly qui e t

a n d O piu m gi ve n in s t e ad o f ca th ar t ic s .
T h e s e con d ca s e w as th a t o f an o ld m a n wh o h a d b e e n s uppo s e d t o
b e s u ffe ring fro m s t rangula t e d h e rni a b u t al th ough a h e rni a e xi s t e d

, ,
th e s ac w a s so flacci d th at th e r e coul d b e n o s t rangula ti on a n d th e ,
c ase wa s in r e ali ty o n e o f p e ri typ h li ti s ; th e p a ti e n t wa s allow e d t o g e t

up an d go d own t o wn wi th th e r e s ul t o f pr e cipi t at ing a p e ri t oni ti s an d
,
d e ath . Au t op sy r e v e al e d p e ri typ h li ti s wi th p e rfor ati on o f th e v e rm i

fo rm app e n dix an d an e m p ty h e rnial s a c on th e ri gh t s i de Th i s .
c as e al s o e m p h a s iz e d th e i m p or t anc e o f r e s t an d O piu m .
T h e th ir d ca se was al s o o f a p h y s ician wh o h a d s ign s o f in t e s ti n al

,
ob str uc ti on d u ring th e pro gr e ss o f p e ri toni ti s : an d th e only r e as on for

s upp o s ing th e t ro ubl e t o h av e b e gun in th e app e n d ix v e r m i form i s wa s
th e e xi s t e nc e o f slig h t p ain in th e rig h t inguin al r e gion La t e r d i s .

,
t e n s ion of th e ab d o m e n an d e l e va t ion o f t e m p e r at ure t o 1 0 4

°
F oc .
2 44 I N D E X OP S UR GI CAL P R O GR E S S .
curr e d ; r e s t h o t fo m e n t a tion s an d O piu m brough t th e t e m p e r at ur e

,
d o wn t o 1 0 2 F al th ough th e p ul s e s t ill con t inu e d rapi d ; th e s p e ak e r

°
.
,
wa s call e d in a t th i s t i m e b ut d i d n o t urg e an O p e rati on t h in k i n g i t

, ,
woul d o ffe r b ut li ttl e ch anc e o f r e cov e ry D e a th e n s u e d an d th e a u

.
t op s y sh ow e d th e fa t al r e s ul t t o h av e b e e n d u e t o univ e r s al p e ri t oni ti s ,
o riginally c a u s e d by p e r for ation o f th e v e r m i for m app e n dix th e p u s n o t ,
b e ing e nclo s e d a s i s u s ual in ab s c e s s e s o f th i s kin d T h e only p o s s ibl e

.
Surgical s ucc e s s in th i s ca s e woul d h av e b e e n e arly lap aro t o m y i f an ,
e arly d iagno s i s h a d b e e n p o s s ibl e .
T h e four th ca s e wa s a v e ry s t ou t yo ung m an ae t 2 1 u p on w h o m h e
, .
,
op e r at e d on th e fo ur t e e n th d ay In th i s O p e ra tion for th e fir s t ti m e in
.
,
h i s e xp e ri e n c e h e acci d e n t ally c u t th e in t e s tin e al th ough p u s h a d b e e n

, ,
wi th drawn by th e h yp o de r m ic s y ring e b e for e th e inci s ion wa s m a de

,
.
Wh e n h e arriv e d a t th e t u m or all th o s e pr e se n t h ad t h e i m pr e ss ion

,
th a t a pi e c e o f in t e s t in e wa s b e ing d e al t wi th an d i t s e e m e d t o t h e
,
op e r at or th a t th e r e wa s a por tion o f th e c ae cu m in th e woun d in st e a d o f

th e u s u al ab s c e s s cavi ty ; h e m a d e a c u t wi th t h e s ci ss or s an d t h e i m ,
pr e s s ion conv e y e d t o h i s m in d wa s th a t h e wa s cu t ti n g in te s t in e ; fro m

th e O p e ni n g ca m e p u s an d a i r b u t n o fae c e s ; fae c e s app e ar e d h ow e v e r
, , ,
th e n e x t d ay an d on th e s e con d d ay in larg e quan t i ti e s con tin uing fo r

, ,
ab ou t t e n d ay s h aving c e a s e d al t og e th e r at th e e n d o f t wo w e e k s T h e
, .
p a ti e n t r e cov e r e d e n t ir e ly in th r e e w e e k s ; th e op e ra t or th oug h t th e h y
p o d e rm i c n e e d l e m u s t h av e p a s s e d t h roug h b o t h wall s o f th e in te s tin e
b e for e p e n e tra ting th e ab s c e ss .
A fi fth c a s e was of a y ou n g lad th e r e b e ing s y m p t o m s o f p e ri t oni ti s

,
in conn e c tion wi th p e ri typ h li ti s th e ca s e progr e s s e d w e ll for a w e e k ,
wh e n s ubnor m al t e m p e ra t ur e ab d o m inal d i s t e n s ion an d o th e r alar m

,
ing s y m p t o m s app e ar e d ; an op e r at ion wa s p e r for m e d an d t h e ab s c e s s

cavi ty fo un d t o con t ain p u s an d fae c e s ; th e p a ti e n t was conval e s c e n t
w h e n la s t s e e n .
T h e s ix th ca s e wa s a la d o f 1 4 in w h o m th e s y m p t o m s h a d e xi s te d
,
for a w e e k a n d wh e r e th e r e s e e m e d t o b e s ign s o f p e r fora t ion on th e
s i d e o f t h e p e ri t o n e u m ; th e r e wa s m ark e d ty m pa n i t e s a n d h e cou ld
m ak e o u t no circu m s crib e d t u m or ; a ft e r d e ba t ing w h e th e r t o c u t in
t h e m e d ian lin e or a t t h e s i d e h e d e ci d e d t o m ak e th e i n ci s ion in t h e

,
la t t e r loc ali ty
. W h e n th e lay e r s o f th e ab do m e n we r e c ut d own up on ,
24 5
ab ou t a h al f an o unc e o f p us wa s s e e n t o fl ow fro m a s m all op e nin g

an d th e ab s c e s s c a vi t y w a s fou n d t o b e v e ry s m oo th th e ab s c e s s wa s
d oub tl e s s in th e cavi ty o f th e p e ri t on e u m a n d a s h a d b e e n s u s p e c t e d , .
t h e c a s e was o n e in wh ic h p e r for at ion h a d o ccurr e d t owar d th e s e ro u s
m e m b ran e a n d n o t a m e n abl e t o t h e u s ual op e ra t ion .
'
I t h avin g b e e n r e m ark e d th a t th e e arly r e cov e ry o f th e fo ur th c as e
r e n d e r e d i t d oub tful wh e th e r th e in t e s tin e h a d r e ally b e e n woun de d .
Dr S an ds s ai d i t th at was qui te p o s s ibl e t o h av e a s i m pl e woun d o f th e

.
in te s t in e an d al s o rapi d r e cov e ry A r e m ark abl e e xa m pl e o f th i s was

.
th e ca se o f a young m a n acci d e n t ally sh o t in th e ab d o m e n wi th a 3 8
calibr e ball e n te rin g th e b o dy on th e ri g h t s i d e o f t h e m e d ian lin e clo s e

,
t o th e p ub e s N o fae c e s app e ar e d on probing fo r th e b all wh i ch coul d

.
,
n o t b e foun d on an in ci s ion e x t e n d ing a s fa r a s th e s pin e o f t h e iliu m

,
.
I t wa s no tic e d t h a t th e r e was s o m e d e e p e m p h y s e m a w h i ch h a s re ,
c e n tly b e e n no t e d a s a s ign o f p e r fora tion o f th e in te s t in e ; th e e xt e rn a l

a b d o m in al rin g w a s s o m e w h a t p a t ulou s b u t n o m or e s o th a n i s o fte n
.
th e ca se O n th e th ir d d ay a fl ow o f fae c e s app e ar e d th e s ourc e o f

.
,
w h ich co ul d n o t b e a s c e r tain e d al th ough th e d rain ag e t ub e was re

,
m ov e d .A fte rwar d h ow e v e r a i r an d faec e s c am e fro m th e e x t e rn al

, ,
a b d o m inal ring a n d t h e b ull e t t h e r e for e

, m u s t h av e e n t e r e d th e ah
, ,
d om n th roug h th i s n a t ural op e ning T h e p a ti e n t r e cov e r e d sh owing

e .
,
th a t a t e m p orary fae cal fi s t ul a m ig h t s o m e t i m e s b e e s t abli sh e d .
I t h a d b e e n cl ai m e d th a t l aparo to m y coul d s ucc e e d in c a se s o f p e r
fo r a ti on o f th e v e r m i for m app e n dix a n d g e n e ral p e ri t oni ti s b u t h e b e ,
li e v e d th a t wi th th e l a t t e r con d i t ion th e O p e ra tion o ffe r e d no h op e o f

, ,
s aving li fe —P r oceed i ag S I V Y S u Tg S oc
. .1 886 Ap ril 2 6
. . . .
VIII . P e lv i c Ab s c e s s l By T H B U R C H A R D M
in th e M a e . . .
,
.
D ( N e w Y ork )
.
, D e fin i ng th e l e s ion as a p h l e g m on ou s infl am m a tion
.
occu rring in th e s up e ri or p or tion o f th e p e lvic cavi ty b e low th e c a vi ty ,
o f t h e ab d o m e n fro m wh ic h i t i s s e p a r at e d by th e p e lvi c r e fl e c ti on s o f
,
t h e p e ri t on e u m an d ab ov e th e m u s cul ar floor for m e d by th e l e v at or

,
an i m u s cl e h e call s a t t e n tion t o t h e fac t th a t th e b ony la t e r a l b oun

,
d ari e s a n d th e d e n s e a n d al m o s t i m p e rvi ou s m u s c u lo m e m br an ou s floor -
r e n d e r i t p o s s ibl e for ab s c e s se s t o origin at e in th e p e lvi s an d pro d uc e

m o s t acu t e con s t i t u t ion al d i s t urb a nc e an d e v e n v e r
y e xt e n s iv e lo c a l
2 46 IN DE X OF S UR GI CAL P R O GR E S S .
d i s org aniz at ion wi th ou t any x te rn al s y m p t o m s Th e

d i s ti ngui sh ing e .
b urrowing o f th e p u s m ay b e v e ry e xte n s iv e p a s sing thr ough th e p e lvi c

,
fora m in a an d app e arin g e x t e rn ally un de r th e glu t e al m u s cl e s ; p e n e tra t

ing th e ac e tab ulu m an d d e s t oying th e h ip j oin t di s s e c ting up th e
r -
,
ap on e uro s i s of th e ili ac m u s cl e s pro d ucing n e cro s i s o f th a t b on e an d

,
app e a rin g upon i ts e x te rnal s ur fac e ; e m e rging fro m th e p e lvic cavi ty

a n d t rav e ling an t e riorly alo n g t h e cour s e o f t h e fe m oral v e s s e l s b e n e a th
’
P oup a rt s li ga m e n t an d app e aring on th e an t e ri or s ur fac e o f th e th ig h ;
p e n e tr a ting th e h ollow vi s c e ra an d e vacua ti n g in t o th e bla d de r r e c tu m ,
or p e ri t on e al c avi ty in fac t th e r e i s no d ir e c tion wh ich i t m ay n ot t ak e

a ft e r h aving e s cap e d fro m i t s bo n y confi n e s T h e clinical h i s t o ry
.
v ari e s accor d ing t o th e acu te n e s s or la te ncy o f th e a tt ack b o th th e ,
con sti t u t ional an d local d i s turb anc e s b e i n g th e gr e a t e r in th e la tt e r ,
wi th gr e a t p ai n an d fe bril e p h e no m e na m or e or l e s s ab do m inal di s te n
,
s ion t y m pani t e s vo m i t ing fl e xi o n o f th e th ig h s d i fficul t or i m po s s ibl e

, , , ,
m ic t uri t ion proc t i t i s an d t e n e s m u s i f t h e t u m e fac tion proj e c t e d in t o th e

,
r e c t u m an d localiz e d or g e n e ral p e ri toni ti s i f t h e infla m m a ti on S pr e a d

, ,
upwar d s Ab s c e s s e s for m e d th u s acu te ly a re m or e lik e ly t o e vacua t e

.
t h e m se lv e s S p on t a n e ou s ly in e i th e r th e r e c t u m or bla d d e r t h an t h o s e,
o f a s ub acu t e or c h roni c c h arac t e r .
W h il e d i fficul t t o s p e ci fy a t i m e i t i s logical t o s uppo s e th a t s upp u

,
r at i on o ccur s s o m e con s i d e rabl e t i m e b e for e i t m ak e s i ts e l f m ani fe s t by

e x t e rn al t u m e fac t ion th e d e lay b e in g d u e t o th e d i fficul t y t h e p u s e x
,
e ri e n c e s in g e t ting t o t h e s ur fac e b e cau se o f th e d e p t h o f t h e s u

p , p
u ra t i o n ra t h e r th a n t o th e ab s e nc e o f T h e con s ti t u t io n al e vi
p , p us .
d e u c e s o f in t e rnal s upp ura t ion are a ll along m or e or l e s s prono un ce d

a n d a car e fully con d u c t e d e xa m ina t i on a t t h i s s t ag e m ay d i s cov e r t h e
locat i on C hronici ty h ow e v e r s e e m s t o b e t h e rul e wi th n on t rau

.
, ,
-
m a t ic ca s e s in t h e m al e wh ic h m o s t fr e qu e n tly occur in th e poorly

,
n ou ri sh e d an d cac h e c tic i n w h o m infla m m a t ory proc e s s e s are s low a n d
s upp ura tion t ar d y ; a wi d e ly d i ffu s e d infla m m a t ion m a

y p e rv a de th e
p e lvi c c e llular t i s s u e m o n th s b e for e i t s fi n al br e aking d own in t o p u s .
T h e d iagno s i s i s o ft e n v e ry b affli n g in s uch ca s e s o wi n g t o th e inac ,
c e s s i b ili ty o f th e p ar t s a n d th e m any d i ffe r e n t t i ss u e s organ s v e s s e l s

, ,
a n d n e rv e s a ffe c t e d . Clinically i t i s i m por tan t t o di s tingui sh b e tw e e n

,
a n infla m m a t ory con d i t ion s i m ply a n d th e s uppura t iv e s t a g e o f th e

C H E S T A N D AB D OM E A .
2 47
s am e con di ti on th e la tt e r o f wh i ch c an n o t b e r e cogni z e d t oo e arly ;

,
a n d lik e wi s e b e t w e e n a p e lvi c c e lluli t i s an d g e n e ral or localiz e d e ri t o n

p
i ti s an d b e tw e e n i t an d cy s ti ti s pro c ti t i s an d pro s ta ti ti s S urgic ally i t i s
, .
n e c e s s a ry t o d i ffe r e n t ia t e b e t w e e n ab d o m i n al p e lvic i l e o p e lvic an d , ,

-
p e rin e al ab s c e s s an d ab s c e s s o f th e i s ch io r e c t al fo s s a a s w e ll as th e
-
,
e xc e p tional acci d e n t s li abl e t o b e foun d h e r e .
T h e tr e a tm e n t na t urally r e s olv e s i t s e l f in t o t r e a t m e n t o f th e c e llu
li ti s b e for e s upp ura tion a n d a ft e r s uppura tion In th e for m e r r e s t .

, .
m orp h i n e quini n e lo cal r e frig e ra t ion a n d local d e pl e ti on by l e e c h e s t o

, ,
t h e p e rin e u m in th e la t t e r e vacua t ion a t th e e arli e s t p o s s ibl e m o m e n t

,
.
I n illu s t ra tion fi v e ca s e s are r e la t e d two o f wh ic h d i e d o f th e d i s e a s e

, , ,
o n e o f an in t e rcurr e n t n e p hr i t i s o n e r e fu s e d a s s i s t anc e a n d o n e wa s
,
t r e a t e d by an O p e nin g e x t e n d ing d own fi v e inc h e s fro m t h e p o s t e rior
s up e rior s pino u s proc e s s o f th e iliu m in t o th e p e ri t on e al cavi t y th e ,
s inu s O p e n e d a n d th e cavi ty drain e d wi th r e co v e r y — I V Y M ca

’
,
R ec . . . .
1 886 . April 2 4 .
J E PI LCH E R ( U S A m y) . . . . r .
IX . O n t h e O p e r at i v e T r e at m e n t o f C a r c i n o m a o f t h e
Large I nt e s t i n e
’
By Dr B R I E D E L ( Aix La C h ap e ll e )
. . . G urlt s - -
.
S t a ti s tic s o f th e Vi e nna h o s pi t al s s h ow th a t o f s o m e 5 0 0 ca s e s o f c arci
no m a o f th e i n t e s t inal t rac t t h e s m all a n d larg e in t e s tin e s w e r e t h e s e at

,
o f d i s e a s e in 1 0 9 ca s e s w h il s t t h e r e c t u m wa s a ffe c t e d in 3 99 ca s e s a ,
propor tion o f ab o u t 1 t o 4 S c h ra m m coll e c te d in h i s work wh ich ap

.
,
e re d in 1 8 8 4 3 4 ca s e s o f carcino m a o f th e larg e in t e s t in e o f w h ic h
p a , ,
b u t a fe w w e r e s i t ua te d in th e t ran s v e r s e or d e s c e n ding colon by far ,
t h e larg e r nu m b e r b e ing fou n d in t h e c oe cu m or s ig m oi d fl e xu re D ur .
in g a p e rio d o f fo ur a n d a h al f y e ar s t h e au th or h a s ob se rv e d 1 4 ca s e s
,
o f r e c t al c arcino m a a n d 9 o f carci n o m a o f t h e l arg e in t e s t in e

,
O f th e .
la tte r 3 w e r e s i t uate d in th e c oe cu m o n e in th e d e s c e n di n g colon an d

,
i n th e s ig m oi d fl e xure O nly o f t h e 1 4 c as e s o f r e c t al c a rcino m a

5 5.
w e r e O p e ra tiv e O f th e s e o n e d i e d in con s e qu e nc e o f t h e O p e r at ion

.
,
wh il s t 4 are livin g 3 wi th o u t r e lap s e th e o th e r O p e ra te d t wo y e ar s

, , ,
ago h aving r e c e n tly s h o w e d sign s o f r e t urn o f th e di s e a s e O f th e 3

,
.
c ase s wi th o u t r e lap se 2 w e r e O p e ra t e d in 1 8 8 3 a n d w e r e v e ry s i m pl e
, ,
a n d e a s y on e s t o op e ra t e T h e ol d e s t an djm os t d i ffi c ul t ca s e ( wo m a n
.
,
24 8 I N D E X OP S UR GI CA L P R O GR E S S .
73 y e a r s o f age ) was op e ra te d i n 1 8 8 1 T h e carci n om a was s i tua t e d

, .
s o h i gh up t h at th e a u th o r a ft e r o e n i n g D o u gla s cul ’
p ,
d e s ac w as - -
,
o b li g e d t o p u ll th e lo we r par t o f t h e s i g m oi d fl e xur e d ownwar d s an d
di vi d e i t tran s v e r s e ly b e twe e n two e la s t i c liga t ur e s th e gut b e ing e x ,
c i s e d fr om ab o v e d o wn war d s All g la n d s in th e cavi ty o f th e 0 5 s a

.
c r um we r e r e m o v e d Pa ti e n t r e c o v e r e d an d i s a t pr e s e n t i n goo d
.
h e al th . O f th e 9 c a s e s o f carc in om a o f th e larg e r i n te s ti n e 2 woul d ,
n o t s ub m i t t o an O p e ra t ion an d d i e d s h o r tl
y a fte rwar d s In th e th ir d .
ca s e ( m an ae t 6 5 wi th carci n om a c oe c i ) an e xplora to ry inci si on s h ow e d

,
.
,
th a t t h e di s e a s e h ad progr e s s e d t o o far t o a dm i t o f a ra d ical op e ra t io n .
An ar ti fi ci al anu s wa s th e r e for e m a d e ab ov e th e c oecu m b u t th i s con ,
d i ti o n b e c om i n g unb e arabl e t o th e p a ti e n t th e ab do m e n was clo s e d ,
an d th e p a ti e n t di e d t wo we e k s la t e r fr o m p e r fora t i o n o f th e carcino m a .
Th e four th a n d fi fth ca s e s ( m an ae t 6 5 wo m an ac t 7 0 bo th wi th car

,
.
, .
,
c in om a o f th e s ig m o i d fl e xu re h a d s e v e r e sym p t o m s o f i l e u s on a dm i s
)
s io n . In b o th c as e s an ar ti ficial a n u s wa s m ad e b u t t oo la te d e a th , ,
t ak i n g pl ac e 2 4 an d 4 8 h o u r s r e s p e c t iv e ly fro m p e ri t oni ti s cau s e d by ,
m i n u t e p e r fora t io n s ab ov e th e s m all ri n g lik e carcino m a Ca s e 6

- .
m an 4 5 ye ar s o f a g e ) wa s on e o f carcin o m a o f t h e s ig m oi d fl e xu i e
( wo , ,
wi th s tro n g a dh e s io n s t o th e p e lvi s W h e n a dm i tt e d se v e r e sy m p t o m s
.
o f il e u s w e r e pr e se n t t ym pani t e s
, vo m i ti n g e t c T h e colo n wa s
, ,
.
op e n e d in th e l e ft in gui n al r e gion A fte r th e co n t e n t s o f th e b ow e l s

.
h a d b e e n e m p ti e d i t was fou n d th at th e t u m or was ab s o lu t e ly n o n O p

,
-
e r ab le , a n d a n ar tifici al a n u s was t h e r e fo r e m a d e Pa t i e n t l e ft th e .
h o s pi t a l in goo d c on di tion Ca s e 7 Wo m a n ae t 5 4 Carci n o m a o f th e

. .
,
. .
s i g m o i d fl e xur e c au si n g gr e a t s t e n o s i s T h e g u t was r e s e c t e d fo r 6 c t m
. .
ab ov e an d b e lo w th e tu m o r Bo th e n d s we r e attach e d by s u tur e s in th e
.
a b d om i n al wo un d th e au th or i n t e n di n g t o u n i t e th e m la te r wh e n th e
, ,
b ow e l s h a d e m p ti e d th e m s e lv e s T h e pa ti e n t h o we v e r wa s w e ll s a ti s fi e d
.
, ,
wi th h e r c o n di tion an d w o u ld n o t co n s e n t t o u n de rgo a n o th e r op e ra
t ion . Sh e r e c o v e r e d an d i s a t pr e s e n t p e r fe c tly we ll n o si gn s o f ,
r e la p s e b e i n g ob s e rv e d .
R i e d e l s e i gh th c a s e i s a h i gh ly i n t e r e s ti n g o n e T h e pa ti e n t a g e n
’
.
,
t le m an 5 1 ye ar s o f a ge h a d b e e n ann o ye d wi t h i n te s ti n al d i s turba n c e s
, ,
for a b ou t o n e ye ar h a vi n g n o tic e d th e t u m o r s ix m o n th s b e fo r e Wh e n
,
.
fir s t s e e n by th e a uth or a lum p th e siz e 0 1 a h e n s e gg was di s ti n c tly

'
,
CH E S T AN D A B D OM E I V .
2 49
fe l t in th e righ t inguin al r e gion I m m e d ia t e O p e ra ti on was urg e d by

.
th e au th or th e p a t i e n t h ow e v e r ac t in g on th e a d vic e o f M i c h a ux ( wh o
, , ,
con s i d e r e d syp h ili s t o b e th e cau s e of th e t u m or) w e n t t o Aix La -
ch ap e ll e for tr e a t m e n t H e con tinu e d t o grow wor s e an d con s ul t e d

.
,
t h e au t h or again in Augu s t 1 8 8 5 b e ing t h e n in an e m a ci a t e d an d v e ry

, ,
forlorn con d i tion wi th d e ci d e d ic t e ru s

, T h e t u m or wa s now foun d t o .
h av e i n cr e a s e d v e ry m uch in s iz e h avi n g s e v e ral di s tinc t s up e rfi cial ,
pro m in e nc e s w h ich w e r e th ough t to b e infil tr a t e d glan d s N o tym p a

,
.
ni t e s or p ain pr e s e n t O p e ra tion was n o t a dvi s e d b ut at th e urg e n t re

.
,
qu e s t o f th e pa ti e n t an e xplor atory i n ci s ion wa s u n de r t ak e n N o i n

,
.
fil tra tion gl an d s we r e foun d an d a ra dical O p e r ation wa s a t onc e d e t e r

,
m in e d o n T h e carci n o m a wa s s i t ua t e d in th e c oe cu m
. O n a cco un t .
o f a dh e s ion s t h e w h ol e a s c e n di n g a n d a p or t ion o f th e t r a n s v e r se colon
h a d t o b e r e m ov e d th e il e u m b e in g d ivi d e d
,
T h e m e s e n t e riu m h a d .
b e e n n e c e s s arily s ubj e c t e d t o con s i de rabl e m al tr e a tm e n t d uring th e

op e ra tion on a ccoun t o f wh ich i t wa s h e l d t o b e a d vi s abl e t o s u t ur e
,
t h e e n d s o f th e s e v e r e d in t e s tin e in t h e ab d o m inal woun d T h i s wa s .
for tun a t e as larg e por ti on s o f th e m e s e n te ri u m b e ca m e n e cro tic an d ,
ab s c e s s e s foun d alo n g th e e d g e s o f th e s u t ur e d gu t by m e an s o f wh ich ,
th e n e cro tic por t io n s o f m e s e n t e ry w e r e e xp e ll e d Pa ti e n t di d w e ll ; .
lo st hi s ic t e ru s an d h i s app e ti t e r e t urn e d Two m o n th s la t e r th e in

, .
t e s tin e was u n i t e d wi th s u t ur e s o f fi n e S ilk a fte r ab ou t 6 c tm h a d b e e n ,

.
r e m ov e d fro m b o th e n d s E ig h t d ay s la t e r fir s t s t ool p e r an u m t ook

.
plac e In six w e e k s p a t i e n t di s ch arg e d cur e d

. N o s ign s o f r e lap s e .
up t o th e pr e s e n t t i m e .
Ca s e 9 Wo m an ae t 5 0 wi th larg e n o n op e rabl e carcino m a o f t h e

.
,
.
,
-
s ig m oi d fl e xure .
A glanc e c ase s will s h ow th a t di s turb anc e s in d e fe ca tion ( al

a t th e s e
t e rn a ti n g d iarr h oe a a n d con s tip a t i on occur in all ca car

) se s of
c i n o m a o f th e larg e r in t e s t i n e T h e s y m p t o m s o f il e u s d o n o t ap
.
p e ar s o o ft e n i n th e se a s in th e carcino m a o f th e s ig m oi d fl e xure th e ,
fae c e s b e ing qui t e fl ui d an d s o ft e v e n a s far d own a s th e e n d o f th e

,
il e u m s o th a t t h e y v e ry e a s ily p a s s th roug h a co n s i d e rably n arrow e d

,
lu m e n In s te no si s of th e s ig m oi d fl e xur e th e fae c e s coll e c t slowly un ti l

.
larg e quan t i ti e s ar e pr e s e n t wh e n vo m i ting e t c a pp e ar s an d th e n p e r

, , .
,
ora tion ab o v e th e st ric t ur e d p ar t Al th ough th e r e al s t a t e o f th e p a .

ti e n t i s lway s r e cogniz e d a d iagno s i s sh oul d n o t b e di ffi cul t To

n ot a ,
.
th i s e n d inj e c t io n s O f wa t e r in t o th e r e c t u m m ay b e a d van t ag e ou s ly
u s e d I f n o t m or e th an 2 0 0 gr a m m e s e n t e r th e r e i s c e r t ainly a s t e no
.
,
si s pr e s e n t I n carci n o m a o f th e c oe cu m th e r e i s o fte n p e rh ap s a t e n
.
, ,
d e n e y t o m i s t ak e t h e t u m or ( m ovabl e in all d ir e c t ion s) fo r a b e nign an t

grow th lying la t e rally t o th e in te s ti n e o r in th e m e s e n t e ry ina s m uch as
, , ,
d i s t urb anc e s o f th e in t e s t inal fu n c tion s are o ft e n s o v e ry s ligh t a t th e b e
gin n i n g D ur ing th e fur th e r progr e s s o f th e d i s e a s e th e u s ual sym p to m s o f

.
s t e no s i s o f cour se will app e a r I n m o s t ca s e s th e ag e s o f th e p a t i e n t s

.
rang e d fro m 4 0 t o 6 0 y e ar s b ut th i s for m o f carcino m a h a s b e e n fre

,
qu e n t ly ob s e rv e d in p e r s on s o f 2 0 t o 4 0 y e ar s o f age R a d ical r e m oval .
o f th e n e w grow th h as b e e n accor d ing t o S ch rai n m s s t a ti s ti c s ( t o

,
’
,
wh ich o n e ca s e o f S ch e d e m u st b e a dd e d) p e r for m e d in 2 2 ca s e s in 1 3
, ,
o f w h ic h t h e r e s ul t w a s u n favorabl e r e cov e ry t aking plac e i n

, 9 R i e de l .
t h ink s th a t t h e op e ra t ion will n e v e r a tt ain an y v e ry gr e a t r e s ul t s a s th e ,
p a t i e n ts pr e s e n t th e m s e lv e s t o o la t e u s ually .
R e gar ding th e ch niqu e o f th e op e ra ti o n th e au th or cau tion s again s t

te ,
uni ting th e e n d s of th e s e v e r e d g ut i f ty m p ani t e s b e pr e se n t pr e te r

, ,
ri n g th e ar tificial anu s Uni on t ak e s plac e e a s ily an d quickly i f larg e

.
p or tion s o f th e s e ro s a are broug h t in co n t ac t wi th e ach o th e r R . .
u s e d v e ry fi n e roun d e d curv e d n e e d l e s a n d corr e s p on d i n gly fi n e s ilk .
H e h a s n e v e r h a d a ca se o f gangr e n e o f t h e e d g e s nor fail e d in a s i n ,
g le ca s e t o g e t union O n uni ting t h e g u t la t e r o n th o s e p or t ion s

.
,
w h i ch h av e b e e n s e cur e d in th e ab d o m inal wou n d s h oul d b e r e m ov ed ,

.
T h e in te s t i n e m a y b e d ivi d e d fro m th e m e se n t e ry fo r a c e n t i m e t e r ,
wi th ou t ri s k car e b e ing t ak e n t o clo s e th e s li t in th e la tte r T he fir st

,
.
row of s u tur e s sh o ul d u n i t e th e m u s culari s an d a s m all s trip o f th e

s e ro s a w h il s t a s e con d row s h o ul d bri n g th e s ur fac e s o f t h e s e ro s a t o
,
g e th e r for th e s pac e o f
, c tm T h e i n t e s tin e s s h oul d b e th orou g h ly
.
e m p t i e d b e for e t h e O p e ra t ion t o pr e v e n t s oilin g o f th e s a m e wi t h fe cal

,
m a t te r T h e au th or a d vi s e s d e lay in uni t i n g t h e i n t e s t in e e n d s owi n g

.
,
t o t h e i m p o s s ibili t y in s o m any ca s e s par t icularly i n ca s e s o f i n c a r c e r

,
a te d h e rn ia o f d e te r m inin g th e r e al s t a t e o f th e g u t a t onc e R e s e c
,
.
t ion a n d s u t uring oug h t n o t t o b e un d e r t ak e n h e s ay s u n t il t h e in t e s

, .
t i n e s a re t h oroug h ly e m p ti e d o f t h e ir con t e n t s w h ic h s h oul d t ak e plac e

,
C H E S T A N D A BD OM E N .
25 I
l
in th e cour se of 24 h o ur s —D ea r . fli ed . Woclz . No . 1
5 an d 1 6 . Apr i
.
1 5 an d 2 2 . 1 886 .
C .
J . C O LL E S (New Yor k) .
X . C as e
Ch o le c y st ot om y
of By Dr A . . .
T h e wi fe o f a sh o e m ak e r ac t 3 5 s u ffe r e d fo r a b ou t e i g h t m on th s fro m
,
.
,
s e v e r e p ain s in th e r e gion o f th e liv e r N o s t on e s w e r e p a s se d ; no .
j aun d ic e occurr e d th e p ain s w e r e in t e rm i t t e n t in ch arac te r A t u m or .
o f th e s iz e o f a c h il d s h e a d wi th irr e gular s ur fac e a n d h ar d t o t h e fe e l

’
, ,
coul d b e m a d e o ut in conj unc t i on wi th th e liv e r an d p ar ticip a ting in

i t s m ov e m e n t s Th e low e r p or t ion gav e a t y m pani tic no t e an d th e
.
,
t u m or s li ghly m ovab le un d e r th e i n t e gu m e n t wa s p ain ful on pr e s

, ,
s ur e e s p e ci ally n e ar i t s upp e r par t

,
Urin e a n d p e lvic organ s n or m al
. .
Inci s i on p arall e l t o th e m e dian lin e ov e r th e t u m or r e v e al e d th e t u

m o r a dh e r e n t t o t h e t r an s v e r s e colo n a n d cov e r e d by h e p a t ic t i s s u e
.
a n d conn e c t e d wi th th e m e s ocolon b e h in d Tapping pro d uc e d m ucu s .
an d p u s a n d v e rifi e d t h e d iagno s i s o f e m py e m a o f th e gall b la d d e r

,
-
.
Asx t irp a tio n wa s i m p o s s ibl e th e a u th or s ti tch e d th e liv e r t o t he

e ,
ab d o m in al wall aroun d th e inci s ion by m e a n s o f fi v e s ilk s u t ur e s a n d ,
a ppli e d s ubli m a t e a n d io d o for m d r e s s ing s A fte r s i x d ay s d uring w h ich .
n o fe bril e r e ac tion occurr e d a larg e trocar wa s in s e r t e d in t o th e gall

,
bl adde r th rough 2 1 / c t m o f liv e r t i s s u e an d d rainag e e s t abli s h e d

2 . .
S ub s e qu e n t ly th e op e ning wa s e nlarg e d by Pa c q u é lin s cau t e ry

’
.
T h e p a t i e n t m a d e a goo d r e cov e ry t h e pain s w e r e e ffe c t ually cur e d , ,
an d o n ly a fi s t ul a r e m ain e d t h roug h w h ic h onl y a fe w d rop s o f ropy

,
m ucu s w e r e d aily d i s c h ar g e d M ea lVoc/zcm c/zr zf t 1 8 8 6 ’

. . .
No 1 7 . .
XI n t e r o t o m y fo r I l e u s
. E By Dr F F U H R ( Gi e s s e n ) a n d
. . .
,
Dr F W E S E N E R ( F r e iburg B a d e n ) In r e vi e wing th e variou s O pin

. .
,
.
ion s h i th e r t o e xpr e s se d o f th e r e la t iv e valu e o f e n t e ro t o m y an d lap a

ro t o m y fo r t h e r e li e f o f il e u s th e au t h or s co m par e th e two m e th o d s t o
,
g e th e r c ri tically an d d e ci d e in favor o f e n t e ro t o m y
, .
O n e c a s e i s giv e n A wi d ow ae t 4 7 h ad worn a p e s s a ry wh ich h a d

.
, .
,
p r e s se d th e s ig m oi d fl e xur e o f th e colon again s t th e s acral b on e an d

h e r e cau se d local circular infl a m m a t ion wh ich s ub s e qu e n t ly le d t o a ,
s tri c tur e of th e gu t Il e u s s e t in an d th e p a t i e n t s li fe wa s s av e d by
.
’
e n t e ro t o m y p e r form e d in th e l e ft inguinal r e gio n th e t ran s v e r s e colon

,
b e i n g s ti t ch e d t o th e woun d T h e fae c e s h ow e v e r coul d p a s s th e ar

.
, ,
ti fi c i a l anu s in p ar t ; a n d a s th e y coul d n o t p a s s th e s t ric t ur e d g u t in

.
,
th e cour s e o f t i m e th e in t e s t in e b e t w e e n th e ar tificial anu s ( in th e
tr an s v e r s e colon ) a n d th e s tric t ur e in th e s ig m oi d fl e xure b e ca m e e nor

‘
m o u s ly d i s t e n d e d a n d pr e s s e d upon t h e ab d o m i nal org an s t o s uch an
e x t e n t t h a t d e a th e n s u e d un d e r th e s y m p t o m s o f con s t ipa tio n a s ci t e s

, , ,
ic te ru s vo m i t in g s ingul t u s d y s pn oe a an d oe d e m a of th e lung s—ab ou t

, , ,
two y e ar s a ft e r th e op e ra t ion An ovarian t u m or ( cy s t o a d e n o m a)

.
-
wa s al s o foun d a t th e p o s t m or te m w h ic h h a d n o t m at e ri a lly influ e n c e d

-
,
th e ca s e .
In s p e aking o f th e m e ri ts o f e n t e ro t o m y a s co m p ar e d t o ab d o m i n al
s e c t ion t h e au t h or s p oin t o u t h o w th e pro t ru s i on o f t h e
, ,
gr e a tly e x
t e n d e d in t e s t i n e s th roug h a laparo t o m y woun d pr e v e n t t h e ir r e plac e
m ent .
Pun c t uri ng th e gu t wi th a fi n e n e e d l e th e y con si d e r t o o d a n g e rou s ,
fo r t h e r e a s on th a t th e in t e rnal e xi s tin g pr e s sur e ca n no t b e s u ffici e n t ly
a ccura t e ly e s t i m a t e d w h i c h m ig h t b e con s i d e r a bl e e n oug h t o forc e o ut

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th e con t e n t s o f t h e in t e s t in e in t o th e ab d o m inal cavi t y a ft e r r e po s i t ion .
T h e y conc e d e h ow e v e r th a t th e an ti s e p t ic m e t h o d r e n d e r s la p a r o t
, ,
om
y a l e s s d ang e rou s proc e e d i n g th an i t for m e rly w a s T h e p e r s onal.
i n conv e ni e nc e att e n di n g ar tificial anu s i s n o t a t all gr e a t an d i t s e x ,
i s t e n c e i s n o t e v e n s u s p e c t e d by t h o s e i gn oran t o f i t T h e fac t th a t
.
s t a t i s t ic s s h ow an e qual a m oun t o f m or t ali t y a ft e r b o th op e ra t ion s i s
a ccoun t e d fo r on t h e grou n d th a t t h e lap aro t o m i e s a t te n d e d by fa t al
r e s ul t s are rar e ly publi s h e d .
As t o th e obj e c tion s o m e t i m e s urg e d again s t e n t e ro t o m y th a t a por ,
ti on o f th e s te no s e d g ut i t s e l f m i g h t b e O p e n e d a n d th u s no r e li e f b e
,
ob t ain e d th e au th or s b e li e v e t h a t th e abn or m al gu t m ay b e r e cog

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n i z e d by th e fac t th a t i t con t ai n s t ra n s u d a t e d bloo d Nor i s th e r e .
m uch d ang e r o f op e ning a loop o f i n t e s ti n e t o o n e ar t h e d uo d e nu m i

f
,
t h e op e ra ti on o f e n t e ro t o m y b e d o n e in th e inguinal r e gion .
Th e au th or s e xplain t h e fac t t h a t e n t e ro t o m y fr e qu e n tly l e a d s to
r a di c al cur e of il e u s by poin ting o ut h ow th e O p e ra t ion a ff ord s m or e

,
CH E S T A N D A BD OM E N .
253
s p ac e i n th e ab d o m inal cavi t y , s o th at th e invagina tion an d axi al t or
s ion of th e g u tr e dr e s s e d
m a
y be .
T h e d ang e r e x e m plifi e d by th e ca s e giv e n h o we v e r s till r e m ai n s an , ,
obj e c tion t o e n t ero t o m y Accu m ula t ion o f fae c e s b e t we e n th e O p e ning

.
an d t h e o cclu d e d p or t ion o f t h e g u t m ay cau s e a fa t a l i s s u e —D eu zs cfi

'
.
‘
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Bd 2 3 H ft 3 4 M arch 1 886
'
Cazr . . . .
, . . .
X I I A C o n t r i b u t i o n t o t h e T re at m e n t o f Ga n g re n ou s
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H e r n i ae a n d o f A r t i fi c i a l A n u s By Dr C A R L K O C H ( N ure m . .
b e rg) T h e au th or giv e s t wo ca s e s o f ga n gr e nou s h e rnia a n d a dds

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ano th e r s till un d e r t r e a tm e n t at th e e n d o f th e p ap e r H e t h e n di s
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cu ss e s th e s ubj e ct a d voca ting th e fom i a ti on o f ar tificial anu s fo r all

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gangr e nou s c as e s o f h e rnia .
1 D e cr e pi t wo m an ae t 6 0 F e m oral h e rnia incarc e ra t e d for t wo

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d ay s ; gangr e n e o f s a c a n d o f in t e s ti n e a n d o f th e c e llular t i ss u e Gu t , .
s t i t ch e d t o th e woun d O n t h ir d d a y gan gr e nou s por t ion s s loug h e d

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o ff . N 0 fe v e r ; no p e ri t oni ti s ye t d e a th e n s u e d d uring granula tion

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p e rio d in con s e qu e nc e o f s e nil e m ara s m u s .
2 .Wo m an 4 5 y e ar s o f a ge I n carc e ra tion o f h e rni a for fi ve d ay s

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T h e in t e s t in e s h ow e d a gangr e n o u s s po t 2 / c t m i n d iam e te r Su 1
. .
t ur e s a p pli e d t o fix th e g u t i n th e w oun d S lo u g h ing e n s u e d in e i gh t .
d ay s t o th e e x t e n t o f t wo t h ir d s o f th e circu m fe r e nc e m uch m or e th an
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wa s an t icip a t e d N o p e ri t on e al or fe bril e r e ac tion S o m e e cz e m a d u e

. .
t o t h e s ubli m at e d r e s s ing s A ft e r t wo m o n th s D up uyte n s clam p ap

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p li e d th r e e ti m e s i n all A ft e r fi v e m on th s op e ra t ion in te s t in e fr e e d
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fro m a d h e s io n s t o s kin a n d s ac p ull e d o u t a n d s u t ur e d a ft e r Cz e rny s ’

, ,
m e t h o d wi th for t y s u t ur e s
, Gu t r e plac e d a n d wo un d clo s e d wi th s u
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t ur e s .
Drainag e s ubli m a te dr e s s ing s R e ac t ionary t e m p e ra t ur e 3 8 C .

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.
G oo d r e cov e ry Pa t i e n t w e ar s a t ru s s b u t h e rnia app ar e n t ly again

.
,
for m ing .
Al th ough m uch i s to b e s ai d in favor o f r e s e ct ion o f gangr e nou s p or

t ion s o f inc arc e ra te d in t e s t in e s wi th s u t ur e o f th e e n d s a n d r e plac e m e n t ,
th e au th or i s o f opinion t h a t ar t ifi cial anu s for m a t ion wi th s ub s e qu e n t
s e con d ary O p e r at io n i s s a fe r a s r e gar d s th e li fe o f th e p a t i e n t T h e h e al th .
o f a p a t i e n t h a ving s u ffe r e d for s o m e t i m e fro m incarc e r at e d h e rni a ,

wh e n pain vo m i ting local infla m m a ti on fe v e r a n d alb u m inuria h av e

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con tinu e d for a ti m e i s t oo b a d t o a d m i t o f a long narco s i s an d col

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lap s e an d sh ock ar e ap t t o b e th e con se qu e nc e .
Th e d a n g e r o f in d uci n g s e p t ic p e ri t oni ti s by r e placing t h e i n fla m e d
t i s s u e s o f th e in t e s t in e in t o th e ab d o m e n i s v e ry gr e a t Th e lo cal s e p .
ti c infla m m a t ion o ccurring a ft e r gangr e n e o f t h e h e r n ia m a y t h u s b e
t ran s m i t t e d t o p e ri t on e u m .
Ano th e r d ang e r th r e a te ni n g p e ri toni ti s i s th e d ir e c t e n tranc e o f fae cal

m a t t e r i n t o th e ab d o m inal cavi t y th roug h th e s u t ur e d p ar t s Th e su .
t ur e b e i n g p e r for m e d upon ab nor m al g ut m ay a t a n y ti m e giv e away

, , .
N or can th e e x t e n t o f th e slough i n g proc e s s b e accura t e ly e s ti m a te d

b e for e h an d in in t e s tin e s th r e a t e n e d wi th gangr e n e e sp e cially i f any ,
por tion o f th e m e s e n te ry h a s h a d t o b e r e m ov e d As fo r S ch e d e s .
’
propo s al t o s u t ur e th e g u t an d l e av e i t ou t s i d e o f th e ab d o m in al cav
i ty th e au th or b e li e v e s th i s m e th o d t o b e no i m prov e m e n t on th e ar
t i fi c i al a n u s. H e t h e r e for e conclu d e s th a t only nor m al g u t s h o n ld b e
s u t ur e d an d r e t urn e d t o t h e ab d o m i n al cavi t y ; b u t ga n gr e nou s in te s
t in e s sh ou ld b e s t i t ch e d t o th e woun d an ar tificial anu s for m e d a n d

, ,
s ub s e qu e n t ly a se con d ary op e r a tio n p e r for m e d .
T h i s m ay e i th e r con s i s t o f D upuy tr e n s original proce d ur e wh i ch

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h ow e v e r i s t e d io u s a n d unc e r t ain ; or i t m ay con s i s t in r e s e c t ion o f

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th e in t e s tin e wi th s u t ur e a n d r e plac e m e n t an d clo s ur e o f th e ab d o m

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in al cavi ty—a m or e pr e fe rabl e b u t s o m e w h a t un s a fe m e t h o d or la st

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ly D upuy tr e n s cla m p m ay b e fir s t e m p loy e d t o de s tro y th e se p t u m
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in t h e ar tificial anu s an d th e n th e g u t m ay b e p ull e d o u t s u t ur e d an d

, ,
r e plac e d th e wo u n d b e ing finally lik e wi s e s u t ur e d T hi s m e th o d i s

,
.
e a s y o f e x e cu t io n t h e s u t ur e n e e d only b e a p pli e d t o t h e p e r fora tion ,
a lo n gi t u di n al s u tur e taki n g th e plac e o f th e m or e d i fficul t an d t e d iou s

circular o n e N or n e e d t h e m e s e n te ry b e t ouch e d in th i s O p e ra tion
.
,
a s in r e s e c t ion o f th e
g ut .
T hi s proc e e d i n g i s th e r e fo r e th e on e which th e au th or r e co m m e n d s
, ,
fo r all ca s e s o f ga n gr e n ou s h e r n ia H e a dd s s o m e m o r e s p e cial
.
in stru c tio n s co n c e rni n g th e te ch nical d e t ail s o f th e O p e ra tion .
—D czztsc/z Z c ztyc/zr f C/zzr Bd 2 3 H ft 3 4 Marc h 1 8 8 6

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'
. . . .
,
. . .
E X TR E M I TI E S .
255
E XT R E M IT IE S .
I . Cas e of xt i r p at i o n of S ca p u l a w ith E x c i s i o n
T ot al E
o f t h e H e a d o f t h e H u m e r u s a n d t h e A c r o m i al P o rt i o n o f
t h e C l a v i c l e fo r C a r i e s W i t h F i n al R e c o v e r y W it h G o o d
,
U t i l i t y o f A rm By Dr S c H U Lz o f S onn e nburg in N e u m ark A

. .
,
.
far m h an d ae t 1 6 w a s a d m i tt e d t o th e J o h anni t e r Ho s pi t al in S onn e n

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.
,
b urg Augu s t 1 1 1 8 8 4 for p ain r e dn e s s an d s w e lling o f th e sh o ul d e r

, , ,
j oin t H e h a d gon e t o s le e p J uly 1 8 8 4 an d o n awak e ning coul d n o t

.
, , , ,
m ov e h i s arm Tr e a t m e n t W i th tr i o din e A ft e r on e w e e k inci s ion

. . .
lib e ra ti n g p u s F i s t ul ae r e m ai n e d b e low th e s pin e o f s cap ul a an d in

.
t h e in t e rnal a s p e c t o f th e upp e r th ir d o f a r m Mov e m e n t wa s gr e a tly .
i m pair e d Pr e s s ur e cau s e d p ain t e m p e ra t ur e 4 0

. C ; p ul s e fe e bl e ;
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o cca s ion al fain ti n g s p e ll s Tr e a tm e n t— t onic e gg s win e quinin e

.
, , , ,
p h o s p h a te s ; r e p e at e d inci si on a n d d rainag e a rm m ain tain e d i n fix e d

po s i tion .
S ub s e qu e n tly i m prov e m e n t s e t in But inci s ion o f an ab s c e s s ab ov e .
th e S pin e o f th e s capu la b e ca m e n e c e s s a ry ; t h e focu s wa s s crap e d o u t
wi th th e sh arp s poon R ough e n e d b on e coul d b e fe l t ov e r th e w h ol e

.
o f th e s c a pula wi th prob e s a n d j oin t a ffe c t ion wa s e s t abli s h e d

,
- .
S e p te m b e r 1 Ar s e n ic giv e n wi th g e n e ral i m prov e m e n t s ub s i

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,
d e nc e o f s uppur a ti on ; incr e a se o f app e ti t e S o on h ow e v e r ano th e r .

, ,
ab s c e s s app e ar e d n e ar th e a cro m ion d e m an d ing inci s ion .
D e c e m b e r 1 2 E x tirp a tion o f s cap ula ; inci s ion fro m S pin e t o angl e ;

.
s ub s cap ular ar te ry ti e d ; h e a d o f h u m e ru s e x s e c t e d a s w e ll as acro m i al ,
e n d o f clavi cl e b o th b e i n g cariou s S ubli m a te dres s i n g s ; r e ac ti onary

,
.
t e m p e r at ur e s ub s e qu e n t r e conval e s c e nc e .
F e brua ry 1 0 P a t i e n t up an d ab ou t ; c an m ov e fing e r s a n d for e ar m

.
,
a n d ro t a t e an d s wi n g upp e r arm b ut can no t ab d uc t i t ,

.
M ay 6 Di s m i s s e d wi th a s uppp or t ; can wri t e ; was se e n a ft e r fi v e

.
m on th s agai n s t ill i m provi n g ,

.
S o m e r e m ark s are a dd e d a n d bri e f m e n ti on o f t w e lv e o th e r c ase s

i s m a d e —D cc sc/z f Cfi zr Vol 2 3 H ft 3 an d 4 M ar
’
. . . . . . . .
1 886 .
I N D E X OF S UR GI C AL P R O GR E S S .
I . On x t i r p at i o n o f t h e K i d n e y
E By Pro f E R N S T VO N . .
B E R G MANN ( B e rlin ) A p ap e r w a s r e a d a t an anniv e r s ary m e e ting o f

.
t h e B e rlin M e d ical S oci e t y con t ai n i n g b e si d e s r e fe r e n c e s t o t h e s t a

, ,
t i s t i c a l con t ribu t io n s t o t h e s ubj e c t by Cz e r n y Balz a n d Gro s s a n d , .
g e n e ral r e m ark s fi ve n ew ca s es an d s ix o th e r on e s w h i ch th e au th or
, ,
h a d m e n t io n e d i n a pr e viou s p a p e r r e a d a t th e Mag d e b urg C o n v e n
t ion o f S ci e n t i s t s in 1 8 8 5 b u t w h i c h h av e n o t as ye t b e e n publi sh e d
, ,
m aking e l e v e n in all .
T h e un favorabl e progno s i s o f op e ra t ion s fo r m a lignan t t u m or s o f th e

ki dn e y m ay ye t b e i m prov e d in th e opi n ion o f t h e au th or by a d vanc e s
, ,
in th e dia g no s i s a n d te ch nical e x e cu ti on o f th e O p e ra ti on Ma lignan t .
t u m or s gr e a t ly vary in t h e ir co ur se s o m e gro wing rapi dly o th e r s v e ry

, ,
s lowly .S o m e pr e s e n t e arly m e t a s t a s e s o th e r s non e a t all I n ch il

, .
d r e n a v e ry gra d ual grow th i s th e rul e l e a d i n g t o in t e r m i t te n t h ae m a

,
t uria m aras m an d w e ak e nin g d i arr h oe a b u t o th e r ca s e s in wh ic h n o

, ,
r e n al s y m p t o m s occur are ob s e rv e d a s w e ll T h e p e rio ds o f occurr e nc e .
o f m alig n an t d i s e a s e b e for e t h e fi fth an d a ft e r t h e fi ft i e th y e ar al s o

, ,
t e n d t o r e n d e r t h e d iagno s i s e a si e r T h e m ovabili ty o f t h e t u m or
.
d o e s n o t h ow e v e r app e ar con s t an t e noug h t o prov e valuabl e in d iag

, ,
n o s i s n or i s any con s t a n cy t o b e foun d i n th e a d h e s ion s o f t h e t u m or

,
t o s urroun d ing orga n s A S t o t e c h n i qu e th e au th or a d voca t e s lu m b ar

.
inci sion for th e r e m oval o f m alignan t n e opla s m s a n d illu s tra t e s th e ,
d a n g e r s o f a n te rior p e ri t on e al s e c tio n by t w o un s ucc e s s ful ca s e s If .
t h e t um or i s t o o l ar ge t o b e r e a d ily r e m ov e d an obliqu e lu m b ar s e c t i on
i s t o b e m a d e wi th o ut i n ci s i n g t h e p e ri t on e u m
, In th i s w ay h e .
s ucc e s s fully O p e ra t e d i n o n e ca s e fo r m a li g n an t d i s e a s e o f t h e kid
ney .
W e ll d e v e lop e d
ab s c e s s o f th e ki d n e y i s t o b e tr e a te d s ol e ly wi th th e
kni fe . T h e diagno s i s can b e m a d e fro m t h e pr e s e nc e o f a lu m b ar t u
m o r a n d th a t c o n t ainin g p u s
, T h e au th or wa s abl e t o li m i t t h e diag
.
n o s i s t o o n e ki d n e y in fi v e ca s e s .
T wo ca s e s o f e x tir p a tio n o f t h e ki d n e y fo r p ye lO n e p h ri t i s are giv e n -
o n e o f w h ic h e n d e d fa t ally A t u m or was pr e s e n t an d e v e ning e l e va

.
t ion s o f t e m p e ra t ur e w e r e ob se r ve d i n b o t h ca s e s T h e uri n e was c o m .

GE N I T O- U R I N A R Y OR GA N S . 257
p ar a ti v e ly cl e ar owing t o th e a d m ix t ur e o f h e al th y urin e s e cr e te d fro m

th e h e al th y ki d n e y Bo th p a ti e n t s w e r e fe m al e s a n d a ttrib u t e d th e ir
.
tr oubl e s t o pr e g n ancy In o n e o f th e s e ca s e s a s t o n e in th e r e nal p el

.
v i s cau s e d th e s uppura t ion I n t wo furth e r ca s e s th e cau s e o f s up

.
i
p ura ti o n coul d n o t b e a s c e r t ain e d T h e s e b o th t e r m ina te d favor ably

.
,
a s d i d al s o ano th e r ( fi fth ca s e in w h i ch a ki d n e y w a s e x t irp a te d for

) ,
p e rin e p h ri t ic ab s c e s s o f larg e propor tion s T h e s e ki d n e y s d i d n ot .
bl e e d wh e n th e ir s ub s t anc e wa s i nj ur e d an ob s e rva tion wh ich m a t e ri .
ally fa cili t a t e s s i m ilar O p e ra t iv e pro c e d ur e s I n c e r t ain ca se s wh e r e .
th e p u s i s conc e n t ra t e d in o n e p oin t s i m pl e n e p h ro t o m y m ay b e pr e f
e rab le t o n e p h r e c t o m y T h e for m e r s h oul d b e pr e fe rr e d i f th e d ia g n o

.
s i s i s unc e r t ain a n d i f i t is unc e r t ai n wh e th e r th e o t h e r ki d n e y i s d i s

,
e a se d .
O n e ca s e in w h ich t h e au th or r e m ov e d th e ki d n e y fo r s uppur a t iv e
,
proc e s s e s e n d e d fa t ally a n d th e p o s t m or t e m s h o we d th a t t h e o th e r
, ,
-
ki d n e y was s i m ilarly a ffe c t e d An analogo u s ca se w h e r e s i m pl e n e p h

.
r o t o m y wa s s ucc e s s fully p e r for m e d i s pro m i se d S h or tly , .
I n n o c as e di d any in fe c tion o f t h e woun d occur fro m th e inci s ion

in t o th e s upp ur at ing m a s s .
La s tly a ca s e o f s ucc e s s ful O p e ra tion fo r h y d ron e p h ro s i s i s giv e n ,
in w hich th e a u th or r e m ov e d th e ki d n e y th ro ug h a lu m b ar inci s ion .
T h e p ap e r ab oun d s in in t e r e s ting s t a t e m e n t s a n d h in ts p e r t aining t o

all th e qu e s tion s o f th e s ubj e c t inclu di n g t r e a t m e n t a n d which canno t
, ,
h e r e b e m or e p ar ticularly con s i de r e d —A r é ci ccn a n : d e r c/zi r K /i n i é . .
U ni v B er li n Th I I
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a c r R On ig l
' '
. 1
. . . . .
W W VA N A R S D A L E ( N e w Y o rk ) . . .
I I A R a p i d E v a c u a t o r fo r L i t h o l a p a x y By E A N D R E W S
. . .
,
M D ( Ch icago ) In th e e vacua t or s o f Big e low an d T h o m p s on th e

. . .
rubb e r b ulb m a k e s s uc tion only fo r an in s t an t ; wh e n i t r e ach e s th e

li m i t o f i t s e xp an sion i t s u d de nly s t op s th e o u t war d curr e n t fro m th e
,
bla d de r an d arr e st s in tran s i t a row of frag m e n t s o f s t on e lying along ,
th e Wh ol e l e n gth of t h e t ub e w h ich a t t h e n e x t co m pr e s s ion o f t h e

,
b ulb a re all th rown b ack in t o th e bla d d e r ; th u s a larg e p ar t o f th e

fr a g m e n t s ar e p u m p e d o u t a n d in m any s cor e s o f t i m e s b e for e th e y
fin ally e s c ap e p r olonging th e e v a cua ting s t ag e o f th e op e ra tion t e diou s ly

,
258 I N B E A OP S UR CI CA L P R O GR E S S .
an d i rri tatin g th e i n fl am e d b la dde r by th e r e p e a t e d forc e d e xpan s io n s

an d by th e p e l ti n g o f th e S h arp fr a g m e n t s con ti n u al ly s h o t b ackwar d
i n t o i t To r em e dy th e s e d e fe c t s th e au th or d e vi s e d an in s tru m e n t
.
,
c on si s ti n g o f a d oub le ch a m b e r e d e vacua ti n g t ub e o f which

th e s t rai gh t par t c on si s t s o f a cyli n drical t ub e o f v e ry th in
m e t al wi th an ou t si d e d i am e t e r o f m i lli m e tr e s an d t e rm ina ti n g in a ,
r o un de d tip h avi n g a fe n e s trum li k e B i g e low s wh i le t h e ou t e r e n d i s ’

,
b e n t d own t e r m ina ti n g in a pi e c e o f rubb e r t ub e 9 c e n ti m e tr e s lo n g

, ,
a n d 1 c e n tim e tr e i n s i d e di am e t e r A lon g th e un de r S i de o f th e s traigh t

.
p or ti on o f th i s o v e rfl o w tub e i s s o ld e r e d a th in co n cav e s e m i cylin d e r -

,
m ak in g an i n flow c h a m b e r wh ic h i s wrapp e d h a lf aroun d th e ou t flow

,
t ub e ,
givi n g th e cr o s s se c ti on an ov al S h ap e wi th an ou t s i d e
c i r c um fe r e n c e o f ab ou t m i lli m e tr e s th e di a m e t e r o f th e
,
o u t fl o w c h am b e r b e i n g 8 / m illi m e tr e s wh ile th at o f th e i n fl ow
,
1
,
ch am b e r i s 2 m i lli m e tr e s T h e i nflow c h an n e l t e rm i n a te s in fort y

,
.
p e r fora t i o n s e a c h 1 m il li m e t r e i n di am e t e r
,
T h e ou t e r e n d o f th e i n
.
flow t ub e proj e c t s in a s trai gh t lin e b e yon d th e curv e o f th e ou t flow

a n d t e rm i n a t e s i n a c yli n d e r o f 1 0 m illi m e t r e s o u t s i d e dia m e t e r a n d , ,
h avi n g a s t o p c o c k o f th e sam e c alibr e To th e ou te r e n d o f th i s tub e

.
i s a tt a c h e d a rubb e r t ubi n g wi th an i n s i d e d i am e t e r o f n o t l e s s t h an
on e c e n ti m e tr e an d a le n g th o f ab ou t t wo y ar d s t o t h e far th e r e n d o f ,
wh i ch i s a ttac h e d a s tr ai n e r th ro ugh wh ic h a s tr e a m o f wa t e r i s t o b e
sy p h on e d .
To u s e i t th e e v a c u a t o r Sh ou ld b e in tro d uc e d in t o th e b la d d e r
,
’
wi th th e fe n e s trum t o war d th e pa ti e n t s h e a d an d h e l d a t a s t e e p S lop e so ,
t h a t t h e t ip pr e s s e s th e b o t t o m o f th e bla dd e r g e n t ly d o wn t o wa r d th e
re c t u m , m aki n g a fu nn e l Sh ap e d d e pr e s s i o n in t o w h ic h t h e fr a g m e n t s
-
t e n d t o fall ; n ow t urni n g t h e s t opcock a war m 70 s olu tion o f car

,
b o liz e d wa t e r i s a d m i t te d th ro ugh th e i nfl o w divi s i o n a n d e n te r s t h e

b la d de r by th e s m all p e r for ati o n s s w e e pi n g th e frag m e n ts rapi d ly
,
a r o un d i n t o th e fe n e s tru m o f th e ou t flow t ub e a n d th e n c e ou t war d in t o a
b as i n s e t b e twe e n th e p a t i e n t s th i gh s ; th e curr e n t b e i n g con tinuou s

’
a n d always i n on e dir e c tio n th e e vacu a ti o n i s a cc o m pli s h e d wi th r e

,
m a rk ab le r api di t y T h e wri te r r e fe r s t o a c a s e wh e r e th e fr a g m e n ts o f
.
a h ard o xala t e o f li m e c a lc ulu s ov e r o n e inc h in di a m e t e r we r e a lm o s t

, ,
2 59
c om p le t e ty w e p t o u t in ten s econ ds wh e r e p e rh ap s tw e n ty fi v e m i n
s , , ,
-
u t e s o f c h u rn in g t o an d fr o wi th Bi g e low s e vacu at or woul d s carc e ly

-
’ -
h a v e a cco m pli sh e d th e s a m e r e s ul t an d s ix ty s e con d s m or e o f th e c ur ,
r e n t s u ffic e d t o r e m ov e th e la s t p ar ti cl e r e m aining T h e di ffi cul ty .
c au s e d by frag m e n t s arc h in g ov e r th e fe n e s tr u m of th e e vacu at or an d

ob s t ruc ting th e o ut fl o w h e ov e rco m e s wh e n th e s can tin e s s o f th e s tr e am
, ,
s h ow s ob s tr uc tion by co m pr e ss i n g th e e n d o f th e Sh or t rubb e r o u t
,
fl o w pip e b e t w e e n th e t h u m b an d fi n g e r a n d wi t h th e th u m b an d fing e r
o f th e O th e r h an d s u dd e nly co m pr e s s i n g th e t ub e j u s t ab ov e ; th i s
forc e s a s h or t b u t s tro n g p ul s a tion b ack in t o th e bl add e r an d in s t an tly
di s lo d g e s th e ob s truc t ing fr a g m e n t s — f ou r A m I lI ea Ass n

’
1 886 . . . . .
Jun e 5 .
III . N e p h re ct o m
y o n a P at i e n t T w e n t y t h re e M o n t h s -
O ld . By R PA R K M D ( Bu ffal o N
.
, .In th e s e con d win te r o f a
.
, , .
ch il d h i th e rt o appar e n tly h e al th y an e nlarg e m e n t app e ar e d on th e

, ,
righ t S i d e o f th e ab d o m e n w h ich s t e a dily incr e a s e d in S iz e ; ,
p alp a tion r e v e al e d a fi rm r e s i s ti n g t u m or ab o u t th e S iz e of a foe ta l

,
h e a d at t e r m th e a s pira t or d r e w o ff a browni sh o d orl e s s fl ui d e xam i , ,
na tion o f w h ich gav e n e ga t iv e r e s ul t s T h e t u m or co n tinuing t o in .
cr e ase d e ci de dly i n siz e a ft e r th e lap s e o f a fe w w e e k s th e t u m o r

, ,
b e ing to o l arg e for r e m oval by lu m b ar se c t i on an d inci s ion wa s m a de ,
in th e righ t lin e a se m ilun ari s ; sli gh t a dh e s ion s w e r e foun d b u t th e ,
p e ri t on e u m cov e ri n g th e grow th w a s inci s e d an d th e tu m or sh e ll e d

, ,
o u t wi t h ou t m uc h d i ffi cul t y pro vin g t o b e a s h a d b e e n pr e vi ou s ly di

, ,
a g n ose d a fi b rO cy s ti c t u m or o f th e ri g h t ki dn e y
,
-
t he cy s t ic e le m e n t ,
pr e d o m in a tin g an d w e ig h ing i m m e di at e ly a fte r i t s re m ov al ab ou t four

, , ,
poun ds T h e p e dicl e w as ti e d an d dropp e d in t o th e cavi ty an d th e

.
,
p ati e n t pro c e e d e d t o a rapi d r e cov e ry A se arch in t o th e li te ra tur e of .
th e s ubj e c t s e e m s t o S h ow th e pa t i e n t t o b e th e young e s t t o h av e sur
v i v e d th e op e r a t io n —P r oceed i ng s A m S n rg A s s n 1 8 8 6 . . . .
IV C as e o f H y d r o c e l e of a H e rn i a l S a c B y R F
. . . .
W E I R M D ( N e w Y ork ) A wo m a n ae t 2 4 h a d worn a tr u s s for

, . .
,
.
, .
,
h e rn i a for t e n y e ar s a n d p r e s e n t e d a t th e loca tion o f th e ru p t ur e a con

,
s t an t t u m or w h ic h was d u ll on p e rcu ss ion an d Wi th ou t i m p ul se on
cough in g on gr a s ping i t wi th th e h an d i t di d n o t giv e th a t p e culi ar i r ,

r e gular s e n s a tion wh ich an o m e n t al m a s s wo ul d giv e an d ye t on

, ,
pr e s s ur e th e b ulging was j u s t a s i f coil s o f in te s t in e w e r e un de rn e a th .
In d oub t a s t o th e e xac t con di tion b u t th inking th a t i t m igh t b e a ,
fa t ty t u m or i t wa s c u t d o wn upon looking m or e an d m or e lik e coil s o f

, ,
in t e s tin e un t il th e s ac wa s arriv e d a t wh e n cl e ar flui d e s cap e d th rough

, ,
a m inu t e i n ci s ion T h e op e ning was clo s e d t o pr e s e rv e th e cy s t e n

.
t ir e i f po s s ibl e a n d i t wa s finally d i s s e c t e d o u t e n t ir e e xc e p t at i t s
, ,
n e ck w h i ch ran up t o an d th rough th e fe m oral ring ; on s e izing th i s

,
n e ck an d applying a liga t ur e an d th e n d ivi d i n g i t i t wa s foun d t o b e a ,
fe m oral h e rni al s ac w h ic h h a d b e e n s o s h u t o ff by th e p e r s i s t e n t u s e
,
o f a s nu g fi t t ing t ru s s t h a t th e s ac h a d un d e rgon e conv e r s ion in t o a
cy s t ; i t co n t ain e d s o m e fi ve or s ix o unc e s o f fl ui d — P r oceedi ng s I V Y . .
S uf g . S oc . 1 886 . M ay 1 0 .
V . T h e T re at mn t o f V a r i c o c e l e By R F W E IR M D
e . . .
, . .
,
( N e w Y ork ) T h e wri te r conclu d e s a s th e r e s ul t o f h i s e xp e ri e nc e o f

.
a nu m b e r o f th e m e th o d s d e vi se d for th e tr e a t m e n t o f varicoc e l e ( 1 )
t h a t for s m all varicoc e l e s th e r e i s no t h i n g b e t t e r t h an a Singl e ( or
d oubl e ) s ub cu t an e ou s liga t ur e ( )
2 fo r m e diu m s iz e d varicoc e l e or fo r
ca s e s d e clini n g a m or e h e roi c Op e ra t ion e xci s io n i n car e ful h an d s i s , , ,
t o b e a d vi s e d ; ( 3 ) fo r larg e r varico c e l e s fo r r e lap s e d ca s e s a n d fo r ,
t h o s e n o t v e ry larg e b u t wi th a m uc h e longa te d s cro t u m abla t ion o f ,
th e s cro t u m wi th liga t ur e o f th e v e in s i s pr e fe rabl e — V Y Ill ea f ou r

’
I . . .
1 886 .M arc h 2 0 .
J E PI LCH E R ( U 8 A m y) . .
,
. . r .
W O U N D S —I N U R I E S —A C C I D E N T S
J .
I . S t u n n in g an d B urn by
l e c t r i c L a m p Pro f GE O an E . .
B U C H ANAN ( Gla s gow) Inj uri e s fro m e l e c t ric la m p s a re b e co m i n g n o t

.
u n fre qu e n t In m o s t o f th e ca s e s r e la t e d d e a th h a s b e e n i n s t an e o us
.
, .
I n a ca s e r e por te d on J anuary 2 2 a s occurring a t Liv e rp ool th e m a n , ,
was s t unn e d a n d r e m ain e d u n con s cio u s fo r a t i m e a n d on r e cov e ry
was foun d t o b e qui t e b lin d .
”
A work m an ae t 4 4 was e ngag e d on a cran e w h e n a Bru sh wa s
,
.
,
b y s o m e m i s ch anc e l ow e r e d in t o con t ac t wi th th e c h ain o f t h e cran e .
”
In s t an tly th e m an was d oubl e d up b u t hi s h an d s we r e co m p e l le d t o ,
B ON E S , OI N T S , OR TH OP AE D I C 26 1
j .
s p a s m o d ic ally gra s p th e ch ain s o th a t h e di d n ot fall H e r e m ain e d in .
th i s p o s i t ion fo r four m inu te s un t il th e la m p an d c h ain w e r e s e p ar a t e d .
H e th e n d ropp e d d own s t unn e d H e r e cov e r e d con s cio u s n e s s in an

.
h our Th e r e wa s a s ligh t v e s ica tion on th e h an d wh e r e i t gra s p e d th e

.
ch ain an d a t th e p ar t o f th e s ol e o f th e fo o t th roug h wh ich th e cur

, ,
r e n t p a s s e d in t o th e g roun d two s quar e inch e s o f S kin w e r e co m pl e t e

,
ly c h arr e d a s w as al s o t h e n e i gh b oring p ar t o f t h e s t o cking

,
.
Th e g e n e r a l s y m p t o m s ( wh ic h s oon p a s s e d o ff ) w e r e a s lig h t am oun t
o f g e n e ral S h ock a fe e ling o f h e a t in th e a b d o m e n a n d c h e s t a n d d i m

, ,
n e s s o f vi s ion .
S ir Wm T h o m s on s ugg e s t s th a t i f a by s tan d e r h a d t ak e n th e m an
.
by th e clo th e s an d draw n h i s fe e t fro m con t ac t wi th th e groun d or h a d ,
th ru s t a b i t o f dry clo t h ing un d e r h i s fe e t th e con t ac t wo ul d h av e b e e n ,
brok e n a n d th e h an d r e li e v e d fro m th e ch ain .
C B K E E TLE Y ( Lo n do n ) . . .
BONE S , JO IN T S , O R T H O P IE D I C .
I . C a s e s o f S u d d e n D e a t h R e s u l t i n g fr o m V e n o u s
On
T h r o m b o s i s a n d E m b o l i s m a ft e r F r a c t u r e s o f B o n e s By .
Pro f P B R U N S ( T ubing e n ) T h e au th or giv e s o n e c as e o f h i s own

'
. . .
an d a tab ular synop s i s o f th ir ty fi ve e x t an t ca se s An aly s i s o f

- .
th e s e sh ow s th a t th e fra c t ur e s occurr e d m o s t fr e qu e n t ly in th e low e r
e x tr e m i t y an d in p e r s o n s o f fro m 4 0 t o 6 0 y e ar s o f a g e
, The im m e .
d ia t e ly cau s e o f th ro m bo s i s o f th e v e in s con s i s t s in co m pr e s s ion or i n
j ury o f th e v e in s a t th e s e a t o f frac t ur e ; a n d s o m e pr e d i s p o s i tion i s us u

ally pr e s e n t o n t h e p ar t o f th e p a t i e n t s uch a s varico s i ti e s or circula t o ry
,
i m p air m e n t E m b oli sm m ay o ccur a t an y ti m e b e tw e e n th e four th an d

.
s e v e n t y se con d d a
y
-
a ft e r th e frac t ur e a n d d e a t h m a y r e s ul t i m,
m e d i
a t e ly fro m a s p h yxi a or s yn cop e or a ft e r a long e r p e rio d o f t i m e fro m

, ,
in farc tion o f th e lung or finally r e cov e ry m ay t ak e pl ac e

, , ,
.
II . O n t h e B e h av i o r of th e B o d i l y T e m p e r at u r e i n S ub
c u t a n e o u s F r a c t u r e s By Dr E R N S T M U E LL E R fir s t a s si st ant
. .
,
s urg e on a t th e T ii b in e n S urg Clinic R i s e of b o dily t e m p e ra t ur e

g . .
a fte r s i m pl e frac t ur e s of b on e s was form e rly b e li e v e d t o b e of rar e o c

curr e nce ; b u t of la te r e p e at e d e xac t m e a s ur e m e n t s h av e le d to th e
O pinion th a t h ig h t e m p e ra t ur e s a fte r frac tur e s w e r e a v e ry fre qu e n t

sym p t o m .
In th e pr e s e n t pap e r th e au th or h as con s i d e r e d 3 5 9 c as e s ga th e r e d
fro m h i s own clinic a n d fro m t h o s e o f S t u tt gar t H all e Lon d on
, , , ,
( Univ e r s Coll Ho sp ) an d fro m a r e p or t by S tickl e r ( N e w Y ork ) an d

. . .
,
conclu d e s th a t a ri s e o f t e m p e ra t ur e i s foun d in s ub cu t an e ou s frac

t ur e s in ov e r 8 5 p e r c e n t o f t h e ca s e s an d i s th e r e for e t h e ru le
.
, , , .
T h e au th or s own ca s e s ar e t ab ula t e d a n d pr e se n t t e m p e ra t ur e s
’
,
r angin g fro m to 40 0 C Th e h ig h e s t ri s e was ob s e rv e d on t h e

°
.
fir s t an d s e co n d e v e ning a ft e r t he acci d e n t I n s o m e ca s e s th e fe v e r .
la s te d a s lo n g as th ir te e n d ay s Tran s por t a tion a ft e r th e acci de n t d i d .
n o t app e ar t o incr e a se th e t e m p e ra t ur e s G e n e rally S p e aking t h e .

,
t e m p e ra t ur e s inc re a s e d in d ir e c t prop or t ion t o t h e quan ti ty o f e x t r a
v as a t e d blo o d ; b u t t h i s ra tio d i d n o t h o ld goo d in all ca se s .
T h e S t u t tgar t c as e s wh ic h a r e al s o t ab ula te d S h ow l e s s e r e l e v ati on s

, ,
o f t e m p e ra t ur e th roug h ou t t h an t h e Tubi n g e n on e s a curio u s a n d um ,
e xplain abl e fac t .
Th e au th or v e n t ur e s no e x p lan a tio n o f th e cau s e o f fe v e r a ft e r frac
t ur e s — B e i t r ag e z n r M i n C /zi r a rg M i nt/l e i ] a u s de r c/zi r K li n k

. . . .
z n Tu b i n en
g I I Bd 1 H ft I
. . . . . .
III . F r a ct u re o f t h e U l n a i n I t s U p p e r T h i rd C o m b i n e d
W i t h D i s l o c a t i o n o f t h e H e a d o f t h e R a d i u s By Dr H AN S . .
D OE R F L E R ( Nii re m b e rg) T h e rari ty o f th i s i nj ury a n d i t s li m i te d li t

.
e r a t ure h a s le d th e au th or t o m ak e i t a s ubj e c t o f s p e cial s t u dy m or e ,
p ar ti cul arly S inc e i t i s o n e o f gr e a t prac tical i m p o r tanc e H e giv e s .
four ca s e s s o m e o f wh ich w e r e ob s e rv e d by h nn s e lf
, .
T h e fir s t ca se i s th a t o f a m an 6 6 y e ar s o f a g e wh o 4 0 y e ar s p re , , ,
v i o u sly wa s kick e d by a h or s e a n d s u s t ain e d a co m poun d frac t ur e o f

, .
th e ulna in i t s upp e r th ir d T h e r ad iu s w a s luxa te d . N o appo s i tion .
o f th e frag m e n t s was a t t e m p t e d a t th e t i m e a n d no s plin t s appli e d , .
T h e b on e s in con s e qu e nc e d i d n o t uni t e a n d paraly s i s o f th e e x t e n

, .
,
s o r m u s cl e s o f t h e fing e r s r e s ul te d d ue t o a l e s ion o f th e m u s c ulo ,
s pirali s n e rv e Ar th ri ti s d e for m an s s ub s e qu e n tly s e t in a n d th e fore

. .
a r m b e ca m e e n t ir e ly u s e l e s s .
T h e s e con d ca s e w h ich wa s s e e n s e v e n y e ar s a fte r t h e a cci de n t

, ,
B ON E S , oI N TS , OR TH OP A ZD I C 26 3
j .
pr e se n te d a co m p o un d frac tur e o f th e uln a co m bin e d wi th d i s locati on

o f th e ra d iu s an d s ublu xa t ion o f th e s tyl o i d pro c e ss o f th e uln a in ,
con se qu e n c e o f d ir e c t viol e nc e cau se d b y a fall d o wn s t ai r s

, .
T h e th ir d c as e t h a t o f a c h il d ae t
, y e ar s wa s o n e of frac t ur e o f
.
,
th e ulna s i m ul t an e ou s wi th l uxa tion o f th e capi t ulu m o f th e r a di u s s u s ,
t a in e d by a fall fro m a ro cking h or s e T h e frac t ur e a lon e wa s d iag

-
.
n o s e d at fir s t b ut s e v e n d ay s la t e r th e con s ul ting s urg eo n d i s cov e r e d

,
t h e d i s loca t ion Co m pl e t e r e cov e ry r e s ul te d

. .
T h e la s t ca s e wa s o n e o f th e s a m e inj ury acq uir e d by a fal l on th e
s t air s
. T h e frac t ur e I s s uppo se d t o h av e b e e n ca us e d by d ir e c t vio
l e nc e in con s e qu e nc e o f th e b lo w again st th e e dg e o f th e s t e p a n d th e ,
luxa t ion fur th e r in d uc e d by a fall o n th e o u ts tr e t ch e d p al m T h e .
frag m e n t s for m e d a n angl e wi th th e a p e x p oin ting b ackwar d s .
In di s cu s s i n g t h e m e ch a n i s m o f th e inj ury th e a uth or concl ud e s fro m

th e s t u dy o f 1 9 ca s e s th a t d ir e c t viol e n c e alo n e l e s s fr e q u e n tly o cc a s
,
i on s i t th an co m bin e d vi ol e nc e as e x e rci s e d by a fall th e p rop or tion

, , ,
b e ing 5 t o 1 1 .
T he gr e a t e r nu m b e r o f ca s e s o cc urr e d b e t we e n th e ag e s o f 3 a n d 1 5 ,
all o t h e r s a ft e r th e
3 5 th y e ar .
T h e qu e s tion in wh a t cau s a tiv e r e la t ion t h e t wo inj uri e s s tan d t o
e ac h o th e r i s n e x t co n s i d e r e d Gr en i e r s a s s e r tion t h a t t h e t wo i n
’
.
,
j u ri e s coul d n o t b e s i m ul t an e o us ly pr o d uc e d by m e an s o f any appli e d

viol e n c e i s d i sprov e d by th e au th or wh o e xp e ri m e n te d up o n te n c a
, ,
d av e r s A fte r ch i se ling p ar tly th r o ugh th e uln a h e c o ul d e a s ily frac

.
,
t ur e i t an d by con tinu i ng t h e pr e s s ur e co ul d o cc as ion l uxa t io n o f t h e

, ,
r adiu s .
H e th e r e fo r e b e li e v e s th a t b oth inj uri e s o cc ur S i m ul t an e o us ly b ut ,
th a t t h e frac t ur e i s pri m ar y a n d t h e d i s l o ca t ion o f th e r a d iu s s e con dary .
F ur th e r e xp e ri m e n ts w e r e p e r for m e d t o prov e th i s .
Luxa tion o f th e ra d iu s pr o ve d v e ry d i ffi c ul t t o e ffe c t b u t wh e n pr e s ,
e n t applica t ion o f fur th e r viol e nc e e n tir e ly fail e d t o frac t ur e th e uln a

, ,
b u t pro d u c e d t y p ical frac t ur e o f th e ra di u s i n i t s low e r t h ir d A fte r .
p ar tial inci s ion o f th e ulna h o we v e r d ir e c t viol e n c e e a s ily e ffe c te d t h e

, ,
d e s ir e d inj ury l ux a t ing t h e capi t ul um ra dii fo r war d a n d o u t war d i f a p

, ,
p li e d fro m b e h in d an d la t e rally .
Th e p o s t m or t em con di tion of th e p ar ts i s accura t e ly d e s crib e d in

-
th e se ca s e s o f ar tificial p ro duc tion o f th e i nj ury .
T h e frag m e n t of th e ul n a i s n o t in s tru m e n t al in cau s ing th e d i sloca

’
t io n in th e au th or s O pi n ion b u t th e ra d iu s h e a d m a y b e d i s plac e d
, ,
-
e i th e r by th e con t inu at ion o f th e s a m e d ir e c t viol e nc e wh ich ca u sed
t h e frac t ur e or by in dir e c t viol e nc e as by pr e s s ur e upon th e e x t e n d e d

, , .
h an d . T h e fir s t o f th e se m o de s i s illu st r at e d w h e n th e p a ti e n t h a s
b e e n ki ck e d r un ov e r h i t by a s tick sh o t or h as fall e n a gain s t s o m e

, , , ,
h ar d obj e ct th e latt e r wh e n h e h as fir s t fall e n a gain s t s o m e h ar d b o dy

,
an d s ub se qu e n tly fall e n on h i s e x t e n d e d h an d—a s wh e n falling d ow n
s t air s .
Lux ation o f th e r a diu s canno t occur i f th e ulna b e frac t ur e d b e low

i ts upp e r th ir d .
Th e s e conclu s ion s ar e d rawn fro m fur the r e xp e ri m e n ts on th e c a

d av e r .
T h e symp zam s ‘
inj ury are giv e n a s follow s
of th e In s p e c tion r e v e a ls
an a n gl e ou tli n e d by th e con tour o f th e s o ft p ar t s o f th e d or s al a s p e c t
o f th e for e arm -
T h e e lb ow j oin t sh ow s a w e ll m ark e d b u lging e i th e r
.
- -
t owar d s th e fron t or la te ra lly an d an t e riorly or p o s t e riorly co m bin e d

, .
Th i s pro m i n e nc e cau se d by th e capi tulu m ra dii m ov e s wh e n prona

, ,
t ion an d s upi n a t ion are p e r for m e d T h e circu m fe r e nc e o f th e inj ur e d

.
j oi n t i s incr e a s e d fro m to 4 cm .
O n th e p o s t e rior a s p e c t th r e e p oin ts c an b e m a d e o u t wi th th e h e lp ,
o f w h ich a t ri a n gl e m ay b e con s t ruc te d h avi n g as i t s ap e x th e p o in t , ,
o f frac t ur e o f th e u lna an d a s i t s b a s e a lin e d rawn fro m

, . th e o le ,
c ran on t o t h e capi t ulu m ra d ii Th i s lin e p a s s e s dir e c tly ov e r th e e x

.
t e r n al c o n dyle o f th e h u m e ru s in i t s m i dd l e Th e inj ur e d a rm ap
,
.
p e ar s Sh or te n e d t o th e e x t e n t o f cm T h e di s loca tion o f th e frag .
m e n t s d e p e n d s up on th e dir e c tion o f th e viol e nc e ; th e low e r frag m e n t
r e m ai n i n g parall e l t o th e ra diu s in all ca se s th e upp e r on e varyi n g in ,
po s i ti on T h e for e arm i s g e n e rally foun d h al f fl e x e d an d h al f prona t e d

.
-
,
.
T h e e lb ow i s fr e qu e n tly m uch s wo ll e n Cr e pi ta tion i s al way s pr e se n t

.
a t t h e p o i n t o f frac t ur e F l e xion i s in t e r fe r e d wi th b u t e x te n s ion i s

.
,
p o s s ibl e ; s upi n a ti on i s s om e wh a t i m p e d e d T h e ul n a al o n e i s sh or t .
e n e d ab ou t 3 c m .
P ON E S , oI N T S , OR TH OP z E D I C 26 5
j .
Co m plicati o n s o f th e inj ury ar e s o m e ti m e s p r e se n t an d con si s t in

s ubluxa ti on o f t h e s tyloi d proc e s s o f t h e uln a p araly s i s o f th e m u s c ulo ,
s pirali s n e rv e — a fr e qu e n t s ourc e o f d a n g e r—co m poun d frac t ur e or i n ,
j ury t o th e s o ft ti s s u e an d frac t ur e s o f th e e picon dyl e s or co n dyl e s o f

,
th e h u m e ru s th e la t t e r b e ing o f v e ry rar e o ccurr e n c e

, .
T h e progno s i s i s qui te favorabl e i f th e t r e a tm e n t i s b e gun a t o n c e ,
or e v e n wi th in th e fir s t s ix w e e k s A ft e r t w o m on th s th e r e i s l e s s
.
h op e o f s ucc e s s on acco un t of th e cap s ular d e g e n e ra t ion ; a n e w cap
s ul e i s s oon for m e d w h e r e v e r th e h e a d o f th e ra d iu s r e m ain s s o th a t ,
func ti o n m ay in a m e a s ur e r e t urn i f t h e frag m e n ts o f th e ulna u ni te

, , ,
-
.
I f th e la tt e r d o e s n o t occur t h e u s e o f th e h an d i s e n tir e ly lo s t
, Ar th .
ri ti s d e for m an s m ay occur in la t e r y e ar s a s a r e s ul t o f th e i nj ury T h e .
progn o s i s o f p araly s e s i s un favorabl e .
As r e gar d s t r e a t m e n t i t i s o f gr e a t i m p or t anc e t o b e ar in m in d th e
,
po s s ibili ty o f an e xi s t e nc e o f a luxa ti on of th e ra diu s in all ca s e s o f u l

nar frac tur e A fte r r e placing th e capi t ulu m o f th e ra diu s wi th th e h e lp
.
o f e x te n s ion an d d ir e c t pr e s s ur e fro m b e low th e a rm i s t o b e fix e d in ,
a h al f s up i n a t e d p o s i ti o n an d fl e x e d a t an acu t e an gl e a t th e e lb o w ( s o
-
‘
a s t o e li m i n a t e t h e ac tion o f t h e bic e p s by m e a n s o f a wa t e r gla s s or

) -
s t arc h b an d ag e t o b e l e ft on fo r four or s ix w e e k s
,
Th e po s i ti on o f .
h al f s upina t ion i s m ai n t ain e d in or de r t o pr e v e n t th e n e w for m in g cal

- -
lu s fro m a gai n occa s ioni n g a d i s p lac e m e n t .
In o ld ca s e s wh e r e r e plac e m e n t i s i m po s s ibl e r e s e c t ion o f th e capi t ,
ulu m ra dii i s in d ica t e d O s t e op ali n c la s i s o f th e uln a m ay b e co m e

,
n e c e s s ary in s o m e ca s e s Co m p oun d frac t ur e s are t o b e an ti s e p tically

.
t r e a t e d —D ea f Z e i /s c/zn f . C/zi m crg Bd 2 3

. H 3 an d 4 M arch
. . . . .
1 0 . 1 88 6 .
IV Tw C as e s o f L i p o m a A r b o re s c e n s Ge n u C o m p l i
o ,
c at e d w ith R e ce n t S y n o v i a l T u b e r c u l o s i s A con tribu tion t o .
th e knowl e d g e o f t ub e rculari s a tio n o f proc e s s e s originally o f a n o n t u -
b e r c u lo u s c h arac t e r By Dr GE O R G S CH M OLC K ( Hall e ) Lipo m a o f

. . .
t h e kn e e j oi n t b e i n g rar e S r e fe r s t o o n e s uc h ca s e p ubli s h e d by Jo h
-
,
. .
Mull e r a n d giv e s ab s trac t s o f Six o th e r ca s e s o f S i m pl e lipo m a g e n u .
H e th e n d e s crib e s t wo ca s e s o f arb or e s c e n t lipo m a o f th e kn e e ob s e rv e d
by hi m in Pro f Volk m ann s cli n i c B oth ca s e s r e pr e s e n t s i m ul t an e ou s

.
’
.
lip o m a t ou s d e g e n e r at ion all th e n or m al vi llou s e xcr e s c e nc e s o f th e

of
s ynovial m e m bran e o f t h e j oin t a con di t ion fo r w h i ch th e au th or s u

, g
”
g e s ts th e na m e li 0 p m as i a o f t h e s ynovi al vil li
“
T h i s i s w h a t th e .
n am e lip o m a arb or e s c e n s s ignifi e s In th e s i x o th e r c a se s j u s t r e fe rr e d

.
t o s i m pl e lipo m a t a o f t h e j oin t w e r e pr e s e n t a n d th e a u th or d i ff e r e n
, ,
ti at e s b e t w e e n th e t wo for m s a s r e g ar d s th e ir o ri gin b e li e ving wi th ,
K o e nig th a t t h e s i m pl e lip o m a t a a re o f s ub s e rou s o rigin a n d b e ar an
alogy t o th e p e ri t on e al s u b s e rou s lipo m a t a .
E s p e cial in te r e s t a tt ach e s t o b o th ca s e s for th e r e a s on th a t e vi d e nc e s
o f r e c e n t t ub e rculou s a ffe c t ion o f t h e s ynovi al m e m bran e w e r e pr e s e n t
in e ach c as e T h e au th or quo t e s R i e d e l a s a s se r ti n g th a t t ub e rcul ar

.
s ynovial pro c e ss e s fr e qu e n t ly app e ar s e con d arily s ub s e qu e n t t o fi b rin
o us syn ovi ti s wi t h m e lon s e e d b o d i e s corpora n d argu e s

( - o rz o i d e a
y ) a ,
a n alogically th a t s e con d a ry t ub e rculou s a ffe c t ion s m a y a l s o o ccur a ft e r
lipo m a t ou s d e g e n e ra tion .
T h e fir s t ca s e i s th a t o f a th e ological s t u d e n t ac t 2 3 wh o 1 2 y e ar s , .
,
pr e vi ou s ly h ad s u ffe r e d fro m an acu t e infl a m m a tion o f th e kn e e j oin t -
d u e t o con t u s ion an d col d an d S i n c e th e n h a d h a d r e curr e nc e s t wo or

,
th r e e ti m e s T h e d iagno s i s o f fungou s ( t ub e rcular) infla m m a tion o f

.
t h e j oin t w a s m a d e Inci s ion h o we v e r r e v e al e d four packag e s o f

.
, ,
p olypo u s e xcr e s c e n c e s w h ich w e r e e xci s e d a n d al s o a r e c e n t s y n ovial

, ,
t ub e rculo si s Micro s copic e xa m ina t ion Sh o we d th e p olypi t o b e lipo

.
m a t a a n d d e m on s t ra t e d m iliary t ub e rcl e s g ian t c e ll s a n d s p e cifi c t ub e r

,
c le bacilli .
T h e s e con d ca s e was a far m e r ae t 5 2 wh o h a d h a d s e ro u s e ff us ion

,
.
,
in t o th e kn e e j oin t for fi ve y e ar s Villo u s grow th s w e r e foun d i n th e

-
.
j oin t an d w e r e r e m ov e d R e c e n t t ub e rculou s in fe c t ion was lik e wi s e

.
r e v e al e d —D en ts c/z Z e i i s c/zr f C /i n Vol 2 3 N o s 3 an d 4 Marc h

. . . . . . . . .
1 88 6 .
V . The T r e a t m e n t o f S c o l i o s i s b y M a s s a g e By Dr A . . .
LAN D E R E R ( Le ip s ic ) E ig h te e n ca s e s o f la t e ral curva t ur e o f th e s pin e

.
n o t d ue t o b on e d i s e a s e a n d occurring in y o u th ful in divi d ual s o f a g e s

-
rangi n g b e tw e e n a n d 2 1 y e ar s w e r e t r e a te d by t h e au th or w i t h
,
m a ss ag e a n d wi th s uc h e xc e ll e n t r e s ul t s t h a t h e r e co m m e n d s t h i s m o d e
,
o r t r e a t m e n t in all s i m ilar ca s e s .
B ON E S , OI N TS , OR TH OP Z E D I C 26 7
] .
Th e ca s e s are giv e n in sh or t a n d r e pr e s e n t b o th s ligh te r d e for m i ti e s

o f th e S pinal colu m n an d s e v e r e r s colio t ic affe c t ion s ; m any o f th e m
h a d alr e a d y b e e n in th e tr e a t m e n t o f r e nown e d S p e ci ali s t s fo r a s h or t e r

or long e r p e rio d an d h ad h ad th e a d van t ag e s of th e b e s t o rth O p edi c
,
-
applianc e s an d of m e th o dical e x e rci s e ; in s o m e ca se s th e t ro ubl e h a d

e xi s t e d fo r as m any a s nin e y e ar s T h e r e s ul t s al m o s t con s t an tly far
.
s urp a s se d t h e e xp e c t a t ion s o f t h e au th or .
S t ar ti n g wi th th e propo s i tion h e r e t o for e a s c e r t ain e d th at s colio s i s i s

,
d e for m i t y cau s e d by the in abili t y o f th e s pin e t o s upp or t s o gr e a t a

w e igh t a s i t i s co m p e ll e d t o c arry an d confining h i s s ubj e c t t o th o se
,
for m s o f s colio s i s e i th e r unila t e ral or s e rp e n t in e w h ic h a re known a s

, ,
h abi t u al curva t ur e s as di ffe ring fro m s t a tic t rau m a t ic a n d o th e r for m s

, , , ,
th e au th or pro c e e d s t o S h ow th a t i t i s t h e m u s cular s y s t e m alon e w h i ch
i s a t faul t an d t o th e in e ffici e ncy o f wh ich th e d e for m i t y i s owing

, .
F o r th i s p urp o s e h e fi r s t e xa m in e s t h e p h y s iologic al or nor m al ac t ion
o f th e d or s al m u s cl e s a n d S h ow s h o w th e nor m al s s h ap e d c on fi g ur a
,
-
t ion o f th e s pinal colu m n r e s ul t s o u t o f th e s i m pl e arc o f th e S pin e
o f th e in fan t by th e ac t ion o f t h e c e rvi cal a n d lu m b ar s e t s o f m u s cl e s

,
a n d t h e w e ig h t o f th e t h orax . T h u s m u s cular in divi d ual s pr e s e n t m or e

pronounc e d p h y s iological curv e s o f t h e S pinal colu m n th an w e akly
on e s ; th e y app e ar t o s t an d s trai gh t e r .
O th e r s e t s o f d or s al m u s cl e s h av e the func tion o f p re v e n t i n g th e

S pinal colu m n fro m l e aning la t e ral ly A s a m a s t o f a s h ip i s h e l d i n
.
i t s uprig h t p o s i t ion by t h e s h rou d s th e s pinal colu m n n o t unlik e a

, ,
m a s t co m po s e d o f m any s e g m e n t s i s n or m ally r e t ain e d p e rp e n d icular

,
by m e an s o f th e d or s al m u s cl e s w h il e o th e r s h or t e r d or s al m u s
cl e s p e r for m th e func tion o f h ol ding th e s e g m e n t s t og e th e r .
In s colio tic in d ivi d ual s— s o th e au th or m ain tain s —th e m u s cl e s

of th e b ack a r e in s u ffi ci e n t t o p e r for m th e ir func tion Thi s .
i s m ad e e vi d e n t by th e e a s e wi t h w h ic h on e can aggr a va te s colio s i s i n

c e r t ain in divi d ual s b y pr e s s ur e upo n th e h e a d M or e o v e r s colio s i s i s
.
,
m or e m ark e d a n d m or e d i fficul t t o cur e in in d ivi d ual s w h o s e an t e ro
p o s te rior curva t ur e o f th e S pin e i s n o t w e ll d e v e lop e d Again a trop h y .

,
an d fa tty d e g e n e r a t ion o f th e d or s al m u s cl e s i s a fr e qu e n t p o s t m or t e m -
s ym p t o m o f s colio s i s .T h e h a bi t o f l e an i n g t o o n e s i d e an d di ffe r
68 I NDE X OP S UR GI CA L P R O GR E S S .
e nc e s in w e igh ts s uppor te d by e i th e r Sh oul d e r ar e only o f i m p or t anc e

in d e ci d i n g th e d ir e c tion o f th e curva t ur e s b ut n o t a s h a s b e e n b e , ,
li e v e d in ac t ually cau s ing th e curva t ur e s

, S e con d ary t rop h ic c h ang e s
.
'
in th e o s s e ou s e le m e n t s fi n a lly r e n d e r s uch h abi t ual curva t ur e fix e d ,
wh e r e a s i n ca s e s o f s t a tic s colio s i s ( coxi ti s e t c h e curva t ur e s r e m ain

) t , .
fl e xibl e on accoun t o f th e b e tte r m u s cular d e v e lop m e n t .
I f th e n s co lio s i s i s d u e t o in s u ffi ci e n t m u s cular ac t i on t h e only

, , ,
ra ti o n al t r e a tm e n t i s o n e a ffe c ting th e s e m u s cle s A s m a s s ag e i s v e ry .
e ffi ci e n t in s t r e n g th e ni n g th e m u s cl e s t h e au th or b e li e v e s t h i s m o d e
,
o f t r e a t m e n t a v e ry con s i d e rabl e i m prov e m e n t upo n g y m n a s t ic e xe r
ci s e .
H i s m e t h o d i s a co m bi n a t ion o f t apo t e m e n t an d r e d re s s e “
”
m ent T h e c h i ld s t ripp e d t o th e w ai s t i s lai d in a pron e po s i tion
.
, ,
up o n a m a t t r e s s wi th i ts ar m s e x t e n d e d o u t in fron t T h e e x te n s or
, .
m u s c l e s o f th e b ack a r e t h e n t app e d w i t h i n cr e a s in g forc e wi th th e
fl e s h y p or tion o f th e h an d b e low th e li t tl e fi n g e r m o t ion b e in g m a d e ,
o n ly in th e wri s t j oin t fo r a p e rio d o f fi v e or e ig h t m inu t e s d aily or

-
, ,
e v e n t wic e d aily T h e e n t ir e e x te n t o f th e b ack fro m t h e h ip s t o t h e

.
,
n e ck i s th u s t r e a t e d
, The r e d r e s s e m e n t i s fir s t appli e d t o th e
.
s pi n al colu m n a n d s ub s e qu e n tly t o t h e rib s a n d t h orax wh il e t h e p a t i e n t
i s s t a n d ing th e i d e a b e i n g t o c orr e c t any d e for m i ti e s t h a t are t h u s

,
a m e n abl e to t r e a tm e n t a s w e ll a s ro t ary con di tio n s F i n ally ac tiv e e x .
e r c i s e s a r e a d d e d i n clu d ing s u s p e n s ion s

, .
In m a n y ca se s gra ti fyi n g r e s ul t s c an b e ac h i e v e d a ft e r t e n or t we lv e
s i tting s ; p ai n a n d in t e rco s t al n e ura l ia i s o ft e n rapi d ly cur e d e v e n in
g ,
ca se s o f fix e d s colio s i s wh e r e co m pl e te cur e i s n o t p o s sibl e

,
.
O r th op e d ic appara t u s a n d cor s e t s th e au th or b e li e v e s m uc h in fe rior

t o m a s s ag e fo r th e r e a s on t h a t t h e y t e n d t o m ak e t h e m u s cl e s d e g e n
e t a t e s till fur t h e r ; a n d al t h oug h t h e y p e r m i t s traig h t carriag e fo r a
t i m e th e w e akn e s s r e t ur n s a s s o o n a s th e y a re d i s car d e d T h e pa t i e n t s
,
.
,
t oo m uc h pr e fe r t h e tr e a t m e n t I y m a s s ag e as i t i n cr e a s e s t h e ir s e n s e
, ,
o f m u s cular ac tion .
As fo r th e t i m e r e quir e d fo r t r e a tm e n t S li gh t ca s e s m a y b e cur e d in
,
a fe w m on th s ; o th e r s d e m an d o n e y e ar an d m or e M uc h h o we v e r d e .
, ,
p e n d s upon th e co n d i ti on o f th e b on e s an d th e ag e o f th e pa ti e n t .
C /zi r Bd 2 3 H 5 and 6 1 8 8 6
. . . . . .
W W VA N A R S D A L E . . .
E ON E S , oI N TS , OR TH OP A ED I C 269
j .
VI . T r e a t m e n t o f W h i t e S w e l l i n g o f t h e K n e e By
The .
A B J U D S O N M D ( N e w Y ork ) T h e wri t e r h ol d s th a t wh i t e s we l
. .
,
. .
,
.
lin g or ar ticular o s t e i t i s o f th e kn e e i s an i n fla m m a t ory a ffe c tion at

t e n d e d by d e s truc t ion an d d e g e n e ra ti on a n d follow e d a s a rul e by i m
p air m e n t o f func tion I t s s e v e ri ty a n d d ura tio n ar e i n cr e a s e d by use

.
o f th e j oin t a n d al s o by i m pair m e n t Of th e g e n e ral h e al th w hic h i s r e ,
c i p ro c a lly a ffe c t e d by th e local d i s e a s e I t h as h ow e v e r a s o call e d .

, ,
-
n a t ural cur e w h ic h occur s wh e n th e m orbi d pro c e s s i s s upp lan te d b y

,
th e r e p ara t iv e T h e O bj e c t o f tr e a tm e n t i s t o p r e v e n t ul t i m a t e i m
.
p airm e n t o f func tion a n d t o h a s t e n th e n a t ural cur e by i m provin g th e

g e n e ral co n di tion an d r e m ovi n g cau s e s o f local aggrava tion F unc .
t i on i s t o b e pr e se r v e d or r e s t or e d by s ub d uing i nfla m m a t ory ac t io n .
T h e h e al th i s t o b e m ain t ain e d by appropria t e m e d ica t ion a n d a prop e r
a m oun t o f o u t d o or e x e rci s e M e ch anical m e an s sh ou ld b e a d op te d

- .
t o s e cur e ac t ivi ty i n walki n g wi th ou t inj ury t o t h e a ffe c t e d par t .
Locally fixa t ion o f th e j oin t i s s ugg e s t e d by t h e w e ak e ning a n d lo s s o f

.
th e h ar d ti s s u e s o f th e j oin t a n d by t h e pr e s e nc e o f h yp e r ae m ia a n d e n ,
forc e d by t h e g e n e ral rul e th a t i n fla m m a t ion s h o ul d b e t r e a t e d by ar

r e s t o f func tion T h e a ffe c te d par t S h oul d a ls o b e pr e v e n t e d fro m
.
b e arin g th e w e i gh t o f th e b o d y a pr e c e p t wh ic h i s s ugg e st e d by th e,
s o ft e n e d a n d e xc a va t e d s t a t e o f th e b on e s a n d th e in fr e qu e n t occur
r e n c e o f th e d i se a s e in j oin t s w h ich are e x e m p t fro m th i s d u ty a n d e n ,
fo rc e d by th e s a m e g e n e ral r ul e th a t th e pr e s e nc e o f infl am m a tion d e
m an d s t h e arr e s t o f func t ion F ixa t ion i s conv e ni e n t ly s e cur e d a n d

.
th e d e for m i t y r e d uc e d by a s i m pl e r e te n t iv e s pli n t m akin g pr e s s ur e ,
fro m b e for e b ackwar d s in t h e vicini ty o f th e j oi n t a n d fro m b e h in d fo r ,
war d a t th e upp e r p ar t o f th e th i g h a n d th e low e r p ar t o f th e le g Ar .
r e s t o f th e w e i gh t b e arin g func ti on or pro t e c t ion fro m vi ol e n c e in

-
,
s t an ding a n d walking i s t o b e s e cur e d by s u sp e n s i on o f t h e li m b

, ,
wh ich i s conv e ni e n tly s e cur e d by th e i s ch i a t ic cru t ch o f T h o m a s o f
Liv e rp ool wi th a h ig h s ol e d S h o e on th e foo t o f t h e una ffe c t e d li m b

,
-
.
I V Y M ea f ou r
.
’
. J un e 6
. . .
VI I . The Use of D ri lls an d N ai ls a ft e r R e s e ct i o n .

J .
A W Y E TH M D ( Ne w Y ork ) pr e s e n te d s o m e s te e l drill s fo r fi xa
.
, . .
, ,
t ion o f th e kn e e j oin t a ft e r r e s e c t ion w h ich h e con s i d e r e d t o b e b e tt e r

-
,
270 IN DE X OF S UR GI CA L P R O GR E S S .
th an nail s s inc e th e y coul d b e i n tro d uc e d by d rilli n g wi th l e s s d ang e r

o f cru sh ing th roug h th e b on e s ; t h e par t s s u ffe r e d n o concu s s ion or
ch anc e o f d i s plac e m e n t a s w h e n th e h a m m e r wa s e m ploy e d ; th e drill

p oin t wa s s m all e r th an t h e s h a ft s o th a t a s i t p a s s e d th rough th e b on e , ,
i t b e ca m e t ig h t e r a n d t ig h t e r a n d r e m ain e d p e r fe c t ly fi rm H e u se d .
th r e e o f th e m in op e ra tion t wo p a s s ing obli q u e ly an d la t e rally fro m th e

,
t ibia t o th e fe m ur a n d a t h ir d in th e m e d ia n lin e d ow n war d fro m th e

,
fe m ur to th e t ibia .
C K BR I D D O N M D ( N e w Y ork ) th ough t th a t fix ation o f th e

. .
,
. .
, ,
b on e s was n o t a tt ain e d by th e wir e s u t ur e or by nail s a s or di n arily

u se d H e h a d ob s e rv e d th a t th e nail s c u t th rough th e canc e llou s
.
ti s s u e o f th e bon e s w h e n d riv e n fro m t h e fe m ur in t o t h e t ibia or vic e ,
v e r s a an d h e th oug h t th a t th e b on e s w e r e m or e s ur e ly m ain tain e d in

,
po si tion if th e nail s w e r e d riv e n in th e e xac t c e n t e r o f th e bon e a t th e

s i d e a n d a t a ri gh t angl e t o t h e axi s o f th e bo n e abou t th r e e quar te r s -
,
o f an i n c h ab ov e th e c u t s ur fac e s o n e on e i th e r S i d e o f t h e fe m ur an d ,
t h e tibi a ; t h e s e nail s b e i n g wir e d t og e th e r a t t h e s i d e o f t h e bon e s ,
h e l d th e m s e cur e ly in p o s i tio n a pla s t e r o f Pari s d r e s s ing b e ing ap,
pli e d ou t si d e o f th e wou n d d re s si n g -
.
A G GE R S T E R M D ( N e w Y ork ) r e p or te d a ca s e o f e x s e c tion o f
. . , . .
, ,
th e k n e e j oi n t fo r ankylo s i s th e r e s ul t o f an acu t e o s t e o m y e li ti s in a
,
-
,
g irl, ae t 1
5 T h.e e x tr e m i t i e s o f th e b on e on b e i n g broug h t i n t o p o s i
.
,
ti o n w e r e s e cur e d by n ail s th e fir s t o n e pa s s i n g th roug h t h e d e n s e

, ,
b ony s ub s t a n c e o f th e h e a d o f th e tibi a in t o th e fe m ur a n d th e o th e r ,
t wo pa s s i n g fro m ab ov e d own war d fro m th e fe m ur in t o t h e t ibia se ,
c uri n g e xc e ll e n t fixa tio n a n d a goo d r e s ul t H e h a d foun d t h e or d i .
n ary d ry g o o d s b ox n ail t o a n s w e r all purpo s e s th e only pr e cau tion
h e S h oul d ob s e rv e wa s th a t o f placi n g h i s in d e x fi n g e r b e twe e n th e

b on e s an d th e p o pli t e al S pac e s o th a t n o n ail co ul d b e driv e n th rou gh
t h e b o n e s i n t o t hi s s pac e wi th o u t th e o p e ra t or b e i n g a war e o f i t a n d al s o ,
t o pr e v e n t th e o ccurr e n c e o f an y la t e r a l d i s plac e m e n t d uri n g th e op e r
a t i O IL — P r oceed i ng s V Y S n rg S oc I 1 886
. May 1 0
. . . . .
VI I I x c i s i o n fo r C h r o n i c D i s e a s e o f t h e S h o u l d e r
. E
J o i n t By L W H U BBA R D M D ( N e w Y ork ) T h e wri te r b e li e v e s

. . .
, . .
,
.
t h a t e a r ly e xc i s i o n i s t h e pr e fe rab le t r e a t m e n t fo r c h r o n ic S h oul d e r
j o i n t di s e a s e b e c a u s e o f ( I ) th e probab i li ty o f as g o o d if n o t b e tt e r
,
T UM OR S . 27 1
r e s t ora tion o f th e fun c ti on

li m b ( 2 ) th e S h or t e r ti m e wh ich will
o f th e ,
e lap s e b e for e th e p a t i e n t will b e abl e t o u s e th e li m b ; ( 3 ) th e i m m e di
a t e i m prov e m e n t i n g e n e ral h e al t h w h ich follow s r e m ov a l o f th e di s

e a s e d t i s s u e ; ( 4 th e r e m oval o f a p o s s ibl e s ourc e o f g e n e ral ( t ub e r
)
c ular
) i n fe c t i on wi th ou t cau s i n g any d e form i t y or di s qu ali fyin g th e
,
p a t i e n t fr o m e n gaging i n th e or dina ry p ur s ui ts o f li fe —obj e c tion s wh ich

ar e s trong again s t e xci s ion o f th e j oin t s o f th e low e r e x tr e m i ty —M ed .
N ew s .1 886 April 2 4 .
.
.
IV C h r o n i c D i s e as e o f t h e S h ou l de r
. By V P GI BN E Y . . .
,
M D ( Ne w Y ork )
. .
,
T h e p urpo se o f th i s p ap e r i s t o S h ow by clinical
.
illu s tra tion s th e in e ffici e ncy o f p a s s iv e m o ti on wi th or wi th ou t an amacs ,
th e ti c as a m e an s o f r e li e vi n g fibrou s ankylo s i s an d i t m ay b e r e gar d e d

,
a s s uppl e m e n t ary t o th e pr e c e d in g —M ed N ew s 1 886 M ay 1 . . . .
J AM E S E PI LCH E R ( U S A m y) . . . r .
TU M OR S .
I O n t h e A r s e n i c a l T r e a t m e n t o f M a li g n a n t T u m o r s
. .
By D r F K O E BE L ( Tubing e n ) T h e au th or r e vi e w s th e r e s ul t s ach i e v e d
. . .
at th e Tubi n g e n Clini c ( Pro f Brun s) in th e t r e a tm e n t o f c e r t ain m a

.
lign an t n e opla s m s by m e an s o f in t e rnal a dm ini s tra tion o f ar s e nic .
A s r e g ar d s e pi th e lial c arcino m a t a variou s e xp e ri m e n t s w e r e m a d e at
on e t i m e or a no th e r in inop e rabl e ca se s o f m am m a ry d i se a s e wi th ,
local in j e c tion s o f ar s e n ic ; b ut in no ca s e s w e r e favorabl e r e s ul t s t e

cor d e d .
S a rco m a t a e xc e p t i n g th o s e o f th e ly m p h ati c glan d s h av e lik e wi s e

, ,
g e n e rally b e e n r e gar d e d as incurabl e by m e an s o f ar s e nic But th e .
au th or giv e s a ca s e o f a m an 3 9 y e ar s o f a g e wh o pr e se n te d m u ltipl e
s arco m a t a in r a pi d grow th wh e n a dm i tte d t o th e h o s pi t al a n d wh o ,
’
wa s co m p le t e ly cur e d a ft e r th r e e a n d o n e h al f y e ar s ti m e by co m b in e d
-
l ocal an d in t e rnal a dm ini s tra tion of ar s e ni c Th e diagno si s wa s a s .
s ur e d by m icro s copical e xa m in a t ion o f an e x s e c t e d p or t ion .
Lym p h o s arco m a t a w e r e n o t i n flu e n c e d in th e ir co ur s e by ar se nic al

-
t r e a tm e n t a s w a s prov e d by th e ob s e rva t ion o f se v e ral ca s e s

,
.
Th e gr e a t e r p ar t o f th e p ap e r i s d e vo t e d t o th e con s i d e ra tion o f
n i ali n an t l m
g y p h o m a t a in t h e t r e a t,
m e n t o f wh ic h ar se ni c h as alw ay s
play e d a con s pi cuou s p ar t .

272 I N D E X OF S U R GI C A L P R O GR E S S .
In or d e r t o d raw m or e corr e c t i n fe r e nc e s th e au th or fir s t r e vi e w s
fi ft y t w o ca s e s coll e c t e d fro m variou s s ourc e s an d th e n a dd s t o th i s
-
,
n u m b e r s e v e n ca s e s o f Pro f Bru n s H e t h e n proc e e d s t o d raw h i s

. .
co n clu s ion s T h e ag e s of th e pa t i e n t s vari e d e qua lly b e t w e e n 7 m o n th s

.
a n d 7 2 y e ar s Mal e s w e r e t wi c e a s fr e qu e n tly a ffe c t e d a s fe m al e s In

. .
2 7 ca s e s th e n e ck alon e was a ffe c te d i n 1 3 ca s e s th e wh o le b o dy , .
S t a t e m e n t s a s t o t h e pr e s e nc e o f l e uc ae m i a ar e inco m pl e t e T h e tr e a t .
m e n t con s i s t e d in i n t e r n al e xh ibi tion o f F owl e r s s o lu t ion incr e a s ing t o

’
,
a m axi m u m o f 4 0 t o 4 5 drop s d aily an d in p ar e nchy m a t o u s inj e c tion s , ,
gra d ually a s c e n d i n g t o or c tm d aily . .
A s t o th e r e s ul t s a t t ain e d co m pl e t e cur e w a s ob s e rv e d in 1 7 o u t o f
t h e 5 9 ca s e s ; b u t in fi v e o f th e s e r e curr e nc e s a re r e cor d e d ; in t h e ,
o th e r s no fur th e r no te s ar e m a d e Th e t i m e e lap si n g b e for e th e cur e

.
w a s co m pl e t e vari e d fro m o n e t o s i x m o n th s R e curr e nc e s vari e d in .
th e t i m e o f th e ir app e aranc e fro m t wo t o e ig h t m on th s .
I n 1 4 ca s e s th e r e cov e ry was par ti a l I n 2 8 ca s e s o u t o f th e 5 9 th e .
t r e a tm e n t w a s al t og e th e r in e ffe c t u al I n s o m e ca s e s h ow e v e r t h e .
, ,
t i m e allow e d fo r ob s e rv a t ion w a s t o o s h or t .
T h e au th or conclu d e s t h a t th e t r e a t m e n t S h oul d b e con t inu e d fo r a t
le a s t t wo m o n th s in or d e r t o a s c e r t ai n w h e th e r i t will prov e o f avail or
n o t a n d r e co m m e n d s t h e t rial o f m e d ica m e n t al t r e a t m e n t w i t h ar s e nic

,
i n all i n o p e rabl e ca s e s o f m aligna n t ly m p h o m a a n d i n c e r t ain o n e s o f ,
g e n e ral s arco m a t o s i s Al th ough m an y ca s e s ar e n o t cur e d s o m e

.
,
brillia n t r e s ul t s h av e b e e n o b t aln e d by th i s m e th o d —B e i t r ag e z u r
M i n C/zi m / Tg I lI i cf/ze i l a n s a er C/zi r £7 a z zz Tu b i ng e n I I Bd 1
’
. . . . .
. . .
H ft I V.
II . C o nt rib ut i o n s t o th e P at h ol o gy of T u m o rs . By Pro f .
WI LH .
Z A H N ( Ge n e va) .
( Co n tinu e d fro m Vo l I I I No . .
,
. 1 , p .
95 of
t h i s j our n a l .
’ ’
f f/ze T/z r r oi a B oay
’ ’
os feoi a S a r com
7
Tw o Ca s es f
o C/I on a r o - a o
.
Al th o ugh m alig n an t t u m or s o f th e th yroi d g la n d w e r e fo r m e rly b e li e v e d

t o b e v e ry rar e th e y a r e a t pr e s e n t m or e fr e qu e n t ly ob s e rv e d S i n c e a t
, ,
t e n tio n h a s b e e n di r e c t e d t o th e m T h e au t h or alo n e s a w fi v e ca s e s o f
.
carcino m a i n n i n e y e ar s ti m e S arco m a t a o f th e thyroi d h o we v e r

’
.
, ,
s t ill v e ry rar e an d c h ron d o o s t e oi d s arco m a t a h av e n e v e r ye t -

a re ,
T U M OR S .
27 3
b ee n d e s crib e d . The au th or , r or e now pub li sh e s

th e e f ,
t wo s uch c as e s .
A . Tfiy r oi da l cfi r on do-os feoi d s a r com a w i ck em b ryon a l l r a n s oer sely

s l r i a zed m us cle fi b r i llm a n d p ig m en z cells occu r r i ng i n a lzu m a n f oet us
‘ ‘
-
.
S t ill b or n in fan t pr e s e n t ing a t b ir th a t u m or th e s iz e o f a m an s fi s t

-
.
’
s i t ua t e d on th e a n t e rior a s p e c t o f th e n e ck an d r e achi n g fr o m th e ch in
t o t h e s t e rnu m an d la t e rally t o th e rig h t e ar Th e s up e rfi c i e s w as nu
.
e v e n ; th e con s i s t e n cy d i ffe r e n t i n t h e vari ou s p ar t s T h e s kin ab ov e .
i t wa s blui sh in plac e s n o t a dh e r e n t t o th e t u m or
, T h e th ym u s an d .
c e rvi cal glan d s w e r e nor m al .
T h e t u m or con s i s t e d o f s e v e ral larg e cy s t s wh ich w e r e v e ry s o ft on ,
pr e s s ur e a m e m bran e of conn e c t iv e t i s s u e cov e r e d e ach pro m in e nc e .
T h e con t e n t s o f th e cy s t s con s i s t e d o f an in s pi s s a t e d r e ddi sh fl ui d m i ,
c r o s c o p i c ally con s i s t i n g o f s m all roun d c e ll s ( s i m il a r t o th o se o f lym
p h a tic glan d s) a n d capilla ry v e s se l s N o s tro m a I nj e c tion o f th e t u m or

. .
di d n o t giv e s a ti s fac t ory r e s ul ts .
T h e t u m or e nv e lop e d th e t rach e a larynx a n d oe s op h agu s an d o c c u

, ,
pi e d th e plac e o f th e th yroi d b o d y An i s th m u s coul d b e m ad e o ut

.
j oinin g th e two p orti o n s o f th e t u m or .
Micro s copi c e xa m ina tion s r e v e al e d vario u s h i s t ologi c al e l e m e n t s .
S m all roun d c e ll s group e d t og e th e r wi th ou t any in te rc e ll ul ar ti s s u e

for m e d th e m ain con s ti t u e n t p ar t of th e t u m or Pe rip h e rally m uch .
p e rfe c tly for m e d h igh ly va s cular conn e c t iv e ti s s u e wa s s e e n circu m

,
s c rib e d an d w e ll d e fi n e d d e po s i t s o f car tilag e b o th e m b ryonal an d o s

-
,
s e o u s car t ilag e w e r e foun d in b o th p or t ion s o f th e t u m or

,
an d cavi t i e s
lin e d wi th e pi th e lia ( e m b ryon al thyr oi d t i s s u e ) in th e sh ap e o f follicl e s ,
an d t ub e s . Group s o f pi g m e n t c e ll s an d b un dl e s o f s tri a t e d s pin dl e

c e ll s ( e m bryonal m u s cl e t i s s u e) w e r e al s o pr e s e n t .
T h e d iagn o s i s m a d e wa s on e o f foe t al th yroi d t u m or o ri gin a t ing fro m
th e branch ial for m a t ion s .
B Clzon d r o os teoi d s a r com a of fi l e clay r oi d body a n d lu ng s i n a dog

.
- / .
T h i s t u m or con si s t e d in i ts p e rip h e ral p or tion o f fi rm conn e c tiv e t i s s u e ,
wh ich e xt e n d e d in plac e s in t o th e c e n t e r o f th e t u m or B e t w e e n th e s e .
e x t e n s ion s an d e nclo se d in th e m wa s m uch calcifi e d an d un c alc i fi e d
ca rt ilag e t i s s u e Bo th t og e th e r form e d a r e ticulu m in th e S p ac e s of

.
wh ich sm all roun d c e ll s an d s pin dle c e ll s w e r e s e e n S e con d ary n o d

- .
ul e s w e r e al s o foun d in th e lung s th e s m all e r o f wh ich prov e d t o b e ,
s arco m a t a th e larg e on e s h ow e v e r al s o con t ain e d h yali n e an d o s t e oi d

, , ,
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th or p oin t s o u t h o w b o th t h e s e t wo t u m or s d e s c ri b e d are o f S p e cial i n
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b e i n g an e xa m pl e o f te ra t oi d m ix e d t u m or s th e o th e r o f organoi d on e s ,
( V irc h ow ) wi t h a c o for m a t ion o f variou s

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ce llu la r a d en om a o f flu: thy r oi d body
in a d og . A u ffe r e d fro m a t u m or o f t h e
d og h ad s as a n e ck as lar g e
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m an s fi s t an d h a d d i e d fro m co m pr e s s ion o f t h e t rac h e a T h e t u m or

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,
sh ow e d a can alicular s truc t ur e wi th ra m ifica t ion s T h e va s cul ar cap .
s ul e co n s i s t e d o f fi b ri lla ry co n n e c t iv e t i s s u e T h e t rab e cu lar s t ruc t ur e .
wa s co m po s e d o f blo o d v e s se l s fro m w h ich capillary loop s proc e e de d

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cov e r e d wi th cylin d e r e pi th e lia In th i s nr an n e r papill ae w e r e for m e d

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co agulat e d alb u m e n —D eu cs cfi Z e i ls c/zr f C/zi r Bd 2 3 H ft 3 4 . . . . . . .

, .
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an a t o m y o f th e groin wi th e s p e ci al r e la tion t o t h e r e m oval o f t u m or s .
T h e gr e a t e s t d ang e r o f op e ra ti on s h e r e r e n d e ri n g th e ir p e r for m anc e .
v e ry d e lica t e i s th e in ti m a te r e la tion s b e t w e e n t u m or s an d th e gr e at
,
v e s s e l s o f th e groin T h e abla ti on o f s up e rficial t u m or s d e v e lop e d in

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th e s kin an d s ub cu t an e o u s con n e c t iv e t i s s u e i s o f b u t li t tl e in t e r e s t , ,
al th o ugh th e p o ssibili ty t h a t a s up e rficial t u m or m ay b e foun d t o h av e

p u sh e d o u t u n s u s p e c t e d d e e p p ro lon g at io rrs i m po s e d up on th e s urg e on ,
n e c e ss i ty for th e gr e a t e s t car e e v e n in appar e n tly S i m pl e ca s e s In .
s ub apon e uro t ic t u m or s t h e d i s s e c t ion s h oul d b e gin a t t h e ir e x te rnal

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'
fac e a n d e x t e n d inwar d upwar d a n d d o wn wa rd i f n e c e s s ary s o a s t o

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l e av e th e t u m or adh e r e n t only a t th e p oin t corr e s pon d ing t o th e S h e a th

o f th e fe m oral v e s s e l s ; t h e n t h e d i s s e c t ion o f th e p e d icl e s h o u ld follow .
I f th e t u m or i s s o larg e a s t o inconv e ni e n c e th e s urg e on a n d h i d e t h e

s h e a th o f th e v e s se l s w h ic h i t i s i m por t an t fo r h i m
, t o r e cogniz e bo th
T UM OR S .
27 5
wi th th e fing e r and th e e ye i t m ay b e r e m ov e d in frac tion s th at p or

, ,
ti on w h i ch i s th e m or e p ar t icularly a dh e r e n t t o th e va s cular s h e a th
b e ing l e ft in plac e N o t only sh o ul d th e p ul s at ion s o f t h e ar t e ry b e

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con s t an tly u n de r ob se rva tion b u t th e p l an follow e d by D e n onvili e rs

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o f fir s t t racing t h e cour s e o f th e v e s se l on th e s kin i n a ca se w h e r e t h e ,
fe m oral ar te ry was d e vi a t e d m igh t b e a d op t e d

, In th e di s s e c tion o f
.
th e a dh e s ion s o f th e t u m or t o th e sh e a th o f t h e v e s s e l s th r e e con d i ,
t ion s m ay b e foun d giving ri s e t o v e ry d i ffe r e n t prog n o s t ic a n d t h e ra

,
p e u t i c con s i d e ra t ion s ( )
1 . I t m a y b e p o s s ibl e t o d e s t roy t h e a d h e s i on s
co m p le t e ly th e fe m oral s h e a th r e m aining in t ac t ; ( 2 ) t h i s S h e a th m ay
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b e op e n e d t o a gr e a t e r or le s s e x t e n t a n d ( 3 ) i n m uc h th e m or e s e riou s
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ca s e s i t b e co m e s n e c e s s a ry t o i n volv e th e va s cular wall s in th e op e ra

ti on by i s ola t e d s e c tion a n d liga t ur e o f t h e v e in or by r e s e c tion a n d
s i m u lt an e ou s liga tu r e o f t h e v e in an d ar t e ry S i m p le d e nu d a t ion o f
.
th e fe m oral v e s s e l s i s o f li t t l e gravi t y ; in t w e lv e ca s e s o f t h i s kin d
d e a th follow e d b ut t wic e an d co ul d n o t b e at trib u t e d t o t h e v e no u s le
s ion . M or e ov e r d e nu d a t ion o f t h e v e s s e l s m a y pr e s e n t t wo v e ry
,
d i ffe r e n t d e gr e e s ; in t h e fir s t t h e s h e a th i s s i m ply lai d b ar e wi th o u t

b e ing involv e d ; in th e s e co n d a gr e a te r or l e s s e x t e n t o f t h e sh e a th
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i s e xci s e d an d th e wall s o f th e v e s se l s a re d ir e c tly e x p o s e d t o co n

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o f s loug h s in t h e va s cular wall s a n d o f s e con d ary h ae m orr h ag e a re
e vi d e n tly m uc h gr e a t e r In a s i m ilar ca s e t h e plan o f M o s e ti g

.
m ig h t b e follow e d wh o s y s t e m a t ically i nci s e d t h e s h e a th o f t h e v e s

,
s e l s wi th th e bi s t oury a nd t h e groo ve d d ir e c t or s e p ara t e d e ac h o f t h e ,
v e s s e l s fro m i t s nor m al p o s i t ion a n d e xci s e d fro m b e twe e n th e t wo

,
a larg e frag m e n t o f t h e n e opla s m Wh e n th e fe m oral v e in i s in

.
v olv e d , th e progno s i s b e co m e s m uch m or e grav e o f e ig h t o f th i s kin d
four w e r e fa t al . T h i s r e s ul t o f l e s ion o f th e fe m oral v e in will o fte n

b e pr e se n t fo r th e wall s o f th e v e in a re i nfi ni t e ly l e s s r e s i s t an t t o
,
t h e in v a s ion o f n e opla s m s t h an t h e ar t e rial ; fur th e r m o r e m os t o f ,
t h e t u m or s b e ing glan d ular a re bro ug h t in t o clo se r r e la tion s wi th

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t h e v e in th an wi th th e ar te ry I n ca s e o f a wo un d o f th e v e in lig
.
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a t ur e o f th e corr e s pon ding ar te ry wo ul d n o t con trol th e h ae m orrh ag e ,
wh il e liga t ur e o f th e v e in i t s e l f far fro m c a us ing gangr e n e i s m or e

, ,
76 I N D E X OP S UR GI C AL P R O GR E S S .
r ar e ly follow e d by i t t h an s i m ul t an e ou s liga t ur e o f th e v e in a n d ar
t e ry an d S h ou ld b e a d op te d
, .
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c e s s i t a t e s r e s e c t ion a n d s i m ul t an e ou s liga t ur e o f t h e ar t e ry a n d th e
v e in i t i s ob s e rv e d th a t th e s e ca s e s ar e m uch m or e grav e S inc e in

, ,
sev e n ca s e s c oll e ct e d fi v e t e r m i n a t e d fa t ally ; h ow e v e r i t wo ul d

, ,
se em prop e r t o m ak e a d i s ti n c tio n b e t w e e n th e ca s e s in w h i ch th e
r e s e c ti on a n d liga t ur e a re t o b e prac tic e d ab ov e an d b e low th e o r
i gin o f th e pro fun d a fe m ori s v e s s e l s In th e m i dd e o f th e th igh or in
.
t h e popli t e al s p ac e , s i m ul t an e ou s r e s e c t ion o f th e t w o principal v e s
s e l s m a y b e e m ploy e d In S carp a s triangl e on th e con trary wh e r e

’
.
, ,
t h e r e s e c t ion woul d m uc h m or e fr e qu e n tly o ccur ab ov e t h e pro fun d a
v e s s e l s thi s cour s e e xpo s e s th e li m b t o ga n gr e n e an d canno t b e re c om

,
m e n de d . If th e n car e ful e xa m ina tion o f th e pa ti e n t S h ow s th e n e c e s

S i ty o f s i m ul t an e o u s r e s e c t ion o f t h e ar te ry a n d v e in a t th e b a s e o f
S carp a s tria n g le i t wou ld b e b e s t t o ab s t ain How e v e r i t m ay

’
.
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o ccur th a t d uri n g th e O p e ra tio n i ts e l f l e s ion s m a y b e r e cogniz e d

, ,
wh ich th e m o s t car e ful e xa m ina t ion h a d n o t b e e n abl e t o s u s p e c t ;
in th e s e ca s e s t h e e x tirpa tion m ay b e l e ft co m pl e t e or r e lying up

, ,
on c e r t ain for t una t e ca s e s in w h i c h liga t ur e o f b o th fe m oral v e s s e l s

ab ov e th e origin o f th e pro fu n d a v e s s e l s h as b e e n fo llow e d by r e
cov e ry r e se c tion m ay b e a d op t e d
,
. I t i s a qu e s tion o f in d ica tion s
a n d c o rrt ra i n d i c a ti o n s
, t h e s olu tion o f wh ic h will d e p e n d up o n th e a g e
o f t h e pa ti e n t h i s g e n e ral con d i t ion a n d th e s t a t e o f th e va s cul ar s ys

.
tem . T h e crural n e rv e an d i t s branc h e s a re l e s s e xp o s e d t o inj ury b y
e x t irpa tion o f t u m or s o f t h e t h ig h th an th e v e s se l s ; ca s e s a re lack
i n g t o S h ow th e ul t e rior co n s e qu e nc e s o f s e c t ion o f th e s e n e rv e s T h e .
p o s sibili ty o f woun di n g th e p e ri t o n e u m in th i s sp ac e i s no t e d an d ,
t h e ca s e o f E ug e n e B oe ck e l in w h ic h t h i s occurr e d th e pe ri ton e al
, ,
wou n d b e i n g s u tur e d wi th ca tgu t wi th r e cov e ry r e fe rr e d t o

, , Th e .
p o s s ibili ty o f th e e xi s t e nc e o f a fe m oral h e r n ia b e low a n e opla sm

r e n d e r s car e d e sirab le F i n ally th e fr e qu e n cy o f e ry sip e la s a ft e r e x
.
,
t i rp a t i on o f t u m or s o f t h e groin i s r e m ark e d an d a t trib u t e d t o t h e
ab u n d an c e o f lyrrrp h ati c v e ss e l s —R evu e de C/zi r u rg i e 1 8 8 6 May

. . .
J AM E S E PI LCH E R ( U S A m y)
. . . r .
R E VI E WS O F BO O K S .
ON TH E S U P R A -PU BI C OPE R A TI O N OF O PE N I N G TH E BL A D D E R F OR
TH E S TO N E AN D FOR TU MOUR S . By S ir H E N R Y T H O M P S O N F R , . .
C . S .
, e tc .
,
Lon d on .
J . an d A C h urch ill 1 1 N ew B urling t o n
.
,
r
st e e t . 1 88 6 . Pp .
57 .
S ir H e n ry T h o m p s on h a s th e s oul o f an ar ti s t an d th e r e i s alway s a ,
ch ar m ab ou t th e m ann e r i n w h i ch h e tr e ats any s ubj e c t h e m av ch an c e

t o d e al wi th As al s o h e wri t e s o n ly on m att e r s o f w h ic h h e h a s h a d
.
an e xc e p tional o ft e n uni qu e e xp e ri e nc e i t go e s wi th ou t s aying th a t an y

, , ,
s urgical b ook o f h i s m u s t b e a valuabl e b ook t o li t e ra t ur e .
A ft e r a fe w pr e li m inary ob s e rva tion s S ir H e nry d e al s wi th th e s upr a

p ubic op e ra ti on i n i t s h i s t orical anat o m i cal a n d prac tical a s p e c ts s u c
,
c e s s i v e ly H e ob s e rv e s inci d e n t ally th a t th e larg e s t s t on e h e h a s ye t

.
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r e m ov e d b y li th o tri ty w e ig h e d ounc e s ( 8 0 gra m m e s) H e adds .
“
I d o n o t d e ny th a t e v e n a larg e r s iz e m ay b e s o e x trac t e d b ut I d o ,
n o t sa y t h a t i t wo ul d b e o ft e n pru d e n t t o un d e r t ak e th e t a s k Much .
d e p e n d s upon th e op e r a tor an d h i s e xp e ri e n c e Ph o s p h a tic cal culi o f .
s t i ll larg e r w e i gh t m ay b e cru sh e d s u cc e ss fully But th e r e i s a li m i t .
wh i ch no m an can d e fin e e v e n t o th e c ap abili ty o f nro d e rn li th o tri t y

, .
Th e r e are calculi t oo larg e an d t o o h ard t o b e r e m ov e d by t h a t op e ra

”
t io n . Th e r e can b e no qu e s tion b ut th a t th e l e s s e xp e ri e nc e d th e op
e r a t o r i s in d e aling wi t h s t o n e th e s oon e r will th e li m i t o f s iz e
, an d
h ar d n e s s b e r e ach e d a t w h i c h h e ough t t o c u t a n d n o t cru s h A s o ur .
au th or r e m ark s s t on e s o f larg e s iz e ough t n o t t o e xi s t in t h e se d ay s

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w h o s e ti m i d i ty an d procra s tina ti on will giv e calculi t i m e t o grow I t .
i s n o t th e r e for e e n t ir e ly a q u e s tion o f i m prov e d s urgical e d uca t io n

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S ir H e nry n ow b e li e v e s t h a t i n th e h an d s of m o s t O p e ra t ing s ur
g e on s s upra pubi c li th o t o m y will prov e a s a fe r an d a far e a s i e r O p e ra
-
t ion th an li th o t ri ty for h ar d s t on e s w h e n t h e y h av e arriv e d a t ab ou t
t o 2 ounc e s in w e i g h t .
T h e h i s t orical acco un t d e al s wi th th e work o f Pi e rr e F ranco

R o uss e t H ildan u s Proby D ougla s
C h e s e lde n ( 1 7 2 3 ) Moran d H e i s te r F r er e Co m e
( 27 7 )
278 R E VI E WS OF B O OK S .
an d v a riou s s urg e on s of th e pr e s e n t c e n t u ry a m o n g wh o m m ay b e e s ,
e c i a ll m e n t io n e d fo r th e valu e o f th e ir p ap e r s G M H u m p h ry C
p y ,
. .
,
.
W D all e s an d E Boul e y
. . .
A sh or t d e s crip tion of th e ordi n ary m o de of op e ra ting conclu d e s

wi th a co n t r a s t o f th e r e lat iv e ri sk s o f s upr a p ubi c a n d p e ri n e al li th o t
”
o m y by n o m e a n s favorab le t o th e la tt e r I t is “
b e s e t wi th d an g e r s .
,
wh il e th e r e a r e b u t t wo c h i e f ri sk s in th e fo rm e r pr o c e d ur e viz ( 1 ) t o ,
.
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th e p e ri t o n e um ; ( 2 ) i n fil tra t ion of uri n e .
N ow i n fil tra tion o f uri n e i s v e ry rar e so th a t th e o n ly r e al ri s k i s th a t ,
o f i nj ury t o th e p e ri t o n e u m Mo d e rn r e s e arch e s e s p e cia lly th o s e o f

.
,
J . G . G ar so n h av e S h own u s h o w to e n s ur e a s a fe s upra pubi c -
i n t e rval in wh i c h t o O p e ra te wi th ou t e n d a n g e ri n g th e p e ri t on e u m G ar .
s on s m e m oir d e s c r i bi n g th e e ffe c t o n th e p o s i t ion o f th e bla d d e r o f

’
,
di s t e n di n g th e r e c t u m an d e s p e cia lly calli n g a tt e n t i on t o i t s b e aring

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on th e O p e ra ti on of s upr a p ubic li th o t o m y wa s r e a d at th e Co n gr e s s o f
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was pr e s e n t ; an d th e r e is li ttle do ub t th a t h e was th u s le d t o t e s t by

prac tic e th e th e or e ti c al qu e s ti o n o f th e ab un d an t S p ac e i n thi s m a n n e r
”
o b t a i n e d fo r th e h ig h O p e r a ti o n t h e n ra i s e d by G ar s on Pe t e r s e n s
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.
,
ap e r a n d r e s u lt s a r e t h e r e o u t li n e d G uyon ’
p h i s m e th o d s an d s ,
accoun t of e igh t ca s e s no te d S ir H e nry T h o m p s on s fir s t ca s e was in

.
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1 8 8 3 an d l a s t N ov e m b e r h e co m pl e t e d h i s e ig h th
, , ,
.
A fte r no o th e r pr e vi ou s pr e para tion th an e nrp tyin g th e bla dd e r th e ,
p a ti e n t i s an ae s th e tiz e d in th e s upi n e p o s i tio n w i th t h e h e a d a n d ,
sh o u ld e r s s li gh tly r ai s e d An e m p t y i n di a rubb e r b ag roll e d in t o a

.
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c on e an d w e ll va s e li n e d i s p a s s e d we ll i n t o th e r e c tu m c o nrp le te ly
a b o ve th e S p h in c t e r T h e n ab ou t tw e lv e o r four t e e n ou n c e s o f w a t e r
.
a re g e n tly th ro wn in t o t h e r e c ta l b a
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.
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6 8 o r 1 0 o u n c e s fe e li n g h i s wa y c ar e fu ll y a c c o r di n g t o t h e r e s i s tanc e
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p e r c e iv e d in th e a c t an d th e d e gr e e o f e nrin e n c e ob s e rv e d ab ov e th e
,
p ub e s alm o s t i nv ari ab ly obvi o u s t o th e e ye a s we ll as to th e h an d

.
,
t a k i n g c ar e t o a voi d t h e ap p li c a ti o n o f for c e T h e r e c t al d i s te n s ion .
”
i s e s s e n tia l th e v e s i c al n e e d n o t b e c o n si de r ab le
, T h e fl ui d u s e d ,
S h o u ld b e a m i ld an t i s e t i c s o lu ti o n s u c h a s o n e o f b oracic aci d The

p , .
ca th e t e r b e i n g wi th dra wn th e b a s e o f th e p e ni s rs fir m ly liga t ur e d wi th
,
a n i n d ia I ub b e r t ub e
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Pa lp a t i orr ab o v e th e s ynrp lrys i s n ow d e m on
.
s tr a t e s th e p o s i t i o n o f th e b la dd e r m o s t o f i t lyi n g ab ov e th e bri m
, of
t h e p e lvi s in th e fornr o f a r o un d e d b a ll T h e r e i s li ttl e t o b e no te d .
ab o ut th e a u t h o r s m e t h o d o f r e ac h i n g th e b la d d e r th roug h an or di n a ry
’
m e d i an i n c i s i o n ab o u t 3 i n c h e s lo n g o th e r t h a n th a t h e u s e s t h e in d e x
,
fi n ge r n ail in s te ad o f t h e k ni fe e xc e p t in d ivi d i n g th e s kin t h e ap o n e u

-
, ,
TH O/V
I P S ON I N S UP R A P UB I C C YS T O T OM Y .
279
ro si s an d th e fas cia t ran s v e r s ali s A s m a ll h o ok fix e s th e bla dde r

.
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w h il e i t i s c u t e n ough t o a d m i t th e ri gh t in d e x fin g e r T h e le ft in d e x .
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p e rio d a t a t i m e .
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i t s conn e c ti o n s a goo d d e al in th e e n d e avor t o g e t h i s fing e r in t o i t .
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t re nri ty i s op e n obli qu e ly an d w h e n i t r e ac h e s th e wall o f th e bl add e r

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2 80 R E VI E WS OP D O OR S .
m ad e an p t t o e ncu m b e r s urg e ry with two m or e in s tr u m e n t s

a tt e m .
T h e au th or e s t i m a t e s h ig h ly th e prob abl e valu e o f th e s upra pub ic -
O p e ra t ion a s a m e an s o f r e m oving v e s ical t u m or s In a d di t ion t o i t s .
fr e e d o m fro m h ae m orr h ag e i t p e rm i t s a s o m e wh a t m or e e x t e n d e d u s e
o f th e s e n s e o f t ouc h th an i s prac t icabl e by th e p e rin e al in ci s ion ; an d
i t a dd s th e r e t o th e abili ty t o s e e t o a c e r t ain e x t e n t con fe rri n g al s o an ,
O ppor t uni ty t o apply th e cau t e ry or s t yp ti c s .
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p o s e s t o d o th e s upr a p ubic op e ra t ion for th e fir s t t i m e canno t d o b e t

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t e r th an s t u d y i t wi th car e H e will fi n d th e t a s k no unpl e a s an t o n e

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b e e n ov e r th e s a m e groun d h i m se l f .
C B K E E TL E Y . . .
PR A C TI CA L N OTE S T R E A T M E N T O F D E F O R M I T I E S By H E N R Y
ON TH E .
F . BA KE R , ( E d in ) A s s i s t an t S urg e on (
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to th e R oyal O r th op ae d i c Ho s pi t al e t c e tc Lo n d on E d S t an for d
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T h i s b ook d e s crib e s no th ing n e w an d d e s t roy s no th i n g o ld a n d ye t ,
i t i s a g e nui n e con trib u t ion t o or th op ae d ic s urg e ry I t s valu e i s d ue t o .
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a t th e larg e s t a n d w e b e li e v e th e ol d e s t or t h op ae d ic i n s ti t u t ion in E u
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glan d a n i n s ti t u tion w e ll known th roug h ou t th e worl d in a s s ocia t ion

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wi th a m aj ori ty o f th e m o s t r e nown e d Bri t i s h n a m e s in th a t bra n c h o f

s urg e ry .
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fan ci ful . Mr Bak e r c an s carc e ly b e bla m e d fo r th i s H e acc e p ts

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wi th an e vi d e n t m o d e s ty an d i n g e nuou s n e s s th e t h e ori e s o f t h e s c h ool ,
wh o s e prac tic e h e follow s th e ori e s e volv e d fro m th e ir own m oral con

,
s c i o u s n e s s by s urg e o n s s o pro fou n d ly s a t i s fi e d wi th t h e r e s ul t s o f

t h e ir t r e a t m e n t t h a t t h e y al m o s t u n i for m ly d e d uc e d th e ir n o t ion s o f
p a th ology fro m th e ir n o tion s o f tr e a tm e n t ; a n d n a t urally d i s fi gur e d

t h e ir b ook s wi th gro s s m i s s ta t e m e n t s s carc e ly t o b e p arall e l e d i n an y
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o th e r d e par tm e n t of s urgical li t e ra t ur e T e rro to nri sin g fo r e v e ry th ing .

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e v e ry th ing i s wi th t h e m
, o f m u s cular origin
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Mr Bak e r i s s o far car . .
ri e d away by th i s i d e a th a t h e b e g i n s h i s b ook wi th th e s ugg e s tion th a t

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r e lap s e d ca s e s o f club foo t o we th e d i fficul ty o f d e ali n g wi th th e m
-
t o t h e fac t th a t th e t e n d o n s h av e n o t b e e n prop e rly d ivi d e d an d h av e
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s t a te m e n t w h ic h app e ar s t o u s t o b e wi th ou t foun d a t ion

, I f he h ad .
M OR R I S ON D I S E A S E S OP TH E K I D N E Y .
28 1
wri tte n th at so c alle d r e l ap se d ca s e s of club foo t an d o f s o m e o th e r

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.
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t h e i m agin a ry cur e con s i s t s in h i d in g o n e d e for m i t y by th e a d d i t ion o f
ano th e r an d wh e n n a t ur e h a s h a d t i m e t o r e m ov e th e l att e r th e orig

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inal ( ol d e r a n d m or e ob s ti na t e ) r e app e ar s an d a r e l ap s e i s s ai d t o occur .
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”
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.
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t e b ra l car t ilag e s b e co m e co m pr e s s e d o n th e s i d e corr e s p on d ing t o th e
conc avi t y o f th e curv e ”

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th a t t h e b o d i e s o f th e v e r t e br ae al t e r i n S h ap e m or e quickly an d m or e
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s h ap e d c h ang e in t h e b o di e s d i d n o t e xi s t ?
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w e ll se rv e th e ir au th or s m ain p urp o s e na m e ly a d v e r ti s e m e n t T h e
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s t yl e i s cl e a r an d una ffe c t e d Bu t t h e c h i e f valu e o f th e work i s d u e

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t o t h e fac t t h a t i t i s a prac tical accoun t o f t h e favor i t e m e t h o d s o f an
abl e m an wh o h a s b e e n for a p e ri o d o f n o l e s s th a n t e n y e ar s r e si d e n t
s urg e on a t a gr e a t m e t rop oli t an or th op ae d ic h o s pi t al a n d wh o m or e , ,
ov e r h ad an e xc e p tionally s oun d a n d prac tical training in g e n e ral

,
m e d i ci n e a n d s urg e ry b e for e th a t p e rio d .
C B K E E T LE Y . . .
S U R G I CA L D ISE AS E S O F TH E K I DNE Y . By Mr H E N R Y M O R R I S
. . Lo n
don : Ca ss e ll 1 8 8 5
. .
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th e app e ar a nc e o f work s w h ic h d e al wi th th e s urgical t r e a t m e n t o f
th o s e r e gion s w h ic h h av e on ly r e c e n t ly co m e un d e r th e h an d o f t h e
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, .
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e rati o n o f th e a na t o m y o f th e ki dn e y in clu ding i t s m alform a ti on s U n

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un til a ft e r d e a th I t d o e s n o t e v e n app e ar t o b e c e r t ain a s Mr Mor

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ri s a s se r t s t h a t a b n orm a li t i e s o f t h e g e n e ra t iv e org a n s are in a n y way

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co nn e c t e d w i th th o s e o f th e ki dn e y .
T h e qu e s ti o n o f i nj u ri e s o f th e ki dn e y i s t h e n fully con s i d e r e d a n d ,
th e for m a t io n o f bloo d c y s t s i n con n e c t ion wi t h i t a n d i t i s pl e a s an t t o ,
ob s e rv e t h a t th e t e r m trau m a t ic h y dron e p h ro s i s which h a s b e e n s o m e

w h a t u n lrap p ily appli e d t o s uch con di t ion s d o e s n o t fi n d pl ac e in the ,
b ook b e for e u s .
O n t h e s ubj e c t o f re n a l calculu s Mr M o rri s i s nro s t e xplici t i n t h e

.
prin cipl e s on w h ich h e in si s t s an d on t h e d i ff e r e nc e s wh ich h e la ys

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d own b e t we e n t h e m o de rn op e ra ti on o f n e p hroli t h o t o m y a n d t h e i h ,
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”
t h e ir ri ta t io n o f a calculu s N e p lrr o li tlro to nry
. h e s ay s th e r e , ,
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, N e p h ro t o nry i s .
th e O p e ra t ion fo r calcul ou s py e li ti s or calculo u s h y d ro n e p h ro si s

. ,
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or pyo n e p h ro s i s e t c N o w wh il s t fully e n d or s i n g th e s e re rrrark s we
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con fe s s i t i s a li t tl e ar bi trary t o de ny th e t e r ni n e p h ro litlro t o nry t o a

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,
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.
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prob ably b e cau s e th e au th or fe e l s h e i s t r e a di n g on d e ba t abl e groun d ,
a n d i s un abl e t o a d vi se in m any c a s e s th e ir r e m oval by an y s urgic al
op e ra tio n .
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a s givi n g an e xc e lle n t r é s u m e o f t h e pr e s e n t S t a t e o f our knowl e d ge
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on th e s ubj e c t . W B R U C E CL A RK E . .
R E C E NT G E R MAN S U R GICA L PUB LI CATI O N S .
1 . VE R H AN D L U N G E N D E R D E U T S C H E N G E S E LL S C H A FT F U R C H IR U R G IE .
VI E R ZE H N T E R C O N G R E S S abg e h al t e n z u Be rlin v o m 8 1 1
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m it 1 Ta fe ln Aob ild un ge n u n d H o lz s c lrn i t t e rr B e rlin 1 8 8 5 Ve r

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2 . Be rra/m o n ZUR I< LI N I S C H E N C H IRU R GI E Mitthe ilunge n a us de r c hir .
urg is c h e n K li ni k T II b ing e n H e ra usge ge h e n vo n Dr PA U L

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BR U NS i tc r Band E rs tc s H e ft l ti b i nge n , H La up p
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R ep or ts / r ow l/ze S u rg i ca l C li n i c
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o f E wi ng en / . E di te d b y Dr Paul .
Zruns . 2d Vo l . Par t I) .
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f Ber li n Edi te d b y Dr E rn s t vo rr Be r g . .
m an n Par t I Wi t h fo ur p la te s )
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ti s c h e Re s e c ti o n ( le s
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r e/fior ls f r om l/I e Il/ u n i ci na / N o r/fi li a l i n Colog ne . E d i te d Iry l ru f
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Bard e nhe ue r , ch e f si urg e o n .
Fir s t p ar t : Os lcop /a s t i c r crec/ i on o / l/zc m a n u lxr i um . I le r n

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5 . DI E K R AN K H MI I ICN ’ '
DEV . VAU I N A . Vo n Dr A IIIrII Is k v O 0 Pro . .

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fe s so r d e r ( le h urt s lnitlte Irh I l ( lynii k o lo g ie a n Ile r De uts c h c n U niv e r

s i tirt z u l r ag Mi t l l o lz s u hn itte n l p X VI I I - 2 0 5 ( D i s e a s es
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Pr e i s s c h ri ft von Dr F R I E D E R I C H E S MA R C H K i e l Li p s i u s
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c ular a trop h y paral ys i s a n d c o n trac t ur e

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o f J oin t s in F rac t ur e s .
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.
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t h e r e i s b u t a r e m o t e p o s s ibili t y o f h e a li n g u n d e r co n s e rva tiv e t r e a t
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p a r ts .
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ol ogy r e c e iv e s d u e m e n ti on a n d i s illu s tra t e d by a fair li th o grap h Th e
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bibli o grap h y i s copiou s .
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an d di s e a s e s pr o m i se s o n ly fair ly I t c o n t ain s fi v e c h ap t e r s ( th e
.
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a n d t h e s arco m a t a ( pag e E pi th e lio m a o f cour s e clai m s t h e , ,
larg e r par t o f th i s ch a p te r ( 2 7 p ag e s) an d t h e se c t ion in wh ich i t i s .
di s cu s s e d i s in th e m ain s a ti s fac t ory alth oug h t h e r e are t oo m any

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t ab le s o f s t a t i s t ic s an d t oo li ttl e abou t t r e a t m e n t
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for m s o f facial di s e a s e an d d e for m i ty a re v e ry goo d T h e r e i s n e i th e r .
a tabl e o f con te n ts nor a bibliograp h y in th e b ook b ut d o ub tl e s s th e s e ,
will b e s uppli e d in th e s e con d par t fo r th e app e aranc e o f wh i ch we ,
s h oul d w a i t b e for e p a s s in g j u d g m e n t up on t h e c h arac te r o f th e work
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o n e o r two o f th e c h a p t e r s a re th orough an d e x h au s t iv e o th e r s a re ,
2 90 R E VI E WS OF E O OA S
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abri d g e d to an e x te n t th ta w o ul d n ot be e xp e c t e d in a s p e cial t r e a ti s e .
9 . \Ve c o m p e ll e d to p a s s in h a s ty r e vi e w th e fir s t v o l um e o f Dr
are .
Ba rd e n h e u e r s wo k w h i c h w h e n co m p le t e d wi ll b e w h a t th e G e r
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.
h e re . O f t h e four te e n ch ap t e r s i n Par t I t h e fir s t d e al s wi th g e n e ral ,
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, ,
t ur e s o f t h e clavi cl e an d s capula a n d d i s loca t i o n s o f t h e for m e r b o n e ,
th e four th fi fth an d s ix th wi th frac t ur e s an d d i s lo ca t ion s o f t h e h u

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m e ru s th e t w o s ucc e e ding c h ap t e r s t r e a t o f i nj uri e s o f th e axillary an d
s ubc lavian ar t e ri e s a n d brach ial pl e xu s t h e n e x t o f t rau m a t ic in fi a m m a ,
t ion o f t h e s h o ul d e r j oin t C h ap te r X d e s crib e s th e di ffe r e n t m e th o d s

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g a n d a m pu t a ti n g th e h u m e ru s C h ap te r XI i nj uri e s o f .
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clu d i n g ch ap te r s are d e vo t e d t o inj uri e s a n d op e ra ti o n s aroun d th e e l

b o w j o in t
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Con s i d e ring th e li m i te d fi e l d o f th i s bulky volu m e th e
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m a n t h oroug h n e s s a n d s uch i s i n d e e d th e fac t
, Y e t th e r e i s no t e n .
d e n c y on th e par t o f t h e au th o r t o in d ulg e in u s e l e s s d e t ail s H i s s tyl e .
i s fr e qu e n tly e pigra m m a ti c ; e ach p aragrap h i s co m pl e t e i n i t s e l f ‘
S t a ti s ti c s a re in tro d uc e d w h e r e t h e y a re n e e d e d b u t alway s in a c o n ,
d e n s e d for m e labora t e t abl e s b e i n g o m i t t e d

,
T h e d rawi n g s ar e nu .
m e r ou s a n d goo d ; m a n y o f th e m will b e qui t e n e w t o r e a d e r s o f E n
gli sh work s .
I t i s u n n e c e s s ary t o analyz e e ach c h ap te r i n d e ta il ; a bri e f r e vi e w

o f o n e will s e rv e t o in di ca t e th e ir g e n e ral arra n g e m e n t Th e ana t o m y .
o f th e s p e cial i n j ury i s fir s t d e s crib e d fo llo we d by t h e e t iol o gy s ym p , ,
t o m a t o lo gy d ia gn o s i s progno s i s a n d t r e a t m e n t ; e ach s e c tion i s p re

, ,
c e d e d by a bri e f h i s t orical s k e t ch T h e pri n cipal poin t s in t h e d i agn o

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s i s a n d d i ffe r e n t ial d iag n o s i s a r e s t a t e d in a s fe w wor d s a s p o s s ibl e a n d ,
ra th e r wi th th e V i e w o f furni sh ing prac tical h in t s for th e s urg e on th an

o f d i s playi n g w e ll roun d e d p e rio ds
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t h an i n w o rk s o n o p e ra t iv e s urg e ry b u t t h e y ar e qui t e co m pr e h e n s iv e
,
.
T h e ana t o m y an d s urg e ry o f th e s ub clavian ar te ri e s a r e th oroug h ly p re

se n t e d in c h ap t e r VI I I t w o ul d b e unj u s t t o th e au th or of s uch an
.
e lab ora t e t r e a t i s e t o j u d g e o f th e c h arac t e r o f h i s work fro m th i s h a s t y
no tic e I t i s wor th a car e ful p e ru s al an d will c e r tainly fi n d a wor th y

.
,
plac e a m o n g s ur g ical m onograp h s I t i s m ark e d through ou t by th e .
t wo car d i n al vir t u e s i n an au th or— cl e ar n e s s a n d br e vi ty T h e i m pr e s .
s ion l e ft afte r a car e ful p e ru s al i s th i s— th a t Pro f Barde n h e ue r h a s .
wri tte n fro m h i s own e xp e ri e nc e a n d at th e s am e t i m e wi th an h on e s t

d e s ir e t o giv e e v e ry m a n th e cr e d i t o f h i s work wi th ou t r e gar d t o h i s
R E CE N T GE R M AN S UR GI CA L P UB LI CA TI ON S .
29 1
n a ti o n ali ty W h e n i t i s co m pl e t e d i t will
.
, n ot be e a sy to fi nd a rival
fo r s uch a m o n u m e n t o f p a ti e n t in d u s t ry . H C . . C OE .
10 . ana t o m y o f th e h u m an b o dy i s tr e a t e d fro m a s om e w h at
Th e
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ro m i e s an d th ro u g h ou t th e fir s t volu m e n ow b e for e u s abun d an t e vi

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n e ss b o th in o ri g i n al r e s e arc h a n d i n th e a cquain t anc e wi th o th e r s o b

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se rva t i o n s wh ich h a s m ark e d th e au th or s pr e viou s wri ting s

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, an d t o ,
wh ich h e d e s e rv e dly ow e s h i s r e p u ta tion .
T h e r e ad e r i s s uppo s e d t o h av e a co m pl e te knowl e d g e o f d e s c rip tiv e

a n a t o m y an d a fair i d e a of th e t opograp h ical r e la tion o f th e p ar ts as
w e ll a s a g e n e r al k n ow le d g e of p a th olo gy an d th e s urgical t r e atm e n t o f
d i s e a se s a n d inj uri e s .
Pr e s u m i n g upon s uc h knowl e d g e th e au th or pro fe s se s t o gui de th e ,
r e a d e r in th e e x am ina tion o f th e livi n g h e al th y s ubj e c t an d th e norm al

ca d av e r an d t o p oin t o ut th e p ar ts di s s e c te d in th e on e th rough th e
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bli n g th o s e fr e qu e n tly occuring in s urgi cal prac tic e a n d ai di n g hi m in ,
th e ir d iagno s i s an d t r e a t m e n t .
In th e pr e s e n t volu m e th e au th or fir s t d e s crib e s th e e x te rn al a sp e c t
o f th e up p e r e x t r e m i t y fro m a s urgical poi n t o f vi e w a s i t r e la t e s t o I n ,
s p e c t i on an d p a lp a t io n a n d e nu m e ra t e s th e d e e p e r s e a t e d p ar ts a s
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th e y can b e m a d e o ut by t h e s e n s e o f t ouc h as w e ll as th e t O p o grap h i ,
cal s i t ua tion o f s uch on e s a s canno t b e fe l t an d t h e poin t s for r e ach ing ,
th e m by inci s ion H e con s i d e r s a ll th e s e th ing s a s th e y va ry un de r

.
th e in flu e nc e o f m ov e m e n t s d i s e a se an d I nj ur i e s ,
.
In th e ana t o m ical d e s crip t ion s o f th e par ts t h e au th or h a s t ak e n

s p e cial car e t o e xplain th e for m s a n d r e la t ion s o f t h e ly m p h s p ac e s an d -
s e rou s cavi t i e s e m pl oying inj e c tion s o f th e in t e r m u s cular s p ac e s j oin t s

, ,
a n d t e n d on sh e a th s t o d e m on s t ra t e h i s s t a t e m e n t s
-
Original e xp e ri .
m e n t s a n d d e d uc tion s fro m th e m ar e lik e wi s e e sp e ci ally no tic e abl e

un d e r th e h e a d i n g s of th e variou s for m s o f d i s loc ation s an d in th e
tr e a t m e n t o f t h e s ubj e c t o f I nj uri e s t o th e larg e r v e s s e l s fr e qu e n t a llu
s ion s t o s p e cial e xp e ri m e n t s a re t o b e foun d .
T h e s ubj e c t m a tte r h a s th u s b e co m e qui t e e x t e n s iv e an d in th i s fir s t ,
par t o f th e work tr e a ti n g only o f th e upp e r e x tr e m i ty 3 7 0 larg e oc t avo

, ,
pag e s are con t ain e d .
T h e work con t ain s in a r e a dily acc e s s ib le fo rm m uch i n for m ation

w h ich s urg e o n s e sp e ci ally th o se wh o h av e b e e n in s truct or s as w e ll a s
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op e r at or s h av e h i th e r t o h ad t o look up in m onograp h s and p e rio d ical

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li t e ra t ur e ; an d fo r th i s r e a s on alon e e v e n wi th ou t con si d e r at ion of ,
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prov e a v e ry valuabl e a d d i t ion t o th e libr ary o f all r e a d e r s o f G e r m an .
T h e t h ir d i ion rch Mili tary S urg e ry will

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1 1 . ed t of E sm a s be we l
29 2 R E VI E W5 OF B O OK S .
c o rn e d by th e public wi th th e m or e pl e a s ur e as i t h a s b e e n awai te d fo r ,
so long a t i m e T h e fir s t t wo e d i t ion s w e r e alr e a d y o u t o f pri n t in th e

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y e ar 1 8 8 1 th e book proving a gr e a t favori te a n d owin g t o th e failur e

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in bu s in e s s o f th e ori ginal pu b li sh e r s th e r e app e aran c e o f th e b ook

,
h a s b e e n d e lay e d t ill now .
Th e book i s s o w e ll kn o wn th a t a m e n tion o f i t s con te n t s app e ar s

s up e r fluou s .
T h e th ir d e d i t ion b e ar s e vi de nc e o f se v e ral al te r a tion s I t app e ar s .
in two volu m e s th e fir s t con tai n ing t h e s ubj e c ts o f woun d d r e s sing and

,
-
b an d a ging ; th e s e con d op e ra tiv e s urg e ry .
T h e an ti s e p tic m e th o d i s g iv e n m o re pro m in e nc e th an b e for e dir e c

t io n s a re incl ud e d fo r pr e p aring an t i s e p tic d r e s s ing m a t e rial a n d for ,
t h e d i sin fe c t ion o f s e p t ic woun d s .
In th e s e co n d volu m e nu m e ro u s a dd i t ion s h av e b e e n m a d e C h ap
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t e r s s uch as th e o n e on s u t ur e o f th e in t e s t in e h av e b e e n e x t e n d e d s o
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h a v e b e e n in s e r te d as th e on e s on r e s e c tion o f rib s a n d on th e o s te o
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la s t ic r e s e c t ion o f th e t ar s u s a fte r Mi k ulicz Wla d i m i r o w -

p .
T h e b ook now a p p e ar s in s m all oc t avo a n d th e t yp e i s s m alle r ,
wh ich ra th e r d e trac ts from i ts e l e ganc e al th o ug h i t m ay l e s s e n i ts co s t

, .
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-
o m i t t e d an d r e plac e d t o s o m e e x te n t by woo d cu ts T h i s appli e s t o .
th e t ran s v e r s e s e c tion s o f th e li m b s a n d t o t h e op e ra t i o n s o f liga t ing

, .
th e ar te ri e s .
In th e la tte r th e s urroun ding por tion s o f th e li m b h av e b e e n o m i t te d ,
wh ich s o w e ll s e rv e d t o i m pr e s s th e localiza tion o f th e v e s s e l s upon

t h e m in d o f th e r e a d e r a n d e nabl e d h i m m or e e a s il y t o fi n d h i s plac e
,
.
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S e v e ral n e w woo d cu t s r e pr e s e n t i n g t h e cour s e o f t h e m ain ar te ri e s are

a dd e d .
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1 2 . T h i s i s a conci s e ly wri t te n h an ds o m e ly p ubli s h e d h an d book o f
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ab ou t 1 2 0 pag e s in t e n d e d fo r th e u s e o f s t u d e n t s a n d giving in fe w ,
w o r d s th e m e c h anical p a th olo g y s y m p t o m s d iagno s i s an d t r e a t m e n t

o f d i s loca t ion s occurring in t h e d aily s urgical prac tic e —o n e o f a cla s s
, ,
o f b ook s n o t v e ry fr e qu e n tl y m e t wi th i n G e r m an m e d ical li te ra t ur e on
accoun t o f I t s e m in e n tly prac tical ch arac te r .
Luxa tion o f th e s pinal v e r t e br ae i s s o m e wh a t qui ckly d i s po s e d o f ,
t h e au t h or s t a t ing th a t local s y m p t o m s ar e fr e qu e n tly n o t w e ll m ark e d ,
a n d th e n e rvou s s y m p to m s n ot p r a ct i ca lly a va i la ble fo r d i a gno s i s .
O th e r fo r m s o f luxa tion h o we v e r s uch a s th a t o f t h e e lbo w app e ar

, , ,
t r e a t e d wi th p e r s pic a ci ty a nd a t s u ffici e n t l e ng th .
T h e au th or b e i n g i n s truc to r in s ur g ical b an d aging a t th e Univ e r si ty

,
o f K o e nig s b e rg in t e n d e d th e vol um e a s a h a n d book fo r t h e us e o f h i s

,
-
s t u d e n ts . T h e p u rp o s e i s e vi d e n tly a d e qua t e ly a tt ain e d .
W W VAN A R S D A L E . . .
EX C I S I O N O F T H E B O N ES O F T H E TA R S U S F O R
T U B ER C U LA R D I S E A S E WI T H RE P O R T O F ,
A C A S E I N W H I C H E X T E N S I VE E X CI
S I O N O F T H E T A R S U S WA S P E R
F O R M E D I N B O T H F EE T .
1
BY FRAN C I S J . S H E P H E R D, M D . .
,
OF M O N T R E AL .
PR O FE SSO R OF ANATO MY IN
’
M G I LL U N I V E R S ITY ; S U R GE O N TO TH E M ONTR E A L
G E N E R A L HO SPI TA L .
O R M E R LY w h e n a c as e o f t u b e r c u l o u s d i s e as e o f th e
b o n e s o f t h e fe e t p r e s e n t e d i t s e l f fo r t r e a t m e n t t h e o n l y
r e s o u r c e w a s a m p u t a t i o n b ut w i th t h e a d v e n t o f a n t i s e p t i c
,
s u rg e r y a n d th e e s t a b l i s h m e n t o f c o n s e r v a t i v e p r i n ci p l e s o f
t r e at m e n t o th e r m e t h o d s o f p r o c e d u r e h a v e b e e n a d o p t e d
,
w i th s u c c e s s I n c a s e s o f t u b e r c u l o u s an d c ari o u s d is e as e o f
.
t h e b o n e s o f t h e f o o t t h e n e c e s s i t y fo r a m p u t a t i o n i s n o t i m
m e d i at e a n d i t i s t h e d u t y o f t h e s u r g e o n t o e n d e a v o r fi r s t t o
,
r e m o v e t h e l o c a l d i s e as e b e fo r e s a c r i fi ci n g t h e e x t r e m i t y In .
d i s e a s e s fo r i n s t a n c e o f t h e t a r s o m e t a t a r s a l a r t i c u l a t i o n o n l y
, ,
-
t h e d i s e a s e d p a r t s o f t h e b o n e s e n t e r i n g i n t o t h i s a r t i c u l at i o n
s h o u l d b e r e m o v e d a n d t h e s a m e m ay b e s a i d o f t h e t a r s a l a
,
nd
ank le j o i nts T h e p r i n c i p l e I w i s h t o a d v o c at e i n t h e s e c a s e s
.
o f t u b e r c u l o u s d i s e a s e o f t h e b o n e s o f t h e fo o t i s n o t a n e w
o n e b u t o n e t h a t i s n o t s u ffi ci e n t l y i n s i s t e d o n
,
It is t h i s viz .
,
.
,
t h at i t i s n o t a l w a y s n e c e s s a r y t o r e m o v e a d e fi n i t e p o r t i o n
o f t h e fo o t b y a H e y s C h o p a r t s o r S y m e s a m p u t a t i o n
’ ’ ’
e ve n ,
w h e n t h e d i s e a s e i s v e ry e x t e n s i v e ; o n t h e c o n t r a r y t h e d i s ,
e as e d p a rts s h o u l d b e c u t d o w n u p o n w h e re v e r t h e y e x i s t a n d ,
o n l y t h e b o n e s a ffe c t e d w i t h d i s e a s e s h o u l d b e r e m o v e d Th e .
re m o v a l o f t h e d i s e a s e h o w e v e r s h o u l d b e th o r o u g h a n d i t i s
, , ,
1
R ead b e fo r e th e S urgi c al S e cti o n o f th e Can a d a M e di c al A s s o ci ati on , Q u eb e c , Au
g us t 1 8, 1 8 8 6 .
2 94 F R AN CI 5 SHE PHE RD
j . .
b e tt e r t o r e m o ve t o o m u c h t h a n t o o l i t t l e a s t h e m o r e c o m ,
e t h e re m o v a l t h e m o re ra p i d t h e c u r e
1
p le t .
I h a v e s e v e ra l t i m e s p e r fo r m e d p a r t i a l e x ci s i o n o f t h e
t a rs u s a n d a n k l e j o i n t w i t h t h e b e s t r e s u l ts I n c h il d r e n .
t h e n e c e s s i t y fo r a m p u t at i o n r a r e l y o c c u r s r e m o v a l o f t h e d i s ,
e as e b y s c r a p in g a n d g o u g in g b e i n g n e a r l y a l w a y s s u ffi c i e n t .
T h e fo ll o w i n g c a s e i ll u s t r a t e s t h i s : A B se t 3 y e a r s a d e l i . .
, .
,
c a t e c h i l d w i t h a s t r u m o u s h i s t o r y h a d fo r s o m e t i m e c o m ,
p l a i n e d o f a s o r e fo o t a n d l a tt e r l y h a d w a l k e d l a m e
,
Wh e n .
s e e n A p ri l
,
1 8 8 4 t h e r e w a s a s m a l l fl u c t u a t in g s w e l l in g o v e r
, ,
t h e s c a p h o i d b o n e o f t h e l e ft fo o t t h e w h o l e fo o t w a s e n l a r g e d ,
a n d i n fl am e d T h e s w e lli n g w a s i n ci s e d a n d a qu a n t i t y o f t h i n
.
c u r d y p u s le t o u t O n p a s s i n g i n a p r o b e c a r i o u s b o n e wa s
.
fe l t . T h e c h il d w as i m m e d i at e l y p u t u n d e r e t h e r a n d t h e ,
c a r i o u s p o r t i o n s w h i c h i n v o l v e d t h e s c a p h o i d a n d c u n e i fo r m
b o n e s w a s t h o r o ug h l y s c r a p e d o u t w i t h a V o l k m a n n s s p o o n ’
.
T h e c a vi ty w a s a ft e r w a r d s s t u ffe d w i t h i o d o fo r m g a u z e a n d t h e
fo o t d r e s s e d w i t h s u b li m a t e j u t e I n th e c o u rs e o f a c o u p l e .
o f m o n t h s t h e c a v i t y h ad c o m p l e t e ly fi l l e d u p a n d s o o n a ft e r ,
w a r d s t h e c h i l d w as r u n n i n g a b o u t a s a c t iv e l y a s e v e r No w .
,
in c a s e h a d th e d i s e a s e b e e n a l l o w e d t o g o o n t h e w h o l e
th i s , ,
t a rs u s w o u l d h a v e b e e n i n v o lv e d a n d a m u c h m o r e s e r i o u s o p ,
e rat i o n w o u l d h a v e h a d t o h a v e b e e n u n d e r t a k e n U p t o th e .
p re s e n t t i m e t h e re h as b e e n n o r e t u r n o f t h e d i s e a s e Th e .
n e x t c a s e I s h a l l r e l a t e i s o n e o f e x t e n s iv e d i s e as e o f b o t h fe e t
i n a y o u n g g i rl ae t I 7 I n o n e fo o t e x c i s i o n o f a n k l e j o in t
,
. .
a n d t a r s u s w a s p e r fo r m e d a n d i n t h e o t h e r p a r t i a l e x c i s i o n o f
,
t a rs u s .
Mary T se t 1 7 a d e lica te looking girl was a d m i tte d i n t o th e Mon

.
,
.
, ,
tr e al G e n e ral Ho s pi t al May 2 7 1 8 8 5 fo r d i se a se o f b o th fe e t
, , , .
N o di s tinct h i s t ory of p hth i s i s or s cro fula in th e fa m ily b u t s o m e o f ,
”
r e la t ion s di e d o f lung di s e a se .
Pa t i e n t up t o o n e ye ar ago h a d alway s e nj oy e d goo d h e al th w h e n ,
sh e n o tic e d th a t bo th fe e t w e r e co m m e nci n g t o s w e ll T h e s w e lling in .
t h e rig h t on e wa s ov e r th e a n kl e th a t i n th e l e ft ov e r t h e d or s u m o f ,
1
Dr . Co n n e r i n an e xh s
a u ti v
p ap e r i n Vo l I
e . of th e T ran s ac ti o n s of th e Am er
i c an S urg i cal A ss oci i

at on r e p o rt s
two c a e of e s s x ci s i on of th e e n ti re t ar u ; s s th e
s
p a ti e n t r e c o e r e d v w i th s
u e fu l fe e t . I n th e s me a
p ap e r h e g i v e s a t blea o f 1 08 c a e s s
x s
o f e c i i o n o f tw o o r m o re b on e s o f th e tar s u s .
E X CI S I ON OF TH E B ON E S OF TH E TA R S US .
29 5
”
foo t . w e lling s brok e s o m e e igh t m on th s ago an d h av e b e e n
The s ,
d i s ch arging e v e r s inc e H a d n o t walk e d for th e l a s t t wo m on th s

. On .
e xam i n a t ion s e v e ral s inu se s w e r e s e e n in e ac h foo t ; in th e l e ft the y ,
w e r e s i t u ate d b e low th e in t e rnal m all e olu s an d le d d own t o th e cariou s

b on e s in th e righ t s e v e ral we r e s i t ua t e d ov e r th e t ar s o m e t a t ar s al j oin t -
on th e d or s u m o f th e foo t a n d on e was s e e n in m i dd l e o f s ol e o f fo o t
,
.
B o th fe e t w e r e m uch s woll e n an d coul d n o t b e ar pr e s s ur e wi th o u t

,
p ain Mov e m e n t s o f l e ft ankl e j oi n t e xc e e d i n gly p ai n ful b ut n o

.
,
rough n e s s fe l t in m ov e m e n t I t wa s d e ci d e d t o r e m ov e th e di s e a s e d
.
p or tion s o f l e ft foo t fir s t On J un e I th e p a ti e n t wa s e th e riz e d an d an

.
,
in ci s ion m a de b e low th e t ip o f in te rnal m all e olu s fro m t he te n d o

Ach illi s d ownwar d s along th e inn e r bor d e r o f th e foo t in th e c our s e o f
th e d i s ch arging s i n u s e s Bar e b on e w as s oon r e ach e d an d s e v e ral s e
.
r a r e m ov e d t h e cavi ty w a s goug e d o u t wi th a V olk m ann s s po o n

’
q u e s t ,
a n d a ft e rwar d s s t u ffe d wi th io d o for m gauz e A j u t e a d wa s t h e n appli e d

p .
,
wh ich wa s s u ffi ci e n tly fi rm w h e n cov e r e d wi th an t i s e p tic b an d ag e t o

k e e p th e foo t in prop e r p o s i ti o n T h e d re s s ing s w e r e r e m ov e d onc e a
.
w e e k an d for a ti m e th e p a ti e n t m ark e d ly i m prov e d b ut lat e r i t was

, ,
foun d t h a t a ll th e d i s e a s e h a d n o t b e e n r e m ov e d t h a t cariou s ac t ion ,
wa s s t ill going on an d th a t s uppura tion wa s m or e pro fu s e th an i t oug h t

,
t o h av e b e e n On th e 1 5 th o f Augu s t 1 8 8 5 p a t i e n t wa s a gai n e th e r
.
, ,
i z e d an d an inci s ion m a d e in th e s am e lin e a s th e for m e r o n e an d th e

p ar t s m or e fr e e ly e xpo s e d I t wa s foun d th at th e ankle j oin t wa s i n
.
volv e d an d th a t th e r e wa s d i s e a s e al s o o f s cap h oi d an d cub oi d b on e s

, .
T h e a s tragalu s h a d an ab s c e s s th e s iz e o f a fi lb e r t in i t s c e n tr e I re .
m ov e d t h e low e r e n d o f th e t ibia a s t ragalu s p ar t o f cub oi d ,

e x t e rnal , ,
cun e i form s cap h oi d a n d a por tion o f t h e o s calci s b ut l e ft th e e x t e rnal

, , ,
m a ll e olu s wh ich wa s app ar e n t ly h e al th y T h e wo un d wa s d r e s s e d a s.
b e for e wi th io d o for m gauz e an d j u t e p a d s A d rainag e t ub e wa s al s o .
p a s s e d th rough th e cavi ty e m e rging b e n e a th th e e xt e rnal m all e olu s

,
.
T h e p a t i e n t di d r e m arkably w e ll rar e ly h avi ng a t e m p e ra t ur e ov e r,
T h e d r e s s ing s w e r e c h ang e d abou t onc e in t e n d ay s or two

°
1 00 F .
w e e k s a s r e quir e d
, .
In S e p te m b e r owing t o th e pr e val e n c e o f s m all p ox in th e ci t y all th e

,
-
,
p a ti e n ts in th e h o s pi t al w e r e vaccina t e d th i s on e a m on g s t th e r e st , .
S h e g ot a s e v e r e a t t ack o f e ry s ip e la s o n t h e arm an d h a d t o b e r e
m o ve d t o th e in fe c tiou s war d an d a ft e r r e cov e ry n o t wi s h in g h e r t o re
, ,
e n t e r th e s urgical war d s a n d s h e b e ing m uc h p ull e d d own by t h e at

,
t a ck o f e ry s ip e la s I a d vi s e d h e r t o go h o m e t o th e cou n t ry for th e
,
win t e r an d co m e b ack in th e s pring t o h av e t h e o th e r foo t att e n d e d

to. W h e n sh e l e tt t he h o s pi t al th e cavi ty in th e l e ft foo t h ad e n ti re ly
29 6 F R A N CI S j . SHE P HE RD .
h e al e d wi th th e e xc e p tion of a sm all fi s t ulo us op e ning b e l o w th e s i te of
th e in te rnal m al le olu s .
F IG . 1 . RES U LT A F ] E R E XC S O I I N O F T H E TA R S U S .
h
R i g t fo o t : T h r e e c un e i fo r m , p ar t o f c u b o i d, s c p h o id
a , and b a e s s of s
m e ta t ar al
b on e s r e m o v ed .
Le ft fo o t : Lo w er en d o f b
ti i a, a s tr a
g l s th
a u ,
re e c un e i fo rm , b
cu o i d , an d s cap h o i d
b on e s rc m o v e d .
On th e sth o f April , 1 8 8 6 sh e r e t urn e d ,

to th e h o s pi t al m uch im
p rov e d i n g e n e r al h e al th T h e r e was s till . a sm all s inu s at s tei o f op
E X CI S I ON OF TH E B ON E S OF TH E TAR S U S . 29 7
e rat i o n in l e ft foo t wh ich d i s ch arg e d a li t tle glai ry s yn ovi al loo king

,
flui d T h e ri gh t foo t wa s in m uch th e s a m e con di ti on a s b e for e th e

.
,
d i s e as e h a vi ng k e p t fair ly s t a t ionary an d b e ing app ar e n t ly confin e d

,
e n tir e ly t o t h e t ar s o m e t a t ar s al j oin t
-
T h e foo t wa s s woll e n an d p ain
.
ful . C a ri ou s b on e coul d b e fe l t wi th a prob e th rough all th e s inu s e s .
F IG . 2 . RES U LT A FT E R E XC S O I I N OF T H E T A R SU s .
S am s
e c a e as F ig . 1 ; d i ff e r e n t vi ew .
On th e 2 5 th o f April ag ain e th e riz e d an d th e d i s e ase d b on e

sh e was ,
r e m ov e d fro m th e le ft foo t Two lo n gi t u d inal inci s io n s w e r e m ade

.
,
o n e on th e ou t e r a n d th e o th e r on th e inn e r s i d e o f th e foo t Th e s oft .
p ar ts w e r e li fte d fro m th e d or s u m o f th e fo o t an d th e e x t e n t o f th e di s
29 8 F R A N CI S SHE PHE RD
j . .
e a s e se e n . T h e th r e e
cun e i for m b on e s wi th th e b a s e s of th e inn e r
th r e e m e t a t ar s al bon e s w e r e foun d t o b e in a ca riou s con di t ion ; al s o
th e a n t e rior p or ti on o f th e s cap h oi d T h e cub oi d b on e al s o was i n

.
volv e d wh e r e i t ar ticula te d wi th th e e x t e rn al cun e i for m

,
But th e ar .
ti c u la ti on s b e tw e e n th e cuboi d an d th e t wo ou te r m e t a t ar s al b on e s w e r e
h e al th y T h e b a s e s o f t h e m e t a t ar s al b o n e s w e r e r e m ov e d wi th a
.
fi n e s aw an d th e th r e e cun e i for m b o n e s t ak e n away T h e an te ri or p or

,
.
tion o f th e s cap h oi d an d th e gr e a t e r p or t i o n o f th e cub oi d w e r e r e

m ov e d al s o A larg e s pac e wa s now l e ft th e p o s te ri or p ar t o f th e
.
,
foo t b e i n g only conn e c t e d wi th th e t o e s by th e s o ft p ar t s T h e c a vi ty .
wa s wa sh e d o ut wi th an an ti s e p t ic s olu tion a n d s t u ffe d wi th i o d o fo rm

gauz e ( fr e sh ly m a d e ) an d th e foo t cov e r e d wi th a ju t e p ad an d ov e r th i s
, ,
an ou ts i d e gu tt a p e rch a s plin t was m o ul de d Th e s inu s in th e l e ft

- .
fo o t wa s s crap e d o ut .
F ro m th e t i m e o f th e O p e ra tio n t h e pro gr e s s o f th e p a t i e n t t owar d s

r e cov e ry wa s u n in te rrup te d T he wou n d w a s r e dr e s s e d e v e ry t e n or
'
.
fi fte e n d ay s in all fo u r t im e s wh e n i t wa s co m p le te ly h e al e d T h e
, , .
foo t th ough s o m e w h a t sh or t e n e d a n d fl a t wa s o f goo d s h ap e

, ,Th e .
t e m p e ra t ur e th ro u g h ou t n e v e r ro s e ab ov e 9 9 5 an d th e foo t n e v e r gav e
°
.
,
th e s lig h t e s t p ain o r k e p t h e r fro m s l e e pi ng T h e s inu s in th e l e ft foo t

.
a ft e r th e s craping rapi d ly h e al e d O n th e 3 o th o f J uly p a ti e n t wa s

, .
walking ab ou t th e war d .
Th e r e was s o m e inv e r s ion o f th e le ft foo t owi n g t o th e pr e s e nc e o f

th e e x t e rnal m all e olu s w h ic h m a d e t h e ou t e r s i d e o f th e foo t m uc h
,
firm e r th an th e i n n e r T h i s inv e r s ion wa s corr e c t e d by a s ui t ably m a d e

.
b o o t wi th an in s i d e m e t al r o d fix e d t o th e s ol e a n d fix e d ab ov e t o th e
le g by a l e a th e r collar H a d I t o p e r for m a s i m ilar op e ra t ion I sh o ul d
.
r e m ov e th e e x t e rn al m all e olu s e v e n i f i t was h e al th y a s by th i s m e an s

, ,
th e sy m m e try o f t h e foo t woul d b e pr e s e rv e d I onc e b e for e l e ft i t in .
’
e xci s ing th e a nkl e j oin t for a b a d ly s e t Po t t s frac t ur e wi th go o d r e ,
s ults . T h i s ca s e e x e m pli fi e s w e ll th e a d van t ag e o f con s e rv ativ e

m e th o d s o f tr e a t m e n t t h e p a t i e n t h a ving now t wo fairly u s e ful fe e t
, .
T h e acco m p anying cu t s s h ow th e pr e s e n t c o n di t ion .

ON T H E A D V A N T A GE S O F S U P R A P U BI C L I T H -
O T O M Y WI T H A RE P O R T O F A C A S E
,
.
1
BY A R P A D G GE R S T E R
.
,
MD
. .
,
OF NE W Y O R K .
S U R G E O N TO M T S INA I .
, AN D T H E GE R MAN H O SPITA LS .
I N CE o d e r n s u r g e r y h as m o r e a n d m o r e s u c c e e d e d i n
m
e x t e n d i n g th e a p p l i c at i o n o f a nt i s e p t i c p r i n ci p l e s t o t h e
o r a l c a vi t y t h e r e c t u m a n d t o t h e b l a d d e r e p i c y s t o t o m y h a s
, , ,
b e e n r e c l a i m e d fr o m u n d e s e r v e d n e g l e c t e rm a n y a n d A u s .
t r o H u n g a r y h a v e e s p e c i a ll y c o n t r i b u t e d a r e s p e c t a b l e s e r i e s
-
o f s u c c e s s fu l c a s e s d e m o n s t r a t i n t h at m a n y o f th e c h i f ob
, g e
o n s t o th i s p r o c e d u re h av e o f i m p r o v e m e n ts o f th e
j e c t i b y d i n t ,
m e th o d l o s t m o s t o f t h e i r w e i g h t
,
It is i n t e r e st i n g t o n o te
.
t h a t t h e l a s t a n d m o s t w e i g h t y o p p o n e n t o f t h i s m e th o d w as S i r
H e n ry T h o m p s o n a c o u n t r y m a n o f t h e b r o t h e r s D r J a m e s
,
.
D o u g l a s a n d M r J o h n D o u g l a s w h o i n 1 7 1 7 a n d 1 7 1 8 fi rs t
.
,
d e m o n s t r a t e d o n t h e c a d a v e r a n d s u c c e s s fu l l y p e r fo r m e d o n
t h e li vi n g s u b j e c t t h e o p e r a t i o n a s t h e v e n e r a b l e Ch e s e ld e n
,
i n fo r m s u s i n h i s e x c e l l e n t l i tt l e t r e at i s e O n t h e H i g h O p e ra
“
,
”
t i o n fo r t h e S t o n e p u b li s h e d i n 1 7 2 3 i n L o n d o n
,
.
V i e w i n g t h e m o r e r e c e n t l i t e ra t u re o f t h e s u bj e c t w i th o u t
p r e j u d i c e i t m u s t b e a c k n o w l e d g e d t h at t h e r a n g e o f t h e i n d i
,
c at i o n s fo r t h e p e r fo r m a n c e o f e p i c y s t o t o m y h a d b e e n u n t i l
r e c e n t l y u n n e c e s s a r il y n a rr o w T h e m a i n o b j e c t i o n s ra i s e d
.
w e r e t w o : F i r s t t h e d i ffi c u l t y o f i t s p e r fo r m a n c e e s p e c i a l l y
, ,
i n a d u l t s u b j e c t s w h i c h r e fe r s p r i n c i p a l l y t o t h e d a n g e r o f i n
,
j u r i n g t h e p e ri t o n m u m S e c on d t h e d i ffi c u l t a ft e r t r e a t m e n t
.
,
-
,
i n v o l vi n g t h e k n o tty q u e s t i o n o f s u t u r i n g t h e b l a dd e r o r c h o o s
i n g t h e o p e n t r e a t m e n t i n s t e a d a n d fi n a l l y t h e av o i d a n c e o f
,
u r i n e i n fi l t ra t i o n a n d i t s c o n s e q u e n c e s .
1
R e ad b e fo r e t he N e w Y ork S urgi cal S o c i e ty, M ay 1 0 , 1 8 86 .
( 2 99 )
3 00 A R P AD G . GE R S TE R .
Ga rs o n and P e t e rs e n h a v e s h o w n t h at d i s t e n s i o n of th e re c
t al p o u c h b y a s u i t a b l e s o ft r u b b e r b a g fi l l e d w i t h w a t e r w h e n ,
i n p o s i t i o n w i l l r a i s e a fu l l b l a d d e r o f a n a d u l t s u b j e c t s u ffi
,
c i e n t ly a b o v e t h e l e v e l o f t h e s y m p h y s i s p u b i s t o p e r m i t a fr e e
i n ci s i o n o f s i x c e n t i m e t r e s i n l e n g t h i n t o t h e o r g a n w i t h o u t t h e
l e as t r i s k o f c u t t i n g t h e p e r i t o n ae u m .
W il li e M e y e r l at e l y o f B o n n a t p r e s e n t o f t h i s c i ty re p o rt e d
, , ,
”
i n 1 8 8 4 i n L a n g e n b e c k s A r c h iv fo r t y o n e c as e s o f s u t u r e o f
,
“ ’
,
-
t h e b l a d d e r s i x t e e n o f w h i c h w e r e s u c c e s s fu l ; i n s e v e n t e e n
,
c a s e s s u p p u r a t i o n fo l l o w e d b u t e n d e d i n c u r e,
Ei g h t p at i e n t s .
d i e d i n c o n s e q u e n c e o f t h e o p e r a t i o n — o n e o f e r y s ip e l as a n d
S e v e n o f s e p t ic a m ia T h e r e s ul t s r e p o r t e d s i n c e b y B e r g m a n n
.
,
A n ta l a n d o t h e r s h a v e m u c h i m p r o v e d w h i c h m ay b e u n
, ,
d o u b t e d l y as c r i b e d t o a m o re c a re fu l s e l e c t i o n a ll c a s e s a c
'
c o m p a n i e d by s e p t i c p r o c e ss e s b e i n
g r e j e c t e d a n d t r e at e d b y
th e o p e n m e th o d .
Th e o p e n m e th o d h o w e v e r a s a d v o c at e d a n d p r a c t i c e d b y
, ,
D r Tre n d e l e n b u r g o ffe rs t h e g r e a t e s t s a fe t y a s re g a r d s a v o i d
“
.
,
a n c e o f s e p t i c ae m i a d u e t o u r i n e i n fi l t r a t i o n p h l e m o n o r e r
g y , ,
s i p e l as . A n e s s e n t i a l p a rt o f t h i s i s t h e s e m i p r o n e p o s t u r e -
o f t h e p a t i e n t t o b e o b s e r v e d a ft e r t h e o p e r a t i o n I n th i s p o .
s i t i o u n o t a d r o p o f u r i n e c a n b e r e t ai n e d i n th e b l a d d e r ,
b u t i t m u s t e s c a p e t h r o u g h a s o ft d r a i n a g e t u b e s u i t a b l y a t -
tac h e d .
Th e n o rm o u s a d v a n t a g e s o f e p i c y s t o t o m y i n c a s e s w h e re
e
a n e x a c t e x p l o rat i o n o f t h e b l ad d e r b y t o u ch an d s ight b e
c o m e s n e c e s s a r y n e e d n o t b e d we l t u p o n Th e e x a c t d i a g n o .
s is o f th e m o re i n t i m at e r e l a t i o n s o f o n e o r m o r e e n c y s t e d
s t o n e s a n d t h e i r r e m o v a l t h e s t a n c h i n g o f r e b e l li o u s
,
c y sti c
h ae m o rr h a g e s b y l i g a t u r e o r t h e c a u t e r y t h e d i a g n o s i s a n d s a fe ,
a n d c o m p l e t e r e m o v a l o f c y s t i c t u m o rs w i l l b e rat i o n a l a n d ,
s a fe p r o c e s s e s e v e n i n c as e s o f a v e r y m u c h e nl a r g e d p r o s t a t e
, ,
i n s t e a d o f b e i n g h ap h a z a r d d a n g e r o u s a n d o ft e n i n c o m p l e t e
-
,
a n d u n s at i s fa c t o r y e n d e a v o r s a s t h e y fr e q u e n t l y m u s t b e
,
if
t h e p e r i n e a l s e c t i o n i s e x c l u s i ve l y e m p l o y e d .
N o t w i s h i n g t o t a k e u p t o o m u c h o f y o u r t i m e I r e fe r yo u , ,
fo r a c lo s e r s t u d y o f t h e m e r i t s o f t h e q u e s t i o n t o t h e l u c i d a n d ,
v e ry i n t e r e s t in g p a p e r o f D r M e y e r a l l u d e d t o ( A r c h f k li n
“
. . .
vo l x x x i
. p ,
w h i c h c o n t a i n s a b u n d a n t c a s ui s t i c
.
A D VAN TA GE S OF S UP R A- P UB I C LI TH O T OM I" .
30 1
m at e r i a l t o b e a r o u t e v e ry s t a t e m e n t m a d e t h e r e i n i n fa v o r o f
t h e o p e rat i o n .
I d e e m i t p r o p e r t o b r i n g t h e s u bj o i n e d c as e t o y o u r n o t i c e ,
a l t h o u g h i t t e r m i n a t e d fa t a l l y fi rs t o n a c c o u n t o f it s i n h e r e n t
,
p at h o l o g i c a l i n t e r e s t a n d c h i e fl y b e c a u s e i t w as m a rk e d b y p e r
,
fe e t s a fe t y a n d e as e i n e x p o s i n g a n d i n c i s i n g t h e b l a d d e r w i t h
h a r d l y a n y l o s s o f b l o o d a n d b y t h e fa ci li t y w i t h w h i c h t h e
,
s t o n e s c o u l d b e g ra s p e d a n d e x t r a c t e d u n d e r t h e
g u i da n c e o f
t h e e ye fr o m b l a d d e r a n d d iv e r t i c u l u m T h e h i s t o r y i s a s fo l .
lo ws
Mar tin Gyr a S wi ss l ab or e r R t 5 0 wa s adm i tte d t o th e Ge r m an

, , .
,
H o s pi t al on Ap ril 8 H e s t a t e d th a t h e h ad b e e n s u ffe rin g fro m diffi

.
cul ty of m ic tu ri t ion fo r m or e th an t e n y e ar s h avi n g h a d no t r e atm e n t ,
wh at e v e r un til wi th in a fe w d ay s wh e n a cy s tic s t on e wa s d e te c te d b y
,
Dr M e y e r at th e Ge r m an Di s p e n s ary T h e u s u al sy m p t o m s o f the
.
, .
m o s t pronounc e d c h arac t e r w e r e pr e s e n t T h e p ati e n t co ul d n o t r e t ain

.
m or e th an an o unc e o f wa t e r an d h ad t o urin at e e v e ry fi ft e e n m inu t e s

,
b y d ay a n d nig ht E xa m i n a t ion o f th e alkalin e urin e gav e e vi d e nc e

.
o f in te n s e cy s tic c a t arr h an d o f
p ye lo n e p h ri t i s ca s ts a n d p e l vi c e p i th e
-
,
li a b e i n g foun d T h e fil t e r e d urin e con t ain e d a con s i d e r abl e am oun t

.
o f a lb u m in .
T h e p ati e n t pr e s e n te d an abj e c t pic t ur e o f e m a ci a tion pain a n d s u f ,
fe ri n g an d was d e ligh t e d a t th e p o s s ibili t y o f g e tting r e li e f by an

,
op e ra tion S ligh t e l e vat ion s of t e m p e ra t ur e w e r e ob se rv e d e v e ry e v e n

.
ing .
Ph y s ical e xa m in a tion d e m on s t ra t e d a nor m al con di tion o f th e in t e r

n al org an s e xc e p ting th e ki dn e y s a n d bla dd e r ; an ae m i a wi th r a pi d
, ,
an d r ath e r fe e bl e p ul s e T h e s t on e s e arch e r e s t abli sh e d th e pr e s e nc e

.
-
o f s t o n e in t h e bl a dd e r b ut fe a rin g a p o s s ibl e r e ac ti on n o e x t e n de d
.
, ,
e xa m ina tion a n d m e a s uring o f th e s t on e s w a s in s i s t e d u p on S o m uch .

,
h ow e v e r wa s cl e ar th a t th e m uch con t r a c t e d bla dde r con t ain e d e i th e r

, ,
-
a s ingl e larg e or a nu m b e r o f s m all e r s t o n e s By in tro d ucing th e fing e r .
in t o th e r e c tu m a r ath e r m a s s iv e pro tru s ion o f a h ar d b o d y t owar d

th a t organ coul d b e fe l t T h e p a ti e n t was m a de co m for t abl e by th e
.
fr e e a dm ini s tra tion o f O pia t e s an d all e n d e avor s w e r e e m ploy e d t o i m

,
p rov e hi s g e n e ral con di t ion b y ab un da n t s ti m ula t ion a n d foo d In .
w e igh ing th e ad m i ss ibili ty o f an op e ra tion th e wr e t ch e d s ta te o f th e ,
p at i e n t m ade i t cle ar th at any op e ra t iv e in t e rfe r e nc e wou ld b e fraugh t

wi th unu s ual d ang e r fro m sh ock ye t in vi e w o f th e fac t th at long e r
, ,
d e lay was in a d m i s sib l e an d th a t unr e li e v e d th e pa ti e n t woul d h av e

, , ,
3 02 AR P A D G . GE R S TE R .
to s uccu m b s oon a n d c e r t ai n ly i t wa s d e ci d e d prop e r t o o ffe r h im a ,
ch anc e h ow e v e r s l e n d e r o f r e cov e ry by op e ra tion R e gar din g th e

, ,
.
s e le c tion o f th e m e th o d i t h ad t o b e b orn e in m in d th a t a pr o l o ng e d
,
a n a s t h e s i a s uc h a s li th o lap axy woul d r e n d e r n e c e s s ary was i n a dm i s

, ,
s ibl e in th i s ca s e A grav e obj e c t ion t o any o n e o f th e p e ri n e al s e c

.
t ion s wa s t h e unavoi d abl e h ae m orr h ag e th e a m o u n t o f w h ic h vari e s ,
co n s i d e rably i n d i ffe r e n t ca se s can n e v e r b e e s ti m at e d b e for e h an d an d , ,
occa sio n ally i s s e ri o u s T h e h igh op e ra tion wa s na t urally th ough t o f

.
,
fir s t b e cau s e i t wo ul d p e r m i t bloo d l e s s acc e s s t o th e bla d d e r ; s e c o n d

, ,
b e cau s e i t woul d p e r m i t rapi d co m pl e tion o f th e e x trac tion o f th e s t on e

or s t on e s ; an d finally b e cau s e i t wou ld s e cur e p e r fe c t d rai n ag e Th e
.
, .
qu e s tion w hich an ae s th e tic s h o u ld b e e m ploy e d wa s d e ci d e d i n fav or o f

ch loro for m o n accoun t o f th e d ang e r th a t th e a dm ini strat ion o f e th e r
'
woul d e n t ail in th e pr e s e n c e o f th e r e n al con di t ion .
O n April 1 2 th e pa t i e n t h avi n g b e e n br o ugh t u n d e r th e influ e nc e

, ,
o f c h loro for m a s o ft rubb e r bag was in tr o d uc e d in t o th e r e c t u m a n d

,
-
w a s d i s t e n d e d by ab o u t 5 0 0 c c o f t e pi d wa te r A ft e r th i s t h e bla d . . .
d e r was fill e d wi th 2 00 c c o f t e pi d b oro s alicylic s olu t ion . A l o ngi

.
- .
t udi n a l inci s ion was carri e d t h roug h t h e in t e gu m e n t an d lin e a alb a
d own up on th e fa s ci a t ran s v e r s a li s wi t h m inu t e lo s s o f blo o d c o m ,
m e n c i n g a t ab ou t th r e e inc h e s fro m a n d e x t e n d i n g d o wnwar d t o a li t
tle b e yon d t h e s y m p h y s i s T h e fa s cia t ran s v e r s ali s h aving b e e n s e v

.
e r e d th e p e ri t o n ae u m b e ca m e e xpo s e d t o vi e w a n d d oub t s w e r e e n
, ,
t e r t ai n e d abou t th e p o s s ibili ty o f now i n ci s ing th e bla d d e r T h e r e upon .
i t wa s d e ci d e d t o inj e c t 1 0 0 c c m or e o f flui d in t o t h e bla dd e r W h il e . . .
th i s wa s d o n e i t coul d b e d i s t inc t ly s e e n h o w t h e b la d d e r ro s e up fro m
b e h in d th e sy m p h y s i s pu s hing b e for e i t th e r e fl e c t e d fol d o f th e p e ri

,
t on ae um m ark e d by a c le arly d e fin e d t ran s v e r s e d e pr e s s io n An i n c i s .
i o n o f o n e inch an d a h al f b e ing m a d e i n t o th e bla dd e r i t s con t e n t s ,
e s cap e d T h e e d g e s o f th e inci s i o n w e r e d raw n apar t th e r e m nan t o f

.
,
th e b oro s alicylic s o lu t io n was m o pp e d o u t a n d t h e r e upon t h e pr e s

-
,
e n c e o f m or e t h a n o n e s t on e coul d b e s e e n a n d fe l t F ir s t an ovoi d .
,
s m oo th h ar d s t on e was gra s p e d a n d e x trac t e d

, A fte r th i s a s e co n d .
ra th e r rough v e ry h ar d s t on e b e ca m e vi s ibl e w h ich wa s n o t s o fr e e ly

, ,
m ovab le a s th e for m e r b u t s e e m e d t o b e a t t ac h e d s o m e w h e r e on i t s
,
p o s t e rior fac e a n d yi e l d e d only a ft e r b e ing forcibly ro t a t e d O n i n

,
.
s p e c t i o n t h e fr e s h ly brok e n o ff s ur fac e o f a s t alac t i t ic proj e c t i o n wa s

,
-
s e e n o n i ts po s t e rior S i d e in d ica t ing th a t a con t inua t ion o f i t h a d e x ,
i s t e d proj e c t ing e i th e r i n to a ur e t e r or i n t o a d iv e r t iculu m

,
- Thi s s e c .
o n d s t on e s h o w e d t wo fac e t s —a larg e o n e corr e s pon d ing t o th e r o un d
s m oo th s t on e fir s t e x trac t e d an d ano th e r s m all e r o n e o f appar e n t ly re ,

AD VA N TA GE S OI " S UP R A -P UB I C LI TH O T OM Y .
30 3
c e n t fo r m a tion O n in tro d ucing th e fing e r in t o th e b la d de r a conical

.
,
s t on e was fe l t t o proj e c t fro m a d i v e r ticulu m s i t ua t e d p o s t e riorly a n d
t o th e l e ft sid e th e s i t e o f t h i s corr e s p on d i n g t o th e r e s i s t an t t u m or
,
fe l t in th e r e c t u m T h e in d e x fi n g e r w a s c a u tiou s ly in se r te d in t o th e
.
-
orific e o f th i s div e r ticulu m w h ich wa s fe l t t o yi e l d t o th i s g e n tl e dila ta

,
t ion . A forc e p s gra sp e d a n d e x trac t e d th e s t on e e a s ily fro m i t s b e d .
I t wa s cl e ar th a t ano th e r s t on e r e m ain e d t o b e e xt rac t e d ; b u t th e ,
pa ti e n t h aving b e e n un d e r th e infl ue nc e o f th e an ae s th e tic for t we n ty

m inu t e s an d h i s pul s e b e co m ing t h r e a dy i t was d e e m e d i m pru d e n t t o ,
con t in u e fur th e r se arch A s i t was in te n d e d t o l e av e th e inci s ion op e n

.
,
\
th e e x t rac tion o f t h i s r e m aining s t on e i t wa s t h oug h t co ul d b e e a s ily , ,
a c co m pli s h e d a t t h e fir s t s ui tabl e occa s ion A nu m b e r o f cam p h or a .
t e d e t h e r i n j e c t i on s w e r e a dm ini s t e r e d h ypo d e r m ically a n d th e p at i e n t
wa s p ut t o b e d Pr e viou s t o th i s a T sh ap e d d r ain ag e t ub e pr e p ar e d
.
- -
,
a ccor d ing t o th e d ir e c tion s giv e n by Tr e n d e l e nb urg wa s i n s e r t e d in t o ,
th e bla d d e r a n d ano th e r d rainag e t ub e was p a sse d in t o th e b o tt o m o f

,
-
th e d iv e r ticulu m T h e po s i t ion occupi e d by th e pa t i e n t in b e d was

.
s e m i pron e hi s l e ft h i
p r e s ti n g upon a ring sh ap e d air cu sh ion h i s
- - -
, ,
k n e e s b e ing drawn up an d h i s b ack b e ing s uppor t e d by a nu m b e r of

,
pillow s h e l d up b y th e b ack o f a ch air T h e s kin o f th e b e lly was .
fr e e ly anoin t e d wi th v a s e lin e a n d a p u s b a s i n wa s pl a c e d u n de rn e a th
,
-
th e proj e c t ing e n d s o f th e d rainag e t ub e s fro m wh ic h urin e wa s s e e n t o -

,
e s cap e in dribl e t s H o t b o t tl e s a n d s ti m ulan t s w e r e u s e d b ut in

.
, ,
S pi t e o f t h e in s ignifican t lo s s o f bloo d a n d o f th e s m all quan ti t y ( 1 0
gra m m e s) o f ch l oro for m u se d th e sh ock of th e op e ra tion prov e d t o b e

,
t o o gr e at . H e ralli e d th r e e or fo ur t i m e s t o r e lap se in t o a coll ap s e d ,
con d i tion an d d i e d fi ve h our s a fte r h aving b e e n plac e d in b e d

,
.
T h i s n o t wh olly u n e xp e c t e d r e s ul t o f th e op e ra tion prov e s th a t th e

r e s i s te nc e o f th e p a t i e n t h ad b e e n low e r e d t o s uc h an e x te n t th at e v e n
th i s m il d a n d bloo dl e s s proc e d ur e le d t o a fa t al t e r m ina t ion an d th a t ,
a n y o th e r op e ra t ion s uc h a s li th o tri ty or a p e rin ae a l s e c t i o n wo uld h av e

, ,
cau s e d d e a th m or e s p e e dily F ur th e r i t se e m s to b e cl e ar th a t in th i s
.
,
ca s e an e x trac tion of th e s t on e s fro m th e d iv e r ticula b y th e low e r O p

c r a t ion or li th o t ri t y coul d n o t h av e b e e n acco m pli sh e d .
O n po st m or t e m e x am inat ion th e four th s t on e con t ain e d in a s m all e r

-
, ,
d iv e r ticulu m wa s r e m ove d
, I t w a s th e n s e e n th at i t s d e te c t ion an d
.
e x trac tion coul d h av e b e e n e a s i l acco m pli s h e d T h e aggr e ga t e

y .
w e i gh t o f th e four s t on e s wa s 5 1 gra m m e s th e h e avi e s t b e ing th e roun d ,
sm oo th s t on e e x t rac t e d fro m th e bla dd e r i t se lf we i h i n gr am m e s

g g , ,
i t s longi t u din al d ia m e te r b e ing cm i t s t ran s v e r s e d iam e t e r .

,
cm . T h e n e x t in w e igh t 1 5 gra m m e s wa s a p e ar s h ap e d s t o n e re
, ,
-
3 04 A R P AD G . OE R 5 TE R .
m ov e d fro m arg e r d iv e r ti culu m i ts l e ng th b e ing

th e l , cm i t s thick .
,
n e s s 3 c m ; i t s ap e x wh ic h h a d proj e c t e d in t o th e bla dd e r s h ow e d an
.
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ob liqu e fac e t corr e sp on ding t o th e s m all e r fac e t o f th e o th e r s ton e

fo un d in th e cavi ty of th e bl a dd e r Th e th ir d s t on e j u s t allu d e d t o a s
.
foun d in th e bla dd e r wa s irr e gularly sh ap e d h aving t wo fac e ts an d a ,
s t al a c t i tic frac t ur e s ur fac e abou t

-
cm i n d ia m e t e r Th i s w e igh e d 1 0
. .
gra m m e s an d wa s app ar e n tly o n e wi th th e four th ; th e sm all e s t s t on e

,
fou n d in th e s e co n d d iv e r ticulu m wh ich w e ig h e d , gr am m e s wa s ,
p e ar sh ap e d an d wa s
-
cm long an d
. c m wi d e All th e s ton e s . .
sh o w wh e r e t h e y h av e n o t b e e n worn s m oo th a cry s t allin e s ur fac e o f

, ,
w hi ti sh color T h e y con s i st o f al t e rna te l ay e r s o f carbona t e an d o f

.
oxala te o f li m e the la t te r s ub s tanc e pr e pon de ra tin g

, .
In s t u dying th e po s i ti o n an d r e l ation s o f th e se s t on e s i t s e e m s al
m o s t c e r tain t h a t th e r e w e r e ori in ally only t wo s t o n e s pr e s e n t t h e
g ,
l arg e s t s m oo th on e b e ing th e ol d e st T h e r e m aining s t on e s m u s t h av e

.
b e e n o riginally o n e b o dy th e m ain p ar t o f w h ich w as s i t ua t e d in th e

,
bla dd e r an d gra d u ally s e n t o u t two p e ar sh ap e d proj e ction s e ach o f -

,
wh ich was fo un d t o b e lo d g e d in a d iv e r ti culu m o f corr e s pon ding s iz e .
Th e larg e r o n e th e pr e s e nc e o f w h ic h coul d b e fe l t b e for e th e op e ra

,
t ion by t ouch th roug h th e r e c t u m m u s t h av e b e e n br o k e n o ff s o m e

,
t i m e pr e viou s t o t h e O p e r at ion T h e frac t ur e d s ur fac e s pr e s e rving

.
,
appo s i tion b e ca m e worn i n t o fa c e ts

, Th e p e ri s t al tic m o t ion a t d e fe
.
ca ti o n m ay h av e play e d an i m p or t an t par t in th e pro d uct ion of th i s

p h e no m e non .
T h e po s t m or te m e xam i n ation r e v e al e d a nor m al ur e th ra e nor m ou s

-
,
c onc e n t ric h yp e r trop h y o f th e bla d d e r th e two d iv e r t icula ab ov e d e

,
s crib e d wi th in i t s po s t e rior w all a n d v e ry m uch d i s te n d e d ur e t e r s

, The .
la tt e r r e se m bl e d i n fan til e s m all i n t e s tin e s th e ir wi d th v a rying b e tw e e n

,
1 a n d 3 c tm th e t h ickn e s s o f th e ir wall s al s o va ryi n g t o a con s i d e ra

.
,
b le e x t e n t Th e gr e a t e s t am oun t of d i s t e n s ion wa s no t ic e d in th at
.
p ar t o f th e ur e te r s lyi n g n e x t t o th e blad de r Bo th ki dn e y s w e r e s o m e .
wh a t e n larg e d th e ir c ap s u le coul d b e s tripp e d o ff v e ry e a s ily col o r

, ,
p al e
,
calic e s a n d p e lv e s m uch th ick e n e d an d d ila t e d th e ki dn e y t i ss u e ,
in an a d va n c e d s tat e of fa tty d e g e n e r ation .

C LI N I CA L O B S E RV A T I O N S O N F I B R O M Y O M AT O U S
TUM O RS OF THE U TE R U S J
l
BY F RE D E R I C K LAN GE M D ,
. .
,
O F NE w YO R K ,
S U R GEO N T O TH E GE R MAN H O S I TA L ;
P CO NSU LTING S U R GE O N T O T H E P R E SBYTE R I A N
H O S ITAL
P .
MONG a l i m i t e d n u m b e r o f t h e fi b ry o m yo m a t o u s t u m o r s
o f th e u te r u s w h i c h h a v e a l t o g e th e r c o m e u n d e r m o b
y
s e r v at i o n I h a d t h e
,
o p p o rt u n i t y i n t h re e i n s t a n c e s t o s e e a
ra t h e r u n c o m m o n t e r m i n a t i o n o f t h e d i s e as e n a m e l y i n t w o , ,
c as e s b y e x p u l s i o n o f t u m o r m a s s e s a ft e r s p o n t a n e o u s s l o u g h
-
i n g ; i n t h e t h i r d c a s e b y s h r i n k a g e o f t h e t u m o r a ft e r c e n t r a l
s u p p u r a t i o n a n d s o ft e ni n g I n a ll o f th e s e c a s e s m o r e o r l e s s
.
s u r g i c a l h e l p b e c a m e n e c e s s a r y t o a id t h e n a t u r a l p r o c e s s b ut ,
a ll o f t h e m i n s p i t e o f p r o t r a c t e d s e r i o u s i l l n e s s a t l as t e n d e d
, ,
N i t h r e c o v e r y a n d i ll u s t r a t e i n a v e r y e l o q u e n t m a n n e r
,
th e ,
a b il i t y o f n a t u r e t o fi n d i n s p i t e o f s e r i o u s o b s t a c l e s
,
i t s w ay ,
t o wa rd u l t i m at e r e c o v e ry T h e fo l l o w i n g s h o r t h i s t o r i e s m a y
.
s u ffi c i e n t l y p o i n t o u t t h e e s s e n t i a l fe a t u r e s o f t h e s e c a s e s .
C A S E I —O u th e 1 2 th o f O c t ob e r 1 8 8 3 I s aw in con s ul t ation wi th
.
, ,
Dr S c h a i de of th i s c i ty M rs B th e n aet 4 5 wh o wa s s u ffe r
.
, ,
. .
,
.
,
ing fro m a larg e ab d o m in al t u m or wh ich h a d e xi s t e d for ab ou t th r e e

,
y e ar s an d by a nu m b e r o f p h y s ician s b o th h e r e an d abroa d h ad b e e n
, , ,
d i a gno s tica t e d a s fi b r o m yo m a o f th e u t e ru s To Dr S I owe m o st o f . . .
th e foll o wing no t e s ab ou t h e r h i s t ory M rs B h ad b e e n a dvi s e d . . .
e v e ryw h e r e n o t t o h av e an O p e r at ion d on e on accoun t o f t h e gr e a t ri sk
a tt ach e d t o i t Wi th in th e la st y e ar sh e h ad b e e n tr e a te d r e p e ate dl y
.
for lo n g p e rio ds o f ti m e wi th e rgo t a d m ini s t e r e d h ypo de r m ically a s w e ll

,
as in t e rnally b u t wi th ou t any n o t e wor th y s ucc e s s i n r e fe r e nc e t o

, ,
h m m orrh a ge a s w e ll a s s iz e o f t h e t u m or Th e la tte r wh e n I s aw th e .
,
1
R e ad b e fo r e th e N e w Y o rk S urgi c a l S oci e ty, M ay 2 4, 1 886 .
( 30 5 )
F R E D E R I CK LAN GE
'
p ati e n t fill e d a s a r e s i s t an t s o m e wh at irr e gularly sh ap e d m as s alm o s t

, , ,
th e e n tir e ab d om e n H aving a t th a t ti m e alr e a d y op e ra te d s ucc e s s

.
fu lly upon s e v e ral p at i e n t s wi th e xc e p tion ally larg e s oli d u t e ri n e t u m or s ,
I propo s e d in vi e w of th e in t e n s e s u ffe ring o f th e p a ti e n t th e ra dic a l

, ,
O p e ra t ion T h e p a ti e n t d e clin e d
. In th e b e ginning o f N ov e m b e r h e r .
con di tion b e c am e fe v e ri sh th e r e ap p e ar e d an o ffe n s iv e d i s ch arg e fro m

,
th e vagina a n d th e p a t i e n t lo s t rapi d ly in fl e sh
, On th e 1 8 th o f N o .
v e m b e r Dr S w a s abl e t o r e m ov e a pi e c e o f th e t u m or ab ou t t h e s iz e o f
. .
th e fi s t in a d e co m po s e d n e cro t ic con di t ion fro m t h e vagin a w h ich

, , , ,
fo r th e n e xt t wo w e e k s wa s al m o s t d aily follow e d by o th e r s o f s m all e r

,
or larg e r s iz e A p ar ticularly larg e pi e c e was e x t rac t e d fro m th e u t e ru s

.
a t th e e n d o f N ov e m b e r I th e n s a w th e p a ti e n t again in co n s ul t a tion
. .
To m y s urpri se th e e nor m ou s t u m or h ad s o m uch di s app e ar e d th a t th e

u te ru s now wa s n ot larg e r th an a t ab ou t th e four th or fi fth m on th o f
pre gnancy Th e r e e xi s te d s till a v e r y o ffe n s iv e d i s ch arg e wh i ch h o w
.
, ,
e v e r c e a s e d v e ry pro m p t ly a ft e r I h a d e x t rac t e d fro m th e u t e ri n e c av

, ,
i ty th e r e m ain d e r o f an e n t ir e ly s e p ara t e d m a s s o f t u m or T h e o ffe n .
s iv e s m e ll o f th i s s loug h e d t i s s u e was b e yon d d e s crip t io n T h e u t e ri n e .
cavi ty wa s d i sin fe c te d a s th oro ug h ly a s p o s s ibl e a n d d i sin fe c ti n g irri ,
g at i o n s k e p t up fo r s o m e ti m e a ft e r Th e p a t i e n t t h oug h v e ry m uch .
,
run d own m a de a rath e r rapi d r e cov e ry an d was abl e four w e e k s la t e r

, , ,
t o s e e Dr S a t h i s o ffic e
. T h e la t t e r h a d th e ki n d n e s s t o in for m m e
. .
th a t M r s B i s now in p e r fe c t h e al th
. . Abou t a y e ar ago h e r m e n s e s .
,
wh ich h a d b e co m e qui te nor m al c e a s e d Th e r e i s no r e curr e nc e o f , .
t h e t u m or a n d t h e p ar t s s e e m t o b e in an al m o s t nor m al con d i t ion S o

,
.
far a s I r e m e m b e r th e m a s s o f th e t u m or a t m y fir s t vi s i t m u s t h av e
,
w e igh e d a t l e a s t fi fte e n t o t we n ty p oun d s .
C A S E 1 1 — M rs H ae t 4 6 wh o h ad n e v e r b e e n pr e gna n t
. . .
, .
, ,
con s ul t e d m e in O c tob e r la s t T h oug h o th e rwi se in g o o d h e al th sh e .

,
h ad s u ffe r e d fo r th e la s t t wo y e ar s fro m pro fu s e a n d pr o lo n g e d m e n

s tru a t i on now a n d th e n a s s oci a t e d wi t h s e v e r e p ai n s in h e r back an d
,
v om i ting Wi th in th e la s t m o n th a fe w d ay s b e for e an d a ft e r m e n
.
,
s tru at i on a w h i t e d i s c h arg e app e ar e d

, T h e r e wa s no d o ub t th a t h e r .
t roubl e wa s d u e t o a fi b ro m yo m a t o u s t u m or o f s uc h s iz e th a t t h e
u te ru s on e xa m ina t io n r e ach e d wi th in abou t t wo fi n g e r s br e a d th o f
, ,
’
th e u m bilicu s D uri n g th e ti m e fro m the 1 2 th of O c tob e r t o th e 6 th

.
o f Nov e m b e r abou t e ig h t e e n h yp o d e r m i c i nj e c t io n s o f S quibb s flui d

’
e x trac t o f e r g o t w e r e a d m ini s t e r e d i n th e h ypoga s t ric r e gion Th e y .
cau s e d a goo d d e al o f p ai n an d infla m m a t ory irri ta t i on w hich h o w , ,
e v e r by col d applica t ion s wa s k e p t d own

,
s o t h a t no ab s c e s s e s o c ,
cur re d S m all in d ura ti o n s h ow e v e r r e m ain e d at th e poi n t s o f i nje c

.
, ,
F I BR OM Y OIP
I A T O US T U M OR S OF TH E U TE R US .
30 7
t ion . Durin g th e m e n s trual p e r zo d th e p a t i e n t r e s te d a t h o m e d id n o t ,
g e t a n
y h ypo d e r m ic inj e c t io n s b u t t ook t h e e rgo t in t e rnally 1 5 t o 20
, ,
d ro p s twic e a d ay O n t h e 1 4 th o f D e c e m b e r I w as call e d t o s e e
.
M r s H a t h e r h ou s e
. . S h e h a d a bloo d y s o m e wh a t o ffe n s iv e d i s
.
,
ch arg e fro m th e v agina a n d s u ffe r e d fro m gr e a t r e stl e s sn e s s an d p ain

,
o f lab or lik e ch arac t e r

-
T h e vaginal por tion o f t h e u t e ru s wa s s o ft e n e d
.
a n d d ila t e d a n d a s o ft m a ss coul d b e fe l t wi th in i t
, O n th e following .
d ay un d e r ch loro for m a co n s i d e rabl e m a s s ab ou t a p oun d an d a h al f

, , , ,
o f s loug h e d fi b r o m yo m a t o u s t u m or wa s r e m ov e d fro m th e u t e rin e cavi ty ,
a tt e r la t e ral inci s ion s in t o th e vaginal p or t ion h a d b e e n m a d e On .
accoun t o f th e n arrown e s s o f t h e s e xual pa s s ag e s an d th e i m p o s sibili ty

o f pulling d ow n t h e u t e ru s I co ul d n o t p a s s m y fing e r h ig h up in t o t h e,
u t e rin e cavi ty But I wa s abl e t o a s c e r t ain th a t a goo d m any n e cro t ic

.
irr e gular pi e c e s o f ti s s u e r e m ain e d un d e t ach e d as ye t Two d raina g e .
t ub e s w e r e in t ro d uc e d in t o th e u t e ru s an d r e p e a t e d irriga t ion s m a d e ,
wi th a wa rm s olu tion o f s alicy lic an d b oracic aci ds an d onc e or t wic e ,
a d ay o f corro s iv e s ubli m a t e s olu tio n 1 5 0 0 0 But i n s pi t e of m y e n .
d e av or s I di d n o t s ucc e e d i n p r e v e n t ing fur th e r d e co m po s i t ion

, The .
dr ain ag e t ub e s w e r e s o o ft e n clo s e d by s m all p ar ticl e s o f n e cro ti c t i s

s u e t h a t t h e y d id n o t a c t s a t i s fac t orily B e s i d e s th a t th e ir pr e s e nc e in .
,
t h e in t e rn al orifi c e s e e m e d t o b e th e s ourc e o f con s t an t irri t a t ion I .
t h e r e zor e r e m ov e d th e m an d appli e d irriga t ion se v e ral t i m e s a d a y b y

, ,
p a s s ing a F rit s ch e s u t e rin e irrigat or hi g h up in t o th e u t e ri ne cavi ty

’
,
u s ually inj e c ting fir s t a s trong e r s olu tion , o f corro s iv e s ub
li m a t e fo llo we d by i nj e c tion o f bor s alicylic aci d accor d ing t o

,
-
,
T h i e r s ch s pr e s crip tio n
’
.
Ve ry s oon un de r r e p e at e d c h ill s an d h ig h fe v e r th e palp abl e s ym p

, ,
t o m s o f p e ri a n d para m e tri t i s s e t in E s p e cially in th e cavu m D o ug

-
.
la s ii w h e r e a fi b rom a in s e r t e d a t th e s upravaginal p or t ion o f t h e

, ,
c e rvix wa s fe l t b e for e a d i ffu s e i n fil t ra ti on an d e xu d a tion coul d b e

, ,
m a d e o u t p u sh ing t h e low e r por t io n o f th e u t e ru s t owar d th e s ym

,
p hys i s Dr N o e gge rath was call e d in con s ul t a tio n an d wa s lik e wi s e

. .
,
co n vi n c e d o f th e e x t r e m e ly pr e cario u s co n di tio n o f th e p a ti e n t I t wa s .
d e ci d e d t o r e n e w t h e a tt e m p t t o r e m ov e th e s ourc e o f in fe c ti on fro m
th e u t e rin e cavi t y an d on th e 2 3 d o f D e c e m b e r
,
in th e pr e s e nc e an d ,
wi t h th e kin d h e lp o f Dr N oe gg e r ath s loug h e d m a s s e s m uch l e s s . , , ,
h ow e v e r t h an t h e fir s t t i m e w e r e again r e m o v e d p ar tly by forc e p s

, , , ,
par tly by cur e t te I t was d i s cov e r e d th a t fro m th e an te rior a s w e ll as

.
t h e p o s t e rior a sp e c t t u m or lik e pro m i n e n c e s pro t ru d e d t owar d t h e

,
-
u te rin e cavi ty an d th a t th e proc e s s o f s lough ing wa s p articularly s e at e d

,
po s te riorly an d t owar d th e fun d u s T he u t e ru s by th i s ti m e h ad al .

, ,
3 08 F R E D E R I CK I A N OE .
r e a dy b e co m e con si d e rably r e d uc e d in s iz e O n th e 5 th o f J anuary I .
m a d e a d e e p inci s ion i n t o th e e xu d a tion th rough th e p o s t e rior cul d e -
s a c e vacua ting p u s m ix e d wi th s m all pi e c e s o f n e cr o t ic t i s s u e

,
as I ,
s uppo s e d fro m th e c e n t r e o f th e fi b ro m a wh ich h a d un d e rgon e s up

,
u ra t i o n an d fro m th a t t i m e w h il e t h e d i s c h arg e fro m t h e u t e ru s b e

p , ,
c am e gra d ually l e s s an d al m o s t d aily s m all p i e c e s o f n e cro tic t i s s u e

,
’
w e r e e xp e ll e d th e pa ti e n t s con d i tion b e ca m e d e ci d e dly b e tte r S e v
,
.
e ral t i m e s s lig h t h ae m o rrh a g e acco m pani e d th e e xp ul s ion o f s loug h s .
At pr e s e n t for m o r e th an a m on th th e d i s ch arg e h as e n tir e ly c e a s e d

, , .
T h e u te ru s 1 5 v e ry li ttl e larg e r th an i t s norm al s iz e T h e r e i s s t ill a .
d e ci de d in d ura t i on a t th e s e a t o f th e p ara a n d p e ri m e tri ti c i n fl am m a -
tio n wh ic h h ow e v e r i s g ra d ually d i m ini s h ing

, , , T h e g e n e ral con d i tion .
i s v e ry go o d a n d t wi c e alr e a d y if I a m n o t m i s t ak e n t h e m e n s t rual
, , ,
flow h as app e ar e d a g ain nor m al in quan ti ty a n d d ur ation M rs H i s

, . . .
n o w 4 7 y e ar s o f a g e a n d c e r t ainly v e ry n e ar th e e n d o f h e r m e n s t rual
,
li fe
. I th ink th e r e i s v e ry li ttl e prob abili ty th a t a n e w fo r m ation o f
fi b r o m yo m a t a will occur I am un d e r th e i m pr e s sion th a t in th i s ca s e
.
th e w h ol e m a s s o f th e t u m or h a d n o t s loug h e d b u t t h a t s e v e ral lum p s , ,
t og e t h e r wi th th e gra d ual con t rac tion o f t h e u te ru s h av e d i s app e ar e d ,
e i th e r by a t rop h y or fa t t y d e g e n e ra t ion I t s e e m s fur th e r th a t in th i s .

, ,
ca se th e a d m ini s tra tion o f th e e rgo t h a d a cau s al r e la tion t o th e n e cro

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F I B R OM Y OM A T O US T UM OR S OF TH E U TE R US .
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t h e m a n n e r d e s c r ib e d i n t h e p r e c e d i n g h i s t o r i e s fi b r o m y o m a ,
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s m a l l p e r c e n t a g e o f c a s e s e n d in g fa t a ll y We a re t h e r e fo r e .
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a b l e c o u r s e o f t h e d i s e a s e s o fa r a s t o g iv e i t a n y i m p o r t a n t
w e i g h t i n r e g a r d t o o u r p r o g n o s i s o f fi b ro m yo m a t o u s t u m o r s
o f th e ut e ru s W e k n o w o n l y t o o w e l l t h a t s o m e t i me s t h e s e
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t u m o r s w il l h a v e a n u n b o u n d e d d e v e l o p m e n t a n d a ft e r t h e y , ,
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a s i n t h e s e c as e s m e d i c i n a l t r e a t m e n t i s u s u a l l y n o t h i n g b ut
loss of t im e .
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to th e ,
t h e o v a r i e s m a y e ffe c t u a l l y c h e c k t h e d e v e l o p m e n t o f fi b ro m y
o m at o u s t u m o rs I am u n a b l e t o g i v e a s a t i s fa c t o ry a n s w e r
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ri e s w o u l d h av e b e e n a v e ry t e d i o u s o p e rati o n a n d p r o b ab l y n o t ,
m u c h l e s s d a n g e r o u s t h a n t h e re m o v a l o f th e w h o l e m a s s In .
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b e e n n o e as y t h i n g a t a ll t o g e t t h e o v a r i e s a n d t h i s t o g e t h e r , ,
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i n re c o v e r y ; t w o o f t h e m h av e b e e n r e p o rt e d t o t h i s S o c i e t y i n
p r e vi o u s y e a r s o n e b e i n g c o m p l i c a t e d w i t h p r e g n a n c y ; t h e
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l as t t w o c a s e s w h i c h h a v e b e e n o p e r a t e d u p o n i n t h e c o u r s e
o f t h i s y e a r I p r e s e n t b e fo r e y o u t h e t u m o r s r e m o v e d
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e ra l y e a rs at e v e r y m e n s t r u a l p e ri o d h a d b l e d s o a b u n da n t l y a s
t o b e c o m e q u i t e a n ze m i c h e r w h o l e w a y o f liv i n g fi n a ll y b e in g
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u t e r u s a n d fo r m i n g a t u m o r o f t h e s i z e o f t h e u t e r u s i n t h e
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m o n t h s a ft e r t h e o p e r a t i o n t h e e l a s t i c li g a t u r e b y w h i c h t h e
s t u m p o f t he u te r u s h a d b e e n s e c u re d p as s e d a w a y t h r o u g h
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F I B R OM YOM A T O US T U M OR S OF TH E U TE R US .
31 1
n i n e m o n t h s a g o s h e p a s s e d a c o n s i de ra b l e q u a n t i t y o f b l o o d
w i t h h e r u ri n e fo r t h r e e o r fo u r d a y s w i t h s o m e fe e l i n g o f p a i n
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i n h e r b a c k a n d a g e n e ra l s e n s a t i o n a s i f s h e h a d h e r p e r i o d .
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i n t e r c o u r s e w i t h o u t i m p a i r m e n t a s c o m p a r e d w i t h h e r h e a l th y
p e r i o d o f m a rr i e d l i fe b e fo r e t h e O p e r a t i o n Late ly s h e h as
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s m o o th t u m or r e ac h i n g fro m t h e o s p ubi s h ig h up t o t h e e pi a s triu m

g
a n d t h e fr e e b or d e r o f t h e rib s .T h e t u m or w a s v e ry m ovabl e a n d a l
low e d o f pa s s ing th e fi n g e r s par tly un de r i t t owar d th e e n tranc e o f th e
s m all p e lvi s s o t h a t on t h e fir s t e xa m in a t ion i t d i d n o t s e e m
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la te d fibrou s t u m or th e m o s t prob abl e .
In th i s c as e t h e o p e r a t i o n w as c o m p a r at i v e l y s i m p l e .
T h o u g h it w o u l d h a v e b e e n p o s s i b l e t o re m o v e t h e t u m o r
w i t h o u t s a c r i fi c i n g t h e i n t e r n a l s e x u a l o rg a n s 1 s t i l l d e e m e d it
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a d vi s a b l e t o p e r fo r m t h e s u p r a v a g i n a l a m p u t a t i o n fo r t h e fo l
l o w i n g r e a s o n s : F i r s t I t h o u g h t o f t h e p o s s i b i l i t y t h at fr o m
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a s s u m e d a m o r e m a li g n a n t c h a r a c t e r ; a n d s e c o n dl y s e v e ra l ,
s m a l l b e g i n n i n g fi b r o m a t a c o u l d b e d i s t in g u i s h e d l o w e r d o w n
w i t h i n t h e w a l l s o f t h e u t e r u s w h i c h if l e ft b e h i n d w o u l d h a v e
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d e v e l o p e d fu r t h e r a n d p e r h a p s m o r e r a p i d l y .
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a n i n ci s i o n in th e lin e a alb a r e ac h i n g fro m t h e e pi ga s t ri u m al m o s t d own
t o t h e s y m p h y s i s p ubi s th e t u m or wa s S lowly a n d wi th ou t di fficul ty

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fro m b o th s i d e s i n a h oriz on t al d ir e c t ion t h e broa d li ga m e n ts w e r e ti e d

3I2 F R E D E R I CK LA N CE .
in se v e ral p or tio n s b e tw e e n t wo liga tur e s u n til clo s e t o th e la t e ral

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a m pu ta t e d an d th u s th e wh ol e m a s s r e m ov e d T h e ti ss u e o f th e .
s t u m p wa s th e n e xci se d in th e sh ap e o f a fu n n e l s o t h a t th e m ucou s ,
m e m bra n e w a s r e m ov e d a s low d own as th e e la s tic lig at ur e p e r m i tte d .
At th e d e e p e s t poin t th e ac t ual cau t e ry wa s appli e d an d a s m all quan

t i ty o f io d o for m pow d e r e d ov e r th e e s ch ar T h e fu n n e l wa s th e n .
clo s e d by a n u m b e r of d e e p ca tgu t s u t ur e s b e tw e e n w h ich th e p e ri ,
t on e al cov e ri n g wa s adj u s t e d by s up e rficial on e s T h e e n d s o f all th e .
lig at e d t i s s ue s w e r e th e n cau te riz e d spri n kl e d wi th i o d o for m an d th e

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a d m e n clo s e d by p e ri to n e al an d o th e r su t ur e s in th e u s ual m an n e r .
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r e ac tion an d i s s o far e n tir e ly w e ll
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p r o p e r c a re i s tak e n n o t t o e x p o s e th e p at i e n t t o a n u n n e c e s
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t h a n a n o u n c e o f b lo o d T h e w a y o f p as s i n g t h e e l a s t i c l i g a t u r e
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I t i s t h r o u g h o u t a ll
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i t s s u b s t a n c e a fi b r o m yo m a .
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,
t h e o p e r a t i o n w as o nl y u n d e r t a k e n a t t h e u r g e n t r e qu e s t o f
th e p ati e nt .
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forc e d trac tion s w h ich coul d n o t v e ry we ll b e avoi d e d d u ri n g th e a t
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F I B R OM YOM A T O US T UM OR S OF TTI E U TE R US .
317
ing t o th e d ang e r and

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’
c o u n t o f th e au th or s d iv e rg e nc e fro m th e in d ica t io n s a n d m o de o f
t r e atm e n t h e r e t o for e g e n e rally acc e p t e d in co m p oun d inj uri e s t o t h e
s kull a n d th e a t t e n t io n g iv e n t o t h e an t i se p t ic m e th o d
,
.
T h u s th e au th or i t will b e s e e n i s n ot in favor o f tr e p h ini n g for rup

.
,
t ur e o f th e m i ddle m e n i n g e al ar t e ry a t l e as t n o t i n any b u t e x t r e m e
,
c a s e s o f i n t racr a n ial pr e s s ur e n o r d o e s h e t h i nk i t n e c e s s ary t o e le v a t e
s m all e r d e pr e s s e d pi e c e s o f s kull ; b u t i f t h e s lig h t e s t quan t i ty o f fo r
e i g n m a tt e r or a s m uc h a s a h air h av e p e n e tra t e d th roug h a fi s s ur e in

,
th e s ku ll h e d e e m s i t an u n avoi d abl e n e c e s s i ty t o lay op e n th e cr a nial

,
c avi t y a p oin t whi c h our r e a d e r s will r e m e m b e r t o h av e b e e n in s i s te d

u p o n by Wi e s m a n o f Z ti ri c h in a r e c e n t c on trib u tion t o th e s ubj e c t
z
.
, ,
Th e ca s e s a ll tr e a te d fro m th e s a m e poi n te o f vi e w an d in th e sam e

,
h o s pi t al th e h o s pi t al fo r coal m in e r s at K On i g sh ii tt e d uri n g a p e rio d o f

, ,
n in e ye a r s are
9 5 in n u m b e r a n d c o n s i s t fo r t h e m o s t p ar t o f s e v e r e
,
inj u ri e s to th e skull s uch a s m in e r s ar e co n s t an tly e xpo se d t o Th e

,
.
gr e a t e r m aj ori ty w e r e r e c e iv e d in t o th e h o s pi t al i m m e d ia t e ly or v e ry
s oon a ft e r th e inj ury a n d t h e m or t ali t y p e rc e n t ag e o f t h e s e c a se s i s
,
Ab ou t o n e s e v e n th o f th e nu m b e r h ow e v e r d id n o t apply fo r
-
, ,
1
No s . 2 7 1 an d 2 7 2 . h
C i r urg N o 8 5
. . . Ap ri l 20 , 1 886 .
2
Vi d e An n al s of S urg e ry . Vo l I I
. . P 5 02
. . Dec .
, 1 88 5 .
( 3 1 8)
TR E A T M E N T O F C OM P O UN D F R A C T UR E S OF S K ULL .
319
t r e a tm e n t un til a t l e a s t tw e n ty four h our s a fte r th e acci d e n t ; an d in

-
t h i s group t h e m or t ali ty av e rag e d 3 p er c e n t Th e d i ffe r e nc e .
in th es e fi gur e s i s d u e t o an ti s e p ti c prop h ylaxi s .
T h e au th or o n ly cur s orily con s i d e r s th e p a th olo g y a n d s ym p t o m a t
ology o f th e s ubj e c t confining h i m s e lf a s h a s b e e n r e m ark e d al m o s t

, , ,
e xclu s iv e ly t o th e th e rapy o f th e inj uri e s t o th e S kull ; a n d a ft e r givin g
qui te a de t ail e d r e vi e w o f th e h i s t ory o f h i s s ubj e c t wi th s p e ci al r e fe r ,
e n c e t o t h e o p e ra ti on o f t r e p h ini n g h e fir s t con s i d e r s t h e d ang e r s o f

,
s e p t ic in fe c t ion s o f S kull wo un d s - T h e s m al le s t woun d o f th e i n t e g u

.
m e n t w h e n i n fe c t e d wi th s e p ti c m a t t e r m av l e a d t o th e m o s t s e riou s
, ,
d i s t urb a nc e by th e progr e s s o f t h e s e p tic i n fl am m a tion t o war d s p e ri

o s ti ti s p urul e n t o s ti t i s o s t e o p hl e bi ti s m e ni n gi ti s e nc e p h ali ti s ; or
, ,
-
, ,
t h e co ur s e o f t h e i n fe c t i on m ay l e a d fro m p e rio s ti ti s th r o ug h o s
t e O p h le b i ti S t o t h ro m bo s i s o f t h e v e nou s s inu s e s a n d py ae m ia Th e .
d a n g e r s inci d e n t t o s e p t ic in fe c t ion s incr e a s e a s t h e i nj uri e s t o th e t i s

s u e s p e n e tra t e m or e d e e ply .
I f th e p e ri t on e u m i s s e v e r e d or i f t h e bon e s o f th e s kull a re inj ur e d

, ,
t h e in fe c tiou s m a t t e r i s rapi dly d i s s e m ina t e d by m e an s o f t h e v e in s o f
t h e d i p lo é a n d in fe c t ion o f th e br a in a n d i ts t i s s u e s or py ae m i c m e t a s
,
t a s e s r e s ul t I f t h e cra n ial cavi ty i s lai d O p e n th e s e p tic in fe c t ion l e a d s

.
,
t o an i n fla m m a tio n o f th e d ur a m a t e r p achy m e ningi ti s e x te rna w h ich

, ,
m ay s pr e a d t o t h e s o ft t i s s u e s e nv e loping th e brain But w h e n th e .
d ura m a t e r i s inj ur e d a s w e ll t h e d an g e r fo r th e p a ti e n t i s m uch e n

,
h anc e d b y t h e i m m e n s e s u s c e p tibili ty o f th e pia m a t e r t o se p ti c i n fe c
t ion .
A fe w h o ur s in th e s e la tt e r ca s e s for th e in fe c tion t o gain a

s ufli c e , ,
fi rm h ol d s o th a t n o th i n g can s t ay th e rapi d d e v e lop m e n t o f i n fl a m m a

,
t o ry pro c e s s e s d uring th e followi n g d ay s .
E rys ip e la s al s o p lay s a n i m p or t an t par t a m ong s uc h in fe c tion s o f .
s calp woun d s b u t d o e s n o t m a t e rially d i ffe r a s r e gar d s i t s pro p h ylac t i c

,
t r e a t m e n t fro m th e o th e r infl a m m a t ory proc e s s e s .
An ti s e p tic prop h ylaxi s in fac t r e pr e se n ts th e k e y no t e in th e pr e s

, ,
-
e n t t r e a t m e n t o f all woun d s an d inj uri e s t o t h e s kull an d s h oul d in d i

,
c at e w h a t ac tiv e th e r ap e u tic m e a s ure s are t o b e ch o s e n in e ach ca s e .
T h orough cl e an s ing o f th e inj ur e d p ar ts an d th e ir i m m e dia te a n d

m or e r e m ote s urroun d ing s sh oul d b e th e fir s t s te p in all ca s e s wi th ou t

e xc e p t ion. Th i s pre cau tion i s o f th e u tm o s t i m p or ta n c e a s t h e s calp
i s alway s s oil e d by fa tty s ub s t anc e s th e s e cr e t ion s o f th e s e b ace ou s
,
a n d s ud o r i fi c glan d s a n d by d u s t a n d fl o a t in g m att e r fro m th e air

,
.
S i m pl e s crubbing wi th s oap wa te r an d a br ush i s n o t s uffi ci e n t A .
b e tte r way i s t o fir s t s crub th e s calp wi th s oap an d carbolic ( 3 or s ub

li m a te s olu tion a n d th e n sh av e t h e p ar ts s urr o un d i n g th e wo un d .
T h e h air o f th e e n tir e h e a d i s th e n t o b e wash e d by m e an s o f wa d s
o f co tt on s o ak e d in eth e r t urp e nt in e or ab s ol ute alco h ol un til all fa tty

, ,
s ub s t anc e s h av e b e e n r e m o v e d T h e n th e s calp i s t o b e cl e an e d wi th
.
s oap an d war m wa t e r a n d finally wi th an an t i s e p ti c s olu t ion

,
Th e .
woun d i s th e n t o b e e xam in e d I n c as e th e b on e or e v e n t h e p e ri o s
.
t e u m can b e fe l t by m e an s o f th e in se r te d fi ng e r th e woun d i s t o b e ,
op e n e d up e i th e r wi th r e tra c t or s or i f n e c e s s ary by inci s ion an d

, , , ,
aft e r lig at i n g all bl e e d ing ar te ri e s a n d th oro ug h ly cl e a n s ing th e wo un d ,
th e p ar ts m inu te ly in s p e c t e d I t m ay b e n e c e s s ary t o an ae s th e ti s e th e
.
p at i e n t b e for e d oing th i s .
T h e s i m pl e s t ca s e o f co m poun d fr a c t ur e o f t h e S kull i s i nj ury L t o t he
e x te rn al la m in a g e n e rally pro d uc e d by s wor d c ut s

, F r e qu e n tly fr ag .
m e n t s o f th i s l ay e r are m e t wi t h w h i c h sh oul d b e co m pl e t e ly r e m ov e d
, ,
e xc e p ting in th o se ca s e s w h e r e larg e con tinu o us pi e c e s o f b on e h av e
b e e n s lic e d o ff and a re s till conn e c te d wi th th e s kull by m e an s o f th e

p e rio s te u m .T he s e lat te r frag m e n t s m ay b e h e l d in p o s i tion by s u
t ur e s an d d rainag e e ffe c te d by p e r fora ting th e m
, I n o th e r ca s e s .
d i s in fe c t ion e v e ning o ff o f th e m argin s o f th e wou n d e xac t s u t ur e

, , ,
d rainag e a n d applica tio n o f an an ti s e p tic d r e ss ing s u ffi c e s .
I n ca s e a p e n e tra ting fi s s ur e i s fo un d t o e xi s t th e t r e a t m e n t sh o ul d ,
vary acc or d ing t o wh e th e r for e ig n b o di e s h airs e tc h av e b e c o m e i m , , .

,
p a c t e d b e t w e e n th e frag m e n t s o r n o t an d wh e th e r th e m argin s o f th e
.
fi s s ure are co m m inu te d or s oil e d I f n e i th e r is th e ca s e th e woun d i s

.
t o b e clo se d a s b e for e ; th e p a t i e n t sh o ul d b e k e p t in b e d for a t l e a s t
t h r e e d ay s and
, calo m e l g m b i d ) a d m ini s te r e d
. . T. h ese
. .
d r e s s ing s w h ich s h o ul d inclu d e th e wh ol e h e a d t o t h e m i ddl e o f th e

,
for e h e a d a n d th e c h i n an d sh o ul d b e so appli e d a s t o e x e r t a c e r t ain

,
pr e s s ur e upon th e wou n d m ay b e ch ang e d on th e fo ur th d ay w h e n

, ,
TR E A TAI E N T OF C OIWP O UI VD F R A C T UR E S
-
OF S K ULL .
32 1
th e d rai n a g e ub e s are t o b e t ak e n o u t ; an d a gain on th e e i gh th in

t
o r d e r t o r e m ov e t h e s u t ur e s ; t h e y s h oul d n o t b e co m p le t e ly l e ft o ff
un til all par t s h av e c e a se d t o gr an u lat e fo r fe a r o f e ry s ip e la s

,
.
I n th o se c a s e s h owe v e r in wh i c h h air s or oth e r b o di e s app e ar i m

, ,
ac t e d in t h e fi s s ur e s t h e y s h ou ld a t on c e b e r e m ov e d w i th t h e ch i s e l
p ,
a n d h am m e r .
Co m m i n u te d fr agm e n t s o f b o n e an d s oil e d m argi n s o f fi s s ur e s sh oul d

b e r e m ov e d i n th e s a m e way But in ca s e th e fi s s ur e e x t e n d s th roug h
.
t h e cr a niu m fo r s o m e di s t a n c e un d e r uni nj ur e d p or t i o n s o f th e i n t e gu
m e n t n o i n t e r fe r e n c e i s n e c e ss ary
, N or d o sligh t di ffe r e nc e s in e le v a
.
t io n o f th e frag m e n t s cau se d by d e pr e s s io n s I n dica t e O p e ra tiv e i n te r

,
fe r e n c e . In d e e d e v e n fract ur e s in wh ich pi e c e s o f bon e h av e b e e n

,
v e ry appr e c i ab ly d e pr e s s e d by n o m e an s n e c e ss i t a t e op e ra t iv e
, pro
c e d ure s a s lo n g a s n o i n fe c tion h a s t ak e n p la c e a l th oug h for m e rly s uc h
, ,
d e p r e s s e d pi e c e s o f b on e form e d i n dic ati on s for t r e p h ini n g F or th e .
s ym p t om s t h e or e t ica lly a t trib u t ab le t o c o m pr e s s i o n o f th e br ai n are in
prac tic e s o con fu s e d wi th th o se o f c on c ussi on an d co n tu sion o f th e brain ,
th a t t h e i n di c at io n s a r e n o t s uffi ci e n tly c le ar ly d e fin e d T h e d an g e r s
.
o f i n tr a cr a n ial pr e s s u r e a r e gr e a tly e x a gg e ra t e d T h e br ain e as ily ao

.
c u s t o m s i t se lf t o d e pr e s se d fr agm e n t s an d c an we ll b e ar t h e pr e s s u r e
,
o f a m o d e r a te h aem o r rh a g e fr om th e m i ddle m e ni n g e a l ar t e ri e s u n til
t h e c lo t i s ab s orb e d I t i s o f far gr e a te r i m por t a n c e t o pr e v e n t th e

.
in fe c tion o f in tr acranial ti s s u e s th an to r e li e v e th e brain fro m pr e s sur e ;

an d i t i s th i s d an g e r o f i n fe c t i on ari si n g fr o m s oil e d w o un d s th a t m ay
o fte n d e m an d Op e r ativ e i n t e r fe r e n c e E n tr an c e o f for e ign b o d i e s in t o

.
t h e wo un d an d i nj uri e s cau s e d wi th u n c le an o bj e c t s t h e r e for e in dic at e

,
t h e u s e o f t h e t r e p h i n e or t h e c h i s e l D e ta ch e d pi e c e s of b on e sh ou ld
.
b e e li m i n at e d i n o r de r t o a n ti ci p a t e a p o s sib le n e cro s i s wi th prolong e d
s uppura tion I n c as e s wh e r e poin t e d in s tru m e n ts h a v e p e n e tra te d

.
th r ou gh th e b o n e s o f th e sku ll a s u ffici e n tl y larg e pi e c e o f b on e sh ou ld

,
b e r e m ov e d wi th th e i n s tr u m e n t t o p e r m i t o f p e r fe c t di si n fe c ti on o f th e
d e e p e r i nj ur e d par t s S e p ti c i n fe c tion c an n e v e r b e e xclu de d wi th c e r

.
t ain ty wh il e an an t i s e p t i c O p e ra tion m ay b e d o n e wi t h ou t incurri n g

,
t h e l e as t ri s k .
E x t e n s iv e co m m i n ut e d frac t ur e s a re t o b e t r e at e d a ft e r th e s am e
prin cipl e s a s giv e n ab ov e ; n or sh o ul d th e pr e s e nc e o f m or e alar m in g

n e rvou s s y m p t o m s r e fe rabl e t o co m m o tion an d co m pr e s s ion o f th e
brain d e fe r th e s urg e on fro m th e con s ci e n ti ou s e x e rci s e o f an ti se p ti c
m e a s ur e s . O s s e o u s frag m e n t s a re t o b e e x trac t e d t h e wo un d fr e e l y
,
l ai d O p e n coagula o f blo o d r e m ov e d for e i g n bo di e s e x tra c t e d un l e s s

, , ,
s uc h a pr o c e d ur e woul d n e c e s s i t a t e inj uri e s t o t h e brain H ae m or

.
rh a g e s occurri n g in t h e brain s ub s t anc e s h oul d b e s t i fl e d by m e an s o f

-
th e ac t ual cau t e ry .In ca s e t h e r e i s r e a s on t o fe ar an accu m ula

t ion o f bloo d b e n e a th t h e d ura t h e la t t e r s h oul d b e inci s e d
, E le va tio n
.
o f larg e m a s s e s o f d e pr e s s e d b on e m ay b e n e c e s s ary in s o m e v e ry e x
t e n s iv e co m p ou n d frac t ur e s o f par t s o f th e s kull w h e n th e p a t i e n t h a s

,
e s cap e d i m m e dia t e d e a th .
I n th e a dj u s tm e n t o f th e d r e s s in g c ar e m u st b e t ak e n th a t th e d rain
a ge t ub e s d o n o t e n t e r t o o fa r in t o t h e woun d T h e wou n d m a y b e
.
cov e r e d wi th th e h e lp o f p las ti c m e th o d s .
T h e g e n e ral tr e a t m e n t Sh o ul d b e a d ap t e d t o th e g e n e ral con d i t io n
o f th e p a t i e n t In th e s tag e o f d e pr e s sion a fte r concu s s ion o f th e brain

.
e xci t an t s s h o ul d b e giv e n s ub cu t an e ou s inj e c ti o n s o f e t h e r a n d c am

,
p h or or d e r e d an d s inapi s m s an d h o t p acking s b e appli e d t o th e s kin

,
th e head lai d low .
In th e s t ag e o f e xci t a tion following th e h e a d s h oul d b e rai se d an

, ,
i c e b ag appli e d t o t h e h e a d a n d a bri s k ca th ar tic a dm ini s t e r e d

- I n tr a
.
crani al pr e s s ur e d e m an d s t h e s a m e tr ea t m e n t . I n b o t h ca s e s th e a p
plica tio n o f l e e ch e s in t h e r e gio n o f s o m e e m i s s ary d o e s e xc e ll e n t s e r

vic e O f th e ac tion o f e rgo tin th e au th or h a s li t t l e e xp e ri e nc e Bu t th e
.
.
m ain i m por t anc e s h oul d b e a t t a c h e d t o t h e local s urgical t r e a t m e n t .
S p e ci al pr e cau ti o n s a re n e c e s s ar y wh e n frac t ur e o f b o th w all s o f t h e

fro n t al s i n u s h a s e s t a b li s h e d d i re c t c o m m u n ica ti o n b e tw e e n t h e n as al
ca v i ty a n d t h e brai n t i s s u e s . I n t hi s ca s e t h e e ffe c tiv e a p p lica ti o n o f

a n a n t i s e p t ic d r e s s i n g o c clu din g th e w ou n d i s r e n d e r e d d i ffi c ul t o f p e r
fo r m a n c e . T h e au t h o r a d vi s e s t a m p o n a d e o f t h e fro n ta l s inu s w i th a n
t i s e p ti c gauz e in all s uc h ca s e s e v e n t h ou gh i t s h o u ld b e n e c e s s ary t o

,
e nl arg e th e e x t e rn a l wo un d a n d a t t h e ri s k o f e s t ab li s h i n g a fron t al
fi s tula—di s a d van t ag e s w h ich ar e o f li ttl e co n s e qu e n c e in c o m p ari s on
t o th e d ang e r s o f s e p t ic in fe c t ion incurr e d by p e rm i t t i n g fr e e ac c e s s o f

TR E A TM E N T OF C OM P O UN D F R A C T UR E S OF S A Z L L 32 3
’
'
air t o th e cranial cavi ty Ab s orp tion o f th e s e cr e tion s by th e ga uz e

.
m ay c au s e ar t ificial co m pr e s s ion o f th e br ain in th e s e ca se s a d an g e r

,
w h ich S h ou ld b e b orn e in m in d .
T h e s e con s i d e ra tion s apply t o o th e r cavi ti e s s i t ua t e d in th e i m m e

d i a t e vicini ty o f th e brain as we ll an d e s p e cially t o th e orbi t a an d t o
,
t h e au d i t ory m e a t u s . R e s e c t io n o f a p ar t o f th e orbi tal m argin m ay

b e c o m e n e c e s s ary in or d e r t o e x trac t for e ign b o di e s an d to r e m ov e i n
fe c ti o u s m a tt e r
. T h e au di t ory canal a fte r b e in g cau tiou s ly cl e an s e d
,
by m e an s o f an t i s e p ti c s olu tion s m ay b e fill e d wi th io d o for m po wd e r

,
a n d loo s e ly plugg e d wi th gauz e . In ca s e s o f frac t ur e o f th e e th m oi d

b on e ab un d an t d u s tin g o f th e e n tir e upp e r p or ti on o f t h e n a s al cavi ty
wi th io d o for m i s t o be pr e fe rr e d t o an t e rior an d po st e rior t a m pona d e .
I o d o for m infl a tion i s al s o t o b e u se d in l e s s r e c e n t ca s e s wh e n p uru

l e n t s e cr e tion s o f th e cavi ti e s m e n tion e d h av e alr e a dy app e ar e d .
T h e au t h or b e li e v e s th a t h i s favorabl e r e s ul t s i n ca s e s o f fr a c t ur e o f
t h e b a s e o f th e S kull w e r e e n tir e ly d ue t o th e a d op tion o f th i s m o d e o f
t r e a tm e n t. F o r al th o u g h m any ca s e s o f frac t ur e o f t h e s kull t er m ina t e
fa t ally in th e cour s e o f a fe w h our s a fte r th e acci d e n t in con se qu e n c e

,
o f inj uri e s a ffe c tin g th e c e n t ral organ s a n d s o m e o f th e a u th or s ca s e s

’
,
t ook th i s co ur s e ye t o f a ll t h o s e wh o h av e s urviv e d t h e fir s t 2 4 or 4 8
, ,
h o ur s a n d wh o w e r e t r e a te d in th e m ann e r d e s crib e d h e s ub s e qu e n tly

, ,
lo s t n o t a S ingl e o n e— a r e s ul t r e fe rab le only t o th e an ti s e p ti c prop h y

lac t ic t r e a t m e n t . T h e n u m b e r o f th e s e ca s e s a m ou n t s t o t w e n ty
th r e e.
A s t o th e t r e a t m e n t o f l e s s r e c e n t i n juri e s t o t h e s kull i n w hi c h s e p
,
t i c pr o c e s s e s h av e alr e a d y b e co m e e s t ab li s h e d i t s h ou ld n o t d i ffe r in
,
pri n ci pl e s fro m t h a t o f i n le c t e d w o u n d s s i t ua te d i n o th e r p ar t s .
F o r t h e pur p o s e s o f d i s i n fe c tio n t h e a u th or u s e s a n S p e r c e n t s olu

e
.
t i o n o f c h l o ri d e o f zi n c a n d a p p lica tio n o f i o d o for m p ow d e r a fte r ,
h avi n g cl e an e d th e wo un d t h or o u g hly wi th th e h e lp o f a Vo lk m ann s ’
s poon an d inci s e d all p h l e g m onou s fo ci a n d r e c e s s e s

, E x t e n s iv e
.
p h l e g m on s an d e rys ip e la t ou s i n fl am m a ti o n s o f th e s calp are tr e a te d

wi th lo t ion s con t aini n g a c e t a te o f alu m ina .
I n fl am m ati o n s o f th e in tr a cr ani al t i s s u e s are n o t a m e nabl e t o tr e a t
m e n t ; b ut i f incipi e n t for m s o f m e nin g i t i s are t o b e t r e a t e d th e au th o r,

3 24 E D I T OR I AL A R TI CLE 5 .
i s i n favor of thoro ugh d i sin fe c tion o f all acc e ssibl e p ar ts or at l e a st ,
o f an a t te m p t t o d o s o an d e v e n o f t r e p h ini n g fo r th i s p urpo se i f th e r e
, ,
i s an y h op e of r e n d e ri n g th e focu s o f in fe c tion a s e p t ic .
T h e c a s e s acc om p an yi n g th e p ap e r are m an y o f th e m in divi dually o f

th e h i gh e s t in t e r e s t an d will r e p ay m inu t e p e ru s al ; s o m e o f th e m are
als o m a de th e s ubj e c t o f v aluabl e s p e ci al an d g e n e ral r e m ark s in th e

,
te xt .
Al th o u gh th e ch i e f r e s u lt o f th e p ap e r will b e to h av e giv e n m or e
pr om i n e n c e t o th e propri e ty of co n si de ri n g th e ch a n c e in tro d uction o f
fo r e ign m a tt e r i n t o fi ss ur e s an d woun ds o f th e S kull as an urg e n t in di
c ation for tre p h inin g ye t th e p o si ti o n tak e n by th e au th or in r e g ar d to

,
th e qu e s tion o f tr e p h ini n g for i n t racra n ial pr e ss ur e i s o n e o f s uch
s p e cial i n t e r e s t a t th e pr e s e n t m o m e n t wh e n th e re i s a con trov e r sy

,
b e in g carri e d on an d trac e ab l e th rough p e rio dical li te ra tu r e r e l ating

, ,
t o th e s e v e ry qu e s ti o n s th a t i t m u s t p lay a co n s picuou s p ar t in d e ci d
,
i n g th e b a tt l e .
Wi th o u t h e r e e n t e rin g in t o a m ore d e tail e d di s cu ss ion o f th i s l atte r

s ubj e c t we woul d r e fe r b e s i d e s t o Wi e sm ann s t o Von B e rg m ann s
’ ’
, , ,
’
K ro e n l e in s m or e r e c e n t co n trib u ti on s t o th e s ubj e c t .
1
l Vi d e A NNA LS O F S U R GE R Y , Augu s t 1 88 6, p . 1 67 ; S ep t . 1 8 86, p . 232 .
W W VAN A R S D A L E
. . .
O N T H E CO N T A GI O U S N E SS O F LE PR O S Y .
The qu e s tion wh e th e r le pro s y b e con t agiou s h as b e e n m uch di s cu s s e d

r e c e n tly at th e Aca de m y o f M e d icin e o f Pari s T h e th e ory o f con .
t a gi on h a s i t s p ar t i san s an d i t s O ppon e n t s an d th e la t t e r s e e m t o b e in
,
th e m aj ori t y in t h a t l e arn e d a s s e m bly I t m ay n o t b e wi th ou t in te r e s t

.
t o publi sh th e r e s ul t s o f r e s e arc h e s on th e s ubj e c t un d e r t ak e n in th e
S an dwich I slan d s M a uriti u s an d R e uni o n a s w e ll a s in Bri ti sh Guian a

’
.
, ,
T h e s e h av e r e c e n tly b e e n s um m ariz e d i n an in te r e s ti n g con trib u tion t o

th e P r og r és M éd i ca le by Dr R S u z o r o f M auri tiu s an d fro m w h ich
, . .
,
we sh a ll fr e e ly quo te .
It i s o f s e con d ary i m p or t anc e to k n ow if l e pro sy e xi s te d i n th e S an d

TH E C ON TA CI O U5 N E 5 5 OF LE R R 05 r .
32 5
wich I s lan d s prior to 1 8 4 8 i f M Q u oy h a s S e e n i t th e r e in 1 8 1 9 T h e

, . .
fac t r e m ain s th a t at an y r at e th e di s e a s e wa s e xc e e di n gly r ar e I n 1 8 4 8 .
At ab ou t th a t t i m e co m m e nc e d th e i m m igr at ion o f th e C hin e s e a n d ,
a m ong s t th e m th e pr e s e nc e o f l e pro s y wa s r e cogn iz e d T en y e ar s .
lat e r in 1 8 5 8 th e di se a s e was for th e fir st ti m e m e n t ion e d a s co m m on

, ,
in th e coun try E i th e r i t di d n ot e xi st b e for e th e arrival o f th e Chi

.
n e se an d th e r e for e i t wa s th e y wh o in t ro d uc e d i t; or i f i t di d e xi st
, ,
b e for e th e ir t i m e h o w can we e xplain th e e x tr e m e s lo wn e s s of i ts d e

,
v e lO m e n t b e for e t h e ir a rriv a l an d i t s s u dd e n e x t e n s ion in th e fo llow

p
ing te n y e ar s to s uch an e x t e n t th a t a t e n th o f th e p op ulat ion b e c am e
l e p e r s ? I f th e la tte r h ypo th e s i s b e tru e i t r e m in d s u s forcibly o f th e ,
ca s e of E urop e in th e Mi ddl e Ag e s Le pro s y e xi s t e d b u t i t was c om .

,
a rat i ve ly r ar e Th Cru a d r w h il in t h E a t w n t in t o t h e n
p e s
. e s e e s e ,
a ,
ci e n t h o m e s o f th e s courg e an d sh or tly afte r th e ir r e t urn to th e ir o wn

,
coun try th e d i s e a s e b e c am e s o pr e v al e n t th at p e opl e t alk e d of e p i

d e m i c s o f l e pro sy a n d in F ranc e alon e m or e t h an
,
l e p e r h ou s e s -
w e r e e s t abli sh e d t o i s ola t e th e S ick Ano th e r fa c t i s t o b e no t e d th at .

,
wh e r e v e r i s ola tion h as b e e n s tring e n t th e nu m b e r o f th e a ffe c t e d h a s

rapi dl y d i m ini sh e d I t i s th e inv e r s e of wh a t h as p a ss e d a t th e San d
'
wich I slan ds an d th e t wo fact s s e e m t o m ili t at e in favor o f th e i de a o f

,
co n t agion .
M a uri tiu s a nd R eun i o n un t il th e 1 7 th c e n tury w e r e unin h ab i te d an d ,
th e fir s t coloni s t s p e r m an e n tly e s t abli s h e d w e r e F r e nch T h e n c am e .
i m m igra tion s o f A fric an s Hin d o o s an d la stly C h in e se At th e pr e s e n t

,
.
t i m e h un dr e d s o f l e p e r s can b e coun t e d wi th ou t d i ffi cul t y o f all r a c e s , ,
e v e n E urop e an s N ow i t i s prov e d th at se v e ral l e p e r s h av e lan de d

.
i
th e r e co m ing fro m A fr ca or A s ia a s s lav e s or a s cooli e lab or e r s
, In .
Bri ti sh Guian a th e h i s t o ry o f l e pro s y i s s ti ll cl e ar e r an d m or e in t e r e s t

ing I s t p e ri o d pr e h i s t oric T h e cou n try was inh abi te d e xclu s iv e ly
.
,
.
by In di an trib e s 2 d p e rio d : E urop e an coloni e s e s tabli sh e d

. No .
l e pro s y 3 d p e rio d S lav e ry A m ong th e A frican slav e s wh o w ere

. . .
lan d e d th e r e a fe w w e r e att ack e d wi th l e pro s y T h e y w e r e rigorou s ly .
i s olat e d on th e confin e s o f th e plan t ati on s a n d th e ca s e s all r e m ain e d ,
li m i t e d t o th e bl a ck s In 1 8 3 1 th e r e w e r e a l t og e th e r 4 3 1 an d a
.
s p e ci a l e s t ab li s h m e n t wa s foun d e d o n th e b an k s o f t h e riv e r Pom e roon ,

3 6
2 E D I T OR I A L A R TI C LE 5 .
wh e r e y w e r e all s e n t But a t t hi s s po t th e r e w e r e alr e a dy e s t ab

th e ,
li sh e d s e v e r al trib e s o f In dian s—C arri b s A c c o ways Arr o wa ck s War .

, ,
row s e tc Di s liki n g th e ir n e w n e igh b or s th e y all l e ft th e d i s tric t e x

,
.
c e p t th e Warro w trib e wh o fra t e rniz e d an d h a d in ti m a t e r e la tion s wi th

,
th e l e p e r s In 1 8 4 2 M c Clin to ck wro te
. We h av e t ak e n a c e n s u s of
th e w h ol e In dian p opula tion We h av e m e t wi th a gr e a t nu m b e r o f
.
”
le p e r s o f bo th se x e s b u t all invariably b e l ong e d t o th e Wa rro w t rib e
,
.
T hi s p o in ts to con t agion T h e Bovi a n d e rs h ybri d s o f N e gro e s an d

.
,
Warrow In di a n s are al s o fr e qu e n tly th e s ubj e ct o f l e pro s y Th i s poin t s

,
.
to h e r e di ty .
In 1 8 3 8 ca m e th e e m ancip a tion o f th e slav e s wh o spr e a d th e m ,
s e lv e s all ov e r th e colony going wh e r e v e r i t s e e m e d b e s t for th e m

,
an d m ixing fr e e ly wi th th e g e n e ral pop ula tion At abo u t th e s a m e .
t i m e th e plan t e r s i m p or t e d cooli e s fro m C h ina a n d In d i a a n d a m ong ,
th e s e a s u s ual le p e r s w e r e s o m e t i m e s foun d
, , To da y th e r e ar e t wo .
-
l e p e r s p e r th ou s an d o f th e p opulat ion an d th e wh i te s a n d m ula tt o e s

,
furni sh th e ir con ting e n t t o t h e d i s e as e as w e ll a s t h e N e gro e s an d

In dian s .
S o m e ca s e s m ay b e ci t e d
1. Ca s e s o f Dr R e gnaul d ob se rv e d a t M auri tiu s

.
, .
a
( ) A
. black wo m an a wi d o w wi th ,a c h il d ac t 5 b y h e r fir s t h u s .
ban d m arri e d again a m an s u ffe ring fro m l e pro sy T h e la t t e r fon dl e d

,
.
th e c h il d a gr e a t d e al an d t h e y w e r e con s t an tly t o g e th e r T h e d i se a s e .
s oon app e ar e d in th e c h il d T h e re wa s no t rac e o f h e r e di t ary l e pro sy

.
in th e wo m an or in h e r for m e r h u s b an d .
( b ) A wh i te m an acquir e d an ae s th e tic l e pro s y wi th ulc e r s H i s wi fe

. .
a s si s te d th e d oc t or e v e ry d ay in th e d r e s s ing Sh e w a s prob ably l e s s .
car e ful in a fte r war d s wa sh ing h e r h an d s A t an y ra te a m on th a ft e r .

,
th e d e a th o f h e r h u s ban d a l e prou s s p o t d e v e l op e d on th e rig h t ch e e k

, ,
a n d t wo m on th s la t e r s h e was e v e rywh e r e c o v e re d an d th e d i s e a s e gr e w ,
wor se .
A gr e a t m any ca s e s o f th i s kin d coul d b e ci te d S i m pl e c oi n c i .
de n c e s th e y m ay b e call e d b u t in th i s ca s e we sh o ul d h av e to s ay
, ,
th a t th e e xc e p t ion s are m or e n u m e ro u s th an th e rul e .
2. A y o ung S co tch m a n b orn in S co tl an d o f p ar e n t s wh o h ad n e v e r

, ,
TH E C ON TA GI O US N E S S OF LE P R OS Y .
327
le ft E urop e wh o s e h e r e di t ary h i s t ory wa s in e v e ry r e s p e c t p e rfe c t

an d ,
arriv e d a t G uiana O n e ni gh t b e ing drunk h e h ad conn e c tion wi th a

.
,
wo m an w h o m h e fou n d t o h i s h orror th e n e xt d ay to b e a confir m e d

,
l e p e r T e n m on th s la t e r h e d e v e lop e d th e firs t sy m p t o m s o f l e pro sy

.
,
o f wh ic h h e d i e d ( Drs M an g e t E d g e Wa tt)
. .
, ,
.
T h e au th or k n ow s s e iI e ral o th e r s i m ilar c a s e s o n e o f w h ich wa s in ,
h i s car e .
3 J o s e p h F ranci s C ac t 2 0 Por t ugu e se wh i te b orn in D e m arara

. .
,
.
, , , ,
hi s p ar e n t s s till living an d h e al th y T e n y e ar s ago h e was att a ck e d .
by l e pro sy th e t ub e rculou s for m lik e th e pr e c e ding A s i st e r act 1 8

, .
,
.
,
i s al s o le prou s T h e y w e r e b o th vaccin a te d wi th ly m p h t ak e n fro m an

.
in fan t b e lo n gi n g t o a l e pro u s fa m i ly Th e ir bro th e r a n d th r e e S i s te r s .

,
wh o w e r e n o t vaccina t e d fro m th e s a m e s ourc e a re p e r fe c tly w e ll , .
T h e D r s M an ge t Ar m y S urg Ge n l an d Hilli s Phy s i ci an t o th e

’
. .
, .
, ,
’
Le p e r s A sylu m o f Bri ti sh G uiana wh o p e r s onally kn e w th i s fam ily , ,
c o n s i d e r th e fac t s a s ab s olu t e proo f o f th e propaga tion o f th e d i se a s e

by vaccina tion I t woul d b e e a s y t o quo te o th e r s
. .
T h e ca s e s o f h e r e di t ary l e pro s y are n u m e ro u s Le t i t s u ffi c e t o ci t e .
th e work s o f Bo e k Dani e l s on Car te r Hilli s e t c ,

H e r e ar e a fe w fac t s
, , , .
b orrow e d fro m th e la s t au th or .
’
a
( ) J . L E s p
. e r an c e co n fir m e d l e p e r a t 2, y e ar s Mix e d for m o f t h e .
di s e as e F a th e r an d m o th e r bo th le prou s th e fa th e r h avi n g th e t ub e r
.
,
culo n s vari e ty th e m o th e r th e a n ae s th e ti c T h e m ix e d for m u s ually

,
.
only d e v e lop s b e tw e e n th e ag e s o f 2 0 an d 40 y e ar s .
b
( ) .Mari e B ac t 4 3 P ar .e n t s l e prou s
, . S h e h e r s e l f s till fr e e fro m
. .
any m ani fe s t a tion o f th e d i s e a s e b u t s h e h a s s ix ch il dr e n fro m 1 0 ,
m on th s old t o 1 4 y e ar s—all wi th t ub e rculou s l e pro s y— w h ich g e n e rally
d o e s n o t app e ar t ill a ft e r p ub e r t y .
c
( ) .Dr S a t urnin
.
( Trini d a d ) an d th e co m m i t t e e o f th e R Col o f . .
Ph y s ician s o f Lon d on quo t e t wo ca se s o f l e pro s y in th e n e w b orn

, ,
.
T h e s e fac t s wi th ou t an s w e rin g th e r e quir e m e n ts o f K ap o s i s e m in e n t ’
anno t at or s wh o d e s ir e d t o s e e a ch i ld b orn in P ari s o f a le prou s

, ,
m o th e r an d b e ing i m m e d ia t e ly s e p arat e d fro m h e r a ft e rwar d s b e c o m

, ,
i n g l e prou s app e ar t o u s t o sh ak e s o m e wh at th e po s i t ion o f th e a d ve r

,
s ari e s o f th e h e r e d i t ary t ran s m i s s ion o f th e d i s e a s e H ow sh all an a f .

328 E D I T OR I AL A R TI CLE 5 .
fe c ti on , wh ich i s prop ag ate d by h e r e di ty by con ta c t by s e xual in te r

, ,
cours e by vacci n at ion wh ich sh ow s i t s e l f m o s t o ft e n on th e uncov e r e d

, ,
p art of th e b o dy wh ich t ak e s on th e Ski n a s e rpigi nou s cour s e b e

, ,
con si d e r e d con t agi ou s or n ot ? Th e s a m e qu e s ti on m ight b e a s w e ll

as k e d wi th r e gar d t o s yp h ili s wh i c h i s far fro m b e ing con t agio u s in all
,
i t s s t a g e s an d wh ich d o e s alway s pro d uc e i t s h e r e di t ary ch arac t e r

, .
F in ally i t will b e p o s s ibl e we h op e t o t ak e up th e e xp e ri m e n t al

, ,
s t u d y o f th e qu e s t ion
. F o r s o m e t i m e we h av e b e e n tr ying t h e cul ti
v ati on o f th e b a cillu s o f l e pro sy in h u m an bloo d I f p ur e cul ti va ti on s

.
ar e ob t ain e d we sh all h av e th e O ppo rt uni t y o f r e n e win g th e t e n t ati v e

,
in oculation s by N e i ss e r I t will al s o b e in t e r e s ti ng to s t u dy th e b acillu s

.
o f t ub e rcl e in t h i s n e w m e di u m .
P S A BR A H AM
. . .
I ND EX O F S U RGI CA L PR O G R E S S .
G E N E R AL , S U R GE R Y .
I M a li g n a n t A n t h r a x By Dr A B O I S M B act 6 5 a ro
. . . . . . .
, .
,
bu s t m an o f s anguin e te m p e r am e n t living in goo d h ygi e ni c s urroun d ,
i n g s b ut r e c e n tly m uch h ara s s e d h a d for long c ar ri e d a s ub cu t an e ou s

, ,
’
cy s t a s l arg e a s a fowl s e gg at th e low e r p ar t o f th e nap e o f th e n e c k
, , .
A ft e r th e fa tigu e s o f a long j ourn e y a p ar t of th e s kin cov e ring th e ,
cy s t b e c am e r e d an d r ath e r pain ful AS inflam m a tion an d s uppura t ion .
th e te
r a n e d h e s ub m i tte d to th e r e m oval o f th e cy s t E arly in O ct ob e r
, .
a n in ci s i o n s e v e r al c e n t i m e tr e s in l e ng th was m a d e an d th e g ru m ou s
, , , ,
gr e yi sh s e m i li qui d foe ti d s e b ac e ou s con t e n t s r e m ov e d T he in te rior

,
-
, .
o f t h e s a c wa s car e fully cl e an e d c a u te riz e d wi th a ni tr at e o f s ilv e r

,
p e ncil an d fill e d wi th plug s o f lin t By d e gr e e s s upp ura t ion was e s t ab

, .
li sh e d a n d th e cavi ty was a gain s e v e ral t i m e s a n d a t s u ffi ci e n t ly long

, ,
i n t e rv al s cau te riz e d an d frag m e n t s o f th e cau s tic l e ft in th e cavi ty

, , ,
in or de r t o e n s ur e m or e c e r t ainly th e e x foli a tion an d adh e s ion of th e

s e cr e ting m e m bran e Tow ar d s th e m i ddl e o f N ov e m b e r v e ry li ttl e of
.
th e c avi ty o f th e cy s t r e m ain e d b ut a s m all h ar d a n d p ain ful t u m or ap

, ,
p e a re d on th e nap e of th e n e ck a fe w c e n t i m e t r e s ab ov e th e p ar t p r e
,
vi o u s l
y o ccupi e d by th e cy s t I t gr a d u ally d e v e lop e d an d p r ogr e s s e d
.
t ow ar d s th e h ai ry s kin b u t n o t in t h e r e gion o f th e cy s t
, I t was e vi .
d e n tly an an th rax a t fir s t b e nign an d d e v e loping s lowly an d s p on ta

, ,
n e o u s ly s uppura t i n g aft e r s o m e d ay s I t e x te n de d b u t li t tl e a t th e e n d o f
.
th e m on th an d a s i t fr e e ly d i s ch arg e d un d e r th e influ e nc e o f p oul tic e s

, ,
an d gav e b ut li t tl e p ai n i t wa s th oug h t for s o m e d ay s th a t ac tiv e i n t e rv e n

,
t ion w o ul d n o t b e n e e d e d T h i s ab s t e n t ion o f ac t iv e t r e a t m e n t s e e m e d
.
j u s tifi e d by th e au th ori t a tiv e opinion s e xpr e s se d in 1 8 8 1 at th e S oci é t é ,
d e C h irurgi e in t h e d i s cu s s ion on th e tr e a t m e n t o f an th r ax
,
E arly in .
D e c e m b e r th e an th rax co m m e nc e d t o incre as e on th e l e ft s i de of th e
n e ck a t th e s am e t i m e m oun ti n g t ow ar ds th e s calp
,
an d th e r e gion s ,
(329 )
3 3 0 INDE X OF S UR CI CA L R R O CR E 5 5 .
n e wly e n gag e d b e gan t o t ak e on a woo d e n h ar d n e s s T h e u rin e con .
t ai n e d no tr ac e o f s ugar On th e 5 th o f D e c e m b e r i t wa s a s c e r t ain e d
.
th a t th e c e n t r e o f t h e t u m or for a s p ac e a s larg e a s a 5 franc pi e c e

, ,
wa s b oggy an d bl e d fr e e ly fro m nu m e rou s fi n e op e ni n g s

, I t w a s th e .
pr e lu de of a s e ri ou s s lough s uch a s wa s s e e n s e v e ral y e ar s ago in a s i m

,
i lar ca se w h ich rapi dly t e r m ina t e d in d e a th in s pi t e o f r e p e a t e d an d

d e e p inci s ion s I t was r e s olv e d t o e m ploy th e th e rm o cau t e ry a ft e r
.
-
,
th e m e th o d r e co m m e n d e d by M Ve rn e uil—a plan wh ic h co n tr ol s th e
.
h ae m orrh ag e an d m o difi e s t h e d e v e lop m e n t o f th e d i s e a se m or e e ffe c t ,
n ally th an th e inci s ion s m a d e wi th th e bi s t oury Tw e lv e d e e p i n .
c i s i o n s d iv e rg in g in th e for m o f a fa n
, w e r e m a d e un d e r ch loro for m
, ,
wi th th e in s tru m e n t a t a dark re d h e at T h e li m i t s o f th e a ffe c ti on

.
b e ing r e ach e d b ut n ot p a s s e d by th e inci s ion s Th e an th rax h ow e v e r .

, ,
con tinu e d i t s inva ding grow th an d on th e 8 th o f D e c e m b e r th e cau

,
t e ry wa s ag ain u s e d Th e inci s ion s w e r e prolong e d 1 or 2 c e n t i m e

.
tre s b e yon d th e m argin o f t h e d i s e a se an d th i s t i m e i t s e n croach m e n t
wa s d e fini t e ly s t opp e d In th e follo wing d ay s frag m e n ts o f s lough s e p

.
ar at e d wi th ab un d an t s uppura t ion a n d e xpo s ing a r e d an d granula t ing

,
s ur fac e . F or s o m e d ay s s ulp h ocarb ola t e dr e s s in g s w e r e u s e d The .
day a ft e r th e s e con d op e ra t ion a tt e n tion wa s call e d t o a n e w focu s o f

s upp ura t i on wh ic h was rapi d ly d e v e loping in th e m i dd l e o f th e d or s al
,
r e gio n an d wi t h a s urroun d in g in d ura t ion a lre a dy r e ach i n g 5 or 6 c e n

,
t i m e tr e s in d ia m e t e r T h e p a t i e n t wa s again c h loro fo r m e d a n d e igh t

.
or t e n d e e p rad ia ting lin e s w e r e trac e d wi th th e th e r m o cau t e ry e ach o n e -

,
8 or 1 0 c e n ti m e t r e s in l e ng th H e r e th e e ffe c t wa s in s tan t a n e ou s Th e
. .
s e con d focu s d i d n o t fur th e r d e v e lop a n d t h e s or e l e ft by th e O p e ra tion

,
t ook on a h e al th y a sp e c t But th e in fe c tio n o f th e sy s t e m was n o t ar

.
r e s te d On th e r o th of D e c e m b e r a h ar d an d p ain ful s w e lli n g wa s

.
m ani fe s t b e n e a th th e rig h t d e l t oi d m u s cl e wi t h ou t c h ang e o f color o f

,
th e s kin .To co m b a t i t wi th th e th e r m o cau te ry d i d n o t s e e m po s s i

-
b le a n d t onic t r e a t m e n t h a d t o b e r e li e d on
,
T h e d e e p infla m m a t ion
.
e x t e n d e d an d r e ac h e d th e inn e r p ar t o f th e ar m T h e fe v e r b e c am e .
m or e pronounc e d an d on th e 1 5 th d e e p fluc t ua t ion co ul d b e ob s e rv e d

,
a t th e rig h t d e l t oi d An inci s ion gav e i s s u e to bloo d m ix e d wi th s o m e

.
thr e a d s of p u s Th e s upp ur at ion b e ca m e w e ll e s t abli s h e d by th e i n

.
C E N E R A L 5 UR CE R Y .
33I
c i s i o n , an d r o m e t e m porary arr e s t of th e g e n e ral con di tion

th e e wa s s ,
a s w e ll as a rapi d s ub s i d e nc e o f t h e s w e lling D e ath h ow e v e r e n s ue d .

, ,
on th e a 1 s t of D e c e m b e r .
T wo fac t s are e vi d e n t fro m th i s ca s e t h a t th e t h e r m o cau t e ry -
h a s an incon t e s t ibl e p ow e r in s t opping th e progr e s s o f an th rax e v e n ,
w h e n m align an t provi d e d th a t i t b e u se d b e yon d th e li m i ts of th e d i s

,
e a se ; th a t an an th rax m ay for s o m e d ay s m ain t ain a b e nign cour s e ,
incr e a sing in s i diou s ly an d cau s ing a fal s e s e curi ty an d th e n t aking on ,
s u d d e nly th e s e ri ou s c h arac t e r o f a d i se a se b e yon d o ur r e s our c e s in
con s e qu e nc e o f th e s e p tic aem i a wh i ch i t e n g e n d e r s —P r og r es M ed . .
Oc t . 1 885 .
P S A BR
. . AHAM ( L
o n d on. )
II . O n T r a n s fu s i o n I n fu s i o n By Dr LAN D E R E R ( Le ip
and . .
zic) . S in c e 1 8 8 0 L h a s b e e n inv e s tiga ting th i s s ubj e c t e xp e ri m e n t ally

.
a n d clinically Alkalin e s al t s olu tion s pro d uc e only tran s i t o ry i m prov e

.
m e n t w h e r e th e lo s s o f b lo o d h a s b e e n gr e at m or e th an o f th e ,
’
a ni m al s w e ig h t A p a ti e n t th u s t r e a t e d d i e d on e an d a h alf h our s
.
la t e r co n d collap s e
of a s e .
L th e n u s e d a m ix t ur e o f o n e p ar t d e fi b rin a t e d bloo d t o
. p ar t s al
kalin e s al t s olu tion wi th b e tte r r e s ul ts Lo s s o f bloo d up to 5 % m igh t
,
.
th e n b e quickly r e cov e r e d fro m I n a ca se o f s e v e r e poi s oni n g wi th

.
ni tro b e nz ol T h i e r s c h le t 9 0 0 cc bloo d an d r e plac e d i t by

- . cc of .
t h i s m ix t ur e wi th a s ucc e ss ful r e s ul t—n o fe v e r or o th e r cu s t o m ary s e

,
q u e lae T h e. l e s s e r a m oun t o f fi b rin fe r m e n t in tro d uc e d m ak e s t h i s
m e th o d s a fe r t h an w h e n all d e fi b rin a t e d i s e m ploy e d .
S in c e h ow e v e r r e c e n t inv e s t iga t or s all pronounc e again s t th e u s e of

, ,
blo o d at all h e h a s s oug h t s o m e s ub s ti t u t e Ve ry favor abl e r e s ul ts .
w e r e ob t ai n e d by a dding 3 % o f can e s ugar t o th e alkal in e s al t s olu

t ion .A n i m al s r e p e a t e d ly bl e d un til only o f b o dy w e i g h t in
bloo d r e m ain e d r e cov e r e d r api d ly an d r e plac e d th e lo s s—as Sh own b y

coun tin g th e b loo d corp u s cl e s—in an unu s ually s h or t ti m e ( abou t
fo ur te e n d a y s ) H ae m orrh ag e in o n e p a ti e n t was s ucc e s s fully t r e at e d by
.
an in fu s ion o f 3 0 0 cc T h i s s u gar s al t S olu tion h a s se v e ral advan t ag e s

. .
I t s uppli e s a quickly avail abl e nu tri e n t m a t e ri al dr aw s flui d s wi th m uch ,

3 3 2 I N D E X OF 5 UR C I CA L R R O C R E 5 5 .
e n e rgy in t o th e circula tion fro m th e s urroun d ing t i s s u e s h as gr e a t e r ,
con s i s te ncy an d in cr e a s e s th e bloo d pr e s s ur e m a te rially In ani m al s

,
- .
p oi s on e d by ni tro b e nz ol ch loral ch loro for m L m a de a d e pl e t o ry

-
, , , .
v e n e s e c tion an d by in fu s ing th i s m ix t ur e k e p t th e m aliv e —con tr ol an

,
i m als dyi ng In ch ol e ra i t woul d app e ar t o b e c o un t e ri n di c a t e d I t

. .
i s th e or e tically i m por t an t th a t in p oi s oning i t i s n o t a t all n e c e s s ary t o

s upply oxyg e n b e ar e r s —re d corpu s cl e s —R e p or t o f XV Congr e s s o f
-
Ge rm an S urg e on s in Cen t lbl f S u rg . 1 886

. No 2 4 . . . .
W BR O WNI NG ( Broo klyn ) . .
VA S CU LA R S Y S T E M .
I . On C o m p r e s s i o n o f t h e I n n o m i n at e A r t e r y By Pro f . .
T H O MA S A NNAN D A L E ( E d inb urgh) Man ae t 5 3 wh il e li fting a h e avy

.
,
.
,
w e ig h t fe l t s o m e th ing giv e way a t th e ro o t o f h i s n e ck an d t h e s a m e ,
e v e n ing a pul s a t ing s w e lling wa s no t ic e d ab ov e th e c e n t r e o f h i s rig h t
clavicl e Th i s o ccurr e d in A pril 1 8 8 4 O n th e 2 7 th of M ay 1 8 8 5

.
,
.
, ,
t h e inn o m ina t e was e xpo se d by a m e d ian c e rvical inci s i on s o a s t o a l
low t h e fing e r t o p a ss b e hin d th e v e s s e l an d pr e s s i t again s t t h e s t e rno
clavicular j oin t An in dia rubb e r d rainag e tub e h al f an inch in dia m e

.
t e r was in t ro d uc e d an d s o a dj u s te d th a t o n e e n d lay b e h in d th e ar t e ry
an d t h e o th e r pro tru d e d fro m th e wo u n d T h e in t e n tion wa s t o l e av e

.
th e t ub e in po s i tion un t il th e t i s s u e s h a d b e co m e accu s t o m e d t o i t s
pr e s e nc e an d un til th e ri s k o f a se p tic con di tion o f th e woun d wa s d i

m ini s h e d a n d w h e n t h e la t t e r con d i t ion h a d b e e n ob t ai n e d t o in tr o
, ,
d uc e th e s m all b lad e o f a co m pr e s s or w h ic h Mr An n an d al e h ad d e vi s e d
,
.
,
in t o th e dr ai n ag e t ub e a n d carry on co m pr e s s ion o f th e ar te ry m or e or
,
le s s con tin uou s ly a ccor ding t o th e e ffe c t pro d uc e d

, O n t h e 7 th o f .
J un e h ow e v e r th e r e wa s s o m e bloo d on th e dr e ss ing N e xt d ay th e r e
, ,
.
wa s pro fu s e bl e e d i ng a n d th e ar t e ry wa s co m pr e s s e d by t h e fing e r .
S e v e ral a tt e m p t s t o p a s s a liga t ur e b e tw e e n th e bl e e d ing par t an d t h e

a or t a fail e d b u t th e co m pr e s s or was appli e d a n d th e bl e e d in g s t opp e d
,
.
T h e p ati e n t d i e d in fi v e h our s T h e inno m ina t e was foun d t o h a v e

.
ul c e r ate d j u s t b e low th e bi furca tion fro m pr e s s ur e o f t h e t ub e an d th e ,
tr ach e a s h ow e d sign s o f co m m e ncing ab s orp t ion T h e au th or th ink s .
th a t in fu t ur e c o m pr e ss ion m ig h t b e appli e d by t h e fing e r or an i n s tru ,

N E R VO US A N D VA S C ULAR S YS TE M S .
333
m e n t th rough an inci s ion wh il e th e p a ti e n t was un de r an an ae s th e tic

, , .
S uch co m pr e s sion sh oul d n o t b e t o o con tinuo u s a n d Sh oul d b e co m

b i n e d wi th d i s t al ligat ur e or co m pr e s s ion or i f th ough t a dvi sabl e e l e c . ,
tr olysi s —La n cet March 1 3 1 8 8 6 , [ S e e an acco un t o f liga t ur e o f th e

, .
inn o m ina t e by th e r e por t e r in th e A m e rican E ncyclop e dia o f S urg e ry ,
01 wi th a r e por t o f all ca s e s in Bri t M e d J ou rnal O c t ob e r 1 4

, ,
1 882 . .
, ,
.
II . P o p l it e al An e u r i s m in an A t a x i c S u bj e c t C u r e d b y
P re s s u re By Dr LO N G H U R S T ( Lon d on) Pa ti e n t ac t 5 1 An E s
. . .
, . .
’
m arch s b a n d ag e was appli e d t o t h e li m b for an h o ur an d a h al f ; t h e n
a s cr e w t ourni qu e t t o t h e fe m oral a n d s o on d urin g th e d ay Pr e s s ur e , .
was o m i tt e d a t nigh t A sh o t b ag w e igh ing . poun d s wa s t ri e d i n

st e ad o f th e t ourniqu e t an d t h i s t r e a tm e n t wa s pur s u e d fo r th e n e x t t wo
,
d ay s O n th e e v e ning o f th e th ir d d ay no p ul s a t ion was vi s ibl e

. The .
pul s a tion d id n o t r e t ur n — M ed P r ess a n d C i r cu la r M arch 3 1 1 8 8 6 . .

, .
III . T rau m at c i By C M AN S E LL M O U L
I n gu i n a l A n e u ri s m . .
LI N ( Lon d on
) M an ae t 3 4 F our w e e k s b e for e a dm i s s ion r e c e iv e d
.
, . .
blow in th e groin fro m e d g e of fl at pi e c e o f iron S w e lling an d di s c ol .
or ation follow e d an d d i s app e ar e d b u t th r e e w e e k s l at e r t h e s w e lling ,
r e curr e d an d con tin u e d t o incr e a se D uring an e ffor t i m m e dia te ly b e .

,
for e a dm i s s ion h e w a s se iz e d wi t h viol e n t pain a n d a l arg e p ul s a t ing

'
t u m or m a d e i ts app e ar a nc e in th e groin e x t e n d ing in t o th e s cro t u m an d ,
p e ri n e u m An ab d o m inal tourniqu e t wa s appli e d a n d th e s w e lling

.
op e n e d ov e r th e fe m or a l ar te ry in w h ich a s li t was foun d i m m e di ate ly ,
b e low Poup ar t s lig am e n t T h e ar te ry was t i e d b e lo w th i s p oin t T h e

’
. .
e x t e rn al iliac wa s t h e n t i e d T h e m an r e cov e r e d a n d p ul s a tion coul d

.
b e d e t e c t e d in th e p o s t e rior tibi al four m on th s l at e r — La n cet M arch . .
IV . T raum C au s e d b y P u n c t u r e d W ou n d
ati c A n e u ri s m
of Bu ttock By J O S E P H LITT LE GO O D ( N o tti n gh am ) B oy ae t 1 6
. .
, . .
R e c e iv e d a cci d e n t al wo un d in l e ft b u tt ock p o s t e rio r t o g r e at tro c h a n

ter . A p ul s a ting t u m or wa s no tic e d on th e four th day an d r api dly
r e ach e d th e s iz e o f a coco anu t On th e e igh th d ay th e wo un d was .
r api dly e nlarg e d b ut so gr e at wa s th e hae m orrh ag e th a t i t wa s n e c e s

,
sa ry t o apply a n ab d o m in al t o u ri n ue t Th e d i s tal e n d of t h e ar te ry
q .
3 34 I N D E X OF 5 UR C I CAL P R O GR E S S .
wa s foun d Wi th ou t d i fficul ty an d t i e d proxi m al e n d wa s foun d a fte r

th e
a long se ar ch j ust wi th in , th e gr e a t s cia tic n o t ch Th e pa ti e n t r e .
cov e r e d —La ncet March . 27, 1 886 .
WM . T H M N ( D b li
O SO u n ) .
H E AD AN D N E CK .
I . A Cas e of C e re b ral A b s c e s s S u b s e qu e nt to O r b i t al
P e ri os t it i s By C R AW F O R D R E N T O N M D ( Gla s go w) T h e p a
.
, . .
, .
ti e n t a b o y act 1 2 wa s a d m i t t e d t o th e Gla s gow E ye Infir m ary s uf

,
.
,
fe rin g fro m s y m p to m s o f ri gh t orbi t al c e lluli ti s wh ic h h a d p e r s i s t e d for ,
t e n d ay s O n th e s ix th d ay a ft e r a d m i s sion a fr e e inci s ion wa s m a de

.
a lo n g inn e r s i d e o f upp e r e y e li d a con s i d e rabl e quan t i t y o f p u s wa s

,
e vacua t e d an d d r ainag e t ub e in se r t e d F our d ay s a fte rwar d s th e d is

.
ch arg e h ad c e a s e d th e s w e lli n g gon e an d th e p a ti e n t h a d b e co m e

, ,
a l m o s t conval e s c e n t Two d ay s a ft e r th i s no t e was m a de h ow e v e r h e

“
.
, ,
co m pl ain e d o f se v e r e pai n in th e h e ad in te rm i tte n t in c h ara c t e r an d m o st

, ,
s e v e r e ov e r t h e rig h t t e m p oral r e gion Vi s ion nor m al ; O p h th al m o

.
s copi c e x am ina t ion S h ow e d a nor m al fun d u s N o e vi de nc e o f any .
fr e s h for m ation o f p u s in th e t i s s u e s ar o u n d th e e ye b u t th e woun d ,
wa s re op e n e d an d a prob e p a s s e d along i t b u t wi th ou t d e te c t ing any

-
,
b ar e b on e ; th e d rainag e t ub e was r e in s e r t e d I c e appli e d t o th e -

.
h e a d an d s m all d o s e s o f calo m e l gi v e n in t e rn all y Pu ls e 6 4 ; t e m p e ra .
t ur e nor m al Th e s y m p t o m s con tinu e d fo r s o m e d ay s a n d vo m i t ing

.
,
s e t in Bu t ul ti m a t e ly th e p ain an d vo m i ting s ub si d e d a n d co m pl e te
.
,
re li e f e n s u e d A fte r h ow e v e r four d ay s o f r e li e f th e sy m p to m s again

.
, , ,
r e curr e d a nd d e a th s ub s e qu e n t ly t o ok plac e b e in g pr e c e d e d by s pa s m s ,
o f th e l e ft s i d e w h ic h rapi d ly b e ca m e g e n e ral T h e t e m p e ra t ur e wa s .
n e v e r h ig h e r th an
9 9 an d th e p ul s e v ari e d fro m 7 6 t o 5 2 Po s t m or
°
.
t e m e xa m ina tion s h ow e d e x t e n s iv e n e cro s i s o f th e rig h t orbi t al pla t e ,
an d an ab s c e s s occupying th e an t e rio r h al f o f th e rig h t fron t al lob e .
Th e r e wa s no dir e c t c o m m unica tion b e t we e n th e p u s fro m th e orbi t

an d t h e c e r e bral ab s c e s s an d th e d ura m a te r wa s only i n fla m e d ov e r
.
th e n e cro s e d p or t ion o f th e orbi t al pl at e T h e ri gh t e ye was he al thy . .
Two s e con d ar y di s e a s e s th e au th or r e m ark s follow s upp ura tion in th e

, ,
orbi t m e ningi ti s a n d ab s c e s s T h e diagno s i s in th i s ca s e was d ifli

-
.
cul t th e s y m p t o m s poi n ti n g chi e fly t o m e ningi t i s

, .
H . PE R C Y D U NN ( Lo n d on ) .
H E A D A N D N E CK . 335
II . O n t h e O p e r at i v e T r e at m e nt of E m p ye m a of th e Ah
r
t um H i gh m By J M I K U L I CZ ( Cracow ) H e r e t o for e in th i s
ori . . .
a ffe c ti on th e a rti fi cial O p e ning wh e n n e e d e d h as b e e n m a d e th rough

, ,
s o m e p oin t i n th e roo f o f th e or a l cavi ty Th i s m e th o d h a s th e a d .
van t ag e of p e rfora ting the an t ru m at a poin t e as ily ac ce ss ibl e an d favor

ab le for drainag e I t h as h ow e v e r di s a dvan ta g e s T h e op e ning i s
.
, ,
.
n o t alway s p e rm an e n t e noug h s inc e s uppur a t ion fr e qu e n t ly la s t s for

,
m on th s o r y e ar s ; an d i f a s u ffi ci e n t ly wi d e op e nin g i s ob t ain e d bi t s o f
foo d pa s s in t o o e a s ily a n d k e e p up th e s uppura t i on Th e m o s t r a .
t i o n al proc e d ure wo ul d b e t o t e op e n th e n a t ural p a s s ag e in t o th e -
na s al cavi ty as propo s e d lon g s inc e by Hun te r Al th o ugh th i s i s .
h ar d ly prac ti cabl e ye t i t i s n o t di fficul t t o p e n e t rat e th e an t ru m fro m
t h e low e r na s al p a ss ag e a t t h e l e v e l o f th e in fe rior t urbi n a t e d b on e an d
t h u s op e n a wi d e la s t ing co m m unica t io n wi th th e na s al cavi t y The .
inn e r wall i s th in as pap e r at th i s p oin t an d can b e e as ily b or e d th rough

wi th a s harp cu t t ing in s tru m e n t M u s e s a s p e cial s h or t blad e d s tyl e t
. .
-
wi th a prop e rly curv e d h an dl e an d a li ttl e flang e t o pr e v e n t th e bla d e

S in ki n g in t oo d e e ply Th i s i s p a s se d in t o t h e no s tril wi th th e p oin t
.
d o wnwar d s an d w h e n a t t h e in fe rior t urbina t e d b on e th e p oin t i s

,
t u rn e d o u t war d s t o ge t up aro un d t h e b on e Wi th a vigoro u s s t ab th e .
an tru m wall i s p e r fora t e d an d a s m uch o f a pi e c e c u t fro m i t as p o s s i

-
b le . By pr e s e rving a dir e c tion d ownwar d s an d forwar d s no h ar m can

b e d on e as th e wal l h e r e b e co m e s t h ick e r a n d r e s i s ts th e in s t ru m e n t ,
.
I n th i s way a sli t 5 t o 1 0 m m wi d e by 2 0 m m lo n g i s p r o d uc e d Too

. . .
fr e e h ae m orrh ag e can b e con t roll e d by t a m p oning wi th io d o for m gauz e -
for a d ay or t wo A fte r t r e a tm e n t con s i s t s in wa sh in g o ut th e an tru m

.
-
wi th a b alloon s y ri ng e h avin g a nozzl e b e n t lik e th e ab ov e m e n tion e d

- -
s tyl e t . M fin ds th e O p e ra ti on e a s y t o e x e cu t e on th e ca dav e r
. An .
abnor m ally narrow no s tril or an ov e r th ick t urbin a te d b on e m igh t b e

t o o gr e a t an i m p e d i m e n t Th i s op e ra tion h e h a s p e r form e d onc e s u c
.
c e s s fu lly on a m an ae t 3 3 T h e p a t i e n t m a d e th e inj e c t ion s h i m s e lf

. .
fr o m th e fi fth d ay t wic e a d ay fo r four w e e k s an d h a s r e m ain e d cur e d

, ,
n o w for s i x m on th s —R e por t o f XV Congr e s s o f G e r m an S urg e on s
in C en tOl f Cli i rg
. . 1 886 No 2 4
. . . .
W . BR O WNI NG ( B ro o kly n ) .
3 36 I N D E X OF 5 UR CI C A L R R O C R E 5 5 .
III . T o n s i lla r A b s c e s s , ( E de m a of th e G lo t t i s an d T ra
c h e ot o m y in a C h i ld [ E t By Dr F KA TTE R . 1 . R e c ov e ry . . .
F E LD Au th or r e p or ts fo llowing ca se : Mal e ch il d aet , .
m on th s a d m i tte d in a s tat e o f gr e a t d y s pn oea wh ic h h a d d e v e l

, ,
op e d a fte r an a ttack o f m e a sl e s O n e x am ining th e c avi ty o f th e m ou th .
b oth an t e rior pala t al arch e s w e r e fou n d h i gh ly con g e s t e d an d swoll e n ,
a s w e r e als o th e t on s il s On th e s e la tt e r w e r e y e llowi sh brown c ru s t s

.
wh ich w e r e e a s ily r e m ov e d E x te rnally on b o th s i de s o f th e n e ck th e r e

.
was a larg e s w e lli n g ra th e r t ough in con s i s t e ncy in th e r e gi on o f t h e angl e

, ,
o f th e low e r j aw T h e s e p h e n o m e na w e r e m or e fully d e v e lop e d on th e

.
l e ft s i d e N o oe d e m a o f th e glo tti s W h e n pr e s s ur e wa s m a de wi th th e
. .
fi n g e r o n th e b a s e o f th e t o n g u e th e r e e s cap e d fro m th e a n te rior p ar t ,
o f th e l e ft t o n s il a quan t i ty o f y e llowi sh non o ffe n s iv e s m e lling p u s ,

- .
R e s pira t i on s o m e wh a t d i ffi cul t S ligh t fe b ril e m ov e m e n t only T h i s . .
con di ti on wa s follow e d in a fe w day s by gre a t dy s pn oe a on in spira ti on ,
s h owing th a t th e s w e lli n g un til th e n on ly s ubc h or d al in i t s ch arac t e r

, ,
h a d n o w i nvolv e d th e glo tti s C rico trach e o t o m y accor ding t o S ch in

.
,
zing e r s m e th o d A ft e r th i s th e t e m p e ra t ur e ro s e s ligh tly b u t fe ll t o

’
.
,
nor m al in th r e e d ay s an d th e s w e lli n g o f th e ton sil s d e cr e a se d s t e a d

,
ily . N o r e t u rn o f th e glo tti s oede m a A p p e t i te goo d an d g e n e ral .
con di tion m uch i m prov e d Th i s s a ti s fac t ory cour s e was in t e r fe r e d

.
wi th h ow e v e r owing t o th e d e v e lop m e n t o f an acu te ca t arrh wi th con

, ,
s i d e rab le fe b ril e m ov e m e n t a n d r e t urn o f t h e d y s pn oe a Th e la t te r .
c e a s e d afte r a quan ti ty o f blo o dy m uco purul e n t m a tt e r an d granula -
t ion m a s s h ad b e e n e xp e c t ora t e d A sh or t e r an d th in n e r canula was .
th e n in t ro d uc e d a n d applica t ion s o f a s olu tion o f arg ni t ri c to . .
th e ulc e ra t e d S po t in th e l arynx w e r e m a d e R e cov e ry s oon follow e d . .
Ca s e s o f t rach e o t o m y wi th r e cov e ry in chil dr e n un d e r on e y e ar o f

a ge ar e v e ry rar e G Ch aym h avi n g foun d n o t m or e t h an for t y ca se s
, .
in s e arch ing th rough all th e li t e r at ur e on thi s s ubj e c t — D eu tsc/z M ed . .

,
Woc/zens cfzr if t N o 2 8 J uly 1 5 1 8 8 6

. , .
,
.
IV . Tw o n o s i s o f t h e L a ry n x a s a S e q u e l
Cas e s of S te
to T yp h o i d F e v e r By Dr K O R TH Ca s e I Pa ti e n t m al e
. . . . .
, ,
ae t .
4 2 s u ffe r e d m uch in h i s ch il dh oo d wi th ar ticular r h e u m a t i s m an d
,
3 37
a tt ack s of colic H ad a g e n e ral t e n d e ncy t o bronch i al ca t arrh an d

.
,
e ig h t y e ar s b e for e h a d d y se n t e ry Ab o u t fi ve m on th s pr e vi ou s t o hi s
.
a dm i tt a n c e se v e r e a tt ack o f typ h oi d fe v e r l a s ting t e n w e e k s d uring

, , ,
wh i ch s o m e d i fficul ty in br e ath in g h a d d e v e lop e d S inc e t h e n s e v e ral .
a tt ack s o f d y s pn oe a wh ich are b e co m ing wor s e R e spira tion lab or e d

, . .
Voic e roug h an d h oar s e n o t ap h onic h o we v e r Pr e s s ur e on th e cricoi d

, .
c ar tilag e p ain ful O n e xa m ina tion wi th th e laryngo s cop e th e m ucou s

.
lining o f th e laryn x foun d in t e n s e ly i nj e c te d a n d s woll e n T h e glo t ti s .
app e ar e d m uch n arro we d a n d a t ab o u t t h e l e v e l wi th th e t ru e vocal

,
cor d s t wo cong e s t e d an d s woll e n pro m in e nc e s d i s cov e r e d Trach e o .
t o m ia s up e rior a t onc e un d e r t ak e n E xam ina t ion again nin e d ay s la t e r

. .
M u c o u s m e m b ran e l e s s s woll e n b u t th e s tric t ur e i s a b ou t th e s a m e

, .
O n clo s ing t h e c a nula p a ti e n t coul d br e a th e b ut fo r a fe w s e con d s only

th ro ug h th e m ou th O n co m p aring th e con d i tion s d urin g r e s pira
.
t ion a n d p h ona t ion i t wa s s h own t h a t t h e s w e lling s cau s ing th e s t e no s i s

,
d i d n o t li e in t h e plan e o f t h e vocal cor d s b ut low e r d own Diagno s i s ,

.
wa s t h e r e for e p e rich o n d ri ti s o f th e an t e rior p or tion o f th e cricoi d t o

, , ,
w h ich th e pr e viou s a tta ck o f il e o typ h u s th e p ain s on s wallowing a n d

-
,
on p alp a tion o f th e p ar t s an d finally th e r e s ul t o f th e laryn gOs o p ic

,
e xa m ina t ion all p oin t e d D aily in tro d uc tion o f l aryn g e al ca th e te r s th e

.
,
s iz e b e in g gra d ua lly incr e a s e d an d a pplica t ion s o f arg

,
ni t ric t o th e . .
s w e ll e d par t s o nc e or t wic e w e e kly I n s uffl ati o n s o f alu m s u ffic e d t o allay

.
an y s y m p t o m s o f i r ri t a t ion fro m th e u s e o f th e ca th e t e r s I n th e cour s e .
’
of a fe w on th s o f th i s tr e a tm e n t S ch ro tte r s th ick laryng e al c at h e th e r
m ,
N o coul d b e in t ro d uc e d A fe w w e e k s a ft e r b e gi n nin g th e t r e a t
( .
5) .
m e n t p a t i e n t wa s abl e t o br e a th e for h al f an h our wi t h clo s e d canula ,
t h e s t e no s i s b e in g s o m uc h r e d uc e d In t e n m on th s ti m e h e coul d .
work th e wh ol e d ay wi th th e ca n ula clo s e d b ut was oblig e d t o h av e i t ,
op e n wh il e s l e e ping Canula was wi th d rawn a bou t four te e n m on th s

.
a fte r co m m e nc e m e n t of tr e a tm e n t Voic e wa s th e n cl e ar an d r e s pira

.
t ion p e r fe c tly e a s y .
Ca s e I I Pa ti e n t girl act 1 9 A d m i tt e d in J uly 1 8 8 2 Typ h oi d

.
,
. .
,
.
fe v e r in Marc h April a n d May o f s a m e y e ar

,
Ab ou t two w e e k s a fte r .
co m m e nc e m e n t o f th i s la tt e r illn e s s p ain s in t h e n e ck an d larynx s e t ,
in acco m pani e d by d i fficul ty in s wallowing A ft e r th e di s e a s e h a d

,
.
3 8 I N D E X OF 5 UR C I CA L P R O C R E 5 5 .
s ub si d e d p a ti e n t was in wr e t ch e d p h y s ical con di tion T h e r e w as c o m .
p le t e ap h onia a n d o cca s ionally p ai n in th e larynx Di f ficul t y i n .
br e a th i n g b e gan ab o u t fo ur w e e k s b e for e s e e n T h e se a tt ack s o f dys p

.
n oe a are a t ti m e s v e ry b ad W he n a dm i t te d r e s pira t ion labor e d S t e no s i s

. .
m ur m ur s h e ar d ov e r w h ol e c h e s t T h e following d a y s u dd e n or th opn oe a
.
d urin g m e al S inapi s m gav e s o m e r e li e f Dy s pn oe a b e ca m e s o gr e a t h o w

. .
,
e v e r th a t t rac h e o to m i a s up e rior was un d e r t ak e n E xa m in ation wi th lary

.
n go s c o p e e l e v e n d ay s la t e r T h e l e ft a ry te n oi d car tilag e a n d plica a rye p

.
i glo t ti c a v e ry m uch s wo ll e n a n d oe de m a t ou s T h e two fal se ch or d s ov e r

.
lap o n e ano th e r cov e ring e v e ry par t b e low In th e an t e rior p ar t s th e r e

,
.
pro tru d e s b e t w e e n th e fal s e ch or d s a s m o o th roun d por t ion o f t i s s u e ,
ab o u t th e S iz e o f a p e a A t t e m p t t o u s e th e l arynx s oun d wa s v e ry
.
-
p ain ful a n d i t s in tro d uct ion i m po s s ibl e S c ari fi c ati o n s o f th e l e ft ary

.
t e n o i d car tilag e an d ary e piglo tt ic fol d s Pa ti e n t di s ch arg e d in O c t ob e r

.
following . D uring th e fir st fe w w e e k s o f h e r s ub s e qu e n t tr e a t m e n t th e
th ro a t wa s k e p t war m a n d c at a p la s rn s occa s ionally appli e d I n s u ffl a .
t ion s o f alu m m a d e t wic e w e e kly Un d e r th i s t r e a tm e n t s w e lling a n d

.
oe d e m a o f th e p ar t s b e ca m e l e s s N o s ign s o f an ab s c e s s in th e larynx
.
w e r e ob s e rv e d At th e b e ginnin g o f March in th e following y e ar all

.
infla m m at ory sy m p to m s h a d s ub s i d e d O n e xa m i n a tion b o th a ry te n o i d

.
car tilag e s foun d nor m al al s o th e ary e pig lo tti c fol d s T h e fal s e c h or d s

, .
s till s woll e n a n d th e s m a ll pro t ub e ran c e o f t i s s u e b e t w e e n t h e s e s t ill r e
m ain s . Applica tion s o f arg n i tric t wo or th r e e ti m e s w e e kly t o th e s e

. .
p ar ts Cavi ty o f th e larynx app e ar e d t o b e co m pl e te ly obli te ra t e d

. .
I n th e following Augu s t s oun d p a ss e d for t h e fir s t t i m e I t was t h e n .
a s c e r t ain e d th a t th e cavi ty o f th e larynx wa s n o t obli te ra te d a s s up

p o se d b ut i ts l um e n r e d uc e d t o a m ini m u m
, T h e in tro d uc t ion o f
.
ca th e t e r s n o w or d e r e d t og e th e r wi th th e local applica tion s I n O c t o

, .
b e r a v e ry th in E ngli s h ca t h e t e r ( N o 9 ) coul d b e pa s s e d an d p ati e n t

.
,
coul d br e a th e th ro ug h thi s w h e n canula wa s clo s e d I n N ov e m b e r .
( 1 8 8 3 ) pa ti e n t wa s abl e t o forc e s o m e air t hroug h th e larynx an d s ay

”
goo d m orning in a cro aking voic e .
T h i s t r e a t m e n t h a s b e e n k e p t up e v e r s inc e In D e c e m b e r 1 8 8 5 .
, ,
s h e wa s abl e t o clo s e th e canula fo r fi ft e e n t o t w e n ty m inu t e s a t a t i m e .
In s p e aking th e h e lp o f th e fal se ch or ds i s n e c e s s ary an d th e voi c e i s

s o m e w h a t s t rong e r .P a ti e n t i s s till un d e r t r e a t m e n t .
C H E S T AN D AB D OM E N .
3 39
T he ca s e w as un d o ub t e d ly o n e o f p e ri ch on dri t i s o f th e ary te noi d

car tilag e s ( p rincip ally o f th e l e ft) a n d al s o o f th e cricoi d —D eu tsc/z
,
.
M ed Woc/zen
. N o 2 9 J uly 2 2 1 8 8 6
. . .
,
.
C J C O LL E S ( N e w Y o k ) . . r .
AB D O M E N .
I . u r g i c a l I n t e r v e n t i o n i n C e r t a i n C a s e s o f B i l i a ry C a l
S
c u lu s By T T H I R I AR T h e origin o f bili a ry calculi h as n e v e r ye t
. . .
b e e n cl e arly e xplain e d Dr T hi ri ar h ol ds th a t th e y o n ly form wh e r e

. .
bil e s t agn a te s an d w h e n fro m s e d e n t a ry li fe ad vanc e d ag e o r pr e g

, , ,
n an cy th e bil e b e co m e s l e s s alk alin e an d s o p e r m i t s o f a d e p o s i t o f

c h o le s t e ri n e T h u s th e y m ay on ly b e e xp e c t e d t o for m in th e s m all e r
.
bil e d uc t s w h e n t h e m ain d uc t s are ob s t ruc te d fro m any cau se In .
po s t m o rt e m e xa m ina tion s m a d e by Pro f We h e n k e l o f Bru s s e l s no i n

- .
, ,
s t a n c e w a s foun d o f th e for m a tion o f gal l s t on e s wi th in t h e liv e r Th e -

.
gall bla dd e r i s th e r e for e t ak e n a s al m o s t n e c e s s ary for th e for m a ti on

-
o f g all s t on e s an d i t s r e m oval i s h e l d t o b e a ra d ical cur e

-
, again st
th e m .
T he pap e r b e gi n s wi th a bri e f s k e t ch o f th e h i s t ory o f c h ole c ys t e c t

om y .T h r e e ca s e s th e n r e la t e d O n e wa s p e r for m e d by Dr Lang e n
. .
b uch o f Bru s se l s a n d wa s p rono unc e d cur e d in nin e d ay s Th e o th e r

, , .
t wo w e r e d on e by D r T hi ri a r h i m s e l f O n e wa s prac ti cally h e al e d in s i x
. .
d ay s a ft e r t h e op e ra tion in t h e o th e r h y s t e rical s y m p t o m s app e ar e d in

,
t h e p a ti e n t b e for e a n d a ft e r t h e O p e ra t ion : t h e s e s ub s i d e d a n d i n t wo
or t h r e e m on th s sh e wa s d oing w e ll T h e s ub se qu e n t h i s tory o f th e s e ,
t h r e e c as e s i s n o t r e la t e d in d e t ail b u t th e y s e e m t o h av e m a de goo d
,
r e cov e ri e s an d t o h av e b e e n a ft e r war d s r e li e v e d fro m all th e pr e vio u s

,
a tt ack s o f bili ary colic I n ano th e r plac e th e au th or r e fe r s t o th e t wo

.
fir s t ca s e s o f th e op e ra tion p e rfor m e d in J uly 1 8 8 2 T hr e e y e ar s afte r , .

,
in J uly 1 8 8 5 th e p a ti e n t s w e r e in e xc e ll e n t h e a l th e xc e p t t h a t on e
, , ,
h a d b e e n un abl e t o s h a k e o ff a h abi t o f t a ki ng m orp h ia al th oug h th e ,
n e e d fo r i t h ad c e a s e d .
M o d e o f op e r a ting ( I ) F or 4 8 h our s b e for e th e O p e ra ting roo m i s

.
,
k e p t a t a t e m p e ra t ure o f 3 0 C Ab o ut o n e h our b e for e

°
th e O p e ra ti on th e p a ti e n t r e c e iv e s a n e n e m a con t a ining 1 2 grm s - .

oflau danu m an d 2 4 gr m s
,
-
1 dr ) o f ch loral
- . T h e p ati e nt .
i s b ath e d a fe w d ays b e for e an d sh o rt ly b e for e th e op e r ation th e ab d o

,
m e n i s w a sh e d fir s t wi th s oap an d w at e r th e n wi th e th e r an d carb olic

,
lo tion D u ri ng th e O p e r ation a c arb oli c s pray i s u s e d Th e c ut sur

. .
fa c e s are w ash e d wi th 1 t o 1 0 0 0 corro s iv e s ubli m a t e Spong e s are r e .
plac e d by s ubli m a t e d wool t a m p on s in stru m e n t s an d h an d s are di s

in fe ct e d Inci s ion follow s ou t e r b or de r o f righ t ab d o m inal m u s cl e
.
s cular fib e r s a re c ut t ran s v e r s e ly t h r e e fing e r s b r e a d th

’
( R e c t u s
). Mu
b e low fal s e rib s A fte r a dh e s ion s wi th th e colon are brok e n d own th e
.
,
gall bla dd e r i s se e n T h e cy s tic d uct i s th e n i s ol at e d ligat ur e d wi th

- .
,
s ilk in two plac e s an d d ivi d e d T h e m argin s o f th e O p e ni n g in th e

.
d uct are c ar e fully s e wn t og e th e r W i th fi n e s ubli m a t e d S ilk T h e gall .
bl a dd e r i s r e m ov e d an d th e ab do m inal woun d clo s e d Ca t gu t s ti t ch e s .
ar e u se d an d s o m e s t r e ss i s lai d on th e i m por t anc e o f uni t ing lik e

,
s t ruc t ur e s t og e t h e r th u s p e ri t on e u m t o p e ri t on e u m
, fibrou s an d c e llu
,
lar ti s s u e to fibrou s an d c e llular ti s s u e e ach to e ach T h e S h ock o f .
th e op e r at ion i s m uch l e s se n e d by th e e n e m a o f lau d anu m an d c h loral ,
a s th e O piu m s oo th e s an d d i m ini s h e s m u s cular s e n s ibili ty a n d th e ,
ch loral S p e ciall y l e s s e n s th e i rri tabili ty o f th e s pinal cor d T h i s e n e m a .
i s alw ay s u s e d in th e au th or s ova ri an ca se s
’
.
T h e O p e ra tion o f ch o le cy s t o t o m y i s con tra s te d wi th th a t o f c h ole c ys
t e c t o m y an d obj e c tion s t o th e la t t e r are e xa m in e d

, T h e d i ffi cul ty o f
.
th e la tt e r O p e ra t ion i s con s i d e r e d no ob s t acl e a s i t i s no gr e a t e r th an

,
an y s urg e on m ay b e e xp e c t e d t o ov e rco m e an d l e s s in d e e d th an th a t
,
o f ov ario t o m y an d o f h y s t e r e c t o m y N e i th e r i s th e l ar g e r e x t e n t o f
.
i nci s ion s co n s i de r e d o f m o m e n t wh e n an t i se p tic s are u s e d As t o d an .
ge r o u t o f th e 7 c a se s on r e cor d ( 5 by Lang e nbuch an d 2 by T h iri ar)

,
th e r e are no d e ath s wh ic h can b e a tt rib u t e d t o th e O p e ra ti on ; two o f
th e p a t i e n t s d i e d n o t long a ft e r th e ir op e ra t ion s b u t o n e d e a th wa s th e
,
r e s ul t o f a c e r e bral t u m or an d th e o th e r of ulc e ra tion o f th e bil e d uc t

,
fro m th e pr e se n c e o f a calculu s in i t .
I s r e m oval o f th e gall bla dde r e ffi caciou s ? F ro m th e vi e w h e h ol d s

-
o f th e origin o f gall s t on e s T h i ri ar b e li e v e s th at i t i s
-
S o far al s o a s .
th e ca s e s go th e y confir m h i s opinion .
Wh e n sh oul d th e s urg e on O p e r ate ? Th e gall bla d de r sh ou ld b e re -

CII E 5 T A N D A B D OM E N . 34 1
m ov e d wh e n e ffor ts t o h a s t e n th e fl ow o f bil e an d t o in cr e a s e i ts alka

lin i ty h av e fail e d t o r e li e v e a t t ack s o f biliary colic C h o le cy s t o t o m y i s
.
n o t t o b e u s e d b e cau s e i t d o e s n o t m ak e a ra d ical cur e b e cau s e i f a

, ,
liga t ur e s lip s sh or tly a ft e r th e o p e ra tion bil e m ig h t e s cap e in t o th e p e ri

t o n e u m a n d b e cau s e biliary fi s t ul a d e la ys t h e cur e an d allow s bil e t o
,
l e a v e t h e b o dy .
I f i t w e r e s ai d th a t th e pr e s e nc e o f a gall b la dd e r i s n e c e s s ary Dr
-
, .
T hiri ar woul d r e ply th a t s o m e ani m al s s uch as th e e l e p h an t a n d th e

,
h or s e h av e non e ; th a t fro m s o m e ani m al s i t m a y b e e xp e ri m e n t ally re
m ov e d wi th i m p uni t y ; an d th a t in m an i t m ay b e wan ting a trop h i e d ,
or obli t e ra t e d wi th ou t b ad r e s ul t s .
T h u s th e in d ica ti on for c h ole pys t e c t o m y i s a fr e qu e n t r e t urn o f s e v e r e

biliary colic w h ich h a s r e si s t e d m e dical t r e a tm e n t .
W h e n a c alculu s blo ck s th e cy s tic d uc t an d cau s e s d rop s y o f th e gall

bla d d e r th e d i s t e n d e d bla d de r i s t o b e a s pira te d an d if th i s fail s i t i s
, , , ,
t o b e e xci s e d . W h e n th e co m m on bil e d uc t i s b lo ck e d cau s ing p e r ,
s i s t e n t j aun d ic e an d w h e n th e d iagno s i s h as b e e n
, e s t abli sh e d th e a b ,
d o m e n i s t o b e op e n e d an d an e ffor t m a d e t o cru sh th e s t on e through
th e wa ll s o f t h e d uc t a n d failin g t h i s th e d uc t m ay b e inci s e d t o r e
,
m ov e t h e c alculu s an d t h e e d g e s o f th e c u t s e wn up again I f th i s al s o .
fail s C h ol e cy s t o to m y i s t o b e p e r for m e d a n d an e ffor t m a d e t o e s t ab
li sh a biliary fi s tu la i n t o t h e i n t e s tin e — R evu e d e Cli i r u r g i e M arch . .
1 886 .
C HA R LE S W . C ATH CA R T ( E di nb u rg n
) .
II . O n t h e O p e ra t i v e T re at m e n t o f Ab s c e s s o f t h e L i v e r .
’
By D R K AR T U LI S ( Al e x an dria) In T hi e rfe ld e r s coll e c t i o n o f ca s e s
. .
o f ab s c e s s o f th e liv e r tr e a t e d by op e ra ti on we fi n d th a t o f 1 0 ca s e s
O p e ra t e d by Cur t i s ; b u t t wo r e cov e r e d ; J Clark op e ra t e d in 1 3 ca s e s

.
wi th 8 ca se s o f r e cov e ry an d only 6 o f M urray s 1 7 c a s e s w e r e cur e d

,
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.
Warring coll e ct e d 8 1 ca s e s o f O p e ra ti o n wi th b ut I 5 ca s e s o f r e cov e ry ,
S h owing a m or t ali ty o f 8 1 D e Ca s tro r e p or te d th a t o f 6 1 ca s e s
op e r ate d 2 7 d i e d or ,
H e in e m ann ( Ve ra Cruz ) t r e a t e d 2
ca s e s by p unc t ur e b o th wi th fa t al r e s ul t s a n d o f 2 0 ca se s w h e r e Po
, ,
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t ain s a s pira t or wa s e m ploy e d b u t 2 r e cov e r e d
, .
Th e in tro d uc tion o f an ti se p ti c p rincipl e s in s urg e ry for m e d a n e w e ra

in th e tre at m e n t o f th i s d i se a s e Li st e r in 1 8 7 8 wa s t h e fir s t t o op e n an
.
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ab s c e s s o f th e li v e r wi th th e k ni fe un d e r th e ob s e rvanc e o f an t i s e p ti c
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rul e s th e r e s ul t b e ing s ati sfac t ory T h e r e p o rt s o f th e h o s pi tal s in

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, ,
un de r s tri ct ob s e rvanc e of an ti s e p t ic pr e cau tion s are v e ry m uch b e tt e r

th an form e rly nor d o t h e r e por t s o f E ngli sh s urg e on s in I n d i a t e n d t o
,
e ncoura g e th i s m o d e o f tr e a t m e n t b u t ra th e r r e co m m e n d th e u s e o f ,
th e tr ocar .
Th e au th or con s i de r s th e s e un favorabl e r e s ul ts to b e larg e l y d ue t o

th e r e t e n tion o f p u s in th e cavi ty o f th e ab s c e s s th roug h d e fe c t iv e ,
dr ain ag e l e a d in g con s e qu e n tly t o py ae m ia h e ct ic fe v e r e t c

, To ob , , .
vi at e th i s d e fe c t h e wa s in d uc e d fir s t in th e following ca s e t o un d e r ,
t ak e r e s e c t ion o f t h e rib th u s giv i ng fr e e v e n t t o th e d i s c h arg e an d

, ,
un doub te dly th e r e by s ay i n g h i s p at i e n t .
Th e p a t i e n t a m an ac t 3 0 was h e al th y un t il 2 0 d ay s b e fo r e a d m i t
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ta nc e d u rin g w h ic h ti m e h e h a d h a d m uc h di s tr e ss in th e r e gion o f th e
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li v e r wi th fe v e r N o th ing s h o wi ng th e pr e se nc e o f an ab s c e s s for m e d
,
.
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h ow e v e r an d a ch ang e o f cli m a t e wa s a d vi s e d
,
A m on th la t e r h e re .
t urn e d wi th un d oub t e d s y m p t o m s o f ab s c e s s o f th e liv e r Punc t ur e in .
th e 6 th i n t e rco s t al s pac e p e r for m e d t wic e th e r e e s caping e ac h t i m e ,
ab ou t 5 0 0 c c m of p u s
. N o i m prov e m e n t Inci s i o n t h e n m a d e
. . .
,
giving v e n t t o 4 0 0 c c m o f p u s T h e cavi ty 1 2 c m i n d e p th wa sh e d
. . .
, .
,
o u t wi th a s olu t ion o f carb o li c aci d a dr ain ag e t ub e in t ro d uc e d ,

-
an d an t i s e p t i c dr e s s ing s appli e d Al th ough th e p a ti e n t s co n d i tion i m ’

.
prov e d s o m e wh a t d uri n g th e fir st fe w d ay s a ft e r th e O p e ra tion ch ang e ,
for th e wor s e s e t in owin g t o d e fe c t iv e dr ainag e

, Two w e e k s la t e r .
,
th e r e for e 3 c m o f th e 7 th rib wa s r e s e c t e d giving v e n t t o a l arg e

,
.
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quan ti ty o f b ad sm e lling p u s R e cov e ry wa s th e n rapi d th e cavi ty b e

.
,
i n g co m pl e t e ly clo s e d 1 9 d ay s la te r .
I n th e au th or s s e con d ca s e th e p a t i e n t ac t 3 0 h a d co m plain e d in
’
, , .
,
th e r e gion o f th e li v e r fo r fi ve w e e k s p e viou s t o O p e ra tion Liv e r r .
foun d m uch e nlarg e d an d p ain ful t o t ouch Pa t i e n t v e ry w e ak Punc t . .
ur e wi t h t ro c ar in th e 1 0 th i n t e r c o s t al s p ac e allowi n g th e e s cap e o f ,
4 0 0 c .c m o f t h ick
.
p u s Con s i d e rabl e r e li
. e f w as e xp e ri e n c e d by t h e
CH E S T A N D AB D OM E N .
343
p ati e n t a fte r th i s an d h e wa s abl e t o s l e e p for th e fir s t t i m e in m any

,
d ay s . N o m ov e m e n t o f bow e l s an d t e n d e rn e s s on pr e s s ur e r e m ain e d ,
a s b e for e F our d ay s l at e r p unc t ur e wa s ag ain m a d e s o m e 2 7 0 c c m

.
, . .
o f purul e n t m a t t e r e s c a ping Pa ti e n t e as i e r a ft e r th i s b u t s till v e ry

.
,
w e ak an d e xh au s te d H i s con d i tion b e co m ing wor s e h owe v e r a c

.
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co m p ani e d by h igh fe v e r r e s e c tion of th e rib was un de r t ak e n on t h e

,
7 th d a y a ft e r h i s a d m i t t anc e Inci s ion ov e r t h e 9 th rib 10 c

. m in , .
l e ng th in th e axi lla ry lin e an d 5 c m of rib r e s e ct e d T h e ab s c e ss

, , . .
wa s th e n e a s ily O p e n e d giving v e n t t o a l arg e quan ti ty o f p u s

,
The .
c avi ty 1 5 c m in d e p th wa s w ash e d out wi th a 5 % s olu tion of car

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b oli e a ci d t wo d rainag e t ub e s in tro d uc e d a n d an t i s e p tic d r e s s ing s ap

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pli e d th e wh ol e b e ing cov e r e d by a M ar tin rubb e r b an da ge F iv e

,
.
h our s a ft e r th e O p e ra t ion th e p at i e n t was wi th ou t fe v e r an d in th e b e s t

o f s piri t s R e cov e ry wa s rapi d th e cavi ty b e ing co m pl e t e ly fi ll e d up
.
,
on th e 1 0 th d ay a n d t wo d ay s la t e r th e b an d ag e wa s l e ft o ff N o r e
,
.
a c ti on in t h e woun d t ook plac e c h ang e o f d r e s s ing s S h owing th e s e ,
e ach t i m e t o b e o d orl e s s .
Dr Z a n c ardt in Al e xan dria h a s al s o tr e a t e d a nu m b e r o f c a s e s in a

.
, ,
s i m ilar m ann e r an d wi th th e s am e favorabl e r e s ul t s

,
.
T h e a u th or th ink s th e ch i e f d a in ge r in ca rrying o ut a r e se c tion o f th e

rib li e s in th e po s s ibl e inj ury t o th e diaph r ag m wh ich m ay b e inci s e d
, ,
a ccor ding t o th e p o s i t ion o f th e ab s c e ss wh e n no adh e s ion s h av e ,
for m e d H e a dvi se s th e n r e s e c tion o f two or m or e rib s an d d rainag e

.
o f th e c a vi ty o f th e pl e ura AS a rul e h ow e v e r th e O p e ra tion pr e se n ts

.
, ,
n o co m plica t ion s a s a dh e s ion s are g e n e rally pre s e n t o win g t o th e i n ,
cr e a s e d s iz e e tc o f th e liv e r Ab s c e s s e s of th e l e ft lob e are m or e

, .
, .
rar e ly m e t wi th an d u s u ally m uch s m all e r th an th o se o f th e righ t lob e .
Th e y h e al o fte n aft e r o n e punc t ur e Au th or ad vi se s in c ase s wh e r e .

,
l arg e r an d de e p e r ab s c e s s e s are pr e s e n t wi th no a dh e s ion s t o le t th e

canu la r e m ain for s o m e ti m e un de r ob s e rvanc e o f an ti s ep tic p re c a u ,
ti on s inci s ion of th e ab s c e s s t o b e e v e n t ually c arri e d o ut

, .
In ab s c e s se s of th e righ t lob e on th e o th e r h an d in ci s ion s h o ul d b e , ,
un de r t ak e n a t onc e in conn e c tion wi th r e s e ct ion o f th e rib We sh oul d .
n o t w ai t for a dh e s ion s t o for m a s s uch a d e lay i s o f t o o gr e at a r i s k ,
for th e p a ti e n t — D e u tsc/z M ed Woc/zens cfi

. N o 26 . J uly 1 . . . . .
1 88 6 .
3 44 I N D E X OF S UR GI C A L P R O GR E S S .
I I I A C as e o f P e n e t r at i n g P i s t o l S h o t W o u n d o f t h e
.
-
Ab d o m e n R e s e ct i o n o f t h e I n t e s t i n e
. R e c o v e ry By Dr . . .
M F R E Y E R ( D ark e h m e n) T h e op e ra ti on in th e followi n g ca s e wa s
. .
un de r t ak e n un de r v e ry un favorabl e circu m s t anc e s li t tl e or no a s s i s t anc e ,
b e ing ob t ainabl e
Pa ti e n t m al e ae t 1 9 s u ffe ring fro m pi s t ol sh o t woun d in th e ab d o
, , .
,
-
m en . Wh e n fir s t s e e n by th e au th or s ix h our s a fte r t h e acci d e n t h e ,
wa s in a gr e a t ly co llap s e d s t a t e O n e xa m ina tion a larg e loop o f i n

.
t e s t in e wa s foun d pro t ru di n g t h roug h t h e woun d t h i s la tt e r b e ing s i t u ,
a t e d ab ov e th e an t e rior s up e rior s pin e o f th e rig h t iliu m O n n e ar e r .
in s p e c tion s e v e ral sm all op e n ing s in t h e pro tru di n g in te s tin e w e r e d i s

cov e r e d th rough w h ich fe cal m a tt e r wa s o o zing R e s e c tion d e t e r
,
.
m in e d on I n or de r t o pr e v e n t th e fe c e s fro m e n t e ring th e ab d o m i n al
.
cavi ty a roll o f t wi s te d co tt on wool w e tt e d in carb oliz e d wa t e r was

,
-
p lac e d aroun d th e n e ck o f th e lo o p o f in te s ti n e w hich wa s drawn fur ,
t h e r o u t a n d e xci s e d H ae m orr h ag e fro m m e s e n t e ri c v e s s e l s con s i d e r

.
abl e T h e m e s e n t e riu m wa s fir s t s u t ure d an d th e n th e e n d s o f th e d i

.
v i d e d in t e s t i n e I n s u t uring th e la tt e r s e ro s a wa s uni te d t o s e ro s a t h e
.
,
m ucou s e d g e s in t h i s way t urnin g inwar d s o f t h e m s e lv e s Tw e n ty .
s t i t ch e s w e r e m a d e fi n e s ilk b e ing u s e d as al s o fo r t h e liga t ur e s

, , F or .
th e r e s t ora tio n o f t h e in t e s tin e i t w as foun d n e c e s s ary t o e nlarg e t h e
w o un d s o m e wh a t T h i s allow e d th e r e m o val o f s e v e ral s m a ll sh o t

.
foun d lying in th e t orn a n d ragg e d p e ri t o n e u m n e ar t h e wo un d an d ,
al s o of a pi e c e o f p ap e r wa d ding O n t urning th e pa ti e n t ov e r on th e
.
woun d e d s i d e a larg e quan t i t y o f cle ar s e rou s fl ui d e s cap e d fro m th e

woun d Th e low e r p ar t o f th e ab do m e n was m uch d i s te n de d a n d v e ry
.
se n si t iv e t o t ouch Wou n d n o t clo s e d T h r e e rubb e r d rainag e t ub e s

. .
in tro d uc e d a n d an ti s e p tic d r e s s i n g s appli e d Pa ti e n t n e x t s e e n t wo .
d ay s la t e r Pai n wa s r e li e v e d by opiu m
. O nly S lig h t a m o un t o f fe v e r
.
.
Pul se 1 2 0 Dr e s s i n g s r e m ov e d an d woun d looking w e ll Ab d o m e n

.
.
l e ss s e n s i t iv e Irriga tion wi th s olu tion o f s alicylic aci d

.
O n th e t h i r d .
d ay S tool p e r anu m G e n e ral con d i tion v e ry fair

.
O n t h e s ix th d ay .
fe cal m a tte r was foun d on th e d re s s ing s a fi s t ula h aving for m e d S t ool s

, .
p as s e d r e gularly p e r anu m h ow e v e r e xc e p ting on th e se v e n th and

, ,
e igh th d ay s E dg e s o f woun d p ain ful an d r e d

.
A s s oon a s th e n e .
CII E 5 T A N D A E D OM E N .
34 5
c r os e d p or tion s o f th e s e la tte r h a d b e e n c as t o ff d e fini t e clo s ur e o f th e ,
fi s t ula was un d e r tak e n se v e n t e e n d ay s a ft e r i t wa s for m e d Thr e e .
pi e c e s o f goo d s iz e d ca t gu t p a s se d th rough th e w h ol e d e p th o f th e
-
woun d an d t i e d on b o th S i d e s ov e r s trip s of a dh e si v e pla s te r T e n d ays .
la t e r t wo m or e s u t ur e s thi s t i m e s ilk b e in g u s e d w e r e in tro d uc e d in

, ,
th e s a m e m ann e r th e ri g h t t h igh b e ing p lac e d in s u s p e n s ion

, i n or d e r ,
t o r e li e v e t e n s ion I t wa s foun d n e c e s s a ry h ow e v e r t o r e p e at th i s pro

.
, ,
c e d ure th r e e t i m e s m or e b e for e clo s ur e o f th e fi s t ul a was ob t ain e d Pa .
t i e n t r e cov e r e d co m pl e t e ly by th e for ty e i g h th d ay a n d r e t urn e d t o h i s -
h ar d work .
O n e x am ina t ion th e e xci s e d p or tion o f th e in t e s tin e wa s foun d t o b e

p ar t o f th e il e u m — D eu ts c/z M ed Woe/zen s clzr if t
. N o 2 8 J uly 1 5
. . . . .
,
1 886 .
C .
J . C O LLE S ( N e w Y o rk ) .
IV . I l i a c a By Dr A PO D R E z ( H ark off R u ss i a)
C o lo t o m i a . . .
,
.
I n h i s S urgical Clinic Dr P h ad a p a ti e n t on w h o m h e p e rfor m e d colo

. .
tonzi a i li a ca s o m e w h a t m o di fyin g th e m e th o d o f M a d e lu n g
, .
M rs T K se t 4 5 fo r fo ur y e ar s was s u ffe ring fro m carcino m a col

. . .
,
.
,
lO id e s in t h e r e c t u m wh i ch s t ar ting fro m a poin t ab ov e th e se con d

, ,
s p h inc t e r h a d e x t e n d e d ab ov e th e th ir d s p h in c t e r an d r e a ch e d th e ad ,
j ac e n t p ar t s o f fl exura s i g m oi d e a In J anuary 1 8 8 5 Dr Podre z h ad .

, , .
p e r for m e d on hi s p a ti e n t ex t i rp a t i o r ect i r a d i ca li s pr e s e rvi n g th e ,
th e s p h inc t e r e x t e r n u s T h e p a t i e n t r e cov e r e d a n d fo r ab ou t a y e ar
.
h a d nor m al p a s s a g e s ; s h e fe l t h e r s e l f w e ll an d a t te n d e d t o h e r h o m e
d u ti e s . At th e e n d o f O c t ob e r t h e r e app e ar e d a gain all s ym p

,
t o m s o f c arcino m a p ain con s tip a tion in s o m nia lo s s o f app e t i t e an d

, , , , ,
c a ch e tic colori n g o f S kin O n J anuar y 1 4 1 8 8 6 Dr P p e r for m e d

.
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c o lo t o m i a i li a c a all n e c e s s ary pr e cau t ion s b e ing ob s e rv e d
,
inclu ding a ,
prop e rly di sin fe c te d O p e ra ti n g ro o m A c u t wa s m ad e 8 c m long . .

,
’
p ar a ll e l t o cri s t a il e i s i ni s tr 1 inch ab ov e Poupar t s liga m e n t
.
,
T he .
O p e ning in th e p e ri t o n e u m wa s 5 c tm long T he e d g e s o f p e ri t on e u m
. .
w e r e a tt ac h e d t o th o s e o f s kin by s ixt e e n d e e p an d fo ur te e n s up e rfi cial

S ilk s u t ur e s P u tting a si d e th e o m e n t u m an d s o m e loop s o f t h e in te s
.
t in e s th e d e s c e n di n g colon was foun d an d d rawn o ut

, I t was fix e d by .
s ilk l i g at ur e a n d t h e n c u t t h roug h T h e low e r e n d wa s w ash e d in 5

.
p er c e n t s olu tion o f b oracic a ci d an d i ts wall s w e r e s e w e d by S ixte e n

.
,
s u t ur e s a ccor d ing t o Cz e rny an d th e n i t w a s d ropp e d in t o th e ab d o m

,
in al cavi ty Th e n th e m e s ocolon was dr e s s e d an d al s o p ut in t o th e

.
ab d om i nal c avi ty At la s t th e upp e r e n d o f th e colon was fix e d in th e

.
op e ni ng in wh ich O p e ra ti on t h e r e w e r e m a de for ty e igh t s u t ur e s A

,
-
.
rubb e r drainag e t ub e wa s in tr o d uc e d in t o th e in t e s ti n e an d th e woun d

was prop e rly d r e s s e d T h e op e r at ion was bloo d l e s s an d la s t e d abo u t
.
th r e e h our s I c e an d opiu m w e r e p r e s c n b e d t o th e pa t i e n t
. On J an .
u ary 1 8 an d 2 0 s h e h ad s m all p a s s ag e s F o r s o m e d ay s sh e was s uf .
fe ri n g fro m nau s e a an d vo m i ting Bu t on J anuary 1 9 s h e wa s alr e a dy

.
abl e t o t ak e s crap e d m e at an d e gg s On J anuary 2 2 th e p at i e n t was .
allow e d t o li e on th e s i d e an d all th e s u t ur e s ( acc e s s ibl e ) w e r e r e

,
m ov e d J anuary 2 6—3 0 th e app e t i t e an d s l e e p w e r e goo d an d d aily

.
, ,
p as s ag e s F e bruary 1 0—th e woun d i s p e r fe c tly cica t riz e d ; th e e d g e s

.
o f in t e s tin e an d s kin ar e w e ll uni t e d March 5 —a canc e rou s i n fi ltra .
tion wa s foun d aroun d th e anu s ; on March 1 0 a larg e m a s s o f p u s an d
canc er ou s fragm e n t s w e r e r e m ov e d p er a n u m March 2 0 th e p a ti e n t g e t s .
up fro m h e r b e d H e r g e n e ral con di tion i s rapi d ly i m provi n g At th e

. .
ti m e th i s r e p or t wa s giv e n April 8 th e pa t i e n t was in a v e ry goo d con

, ,
di ti on . Dr Po dre z b e li e v e s th a t in ca s e th e r e ct u m i s a ffe ct e d wi th
.
c anc e r c olot om i a ili aca i s prop e rly in dica t e d Clzi r u rg i c/zes Ry Ves t
,
.
-
nié . M ay an d J un e 1 886 . .
P .
J . PO PO FF ( Br o o k l yn ) .
E XT R E M I T I E S .
I . S p o nt an e o u s o ot
P h le b a c t e r i e k t a s i a By A of th e F . .
G GE R S T E R ( N e w Y ork )
. R ob e r t Kla ile ae t 1 4 a w e ll d e v e lop e d
.
,
.
,
-
b oy wa s a dm i t te d t o th e Ge r m an Ho s pi t al J uly 2 1 8 8 5 on a ccoun t
, , , ,
o f a nu m b e r o f r e b e lliou s ulc e r s s i t ua t e d on th e d or s u m o f t h e l e ft foo t .
Th e c o n d i tion wa s s ai d t o h av e e xi s t e d s in c e c h il dh oo d ; no in j ury
wa s r e m e m b e r e d P h y s ical e xa m in a ti on o f th e
. i n t e rnal organ s r e
v e al e d th e ir n or m al s t a t e wi th th e e xce p ti on o f th e h e ar t w h ich was

, ,
foun d t o b e e nl arg e d an d e vi d e nc e d a m ark e d incr e a s e o f th e e n e rgy

,
o f i t s pul s a tion s T h e fe m oral ar te ri e s o f b o th s i d e s w e r e foun d t o

.
b e at wi th unu s ual str e ng th an d wh e n s o m e wh at co m pr e ss e d gav e ri s e

, , ,
E X TR E M I TI E 5 .
3 47
“
to a st ro n g wh irr b o th t o b e fe l t an d h e ar d by th e s t e th o s cop e On in
,
.
s p e c t i on an i n cr e a se d s iz e o f th e l e ft foo t b e c am e m ani fe s t
,
t h e h yp e r ,
trop h y p e r t ai ni n g t o th e s o ft p ar t s as w e ll a s t o th e b o n e s T h e l e n g th .
o f th e rig h t foo t wa s 2 4 c e n t i m e tre s th a t o f th e l e ft 2 5 c e n t i m e tr e s

,
.
T h e ir ci rcu m fe r e nc e wa s 2 3 an d 2 4 c e n ti m e tr e s Th e d or s u m a s w e ll .
a s th e s o le o f t h e l e ft foo t wa s o ccupi e d b y a d ough y s o ft n o d ular , ,
s w e ll in g o f irr e g u lar an d n o t w e ll d e fi n e d ou t lin e s

- T h e S kin o f th e .
plan t ar s ur fac e was nor m al b ut on th e d or s u m a lon g th e co ur se o f th e

, ,
s a p h e n ou s n e r v e a se ri e s o f roun di sh irr e gul a r r a th e r h ar d d ark blu e

, , , , ,
p ar tly conflu e n t n o de s coul d b e s e e n T h e y w e r e p ar tly cov e r e d wi th

.
a th i ck lay e r o f rough e pi de r m i c s cale s p ar tly by a clo s e ly a dh e r e n t,
dry s cab A tte m p t s at r e m ovi n g th i s w e r e follow e d by r ath e r c 0p i o us

.
c api llary h aem orr h a g e T h e ir g e n e r al asp e c t was th a t o f t ele an gi e k

.
t a t i c no d e s A nu m b e r o f e n larg e d v e i n s s urroun d e d th e se no d e s an d
.
,
c ou ld b e p lain ly s e e n th roug h th e s kin I f pr e ss ur e wa s e x e r t e d on th e

.
s w e lli n g s th e y coul d b e m a d e t o d i s app e a r or a t l e a s t di m ini sh in s iz e

, , ,
a n d als o a d e e p S e a t e d p ul sa t ion o f th e w h ol e m a s s b e c am e at o n c e
-
e vi d e n t . Co m pr e ss ion o f th e fe m or al ar te ry pro m p tly s uppr e sse d th e

pu ls a tion an d w h il e th e co m pr e s sion o f th e m ain tru nk la ste d th e s w e ll
,
i n g d i d n o t r e s um e i t s for m e r S i z e On th e o th e r h an d i f th e ar te ry was
.
,
c om pr e s se d wh il e th e t u m or s w e r e t urgi d pu lsation c e as e d b ut th e r e , ,
wa s no a ppr e ciabl e d e cr e ase o f th e s iz e o f th e s w e llin g t o b e ob s e rv e d .
T h e s t e th o s cop e g av e e vi d e n c e o f a s tro n g art e r i al brui t all ov e r th e
swe lli n g s T h e r e was a m ark e d d i ffe r e n c e in th e t e m p e r at ur e in favor

.
o f t h e l e ft foo t .
I t se e m e d cl e ar th a t we h a d t o d e al wi th a m ix e d an gio m a con t ain ,
i n g th e e l e m e n t s o f bo th a cir s oi d an e u ri s m an d o f t e le an gi e k t a s i a wi th
p h le b e k t as i a A S t h.e r e w a s n o h i s t ory o f a gr o ss l e si on o f th e blo o d
v e s s e ls a c h r on i c i n fl am m a t o ry a lt e r a ti o n o f th e e n tir e v a s c ular app a

,
ra t u s o f th e foo t h a d t o b e as s u m e d wh ich by thi s ti m e h a d als o re

,
ac t e d up o n th e fe m or a l ar t e ri e s an d th e h e ar t in a s m uch as th e y t oo
,
w e r e foun d t o b e h yp e r troph i e d .
r m “ “ gam m ‘
Ar a b lati on of th e di s e a s e d p ar t wa s pr op o s e d b ut d e cli n e d wh e r e ,
fo r e h av in g e xp lai n e d th e n o t i n c on s i de r abl e d an g e r o f a d e liga ti o n o f

t h e m ai n ar t e ry an d h a vi n g v ai n ly t ri e d e la s t ic c om pr e s s i o n fo r a con
,
s i d e ra b le ti m e ,
p at i e n t wa s an ae s th e t iz e d on J uly 7 an d th e s up e r
th e ,
fi c i al fe m oral ar t e ry was ti e d in S carp a s t ri angl e Pul s a t ion c e a s e d

’
.
fo r a t i m e b u t b e ca m e fain tly b ut cl e arly no t ic e abl e abou t t e n m inu t e s

,
a ft e r clo s ur e o f t h e v e s se l w h e r e up on th e e x t e rn al iliac ar t e ry w as e x
,
p o s e d an d t i e d Puls a t ion d id n o t r e t urn aft e r th i s T h e woun d s w e r e

. .
clo s e d n o t drain e d an d th e li m b was e nv e lop e d i n a t h ick s wa th ing o f

, ,
co tt on b atting .
Th e cour s e o f th e h e aling o f t h e wo un d s was un d i s t urb e d an d fe v e r

l e s s b ut th e circu la tion i n th e li m b b e ca m e s o d e pr e s s e d t h a t se ri ou s
,
appr e h e n s ion s w e r e e n t e r t ain e d in r e gard t o i t s pr e s e rva tion T h e t o e s .

,
e s p e cially th e fir s t a n d s e con d w e r e col d an d livi d th e ir s e n s ibili ty

, ,
was d e s troy e d a n d in th e cour se o f th e fir s t w e e k n e cro s i s o f th e in

,
»
t e gu m e n t o f th e t e r m in al p h al ang e s b e ca m e m a n i fe s t A t th e s am e .
ti m e th e s kin on th e o u t e r a n d po s t e ri or a s p e c t o f t h e li m b e xac t ly ,
ov e r th e cour s e o f th e p e ron e al m u s cl e s s lou gh e d a n d on b e ing re

, , ,
m ov e d n e cro s i s o f th e e n t ir e b e lly o f th e p e ron e u s lo n g u s wa s a s c e r

,
t ai n e d. A for tnig h t a fte r th e op e ra tion th e m u s cl e was r e m ov e d I t

,
.
h a d th e a s p e c t o f a p al e waxy t ran s luc e n t s ub s t a n c e

, , T h e r e wa s .
h ar d ly a n y s upp ura tio n a n d i t was d e e m e d a d vi s ab le n o t t o l e av e th e

,
s e qu e s tra t i o n o f s uc h a larg e m a s s o f t i s s u e t o th e ra th e r unc e r t ain an d
ri s ky e ffor t s o f n a t ur e T h e t o e s w e re al s o r e m ov e d T h e pa ti e n t
. .
wa s d i s ch ar g e d cur e d in O c t ob e r a n d no p ul s a t ion or incr e a s e o f t h e

,
t u m or s w e r e no t e d a t t h e t i m e T h e s iz e o f th e s w e lling s w as s o m e
.
wh a t s m all e r th an b e for e t h e d e l i ga tion b ut th e r e was no h ar d e ning or

,
m ark e d S h rinkin g s uc h a s woul d foll o w obli t e ra t io n ; on th e con t rary ,
t h e d oug h lik e con s i s t e ncy h a d r e m ain e d u n al t e r e d

- .
Pa t i e n t wa s r e ad m i tt e d to th e h o s pi t a l i n J anuary 1 8 8 6 Pu ls a tion
, .
h a d r e t urn e d an d was j u s t a s e vi de n t a s b e for e th e O p e ra t io n

, T he .
t e le an gi e k t a t i c S po t s w e r e all s upplan t e d by ill con d i t i o n e d ulc e r s T h e

-
.
m e t a t ar s o p h alang e al j oin t o f t h e g r e a t t o e wa s op e n a n d s uppura t ing

-
,
a n d th e b oy co m plain e d o f m uc h pai n a n d d i s co m for t d u e t o th e
ulc e r s .
’
Pir ogo ff s a m pu t a t ion wa s d on e J anuary 2 9 1 8 8 6 wi th t h e a id o f E s ,
’
m arc h s b an d ; th e s e c tion s o f an unu s ual n u m b e r o f larg e v e s s e l s ,
t w e n t y s e v e n w e r e t ak e n up a n d t i e d b e for e ; e le v e n m or e liga t ur e s
-
,
CE N I T O UR I N A R V OR C A N 5 .
34 9
w e r e appli e d a fte r th e r e m oval o f th e con s tric tion T h e se g m e n t o f .
th e calcan e u m w a s nail e d t o th e t ibia a n d th e woun d clo se d by an i n ,
t e rr up t e d ca tgu t s u t ur e Dr ain a g e was e ffe c t e d th rough a coun te r

.
op e nin g m a de along s i d e of th e t e n d o A ch illi s T h e fir s t d r e s s ing .
wa s r e m ov e d t w e n ty o n e d ay s a ft e r th e O p e ra tion an d th e woun d was

-
,
fir m ly uni t e d e xc e p t alon g a s m all por tion o f th e s u tur e wh e r e th e

, ,
ra th e r fi n e c at gu t h a d b e e n ab s orb e d too s oon T h i s narro w s trip o f .
granula tion t og e th e r wi th th e track o f th e n ail was fo un d ci ca triz e d

, ,
ov e r fi v e d a ys la t e r w h e n th e s e con d d r e s s ing wa s ch an g e d
, .
Th e pa ti e n t h as a goo d s t u m p an d walk s on i t wi th o u t s upp or t ,

.
A v e ry e xc e ll e n t an a t o m ical s t u d y o f a ca s e o f con s i d e r abl e m agni

t u d e by W K rau s e will b e foun d in th e s e con d volu m e o f Lang e n
, . .
’
b e ck s A r c/xi v p ubli sh e d in 1 8 6 2 N icola d oni h as al s o r e por te d th r e e
, .
ca se s two in vol 1 8 pp 2 5 2 an d 7 1 1 th e t hir d on e in vol 2 0 p 1 4 6

,
.
, . .
, .
,
o f th e s a m e p e rio d ic al All wi th th e e xc e p t ion o f o n e r e por t e d by

.
,
Nicola d oni w e r e a ffe c tion s o f th e upp e r e x tr e m i ty wh ich i s s ai d t o b e

, ,
th e fa vori t e s i t e o f th e d i s or d e r Bo th ca s e s s e e n by m e involv e d th e .
foo t o n e th e le ft th e o t h e r t h e ri g h t
, I m a y a dd th at th e o th e r c as e
, .
,
pr e s e n t e d e s p e cial ly a s r e gar d s th e local app e ar anc e an d s i t ua tion of

,
th e m ala d y an al m o s t i d e n t ical s t a t e o f a ffair s a s t h e ca s e b e for e yo u

, ,
only of l e s s d e v e lop m e n t .
A s r e gar d s th e t r e a tm e n t th e c as e pr e s e n t e d b e ar s o u t th e e xp e ,
ri e n c e o f o th e r s in as m uc h a s i t d e m on s tr a t e s t h e fu tili ty
,
in t h e m or e ,
e x t e n s iv e ca s e s o f l e ss r a dical m e a s ur e s th an
,
abla tio n — P r oceed i ng s
N ew Yor k S u rg i ca l S oci ety M arc h 8 1 8 8 6 .
,
.
I u p r a P u b i c L i t h o t o m y By N A S o k oLo F F M D ( S t
S
'
.
- . . .
. . .
, ,
Pe te r s b urg ) S t on e in t h e bla dd e r i s a r ar e d i s e as e in th e capi tal o f

.
R u s si a Dr S h a d only four ca s e s of th a t di s e a s e d uring t wo y e ar s in

. . .
’
th e Mary s Ho s pi t al O n h i s p a ti e n t s h e p e r for m e d s upra p ub ic li th o t
.
-
om y Bla dd e r wa s di s te n d e d wi th 4 % s olu t ion o f b orax

. .
Ca s e I M al e ac t 2 5 wa s s u ffe rin g fro m calculu s fo r tw e lv e y e ar s

.
, .
, .
N ov e m b e r 2 9 1 8 8 3 op e ra t ion D e c e m b e r 1 5 u rin e i s di s ch ar g e d
, ,
.
,
th rough th e ur e th ra a n d o nly a fe w d rop s t h ro u gh th e woun d

,
J anuary .
3 5 0 I N D E X OF 5 UR C I C A L R R O CR E 5 5 .
10 to 9 2 li
, g1h t s y m p
8 84 t o,m s o f py Se li t i s F e brua ry 2 1 woun d i s .
,
clo se d an d th e p a ti e n t wa s di s ch arg e d as cur e d

, .
Ca s e I I M al e act 1 8 was s u ffe ri n g fro m calculu s S inc e ch il dh oo d

.
,
.
, .
March 5 op e ra tion April 1 8 was di s ch arg e d a s cur e d ; th e wo un d

, .
wa s p e r fe c tly cica t riz e d .
Ca s e I I I M ale ae t 9 J uly 2 0 1 8 8 5 op e ra tion ; s t on e wa s o f S iz e

. , . .
, ,
’
o f pig e on s e gg J uly 2 2 u rin e p a s s e s th rough th e woun d wh ich was
.
,
s u t ur e d ; s u t ur e s r e m ov e d an d d rai n ag e t ub e in tro d uc e d F e ve r Au . .
gu s t 1 4 urin a t e s n or m ally S e p t e m b e r 2 1 t o O c t ob e r 2 fi s tule now

, .
,
i s clo s e d an d n ow O p e n again ; clo s e d p e rm an e n tly N ov e m b e r 7 In .
J anuary 1 8 8 6 woun d wa s cica t riz e d an d th e p a ti e n t l e ft th e h o s pi t al

, , , .
Ca s e I V Mal e ae t 2 2 wa s s u ffe ring fro m calculu s s inc e ch il dh oo d

.
,
.
, .
O n e xam ina tion in th e bl a dd e r w e r e foun d two larg e s t on e s an d s e v

e ral s m all on e s J un e 2 5 1 8 8 5 O p e r at ion ; o n e s t on e
. cm re , , .
m ov e d th e o th e r brok e n
, T h e wall o f th e bla dd e r a tt ach e d t o th a t o f .
th e woun d J uly 7 a s t on e i s r e m ov e d th rough th e op e nin g s ; c ys

.
,
t i ti s F i s tul e con tinu e d up t o S e p t e m b e r 2 S e p t e m b e r 1 6 woun d i s

‘
. .
,
cica tri z e d an d th e p at i e n t wa s d i s ch arg e d a s cur e d — C/zi r u rg i c/zesky .
Ves t n i k M ay an d J un e 1 8 8 6
.
, .
P
.
J . PO PO FF ( B ro o k l yn ) .
II . Le s i o n s C au s e d b y t h e P re s e n c e of th e E gg s an d Em
b r yo s of B i lh a r z ia H ae m a t obia in th e B ladde r, th e
P r o s t at e , t h e c t u m t h e M e s e n t e r i c G la n d s t h e K i d n e y
R e , ,
an d t h e Li v e r Dr Alb e r t R u ault pr e s e n te d t o th e Ana t o m i cal S o

. .
c i e ty in M arch 1 885 m icro s copic al pr e para tion s o f t h e ab ov e organ s

, , ,
t ak e n fro m t wo s ubj e c t s wh o h a d s uccu m b e d t o th e co m plica tion s of
calculou s cy s ti ti s In th e s e c tion s o f th e b la dd e r a gr e a t nu m b e r o f
.
th e e gg s o f th e d i s t o m a can b e s e e n in th e s ub s t anc e o f th e bla dd e r
wall wh ich i s co n s i d e r a b ly th i c k e n e d T h e e gg s are p ar ticularly abun .
d an t in th e m ucou s coa t an d i m m e d i a te ly b e low i t T h e th ick e ning o f .
th e or gan s s e e m s t o b e d u e t o an abu n d an t form ation o f conn e c t iv e
ti ss u e Th e r e i s als o s o m e al te r ation of th e m u s cular fibr e s b ut i t i s

.
,
n o t c le ar wh e th e r th e d e g e n e ra tion i s v i tre ou s or am yloi d In th e .
pro s t ate al s o th e r e i s a c e r tain qu an ti ty o f th e d i st o m a e gg s an d th e r e ,

A E 5 CE 5 5 E 5 , T UM OR S . 35 1
is m uch con n e c t iv e t i s s u e o f n e w for m a tion T h e s e ction of th e r e ct um .
S h ow s a l a rg e n u m b e r o f th e e gg s in th e m ucou s m e m br a n e T h e al .
t e ra ti o n a pp e ar s t o b e b u t li tt l e a d vanc e d an d th e r e a re n o d y se n t e ry
,
lik e ulc e ra tion s t o b e s e e n T h e s e c t ion o f th e ki d n e y e xh ibi t s s o m e

.
o f t h e e gg s a n d al s o fr e e e m bryo s Aroun d th e e gg s conn e ct iv e ti ss u e

.
o f n e w for m a t ion i s s e e n pro d uci n g an in t e r s ti t ial n e p h ri t i s o f va s cul ar
origin In th e liv e r th e o va are s i t ua t e d in th e n e igh b orh oo d o f th e

.
por t al s p ac e s or in th o s e p ar ts o f th e h e p a ti c lob ul e s n e ar e s t t o th e
,
S pac e s A S M K art uli s s ay s th e r e t rac t ion o f th e liv e r c a u s e d by th e

. .
,
d e po s i t o f th e d i s t o m u m e g g s s e e m s t o b e d ue t o a cirrh o s i s Th e .
cirrh o s i s i s e vi de n t in th e pr e p ara tion —P r og r es M ed i ca le J uly 1 8 8 5

.
’
.
,
.
P S A BR
. . A H AM ( L o n don ) .
ABS CE S S E S , T U M OR S .
I . On D ra in in g P e lv ic Ab s ce s s e s by T re p h in i ng th e
I li u m By Dr R I NN E ( Gr e i fswal d) T h i s i s a r e p or t o f t wo c a se s
. . .
’
o f v e ry t e d io u s p e lvi c ab s c e s s rap id ly cur e d by G F i s ch e r s m e th o d o f .
dr ain a g e th rough th e il e u m T h e fir s t c as e wa s th a t o f a m an ac t 2 6
. .
,
wh o in ch il dh oo d s u ffe r e d fro m coxi t i s e n ding in ankylo si s In th e .
e arli e r y e ar s o f th e coxi ti s h e d e v e lop e d a p e lvic ab s c e s s ( by p e r for a
t i on o f th e s o ck e t) ; th i s for four te e n y e ar s h a d k e p t up a fi s t ul a on t h e
fron t o f th e th ig h Op e r at e d th r e e an d a h al f y e ar s ago cur e in thr e e

.
m on th s T h e s e co n d c a s e wa s th at o f an o th e rwi s e h e al th y girl wh o
.
for e igh t y e ar s h a d s u ffe r e d fro m s uppur ation o f th e fl ang e o f th e l e ft
iliu m prob ably in con se qu e nc e o f non t ub e rcular o s t i ti s

, A fte r lyi n g
-
.
’
t wo y e a r s i t brok e s p on t an e ou s ly a h an d s br e a dth b e low th e S pina a n
t e r i or s u p R e p e a t e d d rainag e o f th e ab s c e ss c a vi ty th roug h th e lon g

.
n arrow r e s i s t an t S inu s s e cur e d t e m p ora ry clo s ur e b ut n e v e r cur e d th e ,
ab s c e s s O p e ra t e d in 1 8 8 5
. cur e in nin e w e e k s Larg e s ub p e ri os .
t e al ab s c e s s i n t h e in t e rnal ili a c fo s s a fill e d wi th gr anula tion s an d

,
s can t p u s .
R m ak e s an an te ro po s t e rior inci s ion th rough th e m u s cula t ur e thr e e

.
-
fin g e r br e adth s ab ov e th e lar g e tr och an te r an d ch i s e l s th rough th e os ,
i ln s o th a t a fing e r c an b e r e a dily in t ro d uc e d T h e proc e d u re i s .
n o t d an g e rou s ; i t i s v alu abl e w h e r e a cur e i s n o t e ffe c t e d th roug h th e

352 I N D E X OF 5 UR CI CA L R R O CR E 5 5 .
us ual p e rfora tiv e O p e nin g —R e por t o f XV Congr e s s of Ge r m . S e rg s .
I n C en tb l f C/zi rg 1 886
. N o 24
. . . . .
WM . BR O WNING ( B kly ro o n .
)
II . T h e R o le of P a r a s i t e s i n t h e D e v e lo p m ent of C e r ta i n
Tum o s r . F i b r o ade n om a of th e R e ctu m Pr o d u c e d b y t h e
E ggs of D is t om b iu m um By Dr V BE LLE LI ( Al e x
H ae m a t o . . .
an dri a E gyp t Th e h ypo th e s i s t h a t m a ny t u m or s h a v e a p ara s i t ic o r

, ) .
igin e v e ry d ay acquir e s gr e a te r prob abili ty Alr e a dy i t i s b e yon d d oub t .
th a t all granul a tion grow th s ( t ub e rcl e glan d e r s farcy lupu s

) a r e th e , , ,
con s e qu e nc e o f th e de v e lop m e n t o f C a s p e cial p ara s i t e T h e qu e s t ion .
”
i s s t ill o p e n a s r e gar d s th e b ulky t u m o ur s
“
wh ich are r e ally wor th y
o f th e n a m e T h e d i s cov e ry h ow e v e r o f ac t ino m yc e s in c e r tain s ar
.
, ,
co m a s O p e n s a larg e fi e l d o f s t u dy an d j u s tifi e s r e s e arch e s dir e c t e d ,
wi th th i s vi e w H e nc e th e in te r e s t in th e d e v e lop m e n t o f c e r t ain
.
t u m or s t ypical in for m an d h i s t ologi c al s t ruc t ur e un d e r th e ac t ion o f a

, ,
”
p ara s i t e v e ry co m m on in E gyp t th e d i s t o m u m h ae m a t obiu m
,
or
”
Bil h arzia h m m atob i a .
I t i s known th a t th e ad ul t ani m al wh i ch liv e s in th e p or t al v e in an d

.
v e s i cal v e in s de po si t s i ts e gg s ch i e fly in th e li t tle v e in s in th e n e ig h
,
b orh o o d o f th e in t e s t in e s an d o f th e bla dd e r T h e d i m e n s ion s o f t h e .
e gg s 1 60
,
lo n g an d 6 0 u broa d h in d e r th e m fro m r e ach ing th e c a p il
,
.
,
lari e s T h e y are s t o p p e d i n th e s m all v e in s wh ich a r e s ub se qu e n tly lac e r

.
”
a te d by th e e ffor t s of th e v i s a te r g o S o m e o f th e e gg s are th u s s e t .
fr e e in th e in t e s tinal an d v e s ical cavi ti e s b u t o th e r s r e m ain i m pla n t e d ,
in th e ti s s u e s In th e w h ol e l e ng th o f th e in t e s tin al r e gion th e in filtra

.
ti on o f t h e Bil h arzi a e gg s m ay pro d u c e d i ff e r e n t e ffe c t s ; th a t wh ich
pr e do m i n a t e s h ow e v e r i s th e for m a t i on o f c e r t ai n t u m or s wh i ch h av e
, ,
t h e app e aranc e o f p o lypi I t i s in th e r e c t u m th a t th e de v e lop m e n t

.
o f t h e s e t u m or s i s p ar t icularly fr e qu e n t or ra th e r i t i s in th i s r e gion ,
‘
t h a t t h e y g e n e rally gro w to a gr e a t e r S i z e By th e ir S i t ua tion at a d i s .

,
t anc e gr e a t e r or l e s s fro m th e anu s th e y giv e ri se t o variou s p h e no m ,
e n a o f w h ich th e princip al ar e h a
, e m orr h ag e d iarr h oe a t e n e s m u s —in a
, , ,
wor d all th e s y m p t o m s o f d y s e n te ry Th e se t u m or s are o fte n as big as a .
walnu t or al m on d b u t m any E gyp t i an d oc t or s h av e ci t e d e xam p le s o f

,
r e c t al t u m o ur s con s e cu t iv e t o th e Bi lh arz i a w h ich h av e r e ach e d th e siz e ,
o f a n e gg or e v e n o f a s m all fi s t
_ ,
.
A BS C E S S E S , T U M OR S . 53
T h e following c ase occurr e d in th e h o s pi t al o f th e D e acon e ss e s o f

A le xan dria un d e r th e car e o f Dr Macki e
,
.
A ch il d ae t 1 2 fo r n e arly t wo y e ar s s u ffe r e d fro m h ae m a t uria a n d

,
.
,
d y s e n t e ric s y m p t o m s I t wa s ob se rv e d th at a t u m or app e ar e d a t th e
.
a nu s d uring e ffor t s o f d e fe ca t ion R e c e n t ly th e h ae m a t uria h a d d i s ap '
e a r e d a n d th e r e c t al t e n e s m u s h a d con s i d e rably d i m ini s h e d b u t d e fe

p ,
ca tio n was m or e an d m or e i m p e d e d by th e incr e a s e d grow th o f t h e t u

m or . T h e ch il d wa s an aem ic ; th e urin e cl e ar a n d t ran s par e n t b u t a ,
r e p e a t e d e xa m ina tion sh ow e d th a t i t co n t ain e d a no t abl e quan ti ty o f

Bil h arzi a o v a R e c t al e xa m ina ti on r e v e al e d a t a d i s t anc e o f 5 t o 6
.
,
c e n ti m e tr e s fro m th e anu s a larg e t u m or i m p lan t e d by a broa d b a s e

, ,
on th e l e ft s i d e o f th e r e c t u m D uri n g th e e ffor ts o f d e fe ca ti on a p ar t
.
o f th e t u m or b e ca m e vi s ibl e th rough t h e orific e o f t h e an u s T hi s t u .
m o ur was r e m ov e d a t t h e l e v e l o f i t s b a s e by ai d o f th e é cra se ur .
E x a m i n a t i on of t/ze t u m ou r —T h e t u m our o f th e approxi m a t e s iz e

.
o f a s m all appl e i s fl e s h colour e d a n d o f s o ft con s i s t e nc e ; th e s ur fac e
r e gularly lob ula t e d wi th fibrou s t rac t s li m i ting th e princip al lob ul e s

, .
E ach lob ul e i s for m e d o f a fi n e ly granular s ub s t an c e O n a cro s s s e c .
t io n t h e a s p e c t i s i d e n t ical wi th t h a t o f th e s ur fac e e xc e p t th a t th e r e ,
ar e e xpo s e d a fe w cy s ti c cavi t i e s fill e d wi t h a g e la t inou s y e llow t ran s , ,
p ar e n t s ub s t anc e In on e o f th e cy s t s i s r e m ark e d a blacki sh m a t e ri al

.
o f h ar d co n s i s t e n c e —e vi d e n tly fos c a l T h e g e la t i n ou s s ub s t a n c e was

.
cur s orily e xa m in e d un d e r a low p ow e r fo r th e d i s to m a e gg s b u t a s th e

r e s ul t wa s n e ga tiv e th e t u m our wa s c u t up in s m all pi e c e s t o b e h ar d
e n e d in alco h ol O n o n e o f th e fr e s h frag m e n t s o f th e t u m our a con
.
s i d e rab le n u m b e r o f th e ova co u ld b e d i s t ingui s h e d wi th th e m icro
s cop e con t aining

, living e m b ryo s a n d o n e o f th e m pr e s e n te d th e
,
vari ou s m ov e m e n t s o fte n ob s e rv e d s o m e m inu t e s b e for e th e rup t ur e o f

th e e gg .
H i s tolog i ca l ex a m i n a t i on —I n
c ion s t re a te d wi th p i c r oc ar
the s e t
m in e larg e t rac t s s trongly color e d c an b e ob s e r ve d wi th th e n ak e d

, , ,
e ye li m i t ing alv e olar s p a c e s m or e or l e s s circular

, for m e d Of a t ran s ,
par e n t t i s s u e o f r e ticulat e s tr uct ur e an d fe e bly color e d wi th th e p i c ro

car m in e Un de r th e m icro s cop e th e op a q u e b ands are s e e n t o b e
.
co m po se d o f conn e c tiv e t i s s u e m or e or l e s s co m p ac t th e alv e ola r

3 54 I N D E X OF 5 UR C I CAL F R O CR E 5 5 .
S p ac e s b e ing m a s s e s o f t ubular glan d s B e twe e n e ach glan d ar e th in

.
n e r d ivi s ion s o f c o nn e c t iv e t i s s u e T h e in t e r alv e olar conn e c t iv e t i s

.
-
s u e i s fi b ro c e llular m or e or l e s s co m pac t ; in c e r t ain s po t s th e fibr e s

-
,
are s o clo se t og e th e r th a t t h e c e llular e l e m e n t s a r e s c a rc e ly vi s ibl e In .
o th e r par ts th e y pr e d o m ina t e M or e ov e r th e r e ar e li m i te d plac e s

.
,
wh e r e th e ti s s u e co m po se d al m o st e n tir e ly of c e ll s a ss u m e s th e a s p e ct
, ,
o f e m bryoni c t i s s u e Mo s t o f th e c e ll s are roun de d b ut m an y are

.
,
e long at e an d fu s i for m T h e ir p ro topla sm i s uni for m in app e arance

.
an d m or e or le s s s t ain e d by th e p icroc ar m in e In th e s e c tion s tr e ate d .
wi th ac e tic aci d th e pr e s e nc e o f a nucl e u s i s m an i fe s te d in s o m e o f th e

c e ll s ; o th e r s S h ow only s o m e gran ul e s s tro n gly s t ain e d prob ably th e ,
d e bri s o f a n ucl e u s In th i s s am e in t e r alv e olar ti s s u e a con si d e rabl e

.
-
nu m b e r o f e gg s an d fre e e m bryo s o f th e di s to m a are di st ingui sh e d Th e y .
a re fo un d fo r t h e m o s t p ar t ou ts i d e th e v e s s e l s a n d ar e e qually s c at
t e r e d in th e fibrou s an d in th e e m bryonic t i s s u e T h e y ar e m o s t o ft e n .
d i s po se d in con s i d e rabl e group s—co n t aini n g as m any a s t w e n ty .
N e arly all th e e gg s h av e th e s pin e t e r m inal a fe w h av e i t on th e s i de ,

.
S o m e o f th e m h a v e th e con te n t s granular o th e r s h av e th e yolk m or e or ,
l e s s s e gm e n t e d an d o th e r s e nclo s e th e e m bryo alre ad v form e d M any

,
.
o f th e m , e s p e cially th o se in th e co m pac t t i s s u e h av e th e con t e n t s ob ,
s cur e a n d blacki s h T h e in tr a alv e olar conn e c t iv e t i s s u e pr e se n ts

.
-
n e arly th e s a m e ch arac t e r s a s th e ab ov e b u t th e fi b rillar conn e c tiv e,
t i s s u e wi th abun d an t proli fe ra t ion o f c e ll s pr e d o m i n a t e s In th i s ti s s u e .
th e Bil h arz ia e gg s a re far fro m b e i n g a s nu m e rou s a s in th e in t e r av e o -
lar b ut a gr e at n u m b e r are to b e s e e n m o s t o fte n i s ola t e d or rar e ly in

, , ,
group s of four or fi ve .
In th e s e c tion s th e glan d s wh ich m ak e up th e alv e oli are c ut in

,
variou s dir e c tion s S o m e are s i m pl e t ub e s o th e r s di furc a t e or h av e

.
,
se v e ral branch e s . Th e ir l e ng th vari e s fro m t o 1 m illi m e t e r ; th e ir
d ia m e te r fro m 5 0 t o 2 5 0 7 S o m e h av e a d i s t inc t m e m bran e

1 . The y .
ar e lin e d by cylin drical e pi th e liu m th e c e ll s h aving no nucl e i

, b ut ,
t ran s p ar e n t an d al m o st h yalin e con t e n t s an d th e y vary in s iz e , So m e .
o f th e gl a n d s con t ain no th i n g o th e r s an am orp h ou s granular s ub s t anc e

, ,
an d o th e r s are fill e d wi th h yalin e S p h e r e s o f cylin dri cal or p oly h e d ral
t ran s par e n t c e ll s .
A E 5 CE )
. 5 E5 , T UM OR 5 .
35 5
In de p e n d e n t ly o f th e gla n d s larg e e m p ty s p ac e s are t o b e s e e n ,
wh i ch e vi d e n tly for m pa rt o f th e cy s t s wh ich are r e co gn iz e d wi th th e

n ak e d e ye . Th e y h av e n o t all th e s a m e o ri gin I n a fe w a gr e a t .
nu m b e r of th e glan ds op e n in dica ting th a t th e y r e s ul t fr o m a ccu m ul a

,
t io n o f th e glan d ular s e cr e t ion ; o th e r s h av e n o co m m unica t ion wi th
th e glan d s an d th e y e nclo s e s e v e ral fibro u s t r ac t s th e y are probably
for m e d by th e d e s tr uc t ion o f a c e r t ain nu m b e r o f fglan d s In d e e d in .

,
s o m e plac e s can b e d i s t ingui s h e d m a s s e s o f glan d s wi th a p ar t o f t h e
walls an d o f th e c e lls d e s troy e d s o a s t o for m a s ingl e c a vi ty

, .
D i ag n os i s —T h e ab ov e h i s t ological ch ar ac t e r s allow th e t u m our t o

.
b e call e d a fi b ro a d e no m a - T h e gr e a t aug m e n t a t ion in th e n u m b e r

.
o f th e glan d s an d th e ir d e via t io n i n t yp e
,
S h ow t h e gr ow th t o b e a ,
tr u e a d e no m a a n d n o t a s i m pl e h yp e r tr op h y o f nor m al glan d ul ar ti s
,
s u e an d th e larg e d e v e lop m e n t o f fibrou s

, co m p ac t conn e c ti v e ti s s u e ,
j u st ifi e s th e na m e o f fi b ro m a i n a ddi t ion .
Oés e r va t i on s —T h e cau s e w h i ch h as d e t e r m in e d th e d e v e lop m e n t i s

.
n o t d oub tful v i z ,
t h e e g g s o f th e Bil h arzia d e p o s i t e d in t h e m uco us
.
, ,
m e m bran e o f th e r e c t u m h avi n g provok e d an i rri t a ti v e proc e s s w h ich

,
h as e n d e d in th e for m a t ion o f an a d e no m a T h e se e g g s h av e n o t ac t e d .
s ol e ly as for e ign b o di e s ; m o s t o f th e m a r e p lac e d li vin g in th e walls o f
th e r e c t u m an d m any e v e n h av e t h e e m b ryo alr e a dy for m e d

, Th e .
m ov e m e n t s o f t h e e m b ryo an d i t s e xi t fro m th e e gg are al s o cau s e s

, ,
i u e irri t a t ion
o f th e t s s .
T h e Bil h arzia e gg s n o t only e xplain th e g e n e s i s o f th e t u m our b u t ,
th e y ar e th e cau s e o f i t s s ucc e s s iv e d e v e lop m e n t a n d i t s con tinu e d
grow th In fac t th e larg e v e s s e l s wh i ch e n d in th e tu m or a re con tin

.
u ally carrying th e living e gg s th roug h ou t i t s e x t e n t a n d th e nu m e rou s ,
foci o f i rri t a tion provok e a con t inual d e v e lop m e n t o f th e e l e m e n t s o f
th e grow th . W h e r e a p ar t o f th e t um o ur i s n e wly for m e d i t s va s cular

s y s t e m h a s a p arall e l d e v e lop m e n t w h i c h allow s o f t h e in t ro d uc t ion o f
e gg s in t o n e w t i s s u e T h i s i s th e r e for e a ca s e in wh ich in plac e o f

.
, , ,
th e h ac k n e y e d i rri t a tion s u s ually in vok e d t o e xpl ain t h e origin a n d
gr ow th o f t u m o ur s i t i s po s s ibl e t o s ub s ti t u t e th e m or e d e fi n i te an d
,
l e s s h yp o th e t ic al ac tion of a s p e cial p ara s i t e I t i s p o s s ibl e t o go fur th e r .

,
a n d t o fi n d in t h e p e culi ari t i e s o f t h e li fe o f th e p ara s i t e an e xplan a ,

3 56 I N D E X OF 5 UR C I CA L R R O C R E 5 5 .
tion o f th e na t ur e o f th e t u m our I t i s g e n e rally a d m i t t e d th a t fo r an

.
a d e no m a t o form th e d e v e lop m e n t o f i t s h i s t ological e l e m e n t s sh o ul d

b e s o m o d e ra t e d t h a t th e y h av e t i m e t o b e d i s p o s e d r e g ularly a n d t o
r e pro d uc e th e typical s truc t ur e T h e Bilh arzi a e gg s pro d uc e a m o d
.
c ra t e ir ri t a t ion T h e p ara s i t e i s n o t fully d e v e lop e d in th e h u m an

.
b o dy—th e ul ti m at e t ran s for m a t ion s d o n o t t ak e plac e in th e ti s s u e s .
T h e e m b ryo i s o n ly e n d ow e d wi th c e r t ai n m ov e m e n t s wh ich s o o n
c e a s e th e irri t a tion of th e t i s s u e b e i n g circu m s crib e d an d con se qu e n t ly

,
m o de ra t e I f on th e con t rary th e ov a u n d e rw e n t a s e ri e s o f t ran s

.
, ,
for m a t ion s e n ding in th e p e r fe c t ani m al i t i s prob abl e th a t t h e m or e ,
e x t e n d e d irri t a tion o f t h e t i s s u e s woul d h i n d e r t h e r e gular d i s p o s i ti on
o f t h e n e opla s t i c h i s t ologi cal e l e m e n t s T h e ab un d a n t for m a ti on o f .
e pi th e lial c e ll s woul d n o t g iv e ri s e t o n e w glan d s b u t t o irr e gular ,
m a s se s o f c e ll s i m b e d d e d in th e con n e c tiv e t i s s u e we S h oul d th e n h av e ,
a ll th e e l e m e n t s o f an e pi th e lio m a or t ru e canc e r T h i s i s o f cour s e .

, ,
a p ur e h ypo th e s i s b u t a lik e ly o n e wh ich i n S i m ilar ca s e s t o th e abov e

, ,
coul d b e e a s ily v e rifi e d In d e e d in st e a d of a p ara s i t e lik e th e Bilh ar

.
,
zia th e r e m ay b e o th e r s wh ich fro m t h e ir S iz e e s cap e a s up e rficial e x

, ,
am i n at ion T h e p ar ticular s o f th e li fe o f th e s e m icro organi s m s m ay

.
-
al s o a s in th e ca s e o f th e d i s t o m u m giv e th e k e y t o th e origin growth

, , ,
an d n a t ur e o f o r d inary t u m our s m alig n a n t an d b e nig n Mo de rn

,
.
s ci e n c e t e n d s t o th e s e i d e a s an d i t i s prob abl e th a t t h e y will b e s oon e r

,
or la t e r v e rifi e d —P r og r es M d J uly 1 8 8 5
. .
,
.
P . S . A BR AHAM ( L on do n
) .
I I I N o t e s T o w a r d t h e F o rm at i o n o f C l i n i c al Gr o u p s o f
.
T u m o r s By J H U T C H I N S O N F R S ( Lon d o n ) A d vanc e s th e h ypo

. .
, . . .
, .
th e s i s th a t th e t i m e h a s a rriv e d wh e n i t i s b o th p o s s ib le a n d d e s irabl e
t o m ak e fo r prac t ical purpo s e s a m or e d e t ail e d cla s s ifica t ion o f t u m or s
th an h as ye t b e e n a tt e m p t e d a n d t h a t th i s m u s t d e p e n d m or e upon 10
,
c ali ty cau s e con t our a n d g e n e ral cour s e o f th e gro wth t h an up on m e r e

, ,
m icro s copical app e aran c e s T h e plan prop o s e d i s t o t ak e any e x

.
a m pl e o f rar e di s e a s e an d k e e p i t by i ts e l f un til o th e r s S i m ilar to i t are

foun d an d th u s con st ruc t group s w h ich in t urn m a y b e co m e larg e
, ,
e nough t o allow o f d e t e r m ining wi th ou t m uch ri s k o f e rror w h a t ar e
th e d i ffe r e n t ial p e culiari t i e s o f t h e m ala dy A s a g e n e ral la w fo r gui d .

AB 5 C E 5 5 E 5 , T UM O R 5 .
35 7
a nc e in clinical ob s e rv ation s in th l S r e g ar d r e p e ti ti on s of s truct ural

,
p e culia ri ti e s m ay b e e xp e ct e d wh e n e v e r th e m orbi d te n d e ncy di s pl ay s

i t s a c t ivi ty in pr e ci se ly s i m ilar r e gion s O f th i s la w th e a u th or s ub m i t s
.
se v e r a l e x am pl e s s uch as ro de n t ulc e r wh ic h occur s wi th s uc h p re p o n

, ,
de ranc e in on e sp e ci al r e gion th a t i t gain e d th e n am e o f “

p e culi ar
”
ulc e r o f th e e y e li d s . Wh il e th e wri te r pr e se n t s nu m e rou s in s tanc e s in
favor o f h i s p r op o s e d m e th o d o f cl ass ifi c a tion s uch a s a ch arac te ri s t ic
,
fungou s t u m our o f lym p h o sa rco m a t ou s co m p o si tion occur ring in th e

-
,
upp e r p art o f th e n e c k m e l a no tic s arco m a o f th e s ol e of th e foo t sym

, ,
m e trically fa tty o u t grow th s a h ar d an d b o s sy t u m or o f th e p a l at e

, ,
wh ich th ough pr e se n ting a d e e p ulc e r i s d e voi d o f ir ri tabili ty and

, ,
p ain wart y t u m or s in cica tric e s e tc h e no t e s m or e at l e ng th th r e e

, , .
,
group s
1. M ela n ot i c W/i i tlozos —Th i s i s on e o f th e se v e ral p e culiar fo rm s
.
wh ich m e lano ti c s arco m a pr e s e n t s un de r th e law o f m o difica tion by

lo cali ty ; th e a m oun t o f pi gm e n t i s v e ry s ligh t in th e vicini ty of the
n ail s an d i t i s o ft e n d i fficul t t o r e cogniz e th e pig m e n t e d s t ruc t ur e in
,
th i s r e gion b u t along t h e un s woll e n b or d e r o f t h e t u m or i s t o b e

,
se e n a fain t m e lano ti c lin e ; th e d i s e a s e S pr e a d s m or e s lowly h e r e

,
th an d o e s m e lano s i s in m o s t o th e r po s i t ion s a n d d e s tr oy s th e nail T h e .
funga tin g grow th wh ic h i t finally pro d uc e s fa il s al t og e th e r t o ob t ain pi g

,
m e n t an d i s qui t e colorl e s s Th e r e i s m uch gr e a te r h op e o f d e l aying

.
th e progr e s s o f t h e d i s e a s e by op e ra t ion t h an in m o s t o th e r for m s o f
m e lano s i s .
2. T h e C r a ter if or m Ulce r a n e w for m of e pi th e lial can c e r o f th e

,
fac e —T hi s i s a m alignan t grow th o f e pi th e lial t yp e m e t wi th a s far , ,
as th e au th or s e xp e ri e nc e go e s only on t h e upp e r p ar t o f th e fac e a n d

’
,
m or e e s p e ci ally in th e pr e ci se loc ali ti e s o f th e co m m on ro d e n t ulc e r .
T h e fir s t s t ag e i s a b o ss y roun d e d lu m p wh i ch rapi dly a tt ai n s c on s i d

,
e rab le S iz e a n d pr e se n t s a s o m e wh at c o nical s u m m i t A t th i s s u m m i t .
ulc e rat ion occur s an d a de e p c avi ty for m s wi th e xc e e dingly li ttl e s up

,
p ura ti on or obviou s ly d e s truc tiv e infla m m a tion for m i n g a cra t e r th e , ,
wall s of wh ich are o f m uch th i ckn e ss an d o f gr e at fir m n e s s th e grow th

i s m uch l e ss v as cular an d l e ss s uccul e n t th an th at o f ro d e n t an d wh il e , ,
i t i s e a s y t o s cr ap e th e la tte r aw ay i t i s qui t e i m po s s ibl e t o d o so wi th

,
358 INDE X OF S UR GI CA L P R O GR E S S .
i
th s . u s ually b e gin s in th o s e p a s t m i ddl e a g e a n d wi t h o u t an y o b
It ,
vi o u s cau s e ; i s rapi d in i t s progr e s s gro wing a s larg e in a fe w m o n th s

,
a s ro d e n t woul d in m any y e ar s As fa r as th e au th or h a s ob s e rv e d i t
.
,
s h ow s n o t e n d e ncy t o fung at e or b e co m e war t y an d in th i s r e s p e c t as , ,
w e ll a s i n h ar dn e s s o f s tr uc t ur e d e n s i t y an d th ick n e s s di ffe r s fro m

, ,
wh a t i s ob se rv e d i n co m m on e pi th e lial canc e r o f o th e r p ar t s .
R u r r i ng F i b r o i d of tlze S k i n ( s pin d l e c e ll e d s arco m a — E xa m

3. ec -
) .
pl e s o f th e r e curr e n t cu t an e ou s fibroi d are v e ry rar e b ut th e y are v e ry ,
p e culiar in th e m o d e o f d e v e lop m e n t th e inv e te racy a n d r ap i d ty wi th

'
wh ich th e y r e cur o n e x tirpa tion a n d in th e ab s e n c e th roug h ou t o f any
t e n de n cy t o glan d d i s e a s e In e ach o f th e ca s e s ob s e rv e d th e e arly

.
,
s t ag e o f t h e n e w grow th w a s in s i diou s an d fo r s o m e t i m e v e ry s low b u t ,
i f l e ft al o n e th e r e wa s ul t i m a t e ly a t e n d e ncy t o funga t e a n d t o th e
,
form a tion o f bloo d cy s t s T h e d e e p fa s cia b e ca m e involv e d i f th e

.
g row t h w e r e n e gl e c te d b u t i n th e fir s t in s t a n c e t h e s kin alon e wa s i m

,
plica te d ; in two o u t o f th r e e ca s e s t h e grow th was o n t h e th igh an d ,
in th e th ir d on th e low e r p ar t o f th e ab d o m e n Th e au th or h a s n e v e r .
s e e n a r e currin g fibroi d o f t h e S kin on th e upp e r e x t r e m i t i e s t h e h e a d , ,
nor wi th on e d oub t ful e xc e p ti on on th e upp e r p ar t o f t h e t runk Th e

, , .
t u m or s s e e m e d t o b e s o ft e r in s t ruc t ur e a n d gr e w m or e rapi d ly wi th
e ach r e curr e nc e th e ir e l e m e n t s w e r e r e p e a t e d ly a n d by d i ffe r e n t m i
c r o s c o p i s t s a s sign e d t o t h e s pin d l e c e ll e d s arco m a t a

-
.
I f r e curri n g fi b r o i d s o f th e S ki n a re gr o up e d by t h e m s e lv e s S i m ilar ,
roup s s h oul d b e for m e d o f th e t u m or s o f s i m ilar s t ruc t ur e b ut m or e

g
fibrou s an d de v e lopi n g in d e e p e r p ar ts wh ich a re m uch h ar d e r an d
,
o ft e n fou n d a t t ach e d t o th e p e rio s te u m or t o t h e d e e p fa s cia a n d o f ,
t h e h ar d fibrou s t u m or s d e ve lop e d d e e ply

, o f v e ry S low grow th a n d
,
t e n d ing t o un s y m m e t rical m ul tiplici t y ( A NNA L S O F S U R G E R Y v o l i p , . , .
By th e se an d by nu m e rou s o t h e r in s tanc e s r e fe rr e d t o l e s s at
l e ng th th e a u th or sh o w s th at by car e ful ca s e c oll e c ting an d th e s e l e c
,
-
t ion an d grouping o f ca se s clini cally alik e cli n ical fa m ili e s m uc h m or e

, ,
m i nu t e ly s ub divi d e d th an i s p o s s ibl e t o th e m icro s copi s t a s ye t m ay ,
b e con s truc te d on a n a t ural b a s i s —I n te r n a t f ou r Med S ci

'
. . 1 886
. . . . .
Jan April July

.
, ,
.
A B5 CE 5 5 E S , T UM OR 5 . 359
IV . C an ce r C a rt i l a g e o r C h o n d r o s a r c o m a
of th e By .
D E S I R D E F O R T U N E T M D ( Lyon ) T h i s s tu d y o f car tilaginou s tu

,
. .
, .
m or s i s b a s e d up on a ca s e o f t u m or origina t i ng in t h e t ibio fi b ular ar -
ti c ular car t ilag e a n d in four t e e n m on th s a t t aining th e S iz e o f th e fi s t th e ,
grow th b e ing a t te n d e d wi th s o gr e a t p ain th a t a m pu t ation in th e low e r

th ir d o f th ig h wa s p e r for m e d fo r i t s r e li e f T h e a m pu t a tion was d on e .
a ccor d i n g t o th e m e th o d o f Molli e r e co m pl e t e h ae m o s t a s i s b e i n g ob ,
t ain e d by t or s ion o f th e v e s s e l s wi th ou t th e applica t ion o f a s ingl e lig
a tur e T h i s ca se i s s ub m i tt e d in oppo s i tion t o th e th e ory th a t ch on

.
dr o m a t a ari s e only fro m ab n or m ally plac e d car tilag e an d t o prov e ,
th a t n or m al car tilag e t i s s u e m a y giv e ri s e t o t u m or s o f a na t ur e i d e n
t ical wi th i ts e l f F ur th e r i t S h ow s th e p o s s ibili ty o f m align an t t u m or s

.
,
o f th e car tilag e a n d t h e au th or prop o s e s th e n a m e o f ch on d ro s arc o m a

,
for i t in oppo s i tion t o c h o n d ro m a u s e d t o d e s ignat e b e nign gr ow th s , .
R evu e de C/zi r u rg i e 1 886 M ay . . .
V . On F at t y an d S ar c o m
o u s T u m ors of t h e Kn e e at
J o i n t By
. R F W E IR . M D
.
( N e w Y ork
) , D e t ail s th r e e u n p ub
. .
, .
li sh e d ca s e s t og e th e r wi th a r e vi e w o f th e li t e ra t ur e o f th e s ubj e c t Th e .
fir s t wa s o f a young m an in wh o s e kn e e j oin t on th e inn e r s i d e o f th e -

,
p at e lla was fe l t a m a s s o f con s i d e rabl e fir m n e ss lik e a lo o s e car tilag e

,
an d th e s iz e o f an alm on d ; i t coul d b e m ov e d fr e e ly wi th in th e j oin t ,
b ut wa s e vi d e n tly p e d uncula t e d a s i t coul d n o t b e forc e d wi th ou t i t .
Un de r an ti s e p tic inci s io n t h e s upp o s e d car tilag e prov e d t o b e a p or

t ion o f fa tt y ti s s u e h ar d e r th a n u s ual a n d a t t ac h e d by a ra th e r broa d
,
th ick p e d icl e wh i c h s t r e t c h e d un d e r th e ligam e n t u m pa t e ll ae an d acro s s

,
t h e j o in t A S th e m a s s coul d b e p ull e d o ut wi th m o d e ra t e t rac t ion

.
,
an a t t e m p t was m a d e in a dd i ti on t o th e r e m oval o f th e b u tt on Sh ap e d
,
-
e n d t o cu t o ff as m uch o f th e lip o m a t o u s grow th a s p o s s ibl e a ft e r liga

,
t uring i t T h i s r e quir e d an u n u s ual a m oun t o f m anipula tion, a n d in

.
S pi t e o f an ti s e p t ic pr e cau t io n s an d i m m obiliz a t ion a s uppura t iv e s ym o ,
vi ti s s e t in w h ich n e c e s s i t a t e d a m pu t a t ion
,
T h e se con d ca s e was o f .
a you n g wo m an wh o h a d s u ffe r e d fo r a y e ar fro m p ain s w e lling an d ,
s t i ffn e s s o f th e kn e e in w h ich wa s d e t e c t e d
,
in te rnal t o th e p a te lla a , ,
lu m p th e s iz e o f a l arg e b e an an d m ovabl e for ab ou t an i n ch p ar all e l

t o th e axi s o f th e li m b ; th e j oin t wa s op e n e d an d un d e r carb oli c ,
3 60 I N D E X OF 5 UR C I CA L F R O CR E 5 5 .
S pr ay , u or e xpo s e d an d li ft e d o ut an d i t s s l e n d e r p e dicl e lig a

th e t m ,
t ure d an d d ivi d e d proving t o b e a gian t c e ll e d s arco m a ; th e pa t i e n t

,
-
m a d e a goo d r e cov e ry T h e t hir d ca s e wa s s i m ilar t o th e o th e r s in

'
h i s t ory an d un de r an t i s e p tic inci s ion an irr e gul a r s h ap e d s o fti sh

, ,
gr ow th y e llowi sh pink in color an d m ark e d by s un d ry e cch y m o ti c

,
p at ch e s th e r e s ul t o f r e c e n t e x e r tion in d ancing wa s e xpo s e d th e

, , ,
grow th b e in g inch e s long by 1 broa d an d n e arly o f an inch
t h ick an d proving t o b e a fib r o s arco m a

, Thi s m as s was h e l d b y a
- .
long S l e n d e r p e dicl e wh ic h was ti e d an d s ub s e qu e n tly divi de d In s pi t e

, .
o f s lippi n g o f th e liga t ur e an d con se qu e n t in tra ar ticular h ae m orr h ag e -

,
wh ich was ch e ck e d by pr e ss ur e by wh ich th e bloo d in th e j oi n t was

,
al s o e vacua te d th e p ati e n t p a s s e d on t o a s a ti s fac tory r e cov e ry A

,
.
s e arch in t o t he li t e r at ur e o f th e s ubj e c t giv e s b u t a s ing l e c a s e o f s i m
i lar s arco m a t ou s grow th an d b ut e ig h t o f lipo m a t a .
T h e prac tical d e d uc tion t o b e d rawn fro m th e r e vi e w o f s o fe w ca s e s
of a s o m e wh a t ob s cur e a ffe c t ion i s t h a t t oo m uch e ffor t s h o ul d n o t b e
m a d e in th e fa t ty growt h s t o e ffe c t t h e ir t o t al e x t irpa t ion S inc e t h e

, , ,
r e m oval o f th e flo ating por tion i s :all th a t i s call e d for ; an d th a t in ,
ca se s wh e r e th e s u s picion o f s arco m a i s m icro s copically v e rifi e d t h e ,
s ub s e qu e n t progr e ss o f th e t wo ca s e s r e p or t e d l e a d s t o th e b e li e f th a t
th e s a m e conclu s ion will b e arriv e d a t —I V Y M ed R ec 1 886

. . . . . .
J un e 2 6 .
J AM E S E PI LC H E R ( U S A m y) . . . r .
VI . M e l an o t i c W h it l o w
By J O NA TH AN H U T c H I N S O N Un d e r
. .
th i s na m e th e au th or allu d e s to ca se s o f s arco m a u s ual by m e lano t ic , ,
wh ich s pring fro m th e b e d o f th e nail T h e black color i s s o m e t i m e s .
li m i te d t o a narrow bor de r n e ar th e n ail H e p oin ts o ut th a t wh e n .
m e lano t ic s arco m a fun ga t e s an d w h e n i t a ffe c t s th e glan d s t h e larg e r

, ,
grow th s are o fte n wh i te —B r i t fil ed f ou r 1 8 8 6 P 4 9 1 . . . . . .
V I I T r a i t e m e n t d e s F i b r o m e s d e la P a r o i A b d o m i n a l e
. .
By T E R I LLO N T h e au th or ci t e s t wo ca s e s r e sp e ct iv e ly o f fi b ro m a a n d
.
fibrou s s arco m a o f th e ab d o m i n al wall i n th e inguinal r e gi o n b o th i n ,
wo m e n H e lay s s tr e s s on th e fac t th a t t h e s e t u m or s are o fte n a d

.
h e r e n t t o th e p e rit on e um a n d a r e m oval o f a por t ion o f t h a t m e m

, _
'
A E 5 CE 5 5 E 5 , T UM OR 5 .
6
3 1
br an e m ay b e n e c e ss ar y; I n o n e of th e ca se s ci te d th e adh e s ion of th e
t u m our to th e s e rou s m e m bran e was fi rm b ut i t s d ivi s ion wa s avoi d e d ,
by r e m oving th e b ulk of th e t u m our an d th e n di s s e cti ng o ff th e ad

h e r e n t p or tion s I f any par t o f th e t u m our b e l e ft r e curr e nc e i s fre
.
qu e n t al th ough th e gr ow th h as th e ch ar a cte r s of a fi b rom a —B u ll

,
. .
,
F S E VE. .
( Lon d o n ) .
VIII . The Im C l o s u r e a n d R a p i d C u r e o f F i s t u la
i
m e d at e
i n An o .By S TE P H E N S M I TH M D ( N e w Y ork) R e fe rring to th e

, . .
,
.
fac t th a t th i s m e th o d o f op e r at ion s e e m s t o h av e occu rr e d t o a n u m
b e r o f s urg e on s in de p e n de n tly an d ack n owl e d ging hi s in d e b t e dn e s s t o

E m m e t s O p e rat ion fo r l a c e ra t e d p e rin e u m th e wri te r d e s crib e s h i s
’
,
m e th o d a s follow s
T h e b ow e l b e in g cl e an e d o u t th e p a t i e n t an ae s th e t iz e d th e p ar ts i r
, ,
ri g a t e d an t i s e p tically a n d a S pong e , wrung out in a bich lori d e s olu

,
t ion in t ro d uc e d i n t o th e r e c t u m a b ov e th e fi s t ul a th e fi st ula an d ab
, ,
s c e s s cavi ty i f th e r e b e o n e are Op e n e d fr e e l y th e pyog e nic m e m

, , ,
br an e th o ro u ghly e n ucl e at e d wi th th e s calp e l or s ci s s or s an d all h aem

orrh a ge arr e s t e d T h e c h i e f obj e ct of th e O p e ra t ion i s t o s e cur e p e r
.
fe e t a pp o s i tion of th e s e fr e s h e n e d s ur fac e s t o b ring th e wh ol e woun d
i n t o Vi e w an a s s i s t an t sh oul d in tro d uc e an in de x fing e r w ell in to th e

,
r e c t u m an d b e n di n g i t as a h ook e xtru de th e b ow e l Th e fir st s u
, ,
.
t ur e s sh o ul d b e s o appli e d as t o b ri ng th e d e e p s u rfac e s t og e th e r an d
e v e r t th e m argin s o f th e m ucou s m e m br an e To a cco m p li sh th i s a .

,
carb oliz e d s ilk ligat ur e wi th a n e e dl e s ligh tly curv e d a t th e p oin t i s

u s e d O n e o f t h e n ee dl e s i s now p a s s e d j u st ab ov e th e h igh e st poin t
.
o f th e inci s ion a n d fro m a four th t o h alf an inch fro m th e m argi n s o f
th e wou n d an d th e th r e a d i s p as se d th rough th e c e n t e r ; t h e n e e dl e s
,
ar e th e n p as s e d in oppo s i t e d ir e c t ion s a t in t e rval s o f h al f an inch

,
in ,
’
a con tin uou s s a ddl e r s s ti t ch s o a s t o d ra w th e two fac e s of th e woun d
t og e t h e r an d s li g h t ly e v e rt th e e d g e s o f th e m ucou s m e m br a n e b ut ,
wi th ou t any s train T h e e n ti r e fi st ul a tra ck b e in g now dr awn o u ts i de

.
by g e n tl e tr ac tion on th e e n ds o f th i s s u t ur e th e e dg e s of th e wo un d ,
a re nic e ly a dj u s t e d by a con tinuou s s u t ur e co m m e ncing a t th e upp e r ,
e x t r e m i t y o f th e woun d T h e O p e r a tion i s co m pl e t e d by p a s s ing t wo

.
36 2 INDE X OF S UR GI CA L F R O CR E 5 5 .
or th r e e larg e carboliz e d s ilk ligat ur e s e n tir e ly un d e r th e fi st ula an d

t yin g t h e m ov e r an io d o for m gauz e p a d roll e d fi m ly an d lai d alo n g ,
r
th e woun d t h e obj e c t b e i n g t o d raw th e d e e p por t ion o f th e fi s t ula

,
in to s ui t abl e app o si t ion T h e p ar t s are th e n dr e s s e d an ti se p tically an d

.
pr e cau tion s t ak e n to pr e v e n t m ov e m e n t o f th e b ow e l s In ca s e of a .
larg e or I rr e gular ab s c e s s cavi ty h e s ugg e s t s t wo m o d e s o f proc e d ur e ,
( )
1 by e m ploy i ng t h e s a dd l e r s
’
s t i t c h t ak e n S t ill far, th e r fro m t h e m ar
gi n s o f th e woun d in or d e r to bring th e d e e p {pa rt s t og e th e r ; ( 2 ) by

,
in t e rrup t e d s u t ur e s p a s s e d a s in lac e ra t e d p e rin e u m co m pl e t e ly aroun d

th e cavi t y— a m e th o d m or e d i fficul t t o e m ploy b u t s ur e r th an t h e
o th e r T h e cur e i s co m pl e t e in a p e ri o d varying fro m e igh t t o four

.
t e e n d ay s T h e p rincipl e s t o be b orn e in m in d in t h e O p e ra tion ar e

.
( )
1 co m pl e t e r e m oval o f t h e lining m e m bran e o f t h e i s t ula an d o f t h e f
ab s c e s s cavi ty wh ich m ay e xi s t ( 2 ) accura t e an d p e r m an e n t a dj u s t

m e n t o f th e O ppo s ing s ur fac e s an d ( 3 h oroug h a n t i s e p ti c t r e a tm e n t
) t,
o f th e woun d —I V Y M e d .
f ou r 1 8 8 6 J un e 1 2
. . . .
J AM E S B PI LCH E R ( U 8 A m y) . . . r .
BONE S , JOINT S , O R T H O P AE D I C .
I . C o n g e n i t al S y m m e t r i c a l E x o s t o s e s By Dr R E U LOS . . .
O b s e rva t io n s o f m ul t ipl e S y m m e trical e xo s t o s e s are fa r fro m b e i n g rar e .
I f au th or s are in accor d as t o th e m o de o f th e ir d e v e lop m e n t th e y are ,
n o t s o wi th r e gar d t o th e ir e ti ology A m ong s t th e ca s e s p ubli sh e d

.
s o m e h av e b e e n a t tribu t e d t o rick e t s s o m e t o a S p e cial an d ch ronic i n

,
fi am m at ory proc e s s o th e r s t o a s up e r abun d anc e o f th e g e r m a t i v e m a

,
-
t e ri al w h ich sh oul d la t e r con t rib u t e t o th e for m a t ion o f o s s e ou s t i s s u e ,
o r t o s o m e t roubl e o f nu tri t ion o f unkn o wn c au s e All th e s e h ypo .
t h e se s are s up p or te d by a c e r t ain nu m b e r o f fac t s In m any o f th e .
ob s e rva ti on s h e r e d i ty play s a s o m e w h a t i m por t an t par t b ut unt il ,
n o w no s uc h go o d e xa m pl e h as b e e n m e t wi th as in t h e fo llo wing ca se :
M r s K d i e d at 7 9 y e ar s o f g oo d g e n e ral h e al th h ad al way s h a d
. .
, , ,
s y m m e trical e xo s t o se s in t h e n e ig h b orh oo d o f t h e fe m o r o t ibi al a rti c u -
la ti o n s .
M R h e r bro th e r
. .
, , di e d y e ar s ; h ad fro m bir th e xo s t o se s on
at 83
th e low e r li m b s He . h ad four s on s wh o all b or e fe m or o t ibial e xo s t o

,
-
E ON E 5 , j Ol N T S , OR TH OP AE D I C .
35 3
se s . In o n e of th e m t h e y we re so de ve lop e d th a t h e walk e d wi th d if
fi c ulty .
Mm eo n ly d augh te r o f M m e X n ow act 6 2 h e al th y p o s se s s e s
. L .
, . .
,
.
, ,
s inc e h e r bir th t wo bu lky e xo s t o s e s on th e inn e r t ub e ro s i t i e s o f th e
t ibi ae S h e h a s h a d e ig h t c h il d r e n o f w h ich four ar e livi n g

. T he y all
,
.
h av e e xo s t o s e s S i t ua t e d on th e low e r li m b s at d i ffe r e n t h e igh t s an d

n e arly all sym m e t rical .
T h e e l d e s t o f th e s on s ac t 3 7 invali d e d on accoun t o f th e m ul tipl e

, .
,
a n d larg e e xo s t o s e s o f th e l e g s h a s two d aug h t e r s wh o pr e se n t e xo s t o

,
s e s o f t h e b on e s n e ar th e fe m o r o t ibial ar ticula t ion T h e se con d s on

-
.
,
ac t 3 4 h a s lik e h i s bro th e r b e e n e xcu s e d fro m m ili t ary s e rvic e on a c

.
,
coun t o f h i s e xo st o s e s H e i s h e al thy walk e d at 1 3 m on th s ; sh ow s no

.
,
incurva tio n o f th e long bon e s t e e th r e gular an d wi th ou t e ro s ion s hi s

m u s cular s ys t e m v e ry w e ll d e v e lop e d a n d ar t icula t ion s nor m al No ,
.
t rac e o f r h e u m a t ic syp h ili t ic or o th e r di a th e s i s

, H i s low e r li m b s are .
alon e th e s e at of th e ab no rm ali ti e s .
L F s o n o f th e pr e c e d e n t ac t 7 o f go o d g e n e ral h e al th brough t
. .
, , .
, ,
up at t h e br e as t walk e d a t 1 1 m on th s t e e th w ell plac e d an d wi th o ut

, ,
e ro s io n s n o incurva t ion o f th e lo n g bon e s or t rac e o f rick e t s

, n ever ,
h a d r h e u m a ti s m or e pip h y s ary p ain s ; e xh ibi t s e xo s t o s e s on th e fe m or a ,
t ibi ae a n d fi b u lae an d al s o o n th e c h on d ro s t e rnal ar ticula t ion s of th e

,
-
fi fth an d n in th rib s a n d on th e s capul ae , .
T h e th ir d s o n o f M m e L ac t 2 4 h as e xo s t o s e s lik e h i s bro th e r s
. .
, .
,
.
T h e four th c h il d o f M m e L i s a d aug h t e r wh o m arri e d young an d

. .
h as h ad e l e v e n ch il d r e n o f wh ich th e fi ve livi n g carry lik e h e r con

, , , ,
g e ni t al s y m m e trical e xo to s e s in th e n e igh b orh oo d o f th e kn e e j oin t - .
T h e h i s t ory o f th e fa m ily s e e m s wor th y o f i n t e r e s t b e cau s e i t e s t ab ,
li sh e s in c on te sti b ly th e t ran s m i s s ion o f th e e x o s t o se s by vir t u e of h e r e d

i ty b e c au s e i t p u t s in r e li e f th e ch ar a c t e r o f th e con g e ni t al e xo s t o s e s
, ,
a n d b e cau s e i t giv e s u s a m e an s o f d i s t ingui s h ing th i s fro m th e s p e cifi c
e xo s t o s e s T h i s ch arac te r i s th e sy m m e try wh ich h a s n ot fail e d onc e

.
in an y o f th e m e m b e r s of th e g e n e ra tion —P r og r es M ed Au gu st . . . .
1 885 .
P S ABR
. . A HAM ( L o n d on ) .
364 I N D E X OF 5 UR C I CAL F R O CR E 5 5
II . E xc i s i on of J o i n t By A M PH E L P S M D
th e Kne e -
. . .
, . .
,
( C h a t e au g ay N , C
. a se s for th i s op e ra t ion S h o ul d b e car e fully s e
le c t e d ; i t sh oul d n e v e r b e r e s or t e d t o i n c h i ldr e n un de r 8 y e ar s o f age ,
e xc e p t in c a s e s o f d e s truc tion o f th e e n t ir e j oin t an d n o t un t il o th e r
m e an s h a v e fail e d I t i s b e tte r at th i s a ge t o e xci s e th roug h e xplora

.
t ory O p e ni n g s s uch p or tion s of bon e an d t i s s u e a s are foun d d i s e a s e d

, ,
u si n g th e goug e s coop an d ch i s e l th orough ly e s t abli sh in g p e r fe ct

-
,
dr ainag e fixat ion an d e x t e n s ion

, C hro nic d i se as e s wi th d e fo rm i ty
.
,
e i th e r p urul e n t or n on p urul e n t n o t yi e l di n g to or din ary m e th o d s of

-
,
t r e atm e n t are s ui t ab l e c as e s a t an y a g e
, E x t e n s iv e s uppur at i on b ur
.
,
rowing o f p us wi th m any sinu se s d i st rib u t e d ab ou t th e j oin t an d e x

,
t e n s iv e n e cro s i s m akin g i t d i fficul t unc e r tain or i m po s s ibl e t o r e m ov e

, ,
all d i se a s e d t i ss u e are ca se s s ui t ab le for a m pu t a t ion

, D e for m i ti e s .
fro m long s tan ding ar th ri t i s wi th b ut li t tl e bon e di s e a se li m i t e d t o th e

, ,
a r ti cul at ion s are v e ry favorabl e ca s e s for e xci s ion Ankylo s i s in b ad

.
p o s i ti on c om pou n d lux ation an d s ublux ation fro m long st an ding j oin t

,
di se a se sh oul d b e e xci s e d M any c a s e s o f j oin t di s e a s e am ong th e p oor

.
,
wh ich m i gh t by lon g tre atm e n t b e cur e d i f th e p a t i e n t s coul d S p ar e

,
t i m e fro m th e ir work sh oul d b e e xci s e d

, b e cau s e th e y are th e n s oon
.
r e s t or e d t o h e al th wh il e i f th e op e rat ion w e r e n ot p e r form e d am p u

, ,
t at i on woul d qui t e lik e ly b e d e m an d e d in a ft e r y e ar s owi ng t o fre ,
qu e n t r e lap s e s Th e e n d s ough t in all op e ration s o f e xci s ion o f th e

.
k n e e j oin t Sh oul d b e ( 1 ) t o r e m ov e all th e di se as e d t i s s ue inclu d ing th e

'
-
,
c ap s ul e o f th e j oin t ; ( 2 ) t o m ak e th e inci sion s in s uch a m ann e r as t o

fii rn i sh e as y acc e s s t o e v e ry p ar t o f th e j oi n t a n d s upply p e r fe c t d rai n
a ge ; ( 3 o r e s t or e o ld ti s s u e s t o th e ir norm a l po s i t ion wi th ou t l e a vin g
) t
c avi ti e s ( 4) t o ge t p e r fe c t drainag e ; ( 5 ) t o in s ur e ab s olu t e i m m o

b ility o f p art s a fte r th e op e ra ti on ; an d ( 6) in ch il dr e n a ft e r r e se c t ion o f ,
th e fl e xor t e n d on s placi n g th e li m b s traigh t an d u t ili z ing th e pa t e lla

, ,
wh e n pr a c ticabl e t o pr e v e n t r e lap se s T h e op e ra tion s wh ich b e s t

, .
m e e t th e s e in d ic ation s are Volk m an n s F e n wick s an d Ne ub e r s

’ ’ ’
.
,
W h il e t e no to m y of th e h am s tring te n d on s h as b e e n fr e qu e n t ly p e r
form e d t o a llow s t raig h t e ning o f th e li m b b e for e th e op e ra t ion t o ob ,
v i at e t h e s ac rific e o f a gr e a t e r am oun t o f bon e th e a u th or b e li e v e s r e

,
s e c tion o f all th e fl e xor t e n d on s t o pr e v e n t th e ir s ub se qu e n t a c tion in

,
G YN E C OL O GI CAL . 36 5
pro d ucin g r e l ap se in ch il dr e n t o h av e o ri gi na t e d wi th h i m s e lf an d con

, ,
s i d e r s th at i t a dd s gr e atly t o th e e ffi cacy o f th e op e r at ion whil e d e ,
tr ac t in g no th ing fro m i t s s afe ty T h e p ap e r i s acco m p ani e d by r e

'
p o rt s o f nin e ca s e s in four o f wh ich th e fi e xor t e n don s w e r e r e se c t e d

, ,
an d t abl e s o f 3 2 9 O p e ra ti on s a n t i se p tically p e r form e d — I V Y IlI ed . . .
R ec . 1 88 6
. J uly 2 1 .
E PI LC H E R ( U S Arm y) . . . .
G Y N IE C O L O G I C A L .
xa n d e r s O p e r at i o n
’
Dr D ol eri s con trib u te s a l e ng th y
. .
a rti cl e on thi s s ubj e c t t o t h e N ou velles A r c/zi ves d OFs tet r i g ue et d e

’
Gy n ecolog i e ( J an t o May inclu s iv e )

. ,
A ft e r r e vi e wing a t l e ng th th e
.
h i s t o ry o f th e op e ra tion w h ich h e cl e arly S h ow s was fir s t s ugg e s t e d by

,
Alqui é in 1 8 4 0 h e ci t e s Al e xan d e r s ca s e s in full a n d a dds t o th e s e

,
’
,
.
1 00 o th e r s w h ich h e h as co lle c t e d in li t e r at ur e To th e s e sh oul d b e .
a d d e d nin e m or e O p e ra t ion s by Dr Polk o f th i s ci ty th r e e by Dr.

J B , . . .
Hun t e r ( n ot r e po rt e d) an d t wo by Dr F B Ha rri ng t on o f Bo st on . . .
, .
S e v e ral o th e r s h av e b e e n p e r form e d in th i s ci ty so th at th e nu m b e r of ,
act ual op e ra ti on s i s p r ob ably 1 7 5 at th e low e s t e st i m a te I n spi t e of .
th e e vi d e nc e th u s a dd uc e d th e r e i s a S ingul ar fe e li ng o f unc e rt ain t y

,
a m on g gyn e cologi s t s wi th r e g ar d t o th e ulti m at e v alu e o f th e op e ra
ti on. I t s t e ch ni qu e r e quir e s n o fur th e r e xp o s i ti on AS r e gar d s th e p er .
m a n en ce o f th e r e s ul t s we ar e s t ill l e ft v e ry m uch in th e d ark .
I I O O p h o r a p h y Un de r thi s nam e D r I m lach d e s crib e d b e fo re

. . .
th e B ri ti s h Gyn e cologi cal S oci e ty a nov e l O p e r ation for th e p e r m an e n t
r e po s i ti on of prolap s e d ov a ri e s wh e n th e ir e x ti rp ati on by l ap aro t o m y

,
i s un d e sir ab l e . I n m ul tip ar ae accor d in g t o th i s g e n t l e m an th e ov ari e s

, ,
are k e p t in plac e by th e in fun d ib ulo p e l vi c li g am e n t s ; w h e n e v e r th e

-
la tt e r b e co m e m uch r e lax e d th e ov ary s in k s d own w ar ds an d b e co m e s

,
co n g e s te d by r e a s on o f th e in te rrup tion of th e circula tion i n th e v e ss e l s

s upplyi n g th e org an Dr I m lach s e e k s t o r e st or e th e prol ap s e d ov ary
. .
t o i t s n orm al p o s i t io n in th e p e lvi s an d t o m ain t ain i t t h e re by Sh or te n
In g th e r e l a x e d in f n d ib ulo p e lvic li ga m e n t an d s u t ur in g i t t o th e
u -
h ilum . F our t e e n s ucc e s s ful c a se s w e r e r e p ort e d In th e di s cu s sion .

3 6 6 I N D E X OF 5 UR CI CA L P R O C R E 5 5 .
wh ich follow e d th e p ap e r Mr Law s on Tai t in s i ste d th at prolap s e d

.
ovari e s w e r e u s ually th e s e a t o f ch ronic inflam m a tion an d th e r e for e ,
th a t th e O p e ra t i o n Sugg e s t e d by Dr I m lach m i gh t r e li e v e b u t woul d

.
,
n e v e r cur e th e p a ti e n t
,
.
I I I A N e w O p e r a t i o n f o r R e p a i r o f C o m p le t e L a c e r a
.
ti o n of th e P e rin eum Dr R A J am i e s on r e por te d t o th e s a m e

. . . .
s o ci e ty th e s ucc e s s ful r e s ul t s ob t ai n e d by th e fol lo wing m e th o d o f O p
c ra t i n g i n ca se s o f lac e ra t ion o f th e p e ri n e u m
, t h roug h th e s p h i n c t e r
S e para t e th e r e c t o vaginal s e p tu m i n t o t wo lay e r s fo r a di s t anc e o f

-
ab ou t h al f an inch [fro m th e anu s th en d ivi d e th e vagi n al p or tion

lo n gi t u di n ally i n th e m e dian lin e d i s s e c ting up th e m ucou s m e m bran e .
wi th a por tion o f th e a dj ac e n t s kin forwar d s on e i th e r s i d e to th e l e ve l

,
o f th e i n s e r t ion o f t h e la é i a m i n or a T h i s i s now s e p ara t e d in th e

.
for m o f a s trip b ut i s s i m ply li ft e d fro m i t s pr e viou s a t t ach m e n t t o th e
,
d e p th o f i n c h e s parall e l to th e long axi s o f th e b o dy i ts fr e e b or

, ,
d e r b e ing th e m e d ia n lo n gi t u d inal in ci sion an d a curv e d li n e d ra wn

ab ou t h al f an inch b e low th e j u n c tio n o f th e p artlyalt e r e d vaginal m u
"
”
co u s m e m bra n e wi th th e S kin o f th e th igh T r an s fi x t h e h orizon t al
.
b or d e r o f e ach flap wi th a pi e c e o f ca t gu t t o th e e n d o f wh ich i s a t ,
t ac h e d a pi e c e o f l e a d A cu t an e ou s flap 4 inch e s lo n g h aving th e

.
,
S h ap e o f an i s o s c e l e s t riangl e wi th i t s b a s e corr e s p o n ding t o th e lin e

,
o f j unc t io n o f t h e S kin a n d m ucou s m e m bran e i s now m a d e on e ac h ,

.
s i de . T h e s e wi th th e m uco cu t an e ou s fl ap s are d i s se ct e d upwar d s

,
- “
,
a n d ou twar d s t o a lin e parall e l wi th th e ir b a s e s b u t a quar te r o f an ,
”
inch e x te rnal t o th e m an d a quar te r o f an inch d e e p e r
, T h e raw s ur .
fac e s o f th e m uco cu t a n e ou s flap s ar e s ti t ch e d t og e th e r wi th fi n e c at

-
gu t along th e m e d ian lin e t o for m th e low e r p ar t o f t h e n e w p o s t e rior

,
vagi n al wall . T h e n e w p e rin e u m i s m a d e by carrying a con tinuou s
c at gu t s u t ur e fro m S i de t o s i d e along th e lin e s o f d e nu d a tion a quar

t e r o f an inch in t e rnal t o t h e inclin a t ion o f th e cu t an e o u s fl ap s t o th e
”
s ubj ac e n t ar e ol ar ti s s u e T h e an t e ri or e d g e o f th e r e ct al wall i s n e x t
.
drawn d own an d fa s te n e d b e hin d th e n e w p e rin e u m a n d th e cu t an e ou s ,
flap s:are loo s e ly r e plac e d l e aving on e ach S i d e

“
,
inch e s b e tw e e n th e ir
C VN AE C OL O CI CAL .
6
3 7
a pic e s an d th e api c e s o f th e ir for m e r b e d s In o r de r t o co m p l e te th i s

.
”
co m plica t e d op e ra tion i t s au th or d ir e ct s th a t two s u t ur e s b e carri e d on

,
e ac h S i d e d e e ply in t o th e p e rin e o crural angl e s o a s t o e n s ur e th e

“ -
for m a tion o f a fol d in th i s S i t uat ion wh il e a lin e o f s u t ur e s i s carri e d

along th e e dg e s o f th e flap s an d th e b or de r s o f th e gap wh i ch r e m ain s
,
ar e d rawn t og e th e r .
In th e cour se o f th e di s cu s sion wh ich follow e d t h i s ra th e r blin d d e

s crip t ion Dr F ancour t Barn e s r e fe rr e d t o t h e op e ra t ion p e r for m e d by
.
Mr Tai t th e e s s e n tial fe a t ur e o f wh ich wa s th e S pli tting of th e r e c to

.
,
vaginal se p t u m Th e a d van t ag e s o f Tai t s m e th o d w e r e rapi di ty ab

.
’
,
se n c e o f s ub s e qu e n t p ai n th e fac t th a t t h e n e w p e rin e u m wa s m o r e
,
s oli d an d th a t th e b ow e l s coul d b e m ov e d s oon a ft e r th e op e ra t ion

,
.
Th e op e ra t ion was equally applica t ion t o any vari e ty o f p e rin e al lac e ra
t ion .
Dr I m la ch d e s crib e d a m e th o d by wh ich a flap was t ak e n r om

.
e ac h labiu m th a t on th e l e ft S i d e b e in g t urn e d ou twar d wh il e t h e righ t

, ,
h an d flap h a d i t s b a s e in t h e m e d ian lin e o f th e po s t e rior vaginal wall .
A s trip fro m th e r e ct o vaginal s e p t u m was th e n t o b e d i ss e c t e d o u t

-
war d s T h e fr e e e d g e o f th e rig h t flap was d rawn acro s s t o th e l e ft

.
labiu m an d a tt ach e d t o i t s raw s ur fac e by fi n e s u t ur e s ; th e l e ft flap

”
wa s uni t e d in a s i m ilar m ann e r t o t h e rig h t labi u m “
T h e n in t h e .
,
wor d s of th e S p e ak e r p a s s a S ingl e s ti tch th rou gh th e an t e rior e d g e s

“
,
t o pr e v e n t infil t ra tion o f vaginal s e cr e tion s a n d th e n th rough th e r e c t o

,
”
v aginal s trip b e h in d Dr I m la ch clai m e d th a t a s oli d p e rin e al bo d y
. .
wa s for m e d in th i s way an d n o t a m e r e m e d ia n cica trix as a fte r m o s t

, ,
O p e ra tion s .
IV . i i o n o f t h e D i s e a s e d P o rt i o n o f a C an c e r o u s
E xc s
U t e r u s P r e li m i n a r y t o T o t a l E x t i r p a t i o n PE AN clai m s pri .
o ri ty in th e following m o d ifi c a tion o f t h e or d in ary op e ra t ion o f va g in a l
h y s te r e c t o m y Th e op e ra t or b e i n g provi de d wi th t wo th e r m o cau t e ry
.
,
-
kn iv e s a t a wh i t e h e a t proc e e ds t o r e m ov e s m all frag m e n t s o f th e di s

,
e a s e d t i s s u e un t il n o th ing i s l e ft b ut th e sh e ll co m po s ing th e h e al th y
u t e rin e wall T h e r e i s no s e riou s h aem orr h a ge d uri n g th i s pro c e d ur e

. .
368 INDE X OF 5 UR C I CAL F R 0CR E 5 5 .
Th e cu l- de-s a c now O p e n e d an d th e u te ru s r e m ov e d in th e u s u al
is
m ann e r e xc e p t th a t th e v e s s e l s in th e bro ad liga m e n t s are at onc e
,
s e iz e d en m asse wi th long h ae m o s t a t ic forc e p s liga t ur e s b e ing appli e d ,
a t l e i s ur e — Ga z d es H o
.
p . 1 88 6 J an 2 1
. . . .
V . C o n s e rv a t i v e O v a ri o t om y . Pro fe s s or S C H R OE D E R h as re
c e n tly d e vi s e d
an ing e niou s op e ra tion w h ich con s i s t s o f e xci s ing th e
,
d i se a s e d por tion o f an ov ary a n d le av mg th e h e al th y t i ss u e wi th a Vi e w ,
t o th e pr e s e rva t ion o f th e func tion o f th e organ A fte r car e fully di s .
s e c ti n g o u t th e larg e r cy s t s Pro f S chr o e d e r uni t e s th e raw s ur fa c e s

, .
wi th fi n e s u t ur e s an d th e n r e s t or e s th e ovary t o th e ab d o m in al c avi ty .
Accor din g t o th e e xp e ri e nc e of th i s c e l e bra t e d s urg e on an d of th o s e ,
wh o h av e pr a c t ic e d th i s O p e ra t ion th e r e s ul ts h av e b e e n m o s t gra ti fy
,
in g. Wh il e m e n s tru ation con tinu e d th e form e r dy sm e norrh oe a was

,
r e li e v e d in s e v e ral in s tanc e s In o n e ca s e th e p a ti e n t b e ca m e pr e g
.
n an t a ft e r e xci s ion o f por tion s o f bo th ovari e s .
V The U C o c a i n e i n G yn e c o lo g y Dr GE O R G E W
se of . . .
J O H N S T O N ( Wa shi n g ton) A fte r di s cu s s in g th e valu e o f th e dr ug as a

.
local an ae s th e t i c in ca s e s o f v a gini sm u s th e wri t e r d w e ll s upon i t s u se

in op e ra tiv e work a cknowl e d gin g th a t i ts ran g e i s r e s tric te d Coc ain e
, .
d o e s n o t pro d uc e th at pro found an d p e rm an e n t an ae s th e s ia wh ich i t i s

n e c e ss ary t o m ain t ain d uring O p e ra t ion s upon s uch s e n s i t iv e p ar t s a s
th o s e in t h e fe m al e g e n i t al t rac t T h e op e r at or m u s t r e p e a t e dly re
.
s or t t o fr e sh i nj e c t ion s o f th e d rug wh il e prac t ically i t i s foun d t o b e

,
d i fficul t to k e e p th e pa ti e n t in a con s t rain e d p o s t ur e e v e n wh e n sh e i s ,
fr e e fro m a c t ual p ain .
T h e a u th or r e co m m e n d s th e s trong e r s olu t ion ( 2 0 u s e d in G e r

m any . Th e p ar t t o b e a n aes th e tiz e d s h oul d b e th orough ly wa sh e d
wi th an an ti se p ti c s olu tion an d th e n car e fully dri e d b e for e th e app li
,
c ation s of cocain e are m ade A fte r th orough ly p e ncillin g th e par t wi th

.
th e s olu t ion ab ov e m e n t ion e d a pi e c e of ab s orb e n t co t t on s oak e d in
th e flui d s h oul d b e allow e d t o r e m ain in co n t a c t wi th i t T h e an aes th e t ic .
e ffe c t i s ob t ain e d in fr o m four t o s i x m inu t e s D e e p inj e c t ion s m ay b e

.
G YN AL C OL O GI CA L 369
‘
pr ac tic e d in c e r tain locali t i e s ; by b e ginning th e d e nu d a tion at th e

m o s t d e p e n d e n t p oin t in p la s t ic op e ra t ion s on th e v a gina e ach ar e a ,
m a y b e cocainiz e d a s i t i s r e ach e d T h e au th or s u m m a riz e s wi th th e

.
opinion th a t by s ur fac e p e ncilling wi th strong s olu tion s in n e arly all

“ -
th e s i m pl e r an d m or e fr e qu e n t pla s ti c op e ra t ion s abou t th e vagin a an d
c e rvix a s u ffici e n tly d e e p an d prolo n g e d an ae sth e s i a m ay b e pro

”
d uc e d .
F ollo wing th e b o dy o f th e p ap e r are a nu m b e r o f r e p or te d c ase s ,
s e v e ral o f w h ich occurr e d in th e au th or s prac ti c e in wh ic h c o lop rr ap h y

’
, ,
t rac h e lorrh ap h y op e ra t ion s on th e ur e th ra e t c

, w e r e s ucc e s s fully p e r
, .
,
for m e d wi th ou t p ain t o th e p a t i e n t T h e p ap e r d e se rv e s no li ttl e c om

.
m e n d at i on a s i t pr e s e n t s in a conci s e for m
,
a coll e c tion o f val uabl e
s urgical m e m oran d awh i c h we r e wi d e ly s ca tt e r e d th rough o u t th e li t
e ra t ur e —Ill ed i ca l R ecor d 1 88 6
. J uly 1 7 . .
V I I T h e T re at m e n t o f R e t ro fl e xi o n o f t h e U t e ru s b y a
.
R e c e nt O p e rat i v e M e th o d VO N R O BE N AU
. T h e au th or s u g
.
g e s t s th e following nov e l op e rat ion for th e r e li e f of ca se s o f re tro fl e xi on

in wh ich e i the r a p e s s ary canno t b e r e t ain e d or i f worn fail s t o k e e p
, , ,
th e u t e ru s in prop e r po s i ti on . T h e an t e rior lip o f th e c e rvix i s c om
p l e t e ly e xci s e d t o t h e h e ig h t o f 4 c e n t i m e tr e s
“
T h
. e i m m e d ia t e r e
”
s ul t in th e wor d s o f a co m m e n t at or in th e Cen t r a lb la t f u r Gy n aleolo ‘
g i e
,
“
i s a p e r fe c t r e p o s i t ion o f th e u t e ru s w h ,ic h i s e xplain e d by t h e
fac t th a t th e larg e r an te rior conv e x s ur fac e i s S o r e d uc e d in s iz e by th i s

”
h igh e xci sion th a t i t b e co m e s s m all e r th an th e fp os t e ri or concav e .
T h roug h th e r e s ul ting cica trization th e organ i s d rawn upwar d in t o

’
i t s nor m al po s i tion . T h e au th or s ob s e rva t ion s an d e xp e ri m e n t s w e r e
in te rrup t e d by h i s un ti m e ly d e a th s o th a t th e nu m b e r o f r e cor d e d op
,
e ra t i o n s only a m oun t s t o s i x . In four o f th e s e th e r e s ul t i s s t a t e d a s

n i l in t h e o th e r t wo d o ub tful
,
. I n r e vi e wi n g th e r e p or t s o f th e ca se s
in w h ich i t i s naiv e ly acknowl e d g e d th at th e e x t e n s iv e cica tricial con

t rac t ion fr e qu e n t ly le d t o s t e no s i s o f th e c e rvi cal c an a l a n d r e s ulting
dy s m e norrh oe a th e r e ad e r will b e le d t o won d e r n o t so m uch a t th e

,
h e roi s m o f t h e s urg e on a s a t h i s fai th in th e e ffi cacy o f an O p e ra tion

,
wh i ch s avor s m or e of th e d ark ag e s th n o fa mo d e rn s ci e n ti fi c gy n ae
c o lo gy .
— B er li n er Rli n . Woc/zen s clz . 1 886 . No 1 8
. .
VI I I i er S t at i s t i cs C a n ce r o f of O p e rat i on s fo r
’
. H o fm e s
th e Ute ru s Di s cu s s i n g th e qu e s tio n o f th e ra d ical cur e o f m alig

.
na n t d i s e a s e o f t h e c e rvix u te ri b e for e th e B e rlin O b s t e trical an d Gyn

e col o g ical S oci e ty H o fm e i e r co m p ar e s th e r e s ul t o f op e ra t ion s a fte r
,
p e rio d s varyi n g fro m o n e t o fi ve y e ar s T h e r e p or te d cur e s a ft e r t o t al .
e x tirpa t ion a m ou n t e d t o 4 8% a t th e e n d o f th e t h ir d ye ar o n ly 1 4 %
o f th e p a ti e n t s r e m ain e d fr e e fro m t h e d i s e a s e H e conclu d e s th a t in .
s ui t abl e ca s e s o f s up r a vaginal a m pu t a t ion n o r e curr e n c e i s

45 % f th -
o e
ob s e rv e d s o th a t th e s e p a t i e n t s m ay b e fairly co n s i d e r e d a s cur e d H
,
. .
b e li e v e s th at i f th e ab ov e O p e ra tion h as b e e n th orough ly p e r for m e d th e

d i s e a s e rar e ly r e t urn s wi th in a y e ar a n d th e n n e arly alway s in th e p e r ,
u te ri n e t i s s u e s W h e n , h e s ay s e m p h a tically a y e ar a ft e r O p e ra tion
.
,
th e r e i s n o e vi d e n c e o f a local re curr e n c e i t m ay b e s a fe ly a ffir m e d ,
th a t th e r e will n e v e r b e an y To th i s rul e h e h as s e e n o nly four e x

'
c e p t i o n s a m o n g for ty fi ve ca s e s - .
X I C a s t r a t i o n i n t h e T r e a t m e n t o f C a v e r n o u s M yo
.
F i b r o m at a o f t h e U t e r u s Dr G O LD E N BE R G lay s p ar ticular s tr e s s
. .
u p o n th e applica t ion o f th e s o call e d H e gar s op e ra tio n t o ca s e s o f

-
’
u t e rin e fi b r oi d s in wh ich th e t u m or i s r e cog n iz e d a s a s o ft i n te r s ti ti al

grow th wi th a rich va s cular s upply In th i s cla s s o f t u m or s th e e n tir e
,
.
u t e ru s i s d i s e a s e d a n d h ae m orrh ag e i s a pr o m in e n t an d d a n g e rou s
,
s ym p t o m b e cau s e o f th e e xc e s s iv e co n g e s tio n wh ich a tt e n d s e ach

,
m e n s t rual p e rio d T h e wri te r b e li e v e s tha t pro d uc t io n o f t h e pr e m a

.
t ur e m e n o pau s e as w e ll as a m ark e d d e cr e a s e i n t h e s iz e o f t h e t u m or ,
a r e r e s ul t s m or e invari ably ob t ain e d w h e n th e fibroi d i s o f th e s o ft or
cav e rnou s vari e t y th an w h e n i t i s h ar d a n d l e s s in ti m a te ly conn e c t e d

,
wi th th e u t e ru s T h e S iz e o f th e t u m or a s w e ll a s t h e a g e a n d g e n e ral
.
co n di ti on of th e p at i e n t d o n o t a ffe c t th e valu e o f th e O p e ra tion .
Cen tb l .
f . Gyn a k f
G YI V/ E C OL O GI CA L .
37 1
X . V ag i n a lH y s t e r e c t o m y fo r C a n c e r Pro f S C H U L TZE . .
( J e na ) S c
. h ul t z e g iv e s t h e r e s ul t s o f t h r e e ab d o m inal a n d nin e vaginal
h y s t e r e c t o m i e s a n d d e d uc e s fro m t h e m c e r t ain prac tical l e s s on s v iz

, ,
I f t h e c e rvix a lo ne can b e a m pu t a t e d a t a p oin t 1 c e n t i m e t r e ab o v e
t h e upp e r li m i t o f t h e d i s e a s e a s fe l t by t h e fi n g e r th e n a m pu t a tio n
, ,
i s t o b e pr e fe rr e d t o t o t al e x ti rp a t ion I f h ow e v e r th e po s t e rior cu l
.
, ,
de s a c i s op e n e d d uri n g t h e for m e r op e ra t i o n th e n t h e s urg e on S h oul d ,
n o t h e s i t a t e t o r e m ov e th e e n tir e organ [ T h i s i s oppo s e d t o th e .
t e ach i n g t h a t op e ning o f th e p e ri t o n e al cavi t y d uring O p e ra t ion s on t h e
c e rvix i s a co m para t iv e ly i n no cuo u s proc e e di n g] .
B e for e un d e r taking th e op e ra t ion a fte r th e p a ti e n t i s an ae s the tiz e d

, ,
a t h orough e xa m in a tion s h oul d b e m a d e by th e r e c t u m vagin a a n d b i ,
m anually in or d e r t o d i s cov e r th e e x t e n t t o whfc h th e s urro u n ding t i s

,
s u e s h av e b e e n inva d e d I t i s i m po s s ibl e t o d e ci d e po s i t iv e ly on t h i s
.
poi n t s inc e in s o m e ca s e s t h e d i s t al por ti on s o f th e broa d liga m e n t s

,
m ay b e a ffe c t e d w h il e th e ar e a s i m m e d ia t e ly a dj ac e n t t o t h e u te ru s
,
are n o t d i s e a s e d .
S b e li e v e s th a t t h e d iag n o s i s o f canc e r o f th e co rpu s u t e ri can b e

.
m a d e m or e p o s i tiv e ly by in t ro d ucing th e fi n g e r th roug h t h e d ila t e d 0 5
th an by e xa m i n ing m icro s copically frag m e n t s r e m o v e d by th e cur e t t e .
—D eu ts cfz . M ed Z e i t. . 1 886 . NO . 24 .
XI . R ete oe t u s i n O n e H o r n o f a n U t e r u s B i
nti on of a F
c orn i s ; E xt i r p at i o n
o f t h e P r e g n a n t H o r n Dr W I E N E R T h e
pa . . .
t i e n t wa s ae t 2 9 a n d h a d b or n e t w o ch il d r e n th e la s t s e v e n y e ar s b e for e
.
, , .
H e r m e n s e s c e a s e d in D e c e m b e r 1 8 8 3 a n d th e foe t al m ov e m e n t s w e r e
, ,
fe l t fo r th e la s t t i m e in S e p t e m b e r 1 8 8 4 Th e wo m an s h e al th b e gan t o
, .
’
d e clin e a n d a m o n th la t e r s h e wa s se iz e d wi th s e v e r e p ain s i n th e l e ft
,
S i d e o f th e ab d o m e n a c c o m p a in e d by u t e rin e h ae m orr h ag e w h ich e r

,
p
s i s t e d fo r t h r e e w e e k s W h e n r e c e iv e d in to th e h o spi t al an d e xa m in e d
.
un d e r e th e r i t wa s fo un d th a t th e u te ru s wa s d i splac e d t o th e l e ft by a
,
s m oo t h h ar d t u m or wh i ch fill e d th e p e lvi s an d th e low e r p or t ion o f

, ,
t h e ab d o m e n .
In th e p o s te rior fornix was a m a s s r e se m bling a foetal h e ad ; t h e

gr ow th app e ar e d t o b e a tt ach e d t o th e u te ru s by a th ick sh or t p e dicl e , .
T he pr obabl e d iagn osi s o f e x tra u te rin e pr e gn an cy was m a de an d -

,
lap ar ot om y wa s p e r form e d Th e t u m o r was fo un d to b e th e ri gh t

.
h o rn o f a d o ubl e u t e ru s con t ai ning a m a t ur e foe t u s in a s ta te o f b e in

,
g
ni n g m ace ra tion T h e m a s s was liga te d an d r e m ov e d in th e s am e
.
m ann e r a s an ovari an c ys t Th e r e wa s pr o fo un d sh ock for fi ve d ays

.
,
wi th rapi d fe e bl e pulse vo m i t ing a n d m ode ra t e ri s e o f te m p e rat ur e

, , .
Th e pa ti e n t th e n ralli e d a nd was d i s ch arg e d cur e d a t th e e n d o f fo ur , ,
w e ek s .
An e xa m in a ti o n pr e viou s t o h e r d e par tur e r e v e al e d th e pr e s e nc e o f

a le ft h o rn 6 c f m in l e ng th wi th a v e r tical s e p t u m wh i ch h ad for m e rly
.
, ,
s e para t e d i t fr o m t h e rig h t Inv o lu ti on p r o c e e d e d n orm ally a nd th re e

.
m on th s la te r th e u te ru s h a d r e t urn e d t o th e n o r m al S iz e o f th e o rg an
a t th a t t i m e .
C o m m e n ting upon th i s ca s e th e wri te r b e li e v e s th a t i t s r e s ul t i f l e ft ,
t o i t s na t ural cour s e w o ul d h av e b e e n d i s a s t r o u s s inc e t h e foet u s w o ul d

,
h av e b e co m e d e c om p os e d an d rup tur e o f th e s ac wi th e s cap e o f i ts

,
c on t e n ts in to th e p e ri ton e al cavi ty woul d h av e b e e n a n o t un lik e ly o c

curr e nc e Op e ra tiv e i n te r fe r e nc e i s cl e arly in dicat e d S i nc e th e pr o gn o s i s
.
,
i s fav o rabl e T h e s t u m p sh o ul d b e t r e ate d in t rap e ri to n e ally in e v e ry

.
in s t anc e un l e ss th e r e ar e e vi d e nc e s o f a dvanc e d d e co m po s i ti o n o f th e
,
foe t u s —
. A r c/zi v f Gy n a k Bd XX VI
. . H ft 2. . . . .
XII . I t a li a n S t at i s t i c s of V e s i c o V a g i n a l F i s t u la
Dr - . .
M O R I S AN I Th e au th or r e p o r ts fi fty ca s e s o f fi s tula On e h un dre d

. .
a n d e l e v e n O p e ra tion s w e r e p e rfor m e d fo r t y o n e pa t i e n t s b e ing cur e d

,
-
’
an d se v e n r e li e v e d Th e r e we r e t wo d e ath s fr om s e p tic ae m ia S i m s
. .
O p e ra t i o n wa s th e o n e p e r for m e d in m o s t in s t anc e s th e s ilv e r s u t ur e ,
b e ing pr e fe rr e d —A n n a li d i Os tet
. .
X I I G r a d u al A m p u t at i o n o f a n I n v e r t e d U t e r u s b y
.
M e a n s o f a L i g at u r e Dr PO N CE T T h e inv e r te d u te ru s wa s
. . .
dr awn d ownwar d a s far as p o ss ibl e wi th a v o l s e lla a n d a s t ou t s ilk lig

a tur e wa s p a s s e d aroun d th e p e d icl e of th e t um or a n d th e e n d s at ,
t a c h e d t o a s er r e n ce u d -
T h e cor d was t igh te n e d un til th e p a t i e n t
.
a s n o t an ae s th e tiz e d) co m plain e d o f fe e ling a s ligh t p ain T h

( w h o w e .
vagina wa s th o r ough ly d i s in fe cte d b e for e an d a fte r th e Op e rati on an d ,

5 YP H / L1 5 .
37 3
wa s pack e d wi th io d o for m gauz e T h e li g a t ur e was tigh t e n e d a li ttl e

.
e ac h d ay th e pa t i e n t e xp e ri e nci n g b u t a m o d e ra t e a m oun t o f di s c o m
,
for t a n d h avi n g an i n s i gnifican t ri s e o f t e m p e ra t ur e A larg e s lou gh

cam e away on th e e l e v e n th day an d on th e t we n ty thir d a vaginal e x
,
-
am ina tio n r e v e al e d no t rac e o f t h e u t e ru s b u t on ly a tra n s v e r s e lin e ar ,
cica trix in th e roo f of th e vagina —A r c/z de Tocolog i e 1 8 8 6 Apri l

. . . . .
H . C CO E
.
( N e w Y ork ) .
S Y P H I LI S .
I . N e cros is C la v i c l e o f S y p h i l i t i c O r i g i n S u b F e r i o s
of .
-
t e a l R e s e ct i o n By M G I LL E TT E ( Pari s ) In thi s op e r ati on wh ich

. . .
,
wa s p e r for m e d on accou n t o f ne cro s i s a ttribu t e d to s yp h ili s all b ut th e ,
inn e r 3 c m o f th e b on e was r e m ov e d I t i s no te wor th y for th e r e pro

. .
i
d uc tion of a b r d g e o f n e w b o n e conn e c t ing th e s te rnu m an d th e s cap
ula an d for th e co m pl e te r e s t ora tion o f all m ov e m e n ts
,
.
T h e p at i e n t con trac te d s yp h ili s at th e a g e o f 1 7 wa s t r e a te d fo r a ,
fe w w e e k s an d s u ffe r e d only fro m s ligh t r e m in de r s un til July 1 8 8 4

, , ,
wh e n h e was 2 5 y e ar s old Th e n wi th ou t appar e n t c a u se a s w e lling

.
form e d ov e r t h e m i ddl e o f th e R cl avicl e an d in a sh o rt ti m e s e v e ral

.
,
s inu se s le d d own t o d e a d bon e K e e ping wi th i n th e p e rio s t e u m

.
M Gill e tte s aw e d th rough th e bon e at i t s inn e r h e al th y e n d an d e x

.
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tr ac t e d wi th ou t any m a t e rial h ae m orr h ag e

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m ay b e d oub tful wh e th e r th e n e cro s i s wa s r e ally s yp hi li tic no S p e ci al ,
s e arch wa s m a d e a s t o t ub e rcl e In th e s ub se qu e n t di s cu s sion a Si m

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lar c as e in w hich an e qually s ucc e s sful O p e r ation was p e r for m e d wa s

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m e n t ion e d wh il st M Tr el at m ai n t a in e d th a t th e rig h t t r e a tm e n t wa s t o
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r e m ov e th e s e q e s tra an d n ot t o e xci s e th e wh ol e bon e h e adm i t t e d ,
h ow e v e r th e co m pl e te s ucc e s s o f th e O p e r ation
,
M Tilla ux ( Ana t . . .
Topo grap h P 4 7 9 ) d e s c rib e s th e ca s e of a Pa ri si an w ri t e r wh o i n

. .
s pi t e o f a p s e u d ar thr o s i s in on e cl avicl e s u ffe r e d n o inconv e ni e nc e e x
c e p t wh e n carrying h e avy w e igh t s on th a t Sh oul de r —B u ll de la S oc . . .
de C /zi r u rg i e M arch 1 8 8 6 . . .
3 74 I N D E X OF 5 UR CI CAL F R OC R E 5 5 .
I I T r e at m e n t o f C h r o n i c G o n o rr h oe a b y M e a n s o f
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G r o o v e d B ou g i e s . By Dr LE O P O L D C A S P E R ( B e rlin) T h e au th or
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a s se r ts th at h e h as by th e d aily p a s s ag e o f larg e nick e l p lat e d b ougi e s

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N s 1 8 t o 2 3 C h arri er e ) s ucc e e d e d in curing ab ou t fi fty inv e t e ra t e

( o .
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c a se s o f gl e e t
. E ach b ougi e h as a s e ri e s o f si x longi t u dinal groov e s
wh ich are ch ar g e d wi th an a s tring e n t s alv e . A ft e r vario u s tri al s h e

foun d th e b e s t a s tring e n t t o b e ni tr at e o f s ilv e r wh ich i s m ix e d in t h e
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propor tion o f gr i n s t o 1 0 0 of c a cao b u tt e r an d t wo of b al s am o f

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copaib a Th e cacao b u tte r m u st b e only j u st m e l te d for fe ar o f re

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d u c i n g th e s ilv e r b y ov e r h e at ing
- . E ach b ougi e i s l e ft in th e ur e th ra
’
fo r fro m a fe w m in u t e s t o an h our d e p e n ding on th e p at i e n t s t ol e r
,
a nc e .
Ca sp e r agr e e s wi th th e g e n e rally h e l d O pinion th a t gl e e t u s u ally

ari s e s fro m ch roni c infl am m at ion in th e b ulb ou s p or tion an d th at i t ,
i m pli e s a th r e ate ning s tri c t ur e h e nc e h e in si s t s upon th e u se of l arg e

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b ougi e s T h e r ar e ca se s o f gon o rrh oe a po s t e rior ( i m plic at in g th e

.
m e m br a nou s a n d pro st at ic p or t ion s) h e h e al s by p u s hing th e b ougi e
fur th e r in t o th e ur e th ra . In or de r t o d iagno se th e l atte r con di tion h e

m ak e s th e p at i e n t p as s h i s u rin e in t o t wo v e sse l s con s e cu t iv e ly i f b o th ,
con tain fl ak e s an d fil m s o f wh i te d e p o si t h e in fe r s i ts e xi s te nc e I f .
only gonorrh oea an te rio r ( si t u ate d in fron t 01 th e t ri angul ar liga

m e n t only th e urin e fir s t p as s e d wi ll con t ain th e d e p o si t T e n e sm u s
) .
i s an unc e r t ain S ign in ch r onic g ono rrh oea po s t e rior — L a n cet

. F eb . .
6, 1 88 6 .
J . H U TCH I N S O N , JR ( Lon do n )
. .
R E V I E W S O F BO O K S .
M AN U A L O F S U R G E R Y In Tr e a ti se s by Variou s Au th or s In th r e e
. .
volu m e s e di te d by F R E D E R I C K T R E V E S S urg e on t o an d ,
Le c t ur e r on Ana t o m y a t th e Lon d on Ho s pi t al Vol I G e n e ral . . .

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S urgical A ffe c t ion s T h e Bloo d v e s s e l s T h e N e rv e s Th e S kin Vo l

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I I T h e T h orax T h e O rgan s o f Dig e s t ion T h e Ge ni t o Urinary O r

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g an s Vo l I I I T h e O rgan s o f Loco m o tion an d o f S p e cial S e n s e

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T h e R e s pira t ory Pa s s a g e s T h e H e a d T h e S pin e D uo de ci m o s

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1 8 6 6 p ag e s 2 1 3 e ngraving s
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Le a Bro th e r s 8: Co 1 8 8 6 .
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I t woul d b e n o t only a pl e a si n g b ut a p rofi t abl e t a s k t o c a r e fully r e

vi e w in d e tail th e th r e e h an d s o m e an d sh ap e ly volu m e s i s s u e d b y Mr .
Tr e v e s a n d h is collab or at or s Wi th ou t m or e ti m e an d sp ac e th an can
.
b e allo t t e d in th e s e p ag e s s uch an att e m p t woul d b e b o th ina d e qua te

a n d invi d iou s T h e j u s tic e o f th i s r e m ar k will b e appar e n t wh e n o n e
.
r e fl e ct s th a t th e work con t ain s no l e s s th an fi fty n i n e ar ticl e s by th ir ty 0 .
t h re e d i ffe r e n t wri t e r s an d th at e a c h ar t icl e i s a m o d e l of conci s e n e ss

,
an d br e vi ty To s e l e ct a fe w fro m th e s e for e s p e cial co m m e n dation

.
woul d b e n ot onl y a di s ta ste ful b ut a di fficult un d e r taking in vi e w of ,
t h e h ig h s t an d ar d o f m e ri t t o wh ich e a c h a t tain s .
T h e h an d o f Mr Tr e v e s i s e vi d e n t th roug h ou t th e work in th e
.
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c h oi c e a rr ang e m e n t a n d logical S e qu e nc e o f t h e s ubj e c t s s e l e c t e d for

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pr e s e n t ation I t i s s till m or e e vi de n t i f we m i s t ak e n ot in th e t r a c e s
.
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o f vigorou s an d r e l e n t l e ss pruning w h ic h app e ar fro m t i m e t o t i m e in
t urning i t s p ag e s I t m u s t n o t b e in fe rr e d fro m th e s tr e ss lai d up on

.
t hi s c h arac te ri s t ic o f co nci se n e s s th a t any giv e n s ubj e c t i s s lurr e d ov e r

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o r i m p e r fe c tly r e pr e s e n te d T h i s woul d b e an incorr e c t i m pr e ss ion

. .
E v e ry t opic s o far a s ob s e rv e d i s t r e a t e d wi th a fu ln e s s o f e s s e n ti al d e
t ail wh ich i s s o m e wh at s urp ri s ing in vi e w o f th e n e c e s s a ry li m i ta ti on s
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o f Sp ace T hi s e n d i s att ain e d by a s tr e nuou s e ffor t t o e xpr e s s i d e as

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in th e fe w e s t p o s s ibl e wor d s by th e e xclu s ion of p ol e m ic wri ting by a

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s y s te m a tic cl ass ifica t ion o f e a ch s ubj e c t an d by th e u se o f s m all b ut ,
c l e ar an d r e a d abl e t yp e I t i s al s o app ar e n t th at wi th a fe w e xc e p tion s

.
li ttl e r oo m c an b e allo tte d t o th e th ou san d an d o n e d e t ail s o f tr e a t

m e nt . S uch d e t ail s b e long t o larg e r a nd m or e e xh au s t iv e sp e cial tr e a
ti s e s . principl e s an d m ain lin e s of s urgi c al th e r ap e u si s h ow e v e r

Th e , ,
ar e a m ply no t e d an d e n forc e d T h e ill u s tra tion s are co m p ara tiv e ly

.
fe w in nu m b e r b u t w e ll ch o s e n ,
.
Ano th e r ch arac te ri stic o f th e work i s th e w e ll nigh univ e r s al acc e p t -
anc e o f m o de rn an d progr e s s iv e vi e w s o f p ath ology an d tr e atm e n t .
Th i s i s s e e n e sp e cially in th o se por tion s tr e a ting of s urgic al t ub e rculo

s i s d i s e a s e s o f ly m p h a tic s
, d i se a s e s o f b on e an d th e tre a tm e n t o f
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woun ds A S r e gar ds th e la tt e r an ti se p tic th e ori e s an d practic e see m

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t o b e fully acc e p t e d I t i s curiou s t o ob s e rv e in th i s conn e c t ion th a t

.
s o m e o f th e a u th or s r e pr e s e n t e d s t ill cling t o th e u s e o f carboli c oil ,
an d t h e a n t i s e p t ic s pray b o th o f wh ic h h av e b e e n d i s car d e d by m a n y
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op e ra t or s as fu til e an d th e r e for e m i s ch i e vou s in giving a fal se s e n s e

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o f s e curi t y I t woul d al s o s e e m th at th e co m plica te d an d cu m b e r s o m e

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gauz e dr e s s i n g s r e co m m e n d e d in on e at l e a st o f th e ar ti cl e s coul d b e
, ,
r e plac e d wi th a d van t ag e b y th e m or e e a sily pr ep ar e d an d adj u st e d

p a d s o f ab s orb e n t m ate rial T h e articl e on an ae s th e s i a con t ain s a u s e
.
ful li s t o f con d it ion s in w h ich e th e r sh oul d an d sh oul d n o t b e u s e d N o .
’
m e n t ion i s m a d e o f E sm arch s wir e fram e for giving c h loro form wh ich , ,
’
in th e wri t e r s e xp e ri e nc e i s s afe r an d by far m or e conv e n i e n t th an th e
,
u s e o f a fol d e d napkin .
’
T h e argu m e n t s for th e u s e o f Clov e r s an d s i m ilar app ar a t u s for
givin g ch loro form an d e th e r d o n o t se e m t o coun te rb alanc e th e gr e at
d e fe ct o f s uc h appli anc e s Th i s d e fe ct con si st s in th e fac t th at d urin g
.
th e ir e m ploy m e n t t h e e ffe c t s o f poi s oning by re b re a th e d air are s up e r
a dd e d t o th e n arc o si s fr om th e an aes th e ti c .
T h e bin d ing i s w e ll d on e loo se b a ck s b e ing e m ploy e d so th a t th e

,
volu m e s li e op e n e a s ily an d are conv e ni e n t to h an dl e S o m e e rror s of .
proo f r e adi n g e xi s t b ut n on e th a t canno t b e r e a d i ly corr e c te d by th e

-
,
con t e x t Cro s s r e fe r e nc e s are in se r te d wi th s u ffici e n t fr e qu e ncy an d

.
di scrim in ati on t o bin d th e d i ffe r e n t ar ticl e s in t o an org anic wh ol e .
T h e e n t ir e work i s conc e iv e d a n d e x e cu te d in a s ci e n tifi c s piri t It .
i s con se r v ativ e wi th ou t bigo t ry an d con tain s th e b on e an d m arrow o f ,
m o d e rn s urg e ry D oub t l e s s s o m e i m p e rfe c t ion s m ay b e d i s cov e r e d on

.
clo s e e x am i n ation b ut taki n g th e m anu a l in i ts e n tir e ty i t unqu e s tion

, ,
ably fi lls a pl ac e in th e s urg e on s libr ary wh ich woul d o th e rwi s e b e un

’
t e n an t e d .
G R BU TL E R . . .
TH E S CIE N CE AN D PR A C TI C E OF SU R G E R Y . By FR E DE R I CK J AM E S
GAN T ,
T h i rd ed t o ii n . Lon d on , Bai lli e re , Tyn d all Cox ,
1 88 6 .
The pr e s e n t y e ar h as b e e n rich in th e pro d uction of l arg e te t x b ook s

GA N T ON TH E S CI E N CE A N D P R A C TI CE OF S UR GE R Y .
377
on s urg e ry a nd e ncyclop e di as an d d ic t ion ari e s

, T he th ir d e d i t ion o f.
’
Mr G an t s work i s t o s o m e e x te n t a j oin t pro duc tion for we fi n d s e v
.
,
e ral w e ll known n a m e s a tt ac h e d t o th e m or e s p e ci al s ubj e c t s S t ill th e .
’
work i s m ainly Mr G an t s for m or e th an
. p ag e s are by h i m wh il e
t h e o th e r con t ribu t or s o ccupy ab ou t 2 4 0 p ag e s Th a t h i s work h as .
b e e n appr e cia te d by th e p ublic i s e vi d e nc e d by th i s b e ing t h e th ir d

e di tion an d in th e pr e s e n t i s s u e we fi n d con s i d e rabl e a ddi t ion s b o th t o
,
t h e t e x t an d t o th e e ngravi n g s .
T h e r e i s an d h a s alway s b e e n a s p e ci al fe a t ur e in th i s work th a t i t
, , ,
i s n ot lik e m o s t m o d e rn work s upon th e s ubj e c t wh ic h a re no t ic e abl e ,
for th e ir conci s e n e s s an d e rr ra th e r up on th e S i de o f abrup tn e s s

, In .
t h i s work th e r e i s an opp o s i t e t e n d e ncy an d th e au th or app e ar s t o b e

,
t alking t o yo u wi th pl e n t y o f t i m e a t h i s a n d th e h e ar e r s d i s p o s al
’
.
T h e r e i s s o m e t i m e s a ch ar m in th i s b ut i t no d oub t m ak e s i t o f l e ss
,
valu e t o th e s t u de n t wh o s e t i m e i s only t o o sh or t But th e pr a c t i tion e r .
wh o h a s th e t i m e will fi n d th e in for m at ion giv e n in a pl e asa n t an d g e n

e r ally in a cl e arly e xpr e ss e d for m Au th orit i e s are fully giv e n an d i t i s
.
r e fr e sh ing t o fi n d th e o ld m a s te r s s o fr e e ly quo t e d .
But in con s i d e ring a m o d e rn t e x t b ook on s ur g e ry o r o n e w h ich ,
clai m s t o h ol d s uch a po s i tion i t i s n e c e s s ary t o h av e m or e th an a

,
r e ad abl e b ook S urg e ry h a s no d oub t m a d e con s i d e rabl e a dv anc e s in

.
m o d e rn t i m e s an d th e s e ad vanc e s m u s t b e c ar e fully b o r n e in m in d
,
.
M or e ov e r th e e xpl ana t ion s o f p a th ologic al an d p h y s iologic al pro c e ss e s

,
a re s ubj e c t t o con s i d e rabl e m o d ific a tion fro m t i m e t o t i m e An d we loo k .
t o s e e h ow th e s e m a tt e r s h av e b e e n t r e at e d H e r e we fi n d th a t th e au th or
.
h a s n ot b e e n un s ucc e s s ful an d e s p e ci ally wi th th e a dv anc e s in s urg e ry

,
prop e r . Cl e ar a ccoun t s are giv e n of r e c e n t O p e rat iv e i m p r ov e m e n t s ,
a n d th e illu s tr ation s are c e r t a in ly goo d wh il e th e r e fe r e nc e s t o o th e r

,
work s wi ll b e v alu abl e to th e r e ade r W h e r e th e au th or c an r e fe r t o

.
ca s e s un d e r h i s own car e th e y are m e n tion e d b ut d o n ot o ccupy too ,
m uc h s p ac e—s o m e ti m e s in de e d n o t fully e noug h o r cl e arly e noug h

, , ,
p e r h ap s .
An e n d e avor h a s b e e n m ade t o in te r e s t th e r e ad e r in th e p ath olog

ic al asp e c ts of s urg e ry b ut we c anno t h e lp fe e ling th at i t i s wi th i n fe r
,
e n c e s an d O pinion s th a t th e work i s d e ali ng r a th e r th a n wi th fac t s an d ,
i n th e g e n e ral d i se a se s we d o n o t fi n d th at wh at i s known o f th e p a th ol
ogy i s cl e arly d e s crib e d or th e m or e r e c e n t ob s e rv at ion s al wa y s t ak e n
no tic e o f .
T h e ch ap te r on Py ae m i a i s th u s n o t up t o d at e an d th e r e l ation o f ,
t h i s d i se ase t o org ani s m s i s n ot d e s cr ib e d nor o f s e p ti c ae m i a t o th e

,
p t o m ain e s an d ye t th e S p ac e giv e n t o i ts con s i d e r ation i s m o r e th an

,
37 8 R E I I E I VS O F B O OK S
'
en o u gh t o m ak e o n e e xp e c t a fu ll a c c o u n t o f wh a t i s kn own T h e a c .
c o u n t o f T e t a n u s in th e s a m e way i s wo r dy T h a t o f h ydr op h o bia .
’
s e e m s n o t we ll arra n g e d a n d n o m e n t i o n is m a d e o f Pa s t e ur s o b se r
,
v a t i o n s b u t th i s m a y b e ac c o u n te d fo r by t h e ir b e i n g c h i e fly pub li sh e d
.
v e rv r e c e n t l y —p e r h ap s s i n c e th e typ e o f t h i s w o rk was s e t up We .
d o n o t t h i nk t h e a u t h o r wi s e i n appr o vin g o f d e lay i n th e tr e a t m e n t o f

ca s e s o f bi te s b y p o s si bly rabi d d o g s n o r d o we th i nk th a t e xci si on
,
w h e n h e r e c o m m e n d s w oul d b e lik e ly t o b e e fli c ac ious Much th a t .
we h av e l o ok e d a t i n th i s work i s e x tr e m e ly g oo d b u t th e faul t i s ,
w or din e s s an d thi s will m ak e i t l e ss u s e ful th an i t m i ght b e T h e w ood

, .
c u t s nu m e rou s a s th e y a re
,
a n d o fte n v e ry g oo d a n d o riginal
, a re ,
wan ti n g in c l e arn e ss t o th e r e a d e r b e cau s e th e y h av e n o d e s crip ti o n

a t t ach e d t o th e m .
W W W A G S TA FFE . . .
A GU I D E T o TH E E xAM I N AT I O N OF TH E N O S E W I TH R E MA R K S O N T H E
D I A G N OS I S O F D ISE ASE S OF TH E N A S A L C A V I T I E S By E C R E SS
. .
W E LL B A BE R M E Lo n d on
,
. .
,
.
T h i s li t tle wo rk i s
c e r tainly a m o s t e xc e ll e n t an d c o n ci s e gui d e fo r
t h o s e wh o wi sh t o m ak e th e m s e lv e s c on v e r s an t wi th t h e vari o u s m e th
o d s e m pl o y e d for th e e xp lo ra ti on o f th e n a s al c avi ti e s .
T h e d e s c ri p ti on o f th e a n a to m y o f th e in t e ri o r o f th e no s e an d n a s o
ph aryn x i s th e m o st c om pl e te of any we h av e s e e n in th e E n gli sh lan
guag e a n d wi ll b e fo u n d of valu e n ot o n ly t o th e b e ginn e r b ut al s o to
, ,
th o s e wh o are e xp e r t s in rh i n os c opy .
T h e O p e ni n g c h ap te r d e al s wi th th e ana to m y an d p h y s i ol o gy o f th e
n as al fo s sae T wo e xc e ll e n t illu s tra ti on s a ft e r Zuck e rka n dl o f v e r tical
, , ,
tr an s v e r s e s e c ti on s th roug h t h e an t e ri o r an d po s t e ri o r th ir d s of th e n a s al
c avi ti e s g r e a tly a ss i s t t h e r e a d e r t o gra s p t h e d e t ai ls wh ich are n e e d
ful t o a ll wh o wi sh t o m ak e th e n o s e a s p e cial s t u dy .
A t te n ti on i s d rawn t o th e tub e rcu lu m s e p ti fir s t d e s crib e d by M or ,
g a gn i a n d wh i c h h as b e e n r e c e n tly fi g ur e d by Zuck e rkan dl T hi s .
e l e va t i o n o f th e m uc o u s m e m bra n e o f th e se p t u m d ue to an a cc um u
la ti on of glan d u lar e l e m e n ts li e s opp o si te to th e an te ri o r e n d o f e ach
,
m i dd l e t urbina t e d b o n e an d m ay b e s ai d t o roughly m ark th e li m i ts

,
o f th e s up e ri o r or ol fa c t o ry r e gi o n o f th e n o s e fr o m th e in fe ri o r or re s
p irat ory . A s t h e au th or j u s tly s ay s i t pla ys an i m p ort an t pa rt in th e

,
e xa m i n a ti o n o f th e n ar e s fr o m th e fr o n t a n d h e h a s c e r t ainly d o n e w e ll
,
in i n s i s tin g on th e i m port anc e of th i s s truc tur e an d h e i s s o far a s we ,
a re awar e th e fir s t E n li s h wr i t e r wh o h as d on e s o
, g .
Th e p h y s i o lo gy o f t h e n o se i s d e al t wi th in a fe w pag e s A d i s ti n c .
BAB E R ON E X AM I N A TI ON OF TH E N OS E , E TC .
379
i n
t o is a d e b e tw e e n th e ta s t e o f s ub s tanc e s appr e cia te d by th e t o n gu e
m
a n d th e ir s m e ll w h e n in t h e m o u th p e rc e iv e d by th e o lfac to ry n e rv e .
Th e s o m e wh a t conflic ti n g O pinion s h e l d as t o th e e ffe c t o f t h e na s al

c a vi ti e s o n th e voic e a re allu d e d t o T h a t th e y h av e a v e ry i m por
.
t an t e ffe c t o n th e v olu m e o f s o un d a d m i t s o f no d oub t a n d a n yon e can ,
e as ily d e m on s tr a te th i s fo r h i m s e l f by s u dd e nly c o m pr e s s i n g hi s n o se
wh il e s oun d ing a no te w h e n th e di m inu tion in volu m e b e c o m e s v e ry

e vi d e n t .
Th e sy m p t o m s of na s al d i se a s e a re t r e ate d o f in ch ap te r ii an d th e ,
g e n e ral prac ti tion e r will ge t s o m e u s e ful hin t s fro m th e conci s e de

s c ri p ti on s
giv e n .
Much a tte n tion h as b e e n pai d by rh inologi s ts d uring th e la s t fe w

ye ar s to v a riou s r e fl e x p h e no m e na s uch a s a ttack s o f a s th m a s pa s ,
m o d ic coug h m igr a in e e t c w h ic h ar e accor ding t o Hack an d o th e r

, , .
, ,
con ti n e n t al ob se rv e r s at ti m e s conn e cte d wi th th e pre s e nc e o f na s al

,
polypi or hyp e r trop h y o f th e in fe rior t urbina te d b o d y Dr Bab e r a dd s . .
s o m e in t e r e s t ing in s t anc e s o f s uch ca s e s fr o m h i s p e r s onal e xp e ri e nc e

, ,
in an app e n dix Th e r e i s no d oub t th a t s uch ca se s d o o ccur b u t we

.
,
woul d ad d as a wor d of c au tion th at we fe ar too m uch h as b e e n m a de

,
o f th e m a s r e gar d s fr e qu e ncy a n d a s a r e s ul t m an y unn e c e s s ary O p e ra

,
ti on s h av e b e e n p e r for m e d .
A fe w pag e s are d e vo te d t o th e p h y s ical e x am in ati o n o f th e no se ,
a n d th e r e i s a goo d S k e t c h o f th e t pic al p h y s iogno m y pr e s e n te d by a

y
ch il d s u ffe rin g fr om na sal ob s tr uc tion .
Dr Bab e r call s a tte n ti on to th e valu e o f s unlig h t in e xa m ining th e

.
no s e an d pr e fe r s i t t o any o th e r in th e e luci dation of di fficult ca se s

, .
H e i s al s o in favor o f Trouv e ’s E l e c tri c Ph o t op h or e a s b e ing le s s c um

b e rso m e an d e xp e n s iv e th an th e oxy h y drog e n ligh t Trouv e s ap
'
p ar at u s giv e s a ligh t of ab ou t t e n can dl e pow e r wh il s t th e oxyhydro ,
ge n ligh t i s con s i de rably ov e r fi ve h un dr e d an d we c ann o t b u t th ink ,
th a t in i t s pr e s e n t fo rm i t i s far pr e fe rabl e t o th e p h ot op h or e al th oug h ,
a li ttl e m or e co s tly an d i t co m p e n s a t e s th e surg e on for th e t roubl e o f

,
m anu fac t uring oxyg e n wh ic h h ow e v e r in larg e t own s c an b e o ft e n ob

, , ,
t ain e d in th e co m pr e s s e d for m .
B e ginn e r s will fi n d m uch a s si stanc e fr o m s o m e diagr am s wh ich S h ow

in a v e ry cl e ar m an n e r th e di ffe re n t p ar t s of th e na sal cavi ti e s brough t
in t o vi e w by b e n di n g th e h e ad o f th e p a ti e n t b ackw ar ds or forw ar ds ,
an d th e sk e t ch e s S h owi n g w h a t i s u s u ally s e e n on l o oking in t o th e no s e
fr om th e fr on t are al s o o f v a lu e .
Cl e ar in s truc tion s are giv e n h ow b e s t t o p e r for m an te ri or and p os

t e ri or R h in o s c opy .
We agr e e wi th th e a u th or in pr e fe r ri n g th e s i m pl e s t o f applianc e s in
e x am ining th e po s t e rior nar e s an d b e li e v e wi th h i m th at p ala t e h o ok s
,
a n d o th e r lik e in s tru m e n ts o f t or t ur e are h ar dly e v e r n e c e s s ary Th e r e .
a re woo d cu t s r epr e s e n t ing t h e b e s t for m s o f na s al in s t ru m e n t s

- as ,
”
w e ll a s s o m e s uch a s Zau fal s Tub e s which a re pain ful t o u s e an d
,
“ ’
,
o f v e ry li ttl e a d van t ag e .
A sh or t ch ap te r on palpa tion of th e po s t na s al s p a c e an d ano th e r

-
,
on th e d iagno si s o f th e co m m on e r d i s e ase s o f th e n o s e are b o th us e

ful. Anyon e wh o follow s out th e v e ry e labor at e ou tlin e for a na s al
e x am ina t ion s ugg e s t e d by Dr Bab e r will c e r tainly n o t b e lik e ly t o fall
.
in t o e rror s o f o m i s s ion.
In conclu sion we know o f no b ook wh ich in a sm all nu m b e r of p ag e s

g iv e s s uch a d m irably cl e ar an d conci s e in s t ruct ion s on all th e e s se n
t ial poin t s conn e c t e d wi th th e e x am ina ti on o f t h e no se .
M AN U E L D E T E C H N I Q U E D E S A U T O P S I E S Par B O U R N E V I LL E an d P
. .
B R I C O N 1 8 8 5 Pari s Librairi e d u Pro gré s M e dic al ( H an db ook

. . . .
o f Po s t Mor t e m E xam ina t ion s

-
) .
Th i s i s a u se ful li ttl e book wh ich de al s wi th th e s ubj e c t o f wh ich i t

t r e a t s in a th oroug h ly pr a c t ic al m ann e r T h e fir s t par t d is cu s se s b ri e fly
.
th e variou s con d i t ion s un d e r wh ich po s t m or te m work i s l e gally con

-
d uc t e d in F ranc e an d by way o f co m pari s on in o th e r coun tr i e s U n

, , .
d e r th e h e a d ing o f E dinb urg h th e a u th or s st ate th a t po s t m ort e m s

“ -
a re g e n e rally oppo se d by Ca th olic s b u t th i s O ppo s i tion can b e s e t

,
”
a s i de by th e pri e st at th e in s t anc e o f th e p h y s ici an Ag ain i t woul d .
‘
a pp e ar th at p o st m ort e m s upon Je ws are pro h ibi t e d in P a ri s owing t o
-
,
th e b o di e s b e ing cl ai m e d by th e J e wi sh con s i s t o ry a con d i tion o f th ing s

,
wh ich th e a u th or s sta te i s p e rfe c tly unj u s tifi abl e Th e s e con d p art o f .
th e b ook d e s c rib e s th e pr a c t ical d e t ail s of po s t m or te m work an d -

,
conclu de s wi th an e xc e e dingly u s e ful ch ap te r upon th e m e an s t o b e

a d op t e d for pr e s e rving p ath ological S p e ci m e n s fo r th e m u s e u m AS .
in m o st F r e nch work s upon te ch nical s ubj e c ts s o in th i s a c ar e ful , ,
an d e xh au s tiv e bibliograp h ic al in d e x i s a dd e d .
H PE R CY D U NN . .
THE S E RV O -
B U L GA R I AN W A R F R O M A S U R GI C A L
P O I NT O F VI EW .
BY R LA K E L R C
.
,
. . . P .
,
M . R C S
. . .
T th e c o m m e n c e m e n t o f h o s t i li t i e s e a r l y i n N o v e m b e r ,
1 8 8 5 t h e p o s i t i o n o f t h e fo r c e s a t d i ffe r e n t t i m e s
,
em
a e d w as a b o u t a s fo l l o w s :
g g
T h e m a i n S e r vi a n a r m y lay a t N i s c h a n d P i r o t a n d c o n ,
s iste d o f s o m e m en O p p o s i n g t h e S e r v i a n s w as a
.
B u l g a r i a n fo r c e a t Z a rib ro d o f a b o u t
T h e m a i n b u l k o f t h e B u l g a r i a n a r m y la y a t Ph ili p o p o li s ,
r e a d y t o m e e t t h e T u rk s a t l e as t fo u r d a y s m a r c h fr o m S o fi a
, .
T h e Z a r i b ro d fo r c e w a s g r a d u a l l y d r i v e n b a c k t o S li vn i t z a .
T h i s t o o k o n e w e e k b u t th e S e rv i a n s w e r e u n a b l e t o p r o c e e d
,
fu r t h e r o n a c c o u n t o f t h e b r e a k d o w n o f t h e c o m m i s s a r i a t
-
,
t h u s a l l o w i n g t i m e fo r t h e m a i n B u l g a r i a n a r m y t o a rr iv e On .
i t s a rr iv a l i n t h e s e c o n d w e e k o f t h e m o n t h t h e b a t t l e o f
S l iv n i t z a w as fo u g h t fo ll o w e d b y t h e S e r vi a n r e t r e a t a n d t h e
,
B u l g a r i a n a d v a n c e T h e D r a g o m a n P a s s w a s fo r c e d a n d t h e
.
,
b a t t l e o f P i r o t fo u g h t B y t h e e n d o f N o v e m b e r t h e w a r w a s
'
p ra c t i c a lly o v e r .
B U LGAR I A —A t t h e o u t b r e a k o f t h e wa r w h at t h e r e w as o f
.
,
a n a rm y m e d i c a l d e p a rt m e n t o n t h i s s i d e h a d m a d e it s a r ,
ra n g e m e n t s fo r a c a m p a i g n w i t h T u rk e y W h e n w a r w a s s u d .
d e n ly d e cl a r e d w i t h S e r v i a t h e i r t r a n s p o r t b e a s t s w e r e m o s t l y
r e qu i r e d fo r m o r e i m m e d i at e u s e s a s t h e m a i n fo r c e h a d t o
,
m a r c h a b o u t 3 6 0 k i l o m e t r e s t o t h e s e at o f w a r C o ns e q u e ntl y .
,
e v e n i f th e A rm y M e d i c a l D e p a r t m e n t h a d b e e n capable of
m e e t i n g t h e r e q u i r e m e n t s o f t h e fo r c e s it w as c ri p p l e d a n d
, ,
w h e n t h e s t r a i n c a m e i t c o ll a p s e d T h e r e w e r e n o t r a i n e d
.
o r d e r l i e s t o d o t h e w o rk ; i n fa c t t h e i r A r m y M e d i c a l D e p a r t
,
m e n t w a s i n m u c h t h e s a m e c o n d i t i o n a s w a s t h e B r i t i s h wh e n
t h e Cr i m e a n w a r b r o k e o u t w i t h t h e e x c e p t i o n o f t h e p o s s e s
,
s i o n o f m o s t e x c e l l e n t am b u l a n c e w a g o n s T h e s e l at t e r w e r e .
a b l e t o c a rry t w o l y i n g a n d t w o s i tt i n
g .
82 R . L AK E .
Now it was o u ts e t th a t th e w o u n d e d w e r e n u m e r
n o t at th e
o u s e n o u g h t o c a u s e a n u t t e r b r e a k d o w n o f a ll t r a n s p o r t a r
-
r a n g e m e n t s D u r i n g t h e fi r s t h a l f o f t h i s s h o r t w ar o f h a r d
.
fi g h t i n g t h e B ul g a r s w e r e ab l e t o a l a r g e e x t e n t t o r e m o v e
, ,
th o s e o f t h e i r w o u n d e d w h o e s c a p e d c a p t u r e as th e y we r e ,
c o n t i n u a l l y fa l li n g b a c k o n t h e i r b a s e i n S o fi a .
T h e t ra n s p o r t o f t h e w o u n d e d w a s a c c o m p li s h e d b y t h e fe w
a m b u l a n c e s b u t e s p e c i a l l y b y t h e c o u n t r y c art s
,
r o u gh l o n g , , ,
n a rr o w o p e n v e h i c l e s d r a w n b y o x e n e n t i r e l y w i t h o u t s p r i n g s
, ,
and w ith m e re l y s o m e b r u s h w o o d o r s t r a w i n th e m t o l e ss e n
t h e j a rr i n g . H o w e v e r s h o r t t h e d i s t a n c e t h e r e fo r e t h e t i m e
, ,
b e t w e e n t h e fir s t a i d d r e s s i n g w h i c h w a s r a r e l y a n a nt i s e p
i
t i c o n e a n d t h a t a t t h e h o s p i t a l w a s n e c e s s a r il y v e r y l o n g
, ,
.
F o rt u n a t e l y t h e w e at h e r wa s n o t v e r y t r y i n g a n d t h e m e n
w e r e n o t w o rn o u t b y l o n g m a r c h e s a n d p ri v a t i o n s .
A t t h e m i d d l e o f t h e c a m p a i g n w i t h t h e S e r vi a n s a t S liv n i t z a
c a m e a p a u s e a ll t h e c a p i t a l w a s i n a p a ni c b u t t h e r e w e r e
, ,
v o l u n t e e rs w h o h e l p e d t o fo r m h o s p i t a l s — t w e n t y s i x i n a ll -
a m b u l a n c e s a n d a n u r s i n g s t a ff A ft e r t h e d e fe at o f t h e S e r
.
vi a n s a t S l iv n i t z a t h e r e w a s g o o d p r o vi s i o n fo r t h e r e c e p t i o n
of w o u nd e d T h o s e a l r e a d y fi t fo r t r a n s fe r w e r e s e n t h o m e
.
,
o r wh e r e t h e r e w e r e e i t h e r t e m p o r a r y o r p e r m a n e n t h o s p i t a l s .
A ft e r t h e s e v e r e fi g h t i n g fo ll o w i n g S l i v n i t z a t h o s e b e a s t s p r e
v i o u s ly s p a r e d t o t h e A r m y M e d i c a l D e p a r t m e n t w e r e w i t h
d r a w n a s t h e a r m y S i m p l y p r e s s e d fo r w a r d b y fo r c e d m a r c h e s
,
fi g h t in g m o r e o r l e s s a ll d a y E a c h d a y a d d e d i t s c o m p l e
.
m e n t o f w o u n d e d t o t h e r a p i d l y i n c r e a s i n g t o t a l w h i c h fo r m e d ,
a t th e t i m e P i r o t w as r e a c h e d at l e a s t A l l t h at c o ul d
b e d o n e wa s d o n e b u t s k i l l e d m e d i c a l a s s i s t a n c e w as a b s e n t
, ,
o r o n l y r e p r e s e n t e d b y a fe w B ul g a r i a n d o c t o r s w h o h a d
p r o b a b l y n e v e r d o n e a n o p e r at i o n s i n c e t h e y q u i t t e d t h e u n i
v e rs i t i e s a n d w e r e o n l y t o o r e a d y t o c l o a k t h e i r t i m i d i t y a n d
,
i g n o r a n c e u n d e r t h e d i s g u i s e o f c o n s e r v a t i ve s u r g e r y .
A ft e r t h e l as t fi g h t a t P i r o t a n e w a n d s e r i o u s c o m p l i c at i o n
a r o s e i n t h e c a m p s fo r t y p h o i d a n d d y s e n t e r y a p p e a r e d
,
Be .
fo r e h o w e v e r m a n y h a d s u c c u m b e d t o t h e s e d i s e as e s t h e
, , ,
w e a t h e r c h a n g e d s u dd e n l y t o b i t t e r c o l d w i t h a t e m p e r at u r e
as lo w a s 2 7 F ah r w h i c h s e e m e d t o c h e c k t h e m
°
,
.
S E R VO-B U L C A R I A N WA R H OS P I TA L 5 E R VI C E .
383
T h e t r o o p s wh o w e r e o n t h e m o u n t ai n s w e r e m o s t l y w i t h o u t
g r e a t c o a t s a n d h u n d r e d s p e r i s h e d fr o m c o l d T h e w o u n d e d .
,
w i t h s h o r t r a t i o n s w e r e s t i l l w o rs e o ff a s t h e y h a d o n l y t h e
, ,
o p e n w a g o n s t o c o n v e y t h e m b a c k t o t h e b as e A l l u p th e .
D ra g o m a n P a s s t h e w o u n d e d w e r e e x p o s e d t o a ll t h e v a r i a
t i o n s o f t h e w e at h e r O ft e n a t ni g h t t h e y w e r e n o t a b l e t o
.
r e a c h a s h e l t e r T h e i r li m b s o n S p l i n t s w e r e n u m b e d fo r w a n t
.
o f m o v e m e nt T h e y s u ffe r e d t e rr i b l y fr o m t h e c o l d a n d t h e
.
,
n u m b e r o f fr o s t b i t e s w a s e n o r m o u s
-
I t wa s n o u n c o m m o n .
s i g h t t o s e e o n r e m o v a l o f t h e d r e s s i n g s t h at t h e wh o l e l i m b
w a s g a n g r e n o u s s u c h c a s e s b e i n g o f c o u r s e m o s t fa t a l
, ,
W i th ,
.
t h e fi r s t fr o s t c a m e a h e av y fa l l o f s n o w w h i ch n e c e s s it ate d ,
a ll t h e w a g o n s b e i n g p u t o n r u n n e rs T h i s r e n d e re d t h e ln .
c o n v e n i e n c e l e s s a s t h e w a g o n s t ra v e l e d m o r e e a s i ly
. .
Th e t o t a l d i s t a n c e fr o m fr o n t t o r e a r w a s a b o u t 9 0 k i l o m e
t r e s a jo u r n e y o f a b o u t t w e l v e h o u r s p o s t i n g b u t w h i c h o c c u p i e d
, ,
e v e n as l o n a s fo u r d a y s b y t h e s e w a o n w h i c h w r t h u
g g s e e s
o b l i g e d t o s p e n d fr o m o n e t o t h r e e n i g h t s o n t h e r o a d a n d t h e ,
a c c o m m o dat i o n a t th e r e s t s t a t i o n s w as n o t o n e h u n d re t h p a rt
e n o u gh . A t t h e m i d w a y h a l t i n g p l a c e fo r i n s t a n c e a t t h e t o p ,
o f t h e D r a o m a n P as s n o t m o r e t h a n t e n b e d s w e r e t o b e t
g , g o ,
a n d t h e d e m a n d fo r m e n a t t h e fr o n t l e ft n o m e a n s o f e n la r
g
ing th e s e b u i l d i n gs A t a ll o f t h e m t h e r e w a s a d o c t o r wh o
.
,
d i d w h a t h e c o u l d fo r t h o s e r e q u i r i n g h i s a s s i s t a n c e a l t h o u g h
’
,
a t o n e s t at i o n I w e n t o v e r t h e d o c t o r i n c h a rg e h ad o n l y t w o
,
i n s t r u m e n t s a p a i r o f t o o t h fo r c e p s a n d a s c a l p e l
, .
N o w at t h e e n d o f N o v e m b e r h o w e v e r r e l i e f w a s a t h a n d , , .
Th e Ge r m a n A u s t r i a n H u n g a r i a n E n g li s h a n d R o u m a n i a n
, , ,
R e d Cr o s s S o c i e t i e s s e n t o u t t h e i r a m b u l a n c e s a ll p r o v i d e d
w i th s u r g e o n s a s s i s t a n t s n u rs e s a n d e q u i p m e n t s
, ,
.
T h e A u s t ri a n a n d H u n g a ri a n a m b u l a n c e s h a d m o s t e x c e l
l e n t w a g o n s a n d b r o u g h t t h e i r o w n h o rs e s T h e y w e r e t h u s
,
.
a b l e t o s e t t o w o rk a t o n c e T h e y d ivi d e d t h e w o rk b e t w e e n
.
t h e m i n s u c h a w ay t h at t h e A u s t r i a n w a g o n s w h i c h w e r e c o n ,
s t r u c t e d fo r t h e c o n v e y a n c e o f w o u n d e d o n m o r e o r l e s s l e v e l
'
g r o u n d t o o k t h a t p o r t i o n c o m m e n ci n g a t t h e s u m m i t o f t h e
,
D r a g o m a n P a s s t h e H u n g a r ia n w a g o n s b e i n g o f l i g h t e r b u il d
, ,
an d o n v e ry str o n p r i n d o i n t h at to w h i c h t h i r m b u
g s g s g ,
e a
l a n c e s w e r e m o r e s u i t e d i e th e m o u n t a i n r o a d s a n d p as s e s
,
. .
,
3 84 R . LA K E .
fr o m P irot to D ra g o m a n . N o w th e re wa sn o l o n g e r n e c e s s i ty
fo r i n c r e a s e d a c c o m m o d a t i o n T h e j o u r n e y t o o k fr o m 2 4 t o
.
3 6 h o u r s u n d e r t h e s e m o r e fa v o r a b l e c i r c u m s t a n c e s t h e r e b y ,
g r e a t l y d i m i n i s h i n g b o t h t h e m o r t a l i t y a n d s u ffe r i n g .
E a r l y i n D e c e m b e r t h e R e d Cr o s s s u r g e o n s w e r e w o rk i n g
h a r d h a vi n g c o m p l e t e d t h e i r a rr a n g e m e n t s ; m o s t o f t h e c as e s
,
h a d b e e n i n h o s p i t a l s o m e w e e k s b y t h i s t i m e a n d m u c h v a lu a ,
b le t i m e h a s b e e n a b s o r b e d i n r e n d e r i n g t h e v a r i o u s h o s p i t a l s
l ess se pti c .
W h e n o p e r a t i n g c o m m e n c e d i t w a s fo u n d t h a t t h e p a t i e n t s
w o u l d a s o ft e n a s n o t r e fu s e p e r m i s s i o n t o t h e s u r g e o n t o a m
p u t at e w h e r e o n t h e s u r g e o n s w e n t t o t h e c o u n c i l fo r h e l p
,
A .
la w w as p a s s e d t o s u i t t h e c a s e w h i c h s a i d t h a t i f t h r e e m e d i
,
c a l m e n a g r e e d t h a t i t w a s n e c e s s a r y fo r a p a t i e n t t o u n d e r g o
a c a p i t a l o p e r a t i o n a n d r e fu s e d
,
h i s c o n s e n t t h a t t h e o p e ra ,
t i o n m i g h t b e d o n e w i t h o u t o r rat h e r a g a i n s t h i s c o n s e n t .
W i t h r e g a r d t o t h e t e m p o ra ry h o s p i t a l s t h e r e i s r e a l l y b u t
l i tt l e t o s a y as t h e y w e r e a ll l a r g e fa i r l y w e l l v e n t i l at e d p u b
, , ,
l i c b u il d i n g s a n d w i t h t h e e x c e p t i o n o f t h e w a t e r s u p p l y a n d
,
d r a i n ag e w e r e a s g o o d a s c o u l d b e e x p e c t e d Th e c o l d r e n .
d e r e d a n i m p o rt a n t s e rv i c e i n p re v e n t i n g a ny d e c o m p o s i t i o n i n
t h o s e t h i n g s c a p a b l e o f p u t r e fa c t i o n l e ft a b o u t b y t h e B u l g a r s ,
w h o h a v e n o t m u c h i d e a o f cl e a n l i n e s s .
O v e r c r o w d i n g i n h o s p i t a l s e x c e p t a t t h e fr o n t a n d a t s h o r t
,
i n t e r v a l s w a s n o t c o m m o n a n d o ft e n t h e n o n a c c o u n t o f t h e
, ,
l a z i n e s s o f t h e c h i e f o f th e h o s p i t al I n m y h o s p ita l o f 60
.
b e d s t h e a s s i s t a n c e i n t h e n u r s i n g li n e w a s fa i r l y t y p i c a l o f
w h a t o n e w o u l d e x p e c t o f u n t ra in e d t h o u g h k i n d w o m e n ; th e y
a t t e m p t e d w h at t h e y w e r e a s k e d b u t w i t h o u t i n t e l li g e n c e o r
,
u n d e r s t a n d i n g t h e r e as o n o f w h at t h e y d i d .
P y e m i a a n d i t s a l l i e d d i s e a s e s w e r e s o fa r a s I c o u l d l e a r n
, ,
r a r e T h i s m ay h a v e b e e n fr o m t h e fa c t t h a t t h e m o r e w e a k l y
.
a n d w o r s e i nj u r e d d i e d e n r o u t e S t i l l b l u e p u s a n d fo u l s m e l li n g
.
w o u n d s w e re t h e r u l e w h e n I s ta rt e d w o r k .
T h e r e w a s s c a r c e l y a S i n g l e p r i m a r y o p e r at i o n o f a n y m a g n i
t u d e d o n e d u r i n g t h e c a m p a i g n o n l y a fe w m i n o r p r i m a r y b e
,
i n g d o n e a t a ll .
5 E R VO-B UL C A R I A N WA R H OS P I TA L 5 E R VI CE .
38 5
S E R VI A .
On a c c o u n t o f t h e r e v e r s e s t h e y h a d s u ffe r e d t h e S e r v i a n s
r e fu s e d p e rm i s s i o n t o t h e R e d Cr o s s s u r g e o n s t o g o b e y o n d
B e l g ra d e e ffe c t u a l l y p r e v e n t i n g a n y k n o w l e d g e o f t h e r e a l
,
s t a t e o f t h e w o u n d e d a t t h e fr o n t a n d a t N i s c h T h e r e is g o o d .
r e as o n t o b e li e v e t h e s t a t e o f a ffa i r s w a s w o r s e e v e n t h a n i n
B u l g a r i a d u r i n g a n d a ft e r t h e b att l e s o f S l iv n i t z a D r a g o m a n
, ,
and P i r o t .
H e r e h o w e v e r t h e R e d C r o s s w a s e a r li e r o n t h e fi e l d o n
“
, , ,
a c c o u n t o f t h e g r e a t e r fa c i li t i e s o f g e tt i n g t o S e r v i a ; a n A u s
t r i a n t r a i n b e l o n g i n g t o a n d w o rk e d b y t h e K n i g h t s o f M a l t a
u n d e r B a r o n M u n d i c am e a l s o at t h i s t i m e .
MA P OF THE S E AT O F WA R .
S h o wi n g s
H o p i ta l Ac c o m m o d a ti o n s .
Th is t ra i n i s c o n s tr u c te d o n o s t i m p r o v e d a n d p e rfe c t
th e m
’
s y st e m o f ra i l w a y a m b u l a n c e s C a p a b l e o f b e i n g r u n o n a ll
.
c o n t i n e n t a l li n e s a s t h e g a u g e i s e v e r y w h e r e s i m il a r
,
It was .
c o m p l e t e i n a ll i t s m i n u t e s t d e t a i l s a n d b y a i d o f o r d i n a r y c a r
,
ri a g e s t h e y c o n v e y e d a s m a n y a s 3 00 w o u n d e d w h o w e r e s u p ,
p l i e d w i t h t h r e e c o o k e d m e a l s a d ay t h a t b e i n g a b o u t t h e t i m e
,
o c c u p i e d b y t h e j o u r n e y fr o m N i s c h t o B e l g r a d e .
Th e t r a i n c o n s i s t e d o f w a g o n s t o c a rr y t h e w o u n d e d e a c h ,
w i t h i t s h e at i n g a p p a r at u s a n d a l s o k i t c h e n w a g o n s a s t o r e
, ,
w a g o n a n d a d is p e n s ar y .
3 8 6 R . LA K E .
Th e m edi c a l m e n i n C h a r g e o f t h e t r a i n fo u n d a l a r g e n u m
b e r o f w o u n d e d w i th a li g a t u r e r o u n d t h e w o u n d e d l i m b n o ,
o t h e r m e a n s h a vi n g b e e n t r i e d t o s t o p t h e h aem o rrh a g e a n d ,
t h i s h a d o ft e n b e e n o n fo r d a y s I t w a s o ft e n t o o l a t e t o s a v e
.
th e l i m b w h e n t h e y c a m e u n d e r h i s c a r e . Th e h o s p i t a l s a n d
t h e h o s p i t a l o r g a n i z at i o n s w e r e g o o d ; fo r m a n y r e a s o n s b e t t e r
t h a n a t S o fi a fo r t h e t o w n i t s e l f w a s l a r g e r a n d t h e w a r h a d
,
neve r b e e n so c l os e T h e r e fo r e m o r e t i m e wa s a v a il a b l e a n d
.
,
t h e p u b l i c b u i l d i n g s a n d s c h o o l s w e r e o ft e n l a r g e r a n d m o r e
s u i t a b l e th a n th o s e a t S o fi a .T h e r e w a s a l s o a v e r y u s e fu l s up
p l e m e n t t o t h e n u r s i n g d e p a r t m e n t i n t h e fo r m o f a s t a ff o f
d re s s e rs . I t c o n s i s t e d o f t w o p a rt s o n e o f a c e rtai n n u m b e r
,
o f m e d i c a l s t u d e n t s a n d th e o th e r o f s c h o o l b o y s . T h i s w as a
v e r y g r e at i m p r o v e m e n t o n t h e B u l g a r i a n d r e s s e rs A m o n g s t
.
t h e S e r vi a n w o u n d e d i t w a s m o s t n o t i c e a b l e t h a t a l a r g e p e r
c e n t a g e w e r e w o u n d e d i n a p e c u l i a r w a y I t i s a w e ll k n o w n
.
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fa c t t h a t w h e n h a n d w o u n d s o c c u r b e h i n d e n t r e n c h m e n t s t h e
l e ft h a n d a n d e s p e c i a ll y t h e i n d e x fi n g e r a n d t h u m b o f t h at
,
h a n d s u ffe r m o s t fr e q u e n t l y
,
T h e s e m e n w e r e S h o t s o th at
.
t h e b u ll e t w o u n d e d t h e i n d e x fi n g e r o n t h e r i g h t h a n d ( t h e
.
t r i g g e r fi n g e r ) o r p as s e d b e t w e e n i t a n d t h e n e x t o r t h r o u g h
,
th e p a l m T h i s w as t h e c l as s o f w o u n d e d m o s t fr e qu e n t l y a t
.
t a c k e d b y t e ta n u s I h a d t w o c a s e s ; o n e w a s r a p i d l y fat a l b u t
.
,
th e o th e r r e c o v e r e d w i t h o u t a ny o p e rat i v e t r e a t m e n t . Pro f.
M o s e t ig t r e at e d h i s c as e s b y a m p u t at i o n a b o v e th e j o i n t o n
t h e p r o x i m a l s i d e o f t h e l e s i o n a n d s t r e t c h e d a ll n e rv e t r u n k s .
H e a l s o t r e a t e d t h r e e c a s e s o f t r a u m at i c a n e u r i s m m o s t s u c
c e s s fu lly o n e s u b c l a v i a n a n d o n e
,
b r a c h i a l b y i n ci s i o n o f t h e
,
s a c a n d e v a c u at i o n o f it s c o n t e n t s a n d t h e n p l u g g i n g t h e s a c
,
b y i o d o fo r m t a m p o n s w h i c h w e r e a l l o w e d t o s e p a r a t e o f t h e m
,
s e l v e s i n n o c as e was an
, y gl i a t u r e a p p li e d to the m a i n t r u n k
.
A N I M R R O VE D TR O CA R .
8
3 7
AN I M P R O V E D T R O CA R F O R PA RA C EN TES I S AB
D O MI NIS .
BY JOHN S . M I LL E R ,
M D . .
,
OF P H I L A D E LP H I A .
A S I STANT
S TO TH E S U R G I CA L C L I N I C , JE FF E R SO N M E D I CA L CO LLE G E H O SPI TA L .
H E fr e q u e n t
occlu s ion of th e canul a by in te stin e or o m e n t u m in
th e op e ra t ion o f t appin g h a s s ugg e s te d t h e d e vi s e s h own in
t h e acco m p anying c u t T h e s t opp ag e g e n e rally occur s wh e n ab o u t

.
a pin t o f flui d h as b e e n wi th drawn an d vari ou s m an oe uvr e s are r e s or te d

,
to , s uch a s t h e e n d e avor t o floa t away th e ob s t ruc t io n by ch anging

th e pa ti e n t s p o si t ion or th e d ang e rou s on e o f in tro d ucing a pr o b e
’
,
t h roug h t h e canula—an d g e n e rally wi th ou t s ucc e s s .
T h e d e vic e t o w hic h r e fe r e n c e h a s b e e n m a d e i s a s m all e r an d lo n ,
e r canula in t ro d uc e d in t o t h a t alr e a d y in p o s i t ion in ca s e t h e r e i s a

g
c e s sat ion o f flow .
I t i s blun t a n d provi d e d wi t h t wo long fe n e s t ra I n th e la t te r ar e .
s pring s w h ic h e xpan d a n d p u s h away t h e ob s truc ti on on e m e rging

fro m th e origin al canula a n d wh ich ar e s o s oli d ly s ol d e r e d a s t o o ffe r
,
no d a n g e r o f br e aking o ff in th e ab d o m in al c avi ty In r e ply t o th e .
qu e ry w h e th e r or n o t th e g u t c an b e co m e incarc e ra t e d an d woun d e d
in th e s pri n g s i t m ay b e s t a t e d t h a t in s e v e ral O p e ra tion s no s uch acci
d e n t h aS o ccurr e d n or w e r e e ffo r t s s ucc e s s ful to bring s uc h abou t up o n
,
th e r e c e n t ca d a v e r T h e in s tru m e n t c a n b e u s e d wi th any t rocar an d

.
canula ab ov e c alibr e s ix t e e n —F r e nch T h e in stru m e n t i s m an ufac .
t u re d by C h a s Le n t z 8 S o n s 1 8 N E l e v e n th S t
.
:
, Ph ila d e lp h ia
. .
, .
E D I T O RI A L A RT I C LES .
S U R G I CA L T R E A T M E N T O F M ALI GN AN T T U M O R S O F T H E F A U C E S .
Ca s te x co n tr ibu te s t o th e R evue de C/zi r u rg i e a s e ri e s o f ar ti cl e s on

th i s s ubj e c t w h ic h a m oun t s t o an e lab ora t e t r e a t i se o f s uc h valu e as t o
m e ri t an e x t e n d e d r e vi e w Pro fe s s io n al O pi n io n h as u n de rgon e a
.
m ark e d c h a n g e r e gar d i n g t h e s urg e ry o f th i s p e rilou s r e gio n wi th in a
fe w y e ar s a n d d oub tl e s s as th e e xp e ri e n c e o f O p e ra t or s incr e a s e s a n d
, ,
th e prac t icabili t y o f e x t irpa t i o n o f t h e n e opla s m s o f t h e fauc e s b e co m e s
g e n e rally acc e p te d m a n y liv e s will b e s av e d or a t l e a s t con s i d e rably

,
.
,
.
pr olong e d w h ich now are lo s t th roug h th e i g nora n c e a n d t i m i d i ty of

,
s urg e o n s . Blan d in co n d e m n e d th e s tupi d ra s hn e s s o f a n y a tt e m p t at

r e m oval o f th e m alignan t t on s il an d a fe w y e ar s la te r inv e n t e d a pro
,
c e d ur e fo r t h i s v e ry p urpo s e Many s urg e o n s h av e e s s ay e d th e O p e r

.
a ti on an d Ca s te x h as wi th in tw o y e ar s colle c te d r e por ts o f th ir ty fi v e
, , ,
-
ca se s o f th e d i s e a s e e l e v e n o f wh ich w e r e u n d e r h is o wn ob s e rva tion

,
.
H i s o ppo rt uni ti e s h av e b e e n larg e a n d h i s s t u d y o f t h e li t e ra t ure o f

,
t h e s ubj e c t th oroug h .
T h e b e g in n i n g o f t h e s e g row th s i s g e n e rally in s i d iou s a n d t he p h y ,
s i c i an i s qui t e li k e ly t o pr e s crib e c h l o ra t e o f p o t a s s iu m t h e pa ti e n t i s
for tuna te i f h e e s cap e s cau t e riza t io n wi th ni tra t e o f s ilv e r .
Cu ri o u sly th e d i fficul ty an d p ai n in s wallowi n g d i s app e ar in m any ca s e s

a n d t h e p a t i e n t fo rg e t s h i s troubl e u n t il fo ur or fi v e m on th s a ft e rwar d
, ,
h e n o tic e s a s w oll e n glan d a t th e a n g le o f th e j aw an d t h e ca s e m ay ,
h av e progr e s s e d b e yon d th e poin t o f j us t ifi ab le O p e ra tion .
All th e p ar t s o f th e fauc e s d o n o t d i s p lay a n e qual t e n d e ncy to the

d e v e lop m e n t o f m alig n an t t u m or s T h e t o n s il i s t h e poi n t o f l e a s t re
.
s i s t an c e i n t h i s r e s p e c t O f t h ir ty o n e ca s e s i n w h ic h th e s t ar tin g
.
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p o in t was ob se rv e d in tw e n ty o n e th e t o n sil was th e p ar t inva de d fir s t

,
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.
Involv e m e n t o f b o th t on sil s i s v e ry rar e W h e n th e ca s e i s n o t s e e n

.
( 5 88 )
S UR C I CA L TR E A TM E N T OF M ALI C N A N T T U M OR 5 .
3 89
ea rly th e t on sil i s u s ually foun d t o b e m or e e x t e n s iv e ly d e s troy e d th an

,
an y o th e r par t . N e x t t o th e t on s il th e an t e rior pillar i s m o s t s u s c e p t i

b le t o a t t ack .
N e crop s i e s a re r ar e ly m a d e an d v e ry fe w h i s t ological ob s e rva t ion s

,
h av e b e e n r e cor d e d Ca s t e x h as m a de a p ar ticular s tu dy o f th e nor

.
m a l ana t o m y o f th e par t s T h e t on s il i s v e ry n e arly O ppo s i t e t h e a n

.
gle o f th e j aw . H e r e gar d s i t a s an agglo m e ra t e glan d a n d call s a t ,
t e n tion t o t h e fac t th a t t h e r e are m i n a t ur e t on s il s i n th e fauci al d e p r e s
s ion wh ic h s a t e lli t e s a r e prob ably th e s e a t o f th e no d ular grow th s aroun d

,
th e principal t u m or Lu s ch ka d i s cov e r e d th e p h aryng e al t on s il in

.
1 856 Ge rlac h h a s r e c e n t ly fou n d a s i m ilar s t ruc t ur e aroun d th e orific e

o f t h e E u s t ach i an t ub e T h e r e i s al s o a s e ri e s o f i s o la t e d glan d s b e h in d
.
th e circu m valla t e papill ae o f t h e t ongu e conn e c t ing t h e t wo princip al ,
t on s il s an d m e ri t ing t h e na m e o f t h e lingual t o n s il
, B e tw e e n t h e s e .
variou s gla n d s th e r e i s ly m p h oi d t i s s u e b u t n o d i s tinc t e m in e nc e of i t

, ,
an d o n th e in fe rior an d m i d d l e t urbina t e d b on e s a n d t h e p o s t e rior
wall o f th e p h arynx th e r e ar e i s l e t s o f th e s a m e w hi ch are co m p arabl e ,
’
t o Pe y e r s pa t c h e s Th u s i s for m e d wh a t Wal d e y e r h as d e s ign a te d th e
.
ly m p h a tic ring o f th e th ro a t T h e ly m p h a tic v e s s e l s o f th e t on s il s are

.
nu m e ro u s an d larg e an d a ccor di n g t o Cruv e ilh i e r e m p ty in to th e

, , ,
g lan d s a t t h e angl e o f th e j aw .
T h e m alignan t t u m or s o f th i s r e gion vary in ch arac te r Mo s t a u .
th or s con s i d e r e n c e p h aloi d as th e m o s t co m m on obviou sly b e cau s e ,
t h e y i n clu d e un d e r t h i s h e a d all t u m or s w h ic h h av e a c e r e bri for m a p
p e a ra n c e s
, uc h a s ly m p h a d e no m a t a a n d ly m p h o s arco m a t a U n fo r
t un a t e ly m i cro s copic e xa m ina ti on s h av e b e e n so i n fr e qu e n t ly m a d e
th a t i t i s i m po s s ibl e t o s t a t e p o s i t iv e ly t h e r e la t iv e fr e qu e ncy o f t h e
d i ffe r e n t vari e ti e s In th e ob s e rva tion of Ca s t e x e pi th e lio m a t a are by

.
,
far th e m o s t fr e qu e n t .
H e r e di ty i s b e li e v e d t o h av e li t tl e if any influ e nc e on th e d e v e lop

, ,
m e n t o f th e s e growt h s T h e y h av e b e e n s e e n in p e r s on s o f va rio u s
.
a g e s fro m 7 t o 8 2 y e ar s E pi th e lio m a a n d carcino m a are m or e fre

.
qu e n t in a d ul ts s arco m a in th e young But a s m all propor tion o f th e

,
.
V i ct i m s are fe m al e s Th e all e g e d infl u en c e o f t ob acco s m oking m ay

.
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w e ll b e d oub t e d T h e c o m c i d e n c e o f buccal e pi th e lio m a an d d iab e te s

.
h a s b e e n no t ic e d .
Th e s e t u m or s m ani fe s t th e m se lv e s by vario u s s y m p t o m s I n th e .
t h roa t th e r e m a y b e abnor m al s e n s a t i on s— di s t r e ss in s wallowing
s oli d s e s p e ci ally in t h e s e con d s t ag e o f d e glu t i t ion ; i n s o m e c as e s

,
t h e r e i s n o p ain b ut a d i s tr e ss ing d ryn e ss

, i n o th e r s th e r e i s e xc e ss w e
form a ti o n o f s aliva Pain i s n o t o ft e n e xci t e d by s wallowing s aliva
.
,
b u t i s cau s e d by pr e s s ur e a t th e angl e o f th e j aw F r e qu e n tly th e r e i s

.
le s s p ain a fte r th e s ur fac e o f th e t u m or h a s b e e n r e m ov e d by ulc e ra
t ion . M e an t i m e pul s a ting or lancina ting p ain s o ccur in th e h e ad ,
n e ck an d fac e an d e s p e cially in th e e ar Th e a ural p ain o ccurri n g in

, , ,
di ffe r e n t di s e a s e s o ft e n d iv e r t s th e a tt e n tion o f th e p h y s ician fro m th e

,
th roa t . T h e voic e i s al te r e d th e d e gr e e o f ch a n g e d e p e n d i n g on th e
,
S iz e o f t h e t o n s il t h e a m ou n t o f s alivary s e cr e t ion an d th e involv e m e n t

, ,
o f th e v e il . O n e o f t h e s a d d e s t co m plica tio n s i s th e p tyali s m w h ich ,
a t fir s t i s an i n conv e n i e nc e only a ft e r e a ting b u t la te r i s con s t an t a n d

,
m a y b e pro digiou s s e riou s ly i m pairi n g s p e e c h

, Di fficul t y in s wallow
.
i n g i s m ark e d an d unl e s s car e i s e x e rci se d liqui d s m ay b e e j e c t e d

, , ,
fro m th e no s e . A S s o m e p a ti e n t s h av e no pai n d uri n g d e glu t i tio n

th oug h gr e a t t ro ubl e in th e p e r for m anc e Ca s t e x prop o s e s t h e wor d
,
ody n o p lzag i a t o d e s i n a t e pain ful s wallowing

g as d i s t i n g
, u i s h e d fro m
dy s p h agia or di ffi cul t s wallowing H aem orrh ag e s a re in fr e qu e n t a t

.
,
le a s t b e for e th e l a s t s t ag e s an d ar e co m m only i n si gnific an t

,
Th e .
br e a th i s rar e ly fe ti d e xc e p t in th e a d va n c e d con di tion o f th e d i s e a s e

, .
Gr e a t car e i s n e c e s s ary in th e e xa m in a t ion o f th e fauc e s an d n e ig h

b ori n g p ar t s o f th e p h arynx ( Wo ul d th a t we h a d an E ngli sh wor d
.
e xac t ly corr e s pon d ing wi th th e F r e nc h a r r i e r e Oou c/ze N a ural lig h

) t t
i s th e b e s t . W h e n th e pa ti e n t op e n s h i s m o nth h e S h oul d b e a s k e d ,
t o S h ow h i s t e e th s o th a t th e lip s m ay b e fully s e para t e d T h e l e ft for e .
fing e r s h oul d th e n pr e s s b ack th e rig h t labi al co m m i s s ur e i n or de r t o

e xp o s e th e th ro a t t o obli qu e illu m ina ti o n t h u s p e r m i t ti n g th e e xa m i n e r
,
t o plac e h i m s e l f in fron t wi th ou t i n t e rc e p t i n g th e lig h t F r e qu e n t o b .
s e r v a t i on s a re d e s irabl e D e pr e s s ion o f th e t ongu e i s s o m e ti m e s i m

.
p o s s ibl e b e cau s e i t s v e r t ica l por tion h a s alr e a dy b e co m e h ar d e n e d

, ,
a n d s o m e t i m e s b e cau s e i t i s e xqui s i t e ly t e n d e r .
T h e t o n s il m ay b e gr e a t ly e nlarg e d I t i s s o m e ti m e s crack e d a n d
.
,
t h e n i t i s di fficu lt t o d i s t ingui s h th e d i s e a s e fr o m s yp h ili s I t m ay b e .

S UR GI C A L TR E A TI WE N T OF I II A LI GA’A N T T U M OR S .
39 1
lob ula t e d or it m ay h av e d i s app e ar e d

by ulc e ra t ion I f th e t u m or h a s .
i n va d e d th e s ur roun ding p ar ts i t i s e l e va t e d a s i t h ar d e n s an d l e av e s
, ,
t h e t on s il in a p i t T h e an t e ri or pi ll ar b e co m e s th ick s h or t sh ri v e le d
.
, ,
a n d h ar d Th e n th e t o n gu e an d th e v e il o f th e p ala t e ar e inva d e d
. .
H avin g acquir e d a c e r t ain volu m e t h e n e opla s m b e gin s t o br e ak ,
d own I t r e s e m bl e s a m u sh roo m i t s b or d e r s s pr e a d in g o u t un d e r th e
.
-
,
v e il th e p e dicl e b e ing conc e al e d I t o ft e n b e co m e s lob ula te d owing

, .
,
prob ably t o th e m ov e m e n t s o f th e t o n g ue an d a s s u m e s a g rayi s h h u e ,

.
T h e ulc e ra t ion look s lik e th a t in canc e r o f th e t ongu e ; th e r e i s rar e l y
a
g ra n u la t e d s u rfac e ; t h e e d g e s a re r e d ; t h e s or e i s cov e r e d wi th a
gray p ulpy glaz e wh ich g e t s o n t o th e t e e th a n d t ongu e T h e d i s e a s e
, , .
i s n o t e n t ir e ly confin e d t o th e princip al t u m or Aroun d i t a t .
variou s poin t s m ay app e ar s po t s o f th e s a m e ch arac t e r th ough s e pa ,
ra t e d by ar e a s o f s e e m i n gly h e al th y ti s s u e w hi ch h o w e v e r are 5 00 11 , , ,
involv e d a n d b e co m e p ar t o f th e m ain ca n c e rou s m a s s an d o th e r s ,
co m e in t o vi e w ou t s i d e th e incr e a s e d li m i ts .
I t i s v e ry i m p or t an t t o e xa m in e e v e ry p ar t wi th th e pulp o f th e fi n
g e r
. P ain i s pro d uc e d by t h e d igi t al t ouc h b u t all t h e r e gion h as lo s
,
t
i t s r e fl e x s e n s ibili ty a n d o cca s io n ally i s ana lg e s ic as i f i t h a d b e e n

, ,
t r e a t e d wi th cocain e I t i s d i ffi cu lt t o a s c e r t ain th e d e gr e e o f d e n si t y
.
o f grow th s on t h e v e il on acco un t o f i t s m o t i o n .
T h e m o s t co m m o n s e a t o f ly m p h a t i c involv e m e n t i s a t th e a n gl e o f
-
t h e jaw T h e d i s cov e ry o f a h ar d g la n d a t th i s s p o t S h oul d l e a d i m

.
m e d ia t e ly t o an e xa m i n a t i on o f t h e fauc e s T h e s e glan d s only e xc e p

.
ti o n ally s uppura t e S o m e t i m e s no d ul e s ar e foun d in th e s ub m axillary

.
r e gion ; th e y a re h ar d m ovab l e an d p ai n ful At th i s t i m e e xci s ion

,
.
o ffe r s a ch anc e o f s ucc e s s Gra d ually al m o s t all th e o th e r ly m p h a ti c s

.
i n th e n e ig h b or h o o d a r e inva d e d .
T h e g e n e ral h e al th m ay n o t b e a ffe c t e d for a lo n g ti m e b ut s o m e ,
p a t i e n t s d e clin e rapi dly b e cau s e th e y d e n y t h e m s e lv e s foo d in or d e r t o

,
avoi d o d ynop h ag i a .
Th e progr e s s i s u s ually s t e a dy b u t th e r e a r e p e rio d s o f arr e s t e s

, ,
p e c i a lly b e t w e e n t h e app e ara n c e o f t h e t u m or a t t h e angl e o f th e j aw
a n d th e e nlarg e m e n t o f t h e c e rvical glan d s T h e v e il i s p ar ti cularly .
liab le t o in v ol ve m e n t a n d th e d i s e a s e e x t e n d s fr o m i t d ow n th e a n
,
39 2 E D I T OR I AL A R TI CLE 5 .
t e ri or pillar an d involv e s th e t ongu e T h e p o st e ri o r n ar e s a n d th e .
l ary n x are rar e ly a ffe c t e d A fte r a long t i m e th e h yp e r trop h i e d glan d s

.
m ay b e c o m e s arco m a t ou s Th e d ang e r o u s p e ri o d b e gin s wh e n t h e

.
g lan d cap s ul e br e ak s d own ; th e n r e m oval i s i m p e ra tiv e ly d e m an de d .
T h e d ura t io n o f t h e di s e a s e i s e x tr e m e ly variabl e I t m ay b e fi ve .
y e ar s or o n ly a fe w m on th s accor d i n g to th e n a t ur e o f th e t u m or a n d
,
t h e co n s ti t u t ion o f t h e in d ivi d ual T h e m o d e o f d e a th i s e qually u n

.
'
c e r tain H ae m o rr h ag e qui t e o ft e n e n d s th e s c e n e co m i n g fro m th e

.
,
bran ch e s o f t h e e x te rnal caro ti d Th e i n t e r n al caro t i d i s n o t as n e ar

.
t h e t o n s il a s c e r tai n un for t una t e acci d e n t s o f t o n s illo t o m y s ugg e s t it

i s t wo c e n t i m e t r e s fro m t h e ou t e r s ur fa c e o f t h e
g lan d .
I n m akin g a d iagno s i s we S h oul d b e s u s piciou s o f unila t e ral h yp e r

,
trop h i e s o f t h e t o n s il in m a t ur e p a t i e n t s e s p e cially as a troph y i s th e

,
[
rul e a t th i s t i m e o f li fe Pai n an d s or e n e s s in th e th r o a t s h oul d n e v e r

.
b e d i s r e gar de d . I n fe c ti n g ch an cr e which Di d ay con s i d e r s n o t rar e on

,
th e t on s il an d s o ft p ala t e m a y b e r e cogniz e d by i t s s ub acu t e progr e s s

, ,
th e p r e auricular a d e ni t i s i t s s ingl e n e ss i ts r e gular

-
,
oval or circular
, ,
for m th e e v e n n e s s o f i t s b o t t o m an d e d g e s i t s occurr e n c e in y o u n g
, ,
wo m e n an d i t s rapi d cica tr iz a tion T h e d iagno s i s i s far l e s s e a s y in

, .
s o m e o f t h e s e con d ary m ani fe s t a tion s o f s yp h ili s Mucou s pa t ch e s e s .
p e c i a lly are liabl e t o b e m i s t ak e n fo r e pi th e lio m a I n a g e n e ral way .

,
wh e n th e ulc e r h as a grayi sh b o t to m i s i n d ol e n t a n d i s n o t a e co m
, ,
p an i e d by ly m p h a tic e nlarg e m e n t s yp h ili s i s t o b e s u s p e c t e d Tub e r .
c u lo s i s o f t h e p h ary n x i s d i s t i n gui s h e d by ab s e nc e o f i n d ura t ion a n d o f
larg e ly m p h a t ic t u m or s Tub e rculou s ulc e r s g e n e rally d o n o t ble e d ,
a n d th e s ur fac e i s granula t e d as th a t o f canc e r i s n o t

,
S c ro fuli d e s .
d i s play irr e gular gra n ula t ing pla t e s wi th cica t ri cial p oi n t s or an uh

, ,
e v e n s e rp e n t in e ulc e r
,
a t ion or s e v e ral s m all j agg e d ulc e r s e a ting b e
, , .
n e a th th e s urfac e m ark s o f s cro fula will b e pr e s e n t e l s e wh e r e T h e .
m i cro s cop e d o e s n o t furni s h m e an s for p e r fe c t d i ag n o s i s b e tw e e n s i m
le a n d m alignan t h yp e r trop h i e s o f th e t on s il
p .
E pi th e lio m a i s ch arac t e riz e d b y e arly ulc e ra t ion on an in d ura te d
b a s e an d by t h e s lown e s s o f i t s e x t e n sio n an d o f i t s i n volv e m e n t o f

,
ly m p h a t ic glan d s Ly m p h a d e no m a and ly m p h o s arco m a a re c e r e bri

.
fo r m o f larg e volu m e quick ly a dh e r e t o th e v e s s e l s grayi sh an d b u t

, , , ,
S ligh t ly e n de r Tru e carcino m a i s v e ry rar e

t
. .
S UR GI CA L TR E A TM E N T OF Il/I ALI GN A N T T U M OR S :
39 3
Whe n th egrow th i s circu m s crib e d th e ly m p h a t ic s are n ot involv e d

, ,
a n d th e g e n e ral con di t io n i s goo d all s urg e on s a re agr e e d t h a t th e t u

,
m o r S h o ul d b e r e m ov e d b ut w h e n th e d i s e a s e h a s inva d e d th e wall s
o f th e p h arynx a n d t h e n e igh b oring glan d s th e r e i s roo m fo r a qu e s

,
t i on a s t o th e propri e ty o f an op e ra t ion E ach ca s e m u s t b e t r e a t e d

.
on i t s o wn m e ri ts as in m a m m ary can c e r I f th e t on s il an d a par t o f

,
.
th e s o ft p a la t e a re i n volv e d abla t ion i s call e d for e s p e cially i f th e

, ,
gr ow th h as b e e n S low O p e ra tion i s p e r m i s s ibl e e v e n if th e ly m p h

.
glan ds a t th e m axillary angl e are i m plica t e d pro vi d e d th e y a re m ova ,
b le. Bu t w h e n th e ir m obili ty i s lo s t w h e n t h e ly m p h a t ic s in th e caro

,
tid a n d s ub cl avi an t riangl e s ar e a ffe c t e d O p e ra t i on i s con t rain dica t e d

, ,
b e cau s e i t only h a s t e n s th e grow th o f th e t u m or Cach e xia an d rapi d .
grow th ab s olu te ly pro h ibi t th e u s e o f th e k n i fe E v e n i f th e s urgical .
pr o c e d ur e d o e s n o t cur e wh e r e i t i s p e r m i s s ibl e i t r e li e v e s th e pi ti ful ,
con di t ion o f th e p at i e n t s avi n g hi m th e p ain in t h e e ar o dynop h agia

, , ,
h aem orrh ag e d y s pn oe a an d t h e s wallowing o f pu t ri d d i s ch arg e s fro m

, ,
th e ulc e r .
Many d i ffe r e n t m e th o d s o f o p e ra t ing h av e b e e n tri e d Chloro fo rm i .
z a t i o n i s o ft e n d i ffi cul t on accoun t o f th e t e n d e n cy t o s u ffoca tion Pre .
li m inary t rach e o t o m y e xp e d i t e s th e pro c e s s a n d s av e s m uch troubl e ,
clo s in g th e wi n dpip e again s t th e e n tranc e o f bloo d e s p e cially wh e n ,
t h e in s tr u m e n t o f T r e n de l e nb urg i s u s e d A n t e c e d e n t liga tion o f th e

.
caro t i d i s con s i d e r e d in di s p e n s abl e by Polai llo n a s i t gr e a tly l e sse n s ,
h m m orrh a ge an d s o m e ti m e s d i m ini sh e s p ain

,
.
In th e r e m oval o f th e t u m or th e r e h av e b e e n u s e d th e e cra s e ur
, ,
th e r m o cau t e ry galvano cau t e ry a n d cu tting in s t ru m e n t s b u t th e la s t

-
,
-
, ,
t wo a r e b e s t W h e n th e grow th i s n o t v e ry larg e i s m ovabl e an d t h e

.
, ,
gla n ds a re n o t involv e d th e op e ra tion sh oul d b e d on e th rough th e

,
m ou th . T h e kni fe can b e u s e d Le F o rt r e m ov e d a canc e r w h ich i n

.
volv e d th e t on sil an d p ar t o f th e b a s e o f th e t ongu e by p a ss ing curv e d "
n e e d l e s un d e r th e t u m or a n d applying th e loop o f a galvan o cau t e ry -
b e n e a th th e m .O r d ina ry m e an s will con t rol t h e bl e e d ing Th e r e i s .
n o t m u c h d an g e r o f woun di n g t h e in t e rnal caro t i d W h e n th e op e ra

'
t ion can n o t b e p e r form e d th roug h th e m ou t h an ar ti fici al O p e ni n g ,
m u st b e m ade J ae g e r prac ti s e d inci s ion of th e ch e e k on th e affe c t e d

.
394 E D I T OR I A L A R TI C LE 5 .
s i de i n d ir e c t
con tinua tion o f th e lin e o f th e m ou th Polaillo n li g a t e d .
th e e x t e r n al caro t i d a n d th e n j oin e d t h e upp e r e n d o f th i s inci s ion t o

,
th e a n gl e o f th e m ou th by a h oriz on t al c u t m aking a flap w h ic h h e ,
t urn e d d ownwar d an d fo rwar d t owar d s th e h yoi d Wi th t h e Ch ain s aw .
h e d ivi d e d th e l o w e r m axillary a t th e rig h t o f th e s y m p h y s i s a n d acro s s
th c o f t h e ram u s T h i s por tion o f b on e b e i ng rai s e d h e coul d

.
,
r e ach th e t u m or H e p a s s e d a pla ti n u m wir e th rough th e t ongu e fro m

.
a li ttl e ab ov e th e gr e a t h orn o f th e h yoi d t o th e ap e x o f th e li n gual V

a se co n d loop wa s pl a c e d b e low th e t on s il fro m th e b a s e o f th e t ongu e
t o th e p h arynx ; a n d a th ir d b e h in d t h e t on s il c u t th e wall o f th e
p h arynx T h e tu m or was r e m ov e d ; th e h ae m orrh ag e was gr e at ; th e

.
ch e e k wa s s u t ur e d ; no drain wa s u se d On e carb ol i z e d s pong e wa s .
plac e d in si d e an d on e o u t s i de fa s te n e d t og e th e r by a thr e a d p a s s in g
, ,
th rough t h e woun d ; th e inn e r o n e wa s t ak e n o u t t h e n e x t d ay T he .
woun d h e al e d a dm irably an d th e p at i e n t l e ft in t w e n ty d ay s abl e t o

, ,
s wallow liqui d s an d s e m i s oli d s p e r fe c tly Pola i llon h as al s o pr a c tic e d

- .
a s e m i circular inci s ion ov e r t h e p o s t e rior a n d low e r b or d e r s o f t o th e

-
low e r j aw b on e t o circu m s crib e th e t on s illary fo s s a

-
,
A m o d ifica tion .
o f t h i s con s i s t s o f t wo h orizon t al inci s i o n s uni t e d by a v e r tical w h ich
follow s th e p aro t i d bor de r o f th e jaw Ch e e v e r e x tirpa t e d th e t o n s il

. .
H e m a d e a h oriz on t al inci s i o n on t h e low e r e d g e o f th e jaw c ut th e ,
b on e in fron t o f th e m a s s e te r dr e w o ut th e t o n s il wi th h i s fing e r all

, ,
wi th ou t h ur t ing a n e rv e or i m por t an t v e s s e l th e n s u tur e d th e pi e c e s o f ,
b on e an d l e ft an Op e ning for d i s ch arg e In ano th e r ca s e h e carri e d

,
.
,
h i s i n ci s ion fro m th e e n d o f th i s fir s t alo n g th e a n t e ri o r b or d e r o f th e
s t e rno m a s t oi d
- T h e inci s ion along th e b a s e o f th e j aw allow s o n e t o
.
p a s s u n d e r th e p aro t i d b e tw e e n th e s ub m axillary an d t h e caro ti d v e s

,
s el s . M a un o ury i n a ca se o f e pi th e lio m a o f th e v e il a n t e rior pillar

, ,
an d b ack par t o f t h e g um m a d e a v e r tical inci s ion fro m th e c o r n e r o f

'
m o uth d own t o th e low e r e d g e o f th e j aw an d a h o riz o n t al c u t t o i t s ,
angl e I sra e l in a ca s e o f e pi th e lio m a of th e th ir d par t o f th e p h ary n x

.
, ,
wh ich was a tt ach e d t o th e b ack o f th e p h arynx m a de a pr e li m i n ary ,
t rach e o t o m y an d th r e e d ay s a ft e rwar d s m a d e a n i n ci s i o n fro m t h e

, , ,
b a s e o f th e j aw t wo fi n g e r s br e a d th in fron t o f th e angl e t o th e upp e r

’
, ,
p ar t o f th e t rac h e a T h e larynx wa s t urn e d aroun d o n i t s axi s a n d

.
,
V
S UR GI C A L TR E A TI ’I E N T OF M A LI GN A N T T U M OR S .
39 5
m a de pr e s e n t i ts p o s t e rior fac e wh ich wa s th e n fr e e d fro m th e t u

to ,
m or . D e a th occurr e d in s e v e n d ay s fro m ga n gr e no u s r e t ro laryng e al -
ab s c e s s Billr o th p e r for m s p h ary n go to m y by a ou t along th e an t e rior

.
b or d e r o f th e s te rno m a s t oi d Blan d in an d D um ar q u a y wh e n th e
- .
,
t u m or i s t oo larg e t o b e r e m ov e d th rough th e m ou t h op e n in a t th e ,
s a m e p oin t an a s s i s t a n t d rawing b ack t h e i m por t an t v e s s e l s

, D uplay .
r e co m m e n d s Malgaign e s s ub h yoi d p h aryngo t o m y in wh ich an inci s io n

’
,
fi v e c e n ti m e t e r s long i s m ad e alo n g th e low e r b or d e r o f th e hyoi d th u s ,
e s caping th e s up e rior la ryng e al v e s s e l s a n d n e rv e s .
Th e following e xa m pl e s of l arg e O p e ra t ion s ar e giv e n b e cau s e th e y
w e r e brillian tly s ucc e s s ful I n 1 8 8 2 Labb e r e p or t e d a ca s e of e p i th e

.
lio m a o f t on s il v e il n e i gh b o ri n g p h arynx p ar t of t ongu e an d floor o f

, , ,
of m o u th H e m a d e a pr e li m inary r e s e c t ion o f th e in fe rior m axi llary

.
,
a n d t o t ally abla t e d th e grow th wi th t h e t h e r m o cau t e ry Two ob je c - .
tion s m ay b e rai s e d t o th i s m o d e o f proc e e d ing : ( 1 ) th e ab s o rp tio n

o f s e p t ic pro d uc t s w h ich for m on t h e e s c h ar s w h ich h ow e v e r m ay b e , , ,
r e m e di e d by fr e qu e n t an ti s e p tic wa sh ing an d l e aving an ap e r t ur e t o

th e ou t s i d e fo r a drainag e t ub e ; ( 2 ) t h e d i fficul t y o f ali m e n t a t ion ,
wh ich Labb e ov e rca m e wi t h th e t ub e o f F auch e r I n 1 8 8 4 N avaro .

, ,
Turin r e m ov e d fro m a fe m al e Pe t 4 5 t h e low e r par t o f th e p h arynx

, ,
.
,
a n d upp e r p ar t o f th e gull e t F iv e m o n th s a fte rwar d s S h e coul d t ak e

.
s oli d foo d wa s in go o d con d i t ion a n d t h e d i s e a s e h a d n o t r e t urn e d

, ,
.
On e o f t h e m o s t e x t e n s iv e op e ra t ion s a tt e n d e d w i t h go o d r e s ul t s wa s
m ad e in 1 8 7 9 by C a s e l i o f G e n e s on a girl ac t 1 9 wh o h a d e p i t h e
i , , .
,
lio m a o f p h arynx uvula t o n s il s b a s e o f t o n gu e a n d p ar t o f larynx

, , .
Th e r e wa s no ly m p h a ti c e nlarg e m e n t a n d th e g e n e ral con di tion wa s ,
goo d Pr e li m inary trac h e o t o m y was prac ti s e d wi th th e galvano cau t e ry

.
-
an d th e t ub e o f Tr e n d e l e n b urg w a s in s e r t e d T th e inci s io n e x t e n d e d .
fro m th e s y m p h y s i s t o t h e s t e rn u m T h e larynx an d p h arynx w e r e d e

.
t ac h e d a t t h e l e v e l o f th e cricoi d car t ilag e th e h yoi d wa s c u t i n t h e ,
m i ddl e th e ba se o f th e t ongu e wa s e x t irp a t e d th e p h arynx e n t e r e d

, , ,
a ll th e s o ft p ala t e d e t ach e d t h e p h aryn x a m pu t a t e d ab ov e an d t h e

, ,
t o n sil s r e m ov e d An oe s oph ag e al t ub e wa s in s e r te d an d th r e e quar

.
,
-
t e r s o f th e woun d clo s e d Le ss th an t wo o unc e s o f bloo d wa s lo s t

. .
T h e O p e ra tion la s t e d ov e r th r e e h o ur s T h e poin t s o f c h i e f d i fficul ty.

39 6 E D I T OR I A L A R TI CLE 5 .
were th e i s ola t i on o f th e larynx s o a s n o t t o i nj ur e th e caro ti d s an d

,
vagi , an d th e e x t irp a t ion o f th e t on s il s Union wa s co m pl e t e in .
on e m on th an d in an oth e r th e p a t i e n t cou ld s wallow s oli d s an d li

,
qui d s .
T h e s e o p e ra tion s are m e r e ly pallia tiv e b ut in s uc h t u m or s a s s ar ,
co m a t a th e y prolong li fe an d m ak e i t fairly co m for t abl e W h e n th e .
r e curr e n c e t ak e s plac e th e p a t i e n t s u ffe r s le s s th an a t fir s t b e cau s e

, ,
th e p ar t s i n va d e d ar e l e s s se n s i t iv e t h an t h e m uco u s par t s a t fir s t a t
t ack e d an d t h e t u m or n o lo n g e r pr e s e n t s r e t rac t e d or b ulging s ur fac e s

,
fo r th e b olu s o f foo d t o irri t a t e I f th e di se a s e r e t urn s in th e glan d s

.
,
th e p ain i s l e s s acu t e Cach e xia r e d uc e s th e p ai n ful e xci te m e n t o f th e

.
n e rvo u s s y s t e m As G o s s e lin s ay s i t i s b e tt e r t o s ub s ti t u te a woun d

.
,
w hich th e p a ti e n t s e e s h e alin g th an t o allow h i m t o o b s e rv e con s t an tly

,
a growing di s e a se I t i s e a s i e r al s o t o d e c e iv e th e pa ti e n t ab ou t th e
.
, ,
r e t urn o f th e d i se a s e th an ab ou t t h e ch arac te r o f th e d i s e a s e at fir s t
, .
I f de ath by h ae m orrh ag e th r e a te n s th e liga tion o f t h e co m m on caro t i d

, ,
afte r W e i s s sh oul d b e prac ti s e d

,
.
A s r e gar d s m e d ica t ion s yp h ili ti c t r e a t m e n t S h oul d b e giv e n in

,
d oub t ful c a se s Ar s e ni c i s e m ploy e d by Ve rn e uil an d Bour don b ut i s

.
,
princip ally u se ful th rough i t s m oral e ffe c t Applica t ion s o f cocain e ,
ar e s e rvic e abl e .
Ca s te x s u m s up as follow s
Malignan t t u m or s o f th e t on s illar r e gio n ar e m o s t fre qu e n tly e p i th e
li o m at o us a n d th e t on s il i s th e ir u s ual poin t o f d e par t ur e
,
The y g e n .
e ra lly a t t ack a d ul t s ra th e r t h an ch il dr e n T h e Ch i e f func t ional s ym p .
t o m s ar e e ar p ain -
s aliva t ion
, d y s p h agia a n d o dynop h agia
, Th e .
obj e c tiv e ch arac te ri s tic s are t e n d e ncy of th e ulc e ra tion t o s pr e a d

ra th e r th an t o go d e e ply grayi sh an d p ulpy de po si t cov e ri n g th e ulc e r ;
,
cru s h e d form s or s ca tte r e d S po ts s o m e ti m e s cov e ring th e grow th a n

ae s th e s ia t o t ouch ; angular glan d ular e nlarg e m e n t Th e g e n e ra l .
s y m p t o m s app e ar la t e T h e progr e s s i s n o t s t e a d y
. S o m e e pi th e li .
o m a t a b or e th rough th e b a s e o f th e s kull A d e no m a t a o f th e v e il .
,
a t fir s t e ncap s ul at e d m a y br e ak o u t an d b e co m e s arco m a t a
, E arly .
d iagno s i s i s v e ry i m por t an t a n d in e l d e rly p e opl e un ila t e ral t on s illa r

,
h yp e r trop h y i s s u s piciou s T h e principal di s e a s e wi th w h ic h i t

.
E X CI S I ON OF TH E LAR VN X .
39 7
liabl e t o b e co n foun d e d i s s yph ili s e s p e cially ch ancr e o f th e t on s il

,
.
T h e rul e s for s urgical in t e r fe r e nc e ar e ( 1 ) wh e n th e n e opla s m i s cir
c u m s c ri b e d an d th e ly m p h a t ic s a r e n o t involv e d
,
op e ra t e ( 2 ) wh e n ,
th e t u m or m or e e x t e n d e d b u t s till circu m s crib e d an d m o vabl e i s a o

, , ,
co m pani e d by s e co n d ary ly m ph at ic di s e a s e op e rat ion i s j u s t ifi abl e , ,
in te rv e n tion b e i n g u s e ful m or e g e n e rally th an h ar m ful ; ( 3 ) wh e n th e

involv e m e n t i s gr e a t e r i n t e rfe r e nc e th ough only pallia ti v e i s p e r m i s
, , ,
s ibl ei f c e r t ain con di t ion s ob t ain in t ol e rabl e p ain in t e n t ion o f s ui ci d e

, , , ,
e tc. T h e O p e ra t io n h as a pr e li m i n ary an d a fu n d a m e n t a l s t ag e It .
m a y b e d o n e t h roug h th e n a t ural or ar t ifi cial p a s s ag e s An O p e ning .
for d rain ag e sh oul d alway s b e pr o vi de d G e n e rally i f th e op e rat i on i s

.
e arly a n d t h oroug h th e prolonga ti o n o f li fe i s s a t i s fac t ory

, .
F H GE R R I S H . . .
E X CI S I O N O F T H E LAR Y NX .
L e P r og r es M ed i ca le M arch 2 7 an d April 1 0 o f t h e pr e s e n t y e ar
of ,
con t ain s an e xh au s tiv e m e m oir by M Bara t o ux on th e s ubj e c t o f E x .

“
,
”
c i s i o n o f t h e Larynx T hi s m ay b e con s i d e r e d as s uppl e m e n ting th e
.
con trib u t i on on th i s s ubj e c t by H ah n ( se e A NNA L S O F S U R G E R Y Vo l , .
III No . P 6 7 J anuary 1 8 8 6) a n d S h o ul d b e s t u di e d in conn e c

.
, ,
t ion wi th i t Hah n p ubli sh e d a li s t o f nin e ty on e ca s e s t og e th e r

.
-
,
wi th e l e v e n h i th e r to unpubli sh e d ca s e s o f h i s own Bara t o ux h a s a s .
s e m bl e d 1 0 4 ca s e s fo r th e p urpo s e o f h i s s t u dy T h e con trib u t ion s .
o f G e r s t e r P ark a n d La n g e
,
in th e nu m b e r o f th e A NNA L S O F S U R
,
G E R Y ab ov e r e fe rr e d t o sh oul d al s o b e con s i d e r e d i n t h i s conn e c tion

, ,
.
T h e s ub s t anc e o f Bara t o ux s m e m oir i s a s follow s

’
B i s tory — Un til Le vr e t t u m our s o f th e larynx w e r e l e ft t o na t u r e

’
. .
,
D e s aul t was th e fir s t t o propo s e th e r e m oval o f laryng e al n e opla s m s

h e d e s crib e d la ryngo t om y b u t n e ve r prac t ic e d i t
, T h e fir s t a tt e m p t .
o f th e kin d wa s m a d e by Bra ii e r s o f Louvain in 1 8 3 3 a n d S i n c e th a t

, , ,
t i m e th e O p e ra t ion h as b e e n m any t i m e s r e p e a t e d In 1 8 2 9 Alb e r s .

, ,
o f Bonn in e xp e ri m e n t ing t o e s t abli s h a t w h a t p o in t t h e l a rynx p ar

‘
t i c i p a t e d in r e spira t ion r e m o v e d a p ar t an d e v e n th e wh ol e o f th e lar

, ,
y n x o f d og s ; b u t h i s t wo e x p e ri m e n t s we r e n o t e nc o uraging fo r one ,
o f th e ani m als di e d o f h ae m orrh ag e d uri n g th e O p e ra tion a n d th e ,
o th e r s ank fro m i n a n i tion nin e d ay s a fte rwar d s In 1 8 5 4 Lan g e n b e ck .

,
h aving b e e n co n s ul t e d by a p a t i e n t wi th m alig n an t t u m our o f th e lar

n x d i s cu s s e d i n o n e o f h i s clinical l e c t ur e s t h e op e ra t iv e proc e d ur e
y , ,
o f e x t irp a t io n o f t h e larynx b ut th e i n vali d r e fu s e d th e O p e ra tion

,
.
Lat e r K o eb e rle s t a t e d th a t h e woul d n o t h e s i t a t e t o e xci s e t h e vocal

”
organ in a ca s e o f canc e r “
b e cau s e
, s ai d h e
“
,
i t wou ld b e m or e ,
s e rvic e ab le t o h av e r e c our s e t o th e O p e ra t i o n ra th e r th an n o t t o in t e r ,
”
v e n e a t all . Hu e t e r al s o a tt ribu te s t o h i m s e l f p ri ori ty in th e op e ra
t io n wh ich h e i n t e n d e d t o e m p loy in th e ca s e o f a wo m an wi th canc e r
,
o f t h e ary t e noi d m ucou s m e m bra n e H e was g o i n g t o d o a p r e lim i

.
nary trach e o t om y wh e n th e p a t i e n t di e d I n 1 8 6 6 Pa trick H e ron

,
.
,
Wa t s o n o f E dinb urgh h avin g t o t r e a t a p a ti e n t wi th t e r tiary s yp h ili s

“
, , ,
a n d d e s t ruc t ion o f t h e laryn g e al cavi t y d e t e r m i n e d t o e xci s e t h e lar

,
y n x . Th e p a t i e n t d i e d o f p n e u m oni a th r e e w e e k s a ft e r th e r e m oval o f
h i s v o cal organ .
Ignoran t o f th i s a t t e m p t Cz e rny o f H e i d e lb e rg wi sh ed t o a s s ur e
, , ,
h i m s e lf t h a t r e m oval o f t h e lary n x d i d n o t i m p e ril t h e li fe o f an i m al s .
H i s fir s t e xp e ri m e n t s w e r e n o t fo r t u n a t e fo r o n e o f h i s d o g s d i e d a t
,
th e e n d o f t wo d ay s t wo o th e r s a ft e r fi ft e e n d ay s a n d t h e la s t a t th e
, ,
e n d o f t h e four t h w e e k fro m a s p h yxia d u e t o d i s plac e m e n t o f t h e c a n
ula I n a lat e r e xp e ri m e n t Cz e rny p e r form e d a pr e li m i n ary trach e ot

.
,
o m y a n d wh e n th e t rac h e a h ad b e co m e a d h e r e n t t o t h e S kin
, h e di d ,
th e e xci s io n Making u se o f canul ae o f larg e r calibr e h e h a d no th ing

.
,
m or e t o fe ar fro m d i s plac e m e n t o f t h e t ub e wh i ch h a d b e e n th e cau s e ,
’
o f h i s fir s t failur e s Cz e rny s m e th o d o f O p e rat i n g i s th e following
.
T h e an im al b e ing an ae s th e tiz e d h e inci s e s t h e s ki n i n th e m e dian lin e

,
fro m th e h yoi d bon e t o th e t rach e al fi s t ula ; t h e n wi th a blun t i n s tru
m e n t h e d e t ac h e s t h e s o ft p ar t s h e only u s e s t h e b i s t oury t o d ivi d e
th e th yro h yoi d an d s t e r n o th yr oi d m u s cl e s a t t h e ir i n s e r tion t o t h e th y

- -
r o i d H e th e n cu t s th e t rach e a b e lo w th e cric o i d an d i n tro d uc e s in t o

.
,
i t a s m oo th caou t ch ouc t ub e wi th th ick wa ll s i n or d e r t o h in d e r th e ,
e n tranc e o f blo o d a n d al s o t o allo w o f t h e con t inuanc e o f t h e a n ae s

,
t h e t ic i n h ala t io n By d rawi n g up t h e lary n x h e s e p ara t e s i t fro m th e

.
oes op h agu s in o r de r t o d i s s e c t i t s po s t e rior s ur fac e as fa r a s t h e poin t

E X CI S I O N OF TII E LA R YN X .
3 99
o f th e a ry t e noi d s ; cu t s th e larg e cornua o f th e h yoi d b on e an d di ,
vi d e s th e la rynx parall e l t o th e upp e r b or d e r o f th e thyroi d In h i s .
fi ve op e ra t i o n s Cz e rn y l e ft th e e piglo t ti s in plac e wi th th e aid o f a

,
s u t ur e I n h i s o th e r e xp e ri m e n t s h e r e m ov e d i t an d fr o m th e fo llow
.
,
i n g d ay th e d o g co ul d e a s ily s wallow fo o d Th i s op e rat or d o e s n ot

.
d oub t th a t th e e xci s ion m ay s ucc e e d in th e ca s e o f m an — pro vi d e d th e

p a ti en t b e nouri sh e d by m e an s o f an oe s op h ag e al t ub e for a fe w d ay s .
La t e r s p e e c h c an b e r e s t or e d by e m ploying an ar t ificial l arynx p e r ,
m i tt i n g th e air t o p a s s th rough th e m o u t h an d no s e In p u tt ing th i s .
la s t i d e a in prac tic e in d og s Cz e rn y prov e d th a t h e coul d th u s r e

,
e s t abli s h th e func t ion o f t h e vo cal organ A sh or t t i m e afte rwar d s on

.
,
th e 3 i s t o f D e c e m b e r 1 8 7 3 th ank s t o Bil lr o th o f Vi e nna e xci s ion o f

, , , ,
th e larynx wa s a d m i tt e d t o s urgi cal prac t ic e T h e following t abl e .
g iv e s a r es um e of th e e xci s ion s w h ich h av e b e e n p e rfor m e d s inc e th e

fir s t op e ra tion .
Up t o th e pr e se n t ti m e th e r e h av e b e e n 1 0 2 e xci s ion s—7 3 for can

c e r s or e pi th e li o m a s 1 0 for s arco m a s 1 0 fo r s t e no s i s n e cro s i s p oly
, , , ,
u s a nd fo r a ffe c ti on s th e na t ur e o f w h i c h w e d o n o t kn ow—prob a
p , 9 ,
bly h ow e v e r e pi th e lio m a t ou s or s arco m a t ou s t u m our s

, , O f th e s e .
nin e th e op e ra tiv e proc e d ur e an d r e s ul t s a re n o t giv e n in 5 c ase s .
Th e r e r e m ain th e r e for e 9 7 ca se s whi ch we m ay an alyz e Th e e x

, , .
c i si on wa s t o t al in 8 3 a n d p ar ti a l in 1 4
,
.
T h e t o t al e xci s ion s w e r e
R E SU L T
CUR E S . D E A TH S . U N K N O WN .
F or epi th e li o m as or canc e r s , 21 47 1
s arco m as , 2 7
con trac tion s n e cro s i s e tc
, ,
.
, 3
d i s e a s e s un k nown , 1
In th e se s t a ti s ti cs we inclu d e as cur e d 5 canc e rou s ca se s o f wh i ch

th e r e s ul t s w e r e r e por t e d l e s s t h an t wo m on th s a ft e r op e r at ion an d ,
t wo o f th e m w e r e only op e ra t e d on qui t e r e c e n t ly .
IO E D I T OR I A L A R TI CLE S .
The par tial e xci s i on s w e r e
F or epi th e li o m a s ,
s arco m a s ,
c o n tra c tion s n e cro s i s , , e tc .

,
unk n o wn a ffe c tion s ,
To t al ,
E xci s io n larynx h a s t h u s giv e n u s 3 2 cur e s an d 6 4 d e a th s O f

of th e .
4 9 d e a th s foll o wing t h e O p e ra tion fo r ca n c e r s 2 s uccu m b e d on th e ,
s e con d d ay ( c o llap s e s h o ck o f w h ic h 1 wa s a par tial e xci s ion o n

) 3 , , , ,
th e th ir d d ay ( collap s e p n e u m o n ia) ; 6 o n th e fo ur th d ay ( collap s e

, ,
pn e u m onia h ae m o rrh ag e a s p h yxia) ; 4 o n th e fifth d ay ( pn e um onia

, , ,
pl e uri sy h ae m orrh ag e ) 6 a t th e e n d o f a w e e k ( p n e u m o ni a e m b o li sm
, , , ,
e xh au s tion ) 7 a t th e e n d o f a fo r tnigh t ( pn e u m o n i a gangr e n e p h thi

, , ,
s i s h ae m orr h ag e ) o n e o n th e t we n ty fi fth d ay ( pn e u m o nia )

, , o n e a t th e -
,
e n d o f a m o n th ( pn e u m o n ia) 3 i n t h e s e con d m o n th ( p n e um o nia re

, ,
curr e nc e s lip p i n g o f th e t ub e ) o n e in th e th ir d m o n th ( pn e um oni a)

, , ,
4 i n th e fo ur th m o n th ( pn e u m o ni a ) 3 i n t h e fi ft h 2 i n t h e s ix th in th e , , ,
s e v e n t h an d in th e n in th o n e a t th e e n d o f a y e ar , a n d o n e la s tly ,
a fte r t wo y e ar s T h i s o n e h a d b e e n op e ra te d on par tially for carci

.
no m a w h ich r e t urn e d abou t t h e s ix th m o nth O f th e 7 s arc o m a s op

,
.
e rat e d o n by t o t al e xc i s i o n o n e d i e d o n th e s e v e n t e e n th d a y
, the ,
s e co n d in th e th ir d m o n th ( p n e u m o nia) th e th ir d in th e se v e n th ,
m o n th ( r e curr e nc e ) th e four th in th e e ig h th ( p n e u m oni a)

,
t h e fi fth a t ,
th e e n d o f a y e ar ( acci d e n t al pl e uri s y ) t h e S ix th i n t h e fi ft e e n th m o n th ,
( r e curr ence
) a n d th e la s t a t th e e ig h te e n t h m on t h ( pul m onary t ub e r
,
c ulo s i s O f th e 7 d e a th s a m o ng ca s e s o f t h e c o n t rac t i o n s n e cro s e s e t c

.
, , .
,
th e 3 o e p ra t e d on by t o t al e x t irpa t io n s uccu m b e d — o n e on t h e fi fth da y ,
th e s e c o n d a t th e e n d o f a m on th a n d t h e la s t at th e fi ft e e n th m o n th of ,
m ara s m u s p n e u m o n i a an d t ub e rcul o si s r e s p e c t iv e ly
,
AS r e gar d s th e .
p ar ti al o p e ra ti on s o n e di e d on th e th ird d ay th e s e con d at th e s e c o n d
, ,
m o n th ( d iab e t ic s l o u gh ) t h e th ir d a fte r t wo an d o n e h al f m o n th s ( e x
,
-
h a u s t i o n ) a n d th e la s t in th e e l e v e n t h m on th ( pr o gr e s s o f th e d i s e a s e )
, ,
We only k n ow o f o n e d e ath on th e fo ur th d ay i n a pa ti e n t fr o m wh o m
th e larynx was t o t ally e xci s e d for an a ffe c t i o n n o t s t a t e d ( c anc e r or sar
c o m a)
E X CI S I ON OF TII E LA R YN X .
41 1
Th e 3 2 cur e s are th u s co m p o s e d : Tw e n ty t hr e e to r e pi th e lio m a s -

,
0 1 w h ic h 2 1 w e r e t o t al e xci s io n s an d 2 p ar t ial d a t ing fro m 4 y e ar s 2 , ,
y e ar s 1 9 1 8 1 7 1 6 1 4 ( 2 o f w hi c h on e was a p ar tial e x tirpa t ion ) ;

, , , , , ,
1 2 ( on e a n d 2 m o n th s ( 2 ca s e s ; ( in t h e 7 r e m ai n ing e p
) 1 1 8 ,5 4 , , , )
i th e lio m at o u s ca s e s w e only know t h e r e s ul t fo r a fe w w e e k s ) 3 for ,
s a r c o m a s wi t h t wo t o t al an d o n e par t i al e xci s ion — goi n g b ack t o s i x

,
y e ar s fi v e y e ars an d th r e e y e ar s ( th e p ar t ial) 3 fo r con trac t i o n s n e

, ,
o f w h ic h o n e wa s t o t al ( p o lyp an d 2 par t ial ( papillo m a

c ro s e s e t c
. .
, )
an d s t e n o s i s co n s e cu t iv e t o t yp h oi d fe v e r ) a n d 3 fo r a ffe c tion s o f w h ich ,
we d o n o t k n o w t h e n a t ur e ( ca n c e r or s arco m a) T h e s e w e r e par t ial .
e xci s ion s — p e r fo r m e d t h e on e t wo y e ar s a go t h e o th e r s only a fe w ,
m on th s .
In co m paring th e prop or tion O f d e a t h s an d cur e s we se e th a t for e ni

t h e li o m a wi th ou t r e gar d i n g th e fi ve la t e s t e xci s ion s o f wh ic h our i n
-
,
for m a t ion d o e s n o t e x t e n d fo r m or e t h an t wo m on th s a n d o n e ca se , ,
th e e n d o f w h ic h i s unk n own t o u s th e r e w e r e 4 7 d e a t h s an d 1 5 cur e s , ,
th a t i s -t o s a y th a t cur e s only r e s ul t e d in a quar te r o f t h e ca s e s i f w e ,
m ay con s i d e r t h o s e O p e ra t e d on fo r t wo m on th s t o a y e ar A th ir d .
o f th e pa t i e n t s O p e ra t e d o n d i e d in th e fir s t w e e k fro m s h ock e xh au s
‘
,
t ion pl e uri s y pul m onary e m b oli s m

, ,
h ae m orr h ag e ( t wic e ) collap s e ( 3 , ,
ti m e s ) ,
pn e u m onia ( 1 1 ti m e s ) I n th e fir s t m on th th e r e w e r e 8
.
d e a th s—th a t i s t o s ay th a t a fi fth o f t h e s urvivor s s uccu m b e d— 6 fro m

,
p n e u m o n ia an d in th e fi v e followin g m on th s th e m or tali ty was 1 2

, ,
fro m pn e u m onia r e curr e n c e e t c i e m or e t h an a th ir d o f th e

"
. . .
, , , ,
r e m aining s urvivor s .
T h e r e s ult s in th e s arco m a ca s e s w e r e m or e favorabl e s i n c e in th e ,
se v e n fa t al ca se s fi v e p a t i e n t s liv e d fro m s e v e n t o e ig h t e e n m on th s .
H e r e cur e s r e s ul t e d in n e arly h al f o f th e ca s e s But o f t h e s i x ca s e s .
op e ra t e d on for con tracti o n s s te no s e s e tc fi ve liv e d for l e s s th an th re e

, , .
,
m o n th s o n e l e s s t h an for s i x m o n th s a n d th e la s t l e s s t h an a y e ar
, , .
H e nc e i n th e e xci s ion s o f th e laryn x d e a th h a s s up e rv e n e d b e for e

th e s ix th m on th in m or e t h an t wo th ir d s o f t h e ca s e s—i f we e xc e p t -
,
h o we v e r th e s arco m a c as e s in w h ich only t wic e a s i m ilar rapi d i ty o f

, ,
m or t ali ty h a s b e e n no t e d .
In p ar tial e xci s ion s ucc e s s h a s b e e n O b t ain e d twic e in thr e e t i m e s ,

412 A R TI CLE S .
whil st in t o t al e xci si o n d e a th h a s t ak e n plac e i n m or e th an t wo th ir d s -
o f th e ca s es h al f o f th e p a t i e n t s n o t living b e yon d th e four th m o n th

, .
—To t al e xci s ion O f th e larynx app e ar s t o b e in di

c a t e d i n th e ca s e o f m alig n an t n e o p la s m s w h ic h h aving inva d e d m or e ,
th an h a lf o f th e or g a n h av e s par e d th e n e ig h boring par t s

, Pa t i e n t s .
t o o a d vanc e d in a ge sh o u d n o t b e O p e ra t e d upon
l O n e o f H ah n s ’
.
a t i e n t s h o we ve r ae t 6 7 w as cur e d wi t h ou t an y acci d e n t s urvi vin

p , , .
, g ,
th r e e a n d on e h al f y e ar s a ft e r O p e ra t ion
- .
E xci si o n i s c o n t ra in d ica t e d in all ca s e s O f b e n i gn grow th s p a p il

-
,
l om a s p e rich o n dri ti s or n e cro s i s o f th e car tilag e s an d in ca s e s Wh e r e

, , ,
m align an t t u m our s h av e inva d e d th e n e ig hboring t i s s u e s or organ s a t
a d i s t anc e T h e O p e ra tion sh o ul d als o b e r e fu s e d wh e n the p at i e n t

.
i s th e s ubj e c t o f a s e riou s di s e a se .
P ar ti al e xci s ion i s pr e fe rabl e t o t o t al i n s o m uch th e m or e th a t re

,
curr e n c e i s n o t m or e fr e qu e n t in th e fir s t th an in th e s e con d I t m us t .
al s o b e con s i de r e d th at wi th p artial e xci s ion th e p ati e n t can di sp e n s e

wi th th e canula H e can th e n s p e ak wi th a b a s s ph aryng e al voic e
.
,
a n d in c e r t ain ca s e s e ve n a n e w glo t ti s i s for m e d O n t h e o n e s i de

'
, .
i s a vocal cor d an d o n th e o th e r a cica t ricial t i s s u e r e plac e s th e cor d ,
pro d ucing a laryn g e al voic e far s up e rior t o th at of all th e ar tificial lar

y gn e. s Par t ial e xci s ion will b e e m ploy e d in all th e ca s e s o f m alig n an t
gr ow th s wh ich d o n o t e x t e n d b e yon d h alf th e larynx in c e r t ain con ,
tr a c t ion s d u e t o a fibrou s t ran s for m at ion o f t h e ti s s u e s an d t o h yp e r ,
tr op h y or o s s ificat ion o f t h e car t ilag e s h in d e ring th e u s e o f th e or d inary

,
m e th o d s o f di la t a t i o n Bu t th i s op e ra tion sh oul d n ot b e r e s or t e d t o
.
fo r th e cur e o f s i m p le co n t rac t ion s papi llo m a s p e rich on dr i t i s an d n e

, ,
c rosi s o f th e cart ilag e s .
Op e r a t i ve P r oced u r e P r eli m i n a ry Tr a efi eoze m y —

. I n th e gr e at e r
‘
.
n u m b e r o f t h e ca s e s t rach e o t o m y was pr e li m inarily p e r fo r m e d e i th e r

, ,
on acc o un t o f dy spn oe a or s p e cially in Vi e w o f the e xci s ion o f th e lar

,
yn x as Cz e rn y ad vi s e d or aga i n l n or d e r t o r e m ov e a lary n g e al t u
, ,
m our wi th ou t e x t irp a ting th e organ i t se l f I t h a s b e e n m ain t ain e d

.
th a t t rach e o t o m y p e r form e d abou t two w e e k s b e fo r e th e e x ci s ion p e r ,
m i tt e d th e p a ti e n t t o r e gain s t r e ng th t h a t i t h abi t ua t e s th e m ucou s

,
m e m bran e o f th e air p a ss ag e s t o th e d ir e c t ac tion o f th e air an d t o ,

E X CI S I ON OF TH E LA R YN X .
413
th e t ick li n g pro d uc e d b v th e ca n ula th a t i t h ad th e a d van t ag e o f fixi n g

,
t h e t rac h e a s oli d ly t o th e i n t e gu m e n t s a n d O f pr e v e n tin g a t o o gr e a t

,
s i n ki n g o f th e a e rial t ub e a n d a flow o f bloo d an d

, p u s in t o th e t ra
ch e a d uri n g a n d a ft e r th e O p e ra tio n By m e an s o f i t al s o an ae s th e si a
.
c a n b e m ai n t ai n e d d uri n g t h e w h ol e op e ra t ion .
A n wi i zes za — S urg e o n s h av e g e n e rally an ae sth e ti s e d th e p a t i e n t s wi th

'
ch loro for m wi th th e m ix tur e o f alco h ol e th e r a n d ch loro for m or by

, ,
m e a n s o f bic h lori d e o f m e th yl e n e ( H e in e A c e r t ain nu m b e r h av e

) .
u s e d b e s i d e s s ubcu t a n e ou s i nj e c tio n s o f m orp h in e Bo ttini h as p r o

. ,
.
p o s e d t o e m ploy e th e r s pray o n th e s ki n b u t h e wa s inco m m o d e d by ,
th e r e s i s t e n c e a n d m ov e m e n t s o f h i s p a t i e n t w h o m h e h a d n o t p u t t o ,
sl e e p . I f pr e li m i n ary t rach e o t o m y h a s n o t b e e n alr e a dy p e r for m e d i t ,
m u s t b e d o n e a s lo w d own a s p o s s ibl e a n d t h e n t h e plugging of th e

,
t rac h e a m u s t b e e ffe c t e d .
P lugg z7zg — A fte r r e m ovin g th e canula an d e nlarging i f n e c e s s ary

'
.
, ,
th e t rac h e al O p e n i n g th e canula plug O f T r e nd e le n b o urg i s i n

,
-
t ro d u c e d T hi s i s co m po s e d o f a cao u t ch ouc cylin d e r fi x e d b e lo w t o

.
an or di n ary canula wh ich carri e s a t ub e t e r m ina ting ab ov e in th e in te rior

o f t h e c yli n d e r an d b e low in a caou t c h ouc b ag w h ich allow s infla tion
'
’
wh e n th e canula i s in plac e T re n d e le n b o urg s p lu g ap p li e d t o th e in
.
,
t e rn al wall o f t h e t rach e a pr e v e n t s th e bloo d fro m p e n e tra ting in t o th e

.
air p a s s a g e s whil e i t l e av e s th e r e s pira tion fr e e th rough th e t rach e al

,
ca n ula A clip fix e d on th e in dia rubb e r t ub e th rough wh i ch th e plug

.
,
-
i s in fla t e d pr e v e n t s th e la t te r fro m con trac ting

,
I t i s w e ll t o h a v e s e v.
e ral o f T r e n d e le n b o u r g s canul ae a t h an d in ca s e o n e or o th e r
’
o f th e m
,
d o e s n o t ac t conv e ni e n tly .
T h i s m e th o d o f plugging h as b e e n r e co m m e n d e d by H e in e Lang e n ,
b e ck Brun s Ca s e lli S ch oe nb orn e tc Billro th s ta te s th at h e h a s b e e n

, , , ,
.
ra th e r h in de r e d th an w e ll s e rv e d by th i s pluggin g app ara t u s an d Bo t tini ,
a s s e r ts th at i t h a s no a d van t ag e I f th e b ag b e di s t e n d e d a s i t m u s t
b e i t m ay al s o d i s t e n d th e lu m e n o f th e tr ach e a t o o m uch an d th e
, ,
p a ti e n t can no long e r b e ar th e in s tru m e n t I f on th e o th e r h an d i t b e .

, ,
r e d uc e d in s iz e e nough t o b e t ol era te d bloo d in s inua te s i ts e lf b e twe e n

,
t h e p lu g an d th e t rach e al wall th u s aug m e n t ing th e d ang e r s o n e i s tr

, y
”
in g t o avoi d T h e co m pl e t e d i s t e n tion o f th e cylin de r sh oul d n o t b
.
e
e ffe ct e d un til th e
arco si s i s confir m e d In a d di t ion t o th e u s e O f
n .
’
T r e n d e le n b o u rg s ca n ula wi th th e vi e w t o avoi d th e in tro d uc tion o f
,
blo o d in to th e lung s Ca se lli an d Lang e a d vi s e th e h e a d t o b e plac e d

,
i n a d e p e n d e n t po s i tio n — a s R o s e r e co m m e n de d C e r t ain op e ra t or s .
e v e n in s te a d o f p lugging t h e t rac h e a c o n te n t th e m s e lv e s wi th p lacin g

, ,
’
t h e ir p a t i e n t s in R o s e s po s i t ion Hah n pr e fe r s t o T re n d e le n b o urg s
.
’
app ara t u s a canula wi th th e low e r e n d s urrou n d e d by pr e par e d spong e .
Bo ttin i plac e s a pi e c e o f e la s tic t ub e in t h e canula a ft e r p e rfor m ing ,
pr e li m inary t rach e o t o m y wh il e Alb e r t only in tro d uc e s th e i n dia rubb e r

,
t ub e a ft e r h e h a s s e p ara t e d th e t rac h e a fro m t h e lary n x th u s avoi ding
t rach e o t o m y .
’
I f T r e n d e le nb o u rg s arra n g e m e n t ch loro
be em p loye d , th e t ub e o f th e
form i n g appara t u s i s p a s se d th roug h i t T h i s co n si s t s o f a m e t allic .
t ub e wh ic h i s a d ap t e d on th e o n e h an d t o t h e e x tr e m i ty o f th e t rach e al
canula an d on th e o th e r t o a c a o utc h o us t ub e wh i ch i s a tt ach e d t o a

.
,
funn e l s h ap e d m e t allic pi e c e clo s e d by a pi e c e o f t a ffe t a upon wh ic h

-
,
th e c hloro for m i s p our e d T h e m e t alli c p ar ts b e n t a t a ri g h t angl e can

.
b e co m pl e t e ly ro t a te d aroun d th e axi s By m e an s o f th i s t ub e ch loro.
for m can b e giv e n fro m a d i s t anc e .
Op er a f zorz —I n or d e r to lay b ar e th e lary n x a s ingl e inci s ion can b e

'
m ad e alon g th e m e dian lin e o f th e n e ck an d a t e ach e x tr e m i ty on e or ,
t wo p e rp e n dicular inci s ion s s o a s t o h av e t wo la t e ral flap s

,
The m e .
di an inci s ion s h oul d co m m e n c e ab ou t o n e c e n ti m e tr e ab ov e th e h yoi d

b on e an d e x te n d a s far as th e trach e al fi st ula i f po ss ibl e wi th ou t ar , ,
»
rivin g h ow e v e r at th e s up e rior b or d e r O f th e cica trix In m aking a

, ,
.
s e con d inci s ion t r an s v e r s e ly a cro s s t h e upp e r e n d o f t h e fir s t fro m th e ,
in te rn al bor d e r o f th e rig h t s te rno m a s t oi d m u s cl e t o th e s a m e m u s cl e

-
o f th e o th e r s i d e th e T inci s ion i s ob t ain e d wh ic h Lang e n b e ck h a s

,
r e co m m e n d e d Bo t ti n i m or e ov e r m ak e s an inci s ion p e rp e n d icular t o

.
, ,
t h e low e r e n d O f t h e m e d ian o n e .
2 2 S zag e
7 ‘
B e for e going fur th e r S ch o e nborn h a s a dvi se d th e pe r
.
form an c e O f laryngo to m y in or d e r t o v i e w th e in t e ri or o f th e laryn x

,
.
Th i s O pinion i s n o t sh ar e d by a gr e at nu m b e r o f op e r at or s wh o at ,
t e m p t t o i s ola t e th e larynx by m e an s o f a forc e p s a gr oov e d s oun d an d ,
a galvano cau te ry kni fe ( Bo ttini ) T h e m u s cul ar in s e r tion s are th u s

- .
E X CI S I ON OF TH E LAR YN X . 41 5
d e t ach e d an d la t e ral s ur fac e s O f th e larynx d e nu d e d—avoi din g

th e
wi th car e th e v e s s e l s a n d n e rv e s A ccor d ing t o Bo ttini co m pr e s s ion

.
,
o f th e pn e u m oga s t ri c m ig h t pro d uc e s yncop e .
3 d S ta
g e — T h e e x ti rp a tion m a y b e e ffe c t e d fro m b e lo w upwar d s fol ,
lowi n g th e e xa m pl e o f Cz e rny Billr o th H e i n e S ch o e nb orn e t c or

, , , , .
,
fro m abov e d ownwar d s lik e M aa s an d Lang e nb e ck

, In th e m e th o d .
fro m b e low upwar d s t h e larynx i s d rawn forwar ds by m e an s o f a h ook ,
an d th e t rac h e a i s d ivi d e d i m m e dia t ely b e low t h e cricoi d e i th e r wi th ,
t h e bi s t ou ry or wi th th e galvano cau t e ry ( Ca s e lli ) -

I f pl u gging h a s n o t .
b e e n d on e th e r e m u s t b e plac e d i m m e d ia t e ly in th e t rach e a a canula

, ,
pr e p ar e d b e for e h an d or an In dia rubb e r t ub e th e calibr e o f wh ich will

, ,
co m pl e te ly ob s tr uc t th e lu m e n o f th e air pa s s ag e T h e p o s t e rior wall .
o f t h e lary n x i s th e n d ivi d e d wi th ou t wo un d ing th e oe s op h agu s t h e ,
l arynx i s drawn forwar d s s o a s t o i s ola te i t fro m t h e an te rior wall o f

t h e ali m e n t a ry canal a s far as i t s s up e rior b o r d e r a n d th e n t h e th yro
,
h yoi d m e m bran e i s inci s e d T h e larynx i s th u s r e m ov e d wi th o u t th e

.
e pig lo t ti s w h ic h i s e xci s e d a ft e r war d s i f th a t b e n e c e s s ary

, .
I n th e m e th o d fro m ab ov e d own war d s t h e th yro h yoi d a n d th yro

,
-
e p i glo tt i d e an ligam e n t s a r e fir s t inci se d th e n th e larynx i s d r a wn fo r

,
war d s an d a ft e r h avi n g c u t th e la t e ral a t t ach m e n t s O f th e larynx an d

,
oe s op h agu s th e vo cal organ i s d ivi d e d b e lo w t h e cricoi d ca r t ilag e or

, , ,
b e t te r th e la tte r i s d ivi d e d wi th th e h e lp o f Li s t on s forc e p s s o a s t o

,
’
,
l e av e at th e s up e rior O p e ning o f th e t rach e a a ri n g wh ich will pr e v e n t r e

tr ac t ion . I t i s e vi d e n t th a t t o a c t in th i s way th e cricoi d m u s t b e fr e e
,
fro m th e n e opla s m .
F o r th e e x tirpa t ion Bo t t ini r e co m m e n d s th e in tro d u c tion o f a s o un d

,
in t o th e trach e a t o s e rv e a s a gui d e for th e inci s ion o f th e la tte r A ft e r

,
.
m aking a T inci s ion an d O p e ning th e t h yroi d H ah n a d vi s e s an e x am

, ,
i n a t i on o f th e in t e ri or O f th e larynx t o d e t e r m in e wh e th e r a t o t al or uni
la t e ral e xci s ion sh oul d b e d o n e In th e la t te r ca s e h e d e t ach e s th e
.
,
t h yr oi d a n d s li t s th e cricoi d w h ic h h e p ar tly r e m ov e s
, In th e ca s e o f .
t o t al e x t irp at ion a ft e r d ivi ding t h e cricoi d h e plug s th e c avi ty wi th

.
,
g auz e d e tach e s th e s o ft p ar t s o f th e O pp o s i te s i d e an d s e par at e s th i s

, ,
c ar til a g e fro m th e tr ach e a th e n h e r e m ov e s th e larynx co m m e ncing

,
fro m i t s low e r p ar t .
41 6 E D I T OR I AL A R TI CLE S .
Th e r e m oval b e i n g acco m pli sh e d th e p o s t e rior wall o f th e p h arynx

,
an d th e s up e rior O p e n ing O f th e t rach e a a re e xpo s e d t o vi e w Th e v e s .
s e l s ar e t i e d T r e d e le n b o urg s app ara t u s i s r e plac e d by a trac h e al can

’
,
ula or by a canula inth e for m o f

, e n d i n g ab ov e in a th ick c a o u t
ch ouc t ub e clo s e d a t th e upp e r e n d on accou n t o f th e abun d an t m u

cou s s e cr e ti o n Th e st opp e r m ay b e a ft e rwar d s r e m ov e d s o a s t o al
.
low th e pa t i e n t t o br e a th e th rough th e m ou th th e t rac h e al op e ni n g O f

,
th e ca n ula b e ing clo s e d ( Bru n s) An oe s op h ag e al ca th e t e r i s th e n

.
plac e d in po si tion an d th e n e c e s s ary s u tur e s are e m ploy e d to b ri n g t o

,
g e th e r th e e d g e s of th e woun d A p h en ic aci d or i o dofor m dr e s s i n g i s

.
th e n appli e d Carb olic gauz e or gauz e s t e e p e d in d ilu t e alco h ol or in

.
,
a s olu tion o f ch lori d e o f zinc h a s al s o b e e n u s e d H ah n h as a dvi s e d

.
u n i ting th e oe s op h agu s t o th e th yroi d m e m bran e s o a s t o e st abli sh a

,
provi sio n al occlu s io n p e r m i t tin g th e p a ti e n t t o s wallow Th e s u t ur e s

,
.
a r e r e m ov e d on th e four th or fi fth d ay .
D uri n g th e fir s t fe w d ay s th e p at i e n t i s e x c lu siv e ly fe d th rough th e

oe s op h ag e al ca th e t e r b u t in m o s t ca s e s h e m a y co m m e n c e t o t ak e h i m
,
s e l f s o ft foo d ,at ab ou t th e fi ft e e n th d ay or e v e n on th e e igh th d ay

Billro ro m ab ou t th e t w e n ti e th d ay th e p a t i e nt m ay h abi t ually
( t h
.
) F
d o wi th ou t th e ca th e t e r A fe w d ay s la te r an a tte m p t t o apply an ar
.
t i fi c i al larynx m ay b e m a d e .
A fte r th e O p e ra ti o n s e con d ary h aem orrh ag e i s t o b e fe ar e d an d ,
ab ov e all pn e u m oni a T O guar d a g ai n s t th i s i t i s w e ll to e m ploy p e r

.
,
m a n e n t p lu g ging o f th e t rach e a an d t o cov e r th e t rach e al can ula wi th

,
a d rainag e t ub e o f cali br e e qual t o th a t o f th e trac h e a Mor e ov e r i n .
h ala tion s an d s olu tion s o f carb olic a n d s o d a b e n zoa t e e tc m a y b e

,
u s e d : i t i s n o t n e c e s s ary th a t th e s e s ub s t anc e s b e i n h al e d d ir e c tly i t i s ,
s u ffi ci e n t fo r th e in s pir e d air t o b e c h arg e d wi th th e vap our s To p re .
v e n t th e p u s fro m p e n e t ra t ing t o th e m e dia s tinu m an d t o av e r t th e,
ri s k O f pn e u m onia i t h a s b e e n r e co m m e n de d to k e e p th e pa t i e n t s
,
’
h e a d b e n t b ack for th e fir s t s ix or s e v e n d ay s s o th a t th e t rach e al

,
O p e n ing m igh t b e th e m o s t e l e va t e d par t o f th e wou n d .
A r t ifi ci a l La ryn x . In or d e r t o r e m e dy t h e lo s s o f voic e an ar tifi cial ,
larynx i s e m ploy e d . Th e la ryn x O f Gu s s e n b a u e r i s co m po s e d
o f two b e n t ca n ul ae O f h ar d e n e d caou t c h ouc O n e o f th e m i s t o b e i n

.
OS TE O CLA S I S .
417
t ro d u c e d in t orac h e a t o allow o f r e spira tion th e o th e r a d ap te d by

th e t ,
i ts low e r e n d t o th e for m e r co n d uc t s th e curr e n t o f ai r t o th e b ack o f

,
th e buccal cavi ty A fte r in tro d ucing th e s e t wo canul ae t h e y a re

.
,
fix e d by a ri bb on arou n d th e n e ck ; a n d t o th e m i s a d ap te d a th ir d
canula of s ilv e r d e s tin e d for th e p h ona tion I t con t ain s a m e t allic
,
.
t o n gu e w h ich i s vibra t e d by t h e e xpir e d curr e n t o f ai r The b ra .
t ion s a re t ran s m i t te d t o th e air in th e upp e r canula an d th e r e s ul t ing ,
s oun d i s ar ticula t e d i n th e p h ary n g e al a n d cricoi d cavi ti e s O n th e .
th ick n e s s a n d l e n g t h o f th e m e t allic t ongu e d e p e n d s t h e d e p th o f th e
voice Brun s larynx i s for m e d o f an e la stic t ub e fla tte n e d an d angu

.
’
,
lar a t th e upp e r p ar t wh ich s upp or t s t wo I n dia rubb e r m e m bran e s

'
t ouc h ing a t t h e ir fr e e b or d e r s T h e s e m e m bran e s vibra te lik e th e

.
,
t ongu e o f th e pr e c e d i n g app ara t u s w h e n th e e x t e rn al orific e o f th e ,
t rach e al canula i s clo se d by m e a n s o f a valv e H e in e an d S ch m i d t .
h av e appli e d t h e ar tificial larynx i m m e d ia t e ly aft e r th e op e rat ion o th e r
s urg e o n s h av e w ai t e d th r e e t o fi ve w e e k s Le i srink h as e m ploy e d .
G u s s e n b a u e r s larynx on th e t w e n t y s e con d d a y in a p a ti e n t wh o coul d

’ -
n o t b e ar i t a l th oug h h e s pok e v e ry w e ll wi th th e appar at u s

, A s ilv e r .
Bru n s larynx wa s th e n appli e d b u t al th ough i t was b e t te r b orn e th e

’
, ,
p a t i e n t coul d n ot s p e ak Le i s ri nk th e r e for e u s e d a Brun s larynx wi th

.
’
’
a Gu s s e nb au e r s p h on e t ic canula .
P S A BR A H AM . . .
O O T E O C LAS I S .
1
A r e c e n t work by Pou ss on o f F ranc e furni sh e s th e m o s t co m pl e t e

, ,
a n d i n s t ruc t iv e acco un t o f o s t e ocla s i s ye t p ubli sh e d Th e a u th or a .

,
d i s ti n g ui sh e d young F r e nch s urg e on h a s r e c e iv e d con s i de rabl e ai d ,
fro m R obin an d o th e r c o m p a trio t s t o Wh o m th e pr e s e n t p o s i t ion o f o s
t e o c la s i s i s m ai n ly d u e .
H e j u s tly r e m ark s th a t i t i s p e rh ap s wrong t o r e gar d o s t e o t o m y
an d o s t e ocla s i s a s rival s To d ay b o th e qually m e ri t confi de nc e a n d

.
-
,
are alik e pr e ci se an d s a fe .
l
O s te oc las i s , b y D r . l
A fre d Po u s s o n . I ll s t
u ra t e d . Pari s .
I . B Ba illi e r e
. et fi ls
1 88 6 . Pp 2 6 2 . .
Th e obj e c t fir s t par t o f th e m onograp h i s to trac e th e h i st ory

o f th e ,
th e principl e s a nd th e m e th o d s o f o s t e oc la s i s .
Tfi e Ger ze r a l f zfi s tor

y
— F our p e ri o d s m ay b e d i s tingui sh e d Th e fir st
. .
”
or p e rio d o f h e s i t a tio n
“
I t d e al t e xclu s iv e ly wi th m al uni t e d frac
.
-
t ur e s . Accor ding t o F ab ri c e de Hil d e n quo t e d by Laugi e r n e i th e r

, ,
Hippocra t e s nor Gal e n r e fe r e i th e r to t h e s e or t o th e m e an s o f r e m e dy

ing th e m . C e l s u s a dvi s e d b ut ti m i dly th e rup tur e o f th e callu s F or
, ,
.
m any c e n t uri e s t h i s a d vic e w as r e p e a t e d by s carc e ly an y o th e r s u r

’
g e on s e xc e p t Oriba siu s R h az es Avic e nna F a b ri c iu s d Aquap e n de n te
, , , ,
a n d H e i st e r T h e y u s e d th o s e o ld m ach in e s wi th wo n d e r ful nam e s

.
,
” ”
s uc h a s th e s c am m u m o f Hippocra t e s a n d th e g l os o c o m i u m o f
Nym p h o d oru s A m bro se Par é wa s a typ e o f m any s urg e on s wh o
.
s h rank fro m o s t e ocla s i s fro m th e fe ar o f br e aking th e bon e in th e wron g
plac e .
’
T h e z a p e r i oa ( t ha t o f app li ea f i e n r a i s orm ée co m m e n c e s in 1 6 9 9
’
wi th th e e xc e lle n t ca s e in w h ich D e La Mo tte ( of Valog n e s) corr e c t e d

a m aLuni te d frac t ur e of th e fe m ur Purm ann wa s th e fir s t t o con s truc t
.
a sp e ci al o s te ocl a s t i c m ach i n e I t wa s a s or t o f woo de n s cr e w wh ich

.
pr e s s e d a p ad again s t th e proj e c ti n g a n gl e o f a m al u n i t e d fract ur e '

.
Bo s ch ( of Wurte m b e rg) in 1 7 8 2 inv e n te d an d u s e d s e v e ral t i m e s a n

a pplia n c e lik e a b ook bin d e r s pr e s s ( E s t e rle n u se d Bo s c h s m ac h in e
’ ’
-
.
a goo d d e al a n d publi s h e d w h ic h Bo s ch d i d n o t
, , ( E s te rle n d e s crib e d
.
”
a m ac h in e o f h i s o wn th e Dys m orp h o s t é o p alin clas te l
,
“ -
T h e g ri p e r i oa ( th a t o f
’
g e n e rali s a tion o f o s te ocla s i s a n d s t udy o f
”
i ts I n 1 8 4 8 R izzoli inv e n t e d h i s m ac h in e tt a o s s i fraga
“
.
I t i s wor th wh il e t o m e n tio n inci d e n t a lly th e obj e c t o f i t s au th or in
con triving th i s m ach in e I t wa s t o s h or te n th e s oun d le g o f o n e o f h i s

.
p a ti e n t s an d m ak e t a tc a e or e li b on
i m h d f m d m th e o r i e
t h e s d '
He
call e d h i s b ook A n e w M e th o d o f Curin g Lam e n e s s ( Boi te ri e )

“
.
During th i s p e rio d o s t e ocla si s for anch ylo s i s o f th e h ip b e ca m e n ot

un fr e qu e n t Pou s s on m e n tion s variou s F r e nch s urg e on s in th i s con
.
n e c ti o n an d our r e a d e r s will r e a d ily r e call th e na m e s o f A m e ric a n s an d

,
E ngli s h m e n Bu t th e ir coll e c t iv e e ffor ts did far l e s s fo r o s te ocla s i s

.
th an d i d th e labour s o f D e lor e o f Lyon s ,

Th i s s urg e on occupi e d h im
.
“ ”
s e l f c h i e fl y wi th th e m anual bri s e m e n t forc e for th e cur e o f g e n u val
gum .
05 TE 0CLA S I S . 4 19
Now app e ar e d th e o s te ocla s t of M Colli n a cl e v e r s urgic al i n s tru .

,
m e n t m ak e r I t was brough t forwar d by M T e rri llon

. T h ough s c i . .
e n ti fi c i t was n o t p e r fe c tly s a ti s fac t o ry .
”
4 th p e rio d t h a t d e p e r fe c t ionn e m e n t e t d applic ation O ur a u
“ ’
.
,
t h or wri t e s t h a t M a c E we n s o s t e o t o m y woul d h av e giv e n th e d e ath

’
blow t o o s te ocla s i s i f i m prov e m e n ts in o s t e o cla s ts h a d n ot co m e t o

,
t h e r e s cu e Un d e r th e p a tron ag e o f two e m in e n t m as t e r s M le pro f

.
,
. .
O lli e r an d M D ani e l M o lli er e M R obin a young Ly o nnai s s urg e on

.
, .
, ,
”
h a s inv e n t e d a v e ri t ably n e w m e th o d o f o s t e ocla s i s wh ich e i th e r by
“
,
m e a n s o f M R obin s own in s t ru m e n t or o f th a t o f M Collin m o difi e d

’
. .
accor din g t o n e w principl e s h as prov e d i t s m e ri ts in all kin d s o f s ui ta

,
b le ca se s inclu d ing frac t ur e s ankylo s e s a nd d e for m i ti e s

, , ,
.
In th e n e x t ch ap t e r d e ali n g wi th fun d am e n t al principl e s proc e d ur e s

, ,
a n d m e t h o d s o f o s t e ocla s i s i n g e n e ral M Pou s s on giv e s t h e followi n g . .
t abl e :
Op e rati o n P c du e s n d m e th o d s ro e r a .
p i n cip l e s
r .
( M nu l o s te “ ’
i th
a th s a
g n s h n dso l on h e lp d b y e ur eo
’
a a e, or e
cl s i s n a m . ss i s t n t s D e l e s m t h d
o e or o re a a : or
’
e o .
( “e i g h t s
Pu ll ys x e c i s i ng t c ti n on th u n m i t f th
i
e , e r ra o e s r o e
an
g l e .
Pu rm an n s M a c i n e
’
h .
Ve rti c a l p r e s Bo c
’
s h s
su re . s
I n trum e n t al
’
( E s t e rle n s
o s te oc l s i s
a l s ss
B a iu
’
v
.
M ais o n n e u e
’
s m ac hi ne
“
D i a c la s t e .
’
’
R i z z o li s o t e o c a t e s l s .
Br u n
’
s
M a u ri qu e s ’
s
E m a rc h
’
s
\\ i t h t h e and h
g ra p i n g th e li m s
an d t ry n
g to s b i
M an u al s b k
re a h
i t e i t e r b y t ra g h t e n i n g o r e nd i n g s i b
c la s i s
o te o
T h e m a n ce u vr e b y c one b re a a t ck w hi h ks si
.
ss
a c ro th e ne e k
il xs
.
T l au
’
m et od h .
( We g h’t i s
l xi
.
F e on . A p p ara tu e m p o yi n
g s
Pu lle y l s .
th e o ng l
a rm of a VO lk m an n s ’
r
l v
.
s
I n tr um e n ta l e er . Co i n
’
r t a
p p a ra t u ll sfi s s .
s
o t e oc a l s is ’
( T a y o r’ a p p a ra t u l s s
b
.
s s
Ap p a ra t u u i n g o n y R o i n a p p a ra tu l s s
v
.
a er
y o r t a rm e d sh ’
Co i n 2 d a p p ar a t u ll s s
l v
.
e er
wi h
.
M an u a l s te o i
\V th th e s s h s s
’
own an d t th o e o f
o ur
g e on or
c la s i s . o n e o r m o re a ss i s t an t s .
Pu e y ll s .
c h n e id e r- M e h ls ’
hi
i
me m ac ne
s
I n tru m e n ta l
vis ’
.
o s te oc l s i s
a .
ar
D i e ffe n
s
b hs ac
’
’
H e n n e q ui n s
M anu a l s teo
{
o
T or i ons .
c la s rs .
Larg e r
’
s p r oc e d u re .
4 20 E D ] ? OR I AL A R TI CLE S .
Manual trac ti on a n d t or s io n are m ainly i f n o t s ole ly u s e d a s a dj u ,
van ts o f forc e appli e d in o th e r d ir e c tio n s .
As a typ e o f th e m e th o d o f m a n u a l ve r t i ca l p r ess u r e i s giv e n ,
’
D e l o r e s own accou n t o f h i s O p e ra tion for g e nu valgu m The p a .
t i e n t ( an aes th e t iz e d i s p lac e d on th e e d g e o f th e b e d B e n e a th th e
) .
e x te rnal m all e olu s i s u t a cu s h io n w h ic h an a s s i s t an t fix e s fir m ly in

p , ,
ord e r t o rai s e th e kn e e ab ov e th e p lan e o f th e b e d In th i s s i tua t ion .

‘
th e a n gl e o f t h e g e nu va lgu m p oi n t s d ir e c t ly upwar d s a n d th e s urg e on ,
pre s s e s upon i t wi th h i s h an d s upon wh ich h e bring s t o b e ar th e .
w e igh t o f h i s b o dy giving a t th e s am e t i m e li t tl e sh ak e s ( s ecouss es )

, , ,
.
Too m uch forc e m u s t n ot b e u s e d Th e p a d b e n e a th th e ou t e r m al

.
le olu s m u s t n o t b e t oo th i ck fo r Obviou s r e as o u s
,
Wh e n th e s urg e on .
fe e l s t ir e d h e giv e s way t o an a ss i s t an t wh o s e m a n oe uvr e s h e d ir e c t s

,
.
Th e op e ra t or s h oul d proc e e d s lowly progr e s s iv e ly a n d wi th o u t b e ing

,
d i s courag e d . A t th e e n d o f a t i m e varying wi th th e r e s i s t an c e o f th e
s ubj e c t he wi ll s e e r e d r e s s e m e n t t ak e plac e
, T h i s t i m e m ay b e fi v e .
m inu te s or e v e n o n e h al f an h our- C h il d r e n o f 2 or 3 y e ar s o ld s till

.
,
ac tive ly rach i t ic d e m an d v e ry li ttl e forc e But gr e a t forc e i s r e quir e d

, .
for p e r s on s o f s ay 1 8 t o 2 0 y e ar s o f a g e Cracki n g s ar e fr e qu e n tly

.
h e ar d d uring t h e op e ra t io n .
O st e ocla s i s for g e n u valgu m can b e p e rfor m e d al s o by br e aking th e

b on e acro s s th e s urg e on s kn e e lik e a s tick o r acro s s th e e d g e o f t h e
’
, ,
t abl e ( Tilla ux s plan e th ig h i s fix e d by an a s s i s t an t a n d th e le g

’
) T h .
,
an d ankl e a re u s e d a s a l e v e r by th e s urg e on .
I t i s d i ffi cul t t o fix th e p e lvi s w h e n d e aling wi th an ankylo s e d h i p .
T e rr illon h a s inv e n t e d an in s t ru m e n t for th i s p urpo s e I t i s a kin d o f .
larg e d oubl e vic e .
All th e old in s t ru m e n t s w e r e acc or ding t o Po uss on d i fficul t t o m a n

, ,
a e a n d m or e ov e r d i d n o t allow t h e poin t o f frac t ur e t o b e e xac tly

g , ,
pr e de t e r m in e d Th e r e for e R izz oli in 1 8 4 5 inv e n t e d h i s m ach in

'
.
, ,
”
e t t a o s s i fraga . T hi s con si s t e d o f a s t e e l b ar provi d e d at i ts c e n tr e
wi th a s cr e w carrying a t i ts e n d a m e t allic a re w h ich pr e s s e d ag ain s t
th e li m b a t th e p oin t w h e r e th e bo n e wa s t o b e frac t ur e d a n d re ,
m ain e d m o t ionl e s s wh il s t th e s cr e w t urn e d in i t s s ock e t t h ru s t i n g th e ,
ar e aw a y fro m th e s t e e l b ar A t e ach e n d o f t h e la tte r w e r e t wo

.
OS TE OCLA S I S .
421
l e ath e r ring s in w h ich th e li m b was fix e d T h e li m b b e ing s e cur e d in

.
t h e se ring s i t was e noug h t o t urn th e s cr e w in or d e r t o p r e s s by me an s

,
o f th e m e t allic arc again s t th e in t e r m e d ia t e p ar t o f th e li m b th u s h e l d

, .
T h i s in s tru m e n t work e d wi th con s i de rabl e pr e ci s i on M auri gue of

.
,
Ma dri d s ub sti t u t e d two s cr e w s wh ich ac t e d on p a ds p r e tty clo s e t o

,
g e th e r an d brok e th e b on e a t a pl ac e b e twe e n th e two .
C B K E ETL E Y
. . .
[T o BE CO NTINU ED ]
I N D E X O F S U R G I C A L PR O G R E S S .
I . O n th e E t i o l o g y of T eta n u s i n M an By R O S E N BA C H .
( G o tt ing e n ) F or
. m e r t h e o ri e s a s t o th e na t ur e o f t h i s t roubl e are s i m
ply r e fe rr e d to b ut n o t d i s cu s s e d A m ong s t m o d e rn au th ori ti e s th e

.
zy m otic th e ory h a s m any a dvo ca te s T h e e arli e r a tte m p ts a t i n o c u

.
la tin g ani m al s all m i s carri e d larg e ly owin g t o th e fact th a t d og s th e

, ,
ani m al s u se d are proo f again s t t e t a n u s in fe c tion Carl e an d R at to ue

,
.
w e r e th e firs t t o g e t p o s i tiv e r e s ul ts an d s ucc e e de d in p a s s ing i t fro m

,
ani m al to a n i m al .N ic o lai e r s e x p e ri m e n ts wi th e ar th t e t anu s are

’
kn own .
E arly th i s y e ar R t ook m a te rial fro m a fat al ca s e o f t e ta n u s fro m

.
froz e n fe e t ab ou t on e h our p o s t m or t e m
, T h i s ca m e fro m b e low th e
.
lin e o f d e m arca tion wh e r e n e cro tic s kin a dj oin e d non n e cro tic bon e
,
.
I t wa s in tro d uc e d a t e v e n ing un d e r th e crural s kin o f a g uin e a pig .
T e tan u s d e v e lop e d by th e n e x t m orning an d t h e ani m al d i e d d uring

th e d ay . F ur th e r inocula t ion wa s only s ucc e s s ful w h e n th e m at e ri al
wa s t ak e n dir e c tly fro m th e s po t inocula te d I t was s ucc e s s ful in four

.
guin e a pig s and e l e v e n m i c e in s ucc e ss ion T h i s inocula t e d t e t anu s

.
was co m pl e t e ly i d e n tical wi th N i c o la i e r s e ar th t e t a n u s I t b e g an ao
’
- .
cor ding t o th e s po t inocula t e d ; i f in th e lu m b ar r e gion e g th e t ail ,

. .
,
s t oo d e r e c t a ft e r nin e t o t we lv e h o ur s inc ub a tion t h oug h i n clin e d t o

,
war ds th e poi n t o f inocula tion i f in an e x tr e m i ty th e n th i s b e c am e

,
s t i ff in all i t s m o t ion s a n d s oon s t r e t c h e d o ut co m pl e t e ly t e t aniz e d t h e ,
s ol e up war d s a n d th e t o e s s pr e a d ; s oon t h e s a m e t h ing b e gan in t h e
o th e r e x tr e m i ty an d th e con trac t ur e S pr e a d t o th e b ack m u s cl e s th e

ani m al coul d only m ov e along wi th i t s for e p a ws By th e e n d o f e igh .
t e e n h our s t h e la t te r al s o ge t s t i ff t ri s m u s a n d O p i s th o t onu s d e v e lo p
, ,
a n d a t e v e ry con t a c t e v e n wi th t h e gla s s co o p t e t anic convul s ion s s e t

.
,
( 42 2 )
GE N E R AL S UR GE R Y .
42 3
in A fte r th i s th e ani m al li e s e xh au s te d wi t h gr e a t di ffi cul ty in r e spi

,
,
ra tion La t e r li fe i s only in dica t e d b y th e rapi d s up e rfici al br e ath ing

.
a n d s lig h t t w i t c h ing d e a th u s ually r e s ul ting in t w e n ty fou r h o ur s

, If - .
a m ou s e i s inocula t e d on th e for e e x tr e m i ty th e n th i s b e co m e s i m m o
bil e fir s t a n d s oon pron e in rigi d e xte n s ion S o m e h our s la t e r th e e ar .
o f th e s a m e s i de li e s d ow n th e o th e r wi se pro m in e nt e ye i s r e trac t e d
, ,
a n d th e li d s a re h al f clo s e d Ab s olu t e lock j aw A ft e r e igh te e n h o ur s

.
-
.
th e w h ol e b o dy i s b e n t t owar d s t h e a ffe c t e d s i d e th e o th e r p aw i s s t i ff , .
th e h in d p a ws s till m ovabl e T e t ani c convul s io ns on b e in g gra s p e d

. .
D e a th in t we n ty four h our s In th e young guin e a pig s u s e d by R th e

-
. .
d i s e ase run s a v e ry uni for m co ur s e In rabbi t s th ough th e co ur s e i s

.
,
e s s e n t ially th e s a m e g e n e ral t e t ani c convul s ion s a re m uc h m or e pro m

,
in e n t . Incub at ion la s t s fro m t w e n ty four to for ty e igh t h our s u s ually

- -
,
th ir ty s ix
-
A local m u s cl e t onu s s pr e a ds fro m th e inocula te d poin t
.
-
.
I n m an te t anu s vari e s gr e a tly a ccor ding t o th e loca ti on o f th e

woun d No t s o v e ry rar e ly th e te t anic cra m p s s e iz e th e woun d e d e x
.
tre m i ty a s in ani m al s
,
H e a d t e t anu s i s o n e form
. B e s i de s o th e r .
m icrob e s R foun d a b ri s t l e sh ap e d b acill us

. lik e th a t d e s crib e d by
-
,
N i c olai e r a s th e cau s e o f e ar th t e t anu s T hi s R c arri e d a s i m p ur e

-
. .
cul t ur e s in s oli difi e d s e ru m th rough four g e n e rat ion s wi th ou t lo s s o f

’
virul e nc e F lugge s c o work e r s h av e s ucc e e de d in ob t aining pur e cul
.
-
t ur e o f th e e ar th t e t anu s b acillu s
-
t h oug h di ffi cul ty wa s fou n d in
,
tr an s fe r ri n g th e m t o o th e r lik e m e d i a W h e th e r th e y can only liv e

.
wi th o th e r m icrob e s or th e o th e r m icrob e s by ab s orbing O favor th e .
li fe o f th e te tanu s b acillu s th e fac t i s in te r e s ting s in ce w o un d s con t ain

-
,
in g m att e r s favorabl e t o p u t r e fac t ion s p e ci ally d i s p o s e t o t e t a nu s .
How th i s b acillu s pro d uc e s t e t anu s i s a qu e s tion ye t t o b e an s w e r e d .
Ni c o lai e r foun d th e b acillu s onc e in th e s cia tic a n d t wic e in th e cor d .
R al s o foun d th e m t wi c e in th e cor d th oug h s ca t te r e d

. H e finally i h
, .
clin e s t o th e vi e w th at s o m e s ub s t anc e l ik e s trych nin e m u s t b e pro

d u c e d to cau s e th e p e culiar s y m p t o m s .
’
In th e d i s cu s s ion K oni g conj oin e d th e i d e n ti ty O f R o se nb ach s a n d
Ni c o lai e r s e xp e ri m e n t al t e t anu s wi th th a t o f m an an d t h e n o t i n fre
’
,
qu e n t for m o f h or s e s a ft e r ca s tra tion In th e la tt e r ca s e i t fr e q ue n tly

.
b e gin s in th e e xtr e m i ti e s or back In m an t e t anu s d o e s n o t by any

. .
m e an s , alway s b e gin wi th t ri sm u s b ut at t i m e s app e ar s fir s t in th e

,
m u s cl e s at th e p oin t in j ur e d .
S o cin ( B as l e ) r e fe rr e d t o h i s e xp e ri m e n tal r e s ul ts wi th gar d e n e ar th
as g e nuin e t e t anu s .
A fte r E b e rm ann ( S t Pe te r sb urg) h ad s ugg e ste d th e p o ssibili ty of

.
’
p t om ain e s T rab lu dowsk y ( B e rlin) r e fe rr e d to a c ase in G e rh ar dt s
,
cli n i c wh e r e th e t e t anic p h e nom e n a di s app e ar e d e ach ti m e on p u m p

ing o ut th e s to m ach ( for pyloric s t e no si s) —Au th or s r e por t o f XV .
’
Ge rm an S urgical Congr e s s in C eu t r b l f Ch i rg , 1 886 . N o 24. . . . .
11 .C a s e o f I n o c u l a t i o n T u b e r c u lo s i s A ft e r A m p u t a t i o n
-
of t h e F o re arm By M W A H L ( E s s e n) In con s e qu e nce o f a

. .
,
brui s e a on e y e ar old b oy d e v e lop e d an i n flam m a tion an d fin ally

- -
gan gr e n e d e s troying th e wh ol e l e ft h an d T h e for e ar m was t ak e n o ff . .
In th e pr e p ara tion G a ffky foun d th e coccobact e ri a s e p ti c a of Billro th

b e si de s a v ari e ty o f bacilli an d co cci Pri m ary union th e b oy b e i ng.
,
d i s ch ar g e d wi th th e s m all dr ain op e ning s till granulat i ng - H e p a sse d .
in t o th e e xclu s iv e car e of a 1 3 y e ar o ld girl wi th lupu s o f th e n o se By

‘
h e r h e was m o s t prob ably in fe c t e d wi th t ub e rculo s i s s inc e o th e r ,
so urc e s o f in fe c t ion e s p e cially i m p air e d h e r e d i t y w e r e n o t app ar e n t

, ,
.
Th e gr an ula t ing s po t on th e s t u m p b e gan t o e nl ar g e an d d e g e n e ra t e d
fun g o u s ly . S oon th e axillary glan d s b e ca m e infil tra t e d an d th e ge n ,
e ra l con d i t ion m uc h wor se T h e glan d s w e r e e x tirp a t e d an d sh ow e d

.
,
m acro s copically an d m icro s copically e xqui s i t e t ub e rculo s i s T h e b oy .
i s now qui t e w e ll H e s ugg e s t s th a t K och h i m s e l f was th e fir s t t o ob

.
s e rv e t ub e rcular inocula t ion F ro m a p riva t e co m m unica t ion i t ap

.
p e ar s th at K in 1 8 7 4 a m p u ta t e d a fing e r for t e diou s ulc e ra tion in an

.
, ,
o th e rwi s e h e al th y p e r s on S o m e y e ar s la te r th e m an d i e d o f t ub e rc u
.
lo si s. O n e xam in in g th e alco h ol pr e para tion o f th e fi n g e r i n 1 8 8 2 t u

b e rc ular b aci lli w e r e foun d .
Wi th r e gar d t o in fe c tion fro m m ilk W s ugg e s t s th a t th e cu st o m in .
s o m e cou n tr y di s tri c t s o f wa sh ing s kin e rup t ion s wi th fr e sh m ilk m ay
e xplain s o m e c a s e s .
I n th e d i s cu ss ion K onig m e ntion e d a ca se o f larg e t ub e rcular ab

s c e s s o f th e r e c t u s ab d o m ini s m u s cl e fro m wh ich t ub e rcular p e ri t oni ti s
,
GE N E R AL S UR GE R r . 42 5
d ir e c tly d e v e lop e d In all prob abili ty i t r e s ul te d fro m hypo d e r m ic i n

.
je c ti on wi th a s yri n g e wh ich a d oc t or car e le s s as r e gar d s cl e anlin e s s , ,
h a d fr e qu e n tly u s e d on a v e ry t ub e rcular in divi d ual In th e ab ov e .
ca s e o f p e ri to ni ti s th e r e m aining organ s w e r e fr e e fro m t ub e rculo s i s .
Vo lkm ann t ol d o f a p a t i e n t in wh o m a fte r th e cur e o f a t ub e rcular ,
fi s t ula o f th e r e c tu m a lupu s e xfoli at i vu s d e v e lop e d at th e po i n t o f th e

,
fo r m e r wou n d —Au th or s R e p t o f Congr e s s o f Ge r m ’

S urg s . in . .
,
Cem bl f C/zi rg
‘
. . 1 886 N o 24. . . .
W BR O WNI NG ( B o ok l yn ) . r .
111 T h r e e C a s e s o f M a li g n a n t P u s t u l e
. By Dr G I U SE PP E . .
M O GG I T h e au th or d e s crib e s th r e e ca s e s o f m alignan t p u st ul e wh ich

.
h a d co m e un d e r h i s own ob s e rva tio n an d draw s a t t e n tion t o th e m o de ,
o f t r e a tm e n t wh ich h e a d op t e d i n e ac h ca se T h e fir s t ca s e wa s th a t .
o f a h e al th y fi n e you n g la d ae t 1 6 wh o wa s worki n g wi t h a b u t ch e r
, , .
, .
T h e di s e ase app e ar e d on th e b ack o r th e n e ck in th e u s ual s i t ua t ion ,
o f carb uncl e s a n d th e s y m p t o m s pr e s e n t e d w e r e un e quivo cally th o s e

,
o f m alignan t pu s t ul e T h e t r e a tm e n t con si s t e d o f cau te rizing t h e p ar t

.
wi th th e galvanic c a u t e ry inj e c ting s o m e carb olic aci d s olu t ion o f th e

, ,
s t r e n g th o f a t four d i ffe r e n t p oin t s in t o th e d i s e a s e d p ar ts an d , ,
d ouch ing th e p ar t wi th th e s am e s olu tio n —T 4 o s R 2 6 P 1 2 0 A °

. . . . .
, ,
s m all d o se o f s ulp h a t e o f iron wa s giv e n a t in t e rval s d uring th e nig h t .
T h e n e x t m orni n g th e p a ti e n t w a s qui e te r b u t th e s w e llin g h a d e x ,
t e n d e d ov e r th e fac e a n d th e n e ck a n d h a d e v e n r e ac h e d th e s h oul d e r ,
an d th e c h e s t T . R 22 P 1 1 0
. T h e p a ti e n t wa s a fte rwar ds
.
,
.
r e m ov e d t o th e h o spi tal whe r e h e d i e d on th e s ix th d ay T h e n e x t

, .
c ase was th a t o f a m an o f abou t 4 0 y e ar s o f a ge a v e n d e r o f s kin s by ,
o ccup ation Th r e e d ay s b e for e h e ca m e un de r ob s e rva tion th e pa ti e n t

.
no t ic e d a b oil on h i s l e ft zygo m a wh ich wa s a cco m pani e d wi th pain ,
an d m uch m alai s e O n e xa m ina t ion th e d i s e a s e prov e d t o b e a m a

.
lignan t p u stul e T h e r e wa s e nlarg e m e n t of th e glan d s in th e axilla

.
,
a bov e th e clavicl e a n d b e n e a t h th e low e r ja w on t h e l e ft s i d e Th e r e , .
'
w e r e al s o g e n e ral w e akn e s s gi ddin e s s an d p ai n in th e j oin ts T 4 o 2
,
. . .
°
,
R 24 P 1 1 0
.
-
, . T h e local t r e a tm e n t was al m o s t i d e n tic al wi th th at de
.
s crib e d—wi th th e e xc e p t ion o f th e appli ca tion o f th e c a u te ry—ab ov e ,
an d s ulp h a t e o f quinin e wa s giv e n in t e rn ally e v e ry h al f h our The .

426 I N D E X OF S UR GI CAL P R O GR E S S .
n ex t m orni n g th e s w e lli n g wa s foun d t o h av e e x te n d e d ov e r th e ch e s t ;

th e pai n h ow e v e r wa s l e s s
, T h e h yp o d e r m ic inj e c ti o n s w e r e r e
,
.
p e at e d T . P 9 4 R 2 0 S ub s e qu e n t ly t h e galvani c cau t e ry w a s
. .
, . .
u s e d owin g t o th e vici n i ty o f th e d i se a se to th e e ye O n th e foll ow

,
.
i n g da y s om e i m prov e m e n t wa s no t e d ; th i s wa s m ai n t ain e d th e e n ,
larg e m e n t o f th e gla n d s s ub s i d e d an d a fte r b e ing un de r t r e a tm e n t fo r

, ,
a m on th th e p ati e n t wa s d i s ch arg e d cur e d T h e th ir d ca s e al s o t e r , .
m i n at e d favorably I t wa s th a t O f a m an ae t 2 5 m arri e d wh o s e o c
. .
, ,
c u p a t i on wa s th e s a m e as th a t o f t h e pr e c e d in g p a t i e n t At fir s t th e .
s ym p t o m s w e r e in d e fini t e b e i n g li m i t e d t o a s w e lling o f th e l e ft s i d e o f
,
fac e an d g e n e ral m alai s e T

. R 2 9 P 1 2 0 In a d ay or two th e
. . .
, . .
d i se a s e b e cam e fully pronounce d th e car d inal s y m p t o m s o f m alignan t

,
pu st ul e app e ari n g ov e r th e l e ft zygo m a Th e p ar t wa s cau t e riz e d wi th .
th e galvanic cau t e ry a n d th e i nj e c t ion s h yp o d e r m ically of carb olic a ci d

,
s o lu tion o f th e s tr e n g th ab ov e r e fe rr e d t o w e r e e m ploy e d I m prov e .
m e n t co m m e n c e d in t e n d ay s ti m e in fi fte e n d ay s th e slough s ep
’
,
ar a t e d o n th e t w e n ti e th d ay th e p a ti e n t wa s qui t e conval e s c e n t
, Th e .
au th or a d ds in c on clu s io n th a t in a larg e n um b e r o f ca s e s of th i s dis

, ,
e a s e wh ich h av e b e e n tr e a t e d a fte r th e m ann e r d e s crib e d abov e goo d
—
r e s u lt s h av e b e e n ob t ai n e d Lo Sp er i m em a le March 1 8 8 6
‘
, , .
H . PE R C Y D UNN ( Lon d on ) .
IV . C as e o f E m o t i o n al I ct e r u s A c c o m p a n i e d b y a
A ,
G e n e r al E ru p t i o n o f L i c h e n By Dr N E G E L ( J a s sy R ou m ania)
. .
, .
A yo ung m an ae t 2 3 wh o h ad a ur e th ral di s ch arg e a n d a h e rp e ti c

,
.
,
e rup t ion on th e m ucou s m e m bran e o f th e pr e puc e h i m se l f cau t e r ,
i z e d th e la t te r wi th ni tr a te o f s ilv e r Th i s le d t o an a cu te b alani ti s .
,
g oi n g on t o gan gr e nou s ulc e ration H e wa s t e rribly al arm e d l es t th e .

,
wh ol e organ sh oul d s l ough aw ay H i s u ri n e b e c am e d ark in color

.
,
th e fae c e s pal e an d a g e n e ral a n d in te n s e ic t e ru s wa s m ani fe s t

,
An .
e rup t ion o f lich e n th e n s up e rv e n e d Un de r tr e a tm e n t th e b alani ti s .
a n d t h e bili ary d e rang e m e n t d i s app e ar e d in t h r e e w e e k s b ut t h e ,
e rup t i on r e m ai n e d for s o m e t i m e lo n g e r Th i s ob se rv ation app e ar s t o .
t h e au th or in t e r e s ting fr o m th e poin t o f vi e w o f th e na t ur e o f ic t e ru s
an d lich e n T h e liv e r an d o th e r organ s w e r e h e al th y th e r e h ad b e e n

.
,
n o ga stri c e xc e s s or h i s t o ry o f col d— o n e can o n ly p ut d own th e c a u s e

N E R V0 US A N D VA S C ULAR S YS TE M S .
4 27
to a s tro n g m oral e m o tio n in d uc e d by fe ar At t h e s a m e t i m e th e

, .
p a ti e n t was o f a h e rp e t ic na t ur e a n d th e m oral p e r t urb a t ion h as acte d ,
o n ly a s an acci d e n t al ag e n t i n m aki n g app e ar t h e m a n i fe s t a tion o f a
con s ti t u tio n al d i ath e s i s — L e P r og r es M ed 2 1 Aug 1 8 8 6

. .
, .
, .
P . S . A BR A HAM ( L o n d on ) .
O P E R A T I VE S U R GE R Y .
I . O n E xt i r p at i o n o f S y n o v i al M e m b ra n e B e h i n d t h e
K n e e J o i nt By Dr D G ZE S AS Th i s sh ort co m m unica tion i s
. . . . .
on avoi d ing th e p opli te al v e s s e l s in ar thr e c t o m y for t ub e rcular j oin t

a ffe cti on s T h e r e m oval of all th e fun gou s m a te ri al i s o f pri m e i m
. ~
p or t anc e W h e n th e s ynovial m e m bran e b ack o f th e j oin t i s al s o a f

.
fe c t e d h e r e co m m e n d s th a t th e v e s s e ls b e pr e p ar e d o u t a s far a s th e
gran ulat ion m a ss e s e xte n d ; th e y can th e n b e h e l d a s i de un t il all th e

‘
m orbi d t i s s u e h as b e e n cl e an e d o ff I n v e ry b a d ca s e s th e v e s s e l s ar e .
t o b e approach e d fro m th e p opli te al s p ac e an d t h e n d rawn back o u t o f
th e way — C em é l f C/zi rg 1 88 6 No 28
‘
. . . . .
WM BR O WN ING ( Bro oklyn ) . .
VA S C U L A R S Y S T E M .
1 . C a s e o f L i g a t u r e o f S u b c la v i a n A r t e r y a n d V e i n
A
U n d e r t h e C la v i c le By Dr M A VA S I LI E F F ( o f War s aw R u s s ia)
. . . .
, .
T h e re are r e cor d e d six ty fi v e ca s e s o f liga t ur e o f s ub clavian ar t e ry

-
un d e r th e clavicl e of wh ich in t w e n ty two th e r e wa s a favorabl e r e

,
-
s ul t th ir ty e i g h t r e s ul t e d in d e a th a n d in fi v e ca s e s t h e r e s ul t i s u n
,
-
,
known But th e r e i s n o t on r e cor d a s ingl e ca s e of th e s i m ul t an e ou s

.
li ga t ur e o f th e s ubclavian ar t e ry an d v e i n un d e r th e clavicl e Th e r e .
for e th e ca s e o f Dr Va si li e ff d e s e rv e s s p e ci a l a tt e n t ion
,
. .
M ari ann a Li a tan sk a ae t 2 0 s e rvan t wa s a d m i tte d in t o th e s urgical

,
.
, ,
clinic of Pro f J A E fre m o vsk y on Nov e m b e r 2 1 1 8 8 4 in wh ich cli n ic

. . .
, ,
Dr V i s an as s i s t an t T h e p a ti e n t coul d n ot m ov e h e r righ t s h oul

. . .
d e r co m plaining o f a s e v e r e p ain in th e axilla wh e r e a h ar d s m all t u

, , ,
m or wa s fe l t T h e t u m or wa s r api dly incr e a s i n g in s iz e

. O n N ov e m .
b e r 2 9 i t was d i s t inc tly fluc t u ating a n d filli n g up th e a xillary an d s ub

c lav i an s p ac e T h e p ati e n t wa s fe v e ri sh
. O n D e c e m b e 1 u n de r .
,
ch loro for m th e t u m or wa s O p e n e d i n th e axillary lin e T h e r e wa s d i s

, .
ch arg e d a con s i d e rabl e quan ti ty o f p us Dr V in tr o d uc e d h i s fing e r . . .
i n to th e cavi ty an d p a s sing i t up war d to th e clavicl e h e fo un d th a t

,
th e r e wa s a p a ss ag e t o o narro w fo r a th ick d rainag e t ub e ; th e r e for e h e
c ut s o m e ti s s u e s wi th a d ull p o i n t e d kni fe A pro fu s e bl e e ding fol .
lo we d wh ich a fte r se v e ral vain a tte m p t s was s topp e d by s e izi n g th e

, , ,
v e ss e l s eu uza sre wi th h e m o s t a tic fo rc e p s As th e cavi ty wa s v e ry d e e p .

,
i t was i m po ss ibl e t o p u t a liga t ur e o n th e bl e e d i n g v e s s e l s ; t h e r e for e ,
Dr V l e ft th e fo rc e p s i n S i cu in th e cavi ty O n D e c e m b e r 3 th e
. . .
d r e s s i n g wa s c h a n g e d In th e e v e ning th e r e app e ar e d h ae m orrh ag e o f

.
a v e n o u s ch arac t e r an d i t wa s r e p e a t e d in th e nigh t
, .
D e c e m b e r 4 T e m p e ra tur e . pul s e 1 0 4 Pr o f E fre m ovs k y

, ,
. .
e n larg e d th e O p e ning t ryi n g t o fi n d th e bl e e d i n g v e s s e l s

, W h e n th e .
forc e p s w e r e r e m o v e d a v e ry pro fu se h ae m orrh ag e s e t in wh ich wa s ,
s t opp e d only by placing a liga t ur e on th e s ub clavian ar t e ry But i m .
m e d ia t e ly a ft e r th a t a v e n ou s bl e e d i n g b e gan w h ic h was al s o s t opp e d
by liga t ur e b e i n g plac e d on t he s ub clavian v e i n T h e cavi ty wa s .
cl e an e d o f cl o t s wa sh e d an d d r e s s e d T he righ t ar m was k e p t war m

,
. .
T h e pa t i e n t p e r s pir e d fr e e ly ; p ul s e in th e l e ft a rm wa s 1 00 .
D e c e m b e r 5 T h e righ t arm was war m b u t oe d e m at ou s ; s e n s a t ion

.
,
in th e th u m b an d th e in d e x fing e r was lo s t F ro m D e c e m b e r 6 t o .
2 0 th e d r e ss i n g wa s ch ang e d e v e ry d ay ; t h e wo und wa s v e ry p ain
ful.
T h e r e was n o pul s e in th e righ t ar m T h e arm wa s oe d e m a t ou s .
all th e ti m e On D e c e m b e r 1 4 th e liga tur e o f th e ar t e ry was r e m ov e d

.
d uring th e d r e s s i n g o f th e woun d O n D e c e m b e r 2 0 th e lig a t ur e wa s

.
r e m ov e d fro m th e v e in S inc e th e n th e dr e s s ing was d o n e e v e ry o th e r

.
d ay . T h e wou n d was fill e d wi th h e al th y granula tion s ( E d e m a wa s .
d i s app e aring But on t o war d th e e n d o f Jan uary i n fla m m a t ion s e t in a t

.
th e s h oul d e r an d e lbow j oin t s r e s ul ti n g in ab s c e s s e s O n F e bruary 2 4

,
.
,
un de r ch l oro for m th e t um or s w e r e O p e n e d yi e l di n g a larg e a m oun t o f

, ,
u s T h e ih u m e ru s wa s e xp o s e d a n d in s e v e ral pl a c e s a ffe c t e d wi th
p . ,
cari e s Acu t e o s t e o m y e li ti s Tr e a t m e n t wi th drainag e S upp ura tion wa s

. . .
v e ry pro fu s e an d Dr V fe are d th at e xar ticula tio n wa s un avoi d abl e

. . .
O n March 1 e ry s ip e la s a t t ac k e d th e a rm a ffe c t ing al s o t h e rig h t s i d e ,
o f th e ch e s t I n a for tnig h t th e e ry sip e la s di s app e ar e d an d th e

.
,
L i M R H A TI C S YS TE M .
42 9
woun d in all i t s e x te n t was cov e r e d wi th h e al thy gra n ula t i o n s B o n e

, ,
.
a n d o t h e r t i s s u e s h e al e d i n th e b e ginning o f April T h e pa ti e n t co ul d .
n o t m o ve h e r rig h t a rm a n d fing e r s M a s s ag e an d e l e ct rici ty O n

. .
J un e 1 6 th e p a ti e n t l e ft th e clinic in th e foll o wing c o n di ti o n T he a rm .
a t t h e s h o ul d e r a n d e lb o w j o i n t c o ul d b e m o ve d ; th e fi e xi o n o f fi n
g e r s wa s ye t d i ffic ul t ; s e ns i b ili ty i n th e fing e r s was r e s to r e d ; p ul s e i n

t h e ra d ial ar t e ry c o u ld n o t b e fe l t I n th e fall o f 1 8 8 5 Dr V vi s i te d
. . .
h i s pa ti e n t a n d fo u nd h e r a rm s t ill m o r e i m p r o ve d ye t t h e r e wa s n o ,
ra dial p ul s e S he wa s i n c o n di ti o n t o a t te n d t o h e r d u ti e s
. .
Dr V b e li e v e s th a t h e c ut o n e o f t h e t h o r a cic ar ter ie s t o g e th e r
. .
wi th an a dj ac e n t v e in ; h e b e li e v e s a ls o t h a t e ry sip e la s h a d a ra th e r
b e ne fi ci a l i nfl ue n c e o n th e p a ti e n t h avi ng c h e c k e d t h e o s te o m y e li ti s
,
.
T h e C lzi r u rg i tc/zes éy Ves t n i k j uly 1 8 8 6 , ,

.
P
.
J . PO PO FF ( B ro o k l yn ) .
LY M P H A T I C SYS TE M .
1 . p h a n g e i t i s a n d S u b l i m a t e Dr W S K I NN E R
Lym . T he . . .
fo ll o wi n g two ca s e s sh o w th e pr o m p t e fficacy o f m e rc uric p e rc h l o ri d e

i n ly m p h a n g e i t i s followi n g s e p t ic wou n d s
X cook o f a s te a m e r on t h e 2 8 th o f Marc h c u t t h e d or s al s u r
.
, ,
fac e o f t h e l e ft in de x fing e r wi th a ki t ch e n k n i fe w h ic h d ivi d e d th e n ail
t ran s v e r s e ly T h e wo u n d was ba th e d wi t h carb oliz e d wa t e r a n d c o v

.
e r e d wi th d i a c h yt o n pla s t e r O n t h e 3 o th in fl a m m a t i o n o f th e lym
.
,
p h a t ic s h a d s e t in wi th p ain ful gl an d s a t th e e l b o w a n d in th e axilla

, .
T h e fi ng e r was r e d s woll e n a n d th e l e a s t t ouch cau s e d gr e a t p ain

, .
T h e wo un d h ad a b a d a p p e ar an c e a n d s h o we d n o t e n d e n cy t o cl o se
up . T h e t r e a t m e n t was c h a n ge d t h e wo un d w e ll b a th e d wi th c a m
,
h o ra t e d s iri t a n d co m r e s s e s a li e d w h ic h h a d b e e n s t e e p e d i n
p p p , pp
a s ol utio n o f s ub li m at e 2 par ts i n , T h e y we r e l e ft o n fo r t we n
t y four h our s
-
O n th e followin g d ay all th e s y m p to m s h a d d i m ini sh e d
.
,
th e ly m p h a t ic glan d s s carc e ly p ain ful t h e fi n g e r m uch l e s s s woll e n

,
a n d r e d or t e n d e r O n th e 7 th o f A p ri l t h e ly m p h ang e i t i s wa s cur e d
.
,
an d th e woun d rapi d ly cica t riz e d .
Mll e V pr e s e n te d a w e ll m ark e d a n d e x t e n s iv e ly m p h ang e i t i s

. .
o f t h e d or s al s ur fac e o f th e fo o t a n d lo we r h al f o f t h e le g wi th t h e i n ,
g ui n al g lan d s e nlarg e d a n d p ain ful S h e h a d pr e vi o u s ly s cal d ed h e r

.
fo o t a n d h a d prick e d wi th a d ir ty p i n o n e o f th e bli s t e r s cau s e d by th e
b u rn At th e fir s t e xam inatio n th e foo t s e e m e d t o b e t h e s e a t o f

.
p h l e g m on ou s in fla m m ati o n wh ich th r e a te n e d s upp ura tion a nd i t b e ,
cam e a q u e s ti o n wh e th e r t h e k n i fe sh oul d n o t b e u se d T h e t r e a t .
m e n t h ow e v e r wa s li m i t e d t o rai s ing th e li m b applying N e o p oli t a in

, , ,
oi n tm e n t an d poul tic e s t o th e foo t F o r th r e e d ay s th i s wa s con t i n u e d

.
,
b ut n o i m prov e m e n t e n s u e d a n d on th e 3 o th th e poul t ic e s w e r e l e ft o ff
,
a n d t h e foo t was d r e s s e d wi th co m pr e s s e s d ipp e d in a 2 p e r so
lu t i o n o f s ub li m a t e O n th e 2 n d o f May th e a m e liora tion wa s no t abl e

.
,
th e in guinal glan d s w e r e n e arly in a norm al con d i tion an d all th e
p ath o logica l ph e no m e na h a d d i m ini s h e d in in t e n s i ty O n th e follow .
i n g d ay t h e lym p h ang e i ti s wa s qui t e cur e d a n d t h e woun d co m m e nc e d

t o h e al .
Th e rapi d s ucc e s s o f th i s m o d e o f t r e a t m e n t in t h e s e ca s e s l e a d s t o
b e li e v e a p r i or i in th e e fficacy o f s ubli m a t e in ca s e s o f e ry sip e la s

”
w hich n o t ably r e s e m bl e s r e ticular a n giol e uci ti s in i t s s e p tic an d
“
o th e r obj e c t iv e ch arac t e r s I t will b e i n d i s p e n s abl e h ow e v e r t o wa t ch

.
, ,
car e fully th e ab s o rp tion o f th e s ubli m a te by th e infla me d s kin w hich ,
by i t s gr e at pa th ological va s culari ty m igh t i n tro d uc e in t h e s y s te m

t oxic quan t i t i e s o f th e ag e n t —Le P r og r es M ea
’
. Aug 7 1 8 8 6 . .
, .
P S A BR
. . A HAM ( L o n do n
) .
H E AD AND N E CK .
1 . D i re ct F r a ct u re of th e V a u lt of th e C ra n i u m Co n s e cu
t iv e t o a F a ll on th e Pa r i e t a l i n a n I n fa n t o f F o u r M o nth s .
I nt e g rit y of th e S c a lp T r a u m at i c M e n i n g i t i s
. D e at h . .
M N O TT A An in fan t fe ll o u t of a b e d on th e floor th rough a h e i gh t

. .
o f 7 5 c e n t i m e tr e s F iv e d ay s a ft e rwar d s h e s u d d e nly b e ga n t o v o m i t
.
,
t o cry viol e n t ly an d t o b e c o nvul s e d e s p e cia lly i n t h e rig h t arm

, At .
t h e a u t op s y a y e llow purul e n t lay e r wa s s e e n t o e x t e n d O v e r th e l e ft

'
h e m i sp h e r e o f th e brai n a n d wi th car e a frac tur e o f th e le ft p ari e t al

,
wi th ou t di s plac e m e n t o f th e frag m e n t s coul d b e m a d e o ut obli q u e ly

d ir e c t e d upwar d s an d b ackwar d s t o th e s agi t t al s u t ur e .
T h e ra ri ty o f s i m ilar ca s e s i s d u e t o t h e e la s t ici ty o f th e c ran i al b on e s

H E A D A N D N E GR . 431
in in fancy Th e you n g e r th e ch i ld th e m or e d i ffi c ult th e di a gn o

.
s i s O f s uch le s ion s F ract ur e o f th e v a u lt o ft e n giving ri se at fir s t t o

.
,
n o s e ri ou s s y m p t o m s m ay a ft e r s o m e ay s e n d in acu t e an d r api dly fat al

, d
m e ni n gi t i s —S o c A n a t O c t
’
. 1 885 Le P r og Ill ea
. .1 3,
F eb 1 8 8 6 . . . . .
, .
II . C o nt ri b u t i o n t o t h e S t u d y o f Ga s e ou s T u m o rs o f t h e
A n t e r i o r p a rt o f t h e N e c k By Dr PA U L F A BR E ( Co m m e n tr y). . .
A e ri al t u m our s of th e n e ck are s u ff i ci e n tly rar e for th e follo wi ng two

c a s e s t o b e i n t e r e s ti ng
C A S E 1 Unilat e ral a e rial goi tre —Spon t an e ou s e m ph y s e m a on th e

.
righ t s i d e o f th e n e ck a ri s ing d uring th e co urs e o f bronch i t i s A T . . .

,
b orn D e c e m b e r 2 8 1 8 8 4 s uckl e d by h e r m o th e r a tt ack e d by cough

, , , ,
o f s i m pl e bronch i ti s M arch 1 3 1 8 85 O n th e 1 6th a s w e llin g wa s no

, .
t ic e d in th e rig h t s upra an d s ub clavicul ar r e gion ; on p alp at io n th e -

,
ch ar ac te ri s tic cr e pi tat ion o f t r a u m a ti c e m ph y se m a ; no tr ac e of tr au

m a ti s m . T h e m o th e r s t at e d th a t t h e s w e lling b e gan in t h e fol d o f th e
groin an d m oun t e d rapi dly up t o th e n e ck Th e r e was con st an t cough .

,
e ac h e ffor t aug m e n ti ng t h e t u m o ur wh i ch s e e m e d t o s t r e t c h al s o w h e n
,
th e in fan t cri e d Au s cul t a ti on r e v e al e d lou d an d s ibilan t r al e s in th e

.
le ft lung . I t wa s e vi de n t th a t th e e ff or t s o f cough ing h a d pro d uc e d
a rup t ur e o f th e a e rial canal follow e d by e m p h y s e m a No fr a c t ur e .
o f th e rib s or o f t h e l aryng e al c a rtilag e s co ul d b e d e t e c t e d Th e p ul se .
b e at ov e r 1 1 6 p e r m inu t e Lin se e d p oul tic e s an d D e se s s artz s yr up

.
’
w e r e or d e r e d T h e n e x t d ay th e cough wa s l e s s th e s upra clavicular

.
,
-
s w e lling a li t tl e l e ss m ark e d a n d th e e m p h y s e m a h a d al m o s t all d i s

,
app e ar e d b e low th e cl avicl e On th e 1 8 th th e t u m e fac ti on was li m

.
i t e d t o th e n e ck an d th e cough wa s al m o s t gon e ; th e cr e pi t at ion on

,
th e 1 9 th s carc e ly e xi s t e d A te a spoon ful of e qu al p arts of th e s yrup s

.
o f t o lu an d o f e t h e r wa s or d e r e d e v e ry t wo h o ur s On t h e a r s t a ll .
fe v e r h a d di s app e ar e d an d pr e ss ur e s e e m e d to m ak e th e t u m o ur van
,
i sh. T wo d ay s a fte r th e r e wa s n e i t he r fe v e r nor cough an d th e n e ck ,
was n o t m or e bulging on th e rig h t s i d e t h an on th e l e ft F r o m t h at .
ti m e m or e t h an a y e ar ago no th ing o f th e ki n d h a s r e app e ar e d an d

, , ,
th e li tt l e girl h a s b e e n qui t e w e ll .
R efl ect i on s .
(1) F ro m wh a t he coul d e sta bli sh , th e au th o r i s ih
432 I ND E X OF S UR GI CA L P R O GR E S S .
c li n e d t o th ink th t a in i ca s e
th s r
th e e wa s a rup t ur e of th e th yroh yoi d
m em bran e .
( )2 In con s i d e ring t h e s ucc e ss io n o f s y m p t o m s i t s e e m s d i fficul t t o
a s s i m ila t e th i s ca s e t o th a t o f M o rd La va i llé e in wh ich th e r e wa s a ~

1
,
h e rnia o f th e lung o f wh ich th e orific e wa s li m i t e d by th e b or d e r o f the

,
fir s t rib —b e i n g accor ding to S D uplay on ly an e xagg e r a tio n o f th e

, .
2
,
n or m al pro t ru s ion o f t h e a pe x o f th e lu n g abov e th e l e v e l o f th e s up e
rior O p e n i n g o f t h e th orax .
C A S E I I Co n g e ni t al ab se nc e o f th e fir s t pi e c e o f t h e s te rn u m
. .
A e rial d iv e r ticulu m in fron t of th e n e ck a n d in th e upp e r m e d ian

p ar t o f th e th orax .
A m al e in fan t o n e m on th old pr e s e n t e d i n fron t o f th e n e ck a t u

, ,
m our w h i c h s ub s i d e d quick ly a n d co m pl e t e ly a t e ach in s pira tion .
T h e r e wa s t o t al ab s e nc e o f th e m anubriu m o f th e s t e rnu m an d non e ,
o f t h e ri n g s o f th e t rach e a coul d b e fe l t ; t h e r e s e e m e d in de e d to b e , ,
n o s oli d t i s s u e s b e twe e n th e cricoi d car tilag e an d th e an te rior e x

t re m i ty o f t h e four th rib Th e b i acro m ial d i s t anc e was 1 5 c m
.
- . .
,
t h e d i s t anc e b e t w e e n th e in te rnal ar ticular sur fac e s o f t h e cl avicl e s
c m a n d th e l e n g th o f th e s t e rnu m
,
.
, c m T h e s iz e o f t h e pro . .
t ub e ra n c e d i s t e n d e d a t e ach e xpira t ion wa s abou t t h a t o f a goo s e s

’
, ,
e gg By t o uc h th e in te r n al ar ticular s ur fac e s o f th e e n d s o f th e clavicl e s

.
c ou ld b e e a s ily m a d e o u t ; t h e fir s t rib s s e e m e d t o b e j oin e d t o g e th e r
a t t h e ir a n t e rior e x t r e m i ti e s a n d only a t th e l e v e l o f t h e fi ft h rib co ul d

.
th e s t e r n u m b e fe l t Curiou sly e noug h a longi t u di n al fol d or rap h e e x

.
,
t e n d e d fro m t h e xip h oi d car t ilag e along t h e m e d ian lin e a s far a s t h e

’
u m b il icu s T h e ch il d s cri e s cau s e d th e t u m o ur t o proj e c t an d at
.
,
e ac h i n s pira t ion t o d i s app e ar a n d for m an oblong cavi ty T h e s kin .
o f th e p ar t wa s v e ry th in S i x m on th s la t e r th e con di t ion wa s j u s t th e
.
s am e An app ara t u s wa s d e vi s e d n o t t o pr e v e n t t h e proj e ction o f th e

.
,
a e rial h e rnia b u t s i m p ly t o h in d e r any aug m e n t a t ion o f volu m e w h ich

,
m i g h t l e a d t o rup t ur e .
R efl ect i on s T h i s ca s e app e ar s t o th e a u th or uniqu e al th ough m any

.
,
1
Mé m . d le a S o c d e Ch i r urg e ri e
. . 1 8 47 . Vo l . I , p . 1 04 .
2
T ra i té d e Pa t h l
o . x
E te r n e , vo l . v .
H E A D AN D N E CK . 433
d e for m i ti e s of th e s te rnu m are known—e v e n ca se s o f t o t al a b s e nc e o f

th e bon e . In O c tob e r 1 8 5 2 Pro f Abb o tt o f Bah i a r e lat e d t o th e
, , .
, ,
S o c d e Biologi e th e ca s e o f a n e gr e s s ag e d 3 0 wh o s e rib car t ilag e s

.
,
ca m e t og e th e r in th e m an n e r o f fal s e rib s At e ach in s pira t io n th e y .
se para t e d t wo i n ch e s fro m e ach o th e r i n t h e m e d ian lin e approach ing ,
agai n a t th e e xpira t ion I f sh e laug he d th e y s e para t e d s o m uch th a t

.
th e h e ar t coul d b e lai d h ol d o f Sh e wa s qui t e s trong an d h e al th y . .
M S e rvi e r in h i s ar ticl e on t h e s t e rnu m in D e c h am b r e s Dic tiona ry

.
,
’
”
of M e d ical S ci e nc e s 1 8 6 0 s ay s t h a t
,
“
in m any clini qu e s an in d ivi d u a l
,
m ay b e s e e n wh o s e h e ar t d e priv e d o f pr o te c t ion i n fro n t t h ro u g h ab

“
s e n c e o f th e s t e r u m b e a t s i m m e dia te ly b e low th e s kin wh i ch i s rai s e d

n
, ,
a t e ach p ul s a ti o n A pla s t e r ca st o f th e con di tion i s pr e s e r ve d in th e

.
”
m u s e u m o f th e Val d e Grac e -
I n ano th e r ca se t h a t o f a s ol d i e r d ying
-
.
,
o f p h th i s i s a t t h e a ge o f 2 1 r e por t e d by Dr T en i er e s th e diap h rag m

, .
,
wa s v e ry m uch rai s e d i n con s e qu e nc e o f th e s m all l e n gth o f th e s t e r

n um wh ich i n s t e a d O f b e ing for m e d of th r e e w e ll d e v e lop e d pi e c e s
, ,
-
,
only pr e s e n t e d an e qual nu m b e r o f s m all sp ongy no d ul e s uni t e d by ,
car ti lag e s th e wh o le l e ng th b e ing ab ou t fi ve inch e s T h e xip h oi d ap

, .
e n dix d e s c e n d e d v e ry lo w an d th i s con t rib u t e d t o t h e s m all h e ig h t o f

p ,
th e c h e s t n o t b e ing r e cogn i z e d Wi e dm a n n h as ci t e d a ca s e in wh i ch
.
th e s t e rnu m was o n ly r e pr e s e n t e d by i t s upp e r p ar t .
Pa s s i n g ov e r t h e fa r m or e co m m on ca s e s o f a s y m m e t ry o f th e s t e r
n um o n ly t h o s e will b e m e n tion e d wh e r e th e s t e rnu m wa s t rav e r s e d by

,
o n e or m or e op e n i n g s fro m arr e s t o f d e ve lop me n ts O f th e th r e e .
pi e c e s o f th e s t e rnu m t h e xip h oi d app e n d ag e i s th e s e a t o f th e gr e a t

,
e s t n um b e r o f d e for m i t i e s o ft e n o f s urgic a l i m por t anc e

, s uc h a s th e ,
p u s h i n g b ackwar d s of th e xip h o i d poi n t or i t s e xagg e ra t e d proj e cti on ,
in fro n t u n d e r t he s kin
, Dr Tino R a m ir e z ( M e xico ) r e p or te d in th e
. .
-
Ga z elle M ea 1 8 68 p 6 6 th e ca s e o f a m an se t 7 5 wh o h a d n e v e r
’
.
.
, .
, ,
h ad any s e riou s illn e s s an d h a d al way s b e e n lig h t ly e m ploy e d Along .
th e m i dd l e o f t h e s t e rnu m an irr e gular canal wi th conv e x b or d e r s d i
v i d e d th e b on e I t m e a s ur e d four c e n t i m e t r e s in d ia m e t e r a t th e upp e r
.
e nd t h e n n arrow e d a li t t l e a n d a t t h e l e v e l o f t h e th ir d an d four th ri b s
, , ,
th e li t t l e fi n g e r co u l d n o t b e i n se r t e d F ro m th i s p oin t i t again e n .
la rg e d a s far a s t h e fi fth an d s ix t h rib s wh e r e th e r e wa s a k in d o f ,

4 34 I N D E X OE S UR GI CA L P R O GR E S S .
s inu s wh ich b e cam e lo s t in th e e pig as tric r e gio n D uring r e s pira tion

, .
th e can a l al t e rna t e ly con t rac t e d an d e xp an de d a n d th e m ov e m e n ts o f ,
th e h e ar t w e r e qui te e vi d e n t T h e ca s e al s o m ay b e r e calle d w
. h ich
was ob s e rv e d by H a m e rs k y a n d m a d e th e s ubj e c t o f a m e m oir

,
r e a d by M Be h i e r in O c t ob e r 1 8 b f r e th e S o c M ed d e s H opi
.
55 e o
, ,
. .
t aux d e Pa ri s T h e r e w e r e no s te rno c lavi Oular ar ti cula tion s b u t th e

.
-
,
in t e rnal e n d o f e ac h clavicl e r e st e d on th e upp e r p ar t o f th e corr e

s p o n d i n g h al f o f th e s t e r n u m w hich was in th e for m o f a V th e h alv e s
, ,
u n i t ing b e low in a car ti laginou s pi e c e w h ich s uppor t e d th e xip h oi d .
J ah n h as al s o r e por te d a ca s e o f cong e ni t al fi s s ur e o f t h e s t e rn u m in
th e A r clri u f u r Rli n M ea vol XV p F inally S ab a ti e r h a s
’
. . 20 0. . . . ,
o fte n ob s e rv e d a c e r t ain co n g e ni t al m ob ili ty o f th e s e con d pi e c e o f th e

st e rnu m on th e fir s t an d h e ci t e s th e ca se o f a gir l set 7 or 8 y e a r s
,
.
,
wh o pr e s e n t e d th i s con d i tion .
M S e rvi e r in h i s ar ticl e in th e D i cf E n cyc a es S c M ed giv e s n o

.
, . .
’
. .
,
in st anc e o f t o t al ab s e n c e o f th e fir s t b on e of th e s t e rnu m a n d o f thi s

o nly an d on t h i s accoun t e s p e cially th e e xa m pl e giv e n ab ov e m e ri t s
a tt e n tion More ov e r in th i s ca s e th e h e ar t b e at s in i t s prop e r plac e

.
, ,
a n d non e o f t h e l arg e v e s s e l s can b e fe l t i n th e O p e n s p ac e a t t h e u p
p e r p ar t o f th e s te rnu m T h e p rincipal poin t h ow e v e r i s t h e pr e s e nc e

.
, ,
o f th e ae rial d iv e r t iculu m wh ich r e ach e s t o th e s up e rior par t o f t h e

n e ck proj e c ti n g s e v e ral c e n ti m e tr e s s u d de nly e xp an din g at e ach e x
, ,
p i ra t i o n a n d d i s app e ar ing e qually s u dde nly a t e ac h in s pir ation .
In b ri nging forward th e two ca se s t o g e th e r th e au th or i s qu i te ,
aw a r e o f th e d i ffe r e nc e s wh ich th e y pr e s e n t In th e on e c as e t h e t u .
m our i s a cquir e d t e m p ora ry a n d un i la t e ral ; in t h e o th e r i t i s c o n g e ni

, ,
t al p e r m an e n t an d m e d ian in po s i tion
,
. T h e y h a ve th e co m m on .
ch ar a cte r th a t th e t u m our s are s i t uat e d in th e n e ck a n d upp e r p ar t of

th e th o rax th at th e ir con t e n t s a re ga s e ou s
, a n d th a t t h e y w e r e o b ,
s e rv e d in v e ry young in fan ts —Ga za M ea a e P a r i s . Aug 7 1 8 8 6 ’

.
’
. .
, .
R 3 73
111 C a s e s o f E x c i s i o n o f t h e L a r y n x By Dr PE A N
. Tw o . .
,
S ur g e on o f th e S t Lo ui s H o s pi t al Pari s
. E xci s ion o f th e l arynx i s o f
, .
re c e n t d a t e Lik e so m any o th e r O p e ra ti on s th e s ucc e s s o f wh ich i s

.
,
t o d ay a ss ur e d i t i s O ppo s e d by m any s urg e o n s pa rt icul ar ly by th o s e

-
, ,
4 35
wh o h av e n e v e r h ad t o e m ploy i t Pe rfor m e d for th e fir s t t i m e abro a d

.
,
s e v e ral y e ar s ago i t h a s b e e n la t e ly prac t ic e d in F ranc e b y M Labb e

,
.
,
wh o la s t y e ar p ubli s h e d a goo d ca s e T h i s att e m p t e nco urag e d th e

.
O p e ra t ion r e c e n tly in t h e ca s e o f t wo p a t i e n t s wh o w e r e a ffe c t e d wi th
e pi t h e lio m a o f th e larynx an d wh o w e r e n e arly s uccu m bing O n e of .
t h e m se t 3 5 i s now full o f h e al th ; th e o th e r se t 6 5 h a s s e e n th e
, .
, ,
.
,
wou n d cica triz e an d th e op e r at ion woul d h av e b e e n e qually s ucc e s s ful

,
i f i t h a d n o t b e e n fo r a pn e u m onia co m plica tion wh ic h woul d n o t h av e .
s e t in h a d w e p o s s e s s e d m or e e xp e ri e nc e in t h i s ki n d o f op e ra t ion .
Ca s e 1 Loui s B ae t 3 5 r e st aur a n t k e e p e r e n t e r e d F e brua ry 3

. .
, .
, , ,
1 8 8 6 O p e ra t e d on F e bruary 1
, 3 N O h e r e d i ty —n e i t h e r alco h o lic no r
.
s yp h ili t ic
. F i ft e e n m on t h s ago wi th o u t known c a u se h e fir s t b e c a m e
, ,
h oar se a n d dy s pn oe a follow e d T h e se p h e no m e na gr a d ually i ncre a s e d

.
a n d sinc e a y e a r t h e y h av e b e co m e urg e n t At th e pr e s e n t t i m e th e r e
.
i s ap h onia a nd
, a t t a ck s o f p ain T h e e xp e ct ora t ion i s m ix e d
.
wi th bloo d By la ryngo s co p ic e xa m in a tion Dr Poy e t e s t abli sh e d th at

. .
t h e e piglo tt i s wa s nor m al t h a t t h e rig h t h al f o f th e larynx wa s d ark

,
r e d t h a t t h e a r t e n oi d c ar t ilag e s w e r e s wo ll e n an d t h a t t h e in fe ri o r
.
y ,
vocal cor d was cov e r e d wi th s u spiciou s v e g e t a tion s Th e p a t i e n t h as .
m uc h fall e n o ff in fl e s h al t h oug h th e r e ar e n o c e rvical glan d s nor a u v

, ,
d i s or d e r s o f t h e princip al vi s c e ra Oh th e 1 3 th of F e bruary t ra c h e o t
.
o m y wa s p e r for m e d a n d on t h e 2 th t h e or d inary canul a wa s r e plac e d

7 ,
by Tr e n d e l e nb urg s plug canula t o pr e v e n t th e e n t ranc e of bloo d in t o

’
,
th e air p a s sa g e s t h e p a t i e n t was ch loro for m e d t h ro u g h t h e t ub e an d a

, ,
v e r tical in ci s ion was m a d e wi th th e bi s t ou ry in th e m i d dl e lin e e x te n d ,
ing fro m th e m i dd l e o f th e s u b h yoi d s p a c e t o o ne c e n ti m e tr e fr o m th e

-
t r a c h e al woun d T hi s in ci s ion e xpo s e d th e car til ag e s of t h e l arynx ;

.
t h e t h yroi d car t ilag e was t h e n d ivi d e d in th e m i dd l e lin e an d by m e a n s .
o f th e s calp e l th e p e ric h on d riu m was d e t ac h e d fro m i t s e x t e rn al s ur

fa c e. S e izing th e righ t h al f o f t he th yroi d wi th a fl a t bla d e forc e p s ,
th e p e ric h on d riu m wa s d i s s e c t e d o ff fro m i t s inn e r s ur fac e a s far as th e
p o s te rior e d g e T h u s fr e e d on i t s t wo s ur fac e s i t wa s e a s ily r e m ov e d

.
,
by a m ov e m e n t o f t or s ion T he o th e r h al f of t h e ca r tilag e wa s tr e ate d

.
in th e s am e way D uring thi s m anae uvr e th e an te ri or m e m bran e of

.
th e laryn x was foun d t o b e d ivi d e d a n d i t was d i s cov e r e d t o b e i h ,

4 36 I N D E X OF S UR GI CA L P R O GR E S S
v ad e d abov e an d a t th e l e v e l o f t he vocal cor d s in n e arly i t s wh ol e e x

t e n t e s p e cially o n th e righ t s i d e
, I t was e s t abli s h e d al s o th at th e
.
m ali g n a n t u lc e ra t ion occupi e d t h e par t o f th e m ucou s m e m bran e w h ich
cov e r s th e in te rn al s ur fac e o f th e thyroi d car tilag e an d th e laryn g e al

s ur fac e o f th e t wo aryte noi d car tilag e s To facili t at e th e r e m oval o f
.
th e s e i n fe c tiv e ti s s u e s th e cricoi d car t ilag e wa s c u t in fron t in th e m i d

,
d le li n e a n d r e m ov e d i t s p e rich on d riu m b e in g d e t ach e d fro m b o th

,
s ur fac e s. Th e wh o le cavi t y o f th e la ry n x was pr e s e n t e d t o vi e w a n d ,
a ll t h e m uc o u s an d s ubj ac e n t t i s s u e s wh ic h d e g e n e ra t e d w e r e wi d e ly
r e m ov e d— i n clu di n g th e ary te noi d car ti lag e s wh ich w e r e al s o inva d e d

by th e n e op la s m . T h e e piglo tti s b e i n g h e al th y was r e t ain e d
,
F iv e
,
.
h aem o s t a tic for c e p s c o n troll e d h aem orrh ag e d uring th e op e rat ion T h e n .
n i n e s e para t e s i lk s u t ur e s s up e rfici al an d d e e p T h e p oin t s o f s u t ur e

.
w e r e pa ss e d on e ach s i d e as n e ar as po s sibl e t o th e m ucou s m e m bran e

wh ich was le ft on t he p o s t e rior r e gion o f th e larynx s o th a t a fte r cica ,
t riz a ti o n t h e spac e occupi e d by t h e laryn x woul d b e r e d uc e d t o a nar
r ow c h a n n e l Th an k s t o th e d r e s s i n g wi th i o d o for m an d s ubli m a t e ;
.
uni o n t o o k plac e b y fir s t in t e n tion an d th e th r e a d s o f th e s u t ur e w e r e

,
r e m ov e d on th e sixth d ay D uri n g th i s ti m e th e p ati e n t was e a s ily fe d

.
by an oe s op h a g e a l caou t ch ouc t ub e p a ss e d by th e n a s al fo s s ae On th e .
fi ft e e n th d ay th e t ub e was wi th drawn an d th e pa ti e n t wa s abl e t o s wal

low wi th ou t di ffi cul ty liqui d s a n d s oli d foo d No w by m e an s o f a
.
,
s p e cial c a n u la h e s p e ak s an d h e i s abl e t o a t t e n d to h i s work

,
.
Ca s e 1 1 J u le s C ae t 3 5 th e s ubj e c t of e pi th e l i o m a o f th e larynx
. .
, .
, ,
c a u s i n g p aro xym s o f s u ffoca ti o n s o alar m i n g t h a t t rac h e o t o m y h a d t o
b e p e r for m e d on th e 1 3 th O f F e b ruary 1 8 8 6 T hi s O p e ra tion wa s re n

,
.
d e r e d v e ry di fficul t by r e a s on o f th e sh or tn e s s a n d o b e s i tv o f t h e n e ck
an d th e r e trac t ion o f th e lary n x w h ich was s i t ua t e d b e h in d th e upp e r
,
bor d e r of th e s te rnu m Wi th ou t th e au th or s hae m o s t a tic forc e p s an d

.
’
can u la h ol d e r i t woul d n o t h av e b e e n s ucc e s s fully p e r for m e d O n th e .
6 th o f March th e trac h e al wo un d wa s h e al e d b u t th e pa ti e n t s t ill s u f

,
fe re d s u c h pain i n th e laryn x a n d h aem op ty s e s th a t h e wi s h e d fo r i t s
e xci s i o n
.
,
T h e g e n e ral c o n di tio n was s o b a d a n d th e r e la tion s o f th e
.
la rynx so d i s agr e e abl e th a t th e O p e r ati on was a t t e m p t e d wi th m uch

,
h e s i t a ti o n
.
A fte r in t ro d uci n g in t o th e tr ach e a a plug canula a v e rt ical i n ci s i on ,
wa s m a d e in t h e m i d dle lin e fro m t h e c h in t o th e canula T h e t hy .
r oi d car tilag e w as th u s e xp o s e d i ts p e rich on driu m d e t ach e d fro m b o th

,
s ur fac e s an d th e t wo h alv e s s e p ara t e d a s in t h e pr e c e d ing ca s e Thi s .
ti m e th e O p e ra t ion wa s m or e d i ffi cul t fro m th e calcifica tion o f th e car
t i la ge
. T h e m uco u s m e m bra n e wa s s e e n t o b e i n va d e d by th e canc e r ,
an d in par t s th ick e n e d t o th e e x t e n t o f 1 c e n t i m e tr e I t was Wi d e ly .
r e m ov e d T h e cricoi d por tio n o f t h e larynx was n o t invol v e d an d i t

.
,
wa s l e ft un touch e d . O n th e o th e r h a n d t h e po s t e rior an d la t e ral p ar t s

,
o f t h e lary n x w e r e s o m uc h i m plica t e d th a t t h e y w e r e co m pl e t e ly re
m ov e d t og e th e r wi th t h e ary t e noi d car t ilag e s an d th e an t e rior wall

, ,
o f th e oe s op h agu s a s far d own as th e cricoi d a n d th e b a s e o f th e e p i
glo tti s An i m m e n s e gaping wou n d was th e r e s ul t e xp o s ing t o vi e w

.
,
th e p h arynx an d oe s op h agu s T h e r e s ul t s o f t h e op e ra t ion w e r e l e s s s at

.
i s fa c t ory th an i n th e o th e r c a s e T h e p a t i e n t on th e fir s t d ay r e m ov e d
.
th e oe s op h ag e al ca t h e t e r wh ic h wa s b a dly a dj u s t e d an d wh ic h in th e ,
au th or s ab s e nc e h a d b e e n in tro d uc e d in t o th e cavi ty l e ft by th e larynx

’
.
In co n s e qu e n c e m ilk i nj e c te d th roug h th e t ub e h a d p a s s e d i n t o th e
bronch i an d th e n e x t d ay i t wa s n e c e s s ary t o r e O p e n t h e wou n d an d
,
-
r e a dj us t th e ca th e t e r in th e m S O p h ag u s T h e e n tranc e o f m ilk in t o
.
lun g s cau s e d infla m m a t ory ac tion w hic h wi th ou t pr e v e n ting union by

,
fir s t in t e n tion in th e woun d t e r m ina te d in bro n c h o pn e u m o n i a t o

,
-
,
wh ich th e p a ti e n t s uccu m b e d T h i s acci d e n t wo u ld n ot h av e h ap

.
p e n e d i f i t s p o s s ibili ty h a d b e e n for e s e e n .
T h e h i s t ological e xa m ina t ion o f th e p ar t s r e m ov e d i n t h e s e t wo
ca s e s was m a d e by M Cornil wh o d iagno s e d in th e fir s t p av e m e n t

.
,
e pi th e lio m a a n d in t h e s e con d a lob ula t e d e pi t h e li o m a

,
In s pi te o f th e au th or s li t tl e e xp e ri e nc e i n s uch ca s e s t h e op e ra t ion s
’
,
w e r e s ucc e s s ful p e r for m e d In th e fir s t th e p a ti e n t wa s an ae s th e tiz e d ;

.
in th e s e con d e x h au s tion wa s t oo gr e a t t o allow o f i t I n t h e fir s t .

,
w h e r e t h e t r ac h e a wa s s m all th e plug canula was s u ffici e n t t o plug

,
th e pa ss ag e in t h e s e con d th e clo s ur e wa s inco m pl e t e T h i s d id n o t .

,
th ank s t o t h e au th or s h ae m o s t a t ic forc e p s in conv e ni e nc e th e op e ra

’
,
t ion b ut i t w as o f con se qu e nc e in fe e di n g th e p at i e n t
, .
As r e gar d s th e op e r at ion i t s p e culiar fe a t ur e i s i n th e e xci s io n by

,
4 38 I N D E X OP S UR GI C A L P R O GR E S S .
pi e c e s I t co n si s t s o f fir s t th e m e dian i n ci s io n o f th e s o ft par ts fro m

.
,
n e ar th e ch i n d own t o th e ca n ula ; s e co n d th e s e c tion o f t h e th yroi d

,
c ar tilag e th ro gh th e m i d d l e o f i t s an t e rior par t th e d e t ac h m e n t o f th e

,
p e rich on driu m by m e a n s o f a s crap e r a n d th e s e para t e wi t hd ra wal o f

,
th e pi e c e s by m e a n s o f a fla t bla d e d forc e p s

-
I f n e c e s s ary th e s a m e
.
proc e d ur e m ay b e a d op t e d for th e cricoi d W h e n th e car tilag e s are

.
r e m o v e d th e in t e rn al m e m bran e wh ich for m s th e an t e rior wall o f t h e

, ,
lary n x i s e xp o s e d t o vi e w a n d th e d i s e a s e d por tion s e xci s e d

, , The n
.
by m e an s o f r e trac t or s plac e d on e ach s i d e th e la te ral an d po s t e ri o r

,
wa ll s o f th e larynx are e xa m i n e d an d th e a ffe c te d p ar ts r e m ov e d a s

,
wi d e ly as p o ss ibl e Car e b e ing t ak e n t o pr e s e rv e th e e x te rn al p e ri

.
ch o n dri u m th e O p e ra t io n m a y b e acco m p li s h e d wi th ou t fe ar o f woun d

,
ing th e v e s se l s or i m por tan t n e rv e s wh i ch are n e ar th e s ur fac e o f th e

la rynx .
T h e O p e ra tion o ve r th e full vi e w o f th e in t e rior o f th e p h arynx e nabl e s

,
u s t o arrang e in po s m on a caou t ch ouc oe s op h ag e al ca th e t e r p a s s e d by
t h e na s al pa s s ag e . T h e h ae m o s t at ic forc e p s ar e th e n r e plac e d by lig
a tur e s an d th e woun d co m pl e te ly clo s e d by s e para te silk u tur e s s u

,
s ,
e rfi c i al a n d d e e p T h la t t r h oul d b pa d clo se l y a s po s s ibl e

p . e .e s e ss e a s
t o t h e e x t e rnal p e rich o n dri u m t o facili t a te th e union o f i t s bl e e ding

,
s ur fac e s an d t o co n t rol th e h ae m orr h ag e T h e d r e ss ing s h oul d b e

.
d on e wi th io d o for m a n d s ubli m a t e gauz e a n d wa dd ing ba n d ag e On .
t h e s ix th d ay t h e la t t e r i s r e m ov e d an d t h e s u t ur e s wi th d ra wn On .
abou t th e fi ft e e n th d ay th e pa t i e n t can fe e d wi th o u t th e oe s op h ag e al
t ub e wh ich m ay b e t ak e n away ; an d th e lo s s o f t h e voic e can b e r e m
e d i e d by s ub s t i t u t ing fo r th e tr a c h e al canula ano th e r o n e furni s h e d
wi th an ar tificial larynx s uc h a s Ma th i e u h a s con st ruc t e d fo r th e a u

,
t h or s c as e afte r M F ra uv e l s in s t ruc t ion s—s i m ilar t o Gus s e n b a u e r s

’ ’ ’
. .
,
Th i s op e r a tion h as b e e n obj e c t e d t o b e cau s e i t i s liabl e t o h ae m or

rh a g e an d pn e u m onia . I f th e abov e rul e s ar e clo s e ly follow e d th e r e
will b e n o fe ar of loss o f b lo o d ; an d a s for th e pn e u m onia it i s n o t ,
e vi d e n t i f th e i m m e d ia t e cau s e s w h ic h pro d uc e i t b e
,
g uar d e d agai n s t ,
wh y a pa ti e n t o p e ra t e d on sh oul d b e m or e liabl e t o i t ra th e r th an o n e ,
wh o h a s in h i s larynx a pain ful m align an t gr o w th .
I t m a y b e s ai d th a t th e pr e se n t s t a ti s ti c s a re n o t ve t fav o rabl e t o t h e
H E AD AN D N E CK 4 39
O p e ra t i o n b u t t h e r e ply i s th a t s uch i s alway s t h e ca s e wi th big op e ra

.
t ion s s uch as th i s wh ic h prop erly p e r for m e d wi ll b e o n e o f th e tri

, , ,
u m p h s o f m o d e rn s urg e ry Ga z f li ed cle P a r i s April 1 7 1 8 8 6 .

-
. . .
, .
P S ABR . . AH AM ( L on don ) .
IV o u r C as e s o f T ra ch e o t o m y W it h E xt ra o rd i n ar y
. F ,
F e at u re s By Dr K K R E Y E R ( S t Pe t e r s b urg R u s s ia ) Dr R
. . . . .
, . . .
,
s e nior s urg e on o f t h e s urgical d e par t m e n t o f S t Mary s H o s pi t al S t ’

. .
,
Pe t e r s b urg h a s p e rfor m e d t rach e o t o m y in th e fo ll o wi n g four rar e

,
ca s e s
Ca s e I Milan K S e rvi an s ol d i e r d u ring t h e S e rvo Turki sh c am
. .
, ,
-
p g
a i n h a d h i s t rach e a s h o t th rough by a b ull e t H e was s ubj e c t e d t o .
c r i co l r a clzeolom y a n d r e cov e r e d b u t fo r s o m e unknown r e a s o n h e h a d

-
,
th e t ub e i n S i f u for ov e r a y e ar O nc e wh il e cl e an i n g t h e i n t e r n al .
t ub e h e foun d t h a t th e e x t ra t rac h e al p ar t o f t h e o th e r t ub e h a d s e p
,
-
ar at e d fro m t h e in t ra t r ach e al on e w h ic h d ropp e d d own i n t o t h e t ra ,
ch e a cau s ing a s e v e r e paroxy s m o f coug h S urg e on s o f B e lgra d fail e d

, .
t o e x t rac t th e canula fro m t h e t rach e a an d t h e p a t i e n t wa s s e n t t o S t , .
’
Pe t e r s burg F e bruary 2 5 1 8 8 4 h e e n t e r e d t h e Mary s Ho s pi t al
.
, He , .
wa s s u ffe ring fro m bronch i t i s a n d d y s pn oe a N o for e i gn b o d y co ul d .
b e foun d th ro ug h t h e t rach e al O p e nin g a n d i t s v e ry pr e s e nc e wa s ,
d oub t e d March 2 3 laryngi ti s Ma y 1 d y s pn oe a s e v e r e coug h a n d

.
, .
, ,
ch ill s T h e pa ti e n t pray e d fo r a n O p e ra t ion N o e xa m ina ti on sh ow e d

. .
t h e pr e s e nc e o f a for e ign b o dy in th e t rach e a I n t h e b e ginni n g o f .
Augu s t dy spn oe a in c re a se d fe v e r s e t i n a n d b a d s m e ll fr o m t h e tra , ,
ch e a was p e rc e p tibl e O n Augu s t 1 7 Dr R p e r for m e d c/zer m ocom i a

. . .
t r a clzea li s long i t u d i n a li s a o m a x i m u m N o t a s in gl e dr op o f blo o d ’

.
lo st Dr R in tr o d uc e d hi s fing e r in t o th e t rach e a d own t o th e b i fur

. . .
cat ion b ut coul d n ot fi n d any for e ign b o dy T h e p at i e n t was plac e d

,
.
in t h e p e rp e n d icul ar p o s i tion h e a d d own a n d was s h a k e n Th e n D r , , . .
R wi th h i s fing e r fe lt s o m e th i n g h ar d in t h e rig h t bro nc h ial t ub e b ut

g
.
, , ,
t h a t was only fo r a m o m e n t for wi th i n s pira ti on t h e for e ig n b o d y wa s ,
dr awn in d e e p e r A ft e r r e p e a te d s h aking s o f th e p a t i e n t wi th h e ad
. ,
d o wn a t la s t Dr R s ucc e e d e d in e x tr a c ting th e canula wi th t h e

, . .
c urv e d p olyp u s forc e p s T h e can ul a w a s o f h ar d rubb e r . F o r six .

44 0 1 N D E A OP S U R GI GA L P R O GR E S S .
m on th s afte r th e O p e ra tion th e p at i e n t wa s s u ffe ring fro m c o ugh a n d

d y s pn oe a T h e tr ac h e al fi st u la coul d b e clo s e d only a ft e r r e p e a t e d
.
pla s t ic O p e ra tio n s O n F e bruary 1 7 1 8 8 5 th e p a ti e nt l e ft th e h o s pi t al

.
, ,
qui t e cur e d .
Ca s e 1 1 Ci vil o ffic e r A M ae t 4 6 e n t e r e d th e h o s pi t al J un e 2
. . .
, . . ,
1 8 84 H e h a d ca r c i n om a li ng u m
. O n July 2 6 th e l e ft p ar t o f th e .
t o n gu e was r e m ov e d O n J uly 2 8 a s p h yxi a fro m unknown cau s e

.
,
.
E l e c t rici t y oxyg e n a n d ar tificial r e s pira t ion h a d no b e n e fi cial e ffe c t

,
.
Dr R e y e r p e r for m e d th e u s ual trach e o t o m y b ut i t wa s t o no purpo s e

.
,
cyano s i s wa s s e tting in Th e n Dr R p e r for m e d t r a c/zeo i n ci s i o long i

. . .
-
’
T h e trac h e a wa s e xplor e d th orough ly b ut no
’
i u a i n a li s a o m a x i m u m .
,
fo re i g n b o d y foun d p
Dr R in tro d uc e d h i s fing e r d own t o bi furca t ion
. . .
a n d fo un d t h a t t h e t rac h e a b e low th e j ugulu m wa s clo s e d by an an e ur
ism .Pr e s i n g wi th h i s fing e r again s t t h e b ack p ar t o f th e t rac h e a Dr

s .
R o p e n e d a fr e e p a s s ag e t o t h e bronch ial t ub e s an d r e s pira t ion was

.
,
r e s t o r e d T h e n Dr R in tr o d uc e d t h e s pri n g can ula o f K o e nig wh ich

’
. . .
,
t h u s s av e d th e li fe o f t h e pa ti e n t T h e pa t i e n t w a s i m provi n g a n d .
cou ld br e a th e fr e e ly wi th ca n ula r e m ov e d O n S e p t e m b e r 7 th e o p e n .
i n g in th e trac he a was clo s e d an d on S e p t e m b e r 2 2 t h e p a ti e n t l e ft , ,
th e h o s pi t al Ho we v e r o n th e n e x t d ay a s p h yxia t o o k plac e
. A new .
tr ac h e o t o m y was p e r for m e d a n d K o e n ig s canula again in t ro d uc e d

’
.
O n O c t o ae r 2 0 in t h e m orn ing h ae m orrh ag e in t h e e v e ni n g a s p hyxia

, , ,
.
Dr Le vi t s ky in wh o se ch arg e th e pa ti e n t wa s wa n t e d t o e xa m i n e th e
.
, ,
canula b u t in h i s h an d wa s l e ft o n ly th e e x t e r n al p ar t w h il e t h e in
, ,
t e rn al h aving s o m e h o w s e para t e d d ropp e d i n t o t h e t rac h e a

,
Dr L , . . .
c ut t h r e e ring s o f t rac h e a b u t co u ld n o t r e ac h t h e ca n ula Dr R e y e r, . .
arri v e d e xtract e d th e canula an d fix e d i t N e x t d ay th e an e uri s m

,
.
b ur s t .
Ca s e 111 F e m al e o f a s yp h ili ti c fa m il y s i n c e ch il dh oo d wa s s u ffe r

.
, ,
ing fro m s yph ili ti c lary n gi ti s A ft e r m arriag e s h e h ad s yp h ili tic ulc e r s .
in th e t h roa t S h e h a d d y s pn oe a fo r s e v e ral y e ar s
. I n Janu ary 1 8 8 5 .
, ,
s h e caug h t col d—p n eu m on i a c r oup os a a n d s te n os i s la ry ng i s

’
a ewt r a
lu et i ca O n F e bruary 3 b e i n g in a d ang e rou s co n d i t ion sh e wa s

.
, ,
brou gh t int o h o spi t al wh e r e t rac h e o t o m y wa s p e rfor m e d a t onc e O n .
March 3 s h e l e ft t h e h o s pi t a l c ur e d o f p n e u m o n ia S h e c o ul d n o t .
H E A D A N D N E CK . 44 1
br e ath e wi th ou t th e t ub e m or e th an h alf an h our O n Augu s t 2 6 th e .
p a ti e n t again was brough t in t o h o s pi t al s u ffe ring fro m a s e v e r e dys p ,
n oe a S h e was i n th e four th m on th o f pr e gn ancy O n S e p te m b e r 1

. .
,
a s p h yxi a wh ich wa s r e li e v e d by in tro d uci n g th e K o e n ig t ub e S e p

, .
tem b er 3 , th e rm o t o m i a t rac h e ali s longi t u d inali s t rac h e a b e low th e
O p e ni n g wa s fou n d r e d uc e d t o th e s iz e o f a quill T h e K o e nig s t ub e

’
.
wa s in tro d uc e d in t o th e narrow e d por tion o f th e trach e a S e p te m b e r ,
6 a t ub e cm wa s i n tro d uc e d in s t e a d o f th e K o e nig s a n d gra d ually

.
’
,
t ub e s o f a larg e r d i am e t e r w e r e in t ro d uc e d O n D e c e m b e r 2 5 th e p a .
t i e n t l e ft t h e h o s pi t al ; t h e t rach e al canal wa s e nlarg e d four t i m e s In .
th e e n d o f M arc h was e xp e c t e d t h e d e liv e ry I t was t h o ug h t d a n g e r .
o u s or a t l e a s t v e ry inconv e ni e n t t o l e av e t h e K o e nig s t ub e in t h e
’
th ro at d uring th e labor T h e r e for e a t ub e o f s o ft r u ob e r wi th an e n d

.
o f t h e vulcaniz e d rubb e r w a s in t ro d uc e d i n s t e a d a n d th e p a t i e n t wa s ,
s a fe ly d e liv e r e d T h e p a t i e n t wa s e xa m in e d on M ay 1 3 1 8 8 6 ; s h e
.
,
w e ar s a s ilv e r canula all t h e ti m e O n h avi n g clo s e d i t s O p e ning sh e .
c a n t alk d i s t i n c t ly a n d lou d .
Ca s e I V Ivan T p e a s a n t ae t 2 1 s u ffe ring fro m d y s pn oe a was ad

. .
, ,
.
, ,
m i t t e d t o t h e h o s pi t al April 2 8 1 8 8 6 T wo y e ar s ago h e wa s s ubj e c t e d

,
.
t o t rac h e o t o m y a n d s inc e t h e n h e h a d t h e t ub e w h ic h on April 2 7 h a s , ,
s pli t in t o t wo t h e low e r e n d h aving d ropp e d i n t o th e t rac h e a

,
On .
’
April 2 9 Dr R e y e r h a s p e r for m e d fli er m olom i a t r a c/zea li r long i zu a i
.
‘
n a li S . N o for e i gn bo dy coul d b e foun d T h e p a t i e n t was plac e d i n .
t h e p e rp e n d icular p o s i t ion h e a d d own : th e n Dr R ,

on h avi n g in tro . .
,
d u c e d h i s fing e r fe l t th e canu la a t t h e bi furca tion

,
D ue t o i t s gravi ty . ,
th e t ub e gra d ually approac h e d th e op e ni n g an d wa s e x t rac t e d .
T h e th r e e for m e r ca s e s w e r e r e por t e d by Dr A K ro e t s k y a n d t h e . .
,
la s t o n e by Dr R W e b e r Dr K wh o wi t n e s s e d t h e op e ra t io n s d e
. . . . .
,
s crib e d by h i m , co m e s t o th e co n clu s ion t h a t th e pr e s e nc e O f a for e ign
b o dy in t he trach e a an d bronc h i canno t b e al way s prov e d by p hy s ical

e xam ina t i on th a t t urning m an h e a d d own m u s t b e r e s or te d to in c e r
, ,
t ain ca s e s an d t h a t K o e n ig s t ub e i s invaluabl e in s o m e ca s e s o f t ra
’
,
c h e o t o m y — C /zi r u rg i c/zes lz
.
y Ves l n i R J u ly 1 8 8 6 . . .
P .
J . PO PO FF ( Bro o k l yn ) .
—
4 42 IN DE X OP S UR GI CA L P R O GR E S S .
ABDO M E N .
I S t r a n g u l a t e d U m b i li c a l H e r n i a i n a P r e g n a n t W o m a n
. .
O p e rat i o n D e at h . P BE R T H OD . O n D e c e m b e r 2 3 1 8 8 5 th e
. .
, ,
pa ti e n t ae t 4 0 w as a dm i tte d t o S ain t Loui s Ho s pi t al un de r M Le

, .
,
.
D e n tu s u ffe ri n g fro m s trangula t e d u m bilical h e rnia Sh e wa s th r e e

,
.
m on th s gon e i n h e r four th pr e gnancy an d s inc e th e fir s t o n e h a d s u f ,
fe re d fro m an u m bilical h e rnia wh ich a b a n d ag e h a d h i th e r t o con ,
t roll e d wi th ou t i n co n v e ni e n c e E i g h t d ays b e fo r e a d m i s s ion th e h e rn ia

.
h a d cau s e d p ain s o th a t th e b an d ag e h a d t o b e l e ft o ff a n d s ix d ay s ,
lat e r wh e n a tte m p ti n g t o li ft a w e igh t sh e fe l t th e pai n b e ca m e s u d

, ,
d e n ly wor s e a n d s y m p t o m s o f s trangula tion app e ar e d

, Taxi s fail e d .
,
s o t h e s a c w a s op e n e d a m a s s o f fa t liga t ur e d an d c ut o ff
, an d a ,
knuckl e o f b ow e l h aving b e e n fr e e d o f on e or two a dh e s ion s was re

d uc e d T h e s a c was s e w e d up wi th ca t gu t an d t h e s ki n wi th h or se
.
h air— Li s te ri an d r e s s in g S y m p t o m s o f p e ri t oni ti s app e ar e d on t h e a 5 th

. .
Vo m i ting an d s e v e r e hi ccup s ca m e on an d sh e d i e d o n th e m orning

o f th e 2 6 th o f D e c e m b e r N o po s t m or t e m e xa m in a t i on wa s ob t ain e d
. .
T h e au th or d raw s a t t e n tio n t o th e fr e qu e n t a s s ocia t io n o f p e ri t oni t i s
wi th u m bilical h e rnia wh e n s tra n g ula te d T hi s ca s e giv e s li ttl e s uppor t .
t o th e vi e w t h a t th e p e ri t oni t i s i s ap t t o s pr e a d b e low th e d iap hr ag m
an d paralyz e i t a s t h e r e was n o dy s p n oe a al th oug h aggr a va t e d h i ccup

, , .
H e s t a t e s th a t th e s h ock o f th e O p e ra t ion h a d n o fur th e r e ffe c t on th e
pr e gn ancy th an t o cau s e s o m e u t e ri n e h ae m orrh ag e o n th e t wo nigh t s

following th e op e ra tio n T h e fir s t s t opp e d s pon t an e ou s ly th e s e con d
.
,
w as c h e ck e d wi th an inj e c tion o f h o t wa t e r b u t t h e r e wa s no th r e a t e n ,
ing m i s carri ag e — Ga g M ea de P a r i s May 2 2 1 8 8 6

.
'
. .
, .
II . C a s e o f S t r a n gu l at e d I n t e r n al H e r n i a i n t o t h e F o r
A
a m e n o f W i n s lo w E S A A cl e rk ae t 2 5 d in e d in a p
J Q U RE
. . . .
, .
,
par e n t h e al th a t n o o n on May 7 walk e d abou t a quar t e r o f a m il e t o ,
h is o ffic e a n d a t 2 p m wa s s e iz e d wi t h e xcrucia ti n g p ain in th e e p i

. .
ga s tri u m H e r e t ur n e d h o m e a t onc e wi th di fficul t y wa s giv e n bran dy

.
,
a n d wa t e r a n d a d o s e o f ca s t or oil an d at 4 p m b e gan t o vo m i t , . . .
Pai n an d vo m i t i n g co n ti n u e d wi th t wo s l e e pl e s s nig h t s un t il th e 9 t h
, ,
wh e n h e was e a s i e r an d s a t o u t by th e fi re In t h e e v e ning the sym p .

C H E S T A N D AB D OM E N .
44 3
t o m s r e turn e d as b e for e O n th e following e v e n ing— r o t h o f May

.
Mr S quar e s aw h im fo r th e fir s t t i m e at 7 p m
. T h e p a t i e n t wa s t h e n . .
in a m o s t e xci t e d an d r e st l e s s s t a t e wi th d i fficul ty k e p t in b e d ; fac e

,
an xiou s an d s o m e wh a t pinch e d axillary t e m p e ra t ur e ,

p ul s e 1 2 2 ,
r e gular an d s m all H e h ad n o t vo m i t e d for an h our or two T h e

. .
for m e r p ain o v e r th e e n s i for m ca rt ilag e w h ich h a d b e e n e xcruci a tin g , ,
h a d s ub s i d e d Th e l e g s w e r e n o t d rawn up a n d th e ab d o m e n s e e m e d
.
,
n a t ural T h e r e wa s m ark e d te n de rn e s s aroun d u m bilicu s an d a t e p i

.
g a s tri um b u t now h e r e e ls e
, R e s onan c e all ov e r ab d o m e n e xc e p t a t
.
,
flank ; bowe ls bo un d s inc e m or n ing o f 6 th n o alb u m e n in urin e Ih

, .
t e s ti n al ob st ruc t ion was d iagn o s e d a n d an e n e m a o f war m wa t e r an d

,
s o ap a d m ini s t e r e d wi th ou t e ffe c t A larg e r e n e m a in th r e e h ours

.
cau s e d a fl ui d s t ool wi th t wo s oli d fae cal m a s s e s T h e vo m i t wa s n o w .
fae cal . At 3 a m on th e r 1 th Mr S quar e was h urri e dly s e n t fo r ;

. .
, , .
th e pa t i e nt wa s now in a m o s t ch il d i sh con di t ion s o r e s t l e s s th a t h e ,
coul d n e i th e r b e k e p t in b e d nor b e pr e v e n te d fro m th rowing o ff th e

b e d clo th e s H an ds an d fe e t col d an d clam m y p ul s e fe e b le th ough
.
,
qui te con s ciou s A fte r h ypo de r m ic inj e ct ion s o f m orp h in e h e was l e ft

.
m o d e ra t e ly qui e t at a m H e b e ca m e qui e t e r an d s ank at 7

. .
o clo ck afte r an illn e s s o f th r e e d ay s an d s e v e n t e e n h our s At th e p o s t

’
.
m or t e m only a s m all a m oun t o f p e ri t oni t i s wa s s e e n on fir s t op e nin g
th e ab d o m e n Gr e a t o m e n t u m d raw n in a m on g th e s m all in t e s tin e s t o

.
l e ft o f m i ddl e lin e an d m o d e ra te ly cong e st e d In te s ti n e s d i s t e n de d

,
.
wi th ga s b u t wi th li ttl e fae c e s F u lly e i gh t inch e s o f th e il e u m ab ou t

,
.
t wo fe e t fro m i t s c oe cal e n d w e r e fir m ly incarc e r a te d in th e fora m e n o f
Win s low an d w e r e wi th s o m e difli c ulty wi th drawn I t s m e s e nte rv wa s

,
.
m uch cong e s te d th e in t e s t in e m uc h m or e s o
,
N o p e r fora tion or u lc e r .
ati on th roug h th e coa t s o f th e in t e s tin e Margin s o f th e fora m e n .
r oun de d an d th ick e n e d—two fin g e r s e a s ily a d m i tte d C oe cu m fr e e ly .
m ovabl e a n d fu rni sh e d wi th a m e s o c oe cu m Mr S quar e b e li e v e s th a t

-
. .
a n e arly op e ra t ion wou ld h av e b e e n s ucc e s s fu 1 — E r i t Med f ou r . . . . .
J un e 1 9 1 8 8 6 , .
C H A R L E S W CATH CA R T ( E d i n b urg ) . h .
44 4 INDE X OF S UR GI CAL P R O GR E S S .
E XT R E M IT I E S .
1 . P rim a ry T u b e r cu l o u s S yn o v it i s of th e T e n din o u s
Sh e ath s of th e W r i s t a n d H a n d MM JAR D E T an d NO TT A . . .
A far m labor e r ae t 5 9 s t r o n g an d al way s h e al th y no p h th i s ical hi s

,
.
, ,
t o ry . p e r s o n al or fa m ily d e v e lop e d a fluc t ua ting s w e lling on t h e

,
pa lm ar s ur fac e o f th e low e r ar m an d wri s t p ain ful i m p e di n g th e , ,
m o v e m e n t s o f th e fi n g e r s a n d givin g th e c h arac t e ri s t i c s e n s a t io n
, of
cr e pi t atio n o f t h e ric e grain cy s t s Th e t u m our r e m ov e d fro m th e

-
.
a rm con t ai n e d n o liqui d nor vi c e bo d i e s b u t w a s fil le d wi th loo s e fal se ,
m e m bra n e s i t s wall ve ry th ick a n d for m i ng a kin d o f cylin d e r b e c o m

, ,
i n g t h i n a t an d e x t e n d ing b e n e a th th e a n nular liga m e n t Wh e n c ut .
in t o a v e ry li t tl e liqui d s i m ilar t o s ynovial fl ui d coul d b e s qu e e z e d o ut .
I t wa s di s s e c t e d o u t an d a 5 % p h e n i li c s olu t ion inj e c t e d Th e p a .
t i e n t wa s d i s c h arg e d cur e d in t we lv e d ay s a n d was s o on abl e t o r e ,
s u m e h i s work .
T h e h i s t ologi cal e xa m ina t ion sh ow e d t h a t th e fal s e m e m bran e con
s i s t e d e n t ir e ly o f fibri n a n d th a t t h e wall co n t ain e d t ub e rcl e s co m po se d

,
o f e m b rvo m a l c e ll s a n d gian t c e ll s N o bacilli w e r e fo un d —S o c . .
A n a t O c t 1 8 8 5 L e P r og M ed F e b 6 1 8 8 6
. . . . . .
, .
P S A BR
. . AH AM ( L o n do n
) .
11 . O n th e M e T r i g g e r F i n g e r By Dr S T E I N
ch a n is m of -
. . .
TH A L ( H e i d e lb e rg) S h ad th e op p or t uni ty o f e xa m ining t h e righ t

. .
m i d d l e fing e r wh ich h a d b e e n e xar t i c ula t e d a t th e m e t a carp o p h alang e al ~
j oin t for po s t i n fl am m a t o ry a n kylo s i s ( i n t e rp h alan g e al j oin t a t a ri gh t

-
angl e ) H e fir s t c u t th r o ugh th e fl e xo r te n d on ov e r th e ankylo s i s

.
-
,
w he r e upo n m o tion b e ca m e a g ain fr e e b ut h a d t h e t rigg e r f or m Th i s

, .
a ffe c t e d b o th fl e xi on a n d e x te n s ion ; i t was m o st m ark e d in th e fir st

in te rp h ala n g e al j oin t I t s cau s e wa s fou n d i n th e ac t ion o f th e la t e ral
.
liga m e n t s th e ir in s e r tion at th e b a s e o f th e s e co n d p h alanx b e ing s o m e

wh a t d i s plac e d t owar d s th e p al m .
T h e fibr e s o f th e la t e ral b an d s b e ca m e m or e an d m or e t e n s e on
s lowly fl e xing t h e fi n g e r up t o an a n gl e o f ab ou t 4 5 wh e n on fur th e r °
fl e xi o n th e t wo in s e r t ion poin t s b e gan t o appro ach a n d th e pr e vi o u s

t e n s io n pa ss e d in t o th e tr igg e r m o tion T h e s am e t h in g o ccurr e d d ur.
4 15
in g ex t e n s i on o n ly th at h e r e th e vo lar fibr e s o f th e la te ral b an ds b e

,
c a m e t e n s e th e d or s al lax— th e O pp o s i t e occurri n g on fl e xi n g K onig .
h a d m a d e a s i m ilar ob s e rv ation on th e a m pu t a te d p h alan x o f a t o e .
O n ly in hi s ca s e an un e qual e l e va t ion on th e car tilaginou s p art o f th e

ba s al p h a la n x m a de th e la t e ral lig am e n t s in a c e r tain po s i ti on v e ry
te n s e th e n on fur th e r fl e xi o n or e x t e n s ion th e ar t icular s arfa c e s cam e
so i n t o appo s i t i on th a t th i s pro m in e n t s p o t no lo n g e r h a d t o b e ar th e
ch i e f pr e s s ur e At th a t m o m e n t wi th th e r e laxa tion o f th e liga m e n t s

.
’
th e p e culiar sn ap occurr e d In S s ca s e th e di splac e m e n t o f th e b an ds
.
cam e fro m th e pr e viou s infla m m a t ory proc e s s I t was e vi de n t fro m .
t h e pr e para t i o n th a t th e e x t e n s or t e n d on s h a d b e e n princip ally a tt ack e d .
A ft e r th e y h ad n e cro tiz e d th e a c tion o f th e ir an tagoni s t s pr e vail e d

, .
T h e s e w e r e al s o al te r e d Bo th fl e xor t e n d on s w e r e a dh e r e n t t o e ach
.
o th e r an d th e ir s h e a th s th e la tt e r b e i n g s o m e w h a t th ick e n e d an d prox
,
i m ally co n tr a c t e d But fl e xor t e n d on s an d th e ir sh e a th s are conn e c t e d

.
wi th th e j oin t cap s ul e an d i t s l a te r al l i ga m e n t s—th e s ubli m i s te n don

b e ing co n n e c t e d in dir e c tly by s ligh t stran ds o f conn e c tiv e t i s s u e ru n
n ing t o th e b o tt o m o f i t s canal —a n d th e volar acc e s s ory b an d i s a t ran s
v e r s e ra dia tion O f th e la t eral liga m e n t s Con trac tion Of th e se p ar ts .
m u s t h av e cau se d t h e m e n tion e d d i s plac e m e n t H e b e li e v e s th a t in .
m an y c a se s a s h e r e wh e r e e x t e rn al ly no al te ra tion o f t e n d on or j o i n t
,
app ara t u s can b e fe lt th e p e culi ar m o t or di st urb anc e m ay de p e n d on

,
a lik e cau se —Cen tOl f Cfi i rg 1 8 8 6 N o 2 9

. . . . . . .
Two ca é th e fir s t r e p or t e d in A m e ri c a—are d e
s e s o f t ri gg e r fi n g e r—
( -
s c r ib e d by Dr G W J acoby . . . I n th e o n e clo s e ly e xa m in e d th e r e wa s
.
no n o do s i ty or o th e r p alpabl e m e ch anic al cau s e N Y N e urolo g . . . .
S o cy r e p t d in f r u l of N er o a n d M en t D i s
. . . . 1 88 6 J uly
. . . .
I . R e t r o p e r i t o n e a l, an d R e t r o -a n d at t h e S am e T i m e In
t r ap e ri t o n e al I n c i s i o n as a M e t h o d fo r E
p o s i ng T u m o rs x
of th e K i d n e y E s p e c i a lly o f I n fl a m m a t o r y O r i g i n
, By Pro f . .
K ON I G ( Go t t i n g e n) Wi th th e old lu m b ar inci s ion th e r e i s gr e a t d i ffi

.
cul ty in g e tting fr e e a cc e s s t o th e ki dn e y K o ffe r s a p ar t ially n e w . .
m e th o d b a s e d on s t u d i e s on th e ca d av e r a s w e ll a s op e ra tion s on th e
living .
He cu t s th rough th e s o ft par ts s traigh t down fro m th e la s t rib al o ng ,
t h e b or d e r o f th e e r e c t or s pin ae m u s cl e s t o wi thin a fe w c e n t i m e t e r s o f
th e o s iliu m H e th e n curv e s aroun d an te riorly in th e d ir e c tio n o f th e

.
nav e l an d e n d s at ab ou t th e e x t e r n al b o r d e r o f th e r e c t u s ab d o m ini s
if n e c e s s ary e v e n th r o ug h th i s m u s cl e to th e u m bilicu s I t m ay o fte n .
b e a d vi s abl e t o m ak e th e c u t n o t p e rp e n dicular b u t obliqu e in a fl at ,
curv e ru nning in t o th e u m bi lical p ar t All th e m u s cl e s i n th e.
cour s e o f th e s ai d c ut are inci se d qui te do wn to th e p e ri ton e um w h e r e

th i s i s b e n e a th in th e h orizon t al p ar t th e fir st i s th e la ti s s i m u s th e n ,
th e O bliqu e an d t ran s v e r s e ab d o m inal m u s cl e s T h e s e para t e m u s cl e .
e n d s m ay b e se c ur e d by corr e s pon d i n gly kno tty th r e a d s i f d e s ir e d .
T hi s giv e s a s urp ri singly fr e e e n t ranc e b u t i t can b e co n si d e r ably ,
i m prov e d by intr o d ucing th e h an d th rough th e p e rp e n d icular p ar t of

th e c ut s e p ara tin g t h e p e ri t on e u m in fron t a n d pu s h ing i t forwar d s
, .
H e propo s e s t o call th i s th e r e t rop e ri t on e al lu m b o ab d o m i n al inci -
s ion .
I f s u ffici e n t s p a c e i s n o t th u s a ffo r d e d or i f for diagno s t ic or op e ra

,
t iv e pu rp o s e s i t i s de sirabl e t o ap p roac h th e t u m or fro m th e ab d o m in al
c a vi ty th e p e ri t on e al fol d can b e d ivi d e d in th e t ran sv e r se c ut I f

‘
.
,
in fe ct iou s m a te ri al i s t o b e r e m ov e d t hi s p e r i t on e al O p e ning m u s t b e
car e fully lo ok e d aft e r—s e w e d up i f po s s ibl e .
Thi s h e call s r e tro in trap e ri ton e al lum b o ab d o m inal inci s ion

-
'
- .
Two r e ce n t ca s e s illu s tr at e h i s m e th o d s O ld py e l o n e p hr o s i s
.
,
colo s s al calculu s o f p e lvi s of ki dn e y R e m ov al o f s t on e only po ssibl e

.
by th e ad di tional p e ri ton e al O p e ni n g Ve s ical c at arrh

. S tinking .
p ye li ti s Al s o Op e r ate d a ccor ding t o th e s e con d m e th o d Cur e i n

. .
b o th ca se s e xc e p t sm all r e m aining fi stulae

, .
H e warn s finally again s t t h e d ang e r o f ab do m inal h e rni a w h e r e th e

, ,
a ft e r tr e a t m e n t i s t o o gr e a t ly h a s t e n e d I allow th e th r e ad s e s p e cially
“
.
,
t h e d e e p r e t aining s u t ur e —i f th e y d o n o t ge t v e ry loo s e an d th i s r ar e ly
h app e n s un de r a se p t ic con d i t ion s— t o r e m ain th r e e w e e k s an d k e e p ,
t h e pa t i e n t in b e d four w e e k s F or a t i m e a ft e r th i s only g e n tl e m o
.
ti on s uch as can n ot a t all s t rain t h e ab d o m inal wall s i s p e rm i t te d an d

, ,
a b e lly b an d i s wo rn
-
In th i s way ab d o m inal h e rni ae do n ot r e s ul t
. .
Cen t é l .
f . C/zi rg . 1 886 . No 3 5
. .
W O UN D S , I N j UR I E S , A C CI D E N TS .
4 47
W OU NDS .
I
. D e m o n s t r a t i o n o f a H e a le d S h o t W o u n d o f t h e S p i n e .
By Pro f CZE R NY ( H e i d e lb e rg) T he un for t una te inj ury o f Pr e si d e n t

. .
G arfi e l d gav e occa s ion a co upl e o f y e a r s sinc e t o a d e ba te on sh o t

woun d s o f th e v e r te brae E sm arch s i nv e s tigat ion s s h ow e d th a t t h e
.
’
nu m b e r of ca s e s which in a s urgical s e n s e a t l e a s t coul d b e con s i de r e d

, , ,
cur e d was v e ry s m all I th e r e for e t ak e occa s ion t o pr e s e n t a ca s e

.
wh ich can b e call e d a h e al e d sh o t woun d o f th e cor d a s w e ll a s ve r

t e bra .
A youn g wo m an ae t 2 2 whil e at h e r t oil e t wa s s h o t in t h e b ack by

, .
, ,
h e r j e alou s h us b an d May 6 1 8 7 3
, T h e ball e n t e r e d o n e h al f inch t o
, .
th e l e ft o f th e la s t d or s al s pinou s proc e s s Sh e s ank wi th a cry . Th e .
m an s h o t h i m s e l f d e a d I was call e d s o on an d foun d par apl e gia b o th

.
,
l e g s p aralyz e d to th e p e lvi s an d s e n s ory p araly s i s on th e righ t t o t h e

,
i nguinal fol d on th e l e ft o f th e kn e e
, R e fl e x irri t abili t y wa s e n tir e ly
.
pr e s e rv e d an d all th e p aralyz e d m u s cl e s r e ac te d pro m p tly t o w e ak

,
fara d ic curr e n t s . N o t wi t ch ing or con tract ur e in th e s ai d m u s cl e s .
Bl add e r an d r e c t u m w e r e co m pl e te ly p aralyz e d Ca th e te riz ation fo r .
th r e e d ay s wh e n t h e bla d d e r e m p ti e d involun t arily on g e tting full .
Pul s e an d t e m p e ra t ur e nor m al m in d al way s cl e ar ,

T h e cour s e o f th e .
b all and th e co m pl e te i m m e dia te parapl e gia p oin te d to th e conclu sion

th a t th e cor d m u s t h av e b e e n p e r for ate d by th e b all Pr e s u m ably th e .
bull e t h ad lo d g e d in a v e r te bra as no s y m p t o m o f inj ury to t h e ab d o m

i n al organ s was no tic e abl e I th e re for e d id n o t con s i d e r m y s e l f j u s ti
.
fi e d in s o un ding wa sh e d th e woun d s up e rficially wi th c a rbolic cov e r e d

, ,
i t wi th carboliz e d co tt on a n d t h u s th e woun d h e al e d in a fe w d ay s
,
.
T h e p a ti e n t coul d s o on s i t propp e d up in b e d an d wa s plac e d in a r e ,
c lin in g ch air a ft e r fo ur te e n d ay s F ro m th e b e ginning of J un e s h e

.
ro de a bou t s e v e ral h our s d a ily in a roll e r ch air an d con tinu e d t hi s ,
w e ath e r p e r m i tting un til l ate in th e fall : m e an wh il e h e r app e ti te c o n

,
t in u e d e xc e ll e n t g e n e ral con di tion goo d a n d h e r app e aranc e n o t ably

,
fr e sh an d brigh t . In th e e arly w e e k s th e paralyz e d m u s cl e s w e r e fara

diz e d d aily ye t con trac tili ty gra d u a lly d i sapp e ar e d
, Th i s s o e xci te d .
th e pa ti e n t t h a t fur th e r fara d iz at ion h ad t o b e d i s p e n s e d wi th T h e l e g s .

,
which s o far h ad r e m ain e d lax b e c am e sti ff an d infl e xibl e at th e e n d o f

,
448 LND E X OF S UR GI CAL P R O GR E S S .
s u m m e r an d b e gan t o a trop hy wi th r e m arkabl e r api di ty In N o v em

,
.
b e r d e cubi t u s d e v e l op e d s t ar t i n g fro m u ri n e e xcoria t ion a n d s pr e ad

, ,
rapi dly ov e r th e s acru m F ro m th i s on th e r e wa s fe v e r an d th e fatal

.
,
en d ( De c 4 1 8 7 3 a s h a s t e n e n e d by an e ry sip e la s s pr e a d in g fr o m
) w .
,
th e woun d ov e r th e wh ol e b a ck an d th igh .
T h e b a ll wa s foun d h e al e d in b e tw e e n th e la s t d or sal an d fir s t lum
b ar v e r t e br ae t o th e ri gh t O f th e m i ddl e lin e
, Th e s pin al cor d wa s al .
m o s t co m pl e t e ly s e v e r e d th a t b e low b e ing s o m e wh a t th ick e n e d whi l s t

, ,
upwar d s to th e s e c on d d o r s al v e r te bra i t wa s in a s t at e of s uppura t iv e

s o ft e ni n g Th e d ura m a t e r pr e se n t e d a s car a t fron t an d b ack wh e r e
.
,
i t was al s o a dh e r e n t t o th e bon e Pul m ona ry a t e l e c t a s i s o f m o de r at e d e

.
g r e e s o m e wh a t fa tt y liv e r chronic cy s t i t i s
, ,
.
T h e obj e c ti on m ay b e m a d e th a t a s upp ur ati ve ly s o ft e n e d cor d i s n o t
a h e al e d cor d We kn ow h ow d i fficul t i t i s t o di s t in gui sh y e llow s o ft

.
e n i n g O f th e brain fr o m a fr e sh ab s c e s s ye t t o m e th e pr e p arati on ,
m a k e s m or e th e i m pr e s s ion o f an acu t e a s c e n di n g m y e li ti s th an o f an
ab s c e di z in g Th e n i t m u s t b e no t e d th a t th e pa ti e n t ro d e ab o u t s e v
.
e r a l m on th s in s ubj e c t iv e ly goo d con di t ion an d th at th e b ulle t was ,
co m pl e t e ly e nc ap s ula te d .
S inc e b e for e th e t i m e o f an ti se p tic s a s e v e r e s h o t woun d o f th e spin e

h as h e al e d th rough th e avoi d an c e o f probi n g an d by car e ful wa sh in g
o u t a s i m ilar r e s ul t ou gh t now wi th lik e car e t o b e all th e e a s i e r
,
a ch i e vabl e —R e por t o f XV Co n gr e s s o f Ge r m an S ur g e o n s in C en tOl .
f C/zi rg
. 1 88 6 .N o 24 . . .
W . BR O WNI NG ( B ro o k ly n ) .
TU M OU R S .
I M y x o S ar c o m at o u s T u m o u r o f A b d o m e n W e i g h t 8
.
-
,
K i lo 1 2 0 ( lb s 1 8 ) G r o w t h i n 3 2 D a y s
. . By M CH AS SA GN E L D . . .
,
aet 2 4
. S e rg e an t in an in fan try r e gi m e n t pr e viou sly in goo d h e a lth
.
, ,
co m plai n e d o f a vagu e p ain in th e h ypoga s tric r e gi on wor s t b e h in d on , ,
M ay 2 9 1 8 8 4 T h e r e was n o sw e lli n g an d i t was th ough t t o b e o f n o

, .
,
con s e qu en c e T wo d ay s aft e rwar d s h e was a dm i tte d t o h o spi t al wi th

.
,
ab d om e n h ar d an d s om e w h a t d i s t e n d e d an d co m p lain in g o f a s t e ady , ,
fix e d p ain a s b e for e H i s bla dde r was s oun de d wi th ou t r e s ult Ab

, . .
T U M OR S .
44 9
dom en grad ually incr e a s e d in s iz e an d p ain con t inu e d an d at th e e n d

, ,
o f e l e v e n d ay s h e wa s s e n t t o ano th e r h o s pi t al b e ing now s e riou s ly ill ,

.
D iag no s i s a s c i te s H i s fac e was p al e a n d pinch e d T e m p at 5 p

, . . . .
M 1 0 3 F Tongu e dry an d furr e d Ab do m e n was h ar d an d vol um i

.
°
. .
nou s wi th a sh ap e r e s e m bling that of pr e gn ancy ra th e r th an t h a t o f

,
a s ci te s N o irr e gul ari ti e s t o b e fe l t on p alp ation ; s ign s o f a s ci te s

.
n e ga t ive By J un e 1 9 t h e r e was gr e a t oe de m a o f l e g s an d ab d o m in al
.
w all wi th d i s te n tio n o f s up e rfici al v e in s Pain con tinuing on J un e

, .
,
2
3 a ft e r s o m e h e s i ta t ion on accou n t o f th e u n iv e r s al d uln e ss th e ab
, ,
d o m e n was t app e d b e lo w th e u m bilicu s b ut only t h ick bloo dy fl ui d , ,
wa s d ra wn o ff rapi d ly clo tt ing , I c e appli e d t o th e ab do m e n r e li e v e d

.
t h e p ain an d r e d u c e d t h e t e m p e ra t ur e In t wo d ay s h e wa s again .
t app e d wi th a s i m ilar r e s ul t
, O n t h e e v e ning o f J un e 3 0 h e h a d t e
.
g urgi t an t vo m i t ing o f e v e n liqui d foo d an d on th e m orning o f J uly 1 ,
h e d i e d th ir ty two cl e ar d ays a fte r h i s fir s t co m plain t on May 2 9

,
-
, .
At th e p o s t m or te m e xa m ina tion an e nor m o us s oli d m as s was fo un d

-
o ccupying th e abd o m inal c avi ty an d h i d ing all t h e vi s c e ra e xc e p t a

p ar t o f th e t ran s ve r s e colon which wa s p u sh e d fo r war d ; th e a s c e nding
,
an d d e s c e n d ing colon s w e r e e m b e d d e d in th e t u m our t h e s t o m ac h ,
wa s co m pr e s s e d a n d p u sh e d up an d th e s m all in te s tin e s w e r e forc e d

,
up i n t o th e l e ft hyp o ch on driu m T h e s pl e e n ki d n e y s a n d li ve r we r e
.
,
co m pr e s s e d b ut app are n t ly nor m al M e s e n t e ric v e ss e l s ab do m inal

,
.
,
a or t a an d in fe rior v e n a c a va d i m ini sh e d in s iz e T h e t u m o ur c o n .
s i s t e d o f a p al e ou te r m yo m at ou s j e ll y lik e par t an d a c e n tr al p or
, , ,
t ion d ark r e d i n colour an d fibro u s i n t e x t ur e wi th a j e lly lik e fl ui d i n

, ,
i t s in t e r sti c e s T h e au th or s t a te s t h a t th e r api d i ty o f grow th o f t h i s

.
t um o ur i s uni qu e N o s i m ilar c a s e th a t h e can fi n d r e cor d e d t o o k

.
l e s s th a n on e y e ar t o grow an d s o m e t ook a s long a s s e v e n y e ar s

, .
T h e p o s t m or t e m e x am ina t ion sh e w e d th at an y att e m p t t o r e m ov e th e

-
t u m o ur woul d h av e b e e n h op e l e s s e v e n h a d an e xplora t ory inci s ion ,
r e v e ale d i t s tru e na t ur e — Go a Med de P a r i s May 8 an d 1 5 1 8 8 6

. . .
, , .
C . W . C ATH CA R T ( E di nb urg h ) .
BONE S , JOINT S , O R T H O P IE D I C .
I . x c i s i o n o f t h e H i p o f a G i r l S u ffe r i n g fr o m P u lm o
E
n a r y T u b e r c u lo s i s C o n s i d e r a b le A m e li o r a t i o n o f t h e S t a t e
o f t h e Lu n g s By H B R E S S O N Th e followi n g c ase b e ar s on th e
. . .
qu e s tion s ti ll i n di s pu t e o f s urgic al in te rv e n tion in tub e rculou s s ub

, ,
je c ts E G aet 9 y e ar s c am e un de r tr e atm e n t M ay 1 6 1 8 8 5 for

. . .
, .
, , ,
h ip d i s e a s e on th e l e ft s i d e N o pr e c e d e n t t ub e rculou s h i s t o ry e i th e r
.
,
p e r s o n al or fam ily Th e b e g in n in g o f th e d i se a s e was ob s cur e : for

.
t wo m on th s th e r e wa s p ain an d la m e n e ss an d th e ch il d wa s k e p t in b e d for ,
four m on th s S h e th e n w e n t ab ou t for s ix m on th s un t il th e pain a n d

.
,
la m e n e s s r e t ur n e d T h e li m b n o w sh or t e n e d a n d ro t a t e d inwar d s
.
,
a n d s oon in t e n s e p ain a t th e k n e e forc e d th e c h il d t o go b ack t o b e d .
T h e cau t e ry wa s u se d wi t h ou t r e s ul t an d th e co n di tion b e cam e wor se , .
Sh e was th e n k e p t in i m m ovab le appara t u s for th r e e an d a h alf

m on th s a n d wa s a ft e r war d s fr e e for s i x m on th s h e r con d i ti o n h avin g
, ,
i m p r ov e d At thi s ti m e she alre a dy cough e d a gr e a t d e al ; was pal e

.
,
th i n wi th ou t app et i t e an d wi th p e r s i s t e n t d iarrh oe a no albu m e n in th e

, , ,
u ri n e c on s oli da ti on a t t h e apic e s o f t h e lu n g s
, m oi s t r al e s e t c The , ,
.
followi n g m on th an ab s c e ss app e ar e d a t th e upp e r an d ou t e r p ar t o f
th e thi gh At th e co m m e n c e m e n t o f J u ly a ggrava t ion O f th e sym p

.
,
t c m s s u d d e n ly t o ok p lac e wi th s ub acu te infla m m a tion o f th e j oin t

,
-
,
a n d s t r o n g fe v e r was ob s e rv e d on t h e z r s t T h e purul e n t coll e c tion .
wa s op e n e d u n d e r s t ric t an ti s e p ti c pr e cau tio n s T h rough ou t th e .
m on th o f Augu st t h e t e m p e ra t ur e o s cil la t e d b e tw e e n 3 8
°
an d
A lth ou gh th e t ub e rculou s con d i tion o f th e lu n g s ca u s e d a long h e s i t a

t ion, a t th e urg e n t r e qu e st o f th e fa m ily an d i n co n s e qu e nc e o f th e ,
d aily a ggravat i o n o f th e ch il d s co n d i tion fro m th e copiou s s uppura ’
t i o n Dr
, Cazin d e t e rm in e d t o e xci se th e h i p w h ich wa s d on e on Au
.
,
g u s t 3 0 Th e t e m p e ra tur e fe ll fro m
. a n d o s cill a t e d b e t w e e n
37
°
for a for t nig h t w h e n i t r e t urn e d t o th e norm al Th e woun d

°
an d 3 8 , .
,
wh ich wa s s crap e d at th e b o tt om by Volkm ann s spoon uni t e d by fir s t

’
,
i n t e n tion an d pr e s e n t e d no th ing un towar d S ix w e e k s a fte rwar d a

, .
s ili ca t e d appara t u s wa s a ppli e d a n d th e c h il d b e gan t o walk wi th

‘
cru tc h e s S i nc e two m o n th s sh e h a s qui t te d th e infi rm ary h e r c o n di

.
,
t i o n b e c om ing b e tt e r e v e ry d ay app e t i t e r e t u rn e d s w e a t s a n d di ar
, ,
G i N / E C OL O GLC A L . 45 I
r h e a di s app e ar e d pu tti ng on fl e sh an d t h e s te t h o s copi c s ign s c on si d

,
e r ab ly i m prov e d O n M arch 1 th e r e wa s s carc e ly any appr e ciab le

.
d uln e s s a t th e rig h t ap e x an d only a t t h e s ub s pino u s fo s s a o f th e s a m e

, ,
-
s i d e c an a li ttl e cr e pi t a t i on b e h e ar d on co ug h ing Th e ch il d w e ar s no .
local app ara t u s can walk wi th ou t cru tch e s an d th e li m b i s only sh or t

, ,
e ne d c e n ti m e t r e s .
H e r con di tion a t t h e t i m e o f o p e ra ti on w a s al m o s t h op e l e s s ; s i x
m on th s aft e r h e r g e n e ral h e al th was as s a t i s fac t ory a s po ss ibl e The .
r e s ul t no d oub t d e p e n de d larg e ly on th e s trict an ti s e p tic pr e cau tion s ;

, ,
a n d in fr e e ing th e pa ti e n t fro m th e con s t an t lo s s by s uppura t ion her ,
s y st e m wa s p u t in a b e tt e r p o s i tion t o r e s i s t th e pul m onary l e s ion .
Le P r og fi l ed . Aug 1 4 1 8 8 6
. .
, .
P S A BR
. . AH A M ( L on don ) .
I. O n t h e U s e o f S u b l i m a t e i n O b s t e t r i c a l I rr i g a t i o n s .
By Pro f G B R A U N ( Vi e nna) I n Braun s clinic fro m O c t ob e r 1 8 8 4

. . .
’
, ,
t o Nov e m b e r 1 88
5 , s ubli m a t e inj e
, c t ion s o f 1 to s t r e ng th w e r e
m a d e in 4 7 5 o u t o f b ir th s wi th n in e d e a th s T h e 4 7 5 ca s e s
, .
r e pr e se n te d op e ra tiv e d e liv e ri e s s tr e e t bir th s m ac e ra t e d foe t u s e s an d

, ,
p u e rp e ral e n d o m e t ri ti s F o r u t e rin e irri ga t ion i t was cu s t o m ary t o u se

.
li tre an d to i m m e dia t e ly follow b y i rrig at io n wi th a lik e a m o un t o f

wa te r .
H i s principal con clu s ion s ar e : ( 1 ) A ft e r pu e rp e ral irriga tio n v agi ,
n al or i n t ra u t e rin e wi t h s ubli m a t e s olu t ion

-
,
ab s orp tion fro m th e v a ,
gina occur s v e ry e a s ily ( 2 ) Proo f o f m e rc ury in th e fae c e s can b e

.
fu rn i sh e d v e ry e arly ( 3 ) Any i m p e d i m e n t t o th e di s ch arg e o f th e

.
wa sh fl uid fro m th e vagina m ay th u s giv e ri s e t o i t s ra p i d ab s orp t ion

- .
( 4) A conc e n tr a tion o f 1 t o in th e a m ou n t o f 1 t o li tr e
sh oul d only b e u s e d i n s e v e r e ca s e s —t y m p a ni t e s u t e ri p u tri d foe t us in ,
u te ro se p tic p u e rp e ral fe v e r—an d t h e n only for on e m inu t e Thi s

, .
s h oul d b e follow e d b y irri g at io n wi th an e qual or gr e at e r a m oun t o f
d i st ill e d wa te r ( 5) A. s tr e ng t h o f 1 t o m a y b e u s e d a ft e r t h e
bir th o f a pu tri d foet u s in e n d o m e tri ti s s u b p art u a ft e r in s tru m e n t a l

, ,
d e liv e ry w h e r e th e v agin al d i s ch arg e i s s ti nking e t c

, A ft e r irriga ti on s , .
-
wi th wate r sh oul d n ot b e forgo t t e n ( 6) Th e irriga tion sh oul d b e

.
m a d e by th e ph ys ician in p e r s on only a lo w pr e s s ur e sh o ul d b e u se d ,
a n d th e proc e d ur e co m pl e t e d as rapi d ly a s p o s s ibl e .
( )
7 S ubli m a t e irriga t ion s oug h t n o t t o b e fr e q ue n tly r e p e a te d a n d ,
n o t t o b e u s e d a t all w h e r e th e r e i s a lar g e vulvar w o u n d s ur fa c e ,
wh e r e t h e pa ti e n t h a s b e e n un de r m e rcurial t re a tm e n t i s t roubl e d wi th ,
ki d n e y d i s e a s e or i s an ae m ic fro m pr e viou s m e tr o rrh agi a Wi en M ed . . .
Woclz . 1 886 . No s . 21 to 24 .
W . BR O WNING ( Broo k lyn ) .
11 C l i n i c al R e m ar k s o n a F o u r th S e r i e s o f T w e n t y F i v e
.
-
O v a r i ot o m i e s By F T E R R I E R ( Pari s)
. T h i s c ar e ful analy s i s e u
. .
t e r s i n t o a d i s cu ss ion o f th e c h i e f poin t s o f in t e r e s t in t h e s e ca s e s An .
e labora t e t abl e i s d r a wn up a n d th e d e t ail s o f th e m o r e i m por t an t
c a s e s ar e al s o giv e n in full T h e s ubj e c t m a tte r i s con s i d e r e d un d e r

.
variou s h e a ding s th u s ,
1. Ag e o f th e pa ti e n ts —1 7 o f th e 2 5 we r e ov e r 4 1 i e 1 ov e r 6 0 ,
. .
,
( 6 4 d i e d o f canc er an d p e ri ton e u m ) 7 b e twe e n 5 0 a n d 6 0 9 b e twe e n ,
4 0 a n d 5 0 5 b e t we e n 3 0 an d 4 0 2 b e t we e n 2 0 a n d 3 0 I un de r 2 0
, , , ,
i e ae t 1 5
. .
, . .
I n th e 1 0 0 ca s e s th e r e w e re 3 6 b e tw e e n 4 0 a nd 6 0 2 1 b e twe e n 3 0 ,
an d 4 0 a n d 2 0 b e t we e n 1 4 a n d
, 30 .
2 . M en s er o f th e 2 5 p a ti e n ts 1 1 c e a s e d t o m e n s tr ua t e a t t h e t i m e o f
op e ra tion 3 h ad c e a se d a fe w m on th s b e for e 7 we r e r e g ular 2 irr e g ular
, , ,
a n d 6 s u ffe r e d fr o m m e tr o rr h agia 8 h a d r e ac h e d t h e m e n o p au se a t ,
p e rio d s varying fro m s ix m on th s to t h ir te e n y e ar s b e fo re t h e op e ra tio n

'
( ut of th e full 1 0 0 ca s e s 2 8 h ad r e ach e d or p a s s e d th e m e nopau s e )

o .
A t te n tion i s dra wn t o th e fac t th a t o f th e s e v e n ca s e s o f r e g ular m e n

s tr uati on 3 h a d d i s e as e o f bo th ovari e s in t h e for m o f cy s t ic d e g e n e r ,
a tio n p apill o m ato u s gro wth s or ja d e r m oi d cy s t

, ,
.
F e r t i li ty —I h th e 2 5 ca s e s 3 we r e virgin s 4 h a d b o rn e n o c h il
3 .
,
d r e n 4 h a d b orn e o n e c h il d 5 t wo c h il d re n 4 t h r e e c h il d r e n 2 fo ur
, , , ,
c h il dr e n 1 fi ve c hil d re n 1 e l e ve n c hil dre n i e 1 8 o ut o f t h e 2 5 h ad

, , , . .
,
b o rn e ch il dre n We are a sk e d t o r e m e m b e r t h a t t h e m o s t fe r t i l e t i m e
.
o f li fe i s b e lo w 3 0 w h il e in m os t ca s e s th e ,
O p e ra t i o n wa s p e r fo r m e d
a fte r I n th e 1 0 0 ca s e s 1 1 we re virgin s 6 3 h ad b o r n e ch il d r e n 2 6 , ,
h ad n o t — m aking o f t h ose o p e ra t e d o n h a vi n g h a d c h il d r e n T he r e .
G YN AE C OL O GLCA L . 45 3
h ad b e e n e igh t m i s carri ag e s i n th e la st se ri e s o f c ase s in Ith re e h o w ,
e v e r th e grow th o f th e ovari an cy s t d i d n o t s e e m
, t o h av e b e e n t h e
d e t e r m ining cau s e .
4 . D u r a t i o n f
o tlze T u m o r — I n 8 p a t i e n t s t.h e grow th o f th e t u m or
h a d b e e n no t e d fo r e igh t m on th s i n 9 p a ti e n ts for e igh t e e n m on th s in
, ,
3 for th r e e y e ar s in 1 for fo ur y e ar s in 2 fo r s i x y e ar s in r for s e v e n

, , ,
y e ar s in on e for fi ft e e n y e ar s
, .
M r b i d P h en om en a —I h t h er h d b n w lling only in
5 . o
5 e a e e s e 1 2 ,
s h arp p ain in 3 e xc e s s iv e s w e lling

, Vom i ti ng h a d b e e n pr e s e n t in 5
.
o f th e ca se s o n e o f th e s e b e ing a canc e rou s infil tra t ion o f th e p e ri t o

,
n eum A s ci ter wa s ob s e rv e d in 8 o f th e ca se s
. I t wa s g e n e rally .
s ligh t a n d in 3 e sp e cially s o
, In 2 o f th e 8 a s ci tic ca s e s th e r e w e r e
.
papillo m a t o u s grow th s o f bo th ovari e s T h e s e th e au th or e xplain s by .
s upp o s ing th a t th e a s ci tic flui d i s s e cr e t e d fro m th e s ur fac e o f th e t u
m our a s if i t w e r e a co m poun d cy s t wi t h i t s s e cr e t ing s ur fac e t urn e d o u t

,
war d s In an o th e r th e flui d wa s vi s cou s an d was appar e n tly th e s e

.
cr e tion o f s e v e ral s m all cy st s w hich h a d b ur s t an d di s ch arg e d th e ir

con te n ts in t o th e p e ri ton e al cavi ty fi dem a of th e l e g s wa s pr e s e n t i n.
8 o f th e c a s e s 3 h a ving in a ddi t ion p h l e g m a s ia d ol e n s an d 2 oe d e m a

, ,
a n d ly m p h a tic oe d e m a o f t h e ab d o m inal wall .
6 P u lm on a ry Tr ou ble —
. T h e r e h ad b e e n 1 ca s e o f bronch i ti s 1 of
.
,
ob s t ruc tion t o t he r e s pira t ion fro m th e e nlarg e d ab d o m e n 1 o f d o ubl e ,
pl e uri s y b e for e a n d a ft e r th e op e ra tion 1 o f pl e uri s y a fte r i t , .
7 . B la dd e r a n d U r i n e — Incr e a s e d fr e qu e ncy of m i c t uri t i on in 8 o f

th e ca s e s p ain ful m ic t uri t ion in 2
, quan ti ty o f urin e g e n e rally n or m al ;
i n no ca s e s u g ar ; in 2 o f t h e 5 fa t al ca se s a s lig ht q uan t i t y o f
alb u m e n .
8 Op er a t i ve M et/zodS —E xplora tory or e vac ua t o ry p u n ct u r e in 1 7 o f

. .
th e 2 5 c ase s Liga t ur e a n d r e d uc tion o f t h e p e d icl e w h e r e p o s si b l e

.
,
a n d Li s t e r s an ti s e p ti c m e th o d s
’
In 2 2 o f th e 2 5 ca s e s th e p e dicl e was
.
r e t urn e d All o f t h e s e w e r e ti e d wi th c arboliz e d s ilk lig at ur e s d r e s s e d

.
,
in T h ort on s way 2 3 an d 4 o f th e m b e ing u s e d accor ding t o th e s iz e

.
’
, ,
o f t h e p e dicl e Thr e e ca s e s w e r e inco m pl e t e o n e b e ing fa t al in t he

.
,
o th er two a lig at ur e was appli e d t o t h e b a se o f th e p e dicl e t o cau s e

at rop h y wi th an appar e n t ly g o o d r e s ul t T h e ti m e occupi e d by t h e
, .
O p e rati on fro m s ix t e e n m inu te s t o on e an d a h al f h our s In th e s uc .
c e ss i v e fou r s e ri e s o f ca se s th e a v e r a g e t i m e b e c am e s h or te r a s th e O p
e rat or g ain e d e xp e ri e nc e i e in fir st s e ri e s
, . . h our s s e co n d s e ri e s
, , ,
1 h our ; th ir d s e ri e s 5 0 m inu te s ; fourth s e ri e s 4 7 m in u t e s

, ,
.
T h e w e ig /zt o f th e t u m or s re m ov e d vari e d fro m 1 8 kilogr am s t o
grm s .
F iv e fat al ca se s
p e ci ally d e tail e d T h e c a u se of d e ath in e ach
a re s .
was attribu t e d a s follow s : In o n e th e r e wa s s uppur at iv e p e ri toni ti s ,
ass ocia t e d wi th ch ol e raic sym p t o m s S e v e r al ca s e s o f e pi de m i c

.
Ch ol e ra h a d b e e n ob s e rv e d in Pari s at th e ti m e o f th e Op e ra tion an d ,
s o m e of th e s e h a d b e e n tr e a t e d a t th e s a m e h o s p i t al a s th i s pa t i e n t ,
i e l H Op i tal Bi ch a t
. .
’
, In a n o th e r ca se th e r e was a cu t e non s uppu
.
-
r atin g p e ri t oni ti s T h i s p a t i e n t s h e al th was in a d e pr e ss e d con di tion

.
’
at th e t i m e o f th e O p e r a tion a n d th e s pl e e n , liv e r an d ki dn e ys w e re ,
s h o wn at th e po s t m or t e m e xa m ina tion t o h av e b e e n d i se as e d
- In a .
th ir d c a s e m al i gn an t a ffe c t ion o f th e p e ri t on e u m was th e cau se o f
d e a th Th i s was o n e o f th e i n co m pl e te ca s e s In a four th fr e qu e n t
. . ,
and e xc e ss iv e h ae m a te m e s i s Th i s sym p to m h as b e e n ob s e rv e d s e v
.
e r al t i m e s an d i s n o t e a s ily e xplain e d po s sibly by co n g e s tion o f th e

,
g astri c m ucou s m e m bran e or p e rh ap s by e pi th e lial n e w grow th s fr om

,
th e w all o f th e s t o m a c h—pr e viou sly un s u s p e c t e d I n th e la s t c a s e .
d e a th wa s c a u se d by th e gr e a t h aem orrh ag e w h ich r e s ul te d fr o m th e d i

vi s ion o f th e nu m e rou s a dh e s ion s .
9 . A f te r E f ec ts — Cica t ri x vari e d fro m 6 t o 2

.
5 c m in t o . .
b e cam e k e loi d in 2 wa s m uch p i gm e n te d i n 2 an d b e ca m e v e ry re d an d

, ,
v a scu lar in 2 T h e r e wa s a t e n de n cy of th e cic atrix to b ulg e in 1 1

.
,
b e i n g s li gh t in 5 an d v e ry co n si de r ab le in 1 A fi s tula r e m ain e d in
,
»
th e 2 inco m pl e t e c as e s wh ich s urviv e d .
In 8 o f th e ca s e s m e n s trua tion r e turn e d ; in 4 it d i d n o t O f th e 3 .
ca s e s o f s e c o n d o vario t o m y 2 h ad n o r e t u rn o f m e n s trua tio n wh il e in ,
1 ca s e th e r e t urn wa s d i s tinc t O nly on e p a t i e n t b e ca m e pr e gn an t

.
a ft e r th e op e ra tio n an d i n th i s c a s e th e c h il d di e d at bir t h
, M any o f .
th e w om e n gr e w s t ou t e r a fte r th e O p e r ation Thi s th e au th or c on si d.
e r s t o b e d u e t o r e m o v a l o f d i s e a s e ra th e r th a n t o an y s p e cial e ffe c t o f
t h e lo ss o f ovar i e s .
Tlze con c lus i on s d rawn a re

G R i v/ E C OL O GI CAL .
45 5
( 1 ) T h at o vario t o m y i s r e quir e d a ft e r th e age o f 4 0 as w e ll a s b e for e

i t ; 7 7 % o f th e ca s e s w e r e ov e r 3 0 an d m any b e yon d th e m e no p au s e - .
( 2 ) Th e pr e s e nc e o f ov arian cy s ts e v e n on bo th s i d e s h as b ut
, ,
s lig h t influ e nc e on m e n s trua t ion e xc e p t in so far as th e e ffe c t on th e
g e n e r al h e al th in dir e c tly a ffe c t s th e app e aranc e o f th e m e n s e s T h e .
r e l ation o f ovarian tu m our t o fe cun di ty i s d oub tful .
( 3) T h e grow th s a n d a cci d e n t s o f ovari an t u m our s vary in prop or tion

t o th e rapi d i ty o f grow th .
( 4) A s ci t e s r e s ul t s n ot m e r e ly fro m s oli d tu m our s or p o lyp lik e ,

-
v e g e ta tion s of th e ovari e s b ut al s o fro m canc e r o f th e p e ri t on e u m an d

, ,
fro m a d e g e n e ra t ion o f th e wall o f c e r t ain cy s tic grow th s wh ic h cau se s

irri tation o f th e p eri t on e u m .
( 5 ) A ffe c tion s of th e p le ura b e for e a n d a fte r th e op e ra tion are n o t

e xc e p t io n al a n d d i fficul t t o e xplain .
( 6) Mict uri tion i s s e ldo m a ffe c t e d an d i s o f l e s s i m por t ance th an

,
th e uri n e i t s e l f A di m i n i sh e d qu an ti ty in di c at e s a r e s e rv e d progno s i s
.
albu m e n e v e n in sm all q u an t i ty woul d m ak e i t s e riou s

, .
( )
7 I n co m pl e t e op e ra t ion s giv e in d i ffe r e n t r e s ul t s a n d a se ri o u s prog
n o si s . Po ss ib ly liga t ur e s t o cau s e atr op h y m ay prov e o f s e rvic e in
th e s e ca se s .
’
( 8 ) Li s t e r s m e th o d o f tr e a tm e n t s e e m s qui t e applic abl e t o ov ari o t
o m y a s i s b orn e o u t by th e r e s ul t s ob t ain e d
, .
( 9) W e ig h t o f r e m ov e d t u m our s run s fro m 1 7 k ilo 5 0 0

g rm s to -
.
gr m s
( 1 0) F iv e d e a th s a s r e fe rr e d to abov e
,
.
( 1 1 ) M alignan t a ffe c tion s o f th e p e ri t on e u m or colon s o m e ti m e s c o

e xi s t wi t h ov ari a n cys t s Th e r e s e e m s t o b e s o m e re l ation b e tw e e n
. .
th e m wh i c h th e a u th or prop o se s t o con s i d e r a t s o m e fu t ur e t i m e
,
.
R evue de C lzi r u rg i e M arc h 1 0 1 8 8 6

. . .
( LW C
‘
. ATH CA R T ( Lon d o n ) .
111 C a s e o f P e lv i c A b s c e s s i n a n u n u s u a l P o s i t i o n
.
,
S i m u la t i n g S o ft F i b r o i d T u m o u r o f U t e r u s A H N . . . .
LE WE R s M D ,
. . T h e p a ti e n t a wo m an a
,
et 3 7 h a d
,
h a d ,
.
,
nin e ch i ldr e n an d th r e e m i s c arri ag e s Was confin e d four w e e k s p re

.
v i o n s t o a dm i s s io n t o Lo nd on H o spi t al Wi th e xc e p tion of rath e r .

pro fu s e lo s s o f bloo d th e labor wa s n or m al On th e t e n th day wh e n

, .
,
g e ttin g up sh e no ti c e d a s w e ll ing in ab dom e n Sh e wa s oblig e d t o

, .
a gain go t o b e d b u t only fe l t p ain in h yp oga s t riu m

, on m oving A .
s m oo th e la s t ic s w e lling was fe l t ri s ing up fro m th e p e lvi s t o th e l e v e l o f
th e u m bi li cu s—n o t t e n d e r I t was d ull t o p e rcu s s ion an d s y m m e trical

. .
Un d e r e th e r th e urin e h avi n g b e e n dra wn o ff a s w e lli n g was fe l t in

, ,
fr on t o f c e rvix d e pr e s s ing th e an te rior fornix Bi m an ually t hi s s w e lling

.
wa s foun d con tinuou s wi th th at alr e a d y no te d in th e h yp oga s tri c r e

gion U te ru s m o v abl e an d t u m our m ov e d wi th th e organ F un d u s
.
, .
o f u t e ru s n o t cl e arly m ad e o u t S o un d p a s s e d
. inch e s D i a gn o .
si s—prob ably s o ft fibroi d T h e t u m o ur wa s a ft e rwar d s a s pira t e d fro m

.
th e ab d o m in al a s p e c t by p unc t ur e m i d way b e t w e e n p ub e s an d u m
b ili c u s A pin t o f m o s t o ffe n s iv e p u s was d rawn o ff a n d t u m o ur e n t ir e ly

.
,
d i s app e ar e d T h e t u m our ab s c e s s fill e d a g ain an d wa s ul t i m a t e ly

.
,
op e n e d an ti se p tica lly Pa t i e n t m a d e a goo d r e cov e ry —

. La n ce t . .
March 6 1 8 8 6 . .
IV . C a s e o f F a t a l H ae m o rr h a g e i n t o t h e A b d o m i n a l
C a v i t y D u r i n g M e n s t r u at i o n E D M U N D J PE NNY
. .
,
Wh e n Mr Pe nny wa s call e d t o th e p a t i e n t li fe was e x ti nc t

. H e r h us .
b an d s t a t e d th a t sh e alway s e nj oy e d goo d h e al th a n d wa s th e m o th e r
o f t wo c h il dr e n Sh e was 2 7 y e ar s o f a g e
. Ab ou t 7 p m on t h e . . .
e v e ning pr e c e ding d e a th sh e co m plain e d o f p ain i n r e gi on o f s t o m ac h ,
wh ich s h e a ttrib u te d t o th e fac t th a t sh e was m e n s tr u a ting S he gra d .
u ally gr e w wor s e an d s u ffe r e d fro m dy s p n oe a S h or tly b e for e 4 a m . . .
s h e b e ca m e rapi d ly wor s e an d d i e d .
N e crop s y —Th or a ci c organ s h e al thy O n op e ning ab d o m inal cav

. .
i ty a larg e quan t i ty o f d ark flui d bloo d i m m e dia t e ly e s cap e d a n d th e ,
wh ol e o f th e righ t s i d e o f th e ab d o m in al cavi ty wa s foun d t o b e full

o f flui d a n d s e m i co a gula t e d bloo d w h il e th e rig h t iliac fo s s a was o c
-
,
c up i e d by a t ol e ra b ly fi rm clo t Vi s c e ra fo un d t o b e h e al th y
. Bloo d .
v e s s e l s in tac t O n r e m oving bl o o d clo t fro m iliac fo s s a i t wa s fo un d

.
t o l e a d t o th e rig h t ovary a n d a s m all b u t fi rm clo t a t l e a s t an in ch

, , ,
in l e ng th wa s foun d attach e d t o th e ou te r s ur fac e o f th a t orga n Two

,
.
r up t ur e d Graafi an follicl e s w e r e s e e n t o o ne o f w hich an ovu m wa s a d

,
h e r e n t an d in th e n e igh borh o o d o f th e s e s e v e ral s m all b loo d v e s s e l s

,
G YN A EC OL O GI CAL . 457
w e r e foun d to b e di s te n de d wi th clo t , on e o f th e m b e i n g d i s tinc t ly rup

t ur e d an d i t wa s t o th i s s i te th at th e clo t was a dh e r e n t —B r i t M ed . .
f ou r . March 20, 1 88 6 .
H . H . T AYLO R ( Lon d on ) .
V . C y s t o F i b r o i d o f t h e L a b i u m M aj u s W e i g h i n g S i x
A -
‘
P ou n d s C o m p li c a t e d b y P r e g n a n c y
,
By Dr J Z1E LE w1 c z . . .
o a u th or di s ti n gui s h e s cli n ically t wo for m s o f fi b r o m a o f

( P s e n
) T h e
.
th e larg e r labi a I n th e o n e th e t um o ur owe s i t s origin an d d e v e lop

.
m e n t t o th e co nn e c t iv e t i s s u e o f th e labia grow s m o s t ly in an o ut ,
w ar d d ir e c tion an d i s a tt ach e d by m e an s o f a p e dicl e I n th e s e con d

,
.
for m —clinical ly o f m uch m or e i m p or t anc e —th e fi b r oi d s h av e a d e e p e r

origin b e i n g a tt ach e d t o th e p e lvi c fa s cia t o th e p e rio st e u m of th e p e l
,
v i s or t o b o th
,
an d h av e a broa d b a s e an d a m or e roun d e d fo rm
,
.
T h e s e t u m our s cau se th e p ati e n ts gr e a t di s tr e ss by th e con ti nual drag

gi n g on th e s urroun di n g p ar ts ur e thr a r e c t u m e tc , , , .
Z i e le wi c z r e p or t s th e fo llowing ca s e : Pa ti e n t ae t 3 1 m ul tip ara . .

, ,
an d h e al th y un til two ye ar s pr e viou s wh e n a ft e r h e r l a s t co n fin e m e n t , , ,
sh e r e m ark e d a s m all lu m p in th e r e gion o f th e l e ft larg e r labiu m Th e .
s w e lli n g incr e a s e d in s i z e cau si n g h e r m uch p ain an d r e n de ri n g h e r

,
e v e n t u ally u n abl e t o walk Pa ti e n t n o t abl e t o s tan d for a y e ar p as t

. .
Sh e b e c am e pr e gna n t e ight m on th s ago O n e x am ina tion a larg e .
roun d t u m our wa s foun d 5 9 c m in circu m fe r e nc e at i t s l arg e s t di am

,
.
e te r wi th an u n e v e n s ur fac e an d s i t ua t e d in fron t of th e i n tr oi t u s
, ,
v a gi n ae T h e n e op lasm wa s s o li d b ut e la s tic h aving on i ts l e ft si d e

.
,
s e v e ral fl uc t ua ti n g cy s t s Th e le ft l ar g e r a n d s m all e r labia co m pl e t e ly

.
di ffu s e d in t o th e cov e ri n g o f th e t u m our th o s e o f th e righ t s i de ,
b e i n g un affe c t e d T h e i n troi t u s v a gi n ae di s p lac e d s o m uch th at two

.
fing e r s coul d wi th d i flfic ulty b e i n tro duc e d in t o th e v agina T h e ori .
fi c e o f th e ur e th ra ch a fe d an d d r awn t o l e ft s i d e a n d r e c t u m m uch ,
prolap s e d Tu m our alm o s t i m m ovabl e Pr e gn ancy of e igh t m on th s

. . .
E x ti rp at ion de ci d e d on In th e m e an ti m e h ow e v e r p ati e n t h a d a
.
, ,
viol e n t ch ill fo llo wi n g which c e s s a tion o f th e foet al h e ar t t on e s and in

,
-
,
th e ni g h t b e for e th e op e ra ti o n s h e wa s d e liv e r e d o f a d e a d c h il d S ix .
t e e n d ay s l at e r op e ra t ion I n ci sion was in th e r e gion corr e s pon di n g

.
t o th e l e ft l abiu m th e t u m or b e i n g e a s ily di s s e c t e d o ff fro m th e p e lvi c

,
458 I N D E X OF S UR GI GA L P R O GR E S S .
fa s ci a . Th e larg e deep
woun d wa s clo s e d a s m uch a s p o s s ibl e by
,
s u t ur e s an d t h e d am a g e d on e t o v a gin a r e p air e d by pla s t ic m e an s

,
.
D u ring th e O p e ra tion th e r e ct um was inci se d for th e l e ng th o f 2 c m .
by acci d e n t Ca t gu t s u tur e s w e r e a ppli e d t o th e la tt e r a n d no fur th e r

.
,
t roubl e r e s ul t e d Dr e s s ing s o f io do for m and b i ch lori d e g a uz e ap

.
-
pli e d an d a ca th e t e r wa s in tro d uc e d an d l e ft t pr e v e n t s oiling of th e

, , o
b an da g e wi th urin e Dura tion o f op e r ati on ,on e h our Pa ti e n t r alli e d

. .
w e ll b u t h ad con s i de r abl e fe v e r d uri ng th e following four d ay s Thr e e

,
.
w e e k s la te r h a d an a tt ack o f e xu dat iv e pl e uri s y D i s ch arg e d cur e d in .
ab ou t two m on th s fro m ti m e o f a dm i tt anc e h aving fully r e cov e r e d u s e ,
o f h e r low e r e x tr e m i ti e s T h e t u m our w e ig h ing . gr am m e s was , ,
a pur e fibroi d wi th ou t m u s cular fibr e s an d v e ry v a s cular T hi s for m

. , .
o f fi b r o m a app e a r s t o b e v e ry s e l d o m Z we i fe l in h i s work on th e .
,
d i se a se s o f th e e x te rn al fe m al e org an s p ubli sh e d in 1 8 8 5 s i m ply r e fe r s , ,
t o th e O pinion of Ki wi sc h th at s uc h t u m our s d o e xi s t b ut r e por t s n o

, ,
c as e o f h i s o wnob se rv atio n —D eu tsclz M ed Woe/zen rc/z N o 2 4 J un e . . . .
1 7 . 1 88 6 .
C .
J CO LLES ( N e w Y k ) or .
VI . The C o n t e n t s i n a C as e of T u b al P re g
S ac an d
nan cy R e m o v e d b y Lap ar ot om y By H A K E LL E Y M D . . .
,
. .
( Phila d e lp h i a) T h e p a ti e n t h ad b e co m e pr e gnan t s e v e n m on th s p re
.
v i o u sly h e r m e n s e s r e cur ring four m on th s th e r e a ft e r

, E xa m ina t ion .
r e v e al e d an e l o nga te d ovoi d t e n s e cy s t ab o ut t h r e e a n d a h al f i n c h e s
, , ,
long by t wo an d a h al f wi de lying on th e ri gh t s i d e an d in th e plan e ,
o f th e s up e rior s tra i t w h ich wa s d i a gno se d a s t h e pro d uc t o f an e x t r a

,
u te rin e g e s t a tion T he fac t th at th e p ati e n t wa s con s t an tly s u ffe ring

.
p ain fro m th e t u m our an d d e te riora ti n g gr e a tly i n h e al th a nd s piri t s th e ,
p o s sibl e s ub se qu e n t di s ch arg e o f th e foe tal p ar t s by pro tr ac te d s upp u

r ation an d th e fa cili ty of th e op e ra t ion—b i m anual e x am in a tion t e
,
-
v e aling all th e p e culiari ti e s o f th e c as e b e for e th e s e c t ion —c a u s e d th e

wri te r t o d e ci d e up on i t s r e m ov al wh i ch wa s acco m pli sh e d s ucc e ss ,
fully wi th no an t i s e p tic ag e n t e xc e p t e x tr e m e cl e anlin e s s th e rig h t

, ,
F alIO p i an t ub e b e in g r e m ov e d wi th th e t u m our w h ich con t ain e d a m um ,
m i fyi n g foe t u s m e as uring fi ve a n d th r e e qu ar te r s inc h e s in l e ng t h

,
-
.
R e cov e ry was rapi d —I V Y M ed f ou r 1 886 M ay 2 9

. . . . . .
G i N / E C OL O GLCA L 45 9
’
.
VI I R e m o v a l o f t h e R e m a i n s o f a F oe t u s b y A b d o m
.
i n a l S e c t i o n i n a C as e o f E x t r a U t e r i n e P re g n an cy o f
,
-
S e v e n Y e a rs D u r at i on By J H O MAN S M D ( Bo s ton M a ss )
’
. . . . .
, ,
A wo m an ae t 3 5 h ad app ar e n tly p a s s e d th e full t e r m o f g e s tati on

, .
, ,
wh ich h ad b e e n diagno se d as e x tra u te rin e wi th ou t p ar turi tion A fte r -

,
.
a li tt l e m or e th an a y e ar o f pr e gn ancy th e p a t i e n t s h e al th i m prov e d ,
’
,
a n d s h e was abl e t o r e s u m e h e r or d in ary avoca t io n s w h ic h s h e con ,
t in n e d for t h e e n s uing s i x y e ar s in s pi t e o f t h e s iz e o f h e r ab d o m e n , ,
m e n s tru at ing r e gularly b ut n o t conc e iving At th at t i m e s h e b e gan

, .
t o s u ffe r fro m s e v e r e ab d o m inal pain ; a t u m ou r for m e d by i m p a c t e d
fae c e s was di s cov e r e d an d cl e ar e d a w ay th e r e b e ing l e ft a fi rm h ar d , ,
m a ss in th e l e ft h ypoc h on driac a n d iliac r e gion s fro m w h ich oily an d ,
p u-s lik e fl ui d w a s d r a wn by as p i r a t ion D e r m oi d cy s t o f t h e l e ft ovary .
w as d i agno se d an d ovario t o m y for i ts r e li e f propo se d

, O n op e r a tion .
,
an ov arian cy s t wa s foun d and e m p ti e d b ut un de rn e a th i t an d a l m o s t , ,
’
in th e m i d dl e lin e was ano th e r cy s t ab o ut th e siz e o f a m an s h e a d
, , ,
i ts cov e ri n g m e m br a n e b e ing con tinuou s wi th th e p e ri t on e u m o f th e

i n t e s tin e s a n d bl a dd e r I t wa s fou nd t o con t ai n a fl ui d in wh ich fa tty
.
,
gr anul ar d e tri t u s wa s s u s p e n d e d a n d in w h ich all th e b on e s o f a foe tu s

a t t e r m w e r e fo un d T h e s a c an d th e ab d o m inal cavi t y w e r e th or
.
o ug hly cl e an se d a n d the w all s o f th e for m e r s ti tch e d t o th e s kin o f th e

a b d o m inal inci s ion a n d d rainag e provi d e d ,
T h e p ati e n t d id n o t r ally .
fro m t h e O p e ra tion h ow e v e r b ut d i e d four h o ur s la wn —B os ton M ed

, ,
.
i
f) S u rg f ou r. 1 886 May 2 0
. . .
VIII . C as e o f V a g i n a a M i n u t e C a n a l w ith C u re i n th e , ,
C o u rs e o f w h i ch a G as t r o V a g i n a l F i s t u l a w a s E s t a b l i s h e d -
an d C u re d By J R C H AD W I C K M D ( Bo s t on M a s s ) A m arri e d
. . .
,
. .
,
.
girl ae t 1 6 h ad i n locu m vag i n a a m inu te c anal p as s ing fro m a blin d

,
.
, , ,
p o uch j u s t wi th in th e vulv a th r e e an d a quar te r inch e s t oward a nor ,
m al u t e ru s R up t ur e o f th e p ar t s wi th forc e p s an d fing e r a n d d i s te n
.
s ion wi th a gla s s plug e s t abli s h e d a s at i s fac t ory v a gina D uring th e .
t re a tm e n t th e p a t i e n t wa s a ffe c t e d wi t h a larg e ab s c e s s e x t e n d ing fro m ,
h al f way b e t w e e n th e p ubi s a n d u m bilic us n e arly t o t h e ri b s on th e

ri gh t s i de o f th e ab d o m e n an d di s ch arging con st an tly in t o th e in te s
t in e h igh up
,
T h e p a ti e n t was an e nor m ou s e a t e r
.
T h e ab s c e s s was .
as pira t e d , fir s t th rou g h th e ab d o m inal walls an d lat e r th roug h the

at , , , ,
t op o f th e a rt ifici al vagina In th e atte m p t t o e s t abli sh p e rm an e n t

.
dr ai n ag e th e can u la o f th e t rocar was l e ft in th e punc tur e b ut in c om

, , ,
m o d in g th e p a ti e n t an a t te m p t wa s m a d e t o r e pl a c e i t wi th a s o ft rub
,
b e r ca th e t e r b u t frui tl e s s ly
, In d e sp e ra tio n at th e failur e th e tro c ar
.
,
wa s again th ru s t forcibly i n t o th e t u m our a n d wi th dr awn l e avi n g th e

'
canula plugg e d wi th a cork in th e p unct ur e On wi thdrawing th e

, , .
cork for dr ainag e th e n e x t d ay th e ch arac t e ri s ti c con t e n t s O f th e s to m

,
ac h w e r e foun d in ab un d anc e in th e d i s ch arg e an d i t wa s d i s cov e r e d

,
th a t th e t rocar h a d pa sse d t h roug h th e ab s c e ss in t o an e nor m ou s ly
d i s t e n de d s t o m ach th u s e s t abli sh ing a ga s tr o vagin al fi s t ula wh ich

,
-
p e r s i s t e d for th r e e d ay s aft e r th e pro m p t wi th dr awal o f th e canula b ut ,
no un t owar d r e s ul t s s up e rv e n e d an d th e p ati e n t r e cov e r e d — B os ton

M ed a n d S u rg f ou r
. . 1 886
. Jun e 3
. .
T E
. . Pi LCH E R (U . S Ar m y)
. .
S Z Y M A N O WS K I S O P ER A T I O N A PP L I E D
’
AS TO
T H E CUR E OF U RE T H R O -
P E R I N E AL
F I S T U LA .
1
By C H A R L E S M c BU R N E Y M ,
. D .
,
O F NE W Y O R K .
S U R G E O N T O ST LU K E S AN D
.
’
BE LLE V U E H PI TAL
OS S .
R . P RE S I D E N T : I v e n t u re t o b r i n g t h e s u bj e c t o f
t h i s p a p e r b e fo r e t h e s o c i e ty b e c a u s e I a m c o n vi n c e d
b y e x p e r i e n c e t h at t h e o p e ra t i o n w h i c h I s h a l l d e s c r i b e i s a n
e x c e e d i n g l y g o o d o n e a n d a lth o u gh a n a c c o u n t o f it wa s p u b
, ,
li s h e d b y i t s o r i g i n a l d e s i g n e r a s m u c h a s s i x t e e n y e a rs a g o ,
i t h as r e c e iv e d b u t l i t t l e a t t e n t i o n fr o m s u b s e q u e n t w r i t e rs .
P e rs i s t e n t u r i n a ry fi s t u l a i n t h e p e ri n m u m a r e n o t ra r e o c ,
c u rr i n g as t h e r e s u l t o f w o u n d s o f t h e p e r i n ae u m a b s c e s s a n d ,
i n fi l t r at i o n o f t h e u r i n e d ue t o s t r i c t u r e o r r u p t u r e o f t h e u r e
t h ra ,
an d s o m e tim e s r e m a i n i n g a ft e r o r d i n a ry e x t e r n a l
u r e t h r o t o m y o r m e d i a n l i t h o t o m y T h e i m m e d i at e c a u s e o f
,
.
s u c h fi s t u l a as I s h a l l r e fe r t o i s a l m o s t a l w a y s p e ri n e a l s e c
t i o n d o n e b y t h e s u r g e o n fo r o n e r e as o n o r a n o t h e r Wh e n .
u r e th r o p e r i n e a l a b s c e s s h a s r u n i t s c o u rs e w i t h o u t s u rg i c a l i h
-
t e r fe re n c e ,
n u m e r o u s fi s t u lo u s t ra c t s fr e q u e n t l y r e m a i n t h e ,
c as e b e i n g u s u a l l y c o m p li c a t e d b y s t r i c t u r e F o r th e re l i e f .
o f th i s c o n d it i o n n o m e th o d is m o re p o p u l a r th a n a m e d i a n i h
c is i o n i nt o th e u re th ra u r i n e a n d p u s t h e n p a s s i n g fr e e l y
,
t h r o u g h t h e l a r g e r e c e n t w o u n d t h e i rr e g ul a r a n d o u t l y i n g
,
fi s t u l as u s u a ll y c l o s i n g r a p i d l y I t i s t r u e t h at t h e c o m p l e t e
.
r e m o va l o f s t r i c t u r e o f t h e u re th r a a t a ll p o i n t s a n t e r i o r t o t h e
1
R e ad b e fo r e th e N e w Y or k S urg i c al S oci e ty, O c to b er 1 1 , 1 8 86 .
46 2 CH A R LE S M B UR N E Y .
fi stu la ,
y s t e m at i c u s e o f l a r g e s o u n d s t h e c o rr e c t i o n o f
th e s ,
d e fe c t s i n t h e c o n d i t i o n o f t h e b l a d d e r a n d u r i n e a n d t h e a p ,
p l i c at i o n o f t h e a c t u a l c a u t e r y o r c a u s t i c s t o t h e g ra n u l a t i n g
'
e d g e s o f t h e s e u n n a t u r a l o p e ni n g s w i l l o ft e n s u c c e e d i n o b
,
tai n i n g th e i r c l o s u re W h e n l i tt l e o r n o l o s s o f t i s s u e h a s o c
.
c u rr e d t h e t e n d e n c y t o s p o n t a n e o u s c u r e i s v e r y g r e a t a s i s
, ,
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fo r m e d fo r t h e r e l i e f o f u n c o m p l i c a t e d s t r i c t u r e A nd ye t .
t h e r e r e m a i n c e rt a i n c a s e s c h i e fl y t h o s e i n w h i c h c o n s i d e r a b l e
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l o s s o f s u b s t a n c e h a s o c c u r r e d w h i c h a re n o t b e n e fi t e d b y a n y
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o f t h e m e a s u r e s j u s t r e fe rr e d t o F o r t h e s e c a s e s a s y s t e m at i c
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o p e r a t iv e p r o c e d u r e i s r e q u i r e d I n 1 8 7 0 i n h i s H a n d b o o k
.
,
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o f O p e r a t i v e S u rg e ry J u l i u s v o n S z y m an o w sk i d e s c ri b e d a n
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o p e r a t i o n fo r c l o s u r e o f fi s t u l a s i t u a t e d i n t h a t p a rt o f t h e
u r e t h ra a n t e r i o r t o t h e s c r o t u m T h i s o p e r a t i o n w as a s S z y
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m a n o w s k i h i m s e l f s t at e s s u g ge ste d,
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S i m i l a r o p e ra t i o n a l r e a d y d o n e
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b y v o n La n g e n b e c k a n d is ,
t h u s d e s c r ib e d : I n th e c as e o f a fi st u l a l y i n g i n t h e l o n g ax is
o f t h e p e n i s a s t r a i g h t i n ci s i o n i s fi r s t m a d e b e g i n n i n g a s h o rt
, ,
d i s t a n c e i n fr o n t o f a n d e n d in g a s h o r t d i s t a n c e b e h i n d t h e fi s
t u la . Th e s k i n o n o n e s i de o f th e fi s t u l a is t h e n u n d e rm i n e d
w i t h t h e k n i fe a n d m ad e e a s i l y m o va b l e
,
A h a l f o v a l fl ap .
-
o f s k i n o n th e o th e r S i d e o f t h e fi s t u l a is t h e n c u t fr e e d fr o m ,
th e e p i d e r m i s a n d d i s s e c t e d u p e x c e p t a t t h e e d g e o f t h e
, ,
fi s t ul a T h e d i s s e c t e d fl a p i s t h e n t o b e i n v e rt e d p u s h e d u n
.
,
d e r t h e a l r e a d y li ft e d s k i n o n t h e o p p o s i t e s i d e h e l d i n p l a c e ,
b y s u t u re s p a s s e d th r o u g h t h e b o t t o m o f th e p o c k e t a n d t h e ,
m o v a b l e s k i n d ra w n o v e r i t a n d a l s o s u t u re d T o p r o vi d e fo r .
u r i n at i o n S z y m a n o w s k i r e c o m m e n d s t h at a n e l a s t i c c a t h e t e r
,
b e p a s s e d i n t o t h e b l a dd e r a n d t i e d S z y m an o w sk i d o e s not
.
s t at e i n h i s b o o k t h a t h e e v e r d i d t h i s o p e ra t i o n I n 1 8 74 .
D r R o b e rt F W e i r c l o s e d b y t h i s m e t h o d a v e r y o b s t i n a t e
. .
a n t e s c r o t al fi s t u l a i n a p a t i e n t at S t
-
L u k e s H o s p ita l Th is
.
’
.
c a s e i s d e s c r ib e d i n d e t a i l i n a p a p e r b y D r W e i r p u b l i s h e d .
,
i n t h e fi r s t A p r i l n u m b e r o f t h e M e d i c a l R e c o r d fo r 1 8 7 8
“ ”
.
M o d i fi c at i o n s o f t h i s m e t h o d w e r e a l s o m a d e u s e O f b y m e i n
a n u m b e r o f c as e s o f a n t e s c r o ta l fi s t u l a-
S o m e o f th e s e w e re
.
p u b l i s h e d i n t h e J u l y n u m b e r o f t h e I l l u s t r a t e d Q u a rt e rl y
“
UR E TH R O P E R I N E A L F I S T ULA
-
. 46 3
of M e di c i n e and S u rg e r y fo r 1 8 82, an d o t h e rs I hav e r e p o rt e d

at m e e t in g s o f t h i s s o c i e t y s i n c e t h e n .
T h e p a t i e n t a l r e a d y r e fe rr e d t o a s o p e r a t e d u p o n b y D r .
W e i r h a d a l s o a n o b s t i n a t e p e r i n e a l fi s t u l a H e l e ft t h e h o s .
p i ta l w ith h is a nte s c r o t a l fi s t u l a s o u n dl y h e a l e d a n d re t u rn e d
-
,
d u r i n g t h e s e rv i c e o f D r T T S a b i n e D r S ab i n e a p p l i e d
. . . . .
S z ym a n o w s k i s o p e r a t i o n t o t h e p e r i n m u m a n d s u c c e e d e d i n
’
c l o s i ng the o p e n i ng I s a w D r S a b i n e s o p e ra t i o n p e r fo r m e d
. .
’
a n d d e t e r m i n e d t o m a k e u s e o f t h e m e t h o d i n a s i m il a r c as e .
C A S E I —M y fir s t ca s e was th a t o f T h o m a s Hill s ae t 2 8 wh o was

.
, .
,
’
a dm i t t e d t o S t Luk e s Ho s pi t al on J u n e 1 9
. 1 876 l l e h a d a larg e , .
old p e rin e al fi s t ul a T h e op e ra ti on w a s d on e on July 2 8 th an d will

.
,
b e pr e s e n tly d e s crib e d A t th at t i m e I b e li e v e d th a t th e only m e th o d

.
o
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o f co m p le t e ly pr e v e n tin g th e p a s s ag e o f urin e ov e r t h e s e a t o f op e ra
t ion w a s t h e i n tro d uc t i o n o f a ca n ula or c a th e t e r in t o th e bla dd e r p e r

r ect u m ,a n d m ai n t aini n g th e s a m e i n s i t u fo r s o m e d a ys a ft e r th e O p e r
a t ion . T h i s m e th o d I h a v e s inc e foun d t o b e e n tir e ly unn e c e s s ary .
In th e ca se o f Hill s th e ca th e te r wa s i n tro d uc e d b ut a t th e e n d o f a ,
fe w h our s b e ca m e clog g e d an d cau se d s uch in t e n se irri t a t ion t h a t i t

h ad t o b e wi th d rawn a n d t h e bl a dd e r s oon a ft e r e m p tyi n g i t s e l f
, ,
viol e n tly by th e ur e th ra a larg e a m ou n t o f urin e was forc e d th rough

,
t h e woun d T h i s acci d e n t an d prob ab ly al s o m y lack o f e xp e ri e nc e

.
,
in th e d e t ail s o f th e op e r a tio n broug h t ab ou t a co m pl e t e failur e , .
T h i s p ati e n t l e ft th e h o s pi t al b e for e I h a d ano th e r oppor t uni ty t o Op

c r a te up on h i m .
F i v e o t h e r c as e s c o m e u n d e r m y c a r e s i n c e th at t i m e
h av e ,
t h e s e s i x b e i n g a ll t h e c a s e s o f u r e t h r o p e r i n e a l fi s t u l a i n -
w h i c h I h a v e O p e r a t e d fr o m J u n e 1 8 8 6 t o t h e p r e s e n t t i m e , , .
CASE I I — J o h n J urg e n s ae t 3 6 a G e r m an wa s a d m i tt e d t o S t
.
,
.
, , .
Luk e s H o spi t al F e bruary 2 1 8 8 2

’
, Pe ri n e al cy s t o t o m y h a d b e e n
,
.
p e r form e d upon h im in ano th e r h o s pi t al in Augu s t 1 8 8 1 F o r th e , .
clo s ur e o f h i s larg e p e rin e al O p e nin g I O p e rat e d by S z ym an owsk i s ’
m e t h o d on Augu s t 2 5 O n S e p t e m b e r 2 an involun t ary e vacua ti on

.
o f th e bla dd e r forc e d a fe w d rop s o f urin e b e t w e e n th e fl ap s T h e .
s a m e acci d e n t h app e n e d t wo or t h r e e t i m e s a ft e r war d a n d th e woun d ,
wa s n o t pronounc e d t o b e s oun dly h e al e d t h rough ou t t ill th e e n d o f

N ov e m b e r H e was th e n w e ll an d a F r e nch s oun d N o 2 9 p as s e d
.
, .
e a s ily in t o th e bl a d de r .
4 64 CH AR LE S M b UR N E Y
’ ’
.
C A S E I I I —M H G allag h e r ae t 2 8 an A m e rican was a dm i tte d to

. . .
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, , .
th e S t Luk e s Ho s pi t al April 2 6 1 8 8 4 H e gav e a h i s t ory o f p e ri

’
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n e al ab s c e s s an d fi s tulae o f s ix m on th s s t an d ing F or th e r e li e f o f
’
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s t ric t ure e x t e rnal ur e t h ro t o m y was d on e up on t h i s pa t i e n t b y Dr

,
Li t .
t le on May 1 [ h e p e rin e al woun d r e fu s e d t o clo s e al th oug h t r e a t e d

.
,
by nu m e ro u s nOn O p e ra t iv e m e t h o d s Th e ur e th ra a dm i tte d a N o 3 2
- . .
F r e nch s oun d r e a d ily O n J uly 1 8 I d i d S z ym an o ws k i s O p e ra t ion ’

.
,
a n d on Augu s t 4 s e v e n t e e n d ays a ft e r war d t h e par t s w e r e co m pl e t e ly

, ,
h e al e d .
C A SE I V — Willi am P ur t l e ae t 3 9 an Iri sh m an was a d m i t t e d to

.
, .
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B e ll e vu e Ho spi t a l on S e p te m b e r 1 7 1 8 8 4 S ix d ay s p rior t o a d m i s , .
s io n th e pa ti e n t fe ll a s t ri d e a b e am an d rup t ur e d th e ur e thr a I h .
fil tra ti on o f urin e an d a b s c e s s fo llowe d Pe ri n e al s e c t ion wa s p e r .
form e d o u t h e d ay o f a d m i s sion Th e woun d d id n o t co m pl e t e ly .
clo s e an d th e p at i en t ca m e un d e r m y car e in O c t ob e r
, O n Nov e m .
b e r 6 a n t e rio r s t ric t ur e s w e r e d ivi d e d un t il N o 3 2 co ul d b e r e a dily

, .
pa s s e d Vario u s non op e ra t i v e m e t h o d s w e r e a d op t e d t o i n d uc e
.
-
clo s ur e o f t h e fi s t ula wi th o u t s ucc e s s so t h a t on D e c e m b e r 1 8 I di d , , ,

’
S z ym an o ws k i s O p e ra t ion Th irt e e n d ays a ft e r t h e O p e ra t ion th e
,
woun d wa s co m pl e t e ly h e al e d .
C A S E V —J o h n Gi ffofd ae t 4 7 an A m e ri can wa s ad m i t t e d t o B e ll e
.
, .
, ,
v ue H o spi t a l on J anuary 8 1 885 O n a d m i s s i on h e h a d e x te n s iv e

,
i n fi l tra t ion of urin e d ue t o s tri ct ur e Pe rin e al s e c tion was d on e a t

_
.
onc e s e v e ral o th e r inci s io n s b e in g r e quir e d At a s ub s e qu e n t p e rio d

, .
,
March 4 all s tric t ur e s w e r e d ivi d e d by in t e rnal ur e thr o t o m y un t il a

,
No 3 2 F r e nch s oun d co ul d b e e a s ily p a s s e d In s pi t e o f e v e ry car e

. .
,
t h e p e rin e a l woun d r e fu s e d t o clo s e a n d I op e ra t e d fo r t h a t r e a s on ,
o n M ay 1 8 .
J un e 6 ni n e te e n d ays a ft e r t he Op e ra tion th e woun d wa s fir m ly

, ,
h e al e d .
C A S E VI —J R Horn e ae t 4 5 an E ngli s h m an wa s a d m i t t e d to
, . .
, .
, ,
S t Luk e s Ho s pi t al on N ov e m b e r 5 1 8 8 5
.
’
T h i s p a ti e n t h a d h ad e x ,
.
t e rnal ur e th ro t o m y p e r for m e d on h i m fo r t h e r e li e f o f s tric t ur e in 1 8 7 7 .
A p e r in e al a b s c e s s for m e d in 1 8 8 4 H i s fi s t ula r e op e n e d in J un e .
,
1 885 ,a n d d i d n o t again clo s e E x t e rn al a n d in t e rn a l ur e th r o t o m y .
w e r e p e r for m e d upon h i m in Nov e m b e r 1 8 8 5 an d in J anua ry 1 8 8 5 , , , ,
a S z ym an o ws k i s O p e ra t ion wa s d on e fo r t h e clo s ur e o f th e p e rin e al

’
op e nin g Th i s op e r ation d i d n ot s ucc e e d prob ably on a cco un t o f

. ,
cy st i ti s d u e t o a c alculu s wh ic h I d e t e c t e d w h e n th e pa ti e n t ca m e
un de r m y car e in F e bruary la st T h i s calculu s I cru s h e d an d r e m ov e d .
UR E TE R O-P E R I N E A L PJ S T ULA . 46 5
th ro ugh th e p e ri n e al op e ni n g T h e cy s ti ti s b e i n g m uch r e d uce d an d

.
t h e c a libr e o f th e ur e thr a h avin g b e e n r e s t or e d t o N o

3 2 F r e nch I di d .
,
S z ym an ows ki s O p e ra t ion on Jun e 5

’
N 0 acci de n t h app e n e d an d on
.
,
J uly 9 th ir ty four d ay s lat e r th e woun d was s oun dly h e al e d

.
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, .
O n e ca s e th e fir s t owing t o i m p e r fe c t m anag e m e n t fail e d c om

, , ,
p le t e ly .F iv e ca s e s s ucc e e de d an d in non e of th e m w a s an y se con d ,
op e r ation r e quir e d .
T h e s e con d ca s e r e quir e d th r e e m on th s an d s ix d ay s t o ob t ain s oun d

h e ali n g ; th e th ir d se v e n t e e n d ay s th e four th th ir te e n d ay s th e fi fth
, , ,
n in e t e e n d ay s a n d th e s ix t h
, th ir t y four d ay s N o s y m p t o m o f th e
-
, .
s lig h t e s t i m p o rt anc e o ccurr e d in any o f th e la s t fi v e ca s e s an d th e ,
le n g th o f ti m e occu p i e d in r e cov e ry c e r t ainly co m p ar e s v e ry favorably

wi th th at o fte n S p e n t in fu til e an d e v e n s ucc e s s ful a tt e m p t s t o clo s e
p e ri n e al fi st ula wi th o ut op e ra tion .
T h e plan a d op t e d in all o f th e s e ca s e s was a s follow s a n d i f th e , ,
d e s crip ti on s e e m s t e di ou s m y e xcu s e m u s t b e th a t I b e li e v e th e s ucc e s s

,
o f t h e op e ra tion t o d e p e n d larg e ly upon a clo s e a tt e n t ion t o d e t ail s
S o m e t i m e pr e viou s t o op e ration th e e n tir e ur e th r a wa s cl e ar e d o f

all e vi de nc e o f s tric t ur e an d th e ur e th ra a ccu s t o m e d t o th e p a s s ag e o f
,
s oun d s ; any s i nu s e s in th e n e i gh b orh o o d o f th e fi s t ula w e r e O p e n e d
a n d s ou n dly h e al e d I f cy s t i t i s e xi s t e d i t wa S r e m o v e d a s far a s p os
.
'
s ibl e alth oug h a m o d e ra t e a m ou n t o f c h roni c cy s t i ti s

, c e r tainly d o e s
n o t con t ra in d ic at e th e op e ra t ion
-
.
T h e d ay b e for e op e ra ti on th e b ow e l s an d r e c t u m w e r e th orough ly
cl e ar e d in or d e r e s p e cially th a t fo r s e v e r al d ay s aft e r th e r e c t u m a n d
, ,
a dj ac e n t p ar ts m igh t b e k e p t p e r fe c tly qui e t by a fr e e us e of opiu m .
Th e p e ri n ae u m w a s t h e n sh av e d an d p e r fe c t ly cl e an s e d a n d th e bla d ,
d e r e m p ti e d wi th th e ca th e t e r a n d th orough ly wa sh e d o u t wi th a w e ak
s olu t ion of e i th e r b orax or carbolic aci d T h e e d g e s o f th e fi s t ula .
w e r e th e n e i th e r s crap e d or c u t s o a s to r e m ov e all s up p ur ating gra n

ula ti o n s wh ich wou ld n a t urally incr e a se d i s ch arg e a n d pr e v e n t e arly
u n ion .
A s i n gl e s traigh t inci s ion wa s th e n m a d e fro m A th r e e quart e r s o f , ,

-
an inc h in fron t o f t o B th r e e qu ar t e r s o f an inch b e h in d t h e fi s t ula

, ,
-
( F ig. T hi s inci sion pa s se d th rough s kin an d s up e rficial fa s cia an d ,
c lo s e l y s kir t e d t h e rig h t s i d e o f th e fi s t ula T h e e dg e o f th i s inci s ion .
wa s rai s e d an d working wi th a s m all bla d e t o th e p a t i e n t s rig ht s i d e

’
, , ,
th e s kin an d fa s ci a w e r e un d e r m in e d un t il a p o ck e t wa s for m e d inclu d
ing th e ar e a A C B F th e righ t e dg e o f th e p ock e t b e ing in dica t e d by

,
th e d o tt e d lin e A C B .
On th e op po s i t e s i de a cu rv e d inci s ion A D B was t h e n m a d e th e

, ,
gr e ate s t wi dth o f th e flap th u s m ark e d o ut b e in g th r e e quar te r s of an -

46 6 CH A R LE S M B UR N E Y .
Th i s fl ap m u st b e g e n e rou s an d sh o ul d inclu d e a goo d p a dding o f

fa s cia a s wh e n i t i s li ft e d th e sh rink a g e i s gr e a t
, , ,
.
B e for e li fti ng th e flap a th in lay e r of s kin w as r e m ov e d fro m it s s ur

fac e Th i s i s b e s t d on e wi th a s m all curv e d s ci s s or s t h e s up e rfi cial
. ,
lay e r o f skin b e ing rapi d ly ch ipp e d o ff .
T h e fr e sh e ning pro c e s s wa s car e fully e x t e n de d o v e r th e e n t ir e ar e a

A D B F e xc e p ting ov e r a s ur fa c e a li t tl e l ar g e r th an th e fi s tula an d
, ,
i m m e di ate ly n e xt t o i t .
'
I t wa s th ough t b e s t t o l e av e th i s p or tion un d e nu de d for th e i m m e

d ia t e cov e r t o th e fi s t ul a b e cau se l e s s ci cat ricial r e pair woul d occur
, ,
an d l e s s p u s woul d b e for m e d th an i f a r aw s u rfac e w e r e pr e s e n t e d t o
th e ure thr a ( s e e F ig T h e fl ap A D B was th e n d i s s e c t e d up clo s e

.
Fi G . 1 . F IG . 2 .
t o th e m e d ian lin e a n d inv e r te d i t s a tt ach e d e d g e ac t i ng a s a h ing e

, ,
an d as a m e d iu m fo r bloo d s upply - .
F iv e or s ix fi n e ca tgu t s u t ur e s w e r e p a s s e d th ro ug h th e s kin a t di f
fe re n t poin ts a li ttl e b e yon d th e d o tt e d lin e A C B in t o th e p ock e t , , ,
t h e n t h roug h th e fr e e e d g e o f th e flap an d t h e n b ack in to th e p ock e t ,
an d o u t t h roug h th e s ki n F iv e or s ix loop s w e r e th u s for m e d by

.
,
dr a wing upon wh ich t h e fl ap was c lo s e ly d ra wn d own t o th e bo t t o m

‘
o f th e p o ck e t a n d t h e fr e e e n d s o f th e loop s w e r e t i e d
, ( S e e F i g . .
Two or th r e e s u t ur e s o f ca t gu t w e r e n o w p a ss e d wi th a curv e d
n e e d l e th roug h th e upp e r s urfac e o f th e inv e r t e d fl ap s o a s t o fir m ly
bin d i t t o th e p ar ts b e n e a th S o m e ti m e s wi th i n t e rrup te d an d s o m e
.
'
t i m e s wi th a c o n tin u o u s c at gu t s u t ur e t h e fr e e e d g e A F B wa s n ow ,
s e cur e ly fa s t e n e d t o t h e e d g e A D B Irrigat ion wi th

( Se e F ig
2
. .
1In
th e fi s t tw
r o ca e s s s i l k was u s e d an d , , I th i n k i nt
, e rfe r e d w i th h e a li ng .
l of s u tu e w as t h u s em o v e d t s fi s t ul
2
Th e i n e r r o a di ta n c e from th e a, la rg e ra w s ur
fa c e s w e re b ro ug ht i h c o n ta c t , a n d t w o t hi k l
c a ye r s co v e re d th e fi s t ul a.
UR E TH R O-P E R I N E A L F I S T ULA . 46 7
c arb olic a ci d or bich lo ri d e s olu tion was u s e d thr ough ou t e xc e p ting ,
i n t h e fir s t ca s e.
T h e d r e s s ing con s i s t e d o f i o d o for m i o d o for m g a uz e an d a co t t o n

, ,
a d h e l d in plac e wi t h a T b a n d ag e A orp h in e s uppo s i t o ry wa s

’
p ,
- . m
u s u ally in tr o d uc e d b e for e th e dr e s s ing .
T h e s ub s e qu e n t tr e a t m e n t con s i s t e d in a fr e e u s e o f O piu m t o p re
v e n t th e r e c tu m fro m a c ting a n d th e u s e of th e s o ft ca th e t e r th e l at t e r
, ,
a t l e a st e v e ry s ix h our s a n d a s m uch o ft e n e r a s wa s r e qui r e d S o m e t im e s

.
th e c a th e te r woul d b e r e quir e d a s fr e qu e n tly a s e v e ry th r e e h o ur s a n d ,
s o m e ti m e s i t c a u s e d m o d e ra t e ur e th ri ti s .
F IG 4
. .
The ca th e te r was alway s e xc e p tin g in th e fir s t ca se th u s u s e d : I t

, ,
wa s in tr o d uc e d a n d th e wa te r d rawn o ff T h e bl ad d e r was th e n g e n tly

.
w ash e d o ut wi th a w e ak s olu tion o f e i th e r c arb oli c aci d or b or ax I

pr e fe r th e la tte r O n wi th drawing th e in s tru m e n t th e e n d wa s tigh tly
.
,
pinch e d un til th e wh ol e ca th e t e r h ad b e e n r e m ov e d fro m th e ur e thra .
T hi s pl a n s e e m e d t o r e d uc e th e ch anc e of con t am in at ing th e woun d

wi th urin e fro m th e in s i d e t o a m ini m u m an d i s c e r tainly m uc h t o b e
,
pre fe rr e d t o t h e pr a c t ic e r e co m m e n d e d by S zy m ano ws ki o f ty i n g in a
c ath e te r or t h at m a d e u se o f by m e in m y fir s t ca s e O f p unc t uring t h e
,
bl a d de r t hrough th e r e c t u m .
A S ECO ND C A S E O F R E C O VE R Y F R O M P ER F O R
A T I N G GU N S H O T W O UN D O F T H E A B D O
M E N TH R O U G H LA P A R O T O MY .
1
BY WI LL I A M T B U LL M .
,
. D .
,
O F NE W YOR K .
S U R GE O N T O T H E N EW YO R K , AN D C H AM BE R S S T RE E T H PITAL OS S
Dani e l M ah on e y ae t 2 5 s ailor w as brough t t o th e Ch am b e r s S tr e e t

,
.
, ,
Ho spi tal in a c ab Aug us t 1 2 th 1 8 8 6 a t 7 :4 0 P M H e cam e fir s t t o

, , ,
. .
th e r e c e p tion r oo m wi th ou t a s s i st anc e co m plai ning only o f p ai n in th e ,
ab d o m e n wh il e w alk i n g Tw e n ty m inu te s b e for e in a fr i e n dly s c uflle

.
‘
, ,
h e h a d b e e n sh o t wi th a pi s t ol o f 3 8 calibr e H e w as S ligh tly pal e an d .
wa s p e r s piri n g fr e e ly a n d s i n c e th e inj ury h a d fe l t s o m e n au s e a b u t

,
h a d n o t vo mi t e d .
T h e axillary t e m p e ra t ur e was P 9 6 full R 2 6 Th e ab d o m e n . ,

. .
wa s norm al t o s ig h t a nd t ouch b ut fo r th e pr e s e nc e o f a b ull e t woun d ,
t wo inch e s b e low an d t wo inch e s t o t h e l e ft o f th e u m bilicu s in th e vi ,
c in i t
y o f w h ich th e r e wa s t e n d e r n e s s o n pr e s s ur e Th e s kin abou t th e .
woun d was n orm al th e e dg e s w e r e black e n e d an d th e l u m e n occupi e d

,
by a dri e d clo t o f bloo d T h e t row s e r s j u s t b e low t h e wai s t ban d an d

.
,
-
,
two s hir t s w e r e fo u n d t o b e pi e rc e d by t h e b ull e t no t rac e o f wh ic h ,
coul d b e foun d i n s i d e th e s ki n o f th e t ru n k Th e u rin e wa s draw n . .
I t was fr e e fro m bloo d R e c t al e x a m i n a ti on wa s n e ga t iv e

. A fte r .
wa shing th e s kin th orough ly th e woun d wa s cov e r e d wi th a co m pr e s s ,
o f io d o for m gauz e an d ab s orb e n t co tt on a n d gr / m orp h in e a dm in l

.
s
i s t e re d h ypo d e r m ically T h e m a n h a d alway s b e e n in goo d h e al th

. .
dran k only o cca s ionally an d was o f e xc e ll e n t p h y s i qu e T h e d an .
ge r o u s ch arac t e r o f th e w ou n d was e xplain e d t o h i m a n d h e con se n t e d ,
a t o n c e t o an op e ra t ion Two h our s la te r h i s co n d i tion wa s a s fol

.
low s : P 1 0 4 R 2 4 T 9 8 N o p ain s li gh t r e c t al t e n e sm u s ab d o
.
, .
,
'
. .
, ,
m e n unch an g e d .
A prob e coul d n o t b e in tro d uc e d b e yon d th e m u s cular lay e r H e .
1
R e p o r te d at th e m e e ti n g of th e N e w Y or k l
S urg i c a S o c i e ty, O c to b er 1 1 , 1 88 6
F or re
p or t of D r Bu ll s fi s t s
’
r ca e, s e e A NNA L S OF S U R GE RY , 1 88 5 , Vo l . 1 , p 47 9
.
'
( 46 8 )
LA P A R O T O M Y P OR G UN S H O T WO UN D .
46 9
p ati c d ulln e s s norm al N o e m p hy se m a ab o u t th e woun d H e h ad

. .
m a d e an an t e m or t e m s t at e m e n t to th e coron e r an d h a d b e e n vi s i te d
-
by s e v e r al fri e n d s .
At 9 :4 0 P M e th e r wa s a dm ini s t e r e d by Dr T i e rn an an d th e o p e
. . .
,
ra tion wa s b e gun fi fte e n m inu te s la te r T h e woun d wa s e xplor e d by .
a n in ci s i on 3 i n c h e s lo n g an d foun d t o p a s s d ir e c t ly b a ckwar d th rough
th e r e c t u s m u s c le T h e inci s ion wa s th e n m a d e in th e m e d i an li n e
.
fro m th e u m bilicu s t o th e p ub e s Co i ls o f sm all in te s tin e ca m e at

.
onc e in t o vi e w T h e y w e r e b ath e d in o d orl e s s bloo dy s e ru m s e v e ral

.
,
ounc e s o f wh ic h e s cap e d fro m th e cavi ty A S th e g e n e ral con di tion .
di d n o t in dica t e an y s e riou s h e m orr h ag e I proc e e d e d t o e xam in e th e ,
in t e s tin e wi th ou t wai ting to s pong e o u t th e cavi ty Ab ou t h al f th e .
l e n g th o f th e sm all in te s tin e wa s d rawn o ut rapi dly s p ong e d i h , ,
s p e c t e d an d p lac e d un d e r war m t ow e l s b e for e a woun d wa s d i s c ov ,
e red . T h e n a loop wa s m e t wi th th ro ugh wh ich th e b all h a d e vi d e n tly
F ro . 1 . F I R S T PE R F E R AT I NG WO U ND F IG . 2 . S E CO ND WO UND O F S MALL IN
OF S MALL I NTE S I I N E ’ ‘
. T E S TI N E .
( E n tran c e
) O p p o s i te No . I .
p asse d . The woun d on

i d e was e vi d e n tly th at o f e n tr anc e ( F ig 1
on e s .
I t wa s a s larg e a s th e t op o f a l e ad p e ncil i t s e d g e s a dh e ring wi th ou t ,
prol ap s e o f th e m ucou s m e m bran e Th e o th e r d ir e c tly O ppo s i te an d .

,
m i dway b e t w e e n th e fr e e an d a tt ach e d bor d e r o f th e gut was ,
t wic e a s larg e wi th a li tt l e fol d o f m ucou s m e m bra n e occupying i t s
lu m e n ( F i g . T h e r e wa s no e s cap e o f fe c e s T h e gut wa s h e l d
.
.
up by an a ss i s t an t a s p ong e pl ac e d b e n e a th e ac h woun d an d th e ab
, ,
d o m i n al inci s ion pro t e c t e d by a larg e fl a t s po n g e w h il e th e s u t ur e s w e r e ,
i n se r te d afte r Le m b e r t s m e th o d T h e fi n e st iron d y e d s ilk wa s e m

’ ’
p loy e d .
T h r e e s u t ur e s s u ffic e d for th e fir s t an d s ix for th e s e con d woun d , .
I o d o for m was rubb e d :alo n g th e li n e o f s u tur e S e v e r al m or e fe e t .

47O WI LLI A M T . B ULL .
of sm all i n te stin e w e r e e xa m in e d wi th ou t fi n d i n g any o th e r S ign o f i h

j ury th an h al f a d oz e n s ubp e ri t on e al e xtrava s a tio n s o f bloo d n o
gr e ate r in ar e a th an a p e a T h e m e s e n te ry wa s d o t te d wi th s m all e r
.
e x tr ava s a t ion s Th e r e wa s no d e ci d e d cong e st ion o f th e gut nor an y

.
ly m p h y e xu d a t ion on i t s s ur fac e T h e p e lvi s wa s th e n occupi e d by

.
o n e or t w o coil s o f s m all in t e s t in e an d th e s ig m oi d fl e xu re wh il e t h e ,
c ae cu m proj e c t e d fro m th e righ t s i d e p ar tly ob s cur e d by th e s m all ih

t e s ti n e . To e xa m in e th e r e st o f th e gut I r e m ov e d wi th th e h an d, ,
a n d s po n g e s a t l e a s t t wo
, t u m bl e r ful s o f clo t t e d bloo d I t was th e n .
e vi d e n t th e r e w as a h e m o rr h ag e fro m s o m e v e s s e l d e e p in th e p e lvi s .
I t wa s n o t v e ry ac t iv e for th e pr e s s ur e of a larg e s po n g e con tr olle d i t

,
.
All th e sm all in t e s tin e th a t coul d b e d rawn o ut was th e n h e l d un d e r

t ow e l s ou t si de th e woun d an d th e sig m oi d fl e xure al s o e xpo s e d t o
,
F ro .
3 . THi R D WO UN D ; OF S i G M O i D F LE X URE .
( Pe n e tr a ti o n i )
u n c e r ta n .
vi e w . A longi t u d inal woun d an inch i n l e n g th was m e t wi th clo s e

, ,
t o th e a t t ac h e d b or d e r T h e m u s cular coa t wa s b ar e d b ut no m u
.
,
cou s m e m bran e w a s s e e n ( F ig , T h e woun d wa s clo s e d wi th fo ur

.
s u t ur e s Th e c oe cu m was now pu s h e d o u t o f th e way a n d a vi e w O b

.
t a in e d o f th e s ig m oi d m e s ocolo n a n d t h e s ourc e o f th e bl e e di ng di s
,
cov e r e d t o b e a circul ar wou n d n e ar t o i t s a tt ac hm e n t t o th e m i ddl e

lin e an d fully th r e e inch e s fro m th e e d g e o f th e g ut ( F ig
, Whe n , .
th e m e s ocolon wa s m a d e t e n se by trac t ion on t h e fl e x u re t h e bl e e d i n g
c e a s e d ; wh e n r e lax e d a s tre a m o f v e nou s bloo d i s s u e d fro m th e woun d

s o copiou s ly a s t o fill t h e cavi ty o f th e p e lvi s o n e t h ir d full se v e ral -
t i m e s b e for e i t wa s co n t roll e d Pr e s s ur e b e low th e woun d s t opp e d i t

.
,
b ut th e v e s s e l fro m w h ich th e bloo d i ss u e d coul d n o t b e s e e n e v e n a f ,
t e r th e wou n d was e nlarg e d wi t h s ci s s o r s ; T h e t i s s u e s on t h e lo we r

LA P A R O T OM Y F OR G UN S H O T WO UN D .
47 1
ed g e wh e n pr e s s ur e was e ffe c ti v e w e r e finally gra s p e d in a larg e

, ,
.
“
bi t e wi th long ar te ry cla m p s a silk li gat ur e p a s s e d by m e an s o f
, ,
a curv e d n e e dl e un d e r th e bla d e o f th e forc e p s a n d t i e d as th e forc e p s

,
w e r e wi th dr awn T hi s con tr oll e d th e bl e e ding Ab ov e an d t o th e

. .
inn e r s i d e of th e wo un d th e r e was an e x trav as a tion of bloo d wh ich a s ,
i t wa s fir m ly clo tt e d wa s n o t in t e r fe r e d wi th
, Ano th e r woun d o f th e
.
m e s ocolon s t ripping o ff i t s p e ri t on e al coa t ov e r an ar e a as larg e as a
quar te r was foun d clo se by ( F i g , T h i s a n d th e p r e c e d i n g o n e w a s

.
F i t} 4
. T H E T wo WO UN
DS O F TH E V I E SO C O LO N
. .
( T h e s up e r fi c i a l on e in v lv
o ed
l
th e p e r i t o n e um o n y ; th e d e e p e r o n e , w a s th e s ourc e o f th e h e m o rr h ag e .
)
n ot s u t ur e d b ut rubb e d th oro ugh ly wi th io do for m

,
O n e o f th e . ap
e n d i c e s e piploic ae w a s fou n d t orn a n d bl e e d ing a t i t s e xt r e m i ty It

p .
w a s ti e d a t th e b a s e wi th ca t gu t an d c ut o ff Con s i d e rabl e bloo d

. h ad
47 2 WI LLI A M T . B ULL .
b e e n o b s e rv e d t o co m e in t o th e p e lvi s fro m th e r e gion o f th e c oe cu m

d uri n g th e e ffor t s to s t op th e h e m o rr h ag e alr e a d y r e fe rr e d t o b ut on ,
car e ful sp o n gi n g th e r e was foun d no fr e sh s o urc e o f bl e e ding A .
s p o n g e in t h e gr as p o f a lo n g forc e p s wa s pa ss e d in t o bo th th e lu m b ar
an d e piga s t ric r e gio n s a n d bro u g h t o u t p e r fe c t ly cl e an T h e o m e n tum .
h a d n ot b e e n s e e n up t o th i s ti m e b u t th e s p ong e d r e w i t o u t fro m t h e ,
le ft lu m b ar r e gi on an d i t s e x t r e m i ty b e in g foun d lac e ra t e d b u t n o t ,
bl e e di n g was t i e d t o th e e x te n t o f 3 inch e s an d c u t off T h e r e c t u m

, .
wa s agai n e xa m i n e d wi th th e fi n g e r a n d th e b ull e t n o t b e i n g foun d ,
th e r e I conclu d e d i t w a s lo d g e d in th e e x tr ava s at e d bloo d in th e m e s

,
o c o lo n a n d d e ci d e d n o t t o s e arc h for i t fur th e r

, S e v e ral p in t s o f w ar m .
carb olic aci d s olu tion ( ab ou t 1 t o 1 00) w e r e p our e d fro m a pi t ch e r i n

t o t h e p e lvi s a n d s po n g e d o ut a n d th e in t e s t in e s a s th e y w e r e r e
, ,
p la c e d fr e e ly wa sh e d wi th th e s a m e s olu ti o n Th e ab d o m i n al woun d
, .
w a s s u t ur e d wi th s ilv e r wir e an d s i lk s u t ur e s p a s s ing th rou gh all th e

la y e r s an d wi th s up e rfi ci al ca t gu t s u t ur e s
, A co n tinuou s c at g ut .
s u t ur e wa s appli e d t o th e p e ri t on e u m I o d o for m gauz e cov e r e d th e .
li n e o f s u tur e an d ov e r th i s a co m pr e ss o f carboliz e d gauz e wi th a

,
m e t al li c coil h e l d in plac e by a bin d e r T h e i nci s ion i n t o .
th e b ull e t woun d wa s s t u ffe d lig h t ly wi th io d o for m g auz e T h e d ur a .
t io n o f th e op e ra t ion wa s 1 h our an d 5 0 m inu t e s T h e in t e s t in e s w e r e .
h e l d ou ts i de th e cavi ty j u s t on e h our ; a n d th ir t y m inu t e s w e r e s p e n t

in applying th e s u t ur e s E th e r wa s giv e n for 2 h our s an d 1 0 m inu t e s
. .
Th e p ul s e a t th e e n d o f th e fir s t h our w as 1 1 6 a t th e clo se o f th e op
e rat i o n 1 2 8 an d o f fair volu m e
, Th e e x t r e m i t i e s w e r e col d b ut r e s
.
,
i ra ti o n was s a t i s fac t ory F our s ubcu t an e ou s i n je c t ion s e ach o f wh i s

p .
k e y 3 j an d t inc t digi t ali s h t x w e r e giv e n i n th e la s t h our

. .
I wa s for t una t e in h aving th e a d vic e o f Pro fe s s or J D Bry an t wh o . .

,
agre e d wi th m e a s t o th e propri e ty o f th e O p e r a tio n an d th e a s si s t

anc e o f Dr C H Wilkin Dr B F Curti s a n d Dr G arri s o n ; Dr Park e
. . .
, . . .
, . .
,
Dr Ti e rn an an d Dr Bryan t of th e h ou s e s t a ff ; Dr R ob e r t E u s tic e
.
, .
, .
,
an d Dr J o h n P A d a m s al s o r e n d e r e d valuabl e h e lp
. .
, T h e roo m was .
n o t s p e cially pr e par e d fo r th e O p e ra t ion ; i t i s u s e d fo r o ut p a t i e n t s
d uri n g th e d ay Bu t in o th e r r e s p e c t s th e u t m os t a t t e n tion wa s giv e n

.
t o an t i s e p t ic d e t ail s T h e s p o n g e s w e r e t ak e n fro m a 5 p e r c e n t s o
. .
lu t i o n o f carb olic aci d in wh ic h th e y h a d b e e n lying fo r t wo m on th s

, ,
a n d rin s e d i n war m 2
p e r ce nt s olu t i o n D u ring t h e O p e ra t ion
. .
t h e y w e r e wa sh e d in a m uc h w e ak e r abou t 1 t o 1 0 0 an d t h e s ilk e m , ,
ploy e d I b oil e d m y s e l f in a 5 p e r c e n t s olu tion for h al f an h our p re .
v i o u s t o th e op e ra t io n T h e t ow e l s e m ploy e d w e r e old on e s wh ich

.
h a d b e e n wa s h e d in p e r ce nt s olu t ion a n d w e r e k e p t war. m wi t h a ,
h e ate r .
LAP A R O T OM Y P OR G UN S H O T W0 UN D .
47 3
Af te r Hi s tory f
o tfi é cas e —Augu st 1 4 th , 1 0 A . M .
,
P . 1 08, R .
34, T .
1 00 .T h irt y s ix h our s afte r op e ra t ion R e ac tion wa s pro m p t an d i c e

-
.
,
w ate r wa s run thr ough th e coil t w e lv e h our s lat e r an d i s now con tin ,
'
ued .Mag e n di e s s olu ti on “Lxxxii h ad b e e n giv e n s ub cu tan e ou s ly in

’
,
5 inj e c t ion s I c e by .th e m ou th ; a n d by r e c t u m 5 e n e m a t a o f b e e f
p e p to n o i d s gi lj gr a n d wh i s k e y 3 3 s D u ring th e la s t 1 2 h our s h e h a d
. .
b e e n allow e d ch am p agn e gij or m ilk an d li m e wa te r §ij e v e ry 2 h our s , .
H e h a s d oz e d m o s t o f th e ti m e co m plain e d o f a li ttl e p ain Th e r e i s

, .
s li g h t ty m pani t e s H e i s t roubl e d wi th occa s ion al coug h wi th s ligh t

.
,
FI G .
5 . A PPE A R ANCE O F TH E WO U ND O N TH E E I GHTH D AY . A Pr o trud i ng i n te s
.
ti n e ; B . Po i n t o f o ri i n al
g w o un d ; C . Sil v er wi re re la x ati o n s u t ur e s e c ur e d jb y p i ece s
of w oo d.
m uco u s xp e ct orat ion Urin e drawn by c at h e t e r h a s a m oun t e d t o

e .
§xx ,
I t i s h ig h color e d an d con t ain s ur a t e s b u t no gr ,
.
1 0 20 1 0 P M
. P 98 R 2 6 T 1 00
. .
,
Tongu e i s m oi s t an d th e re
.
, .
,
. .
,
h a s b e e n n o n au se a .
Augu st 1 7 th F i fth d ay 9 A M P 8 0 R 2 4 T
. Up t o
,
.
, .
, .
, .
th i s t i m e th e progr e s s o f th e pa t i e n t h a s b e e n un e v e n t ful
474 WI LLI A M T . B U LL .
T h e r e h as b e e n s ligh t p ain an d tym p ani ti s n o n au s e a or vo m i ti ng ,

.
Li qui d d i e t h a s b e e n giv e n a n d occa s ional d o s e s o f m orp h ia h yp o d e r

,
m i c ally . T h e col d wa t e r coil h a s b e e n co n t i n u e d t h ough th e t e m p e ra ,
t ur e h a s n o t b e e n ov e r nor th e pul s e ov e r 1 0 0 A C opiou s .
n o rm a l b u t s o ft fe cal e vacua tion t ook p lac e a ft e r an e n e m a

,
A p ur .
ule n t co ll e c ti on i n th e wou n d m a d e i t se l f e vi d e n t by d i s ch arg e ab ou t
th e s u t ur e s T h e lin e o f u n i on wh ich wa s fi rm wa s brok e n d own an d

.
,
a t h in lay e r o f p u s foun d a t th e b o t t o m in th e e x t rap e ri t o n e al t i s s u e ,
b u t in th e upp e r h al f o f th e wo un d th e p e ri t o n e u m alo n g th e lin e o f

s u t ur e w a s s lo u g h in g a n d on par ti n g i t s e d g e s a p or t ion o f i n t e s t in e
,
wa s vi s ibl e fir m ly a dh e r e n t t o th e p ari e t e s
, I m opp e d i t wi th 2
.
p e r
c e n t carb olic aci d an d s t u ffe d ligh tly wi th io d o for m gauz e T h e p ul s e

. .
,
r e s pira tion an d t e m p e ra t ur e w e r e nor m al a ft e r thi s .
Augu s t 1 8 th S ix th d ay Whil e coug hi n g in th e n i gh t a pi e c e o f

. .
g u t pro t ru d e d fro m th e u pp e r thir d o f wou n d b u t d i d n o t o v e rlap th e,
s ki n
. I t s s ur fac e wa s co a t e d wi th gr a yi s h ly m p h wi th gra n u la ti o n s in
'
p lac e s T h e wo un d w a s 5 inc h e s lo n g an d 2 inch e s wi de

. .
T h e e d g e s w e r e h e ld t og e th e r wi th t wo r e laxa ti on s u t ur e s o f s i l
v e r wir e an d co m pr e s s i on m a d e o n t h e in t e s ti n e wi th a s m all
, p ad o f
io d o for m gauz e a n d w oo d By m e a n s o f th e s e th e gu t wa s p u sh e d
.
,
b ack fro m d ay t o d ay w h i le th e e d g e s w e re b e i n g d rawn t og e th e r an d ,
th e low e r par t o f th e wou n d was filli n g wi th gra n ula tio n s O n th e .
n i n th d ay s o li d fo o d was allow e d O n th e e ig h t e e n t h d a y t h e i n te s t i n e
.
wa s on a l e v e l wi th th e wou n d t h e w h o le s ur fac e
, i nc h e s lo n g an d
wi d e ) was gr a n u la ti n g fi n e ly S kin gra ft s we r e p u t in se v e ral t i m e s
. .
Ba ls am o f Pe ru r e pla c e d th e i o d o for m a n d a t t h e e n d o f e i gh t w e e k s
,
t h e cica t riz a tion wa s co m pl e t e I t i s n o w only a w e e k th a t h e h a s

.
b e e n o u t of b e d .
Wi th th e r e por t o f th e ca se th e p a ti e n t wa s pr e se n te d for th e in s p e c
,
t i o n o f th e m e m b e r s o f th e S oci e t y .
TWO CA S ES LA P A R O T O M Y F O R PE R F O R A T
OF
ING GU N S H O T W O U N D O F A B D O M E N
WI T H F A T A L T ER M I NA T I O N ‘
.
C AS E I .
— Gu n s /zo t w ou n d of a Od o m e n F o u r i n tes ti n a l p erf o r
a t i on s , a n d o n e o Ola d cle r ; Lap a r oto m nd s u tu r i n
f y a
g s i x li o u rs
la ter ; D e a t/z n i n e h o u r s a te r La a r o to m y
f p —BY D R R O BE R T
.
A BBE ( N e w Y o rk )
,
.
Ge org e 53 Hi ll
g e n t,l e m an
ae tlarg
. e p h y s i
, qu e a n d v e r y fa t— a fte r
ri si n g on t h e m o rning o f J uly 8 th 1 8 8 6 e m p ti e d h i s bla dde r an d , ,
dr e s se d Ve ry s o on a ft e r war d s w h il e drawin g s o m e a rt icl e s fro m a

.
,
lo w cupb oar d sh e lf w h il e b e n d in g ov e r dr e w a s m all r e volv e r t o war d

,
h im w h ic h d i s c h arg e d at t h e s h e lf le v e l an d e m p ti e d i t s e lf in t o h i s b e lly
, , .
Walk e d t o an o th e r ro o m an d t h e n a d i s t anc e o f t wo block s Wa s , .
brough t t o S t Luk e s H o s pi t al a t . A M an d s e e n by m e a t
’
. .
,
1 2 o c lock H e wa s th e n s u ffe ri ng fro m s h ock t o s lig h t e x t e n t a s

’
.
,
s h own by p a lli d m ucou s m e m bran e s ( t ongu e d e s pon d e ncy an d ,
d ull e d in t e ll e c t Y e t p ul s e wa s e xc e lle n t a t 8 2
. H a d vo m i t e d onc e .
wh e n giv e n s o m e bran dy dir e c tly a fte r acci d e n t Was n o t s p e ci ally .
r e s tl e s s Co m plain e d o f rapi dly incr e a s ing p ain ov e r th e b e lly prin

.
,
c i p a lly fro m th e n av e l upwar d t owar d le ft h yp o ch on dri u m T ym p a .
n i t e s n o t m ark e d b ut b e lly h a d a full fe e li n g

, T h e ar e a ab ou t th e n a .
ve l h a d a r e s i s t i n g fe e lin g n o t ob s e rv e d e l s e wh e r e a n d was d ull on

per ,
c u s s i on .
A sm all bull e t woun d was s e e n e xac tly in t h e m e d ian lin e th r e e ,
inch e s ab ov e th e p ub e s Prob e p a s s e d th rough i t a t rig h t a n gl e s t o th e

.
s ur fac e H i s u ri n e wa s drawn t o s e e wh e th e r th e bl ad de r h a d b e e n
.
p e r fora t e d an d e ig h t ounc e s o f cl e ar blo o dl e s s urin e we r e d ra wn by a

, ,
s o ft c a th e t e r .
O p e ra t ion : 2 3 0 P M E th e r Pul se un d e r 9 0 fi rm goo d quali ty

. . .
, , ,
con di ti on only ch ang e d fro m 2 h our s b e for e by incr e a si n g d e e p an d

v agu e ab d o m in al p ai n Ty m pa n i t e s b e g i nning t o S h ow a n d c e n t ral a h
.
,
d o m in al fu ln e ss d ull e r m e di an ,
.
M e dian i nci s ion fro m 2 inch e s b e low u m b ilicu s t o n e ar p ub e s C ut .
‘R e
p orte d at th e m e e ti n g o f th e N e w Y or k S u gi c
r al S o c i e ty, D e ce m b e r 1 1 th , 1 8 8 6
( 47 5 )
476 R OBE R T A E E E .
t in g th rough an infl am e d p e ri t on e u m lin e d wi th ly m p h was fo u nd

,
.
O p e n e d up an e ncy s t e d colle c t ion ( a m oun t ing t o ab ou t a pin t) o f

gr e e ni s h wa t e ry flui d s o m e wh a t m u dd y wi th ly m p h fl ak e s an d fe c e s
,
.
I t was c o nfin e d again s t th e ab d om inal wall an t e ri orly wi th t h e m att e d

in te st in e s wh ich w e r e alr e a d y coa te d wi th a th ick lay e r o f lym p h wh e re ,
e xp o se d t o th e flui d w h ic h a s i t accu m ula t e d wa s forci n g th e m away

, , , ,
a n d e n larging t h e s ac co n t aining i t T h e flui d ca m e fro m a coil o f

.
s m all i n t e s t in e s c e n t rally plac e d s h o wing t wo p e r fora t ion s

, o n e n e ar ,
i ts a tt ach e d bor de r th e o th e r O pp o s i t e th e m e s e n t e ric s i d e

, T h e la t .
t e r d i s ch arg e d fr e e ly t h e s a m e gr e e ni sh wa t e ry fl ui d a s wa s in th e s a c .
E ach in spira tion pu m ping i t o u t in copiou s j e t s T h e p e r fora t ion clo s e .
t o th e m e s e n t e ry h a d i t s m ucou s coa t e v e r t e d a n d wa s t h u s se e m ingly ,
plugg e d up T h e flui d was p e rfe c tly confin e d by th e ly m ph b arri e r on

.
a ll s i d e s
. A fte r s ponging th i s c a vi ty th e woun d s o f th e g ut w e r e r e a d
,
’
ily and th orough ly clo s e d by Le m b e r t s s u tur e N o o th e r coil s w e r e .
inj ur e d in th i s s pac e T h e in te s tin e s w e r e now g e n t ly p ar t e d an d i t

.
,
wa s r e adily d e m on s tr at e d th a t th e r e was no g e n e ral p e ri t oni ti s for th e ,
p or tion o f e ach coil facing th e inflam e d s ac was r e d an d h e avily co ate d

wi th ly m p h w h il e th e fr e e s i d e s w e r e u ni n fl am e d an d r e t ain e d th e ir
,
lu st e r Ano th e r pi e c e o f s m all in t e s t in e wo un d e d by a d oubl e p e rfo

.
,
ra tion fro m s i d e t o s i de was foun d s o m e wh a t b e lo w t h e larg e coll e c tion

,
o f flui d j u s t d e s c rib e d I t al s o wa s i s ola t e d by e xc e ll e n t pla s tic a d

.
h e si on s b e t we e n n e igh boring coil s an d con t ain e d a s m all a m ount o f

,
fe cul e n t infla m m at ory flui d T h e involv e d p ar ts w e r e cl e an e d an d th e s e

.
t wo p e rfora t ion s w e r e s u t ur e d N o o th e r woun d s b e ing s e e n a rapi d

.
,
an d c a r e ful s urv e y o f th e in t e s t in e s fro m d uo d e nu m t o colon was m a d e .
T h e b ow e l wa s p a s s e d fro m th e fing e r s o f o n e h an d t o th o se o f th e
ot h e r m o s t ly wi th in th e ab d o m in a l c avi ty
,
War m s pong e s fro m s u b
.
li m at e s olu t ion e nv e lop e d any c oil s th a t e s cap e d at onc e T h e r e wa s no

, .
fu rth e r inj ury o f th e b ow e l A fin al in s p e c tion o f th e p e lvi s sh ow e d a

.
p e rfor at ion o f th e p e ri ton e u m b e tw e e n th e bla dd e r a n d r e c tu m w h ich ,
in thi s s ubj e c t wa s un de rlai d by fat an inch th ick Th e woun d w as .
s m all an d n o t inflam e d I t wa s e vi d e n t no u rin e or fe c e s h a d e s cap e d

.
t o s e t up ir ri t a tion . A prob e p a s s e d d own an d b ackwar d an inch or

s o b u t gav e no fur th e r clu e t o t h e d ir e c t ion o f t h e b ull e t It se em ed
-
, .
prob abl e th at th e m i s s i le h a d ov e r s h o t th e bla dd e r a n d pr e s u m ably

t r av e r s i n g t h e r e c t u m i m b e dd e d i t s e l f in t h e s acru m T h e r e h ad b e e n .
no bl e e ding in t o th e p e ri t on e al c avi ty an d th e l oop s o f in te s tin e dr awn

,
fro m th e p e lvi s w e r e fr e e fro m all s ign s o f inflam m a tion T h e fi fth .
woun d was s u t ur e d an d th e p e ri t on e al cavi ty s pong e d o ut wi th c ar e

, ,
Dr M c Burn e y a s s i s ting S pong e s we r e th ru s t d own in t o th e p e lvi s

. .
LAP A R O T OM Y F OR P E R F O R A TI N G G UN S H O T W O UN D .
477
an d ab ou t th e ki dn e y s b u t r e t urn e d qui t e a s d ry a s wh e n in tro d uc e d

, ,
s h owi n g t h a t no fl ui d h a d l e ak e d in d uring th e op e ra ti on T h e p e lvi s .
wa s d rain ed b ya T h o m a s gla s s t ub e e m e r ging a t th e low e r e n d o f th e

’
woun d wh ich wa s o th e rwi se t r e a t e d as u s ua l B e for e l e aving th e t a

, .
b le a s o ft ca th e te r w a s i n tro d uc e d in t o th e bla dd e r a n d t wo or th r e e
ounc e s o f c le ar urin e d rawn T h e wou n d s ugg e st e d a sm all b ull e t .
,
NO . 2 2.
S u l s eouen t II zs tory
'
—T h e p a ti e n t
co m e o u t fro m e th e r did n ot
w e ll b ut r e m ai n e d i n a s o m nol e nt c o ndi t io n h is br e a th ing b e ing ch ar

, ,
a c t e r is t i c o f pul m onar y oe de m a H e wa s r e s t l e s s a n d h a d to b e t i e d
.
in b e d P ul s e in t e r m i t te n t a n d n o t s trong A ca th e te r b e ing p a s s e d
. .
’
at 7 o clock no urin e wa s foun d in bla d d e r
, H e was fr e e ly s ti m ula te d .
’
wi th wh i s k e y an d digi t ali s a n d h e ar t s ac t ion gr e a tly i m prov e d A
, .
col d wa te r coil was plac e d ov e r ab d o m e n .
At 1 1 P M h i s pul s e co ul d s carc e ly b e fe lt a t th e wri s t t h oug h i t

. .
,
h ad b e e n fairly goo d a fe w m o m e n t s b e for e Pro m p t s t i m ula tion .
brough t i t up ye t s oon a ft e rwar ds h e was t ak e n wi th a s h or t c o n vul

,
s iv e a t t ack t o s s ing abou t th e b e d a n d th rowing ar m s abo u t

, H e s ud .
d e n ly c e a s e d b r e a th ing Ar tificial r e s pira tion wa s i m m e dia te ly b e gun

.
a n d an e n e m a o f bran d y giv e n w h ic h was n o t r e t ai n e d H e d i e d at .
1 1 :1 5 P . M .
F ro m i
p e ra t io n a s I wa t ch e d h i m fro m h o ur t o h our
th e t m e o f th e O , ,
h e s e e m e d t o b e laboring un de r th e s train o f p ul m ona ry oe de m a b re a th ,
ing O ppr e s s iv e ly wi th m or e a n d m or e co ar se r al e s an d labor e d sh allow

i n spira tion T h i s wi th s e m ico m a an d s uppr e s s ion ( wh ich la tte r wa s
.
, ,
-
_
co m pl e te a fte r O p e ra tion) an d fi n ally a fa t al convul sion whi ch I s a w ,
le d m e t o a s s i gn ur ae m i a a s th e r e al cau s e o f d e ath .
A u top sy — J uly 9 th 1 1 :3 0 A M ,
. .
I n sp ecti on —T h e b o dy i s w e ll nou ri s h e d rigor m or ti s w e ll m a rk e d , ,
n o oe d e m a Ve in s o f l e g s v e ry varico s e
. Th e r e i s an in ci s ion in t h e .
m e d ian lin e o f ab d o m e n e x t e n d ing fro m a poin t 1 inc h b e low t h e u m
b i li c u s t o ov e r th e s y m p h y s i s p ubi s e x t e n ding fro m lo we r e n d o f inci

s ion i s a larg e d r ainag e t ub e T h e woun d i s uni te d by nu m e rou s s u
.
t ur e s ab ou t inch ap ar t an d by four m e t al s u t ur e s 1 , inch e s ap ar t .
Pe ri t on e u m i s in t e n s e ly h yp e r ae m i c an d con t ain s r e c e n tly e xu d e d

ly m p h T h e p e ri t on e al cavi ty con t ain s t we lv e o unc e s o f p urul e n t
.
fl ui d In te s tin e s —T h e r e are two woun ds in th e lo we r p or tion of th e

.
j e j unu m oppo s i te to e ach o th e r and care fully s u t ur e d ; ab ou t 7 fe e t ,
ab ov e th e s e two woun d s are t wo o th e r woun d s opp o si te t o e a ch o th e r

an d car e fu lly s u t ur e d T h e in te s tin e s ar e n ot e l se wh e r e woun d e d
.
.
T h e m ucou s m e m br an e i s in t e n s e ly c on g e s te d ; th e m ucou s m e m bran e

47 8 R ODE R T A B BE .
of t h e lar g e in te s tin e i s d e e ply pig m e n t e d B all wa s foun d in b a si n.
wh e n in t e st in e wa s cl e an e d .
K i d n e y s are nor m al in S iz e T h e y s e e m t o co n t ain s o m e fa t in th e

.
cor tic e s an d ar e m o de ra t e ly h yp e r ae m ic .
S t o m ac h i s nor m al .
S p l e e n i s a t rifl e larg e an d s o ft in con s i s t e ncy .
Bla d de r —T h e r e i s a p e n e tra ting wo un d in th e roo f o f th e bla d de r

.
wh ich i s car e fully s u t ur e d An i n ci sio n t wo in ch e s in l e ng th w as m a d e

.
in th e roo f o f th e organ t o th e l e ft o f th e wo un d an d s h ow e d th e bla d

d e r t o con t ain ab ou t an ounc e o f m u ddy color e d urin e T h e organ .
wa s th e n car e fully r e m ov e d a n d s li t up th rough th e a n t e rior wall ,
th roug h th e pro s t a ti c ur e th ra a n d an ar e a i n ch in dia m e te r o f i n

,
t e n s e h yp e r ae m ia wa s s e e n a t th e ou tle t o f th e rig h t ur e t e r .
Liv e r con t ain s v e ry con s i d e r abl e fa t a n d a s li g h t i n cr e a se o f fibrou s

ti s s u e
.
H e ar t —Cavi ti e s are di la te d ; th e valv e s ar e co m p e te n t T h e aor tic .
an d m i t ral v alv e s ar e m o d e ra t e ly t h ick e n e d .
M i c r os cop i c E x a m i n a t i on — H e ar t T h e m u s cular fibr e o f t h e

.
h e ar t i s se e n t o b e granul ar ; th e t ran s v e r s e s tri ae are obli te ra t e d v e rv

‘
g e n e rally T h e r e are fr e e glob ul e s s e e n in th e c e ll fibr e s T h e in te r

. .
s t i ti al fa t i s al s o incr e a s e d .
K i d n e ys —Hyp e r aem ic ; s o m e a t rop h i e d glo m e ru li

.
~
.
Ve ry s ligh t incr e a s e in th e fibro u s t i s s u e e pi th e liu m in convolu te d

t ub e s : granu lar an d in plac e s fa tty .
Liv e n — T h e r e i s con s i d e r abl e fa t in th e liv e r a n d m o de r at e incr e a s e

in i ts fibrou s t i ss u e
R em a r k s —R e gar ding th e no t e by th e p a t h o logi s t th a t 1 2 o unc e s of
.
fl ui d w e r e foun d in th e cavi ty o f th e ab d o m e n I wo ul d no t e t wo i m ,
por tan t poin t s F i r s t I t was lik e p e ri t on e al s e cr e ti o n in s e v e r e acu t e

. .
p e ri toni ti s b ut h ad a sh a de o f gr e e ni sh color abou t i t th a t s ugg e s t e d

,
t o m e th e p o ss ibili t y th a t I h a d l e ft s o m e fl ui d a s a cau se for

p ar t o f th i s an d th a t i t h a d l urk e d in th e lo in s or b e tw e e n fol d s o f
,
in t e s tin e n ot r e ach e d by s ponging S econ d— T h e flui d was foun d in

.
th e lu m b ar r e gion o f th e ab d o m e n a t th e au t op s y a n d m y s pon ging ,
c e r tainly s w e p t in to th i s s e c tion b e for e clo s ing th e ab d o m e n .
T h e b ull e t wa s lo d g e d in th e b ladd e r all th e t i m e a n d wa s n o t d i s ,
cov e r e d by u s ing s o ft ca th e te r s T h e p oin t of i m p ac t on th e p os

,
t e ri o r b ladd e r w a ll wa s brui s e d b ut n o t lac e ra t e d .
C AS E 2 .
—Gun s h ot w ou nd f
o a Od o m e n P e rfor a ti on f
o li v e r ,
w i th r og res s i ve
p kmm /
or r zag e Lap a roto m y , p era t i on i n te r
o
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rup te d D
y d e u tk of tire p a t i e n t . B y D r W T B U LL ( N e w Y o rk )
. . . .
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, .
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wi th a pi s t ol o f 3 2 calibr e ab o u t 9 A M on Jan uary 1 0 1 8 8 5 a n d was . .

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brough t t o th e C h a m b e r s S tr e e t H o s pi t al by am b ulan c e two h our s

la te r O n a d m i s s io n h e w a s s u ffe ri n g fro m sh ock an d lo s s o f bloo d ;
.
th e s ur fac e o f b o d y a n d e x t r e m i t i e s wa s col d an d v e ry p a l e ; th e p ul s e
1 0 0 a n d fe e bl e R
5 an d T 9 4 ( axill ary )
°
2 ,
. . .
H e wa s ra t ional b ut d ull ; h a d vo m i te d onc e th e con t e n t s o f th e

s t o m a c h an d h a d li t t l e or n o p ain
, In th e e piga s tric r e gion was th e
.
e n t ranc e woun d o f th e b ull e t 3 i n ch e s ab ov e t h e u m bilicu s a n d

,
inch e s t o th e l e ft o f th e m e dian lin e T h e woun d o f e xi t wa s on th e .
righ t s i d e in th e axillary lin e m i d way b e tw e e n th e rib s an d cr e st of

,
iliu m . T h e r e was no bl e e d i n g fro m e i th e r woun d Urin e d rawn was .
n or m al i n app e aranc e F our h o ur s la t e r no twi th s t an ding e v e ry e ffor t

.
, ,
h i s con d i t ion wa s wor s e P ( te m poral ) 1 3 4 R 2 8 T

. .
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, .
h un d r e d a n d fi ft y c c o f a s alin e s olu t i on wa s i n fu s e d in t o th e c e p h alic

. .
v e in i n th e cour s e o f \
1 2 m inu t e s T h i s wa s follow e d by i m prov e m e n t
.
,
an d a t th e e xpira ti on o f t h r e e h our s th e ra dial p ul s e wa s 1 1 2 o f fair ,
volu m e R 2 4 T
,
.
, At P M a fte r con s ul t a tion wi th D r . .
, .
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,
.
quar t e r h our s a fte r a d m i s s ion a n d th e g e n e ral co n di ti on h ad un de r

,
gon e a d e ci de d ch an g e fro m th a t no t e d th r e e h our s a fte r th e in fu sion .
F ro m th e s i t ua ti on o f t h e t wo wo u n d s a n d th e e vi d e n t s ign s o f h ae m
o rrh a ge I i n fe rr e d th a t t h e liv e r h a d b e e n wo un d e d a n d un d e r t ook th e ,
op e ra tion in th e h op e o f arr e s ti n g th e b le e d i n g .
T h e inci s ion wa s m a d e fro m an i n c h b e low t h e e n s i for m car tilag e t o

th r e e inch e s ab ov e th e p ub e s an d s h ow e d a t on c e th a t th e b ull e t h a d
,
e n t e r e d th e l e ft lob e o f th e liv e r cu t ti n g i t n e ar ly in t w o ( tr a n s v e r se ly
) .
T h e i n t e s tin e s w e r e fl oa t i n g i n bloo dy s e ru m a n d clo t s ; a fe w lo op s o f

uni nj ur e d in te s tin e w e r e d rawn o u t in ord e r t o e xpo s e th e ri gh t lob e o f
t h e liv e r an d th e blo o d rapi d ly s po n g e d o u t b u t i t w e ll e d up fro m b e ,
n e a t h th e liv e r a s fa s t a s i t w as r e m ov e d T h e pul s e b e gan t o fai l .
a fte r th e ab d o m e n wa s o p e n e d a n d b e for e th e cavi ty h a d b e e n cl e ar e d

,
s o a s t o a llow a s a t i s fac t ory in s p e c tion t h e pa t i e n t e xpir e d j u s t h al f
an h our fro m t h e t i m e t h e a d m ini s t ra tion o f e th e r wa s b e gun Th e re .
w e r e n o o th e r vi s c e ral wo un d s T h e b ull e t h a d t rav e r s e d th e l e ft lob e

.
as d e s crib e d p a s se d th roug h th e roun d li g a m e n t

,
t h e low e r e d g e o f ,
t h e righ t lob e an d th e ab d o m i n al wall T h e v e s s e l s in th e t ran s v e r se .
fi s s ur e e s cap e d inj ury .

T H E RE S U L T S O F A N T I S E P T I C M E T H O D S I N TH E
T RE A T M E N T O F W O U N D S A S S H O W N ,
IN A S E RI ES O F 1 00 CO NS E C
U T I VE O P ER A T I O N S .
BY R O B ER T T . MORRIS ,
M D . .
,
OF NE W YO R K .
Th e o p e r a t i o n s a re n o t d e s c r ib e d i n t h e o r d e r i n w h i c h t h e y
w e r e p e r fo r m e d fo r t h e r e a s o n t h a t a cl as s i fi c a t i o n o f t h e
,
c a s e s a ll o w s o f s o m u c h m o r e c o m fo r t o n t h e p a rt o f t h e r e a d e r .
I n s p e ak i n g o f t h i s a s a l i s t o f c o n s e c u t i v e c as e s it i s n e c e s ,
s ary t o s t a t e t h a t a fe w t r i fl i n g o p e r a t i v e p r o c e d u r e s w h i c h w e r e ,
s a n d w i c h e d i n w i t h m y o th e r w o rk a n d w h i c h a r e h a r d l y w o r
t h y o f t h e n a m e o f o p e r a t i o n h a v e b e e n e x c l u d e d fr o m t h e
'
t a b le .
T h e c as e s t h u s e x c l u d e d a re : O n e o f s u b a c u t e p l e u r i s y ;
p a r a c e n t e s i s t h o r a c i s ; r e m o v a l o f s p i n t s o f fl u i d ; r e c o v e ry .
O n e o f a s c i t e s ; p a ra c e n t e s i s a b d o m i n i s a n u m b e r o f t i m e s ;
r e m o v a l o f 3 0 o r 40 p i n t s o f fl u i d a t e a c h t a p p i n g ; r e c o v e r y
fr o m e a c h t a p p in g .
O n e o f h y d r o c e l e ; p a ra c e n t e s i s s c r o t i ; r e m o v a l o f a fe w
o u n c e s o f fl u i d a n d i nj e c t i o n o f a fe w d r a c h m s o f t i n c t u r e o f
,
i
i o d i n e ; r e c o v e r i n g w h e n l as t s e e n .
T w o o f h y d r o c e p h a l u s ; p ara c e n t e s i s c ap i t i s ; re m o v a l o f s e v
e r a l d r a c h m s o f fl u i d a n d i nj e c t i o n o f s e v e r a l m i n i m s o f M o r
,
to n s fluid
’
. P ra c t i c a l r e c o v e r y o f o n e c a s e a s a r e s u l t o f t re a t
m e n t ; d e at h o f t h e o t h e r p a t i e n t a s a r e s u l t o f t o n i c m u s c u l a r
s p as m w h i c h w as n o t re l i e v e d b y t h e t r e at m e n t
,
.
O n e o f c r u sh e d fi ng e r t ip s k i n a n d b o n e t ri m m e d ; p r i m a r y
u nion .
A n u m b e r o f c o n s t r i c t i o n s o f t h e m e at u s i n c as e s o f g l e e t ;
m e a t u s i n c i s e d ; h e a li n g b y g r a n u l a t i o n .
A n u m b e r o f s m a ll a b s c e s s e s ; i n c i s i o n ; g r a n u l a t i o n o r
p r i m ar y u n i o n .
T h e a n t i s e p t i c m e t h o d e m p l o y e d w a s t h e o n e w h i c h w i th i n
( 480 )
A N TI S E P TI C TR E A TM E N T OF W 0 UN D S . 48 1
a fe w y e a r s h a s c o m e t o b e t h e m o s t p o p u l a r o n e a m o n g c i vi l
iz e d p e o p l e , an d w h i c h I c h o s e a ft e r e x p e r i m e n t at i o n w i th o t h e r
m e t h o d s t h e d e t a il s b e i n g a s f o l l o w s
,
I n s tr u m e n ts w e r e s c r u p u l o u s l y c l e a n e d a ft e r e v e r y o p e r a
t i o n a n d w e r e o ft e n d i p p e d in t o b o il in g w a t e r b e fo r e u s e i n
,
”
dange ro u s A S a r u l e th e i n st r u m e nt s w e re p l a c e d i n
“
c as e s .
a n 1 3 0 c a r b o li c a c i d s o l u t i o n fi ft e e n o r t w e n t
-
m i n u t e s b e fo r e
y
e t h e r w a s a d m i n i s t e r e d t o t h e p a t i e n t ; a n d t h e y w e r e r e t u rn e d
t o t h e s o l u t i o n fr o m t i m e t o t i m e a s w o rk w as p r o c e d e d w i t h .
A n e x c e p t i o n t o t h e r u l e w a s m a d e i n e ye c a s e s ; a n d a l c o h o l
w a s u s e d i n p l a c e o f t h e c a r b o li c a ci d s o l u t i o n T o w e ls .
w r u n g o u t o f I I OOO b i c h l o r i d e o f m e r c u r y s o l u t i o n w e r e
-
p l a c e d o n t h e t a b l e a n d a b o u t t h e p a t i e n t i n s u c h a w a y t h at
i n stru m e nts w h e n n ot i n u s e w o u l d b e d ro p p e d o n a nti s e pti c
s u r fa c e s o n l
y .
M a ter i a ls — S u t u r e s w e r e o f c a t g u t s il k w o r m g u t s i l k o r , ,
s i lve r w i re T h e s i l k s u t u r e s w e r e u s e d o n l y fo r li g a t i n g
.
h e m o rrh o i d s ( o r fo r c o n j u n c t i v a l w o u n d s ) a n d w e r e p r e p a r e d ,
b y s o ak i n g i n 1 2 00 0 b i c h l o r i d e s o l u t i o n fo r o n e o r m o r e d a y s
-
.
S i l k w o r m g u t a n d s il v e r w i r e w e r e u s e d fo r s u t u r i n g b o n y
-
s u r fa c e s t o g e th e r and fo r s u p p o r t i n g h e a vy
,
s o ft tiss u e s , ,
s e d a s S h o t a n d b ut t o n s ut u r e s i n t h e l a t t e r c a s e
( u - -
T h e c a t .
g u t s u t u r e s w h i c h w e r e e m p l o y e d i n t h e g r e a t e r p a rt o f t h e
,
w o rk w e r e p r e p a r e d a c c o r d i n g t o K o c h e r s m e t h o d a n d
,
’
,
1
w h e n r e q u i r e d fo r u s e w e r e e i th e r t a k e n d i r e c t l y fr o m t h e al
c o h o l o r w e r e fi r s t p l a c e d i n o n e o f t h e r e c e p t a c l e s c o n t a i ni n g
som e o t h e r a n t i s e p ti c fl u i d C h r o m i c c at g ut w as u s e d i n
.
-
s o m e c a s e s w h e r e c o n t i n u o u s s u p p o r t fo r s o ft t i s s u e s fo r m o r e
th a n t wo w e e k s at a t i m e w a s t h o u g h t t o b e d e s i r a b l e .
L i g a t u r e s w e r e a l w a y s o f c a t g ut p r e p a r e d a c c o r d i n g t o
-
,
K o ch e r s m e th o d
’
.
D r a i n s fo r l a r g e w o u n d s w e r e o f a b s o r b a b l e b o n e t u b e s r u b ,
b e r t u b e s o r c a t g ut s t r a n d s
,
-
T h e r u b b e r t u b e s w e re k e p t
.
s t o r e d i n 1 2 000 b i c h l o r i d e s o l u t i o n a n d w e r e o n l y u s e d i n t he
-
,
fe w c a s e s w h e r e s u rr o u n d in g t i s s u e s w o u l d h a v e p r e s s e d t o o
t i g h t l y o n b o n e t u b e s o r c at g u t s t r a n d s -
.
L i s t e r s p r o t e c t i v e o i l e d s i l k w h i ch h a d b e e n s t o re d i n w e ak
’
b i ch l o r i d e s o l u t i o n w as u s e d t o c o v e r t h e l i n e o f s u t u re s i n a
,
n d t h e n tr an s fe rre d t o
. i
f o n e o r two d ys
1
R aw c t g u t p l c d i n o i l o f j un i p
a a e er or a a
b o ttle s o f lc o h o l i n w h i ch i t m ai e d un ti l w n te d fo us e
a re n a r .
482 R OB ER T T M oR
. kI S .
w o u n d a n d t o c o v e r g r a n u l a t in g s u r fa c e s
,
It p r e v e n t e d th e
.
'
d i s t u r b a n c e o f t h e w o u n d s fr o m t h e s l i g h t m o v e m e n t s o f t h e
d r e s s i n g w h i c h a re a l m o s t c o n t i n u o u s w h e n a p a t i e n t w a l k s
a b o u t a n d it k e p t t h e v i c i n i t y o f th e w o u n ds i n a m o de rat e l y
,
m o i s t c o n d i t i o n s o t h at s e r u m
,
w as n o t b a c k e d u p b y a t o o
c l o s e d r y in g o f t h e d r e s s i n g a b o u t t h e d r a i n a g e o r i fi c e s .
B i c h l o ri de g a u z e s h ak e n u p i n t o a l o o s e m as s was p l a c e d
n e x t t h e w o u n d i n o r d e r t o a l l o w o f e a s y p e r c o l at i o n o f s e r u m .
S o m e t i m e s c a r b o l i z e d g a u z e w a s u s e d i n s t e a d o f t h e fo r m e r .
B i c h l o r i d e c o t t o n was u s u a l l y p l a c e d o v e r t h e g a u z e a n d it ,
t h e n fo r m e d t h e b u l k o f t h e d r e s s i n g —t h i s fo r e c o n o m y s s a k e
’
p r i n ci p a l l y .
I o d o fo rm w a s s p r i n k l e d o v e r t h e w o u n d a l o n g t h e l i n e o f ,
s u t u r e s a n d o v e r t h a t p o r t i o n o f t h e g a u z e w h i c h la y n e a r t h e
'
wo u n d i n o r d e r t o l e n d a c c e s s o r y a n t i s e p t i c h e l p
,
.
B i ch l o ri d e o f m e r c u r y was u s e d as th e s h e e t a n ch o r o f a nti
s e p s is . An I I OO O s o l u t i o n w a s e m p l o y e d fo r p r e p a r i n g t h e
-
t o w e l s t h e h a n ds o f t h e s u r g e o n a n d o f h is a s s i s ta n t s a n d t h e
, ,
s k i n o f th e p at i e n t i n th e v i c i n i t y o f th e w o u n d T h e 1 2 000 .
-
s o l u ti o n was c o m m o n l y u s e d fo r i rr i g a t i n g t h e w o u n d fr o m
t i m e t o t i m e d u r i n g t h e c o u rs e o f a n o p e r at i o n A n 1 5 000 o r .
-
I I OOO O
-
s o l u t i o n w a s e m p l o y e d fo r th e p e rit o n e a l c a v it y ,
a n d t h i s s o l u t i o n w a s c a r e fu l l y r e m o v e d w i t h s p o n g e s w h e n t h e
o p e rat i o n wa s c o m p l e t e d .
C a rb o li c a c i d s o l u t i o n w a s u s e d a s a n i r ri g a t i n g s o l u t i o n i n a
fe w o f t h e c a s e s b u t i t c e r t a i n l y c a u s e d a n e x c e s s i v e fl o w o f
,
se rum a n d w a s t h e r e fo r e s e l d o m
,
em ployed .
P rep a ra lzo m f o r Op er a t i o n — T h e s k i n i n t h e r e g i o n o f a
’
w o u n d w a s r e g u l a rl y s o a p e d a n d s h a v e d w h e t h e r v i s i b l e h a i r s
,
a n d l o s e e p i t h e li u m e x i s t e d o r n o t Th e s k i n w a s t h e n s c r u b
.
b e d w i t h a n a il b r u s h a n d w a s h e d w i t h I I oo o b i c h l o r i d e s o l u
-
tion . S o m e t i m e s e th e r w a s p o u re d o v e r t h e s k i n i n c as e s
w h e r e a p e n e t ra t i n g a n t i s e p t i c w a s r e q ui r e d T h e h a n d s o f a ll.
p ers o n s wh o w e r e m a n u a l l y i n t e r e s t e d i n t h e O p e r a t i o n w e r e
fi rs t w a s h e d i n s o a p s u d s a n d t h e n c a r e fu ll y s c r u b b e d w i t h
,
1 4 00 0 b i c h l o r i d e s o l u t i o n T o w e l s w r u n g o u t o f I I OO O s o l u
.
-
t i o n w e r e p l a c e d o v e r t h e p at i e n t a n d a b o u t t h e t a b l e i n s u c h
a w ay t h a t h a n d s i n s t r u m e n t s a n d m a t e ri a l s c a m e i n c o n t a c t
,
w i t h a n t i s e p t i c s u r fa c e s o n l y .
A N TI S E P TI C TR E A TM E N T OF W0 UN D S .
48 3
D res s i ng s u s u a ll y r e m a i n e d u n c h a n g e d fo r a t l e a s t t w o
w e e ks at a ti m e S o m e t i m e s o n v e r y e x t e n s i v e w o u n d s th e y
.
, ,
w e r e l e ft i n p l a c e fo r fo u r w e e k s o r l o n g e r a n d s o m e t i m e s , , ,
w h e n t h e y b e c a m e v e ry w e t w i t h s e r u m a d a y o r t w o a ft e r t h e
,
o p e r at i o n i t w a s d e e m e d a d vi s a b l e t o c h a n g e t h e d r e s s i n g s
,
u n d e r i rr i g a t i o n a n d a p p l y d ry o n e s i n t h e i r s t e a d T h i s la t .
t e r p r o c e d u r e i s r a r e l y n e c e s s a r y h o w e v e r b e c a u s e t h e s e r um
, ,
i s h e a vi l y c h a r g e d w i t h a n t i s e p t i c s a n d i t c a n n o t r e a d i l y d e
,
~
c om p ose . I t d r i e s i n a d a y o r t w o a n d t h e n a ll g o e s o n
x p o s e d w o u n d s —fo r i n s t a n c e t h o s e m a d e i n t h e
s m o o th l y
(
. E ,
o p e r a t i o n fo r h ae m o rr h o i d s — w e r e s i m p l y k e p t u n d e r a c o a t
i n g o f i o d o fo r m ) W h e n d r e s s i n g s o n a l a r g e g ra n u l a t i n g
.
w o u n d a re t o b e c h a n g e d t h e w o rk m u s t b e d o n e w i t h t h e
,
m ost c a r e fu l a t t e n t i o n t o a n t i s e p t i c d e t a i l s i f t h e s u r g e o n
w o u l d a v o i d s u p p u r at i o n . I t i s p o s s ib l e t o s o m a n a g e a l a r g e
g r a n u l a t i n g s u r fa c e t h a t n o p u s wi l l b e p r o d u c e d t h e r e b u t i n ,
n o o t h e r c o n d i t i o n o f t h i n g s i s m o r e e x p e r t a n t i s e p t i c w o rk
de m an de d .
A m o n g t h e c as e s h e r e r e p o r t e d i n w h i c h a n y g r a n u l a t i n g
,
s u r fa c e r e m a i n e d a ft e r t h e fi r s t c h a n g e o f d re s s i n g a s l i ght ,
a m o u n t o f s u p p u r a t i o n w as fr e q u e n t l y a l l o w e d a ft e r wa r d be ,
c a u s e t h e s u r fa c e s w e r e n o t l a r g e a n d i t w a s n o t c o n s i d e r e d
,
w o r t h w h i l e t o t a k e t h e t r o u b l e r e q u i r e d fo r e n t i r e l y p r e v e n t
i n g t h e fo r m a t i o n o f p u s .Th e fi rs t d r e s s i n g s t h o u g h w e r e , ,
r e g u l ar l y a s s w e e t a s n e w b r e a d a t t h e t i m e o f th e i r r e m o v a l ,
e v e n w h e n th e y h a d b e e n i n p l a c e d u r i n g a m o n t h o f h ot
w e a t h e r ; a n d i t w as t h e e x c e p t i o n t o fi n d a n y s i g n o f s u p p u
r at i o n a b o u t t h e l a r g e s t o f t h e w o u n ds a t t h e fi rs t ( w h i c h w a s
o ft e n t h e l a s t ) c h a n g e o f d r e s s i n g .
I n t h e g r e a t m aj o r i t y o f c a s e s t h e t e m p e ra t u r e r e m a i n e d
n o r m a l a ft e r a p e r i o d o f fo r t y e i g h t h o u r s a ft e r o p e r at i o n h a d
-
e la s p e d . I n s o m e o f th e l a r g e r o p e r at i v e c as e s i n w h i c h b o n e ,
s y n o v ial m e m b ran e o r p e r i t o n e u m w e r e i n v o l v e d th e re w a s
n o n o t a b l e r i s e o f t e m p e r a t u r e d u r i n g t h e fi r s t fo r t y e i g h t -
h o u rs o r a t a n y s u b s e q u e n t p e r i o d d u r i n g t h e t i m e o f r e p a i r
, ,
( 1 0 0
°
F . c o n s i d e re d a s n o tab l e ) .
T h e o p e r a t i o n s w e r e d o n e u p o n p e r s o n s i n a l m o s t e v e ry
c o n c e i v a b l e s o r t o f p h y s i c a l c o n d i t i o n a n d o ft e n a m i d s t t h e
,
R OB E R T T . M OR R I S .
m o s t u n fa v o r ab l e s u r r o u n d i n g s A l a r g e n u m b e r o f t h e p a
.
t i e n t s w e r e O p e r a t e d u p o n i n t o w n s s i t u a t e d a t a d i s t an c e fr o m
N e w Y o rk a n d t h e c a s e s w e r e l e ft e n t i r e l y t o t h e c a r e o f t h e
,
p h y s i ci a n s w h o h a d k i n d l y i n v i t e d m e t o d o t h e w o rk fo r t h e m .
O w i n g t o t h e h e a rt y c o o p e rat i o n o f t h e s e g e n t l e m e n i n c a rry
.
-
i n g o u t t h e r u l e s o f a n t i s e p t i c s u rg i c a l p ra c t i c e I h a v e n e v e r
,
h a d o c c a s i o n t o r e g r e t m y c o u rs e i n c o n s e n t in g t o d o m aj o r
o p e rat i o n s at th e h o m e s o f t h e p at i e n t s .
I n t h e s u bj o i n e d l i s t o f c a s e s t h e w o r d r e c o v e r y m e a n s ,
i n g e n e ra l t h a t t h e n a t u ra l c o n d i t i o n w a s r e g a i n e d ra th e r th a n
, ,
t h a t li fe w a s s a v e d b y t h e o p e r a t i o n . Th e w o rd i s h e r e a n d
t h e r e i m p r e s s i ve b e y o n d i t s i n t e n t i o n b u t i n o r d e r t o m a k e t h e
,
fo r m o f t h e r e p o r t w e l l o u t l i n e d i t w as n e c e s s a r y t o fi ll a ll
s p a c e s fo r c as e s ac c o r d i n g t o a c e r t a i n p l a n .
A N TI S E P TI C TR E A TM E N T OF W 0 UN D S .
48 5
I n te r m ed i a te Re
Op e r a t i on F in a l R e s u lt
s a lt
.
.
G ‘C Fi b f i is i on a b o u t in Pi i R eco v
F lf l gh
m a ry u n o n
1 21 ro- s a r c o m a o nc 2 r e ry
sh h hs
. .
, .
of in
gl vl
. eat e t p a c e en t
ro ti d and . R em o a of tum or
a n d ti s s u e s in con
tra c t w 1 th 1t
2 F W 1 4, Cy t o - s s a rc o m a a t I isi
nc on ab out 2 in Pi
r m a ry un on i ex R eco v e ry
hs l gh
. . .
tach e d to in ll
i d gl vl i g ig
c e en t cep t a t s m a
l
.
e ft p aro t and . R e m o a o f t um or d ra na e op e n n .
a n d ti s s ue s i n c on
ta c t t i t, wi h
GS Li p o m a o f n e ck (nu I isi s b in Pi i R v
gi ou t
3 70 , nc on a 4 r m a ry u n o n e co e ry
h l hsl g
. . .
M ) and and
i hs l g
c a re on c e on 2
sh ld
.
ou er . nc e on re s
p e c t ve i ly .
S M 6 4, E p i h li f l f R em vl of Pi i R eco v f t e r
h k S s ki vi i i gi s l gh i g
4 t e om a o e t o a tum or r m a ry un on at e ry a
an d s of s f 2 -3 o f
Th
c ee n 1n c n m ar n tr a n ou n o
hs l sp l i
.
Pla s t 1 c d p ie c e , an d a n te d p e c e
w ks g wh i h w
c e tn u t . re e ty . op e ra p an te t ra n .
’
ti o n flap of o u n d o f a rm Re c u rr e n c e 1 11 s u b
“
f gh xi
ee ro t 3 nc
ll ly p h
. . .
ro m ri t a rm m a a ry m
hs l
.
a t Cs i 5 m on t a
t er .
D M 64 , R e c u rr e n t e p i t h e li o Rem vl
is s P i of d i R eco v (5 m on t hs
xi ll s d li i ss
5 o a ea r m a ry u n o n e ry
l s
.
s
.
m a in ub m a ed d)
h i s f il
a t ue ,
an e ap e .
ly m p i on of
P i l v si gat
V sh
ry a t c . ac a ar
on o f d
l w lid f li v
a rt a l e er te r ap e
y . .
" i
i ii l l w lid
o e r e ye ro m 1 n c i s on t o re e e
i
c c a tr c a c o n o e r e ye .
tra c t o n .
6 C 60 , M Ep i h li om a of lo w R e m o a of vl Pi i R eco v f rom
i
s li li hf
t e re r m a ry un on ex e ry op e r
i
. .
Li p a l le (Dea t
f
li p ro m
i l i k
er m a n o p , an te c ep t a t t t a t on
i h
1
s s
. .
re y d e p o rt o n o f in
h i s ki i dd l l i v l
m o t ent r or cre a e n e ar m ou t r e c u rre n c e nec
s d n a n d p or in m s m on t hs
i s if
troye c n e ne e e ra
l
. .
of n e c te d a t e r. )
h ks L g
t on
in
i i
c ee on .
h ks d d w
c 5 o n o u t o n
k f fl ps
c ee an o n
on n e c or a .
S T 40 , Lip of f Inc isi i h sPi i R eco v

l g
7 om a o re on 1 1 -2 nc e r m a ry u n o n e ry
h
. . . .
M . e ad . on .
8 j Ce r vi l a de n1 R em v l gl of an d s H lh g l R v f
ro m
h yp p h y T s l l i
ca tl s o a . ea t y ra n u a eco e ry op
M and ti o n s M
si l ( l f sid ) W d f k i is l
. e rt ro y on 1 0 t o m . . c ra t o n . o r e
o f to n a de n t
lf g l
e t e oun o nec ate r .
ra n u a te
il ls
e t to
O ly p
.
p ss i b l
n a rt a c o
u re o e .
W 3 6, C e r vi l absc e s s Inc is i W0un d W kg ra n u a t o n l i R v fo

B k w lf
9 . ca on . ea . e co e ry r m op
M do t op e n i M
g l ds i is l
. ro en n e . e ra t o n . o r e
an . a de n t a te r.
4 86 R OB ER T T . M OR R I S .
H E AD A N D N E CK .
Ca s e . Op e r a t i on I n t e r m ed i a t e R e F in a l R es u lt .
s u lt .
V l l gs e s ub I i si Con te n t H lh s l R v
m ax
w sh d wi h ea t
i
nc on n u e co
e ry ar y gra a e ry
ss
. .
S E 45 i la ry b
is i
a ce a e out t t on
s l
. . . . .
M ant ep t c o u
W
.
ti o n . o un d le f t
op e n .
T M c M No 3 2 b u e t ll w o un d Cro ss s h p d i n cis Pi i R e co v
s i p i s Ch i s l i gR
1 1 a e r m a ry un on ex e ry
l
. . .
49 , M o r m a to d of
igh i
r o on e n ce p t at c e n tr a
ss gh b
. .
’
of r H ad t o
vl
ce t te m ro u one e
p o rt on
l ll l g h
.
s
.
p ora b on e m o of
bu et
wh i h zi g f
p u t e re t o top
. a
c la y o n d u r a oo n ro m di p
m a te r . lo e .
J O C No ll w bu o un d Cr o ss s h d incis Pi i R eco v
h is l i g
1 2 22 et ap e r m a ry un o n ex e ry
f sq s p ll
.
s
. . . .
46 , M ion C oi
i f igh
uam ou
gh i cep t at m a
o or e n ce n
s l is
.
.
t on o r t te m rou p o nt of t ra b ru e d or
p
p oralb e on . b on e . t1 on .
44 , No
w ll
.
38
s k ll
bu ll et Cr oss s h p d
i i B h b
a e in No n ote as re g a rd s De at hf ro m s u d de n
M ound of ot u n c o n t r o lla b le s e c
w ds p h i
,
u . c s on . one un1 on .
Bu d d dary h a e m or
ig h t
x
e t e n e r e oun t re ne on
sq s Bu ll et tr a c t e d rh a g e o n to llo wi n g
gh
r t ua m o u e
bone and p ss d h dra m d ay

sv s ly h i
a e t ro u age .
of b ra
’
k
tr an er e t ro n .
ku ll
s k ll l f
m . c rac
i ng at
f i
u e t
ron t a l p r o m
n c n oc .
_ M R igh s i d df f i g
t ro n t a l C ro ss s h p d in Pi i of De at h 3 day s l te r
s ki x ig
e o a e r m a ry u n on a
1 4 3o,
s l
.
b ht i i b of o r
i lb i hsi x
out
s ll d i g
3 X4 u t
ij F
an r c s on a
on e n e ce p t a t as re 1
of te n t n al
i hi
an te r or ra c t
ig M k
o e nc e n e m a ra n a e n u ry
sh d
.
b by Bo n e d ed ure o f b as e o f s k ull
h s ki k l v
c ru e tre p
f
ra n n e op e n n ar
sy
.
and (1 o un d a t
g
or e c e e a t e te m re c ov a u to p
p o r a ry
L
. .
i
ar e e ry.
b on e and b ra
v
n
re m o e d,
F S F of cer vi l I hi s is l bg out 7 in Pi i m i R eco v f

v
ra c tu re nc on ex ro m
i
27 ca a a ry u n on e ry op e
1 5
ll h
. .
,
M * e r t e b ra ( o ld ) Re De at
vl l i a t m a
i g
e c e on p t ra t o n
ce
s 10
hs l
. . . . .
of d ra
d s i
m o a am na na e p om t m ont a te r as
s s l
.
of gi n al
ij
an p no u p ro re u t on
ss f 7 th and
s i
ce o n u ry ,
ss 01
vi l v p n o us p r o c e
61h c e r c a e rt e
b r ae .
6 C M 7 0 , Se n il c a t a r a c t, E x tra c t on i of l s Pi i R e co v
F l f) f w m a ry u n o n
1 e en r . e ry
G
. . .
( e ,
t . ra e e up ard .
F P l s e of c r s l E x tr a c t i of l s Pi i R e co v
li l s ( l f ) ww
1 7 30 . . ro ap
y ta on en . r m a ry u n o n . e ry .
Do n a r d c o rn e a ]
i is i
ne en ,
e t .
nc on .
*R e
p or t e d in A N N A LS o r S UR GE RY .
A N TI S E P TI C TR E A TM E N T OF WO UN D S .
Ca s e . Op e r a t i o n . I n t er m ed i a te R e F in a l R es u lt .
s a lt
1 8 P L 6 , Co n v g
er e nt s t ra b i s Sec t i on of l e ft in Pi
r m a ry u n o n i R e co v e ry
l st
. . . .
M . m us . te rn a r e c ru en
don .
1
9 F B 2 8, C on v g
er e n t s t ra b is Se c t i on of l f
e t in Pi i m a ry u n on i
l
.
st
.
M . m us . te rn a re c tu en
don .
A M 3o, G l ss w oun d Tra n s l id Pi i of R e co v

v s l e c tom r m a ry
iu n on
20 a e ry
r y
i s l
~
. . . . .
a c e ra t o n of and
h lf lw
er e .
c e ro t c 2-3
o u te r a of n gh t o f c o rn e a oun d .
and
ig
c o rn e a co r
sp ond n
i
re p o r
t on of i ri s . S c le
r o ti c to rn fo r
li s
one
o r tw o Es
iz
ne
c ap e o f d
vi
-
t ea s e
p i e ce of t re o u s
h um or .
M H , 4o , T i hi sis R em v l f ili P i i R vd f
li w li l v l
21 , r c a . o a o c a ry r m a ry u n o n ex eco e ry a t e r s e c
d m o
s i ski i
ne an n a r ro ce p t at tt e nu on a ry re a
l 1 s d po of t wo h
v s whi h
e c t on 0 n c o e nt or t re e
l sh
.
ab o t ub e
l f
e , a c
h ad b e en e t p re
v i o u s ly .
WD L ss of 1 6 of upp T sp l i of Pir m a ry u n o n o f s ui R v
i f gi
22 . 24
, o -
ra n an ta t on eco e ry .
M o rt o n o f b e l1 x fl a p ro m te m p o t u re d
l f i l i f
p m a r n 5
G
.
ral re g on
i x sd
e t e ar ra n u a t o n o
p s
.
.
te r or
s f
o e po e
ur ac e .
St ) 3 5 , Ce ll l i i s of wh l In c is i i s i d Sl w g ra n u a t o nl i R e co v
F if i xi ll
23 u t o e on on n e o e ry
h
. . .
o f m ou t E va cu
gi i
. n e r or m a a ry .
re on . a t o n o f p u s .
V
\ o u n d s le ft o p e n .
R OB E R T T M OR R I S . .
T RU NK .
Op e r a t zo 7 2 F ina l R es u lt
'
Ca s e . . I n te r m ed ia te R e
sa lt .
D 3 8, FT ub e r c u o l sis L R Pi i R e co v f
vl f i F h
a p a ro t o m y m a ry u n o n ro m
ig h v
24 o e r ex e ry op e
h
. . .
f r1 g h t o v
siz vl
r t o a ry m o a o c e p t t re e o r our ra t on u rt e r
a ry a n d tub e h ead d de m e n t of
i s i s ki g
pin e e op
l
.
po nt n n e n e ra t u b e rc u
s
.
lo s i s at p re
ent .
T 45 , F G ll s t s i h L p I Pi y i R e co v ly
v i ty i l f s p b s p i g
25 . . a on e y n a a a ro to m . n r m ar un on ex e ry ne a r
d i l d l t
’
d 3w k
i g f S i ll
om na c a c s no n ro m u e ce t at ra n a e c om p e ee s
s
.
d d by ou t of b d
i f ys i d
u rr o u n y e p tu near to t e rn u m . o en n ,
r o m e t .
f fib i S p un d e r
d i si s R
t re a t m e n t
w ks f
t
d p sit
m or o r n o us e a ra t o n o m at c t c uc . .
(6 e e
i
e o te n te t ne e ro m op
l f g ll
. .
c ra t o n ) fo r u n
i
m ov a o a
s s d g l s
c o e d , b u t ra
p d
l s i g i li
ton e an se
of abdom i ly c o n b a ry
w ll fis l
m ent
nal a C h l o e tu a
s
. .
c y te c to m y .
26 B 62 , F S tra n gl d i n g ui I n c isi of v Pi i R v f
h i i gh i gs i
u ate on co er r m a ry un on ex eco e ry ro m op e
s
. .
nal R d of ll R e t u rn o f
i g ig h i
cep t a t
p ip l
e rn a t n an m ar 111 a ra t o n
l
. .
gin of R d ra a a b o u t 1 yr
vl f l g
e n t e r o- e oce e r 1n g e na e op e n n e rn
l s l
. . . .
re u t o f
k f il h v l if T
m o a o a r e a te r as
nob o ss
I si s d sil
e p p oon . ea y t . ru
n te t n e r e t u rn e d now u e e a y
l ls
.
and ed
wi h g
cana c o
t cat ut .
W 5 8, F Ch i i i is L x Pi
E i f R e c o v e ry ( 2 5 d ay s
p e r ton t
i isi
27 ron c a p a ro t o m y r m a ry un o n o
l l s
.
s
. .
d f e ap e d) Se c ond
i h sl g
p o r a t o ry n c
w i
on ee p p a r t o
( Pa o und Too ly
i v l g l
5 nc e
s pi
on e ar a xy un on ne ar
l h s
.
b of 48
fiil g f
t en t e ry ar e y a or t on com p e te our
a n d fa t s a p p ro xi m a
cat
i g
up e r c a ut a te r
s s ds of ra n u a t l
i f s ki gi
u t u re a n e pa t on
ra t on o n and i ng m ar n s
s s
.
u b c uta n e ou fa t
in i nc is i l ion ne .
28 C A 8, P l p e ri t o n i L Pe r No g a rd sD h sl
thsix a te r
P i i i l i vw d
n o te
vi
1 u e rp e r a a p a ro t o m y . as re ea our
F i to n e l
k dly f
ti s a t e n t c om
w sh wi h
a c a t y u n on o p e ra t o n re e e
ls
. .
and ed
h s Th
a tos e t
v w kw
p u e a out t m ar e or o
l ss en cam e
b i hl id
e e ry ea a rm o ur
s l l ps
.
d
i
c or e o u r e a e a n
t on . d h
e at .
G P 55, C h i l i is N ph Ex Pi i R v ( 3
i isi w ks l
2
9 ro n c p ye t e ro t o m y r m a ry un on e x e c o e r y
pl s s
. . .
M ll d )
gi i g ig
o r a t o ry nc on cep t a t 111 a ee e ap e
l g
. .
of d ra
l f q
a on m ar n na e op e n n
e t u a d r a t u s
l b um o ru m m u s l c e .
S u b p e ri t o n e a l
Ki
.
d n e y p u n c t u re d
wi h h
t yp o d e r m c i
ne e d e l .
J R 5 6 , S up p r e ss i o n o f u ri n e xl
E p sp i Pi i f R e co v
i gs
30 o r a t o ry a ra r m a ry un on o e ry
A l l
. . .
M c ute a re n c h y of b d de r n e e d e Op e n n
h i is g
p no n a
s h h
. .
m a to u ab dom i
t
w ll
ne p r t . ro u
n al a .
AN TI S E P TI C TR E A T M E N T OF W O UN D S .
489
T RU NK .
Ca s e . Op e r a t i on . I n te r m ed i a te R e F in a l R es u lt .
sa lt .
F i h
S c rr s of vl
R e m o a o f b re a t, s P i i R e co v
i gh ye a r
ou c an c e r r m a ry u n on ex e ry
31
s l ps
.
t b re a s h e a t h o fp e c t o r a li s cep t at fe w li t d )
siz
r t a e a e
j s l h
. .
Ax t le p i n - e ad ed
i ll
m a or m u c e
s s
.
lym p h
gl a r
and and
y
s ves
p ot .
s ls a n d fa t a nd
iv
e
l s ,
conne ct
i ss
oo e e
t ue .
N 37 , F E nc e p h l id Rem vl of b re a st P i
r m a ry u n o n o f a ll i v
R e c o e ri n ( t g s ill
i sj i ss
a o c ance r o a
32
s s s
. .
,
of le ft b re a t p o rt o n of p e c to d t u n d e r t re a t m e n t )
v
op p o e ue
l
. . .
r a li s m a o r C e n tr a d
xi ll
m us un c o e re
c le , a a ry ly m i i hs
g l i g
p o r t o n 2 x1 nc e
p h a ti c s a n d c o m
iv ra n u a t n .
c on n e c t
i ss
m o n e
t an d fa t
vi
ue
l
.
S ub c l a c u a r
ly p h a t i
v
m c 5 re
m o ed .
U 71 , F Sc i h s of Rem vl of b re a st P i i R e co v (10 w ks
ig h
rr ou c an c er o a r m a ry u n o n e ry ee
33
sh h l s
.
s ,
. .
r t b re a t eat of p e c to e ap e d )
j
. .
ra li s m a or m us
c le . Ax 1 lla r y lym
p h a tic s , fa t d
iv i ss
an
conne c t e t ue
s l
.
S ub
iv i ss
c ap u a r con
h ect e t ue .
E B 47 , S c i h s of Rem v l fb s Pi i f t, m a r y u n o n o a ll R v ig (St i ll
l fb i s f
rr ou cancer o a o re a r e co er n
34
s s d i ss s
.
. .
e t re a t p ort o n o p e c to opp o e t ue u n d e r tre a t m e n t )

ll s j
. . .
C e n t r a l u n c o v e re d
i
'
x ill
ra m a or m us
l i lym
g l i g p ort
c e ,
a a ry o n 2X2 1 -
2 n .
p h a tic s , d fa t t n
iv i ss
an ra n u a .
l vi l
c on n e c t e t ue
S ub c a c u ar and
s bsu c ap u ar l ly m
p h a ti c s an d con
n e c ti ve t i ss ue .
H 41 , F Sc i h s R em vi l s f b s P i s i i ss f sll R v i g t, r m a ry u n o n o (St i ll
ig h
rr ou c ancer 0 o a o re a a e co er n
35 .
s
. .
b re a d f p e c to ed t re a t m e n t )
v d
r t t p o rt on o op po t u un er
j l
. .
l
ra i s C
xi ll im a or m us e n t ra un c o e re
c le , i fa t
l h is g l ig
a a ry p o 1 t on 2 x1 1 -2 n .
t n
iv i ss
at c
ym p a n ra n u a .
t
l vi l
c on ne c t e ue .
S ub c a
l h is
c u a r
d
ym p
iv i ss
at c a n
c on n e c t e t ue .
M c B 65 , S c i h s c a nce r of Rem vi l s of b re a t, s Pi i f R v (S ill

l g i isi
r m a ry
36 t
un on o
F lfb
rr ou o a e co e ry .
st
.
of th e d )
p o rt p e ot
gh i g f e r t re a t m e n t
t re a on on nc on un
j
e
s l Sl
.
. . .
h is
ax
xi l
m a or m u c e ou n o one
i lla ry y m p a t c , l ,
f sh
th e o rt
l fl s
o a
fa t a n d c o n n e c t
i ss
a ry ap
s
.
ive t ue 3 nd
s h l
.
a v i c u l ar
ly p h i
u e
m at c s.
490 R OB E R T T . M OR R I S .
T RU NK .
Ca se . Op e r a t i o n . I n t e r m ed i a t e R e F ina l R es u lt .
s u lt .
P F Li p o m a of e t l f Rem v l h g Pi i h R v
gl l g
45 , su o a t rou r m a ry un on ex eco e ry
37
si s ll
. . .
p r a s c a p ula inc1
gi d i g t
re n e on cep t a m a
iz
-
on . S e of fi st . s ton . ra n a e op e n i u g
B 42 , F D o ub e l l
a c e ra t o n D e n u d a ti o n i of ul Pi i R eco v f
v
ro m
vx
3 ,
r m a ry u n o n . e ry 0p
of cer i u t e ri P a R
f
e r a ti o n
i i
eco er
i is
. .
a n d p e r m e tr rom m e tr t
fl sw h g
ra ing .
ti s . ap it cat ut .
P A 42 , T ub e r c u o u l s
b ub o I isi s 4 i d Pi i R eco v
l g Fl p s
nc on n an 2 r m a ry u n o n e ry
39 . . . .
M o f le ft g r o i n O p e n
i gs i ss
. i n . on . a
o n ab dom e n d e c te d In
i
n up
ss s
.
a n d n p e ri n a e u m fe c t e d ti
i
. ue ex
t e n s i v e ly tr m m e d
a w ay .
H M C a n c ro d ah i l
b ub o , S i gl in i si L f g l R e co v
ig h g i i
40 n e c o n e t to ra n u a t e e ry
M ss
. . . .
t O, M r .t ro n . a tr m m e (1
o ut .
J G T ub e rc u o u l s bu S i gl i isi Pi i R v
g i
2 1 n e n c o 11 r m a ry un on ex e co e ry
41
M ss
. .
, .
M bo o f righ t ro m t r m m e d m a ll
i g ig
. . a cep t a t s
ou t . dra na e op e n n
42 S T . 2 4, U re t h l s i
ra t r c tu r e . I n t e rn a l u re th r o to G ra n u a t o nl i . R eco v e ry .
M .
43 T F 44 , U r e t
. . h l s i
ra t r c t u re . I n t e rn a l u r e th r o t o G r anu a t on l i . R eco v e ry .
44 C S . . 2 2, U re t h l s
ra tri c t u r e . I n t e rn a l u re th ro to G ran u a t on l i . R e co v e ry .
I Mc C
. . U re t h l s i
ra tr c tur e . E x Pl i l G
t e rn a u r e th r o t o ranu a t on l i . R e co v e ry .
M and
i g l k l i wii s id l s
40 , . m y . er ne a
ur ne . ute a nc on
al l ep t e y
op e ne d .
46 A R . . 1 7, V a ri c o c e l e . Sm a ll s cro t a l i n c is Pi
r m a ry u n o n i . R e co vi e ry f
rom Op e
M b ut t
f v i
r at o n , 11 o
l
.
w ro m ar coce e .
o rm gu t .
P M S 9 , I n t e rn a a n d l x
L ig a ti o n and xi G l i R e co v
h i ds s i l g
47 e te r c c ra n u a t o n e ry
h
. . . .
M nal e m o rr
a o on of fi ve ar e
il s
. .
p e .
48 A W 3 Q, H m m o rr h o i d s Li g i and G l
ra n u a ti o n R v
s v
a t on ex e co e ry
l
. . . . .
f
01 5 1 0 0 o e e ra
of th e m a ss s e
A N ] I S E P TI C T R E A TM E N T OF W 0 UN D S .
49 1
T RU NK .
Ca s e . Op e r a t i o n I n ter m ed i a te R e F inal R es n lt .
s a lt .
G 4O , M H fi s l hi i d s
e m o rr an d L ig i and xi l si Gr a n u l i R e co v
si
49 . . a o a t on c c a t on . e ry .
tu a f tw o
W ll s f fi s l
n ano on
. o p e .
a o tu a
i
tr d
W ds l f p
m m e o u t .
oun e t O en
50 L S 32, E
.
M
. x ter
na l h ae m or Se v l gs
e ra ta s n i p G l i
ra n u a t on . R eco v e ry .
r h 0 1 ds o ff
. .
ped .
K 2 6, F H e m o rr h i ds n i
a t o n an d e xc i s G l i
ra n u a t o n . R v
f
51 a o e co e ry
h
. . . .
i on of t re e o r our
of th e hmm o rr
h o i ds .
I isi l g G l i R e co v
Co d l ab s ss f nc
b u t to c
on
k W ll s f
as on as ra n u a t o n . e ry .
w h l i g h gl
“
ce o a o
s ss s
.
t ute ab c e c ra p e d
gil ( N
o e r .
a l re on . o tu .
b e rc u o s i s o f
b
dis v d
on e
co e re .
L S E x te n s iv m am m a Se v l l g G incis l i
ra n u a t on . R v
i
53 . 22 , e e ra on e co e ry
bs ss
. .
C on t e n t s
w sh wi h
ry a ce . ons .
d t
is i s l
a e out
i
an t ep t c o u
t on .
N F 40 , I s hi o -r e c t a l b Inc i si C sG on te n t l i
ranu a t on R e co v
w sh d wi h
. . c a on . e ry .
is i s l out
sce ss . a e t
i Lf
ant ep t c o u
t on . e t op e n .
M E n o rm o u p e r r e c s i— L g i isi t in G l i
ra n u a t on R e co v
l gi
30 on nc on a e ry
M s ss gl
. . .
t al ab c e ( Pa s
s iv si d
. ne r u te a re on
p m d e ra s t y o f e ach an d
i
e e
a dm t te d a s c a u e s g q u a n ti t i
,
s
i f si g
re a t e
by p at ent ) de com p o
gh
0 n
d sl
.
ll l i ss
p us an ou
i g
w sh d wi h
n ce u ar t ue
ou t
is p ti s l
a e t
i s
a nt e c o n
t on .
56 O 32, Th t o r tu o u s fis I i si W ll s G l i
ra n u a t on . R e co v
F
. re e nc on . a cu e ry .
t u lae i n a n o t te d P a q u e li n
s v
. . re .
a u t e ry u e d o e r
w ll s si s s
I
of
k
a nu e
W s
.
ound e p t
op en
E B 3 0, Fi s l in Inc is i W ll s cut G l i
ran u at on . R eco v
tu a
wi Wh s h
an o on a e ry
57 . . . .
M out t a rp
sp
.
oon . o u n d
k ep t op e n .
9 2 R OBE R T T . M OR R I S .
T RU NK .
Ca r e . Op e r a t i on . I n ter m ed i a te R e F i n a l R es u lt .
s a lt .
58 U D i S T wo
"
. . fis l tu a in ano . I isi
nc on
wi h s h
.
fW a lls cut G l i
ra n u a t on . R eco v e ry .
I
w
35 , ou t t a rp
sp
.
d
k o u n
oo n
e p t op e n .
59 L J 35, N um e rou s ana l fis A l sp h i

na nc te r s di G l i
ran u a t o n .
s s l d M s
. .
ur e . a te . ar g i n
and
fi ss i
tr m m e d
wi h ll s i s
ure
t s m a c
5 01 5 .
60 E B . 21
,
V e n e re a lw s art . R em o v l wi h k if
a t n e G l i
ra nu a t on . R eco v e ry .
M . a n d c a u t e ry .
6, WN V lw s C i v l is i f R G l i
ra n u a t o n R e co vi f
i g x
. . 22 e n e re a a rt ap rc u m c on . e . e ry ro m op e
M m o w R of
si v lfl w k if W w
p e ar n as e te n a o a r t s ra t o n e t ur n
sl
. .
wn h d
li k g w h
e cau i o e r n e a n a rt a te r.
e ro t c a u t e ry oun d
l s
. .
n ot c o e d .
62 WE 2
9, L on g p r e p uc e C i rc u m c isi on Pi
r m a ry un on i i in R e c o v e ry
l s
. . . . .
a m o t e n t r e
Wo u n d .
63 E S 2 L on g p re p u c e C i rc u m c is i o n Pi
r m a ry un on i i n R e co v e r y.
l s i
. .
. .
,
M
w
. a m o t e n t r e
o und .
64 J G 21 , L on g p re p u c e C i rc u m c isi on Pi
r m a ry i
un on in R e co v e ry
l s i
. . . . .
M
w
, a m o t e n t r e
oun d .
G A 3 4 S yp hili i s is R em ’
l o f p o r t ’n f G l i
i gh p xiill
65 . . t c n e c ro . ov o ra n u a t o n .
M ’
i l di g
r t su m a a
i i is iv
nc u n can ne
f ss
em nence , nc e
d
s ls i
o a, an a n t .
vl f l g
na a p ne .
m o a o ar er
f
p art
s l f
o vo m e r
W
.
o n u d e t
op e n .
A N TI S E P TI C T R E A T/VE N T O F W O UN D S .
49 3
U PP E R EX T M IT I E
RE S .
Ca s e . Op e r a t i o n I n t e r m ed i a t e R e F in a l R e s u lt .
s u lt .
D 35 , No ll s p l i L g i i s i R P i y i v
3? 32 b u
66 R e co
d x v l f f g d i g
et n on nc on e r m ar u n on ex e ry
l
. . .
1
i g
t e rn a at
d yl i d x p si
t e re e p c on m o a o r a ‘
ce t ra n a e
s fb d
.
Ch is l
o e p an on m ent o on e a n o en n
pl f b ll
,
d f
i h s f h s h f l i g f f gh p t
an a c ou e o o u e . e
f h l f h i
nc e o t e a t n o ro u or
s b
h lf f i
o t e e t um er t on o one .
i
i
us n a o ts
d am e te r .
67 J S T u b e rc u o u i s i v xf lj s P i
l s
Inc i s i R v fD
i i g
ro m u t ro m
i g
2, on c ar e r m a ry un on ex eco e ry op e
h
.
o f p o r ti o n o f ead ab o e e dra
k lf i fis l i s
t e rn a e p
i g
cep t at na e ra t on . ra n a e
and nec of e t i c o n d yle t o a c r o Op e n n tu a re m a n

h s l ss h ll
.
Co d of S
l x is i g i
u m e ru m on p roc e op e n a op e
s ss s
. .
a b ce o f n e a r] E c
wh l is s cap u a on . ra t e a a n .
o u te r h a of d e a ed
o e
o f ai m i w ll
t on of b o n e
p or
s ss vi
a
'
o f ab c e
i wi h ca ty
tr m m e d t
ca p e and a rp s l l sh
sp oon .
68 R H N s is of k M d ll i G l i R eco v
i f h i s lld h g lh
. 1 7, e c ro nec e u a ry cav t y ra n u a t o n . e ry .
M and
lf h
p o rt o n o Op e ne t ro u
h
.
e ad of e t u c e e d cana
s s s
,
and
m e ru
v W q ue tru m
e
d ou n d
k
re m o e .
e pt op e n .
69 MS 5 8 , Co m p o u n d c o m m i L g i is i t h ’
Pi i R eco v e r y wi h
fl s i g
on nc on ro r m a ry un on ex t
i s
.
mu t e d ra c t ur e o f tr c e p dra “
fi a il” j o i n t
l f w ig
t e n cep t at na e .
c ondy e of d a nd
do n
l w l g i
e t on, op e n n
h s
.
u m e ru (b o ) . a on n ne r b or
d e r o f u ln a Con
v
.
d y le s e d
gh
re m o .
R ou e n d of hu
m e ru s
re s e c 1e d .
N H a rd s l u a te d R em vl of tu m o r Pi i R e co v
v l
70 5 0, e ncap o a r m a ry u n o n e ry
s h s l h
. . .
M b and cap
’
i isi
m oo t m o a e u e t ro
in
i ss i h sl g
tum or c onne c t an nc on 2
i ve of
l id
t ue ex nc e on
l
.
t e rn a c o n dy o
sp ace of le f t
( Pig
a rm
s
.
si z
e o n e g g
e
N H O le c r a n o n b ur si is Re m v d c on t e n t sG l i
ra n u a t o n Re c o v ig wh
F i
71 23, t o e er n e 11
h l s s
. . .
. C ro n c . of s ac, and di s a t een

s e c te d the
hi k w ll s
o ut
t c ene d a
W l s
.
o un d n o t c o ed
49 4 R OBE R T T . flI
. OR R I S .
U PP E R E XT R E MIT I E S .
I Va m e
N o Ag
. e 67° Ca s e . Op e r a t i o n . F i na l R e s u lt .
Co g wh l
sv s
ee ij n ury Two i h sl f
nc e o ra Pi r m a ry
l s
.
T ra n e r e d i us and u na
if l iwill h s i l wi fi l d Tiwssi hs
se c re a m o t
ti o n a t m d d of d, dr d and
r igh t o re a r m
e s e c re
s u t u re d
e
t n
oun
tra t e d
. ue
t
sh
d a n d la c w 1 re sh Cru ed" s s h
w
c ru
w
e ve r e ru m o t a t
sl s
.
'
e ra t e d C o m p o u n d o un d
f was
m u c e cut a ay
g p ur
i s
.
d d and e nd p o s e ly op e n e d
i
c om m n a te
li l f
ra c oo su a
s
t u re o f r a d u h and t u re d fo
M s l s wi h S ki
t og e t
i g
e r tt e
l ,
r r e e
d ra
s ki gi s i
u na . u c e t cat g ut n na e .
and tr m m e d
s i
n t o rn a m ar n
s
and d and d
fp a rt tr p p e u t u re to
s U g h b o ne l ( Ap p r o x i
i i ll w
ro m et er .
e d by
N vs
a r t e ry
l z d i h sh i g
n ar n ta c t m at on a o
g ll h
er e p a ra y e 2 nc o r te n n
e n e ra
y, b u t of b one .
n o ne of de
N w
t em
s d
b i g v
tr o y e . a rr o
d e o f sk in
l s ki
r o er
l
lf ij
u na, on y n
e t at n u re d p a rt
o f a rm .
73 R 1 5 ,M Wh l f l f ho e o e t t um b A m p utat i lh gh P i
on t i ro u r m a ry u n on ex R eco v e ry
sh d l d s ll
. .
a nd m e ta c a rp a C
fl s d i g ig pt
c ru e Co us ce at m a
bl d l ss
, .
oo e . t o m a ry ap . ra n a e op e n n .
74 4o , M . Pe a siz ed si
cy t c tu R em o vl
a of cy t s . Pi i m a ry u n o n i . R e co v e ry .
(cho l i
wif h i
m or es te r ne
n) o f sh h
s b l i is
t eat
o fl e xo r u m
t e n don o f 2 n d p h a
l x o f 2n d r igh
ig i t
an
d t .
Two l g v R vl of e lli p t i Pi i R eco v

w s l v igh g
75 e ry ar e em o a r m a ry u n on e ry
s
. .
“ ”
cal of
ski whi h
a rt o er m e e m ent
tacar f
w sw i
p a o r t n on c
t h b um . a rt e re S tu a
ted
LOW E R E XI R E M I T I E S
'
76 \V D 9 No ll t w bu ound L g i i si Pi i R e co v
f i s id i ww nc on car m a ry un on e x
i
on r e ry
l g
. 1 . 22 e .
M f d do a rd to c e p t a on d ra n
i gh h igh f
. o nn e r e o r e n
No a g e tra c t
i ps i j s
r t t . e m ur . .
m orta n t t r ue
t u re d n u re ,
S T 26 T ub e r c u o u l s sy V lk s Pi ’
i
v l i gg l De
vi i s k i P ll s w fl sk i f
77 mo o m ann op e ra r m a ry u n on ex e op n e n e ra
h
.
,
M of le ft t n b e r c u 10 5 1 s o
t t on a te
w h i h s l gh j i s
c e p t a t up p e r t
ne e . . a a n n e
i n tw od of th e
vi l vl
an s yn o ap c ou o nt ex
d
br ll i wh
wi h s
a m em a n e e o er p a te a as t re m i t e s e 11
i m m e d o ff f l s s fi rm
ss i wi h
tr t u t o too t
s i ss s
re a een .
g
c or . c om p re on t
b and a e .
“R e
p o r t e d p re vi s l ou y in M di l R
e ca e c or d .
A N TI S E P TI C TR E A TM E N T OF W 0 UN D S .
49 5
LO W E R E X l R E M IT I E S
' ‘
Ca s e . Op e r a t i o n I n te r m ed i a te F i n a l R e s u lt .
s a lt .
78 F G 5 2, F i g h C ss sh d i i P i
f R e co v Bo
si J i vi i A ivg h
ra c t ure o r t ro - ap e nc r m a ry e ry n y
ll
.
M y" l
l g f g w sh F g s ki i si
p a te a ,
re c e n t . on . o nt ca ty cep t a o un o n . ct e m o
Two d b ili ty t o ri
wh i
ar e ra a e out ra one n nci on t ah
s s ll s s s
.
d g le a t p re e n t
wi h gv
m ent ; one m a m ent s ut u r e e re sut u r e
tw o S l lV e r wa y
wi s
one t a e t 0 o
s l
.
re . oon .
R C F llr a c t ure o f ri g h t
' ‘
l r a n s v e rs e i n c i s i o n i Pi R e c o e ry vs i Fi fi
i vi s h
pa m a ry un on ex rm
79 r
l g
. 27, .
M * a , o ld R up J o n t c a ty w a b ro u u n Pa
fi l i f s ki i si
te ce pt a on S up e r on.
s
.
of b ro u b an e d out Bo n y s u r fi cial d
i f s f g i is i wh h is w ll
ne o n t ent a to us e
s fo r of le g
i s g v s sl f
un on , cau e a ce 2 ra nc on e re s u t as e as
s o f p a te ll way he u e
f sh
o p e ra t o n m ent a t u re a e e t one
s
. .
re e n e d a n d ap t oo oo n .
p r o xi m a t e d
l w s wi h
a t
il v w
o e r c o rn e r t
2 S e r i re s .
80 k Inc isi i n n e n Pri m a ry u n i f R e c o v e ry

—
si s
ne e on on on o
s
. .
an d o u te r de o f de e p p a rt In cis I
s
.
Co n te n t
w v
t um or
and ll ed
wi h s h
a re m o op e n
sp
.
t a rp oo n
81 E H H s id s k
’
l n c is io n i Pi i of
lR
F is
21 ou em a ne e on n ne r r m a ry un on e c o v e ry
s I
. .
,
. .
de e p p a rt
ski l f
uc
s
.
Co n t e n t ion of
w ll v
tum or n e t
and ed
wi h s h
a re m o op e n
sp
.
t a rp oon
82 W A 42 S up p ur a t iv e a r t h ri t I isi H l hy g ra n ul a Reco v w t ih fi
is i gh k d i id f i b
. nc on on o ute r ea t e ry , a r
,
of r ou t t ub e us e of k ne e
k w j i J i vi y
t ne e an nne r S e o t on a
s
. . .
Ca u
v y h gh l y
e un no n . o nt . o nt ca t
w sh d wi h
er t o rou
is i s out
a e t
1u
i s ii
an t ep t c 0
t on . Inc s on le tt
i g
op en to c ar r y
d ra s na e t ub e .
83 T K A k yl si s of k Co m p e te x isi P i
l i R e co v Bo n y
f ll wi g k i l kw f wh fi bs f ls i
1 n o ne e e c on r m a ry u n on ex e ry or
. .
3, .
of ne e S fi rm
flx fiil
o o n tr a u m a o rm c ep t e re 2 or 3 ro u un on
s s s s
. .
tis m Le g d k i n Le g
gu t
s xs i v
e e u tu re or up e r c a u e u
s s g
.
and fi Xe d H am b one E '

w ay }
i gs i s f
ect on u t ure a e
s s s
. .
of
h s i
p o rt o n
tr n te n e . o too oo n
a m t r ng 5
h gh s
i is i s
t ro u e p a ra te
nc on .
84 J F 30 , E p t i h li le g Arr p u t a t i o n a t
of id Pi i at R v
H lh
e om a m r m a ry un on eco e ry
l
. .
a t ol d u c e r fo l d le o f t h i g h O b t a i n ed
l wi g g
ea t y
l i s
.
c o m p ound
f ii
o n ra n u a t o n .
r a c t u re o f t b a .
‘R e o r t e d
p p re vi sl ou y in M di l R
e ca e c o rd
49 6 R OB E R T T M OR R I S . .
LO W E R EX T M I TI RE ES .
Ca s e . Op e r a t i o n . I n te r m ed i a te R e F i n a l R es u lt .
. s u lt .
J V 5 0 , Sc i i s d by I ii in Pi i R e co v i i g wsh f
F l ig v fis
-
85 at ca cau e nc s on 2 1 2 r m a ry un on at er n en
l s
. .
lo n g S c i a t i c b u t too e ar y u dde n
f l f v vl lig g wh
m a n a n t t um ou r ner e r t, n c re a e o
s h
. .
t re t c e d r e m o a o f s u t u re s t
ll w w s i si l
o e t o a ry . . m a n an t ro
ed o u n d to d t na
fh i S i i d
a o ca u e n te
t e a r a p a rt s up e r p e r o ra t on an
fi c i a lly de a t c at ca
s
. .
t op p e d by th e
o p e ra t o n i . No p a
r a lys i s .
86 A F Ul d s R e a m p ut a t i o n t ro ’ h Pi i R e co v
if si
35, c e ra te m a ry u n o n e x
r e ry
A ll
. . .
M le g t u b e ro of
f ii i g
m p u ta t o n
ty cep t at 5 111 a
s i
. .
,
b e o re th e t b a S de d ra n a e 1
ye a r
fl ff
or can a
p s; sh
.
s
.
c o m p o un d f r a c a or t . S o t re e car .
tu r e .
J S 83 , G g of f A i i un c Pi i R v g U si
i ll l i i s i p u ta t
l w i s W lks
87 an re n e oot m on a t r m a ry un on ex e co e ry n
h
. . . .
M C on o f e r and l t wo t wo c a n e
kl ff wi
ro n c ce u t t o cep t a t t ny a
h
. .
of ab ou t t o wn ,
sid ifi i l
an e p o m ts So t re e t
s
. .
le g S h o r t d le g ,
fl li ps h
e car a rt c a an
s ly
. .
ap . m a rd at
a ll .
M S Bo w l gs In c isi v Pi
o e r m id i R e c ov e y S li g h
88
F hi s w wi g f
2, e on r m a ry u n on ex t
s
. . . . .
d le o f u p p e r t r d bo of
i i Ti i li s ki w h
. ce pt at n a rr o n e m ur
of t b a b a ne of i nc is
h is l h g h i
. n not or t c o rr e c t
e e d t ro u i ng
c
Fi l f on
. .
.
b u a e ra c tu re d
89 R . S 3, . K noc kk ne e s . I isi s v
nc
i v s P
s
on o er m o t i
r m a ry u n o n i . R e co v e ry.
f tib i
p ro m nent cur e
o d fib ae an u
l B h b s
his l d h gh
ae . ot one
c e e t ro u
on b h l gs ot e .
J K 28 F g s f R em vl of s s G l i R e co v
si l f
ra m ent o n e o a e q ue ra nu a t on . e ry
90
W
. . .
,
M . cros e d b on e a t t e tr a . oun d e t
o f o ld c o m p o u n d
f
op e n .
ra c t u r e .
M F O ld l
u cer of le g Th i k w 1 e ne d 1 G l i R e co v l
F fl w wh
27 c a 5 ra nu a t o n e ry ne a r y
91
l
. .
. .
,
d
S ki g fi g i is
. an oor c u t a ay co m p et e e n
n ra t n la p at e nt d a p p e ar
te r . ed .
—s M O ld l
u c e r of le g Th i k d w 1 Is G l i R e co v
fl w g
o, c e ne a ra n u a t o n e ry
92 . . , .
an d
Sk i
oo r c u t a ay .
n g r a ft i n
l a te r .
Pi bu ll t Bu ll r e m o v d i R e co v
w d f l ff l lw I x i s i i s f hh l gs w ll kpi
44 e et e r m a ry un on e ry
93
.
o un o o er nc on at e ac ar er p a rt of o
tre m d S
l dg d i d w ll s i isi l f
p a rt g o y e
pt e e t o a o e a n
B ll
.
l i s Ab s ss s p d w i h g l
u e t o e n s ce ss , an a nc on e t op e n
H lf
05 c a c ce c r a e t to ran u a t e
sh p sp
.
.
di
ar o on . a
f d
A h i ll i s wy
am e te r o te n o
c cut a a
b ecau s e of s lo u g h
ing
A N TI S E P TI C TR E A T M E N T OF W O UN D S .
49 7
LO W E R E XT R E M IT I E S .
Ca se Op e r a t i c n I n te r m ed ia te R e F inal R e s u lt .
s u lt .
Q4 Iw H O ld d
l ft
i l i
kl s o c at o n x l i i o ff i f P i y
at E c s n o a rt c m ar un i o n v
R e c o e r y, th wi
x
r
ll s i g
. .
M e an u ar s u r cep t at s m a t ff s
l i g s g l s ib i d i g
2 5, e, ac e s o
1 5 e t ro n an
i
.
ye ar s , r e s u t n a tr a t a u k le B o n y u n o n
fi a ra n a e op e n
l
. .
f r om r u p t u r e o f i a nd b u a at a h ng
l l l l s
.
e xt ern a at e r a k e Bon e s u t u r
lg
i am e n t s d fi l h e r m y t og e t
wi h sl
.
er t i k
w or m g ut
F 3 8, So tfi s ar c o m a l?) R e m o v l a of tu P im u n 10 n R e co v
x wh
r ary e ry
s
.
n v o lvi n g e x t e n m or and of
l g s h e ce p t e r 9
.
.
s or
d on
on
of 8 rd e t
u ten
l f
t
h lf
re e an d
h s
one two t r e e eu
or h
i nc of p e r nc i a l s u t u r e s
t oe T u m or s e iz i
a
n vo lv ed e
e
x te n h a d d ap p e a r e d is
h l
.
of
’
e n s e g g an d s s
x i
s or ong u ten t o o o on .
e tend ng don
lig
u p on
l
.
a nnu a r
Si i l
a
m en t m
s ll g w t h s
. a r
m a
i v lvi g
n
er
o
ro
n
sh th f p
ea o e ro
t
neus er ti
us t en
don s i b th
o o
f eet .
96 J C 65 , La g r e bun i on at E x isi o n of d is l P i
ta m ar y i R e co v S o ft
g i f
c u 11 o n er y
fi r
l
.
fi r st m e t a t a rs o e n d of st m e t s Qu
te
h l g l
c ar re e
e xcep
w a o n
i v
5 0
r .
p a an e a ar t a t a r s al b o n e . n arr o m arg n m o e m e n t at ar
t i c u la t i o n R i g h t of thi n k i n t i c u la t i o n
f w h h ll s
. .
o ot .
ic r o ed u p
an d s e p a r at e d
— 47 M Bu n i s don u e t o E x isi of bur P im i

h ll x b
on ary u n on e x
c r
v
'
,
ur sit i s cep t l m ar Re co f m
P d g
a u S% a on g ery r o
h i ki s l l
.
o a ra g i n of t n s bur a t ro u b e
w h i h ll d p
.
n
c ro e u
an d s e p ar at e d .
W W Seco d x i i
d E c s on of cr u
t hi sh P i u n on of i R e cove ry a t t e r
M n
fif h
r r m ar y
s iv
.
1 4, f ou r t han d t e d p ar t s F ap l sh o rt s ol fl ap e x te n sk i n
l f f f
e
f e
.
s l h
. .
t oe s of e t o ot m ad e r o m g ra ti ng ; wit
L g f lf
o e
sh
.
cru ed Co r r e ar e p art o f u se u o ot
h s is
. .
sp ond i ng e ad d or um pe d s
of m e t at ar s a ] e f t u n co e re d l v
h
.
b on e s c ru s e d
i s i
.
Sk n tr p p e d
hi
f r o m t w o -t rds
of d or s u m o f
f o ot .
99 T 1
9, M “
In g wi g
ro n t o e R em o v l f
a o str ip G r a n u a t on l i R e co v i e r ng St i ll
il v h g
'
. .
”
na . of o e r- an g i n u nd e r t r e a r
i nt eg um ent . m ent .
49 8 R OB E R T T [ WOR K / S . .
L OW E R E X TR E M I T I E S .
i a te R
'
Ca s e . Op e r a t i o n . I n ter m ed e F zn a l R e s u lt .
C M 40 , D e e p tu a fis l of L gi n c i s i o 11 P im ar y u ni o n R eco v R
i lik v
1 00 on r e r y e
l s l
. . . . .
M f o ot R e m a n s of C a 1 ti l a g e s e e r a
vi ws i e
w
ap e
s l
. .
ou pu am s t ss e ek at e r
p re car
v ue re .
ra t i o n o u n d m o ed
h gh fi
.
t r ou r t s
an d s
e con d m e
t a t ar s a ls o f e t l f
f o ot .
S U M M AR Y .
Wh l o e n um b er
Ca se s iwhi h n c an a t t e m p t at o b t a ni n i g i
p r m a r y u n o n w a s m ad e i
Ca s sie whi h p i
n c r m a r y u ni o n w a s o b t a n e d i n t h e o e or ir e a t e r p a rt o f wh l g th e
w d ou n
s s i whi h h w ll w dt h l b y g l i
“
Ca e n c t e o und w as p u r p o e y a o e s l o ea r a n u a t on
Ca s s wi h i
e t nt e rcurr e n ce of s i
e p t c ae m a , p y ae m i i ys ip l a, e r e as o r t et an u s 0
hs s l i g f i
.
D e at re u t n ro m o p e r at o n 0
h s s lti g f igi l i s
. . .
D e at re u n r om t h e or na d s
e a e or i nj ur y 6 .
( N am e ly N o 6, r e c u rre n t e p i h li t e om a ; No 13, g un s h ot w ou n d of b ra i n ; No 1 4,
s k ll i k k i ii
, . . .
c r u sh e d u an d bra n ; No 5 b
“
ro en nec No 28 p u e rp e r a l p e r t on t s ; an d
g v i di s s
. , .
,
No 8 5 , m ali n an t o ar an ea e
s s whi h I h wh i h ly ti l l
. .
Th e ca e ly p dc a ve r e c e n t o e r at e up o n , an d c ar e con s eq u ent s
un d O l p
e r t r e at m e n t , a r e : y wi h h l ne a ar ot om t c s
o e c y t e c t om y , o n e e x p o r at or l y l p a ar
ot o m y f i f th b s d
o u r a m p u t a t on s o e re a t , an o n e i n g r o wi n g t oe n a il A ll of th e se
p a
g d di i d I xp hi g l
.
,
i
t e nt s ar e i n oot con t on a n e ec n ot n e ss th a n c om p e te l r e c ov e r y f or a ll
f h t em
d si i l li s f i h ids fi st l
o
h h
.
I n an o t e r an th p m ar t o c as e s , e O e r at o n s f or ae m o r r o an d f or u a
i
n an o w ld b d ou s h w gi pi
e on e in uc a ay as t o a n r m a r y u n on , i i n s t e a d of a l l wi g
o n re
pa i b g l i
r y f ll w
r a n u at o n to o o .
E D I T O R I A L A RT I C LES .
O PE R AT I VE A T T A C K S U PO N T H E H U M AN BR A I N .
1 . Bra i n S urg e ry . i
By V c to r H o r s l ey , B r i t t s /z M ed i c a l
'
j o u r n a l,
1 886, O c t .
9 .
2. Th e C o n d i ti o n of th e Bo n e s o f th e S k llu , an d th e D u r a M a te r i n Ca s s e of Tu
m o ur o f t h e Bra i n . By W . Ha l e Wh i t e ,
M D . . Gu y
’
s H osp i t a l R ep or ts , Vo l .
X Ll I l , 1 88 6 .
3 . O n e H u nd re d C a s s e of C e re b lT ra u m o u r, wi h t R e fe re n c e t o C au se , O p e ra ti v e
T r e a tm e n t, Mo de of D e at h , an d
G e n e ra S ym p to m l s . By W . Ha l e Wh i te ,
M D
.
Vo l XLI I I 1 88 6
’
Guy H osp i t a l R ep o r ts ,
'
s .
, .
4 M i d d l e M e i i n ze al H ae m o rrh a g e
. f By \V H . . A .
j ac o bs on, MD . . Guy
’
s
p i t a l R ep or ts Vo l X LI II 1 8 8 6 , .
, .
In th e S e c tion o f S ur ge ry a t th e r e c e n t a n nual m e e ting o f th e

1 .
Bri ti sh M e dical A s s oci ation Mr Vict or Hor s l e y pr e s e n t e d a c o m m u ,

.
n i c at i o n i n w h ich h e d e t ail e d th r e e ca s e s i n w h ich h e h a d m e t h o d ic
ally a t t ack e d p ar t s o f th e h u m an brain by s urgical proc e d ur e s re m ov ,
ing p or tion s th a t w e r e th e s ubj e c ts o f d i s e a s e b e ing gui d e d in th e p re ,
li m inary s t e p s for e xpo s i n g th e a ffe c t e d p ar t s by alr e a d y e s tabli s h e d

fac ts of c e r e bra l localiz a tion .
Th e fir s t ca s e wa s th a t o f a m a n se t 2 2 wh o w h e n 7 y e ar s o ld h a d , .
, , ,
s u s t ain e d a d e pr e s s e d co m m inu t e d frac t ur e o f th e s k u ll wi t h lo s s o f brain ,
s ub s t a n c e fro m wh ic h h e h a d fi nally r e co ve r e d a ft e r a h i s t ory o f fr e e

,
s upp ura t io n h e r n ia c e r e bri a n d t e m p o rary h e m ipl e gia

, A t ab o u t 1 5
, .
y e ar s h e b e gan t o h av e fi ts wh ich w e r e v e ry i n t e rm i t te n t Wi th th e , .
lap s e o f ti m e th e nu m b e r o f fi ts o ccurring i n b a t ch e s h a d b e co m e , ,
e n or m ou s a s m a n y a s
, h aving occurr e d d uring o n e for tnig h t
s h or tly b e for e b e ing s ubj e c t e d t o O p e ra t ion T h e s e fi ts w e r e al m o s t .
al way s o f th e s a m e ch arac t e r u s ually co m m e n cing in t h e ri gh t low e r ,
li m b : s o m e ti m e s in b o t h t h e rig h t li m b s s i m ul t an e ou s ly
, T h e p ar t s a f .
fe c t e d w e r e in th e or d e r o f lo we r li m b upp e r li m b fac e an d n e ck ; t h e , ,
ch ar a c te r o f th e m ov e m e n t s wa s firs t e x te n s ion th e n con fus ion finally , , , ,

5 00 E D I T OR / A L A R T1
fle xion . F ro m p h e n o m e n a i t w a s i n fe rr e d th a t th e focu s

th e se
O f d i s c h arg e wa s s i t ua t e d aroun d t h e po s t e rior e n d o f t h e s up e rior
fro n t al s u lcu s T h e pa ti e n t w as d i s tinc tly h e m ipl e gic e v e n t e n d ay s

.
,
a ft e r th e la s t fi t b u t h e co uld p e r form all th e m ov e m e n t s o f th e righ t

‘
li m b s th o ug h abou t h al f as s tr
, o n gly a s on th e l e ft s i d e ; th e r e wa s n o
a ffe c t i o n o f s e n s a t i o n o n th e rig h t s i d e wh il e th e r e fl e x e s s up e rficial
, ,
a n d d e e p w e r e e x a gg e ra t e d in bo th t h e rig h t li m b s
, .
O n th e l e ft s i d e o f t h e v e r t e x o f th e h e a d ( th e e xac t s i t e a s d e t e r
m i n ed by m e a s ur e m e n t b e i n g t h e c e n t r e O f t h e upp e r t h ir d o f t h e a s
c e n di n
g fr on t al c o n volu tio n ; t h a t i s po s t e rior t o t h e h i n d e r e n d o f th e
s u p e rior fr o n t al s u lcu s
) t h e r e w a s a q u a d r a d i a t e s car oppo s i t e th e c e n ,
t re o f w h i c h t h e b o n e cou ld b e fe lt t o b e w a n ti n g s o a s t o for m an ,
o val o p e n i n g in t h e s kul l th e lo ng d ia m e t e r o f w h ic h w a s abou t o n e

,
i n c h an d p arall e l t o th e s agi ttal s u tur e Pr e s s ur e on th i s s car alway s

, .
g av e pai n wh ich w as v e ry gre a tly incr e a s e d wh e n t h e pa ti e n t wa s s u f

,
fe ri n g on e o f h is par o xy s m s o f fi t s .
Op e r a t i on M ay 2 5 1 8 8 6 —Th e bo n e arou n d th e o ld op e n i n g wa s
, ,
.
fr e e ly r e m ov e d ; th e d ura m a t e r arac h noi d th e s kin b e i n g fo un d t o

, ,
fo r m a h o m o g e n e ou s m a ss o f fibrou s t i s s u e ; t h e for m e r wa s rai s e d
wi th th e fl ap T he s car in th e brai n wa s fou n d t o b e h ig hly va s cular

.
,
o f a d e e p r e d bolor a n d ab o u t 3 c e n ti m e tr e s lo n g a n d 2 broa d
, T he .
m e m bran e c o v e ri n g t h e brain aroun d app e ar e d t o b e v e ry opaqu e a n d ,
th e brain o f a s li g h t ly y e llow e r t i n g e t h a n u s ual T h e s car an d abou t

.
,
h al f a c e n ti m e tr e o f s urrou n d i n g brai n s ub s t a n c e w a s e xci s e d t o t h e

-
d e p th o f 2 c e n t i m e t r e s I t wa s th e n fo u n d th a t th e s car ti s s u e p e n e
.
-
t ra t e d a fe w m illi m e t r e s fur th e r i n o t h e cor o na ra d ia t a fibr e s o f t h e

t
m argi n al convolu t i o n T h i s p o r t io n w a s t h e n r e m ov e d a n d th e wo un d
.
,
c lo s e d In th e r e m oval o f t h e m a s s th r e e fair s iz e d v e in s co m ing

.
,
-
,
d ir e c tly fro m t h e m i dd l e o f t h e ar e a fo r th e upp e r li m b h a d t o b e lig ,
a t ur e d s inc e t h e y p a s s e d d ir e c t ly in t o t h e s car
, Th e woun d c o m .
p le t e ly h e al e d in a w e e k T h e t e n s ion o f s e ru m was t wic e r e li e v e d

.
( o n c e probably u n n e c e s s arily ) T h e m o s t i n t e r e s ting poin t n ow to

, ,
.
b e r e c o r d e d i s th at a ft e r th e O p e ra tion t h e pa ti e n t was a t fir s t c o m
,
p le t e ly paral ys e d i n d igi t s o f th e ri gh t up p e r li m b ; a n d fo r fur th e r

OP E R A TI VE A T TA CK S UP ON TH E H UM A N B R A I N .
5 0 1
fl e xi o n of wri s t an d s upina t ion of th e for e ar m

th e Coupl e d wi th th i s .
m o t or paraly s i s th e r e w a s lo s s o f t ac til e s e n s ibili t y ov e r t h e d or s u m

,
of
t h e two d i s t al p h a la n g e s o f th e fing e r s H e co ul d n o t localiz e th e .
t o uc h any wh e r e b e low th e wri s t wi th in t h e d i s t anc e O f o n e in t e r n o d e ;
fi n ally h e coul d n o t t e ll t h e p o s i t ion O f a n y o f th e j oin ts o f th e d igi t s

, .
T h e n we h av e h e r e appar e n tly a d i s ti n c t in s t anc e O f lo s s o f t ac til e

, ,
s e n s i b ili t y a n d m u s cular s e n s e coup le d wi th m o t or p ara ly s i s all d ue ,

,
t o l e sion o f t h e c o r t e x I t can n o t h ow e v e r b e t o o cl e arly un de r s t oo d

.
, .
th a t i t i s v e ry p o s s ibl e t h a t s o m e o f th e fibr e s co m ing fro m t h e gyru s
forn i c a t u s in th e c or o n a ra d ia t a m ay v e ry pr o bably h av e b e e n i nj ur e d .
Th i s con d i tion o f m o t or a n d se n s ory paraly s i s g ra d ually d i s app e ar e d

i n th e c our s e o f th e n e x t t w o m o n th s Up t o th e pr e s e n t t i m e th e p a
.
ti e n t h a s h ad n o fi t s .
Th e SE CO N D CA S E lik e wi s e in th e p e r s o n O f a young m an se t
wa s .
”
20 . In J an uary 1 8 8 4 h e b e ga n t o h av e cra m p s
, , i n th e le ft th u m b “
a n d for e fi n g e r th e s e co n s i s t i n g o f clonic O ppo s i t ion o f th e n a m e d

,
di gi t s a n d occurring ab ou t twic e a d ay fo r th r e e m o n th s
, T h e fir s t .
s e v e r e fi t occurr e d in Marc h 1 884 S pa s m S pr e a d up th e arm an d

,
.
,
th e pa ti e n t fe ll H e h a d th e se con d in J a n uary 1 8 8 5
. T h e n follow e d ,
.
a s e ri e s o f r e m i s s io n s o f th e t wi t ch i n g s u n t il i n Augu s t 1 8 8 5 ano th e r , , , ,
s e v e r e fi t i n augura t e d a s e ri e s o f fi t s occurri n g o n c e or t wic e a w e e k ,
un til a d m i s s ion o n D e c e m b e r 4 1 8 8 5 T h e c h arac te r o f th e fi ts wa s

,
.
al m o s t always th e s a m e Th e y b e g an by clo n i c s pa s m o d ic oppo s i tion

.
o f th e th u m b a n d for e fi n g e r ( le ft) t h e wri s t n e x t a n d th e n t h e

, e lb ow ,
an d s h ou ld e r we r e fl e x e d c lo n i c ally th e n t h e fac e t wi t c h e d a n d t h e p a
,
t i e n t lo s t co n s ciou s n e s s T h e h a n d a n d e y e s th e n t urn e d t o th e l e ft
.
,
a n d th e l e ft l o w e r li m b was d raw n up T h e rig ht low e r li m b wa s n e x t

.
a tt ack e d an d fi n al ly th e rig h t up p e r li m b P araly s i s of th e l e ft upp e r

,
.
li m b fr e qu e n tly fol low e d a fi t At fr e qu e n t in te rval s e v e ry d ay th e p a

.
ti e n t s th u m b woul d co m m e n c e t wi t c h ing b ut progr e s s o f t h e c o n v u l

’
,
s i o n cou ld o ft e n b e arr e s t e d by s t r e t c h i n g th e t h u m b or applyi n g a
li ga t ur e D e e p r e fl e x e s w e r e e xagg e ra te d in th e l e ft upp e r li m b T h e
. .
p a ti e n t fr e qu e n tly h ad s e v e r e h e a d ac h e b e gi n ning a t th e o ccip u t an d ,
s h oo ti n g forwa rd e s p e cia lly t o th e

,
p ari e t al r e gion E xp e ri m e n t s o f .
502 E D I T OR I AL A R TI CLE S .
th e au th or h aving S h o wn h im th a t th e m o v e m e n t o f o p p o s i t io n o f t h e
th u m b a n d fing e r can b e e lici t e d by m ini m al s t i m ula t ion o f t h e a s
c e n d in g fr o n t al a n d p ari e t al conv o l ut io n s a t t h e lin e o f j u n c t ion o f th e i r
lowe r an d m i d dl e thir d s i t wa s b e li e v e d th a t th i s p ati e n t was s u ffe ring

,
fro m an irri t a tiv e l e s io n o f unkn o wn n at ur e s i t u at e d in th e p ar t o f t h e

br ain t hus in d ica te d An e xplora to ry O p e ra t io n was th e r e for e d e ci d e d
.
upon .
Op e r a t i on J un e 2 2 1 8 8 6
.
, T h e s e a t o f th e l e s ion h aving b e e n d e
.
t e r m n e d by m e a s ur e m e n t a larg e t r e p h i n e wa s appli e d a n d on rai s i n g

i , ,
t h e d ura m a t e r a t um o ur ca m e i n to vi e w
, M o r e b o n e wa s r e m o ve d .
abov e a n d in fron t s o a s t o co m pl e te ly e xp o se t he m a s s t o wh ic h t h e
d ura m a te r wa s a d h e r e n t T h e b or de r o f t h e t u m o ur s to o d o u t a b o u t
.
o n e e ig h th O f an inch fro m t h e s ur fac e o f t he brain

-
a n d i t wa s m uch ,
d e n s e r th an th e brain s ub s tanc e I t app e ar e d to b e only h al f an inch

.
broa d b u t as th e brain s ub s t anc e all ro un d i t fo r m or e th an h al f an

,
inch app e ar e d d u sky a n d ra th e r livi d th e O p e rat or r e m ov e d fr e e ly all ,
th e par t appar e n tly d i s e a s e d B e for e clo s ing th e wou nd th e c e n tr e o f

.
t h e th u m b ar e a was r e m ov e d by fr e e inci s ion in or d e r t o pr e v e n t as , ,
far a s p o s s ibl e r e curr e nc e O f t h e e pil e p s y

, N um e rou s v e s s e l s w e re .
liga t ur e d .
T h e woun d wa s clo se d F iv e s ix th s o f i t h e al e d by th e fir s t i n te n
.
-
t ion i n a w e e k T h e r e m aining s ix th j u s t a t t h e lo we r b o r d e r o f th e
.
,
flap g av e way a n d h e al e d by gr anula tion a ft e r s e p ara tion o f a s m all

, ,
pi e c e O f s kin a t th e e d g e T h e a fte r con d i tion O f t h e p a ti e n t wa s m o s t

.
-
i n t e r e s ting an d i m p or t an t T h e r e was n e x t d ay par tial m o tor p a raly

.
, ,
s i s o f t h e l e ft s i d e o f th e fac e low r ivi ion co pl o or

( e d s
) m e t e m t p a ra l
y ,
s i s O f th e l e ft upp e r li m b fro m an d inclu ding th e s h oul d e r

, O n th e .
2 7 th o f Ju n e t h e r e wa s no t e d l e ft h e m ian ae s th e sia t o a ligh t t ouc h

,
( s e n s ib ili ty t o p ain unal t e r e d) lo ca liz a t ion o f a prick o f a pin v e ry d e

,
fi c i e n t all ov e r th e l e ft s i d e p e r fe c t on th e righ t co m pl e te lo s s O f m us
, ,
c ular s e n se in t h e l e ft upp e r li m b b e low th e s h oul d e r O n th e s e con d .
d ay a fte r th e O p e ra t ion w h e n m aking an e ffor t t o m ov e t h e l e ft up p e r

.
li m b th e p ati e n t s u dd e nly p u t h i s h an d t o th e wou n d an d s ai d h e

, ,
”
fe lt a b uzzi n g i n th e h e a d t h e r e
“
W h e n th e l e ft upp e r li m b was p a s
.
OP E R A TI VE A T TA CK S UP ON TH E H UM A N B R A I N .
5 3
0
s i v e ly m ov e d al s o co m plain e d th a t p ain s e e m e d t o S h oo t up th e
, he
”
“
b on e s O f th e li m b s i d e o f th e n e ck an d th rough th e h an d t o th e
, ,
woun d Th e d e e p r e fl e x e s w e r e m uch e x agg e ra te d on th e l e ft s i d e in

.
b o th li m b s All th e ab ov e co n d i tion s gra d ually i m prov e d an d a t th e

.
,
d a t e o f m e e t ing th e p a ti e n t h a d r e gai n e d e v e ry th i n g e xc e p t th a t th e
, ,
gra s p O f th e l e ft h an d wa s n o t qui t e so goo d a s b e for e an d th e fi n e

m ov e m e n t s O f th e fi n g e r s r e m ain e d h a m p e r e d F ur th e r t h e d e e p r e .
,
fl e x e s on th e l e ft S i d e are at th e pr e s e n t t i m e s till v e ry m uch e xa gg e r

a t e d T h e p a ti e n t h ad in J uly a fe w s ligh t twi t ch e s in th e th r e e rig h t
.
, ,
fing e r s ; non e in th e th um b or in d e x n o fi t s s inc e O p e ra tion T he .
t u m our was co m po s e d o f d e n s e fibrou s t i s s u e wi th t wo ca s e a t e d foci , ,
m icro s copi cal e x a m ina t ion proving i t t o b e t ub e rcular .
T h e TH I R D C A S E was s till again in th e p e r s on O f a yo ung m an se t , .
2 4 y e ar s . W h e n fi ve y e ar s O ld th e s h a ft o f a carriag e fe ll on th e v e r
,
t e x o f th e h e a d inflic t ing a woun d an d s ligh t punc t ur e d frac t ur e

,
Wh e n .
1 3 y e ar s o ld h e wa s kick e d by a h or s e on th e s a m e s po t
,
. Th r e e .
m on th s la t e r t h e fi ts b e ga n Th e fi ts occur u s ua lly in b a t ch e s o f th r e e
.
or four e v e ry th r e e w e e k s .
T h e p at i e n t was a t all p ow e r ful young m an wi th nu m e rou s s car s

, ,
ab ou t t h e h e a d d u e t o fall s e t c
, wh e n fi t s h ad occurr e d ( h e al s o h ad
, .
,
m o s t O f h i s te e th kick e d o u t by h or s e s wh e n h e h a d fall e n d own n e a r
t h e m h i s occup a t ion b e ing t h a t o f a s t abl e h e lp )

, T h e r e wa s th e s car
-
.
a n d m in u t e d e pr e s s ion O f a rig h t d e pr e s s e d frac t ur e i n th e upp e r a n
t e ri o r angl e o f t h e l e ft p ari e t al b on e clo se to th e m i d d l e lin e T hi s

,
.
s car an d t h e s ca lp aroun d w e r e v e ry t e n de r t o pr e ss ur e T h e pa ti e n t .
fr e qu e n tly h a d in te n se h e a d ach e a t th i s poin t alway s incr e ase d ( wi th ,
al s o th e t e n d e rn e s s) wh e n th e t e n d e ncy t o fi ts cam e on T h e r e was al .
m o s t co m pl e t e rig h t h e m ia n ae s th e s i a th e pa t i e n t n e i th e r fe e ling a t ouch

, ,
nor a p ri ck wi th a p in T h e applica tion o f a strong fara dic curr e n t t o th e

.
a ffe c te d s i d e co m p l e t e ly d i s p e r s e d th i s h e m i an ae th e sia b ut l e ft th e fi ts
, ,
unal te r e d .
T h e aur a wa s e n tir e ly ab d o m ina l T h e p at i e n t h ad a fe e ling a s i f h e

.
we i e goin g t o d e fae ca t e acco m p ani e d s o m e ti m e s by a S h arp p ain in th e

,
l e ft s i de o f h i s ab d o m e n Th i s wa s follow e d by tigh tn e s s in th e th roa t

.
,
an d s o m e t i m e s a s pa s m o dic coug h T h e h e a d ( a n d fr e qu e n t ly t h e
.
e y e s ) th e n t ur n e d t o th e rig h t ; th e righ t a rm wa s j e rkil y pro tru d e d an d ,
th e pa ti e n t lo s t co n s ciou sn e s s All th e li m b s b e ca m e a ffe c te d th at i s

.
, ,
pow e r fully fl e x e d a s a ru le ; th e low e r li m b s h ow e v e r b e i n g fr e qu e n tly

, , ,
e x t e n de d . A ft e r th e fi t t h e pa ti e n t s t a t e d th a t th e righ t a rm fe l t w e ak
,
fo r s o m e ti m e .
Th e S i t e o f t h e S ligh t d e pr e s s ion i n t h e s kull c o inci d e d wi th th e lo
ca tion o f th e po s t e rior th ir d o f th e s up e rior fro n t al convolu tio n T h e .
r e s e arch e s O f th e au th or a n d Pro fe s s or S ch afe r h a d alr e a dy s h o wn th a t

'
th e m o t o r ab d o m in al c e n t r e s a re j u s t O ppo s i t e th e h in d e r e n d o f th e
s up e rior fro n t al s u lcu s Pro fe s s or F e rri e r h as al s o S h own t h a t th e ar e a

.
to r m ov e m e n t o f t h e h e a d a n d n e ck li e s b e low th i s s ulcu s a n d th a t th e ,
ar e a for pro tru s i o n o f th e arm li e s ab ou t th e h i n d e r e n d T h e sym p .
t o m s O f th e pa ti e n t th e r e for e a s w e ll a s th e s i t e o f t h e cica trix poi n t e d

, ,
t o a n irri t a t iv e l e s io n in th e p o s t e ri o r t h ir d o f th e s up e rior fr o n t al con
vo lu tio n T h e followi n g e xplora t ory O p e ra tio n was accor di n gly d on e

.
Op e r a t i on July 1 3 th 1 8 8 6 — A flap b e i n g rai s e d fr o m th e S ku ll

, ,
.
,
an d th e b on e t r e p h i n e d clo s e t o th e l e ft d e pr e s s io n i t w a s fo u n d t h at
,
_
t h e r e h a d b e e n s plin t e ri n g o f t h e inn e r t abl e s o a s t Ofo r m a roug h ,
coron e t rou n d th e inn e r orific e O f th e m i n u t e punc t ur e o f t h e s kull th e ,
s ai d pu n c t ur e b e i n g fi ll e d wi th s car ti s s u e -
F ur th e r th e d ura m a t e r
.
,
wa s foun d t o h av e b e e n t orn by th e origi n al i nj ury an d proj e c ting ,
d ownwar d in t o a cavi ty in th e brain wa s a roug h s m all p la t e O f bon e .
T h e s e frag m e n ts b e i n g r e m ov e d a n d th e d ura m a t e r fr e e ly op e n e d
, ,
t h e ca v i t y j u s t m e n tio n e d w a s foun d t o b e w e d g e sh ap e d a n d ab o u t
-
,
o n e t o fi v e c e n ti m e t r e s broa d fill e d wi th flui d a n d loo s e co n n e c tiv e

,
ti s su e I t wa s S i t ua t e d e xac tly w h e r e d iag n o s e d ( m a e s up r a ) By

’
’
. .
m e a n s O f a circu m s cribi n g c ut a t a d i s t a n c e o f abou t fi v e m illi m e t r e s

, ,
th e cavi t y wa s th e n r e m ov e d .
T h e wou n d wa s co m p le t e ly h e al e d i n four d ay s O n e w e e k a ft e r
.
t h e O p e ra t ion t h e pa t i e n t co m plai n e d o f w e akn e s s i n t h e w h ol e rig h t

,
upp e r li m b All m ov e m e n t s w e r e a ffe c te d e s p e cially th o s e O f th e h an d

.
,
.
Th i s p ar e s i s i s e x tr e m e ly i n te r e s ting a s b e ing wi th o u t t h e s lig h t e s t

, ,
d oub t a n e xa m pl e o f m al e h y s t e rical p araly s i s a n d i t s co n n e c t ion wi th

, ,
th e func t ional an ae th e s i a b e for e t h e o p e ra t i o n i s O bvio u s T h e in t e rval .
o f s ix or s e v e n d ay s b e for e i t s app e aranc e e xac tly coinci d e s wi th th a t

OP E R A TI VE A T TA C K S UP O N TH E H UM A N BR A I N .
50 5
giv e n r e c e n t ly by Pro fe s s or C h arco t T hi s par e s i s h ad a t th e d a te O f

.
,
th e m e e ti n g pr a c t ically d i s app e ar e d
, .
R E MA R K S O N O P E R A T I V E T E C H N I Q U E Mr Hor s l e y a ttri b u te s m uch

. .
o f h i s s ucc e s i n ov e rco m i n g t h e d i fficul t i e s an d d ang e r s o f h i s O p e ra
t ion s a n d i n con d uc ti n g h i s pa t i e n t s t o s uc h r api d r e cov e ry t o th e d e

,
t ail s o f h i s O p e ra t iv e t e c h niqu e w h ic h a re a s follo ws

,
’
P r ep a r a t i on of th e P a t i en t — Th e d ay b e for e t h e op e r at ion th e p a ,
t i e n t s h e a d i s S h a ve d a n d wa s h e d wi th s o ft s oap a n d th e n e t h e r ; n e x t th e
’
po s i ti on of th e l e s ion i s a s c e r t ain e d by m e a s ure m e n t an d m ark e d on ,
th e s calp T h e h e a d i s t h e n cov e r e d wi th lin t s oak e d in 1 in 2 0 s olu

.
,
t ion O f carbolic aci d O i l s ilk a n d co t t on wool b e ing t h u s t h oroug h ly

,
- -
,
carb oliz e d for a t l e a s t t we lv e h our s b e for e O p e r ation F inally th e p a .

,
ti e n t h a s t h e u s ual purg a t iv e a d m ini s t e r e d th e e ve ni n g b e for e follow e d

’
by an e n e m a on th e m orning O f th e op e rat ion .
A n a s tnet ze — T h e m e th o d O f narco tizi n g th e pa t i e n t i s m o s t i m por

'
t an t a n d con s i s t s o f t h e a d m ini s tra t ion by h ypo d e r m ic inj e c tion O f a

, , ,
qu ar t e r O f a gr ain O f m orp h i n e a fte r wh ich th e p ati e n t i s ch loro for m e d

, .
T h e obj e c t in giving t h e m o rp h in e i s t wo fol d In th e fir s t plac e as i s

-
.
,
w e ll known i t allow s O f th e p e r for m anc e of a prolong e d O p e ra t ion wi th

, ,
o ut th e n e c e s s i t y O f giving a larg e a m oun t o f c h loro for m In fact th e .

,
a m oun t a c t ually u s e d in an op e ra tion la s ting t wo h our s h as b e e n

v e ry sm all T h e s e con d r e a s o n fo r e m ploying m orp h in e i s p e rh ap s
.
, ,
th e m or e i m p or t an t s inc e i t i s ba se d up on t h e fac t d e t e r m i n e d by Pro

,
fe ss o r S c h afe r a n d th e au th or fro m e xp e ri m e n t s on m onk e y s—na m e ly th a t

, ,
th i s d rug cau s e s w e ll m ark e d c o n t rac t i on O f t h e ar te riol e s O f th e c e n tral

-
n e rvou s s y s t e m ; an d t h a t co n s e qu e n t ly an inci s ion in t o t h e brain i s a c

, ,
co m p a ni e d by v e ry li tt l e oozi n g i f th e pa ti e n t b e un d e r i ts infl u e n c e .
E th e r h a s n o t b e e n e m ploy e d in O p e r at i o n s on m e n fro m th e fe ar th at ,
i t woul d t e n d t o c a u s e c e r e bral e xci t e m e n t c h l o ro for m o f cour s e pro , ,
duc 1 n g on t he c o n trary we ll m ark e d d e p r e s s io n

, ,
N a t u rally i f th e r e e x .
,
i s t e d any h e ar t co m plica ti o n th e ab ov e th e or e t ical con s i d e ra t i o n s wo ul d

-
,
b e d i s r e g ar d e d in favor o f th e s afe r n arco tic .
T r ea t m en t of t/ze Wou n d —Th e au t h or b e li e v e s th a t th e h ig h m o r
t ali ty w h ic h h a s follow e d t h e op e ra t ion o f tr e p h ining h e r e t o for e h a s

, ,
b e e n cau s e d by s e p tic m e ningi ti s co m in g on a fte r op e ning th e d ura

5 06 E D I T OR I A L A R YI C LE S .
m a te r H e th e r e for e h a s b e e n i m p e lle d in h i s O p e ra t io n s t o a dop t

.
, ,
s t ric t Li s t e ri an m e t h o d s inclu ding th e u s e o f t h e carb olic s pray

, 1 in 2 0 ,
carb o lic lo ti on a n d d r e s s i n g s o f carb o lic gauz e

, .
L i n e of I n c i s i on — I t i s th e g e n e ral cu s t o m t o r e m ov e th e s o ft par ts
fro m t h e cra n iu m by m e a n s o f a cruci for m c u t T h i s m e th o d i s p r a c .
tically i n c o nv e n i e n t s inc e fo ur d i s t inc t fl ap s h av e t o b e h e l d back r e

, ,
quiri n g as m any a s s i s t i n g h an d s all v e ry m uch i n th e way I f o n th e

,
.
,
co ntrary a s e m i lunar flap b e rai se d i t c an b e si m p ly th rown b ack

,
-
, ,
an d r e quir e s n o m or e h o ld i n g ; 1 T h e i n ci s ion m u s t b e carri e d v e r t i

.
cally t o th e b on e an d all p ar t s s up e rfi cial t o t h e p e rio s t e u m rai se d wi th

,
th e flap s 2 . T h e curv e m u s t b e a S h a llow o n e t o avoi d cu t ti n g col

.
,
la t e ral v e s s e l s 3 I t m u s t b e s o d rawn a s n o t t o d ivi d e th e m ain ar

. .
t e ri al t runk s s upplyi n g th a t p or tion o f th e s calp ( Th i s can b e v e ry .
’
e a s i ly d o n e wi t h ou t i n t e rfe ri n g wi th th e fir s t t w e n t y four h our s d rain -
a e o f t h e woun d e v e n i f th e flap b e t urn e d d ownwar d s s i n c e a s th e

g , , ,
p a ti e n t li e s in a s upi n e p o s i tion th e d i s ch arg e c an alway s e s cap e fr e e ly

,
fro m th e po s t e ri or b or d e r) T h e p e rio s t e u m s h oul d b e r e fl e c t e d by a

.
cruci al i n ci s ion fro m an ar e a corr e s po n ding t o th e fir s t tr e p h i n e h ol e -

,
an d s ub s e qu e n t ly a s m or e b o n e i s c ut away .
R em ova l of tb e B on e —On e o f th e s a fe s t a n d m o s t rapi d m e t h o d s i s
t o m ak e a coup le o f t r e p h in e h ol e s a t th e o pp o s i t e e x t r e m i ti e s o f t h e
-
ar e a t o b e r e m ov e d th e n t o h al f c u t th rough th e S i d e s o f s uch an ar e a
,
wi th a H e y s s aw an d fi n ally t o co m pl e t e th e divi s io n wi th a pow e rful

’
, , ,
b o n e fo rc e p s Th e O p e ni n g O f th e s kull sh ould b e co m m e n c e d by th e
-
.
r e m oval o f a larg e di s c wi th th e tr e p h in e an d t h e n th e d ura m a te r s e p ,
ara t e d a s far as p o ss ibl e fro m th e un d e r s ur fac e o f th e b on e t o b e re
m ov e d . Wh e r e i t i s p o s sib le t o pr e s e rv e th e d ura m a te r i n t ac t th e ,
por t io n s o f th e b on e r e m ov e d sh oul d b e pr e s e rv e d in war m a s e p tic

s po n g e s an d a t t h e e n d O f t h e O p e ra tion s h oul d b e
, , plac e d b e tw e e n ,
th e s k in an d d ura m a t e r a ft e r h aving b e e n di vi d e d in t o s m all fra g

,
m e nts .
Tr ea tm en t of fi re D a r a M a ter —T h e d ura m a te r sh oul d b e i n ci s e d

.
rou n d four fi fth o f th e circu m fe r e nc e o f th e ar e a e xpo se d at o n e e igh th

- -
in ch di st anc e fro m th e e dg e o f th e b on e s o as t o r e n d e r i t p o ss ib le t o ,
s t i t ch th e e d g e s t og e th e r a ft e rwar d s T h e d ura m a t e r i s b e s t O p e n e d
.
OP E R A TJ VE A T TA CK S UP ON TH E H UM A N B R A I N .
5 07
fir s t by inci sion wi th th e s calp e l a n d th e n by blu n t poin te d curv e d ,

-
s ci s s or s gr e a t car e b e ing t ak e n n o t t o woun d th e m e n i n g e s b e n e a th

, .
T h e m ain branch e s O f th e m i dd l e m e ning e al ar t e ry ar e b e s t s e cur e d by
a li ga t ur e p a s s e d th roug h t h e d ura m a t e r j u s t ou t s i d e i t s c u t e d g e an d ,
kno tte d b e for e th e v e s s e l i s d ivi de d .
Tr ea tm en t of ti l e B r a i n —T h e fir s t prac t ical poi n t t o n o tic e a ft e r th e
d ivi s ion o f th e d ura i s wh e th e r th e brain i m m e d iat e ly b ulg e s in t o th e

,
t r e p h in e h ol e or n o t
- Th e e xp e ri e n c e o f th e au th or inclin e s h i m t o th e
.
b e li e f th a t th e fac t o f th e brain b ulging v e ry pro m in e n tly in t o th e

woun d in d ica t e s pa th ological i n tra c ran i al t e n si o n— a pi e c e o f e vi d e nc e
,
-
wh ich i f tru e i s o f th e h igh e st i m por tanc e s inc e o th e r th ing s b e ing

, , , ,
e qual i t will in dica t e th e pr e s e n c e O f a t u m our

, T h e co lor o f th e m e m .
bran e s sh oul d n e x t b e n o t e d s inc e th e e xi s t e nc e o f a sligh t y e llowi sh

,
t ing e or p o s s ibly th e con t rary con d i t ion na m e ly livi di ty will in d ica t e

, , , , ,
th e e xi s t e nc e o f a t u m our b e n e a th th e cor t e x in th e corona ra dia t a An .
accura t e knowl e d g e of th e ar t e rial an d v e nou s s upply o f th e brain i s

h igh ly n e c e s s ary t o e n abl e on e t o appr e cia t e w h a t p or t ion s o f th e brain
,
a re ac tually or lik e ly t o b e d e priv e d O f th e ir b loo d s upply wh e n por

, ,
t ion s o f th e brai n s ar e r e m ov e d Al t e ra t ion s in th e d e n si ty of th e brain

.
m u s t lik e wi se b e O b s e rv e d th oug h i t m u s t b e r e m e m b e r e d th a t c e r e bral

,
t u m our s s i t ua t e d b e n e a th th e cor te x are s carc e ly t o b e d e t e c t e d s av e ,
by e xplor at ory inci sion .
H aem orrh ag e fro m in ci s ion s in t o th e brain th ough h e r e t o for e ,
gr e a tly fe ar e d i s e a s ily con tr oll e d Th e a c t ual cau te ry i s un n e c e ss ary

,
.
a n d O bj e c t ion abl e T h e fr e e bl e e ding w h ich a t fir s t follow s an in ci

.
,
s ion Wl ll p e rm an e n t ly c e a s e i f th e wou n d b e plug g e d fo r a fe w m in u t e s

,
wi th a pi e c e o f s po n g e M uch O f th e h aem orrh ag e m ay b e guar d e d

.
again st by th e pr e v iou s a dm in i s tr ati on o f m orp h in e Co n s i de rin g th e .
t e r m inal c h arac t e r o f th e c e r e bral ar t e ri e s e v e ry m ain v e s s e l s h oul d b e ,
l e ft in t act wh e r e po s s ibl e F or t u n a te ly owing t o th e i r runni n g in t o

, .
,
th e pi a m a t e r th e y c an b e rai s e d fro m th e brain a n d e s p e cially o ut O f

, ,
t h e s ulci s o a s t o allow o f t h e s ubj ac e n t brain b e in g r e m ov e d wh il e at

, , ,
th e s am e t i m e th e v e s s e l wall i s s o li ttl e d a m ag e d th a t an y r e s ul t an t
,
thr o m b o s i s will b e o f a v e ry t e m porary na t ur e .
F ur th e r in inci s ing th e brain th e cu t s in t h e cor te x m u s t b e m a de

, ,
e xac tly v e r tically t o th e s ur fac e an d d ir e c t e d in t o th e corona ra d i a t a

, ,
wh e r e n e c e s s ary i n s uch a m ann e r a s t o avoi d d a m ag e o f th e fibr e s

,
co m ing fro m th e por tion s o f c o r t e x a n d s urroun d i n g th e s e a t o f O p e ra

,
t ion . T h i s o f co ur s e i s e a s ily d on e by r e m e m b e ring t he p ath s t ak e n

.
,
by th e fi b r e s fr om th e cor te x t o th e in t e rnal cap sul e T h e r e ar e m an y .
o th e r poin t s con n e c te d wi th th e p h y s iology a n d p ath olo gy o f th e brain

wh ich will r e gula te O p e ra tiv e t r e a t m e n t o f t he s a m e s uch fo r in s t a n c e , , ,
a s th e t aking car e t o l e av e i f p o s s ibl e por t io n s o f e ach c e n tr e s o t h a t

, , ,
th e r e pr e s e n t a t io n s O f t h e m ov e m e n t s o f any p ar ticular j o in t m ay n e v e r
b e t ot ally d e s t ro ye d for t o t al d e s tr uc t ion m e an s obvi o u s ly a p e r m an e n t

,
paraly s i s on th e O pp o s i t e s i d e of t h e m ov e m e n t s pre v iou s ly r e gula t e d

by th e cor tical c e n t r e .
A p or tion o f brain r e m ov e d wh e th e r nor m al or abn o r m al d o e s n o t

, ,
l e av e a s m igh t h av e b e e n s upp o s e d a p e r m an e n t gap wi th v e r t ica l

, ,
s i d e s for e v e n i n a v e ry s h or t t i m e
, , th e floor o f t h e p it—th at i s
, th e ,
corona ra diat a — b u lg e s alm o s t t o a l e v e l wi th th e s urroun ding cor te x .
In a dd i tion th e c u t e d g e s b e co m e sligh tly e v e r te d an d i f l e ss brai n

, ,
th an bon e i s r e m ov e d t h e y are e x t ru d e d in t o t h e O p e ning in t h e S kull

, .
Th u s owing t o t h e m e c h anical r e la tion s b e t w e e n t h e brain an d s kull

, ,
th e r e i s n or m ally a t e n d e ncy t o h e rnia c e r e bri

, , H e rnia c e r e bri can .
on ly oc c ur wh e n t h e r e fl e c te d fl ap o f s calp h as n o t uni t e d by th e fir s t
in t e n t ion a fur th e r n e c e s s ary fac t or b e i n g d e co m p o s i tion in th e woun d
, ,
an d conv e r s ion o f th e la t te r in t o a s uppura t ing cavi ty .
T h e a d van t ag e o f rai s ing a larg e flap o f s calp w h ic h c a n b e lai d ,
d own again lik e th e lid o f a b ox will now b e O bviou s s inc e b e in g c o n

, , ,
t i n u o u s t h rou gh ou t i t o ffe r s pl e n ty o f r e s i s t anc e t o th e upwar d p u s h in g

,
brain w h ich th e poin t o f m e e ting o f four cro s s cu t s can n e v e r d o thi s

, ,
in d e e d on th e con tr ary favoring th e v e ry th ing on e wi s h e s t o avoi d

, , .
T h e p rincipal r e s i s t anc e t o t h i s h e rnial pro tru s ion o f t h e nor m al brain

i s o f cour se s uppli e d in o th e r way s
, , ( S e e Drainag e a n d Dre s sing
.
,
b e l ow) .
C los u r e f
o t/ze Woun d — All oozing ade t o c e a s e
, e tc .
,
h aving b een m
by ge n t l e pr e s s ur e wi th a s o ft s pong e t he flap m u s t b e lai d d own and ,
s e cur e d wi t h m e d iu m s ilk s u t ur e s a t d i s t anc e s o f o n e c e n t i m e t r e an d ,
b e tw e e n th e s e h or s e h air s, .
OP E R A TI VE UP ON TH E H UM A N B R AI N 5 09
’
A T TA CK S
'
Wi th th e clo s ur e o f th e w oun d we are brough t to con s i de r th e i m

,
p or t an t qu e s tion of drainag e T h e con di ti on s of th e probl e m th at now

.
e ng a g e a tt e n t ion are t o s e cur e union by fir s t in t e n tion —th a t i s fi rm ,
union in four or fi ve d ay s t og e th e r wi th pr e s s ur e upon th e br ain wh ic h

,
t e n d s t o e x tru d e In a dd i tion t o th i s i t i s d e s ir abl e t o arr an g e m a t t e r s

.
,
'
s o th a t wh e n th e woun d i s fi n ally h e ale d th e flap o f s kin m ay b e s e p

, ,
a rat e d fro m th e brain b e n e a th by a cu s h ion o f s o ft n orm al ( th a t i s ,
non i n fl am m a tory) conn e c tiv e ti s s u e All th e s e la tte r con d i tion s are t o

- .
b e O b t ain e d by allowing a c e r t ain am oun t o f t e n s ion o f wo un d e xu d a - »
t ion wi th in t h e cavi t y D uri n g th e fir s t t w e n ty four h our s th e r e i s a

.
-
,
s t e a d y oozing o f bloo d an d se rou s flui d fro m th e c u t s ur fac e s Thi s i s .
b e s t r e m ov e d ; an d th e r e for e a drai n ag e t ub e s h oul d b e p ut i n a t th e

, ,
m o s t d e p e n d e n t poin t o f inci s ion ( th a t i s as th e p a ti e n t li e s in b e d

) , .
Th i s t ub e i s to b e t ak e n o u t th e n e x t d ay an d th e woun d car e fully ,
dr e s s e d fi rm b ut g e n tl e pr e s s ur e b e ing m a d e ov e r th e c e n t r e o f th e
, , ,
flap . I f th e woun d e xu d a tion th a t s ub s e qu e n tly coll e c t s in th e cavi t y

-
,
a ccu m ul at e s t o any appr e ciabl e e x t e n t on th e th ir d d ay th e p ati e n t ,
m ay co m p lain o f s o m e p ain an d th robbing in th e woun d wh ich wh e n , ,
e xpo s e d will b e foun d t o b e di s te n d e d in th e c e n tr e th e p e rip h e ry b e

, ,
ing fir m ly u n i te d Now co m e s a m o s t di fficu lt poin t in th e tr e a tm e n t

.
—nam e ly th e qu e s tion wh e th e r th i s t e n s ion i s t o b e allow e d t o pro

,
c e e d or wh e th e r i t s h oul d b e r e l e ase d
,
By ad op ting th e latte r m e as .
ur e th e a d v an t ag e s o f th e pr e s s ur e will b e lo s t ; s o th a t th e p oin t in
,
qu e stion i s on e r e qui ring s p e ci al att e n tion T h e pr a c tic al fe at ur e up .
on wh ich it i s to b e d e ci d e d i s th e v e ry s i m pl e on e wh e th e r th e p ri
m ary union i s i n d ang e r o f b e i n g brok e n d own by t h e pr e s s ur e or n o t .
I f th e for m e r i s th e ca s e th e pr e s s ur e can e a s ily b e di m in i s h e d by

,
g e n tly Op e ning up th e t rack o f th e dr aina g e t ub e wi th a prob e an d -

,
lib e r ating s o m e o f th e e xu da tion T h e valu e o f th e t e n s ion in r e d u c

.
i n g th e te n d e n cy t o h e rnial pro tru sion i s O bviou s b ut i t sh oul d b e r e

m e m b e r e d th at un t il i t i s fin ally ab s orb e d th e h e ig h t e n e d pr e s s ur e
, ,
s e rv e s t wo p urpo s e s In th e fir st pl ac e i t co m p e l s th e ly m p h atic s o f
. ,
th e brain m e ning e s t o ab s orb th e flui d j u s t a s th e p e ri t on e al v e s s e l s ,
d o a ft e r ov ario t o m y s o a dm i tting o f r api d union o f th e w h ol e S kin

,
woun d ; an d in th e s e con d p la c e i t ac ts as a kin d o f s c affol d for th e

, ,
b uil ding up o f n or m al con n e c tiv e t i ss u e in th e p ar t T hi s la tte r poin t .
i s v e ry obviou s in th e low e r ani m al s in wh ic h i f th e woun d b e r e op e n e d

, ,
a t t h e e n d o f a fe w d ays th e cavi ty i s alway s foun d fill e d wi th a d e li

'
ca te s pongy pi n k conn e c tiv e t i s s u e th e m e sh e s O f wh ich con t ain th e

, ,
ab ov e m e n t ion e d woun d e xu d a tio n I t i s th i s conn e ctiv e ti ss u e wh ich

-
.
i s t o for m an e la s tic b arri e r b e t we e n th e s calp a n d th e brain As a .
g e n e ral rul e i t will n e v e r b e n e c e ss ary to d o m or e th an r e li e v e th e t e n

,
s ion in th e woun d onc e At th e e n d o f a w e e k or fi ve d ay s th e woun d

.
,
m ay b e lig h tly cov e r e d wi th a li ttl e pow d e r e d b oracic aci d co tton wool ,

-
,
a n d collo d ion ; an d th e s ti t c h e s m ay b e r e m ov e d a t any t i m e a ft e r t h e
fir s t w e e k I t will alway s b e foun d th a t th e s calp t e n d s t o fall in a li t

.
t le a t th e s e a t o f op e ra tion ; b u t i f th e for e going d ir e c t ion s h av e b e e n

,
fai th fully follow e d o ut th e h ollowin g will b e s ligh t

, .
I t m ay b e con s i d e r e d a s a poi n t o f p rac tical i m por t anc e w h e th e r a

'
p at i e n t will n o t run con s i d e rabl e ri s k in pur s uing h i s avoca tion s wi th a

l arg e gap or gap s in h i s s kull As a m at te r of fac t th i s i s o f li ttl e a c
.
,
coun t a s e vi de nc e d by e xp e ri e nc e
,
.
2 a n d 3 —I n th e fir s t o f th e s e pap e r s
. Dr Whi te r e cor d s th e t e
, .
s ult s o f h i s e x a m ina tion o f th e bony e nv e lop e o f th e br ain i n ca s e s
w h e r e t u m our s h av e b e e n pr e s e n t an d h e h as foun d th a t th a t por tion

,
o f th e b on e ov e r th e r e gion o f th e n e w grow th i s con s i d e rab ly th inn e d ,
o fte n so th at i t i s no th ick e r th an c ar db oar d T h e d ura m a t e r i s u s u

.
a lly th ick e r th an nor m al a t th e s e p oin t s a n d th i s h e a s crib e s t o an i n

,
fl am m at ory a c tion T h e con di t io n o f th e b on e s i s p ar ticularly in t e r

.
e s t ing t o th o s e s urg e on s wh o s till u s e th e s trai gh t in s t e a d O f t h e con
i c al tr e p h in e de p e n d ing upon an o cca sional probing o f th e inci s ion

,
t o d e te rm in e th e d e p th t o w h ic h th e in s tru m e n t h a s p e n e tra t e d for i f ,
thi s con d i tion i s pr e s e n t th e y a r e a p t t o fi n d t h a t th e y h av e p e r fora t e d
th e bon e an d inj ur e d th e alr e a dy infl am e d d ura m a t e r Wi th th e c on .
i cal tr e p h in e th e co n di tion can h av e b ut li ttl e e ffe c t as th a t in s tru m e n t

canno t b e driv e n on a fte r th e b on e i s c ut th roug h wi th o u t cau s ing a
fr a c t ur e .
The con d p ap e r i s o f m uch gr e a te r prac tic a l i m por tanc e i n a sm uch

se ,
a s th e o n e h un dr e d ca s e s e xa m in e d h av e b e e n car e fully t ab ula te d a n d
th e nu m b er c ap abl e o f b e ing r e li e v e d by O p e ra t iv e m e as u r e s cull e d

OP E R A TI VE UP ON TH E H UIV
I AI V BR A I N 51 1
i
A T TA CK S .
f;
fro m th o s e w h e re any in te r fe r e nc e woul d h av e b e e n u s e l e ss i f n o t p o s

i tive ly h ar m ful .
I n for ty fi ve o f th e c a s e s th e grow th was tub e rc ularzan d Z o n ly se v e n

'
O f th e s e w e r e cap abl e o f b e in g r e li e v e d by th e kni fe I t i s o f cour se .

, ,
a qu e s tion wh e th e r any o f th e m sh o ul d r e quir e th e c ar e o f a ls urg e on ,
an d Dr W h i t e h a s t a k e n th e pr e cau t ion t o s t a t e h i s vi e w s as a dd uc e d
.
,
fro m th e e xa m i n a t ion o f th e ca s e s un de rz di s c u ss i on i n th e followin g

t e rm s
”
r st . T h e m a ss occupi e d s o m e vi t al p ar t
“
.
2n d . I t wa s qui t e or al m o s t in a cc e s sib le as w h e n i t was at th e

,
”
ba se of th e brain .
rd I n all t h e ca s e s o n e o r m or e o th e r s truc t ur e s w e r e a ffe c t e d

3 . .
We m ay t ak e i t for gran te d th at no on e woul d l i k e to op e r ate on

ca s e s in wh i ch m or e th an two oth e r organ s w e r e d i s e a s e d
Tw e n ty fo ur ca s e s w e r e glio m a o f w h i ch n u m b e r only s ix w e r e s ui t
-
,
a bl e fo r op e ra t ion .
S arco m a e xi s te d in t e n in s t anc e s o n e of w h ic h m ig h t h av e b e e n
,
r e ach e d an d r e m ov e d F iv e w e r e carcino m a non e o f th e m b e in g c a

.
,
p ah l e o f r e li e f owing t o th e e xi st e nc e o f ano th e r in fe c t e d c e n tr e in th e
b o dy an d th e a u th or a dd s
,
“
con s i d e ring th a t c a nc e r O f th e brain i s i n
,
fini te ly r ar e e xc e p t wh e n s e con d ary t o a grow th e l s e wh e r e i t i s o h

”
vi o n s th a t s urgical in t e r fe r e nc e will n e v e r b e n e e d e d .
G u m m a t a e xi s t e d in fi ve ca s e s an d o f cour s e th e s e a re inclu de d in
, ,
t he n u m b e r th at d o n o t r e quir e any s urgi cal a t t e n t ion a s th e y u s u a lly ,
a b s orb qui te rapi dly w h e n io di de of po t a ss iu m i s a d m ini s te r e d in larg e

dose s .T h e au th or d o e s n ot s t a t e wh a t i s g e n e rally r e gar d e d a larg e
’
d o s e o f th e io di d e a t G uy s Ho s pi t al a n d th i s i s a m a t te r O f s o m e t e
,
gr e t e s p e ci ally sinc e th e m a tte r i s un de r d e b ate an d d o e s n ot s e e m to

, ,
b e an y n e ar e r s e ttl e m e n t th an i t wa s s o m e t i m e ag o .
Cy s t s e xi s te d in fo ur c as e s an d on e o f th e m coul d h av e b e e n r e ach
,
e d by th e s ur g e on .D oub tful t um or s are cl ass e d a s th r e e an d t wo o f ,
th e m are s t ate d a s O p e r abl e .
T h u s i t i s s e e n th a t out o f th e t o t al n u m b e r of on e h un d r e d only ,
t e n m ig h t c e r t ainly h av e b e e n op e r at e d upon an d four a d di tional on e s

,
m ig h t po s sibly h av e b e e n s o th a t in t e n p e r c e n t o f our c ase s we c an

, .
,
”
5 12 E D I T OR I A L A R T I CLE S .
h ol d o m e h op e of op e ra tiv e r e li e f to o ur p ati e n t s provi de d th a t a

o ut s , ,
”
o rre c t d iagno s i s o f th e p o s i t ion o f th e grow th b e m a d e .
Th i s i s s ur e ly n o t a v e ry pro m i s ing s h owing for th e ad voc ate s o f th e

m o s t a d vanc e d o p e ra ti ve
p ro c e d ue s in c e r e bral s urg e ry T h e p ap e r i s .
full o f i n te r e s ti n g an d in s t ruc t iv e poin t s a n d w e ll d e s e rv e s a car e ful

,
p e ru s al .
4 As col la te ral t o th e qu e s t ion o f C e r e bral S urg e ry fro m th e s t an d

.
,
p oi n t pr e s e n te d in th e for e goi n g p ap e r s th e S urg e ry o f Mi dd l e M e ,
n in e al H a e m orr h ag e i s O f in te r e s t an d i s e x h a u s t iv e ly tre a t e d in t h e
g ,
pap e r by Dr H A J acob s on T h e wri te r h a s colla t e d a larg e nu m b e r

. . . .
o f ca s e s i n w h ic h th i s co m plica tion h as r e s ul t e d a ft e r an inj u ry o f m or e
o r le s s se v e ri ty
.
.
T he co n clu s ion s drawn fro m th i s s t u dy are in h i s opinion s i m ilar t o , ,
th o se a lr e a d y a dvan c e d by o th e r wri t e r s na m e ly th a t t r e p h i n i n g s h oul d

, ,
b e r e s or t e d t o a s e arly a s po s s ibl e .
H e s ay s t h a t th e vi o le n c e cau s i n g th e e x trava s a tion i s o ft e n v e ry
s lig h t an d m ay e xi s t wi th ou t any frac t ur e

, or wh e n th e b o n e i s s i m ply
,
fi s s ur e d or o nly th e in te rnal tabl e i s involv e d ; th a t lac e ra tion a n d c on

,
t u s ion o f th e brai n s ub s t a n c e ar e o fte n s e riou s co m plica t ion s t h a t th e
h i s t ory o f th e ca s e par ticularly a luci d in t e rval are invaluabl e ; th a t

, ,
th e sy m p t o m s o f co m pr e s s ion a re s o m e ti m e s d e fe rr e d an d th e n m ay ,
app e ar s u dd e nly an d rapi dly cau s e d e a th th a t as i n th e ca s e s o f t u

, ,
m o r o f th e brain d e a th fr e qu e n tly i f n o t u s ual ly r e s ul t s fro m failur e o f

, , ,
r e s pira tio n ; th a t dila ta tion o f th e pupil on th e s i de o f th e clo t i s an im

p or ta n t s y m p to m ; an d a ft e r tr e p h ini n g a s e v e r e i f n o t fa t al h ae m o rr
, , ,
h ag e m ay s e t i n H e r e co m m e n d s in d e aling wi th th e l a s t con di tion

.
, ,
t h a t an a t t e m p t b e m a d e fir s t t o s e cur e th e bl e e d ing p oin t i f th i s fail

, , , ,
s e c o n d h e appli e s a fr e e zing m ix t ur e ov e r th e d r e s s ing a n d rai se s t h e

, ,
pa ti e n t t o th e Si tting p o si tion an d thir d i f th e bl e e di n g s till con tinu e s

, , , ,
d igi tal co m pr e s s ion ov e r th e co m m on caro ti d ar t e ry s h o ul d b e m a d e ,
an d in ca s e th i s h ze m o rrh a e i s re e s t abli s h e d a ft e r t h i s h a s b e e n con

g
-
,
t in n e d fo r s o m e ti m e h e a d vi s e s t h e liga t io n o f th e e x t e rnal caro t i d

.
.
T h e s e th r e e pap e r s pr e se n t th e s ubj e c t O f C e r e bral S urg e ry in a v e ry

s t rik i ng a n d convincing wa y a n d m u s t s ur e ly d o m uc h t o pl a c e th e
,
O p e ra tiv e in t e r fe r e n c e s wi t h l e s ion s or inj uri e s wi th th e cranial cavi t y

,
OP E R A TI VE A T TA C K S UP OI V TH E H UM A N B R A I N .
5 13
i n a b e tte r p o s i tion th an b e fo r e Wi th th e u s u al i m p e t uo s i ty an d e n
.
t h u s i a s m o f pion e e r s in any un d e r t aking t h e advo c a t e s o f op e ra t iv e

,
proce d ur e in c ase s of th i s kin d h a ve a dvi s e d th e m o s t r adical m e a s

,
~
ur e s an d th e coll e c tion o f nu m b e r s o f c a se s t og e th e r wi th a car e ful

,
t ab ul a t ion o f r e s ul t s an d th e p o s s ibili ti e s r e v e al e d t o th e c ar e ful p ath

,
ologi s t m u s t gr e a tly i m prov e th e principl e s of th i s branch o f s u r g e ry

, .
T h e wri te r i s abl e h ow e v e r t o pr e s e n t only t h ir t e e n s ucc e s s ful ca s e s

, ,
.
o ut o f th e se v e n t y up on w h i ch h i s p ap e r i s b a s e d wh ich h e con s i d e r s
,
b u t a p oor s h owing . We fe e l inclin e d t o t ak e e xc e p tion t o th e la s t

s t at e m e n t
, for s ur e ly e igh t e e n an d a h al f p e r c e n t i s a goo d s h owi n g
.
in c ase s th at woul d wi th o u t O p e ra tion h av e b e e n s ur e ly fa tal .
S AM U E L LL O Y D.
I ND E X O F S U R G I C A L PR O G R E S S .
1 . Lu pus v u lg a r i s a n d T u b e r c u lo s i s BY M H E N R I LE L O I R . . .
T he au t h or r e a ss e r t s th e clai m o f lupu s t o b e co n s i d e r e d a for m o f
t ub e rculo s i s o f th e s kin a n d r e la t e s t h e following ca s e :

, A girl s ix
y e ar s old o f h e al th y p ar e n t s pr e viou s h e alth e xc e ll e n t on e y e ar b e
, , ,
for e h a d a r e d pa t ch app e ar o n th e b ack o f th e l e ft h a n d w h ich h a d ,
incr e a s e d s lowly s inc e T h e p a t ch h ad a tt ain e d th e s iz e o f a t wo fra n c

.
pi e c e a n d wa s s ligh tly p apillo m at o u s— th e “ lupu s s alere ux of th e a u

t h or a n d E Vi d al w h ic h i s t o lupu s vu lg a ri s w h a t fibrou s p h th i s i s i s t o
.
,
or d i n ary t ub e rculo si s o f th e lu n g F ro m th i s p a t ch a S ligh tly p ain ful

.
ly m p h a ti c cor d le d t o a t ub e rculou s n o d ul e on th e back par t o f t h e
for e ar m w h i c h h a d e xi s t e d for t h r e e m on th s an d h ad a tt ain e d th e s iz e

, ,
o f a h a z e ln ut F ro m th i s t u m or a d oubl e ly m p h a tic cor d c o ul d b e

.
t rac e d t o a s i m ilar o n e w hi ch h ad app e ar e d o n e m o n th la t e r S o m e

, .
w e e k s a ft e rwar d s t wo n e w t u m or s w e r e s e e n t o h a v e d e v e lop e d on th e
in t e rn al a sp e c t O f th e arm a n d th e y al s o w e r e conn e c t e d by ly m p h a ti c
,
cor ds T h e e pi troch l e ar glan d wa s e nlarg e d t o th e siz e o f a pig e on s

.
’
e gg a n d th e a xilla ry glan d s h a d b e gun t o s w e ll

,
A ft e r ano th e r in te rval .
o f s o m e w e e k s Le loir foun d th a t t wo O f —
, th e t ub e rculou s t u m or s h a d i n
p ar t s o ft e n e d an d ulc e ra te d p r e s e n tin g th e typical app e ara n c e o f tu

,
b e rc u lo s i s o f t h e s kin T h e axillary g lan d s h a d a t t ai n e d th e s iz e o f

.
pig e on s e gg s an d th e s ub clavia n gla n d s h a d e n larg e d E xa m ina ti o n

’
, .
o f the lung s h a d alway s b e e n car e fully m a de b u t wi th n e ga t iv e r e s ul t s ,
h i th e r t o N ow h o we v e r un m i s t akabl e S ign s o f t ub e rculou s in fe c tion

.
, ,
w e r e fou n d in th e lef t ap e x S ligh t coug h pallor an d e m acia tion w e r e

.
,
pr e s e n t Tr e a t m e n t was a t la s t p e r m i tte d an d th e lupu s pa t ch on th e

.
,
h a n d an d th e t u m or s w h ich h a d ulc e ra t e d w e r e d e s t roy e d wi th th e
t h e r m ocau te ry a n d io din e wa s appli e d t o th e e n larg e d glan d s

, S om e .
t i m e lat e r a li tt le s ubcu ta n e ou s t ub e rcular no d ul e app e ar e d by th e s i d e
( 5 1 4)
GE N E R A L s UR OE R r: 515
O f th e form e r lup u s p at ch an d r
lay b ar e the un de rlying
t h e at e n ed to
a r t i c ula t ion s b ut i t wa s d e s tr
, oy e d wi th th e th e r m oc a u te ry an d inj e c t
ion s O f tinc t ur e o f i o d in e T h e ly m p h angi ti s a n d glan d ular e nlarg e
.
m e n t gra d ually d i s app e ar e d an d th e p u lm on ary s y m p t o m s i m prov e d

,
u n til ( wh e n la s t s e e n) th e r e wa s p e rc e p tibl e only a s ligh tly prolong e d

a n d ru d e r e s pira t ion .
T h e e x t e n s ion o f th e t ub e rcular viru s th rough th e ly m p h at i c ch an
n e l s in th i s ca s e i s n o t e wor th y e sp e ci ally in conn e ction wi th th e a cu t e

,
oe d e m a t o u s ly m p h angi t i s ( s o c all e d s cro fulou s or

- wh i t e e ry s ip e l as) , ,
wh i ch i s qui te co m m on wi th lupu s p ar ticul arly o f th e fac e I n four , .
ca s e s Le loir s aw t ub e rcular in fe c tion o f th e lung s follow th i s lym p h an

gi ti s Th e p se u d o e ry s ip e la s h ad di s app e ar e d fo r a w e e k or m or e b ut
.
-
,
th e s ub m axilla ry a n d s o m e t i m e s th e
, s ubclavian glan d s r e m ain e d
s woll e n an d S lig h tly p ain ful w h e n th e p a t i e n t s u dd e nly d e v e lop e d fe b
,
ril e s y m p t o m s Car e ful e xa m in a t ion o f th e lung s ( h i th e r t o h e al th y)

.
r e v e ale d t ub e rculou s i n fi ltratlon o f th e ap e x .
O f s e v e n t e e n ca s e s o f lupu s vulgari s t r e ate d in h o s pi t al Le loir fo un d ,
t e n a ffe c te d wi th p ul m onary t ub e rculo s i s a n d ano th e r wi th t ub e rculou s ,
ar th rit i s of th e kn e e —agr e e ing wi th th e s t a ti s tic s o f Ha s lun d ( Cop e n

h a g e n ) a ccor din g t o wh ic h 6 0 % o f l upu s p a t i e n ts d e v e lop e d t ub e rc u
,
losi s se con d arily O f nin e p riva t e c a s e s Le lo i r fo un d p ul m onary af

.
,
fe c t i on in only o n e b u t in t wo o th e r s t h e a i llus t u be r cu los i s wa s

,
foun d in s e c ti o n s o f th e lupo u s t i s s u e a n d inocula tion wi th th e la tt e r ,
pro d uc e d t ub e rculo s i s in guin e a pig s T h e s e two ca s e s w e r e young girl s .

,
o th e rwi s e h e al th y wh o h a d lo s t par e n ts by p h th i s i s a n d Le loir s up

, ,
p o s e s loc al inocula tion o f th e b a cillu s t o h av e b e e n th e c a u s e o f th e

—
lupu s A n n a o a er m a n d de Syp /z 1 8 8 6 7 VI I N o 6 p 3 2 8
’
-
’
.
, , .
, .
, . .
B F . A R Q U H A R C U R TI S , ( N e w Y or k) .
II . An t i s e p t i c u r g e r y i n t h e B u lg a r i a n W a r BY M
S . .
M AYD L T h e au th or St at e s th at of
. m e n wo un d e d in th e war ,
wh i ch w e r e brough t t o B e lgra d e only 5 1 di e d ; o f t h e se 2 2 d e ath s

,
w e r e th e r e s ul t o f t e t anu s ; th e s urgic al m or t ali ty was only p er c e nt .

,
”
“
th ank s t o th e u se o f an t i s e p t i c d r e s s ing s T h e s ani t a ry con di tion .
o f th e s ol d i e r s wa s v e ry d e fe c t iv e E ry s ip e la s wa s rar e an d in s pi t e
.
, ,
F
3 I 6 INDE X OP S UR GI CA L P R O GR E S S .
o f th s
i wan t of car e on th e fi e l d M Bl um r e por ts th a t o f 1 3 6 ca s e s o f
,
.
,
wh ich 1 1 6 w e r e lanc e or s word wo un d s 1 2 co m plicat e d fr a c tur e s an d

,
1 0 a rt icu lar wo un d s all t r e a t e d an t i s e p tically

, th e r e w e r e n o d e a th s or
,
p urul e n t d i s e a s e s T h e d r e s s ing s w e r e d o n e wi th carb olic gauz e a t

,
5 p er a n d th e in s tr u m e n t s wa s h e d wi t h d i s in fe c t an t fl ui d a t 2 5
”
p e r I ooo , P r ess a n a C i r o
. Augu s t 2 5 1 8 8 6 p 1 5 3
’
.
, , . .
I I I D e v i c e fo r D i s t i n g u i s h i n g t h e D i ffe r e n t S o lu t i o n s o f
C a r b o li c A c i d M A TTH E W H AY ( Ab e r de e n ) A s at ur ate d s olu tion
.
, .
o f c h lori d e o f s o d iu m i s u s e d I f s uch a s olu tion i s a d d e d in ab ou t

.
e qual qu an t i t
y t o a 5 p e r c e n t s olu tion o f pur e c ry s t all in e carb oli c
.
a ci d the m ix t ur e b e co m e s m ilky an d Op al e s c e n t an d th e m ilkin e ss

, ,
d o e s n ot di s app e a r on sh aking wh e r e a s i f a d de d t o a 2 p e r ce nt so .
lu ti on th e m ix t ur e r e m ain s p e rfe c tly cl e ar

, T h e O p al e s c e nc e i s d ue t o
.
t h e s e p ar ation o f carb olic aci d in th e fo rm o f m inu t e dr op s C hlori d e .
o f s o diu m h a s a gr e a t e r a ffi ni ty for wa te r th an c arb olic a ci d h a s h e nc e ,
i t i s cap abl e O f d i s placin g carb olic aci d fro m i t s s o lu tion T h i s h ap .
p e n s h ow e v e r only wh e n th e s olu tion o f carbolic a ci d i s of s u ffici e n t

, ,
s tre ng th O th e rwi s e th e y r e m ain s i de by s i d e in co m pl e t e s olu t ion

. .
In pr e p aring th e salin e s olu tion i t i s pr e fe rabl e t o u se th e p ur e c ry s t al

,
lin e s o dic ch lo ri d e e m ploy e d in l ab ora t ori e s I t i s qui te a ch e ap s ub .
s t anc e A s olu tion o f or din a ry s al t h a s o ft e n i t se lf far fro m a cl e ar ap

.
, ,
p e ara n ce th e r e i s no o th e r O bj e c t i on t o t h e u s e o f or d inary s al t .
I t i s wo rt h no ti n g th at h e at s carc e ly appr e ciably incr e a se s th e

a m oun t of co m m on s al t di s s o lv e d by wa te r b u t i t d o e s h aste n i ts so
’
lu ti on But th e s olu t ion m u s t n o t b e u s e d h o t or i t wi ll n o t p re c ip i

.
,
t a t e th e c arb olic aci d I f th e s olu tion b e k e p t in b ulk i t m u s t n o t b e

.
,
l e ft in a plac e wh e r e i ts t e m p e ra t ur e m ay b e r e duc e d v e ry n e ar th e
fr e e zing p oin t ; o th e rwi se th e s tr e ng th o f th e s olu t ion m ay b e w e ak e n e d
by th e d e po s i ti on o f th e sal t .
Add th e c arbolic s ol u ti on t o th e sa l t s olu tion—s ay in th e t e st t ub e

n ot th e s al t t o th e c arb olic I f th e a d di tion h e m a de s lowly d rop by
.
dr op i t will b e ob s e rv e d th a t e a ch dr op p r o d uc e s a s m all w h i t e clou d

,
o f se p ar at e d carb olic aci d whi c h di s app e ar s a t onc e b v a s ingl e sh ak e

,
o f th e t e s t t ub e un til t h e c a rb olic aci d s olu tion i s e qual t o ab ou t o n e

N E R VO U S A N D VA S C ULA R S YS TE I WS .
517
fo ur th par t o f th e s al t s olu t ion wh e n th e s e p ara t e d aci d no long e r di s

,
app e ar s on sh aking I f t oo m uch o f th e carbolic a ci d s olu tion b e a d

.
d e d th e pr e cipi t a t e b e g in s t o r e d i s s olv e an d th e m ix t ur e t o cl e ar Al .
s o th e t e m p e ra t ur e m u s t n o t b e ab ov e
74 F ( 24 C ) Dry t e st t ub e s
°
. .
m u st b e use d .
Wi th r e gar d t o th e qu e s t ion How far can a 5 p e r c e n t s olu tion o f

, .
c arb oli c a ci d b e dilu t e d b e for e i t c e a s e d t o giv e th e r e ac tion ? th e
au th or s ay s th a t th e a d di tion of qui t e a s m all qu an ti ty o f w at e r i s

e n oug h t o pr e v e n t th e r e ac tion ; th a t i s no s e p ar a t ion o f c arb olic aci d
,
i s ob t ain e d wh ich d o e s n o t di s app e ar on sligh t sh aking .
T h e r e are m any o th e r in te r e s tin g d e t ail s giv e n in th e pap e r w h ich

i s ra th e r a lo n g o n e —
,
L a n cet 1 8 8 6 Augu s t 7 .
, .
N E R VO U S AND V A S C U LA R SYSTE M S .
I . N e r v e S t r e t c h i n g fo r A n ae s t h e t i c L e p r o s y . BY M R . A .
N E V E Wi th r e fe r e nc e t o h ow lon g th e i m prov e m e n t con tinu e s afte r

.
s ucc e s s ful n e rv e s t r e t ch in g fo r a n ae s th e t i c l e pro sy Mr N e v e wri t e s th a t

Z , .
h e s ti ll occa s ion ally m e e t s wi th ca s e s O p e r a te d on by D r Down e s fi v e .

,
or s i x y e a r s ago M a ny of th e m con tinu e t o h av e goo d se n s atio n

.
,
o th e r s r e t urn t o h av e th e O p e ra tion r e p e ate d C e rtainly in a larg e .

,
propor tion of th e ca s e s th e b e n e fi t i s p e r m an e n t an d in v e ry fe w i n
, , ,
d e e d i s th e r e curr e nc e r api d o r co m pl e t e
, T h e r e ad e r i s r e fe r r e d t o
.
1 7 o c as e s o f w h i ch an accoun t wa s publi sh e d by th e a u th or
, in th e ,
E dinb urgh M e d Journ t wo y e ar s a g o —La n cet Aug 1 4 1 8 8 6 p 3 2 5

. .
, , .
, ,
. .
C B K E ETL E Y ( Lo n d o n ) . . .
II . O p e r at i o n s on M A U R I CE H R I C H AR D S O N
Ne rves . BY .
,
M D ( Bo st on M as s) T h i s pap e r con s i st s of a r e p or t o f t e n ca s e s
. .
, , .
o f op e ra t ion s on n e rv e s wi th r e m ark s e s p e cially on n e rv e s u t u re

,
.
[V er ve S t r ete/zi ng f or Sp a s m oa i e Wry N eck —T h i s c ase prob ably o f

’
,
c e n tr al o ri gin pr e s e n t e d a righ t s t e rn o m as toi d m u s cl e s u ffe ring fro m

,
-
rapi d an d uncon tro ll abl e con tr a c ti on s ; con s ti t u tion al tr e atm e n t h avin g

fail e d an d i m m o biliz at ion o f th e h e ad in a pl a s t e r h e l m e t b e ing t ri e d
,
wi th ou t s ucc e s s th e righ t s pin al a cc e s s o ry n e rv e was e xpo s e d a nd

,
s tre t ch e d t e n poun d s w e i g h t b e ing appli e d

,
A fte r th e O p e ra tion th e
.
,
m u s cl e b e ca m e p e rfe c tly qui e t fo r t wo m on th s d uring w h ich t i m e th e .
l e ft s te rno m a s t oi d b e c am e s i m ilarly a ffe ct e d b ut t o a l e ss d e gr e e

-
, ,
wh il e at th e e n d o f th a t p e rio d th e s p a s m r e tu rn e d t o th e righ t b u t
, , ,
al s o t o a l e s s d e gre e .
N eu r ectom y 1 E igh t m o n th s a ft e r a c u t ov e r th e m i ddl e o f th e

. .
ri g h t th igh th e pa t i e n t s u ffe r e d fro m p ain a t th a t po i n t an d fro m

, ,
“
cra m p s p e r s i ste n t an d fr e qu e n t o f th e calf o f th e le g An inci s ion

, , .
abov e th e s car in th e u s ual co ur s e o f th e n e rv e s h ow e d a sm all branch

, ,
O f t he m i ddl e cu t an e ou s wh ich was follow e d in t o th e s car ; th e s car

,
i t s e l f wi th an in ch o f th e n e rv e involv e d in i t was th e n d i s s e c te d out

, , ,
r e li e vi n g th e a ffe c tion a n d l e aving a s m all pa t ch o f a n ae s th e s ia b e low

,
th e s car in th e p ar t s uppli e d by t h e e xci s e d bran c h

, 2 A c u t on th e . .
i n n e r a s p e c t o f th e foo t l e ft a pai n ful s c ar r e fe rr e d along th e cour s e o f

, ,
th e i n te rn al s ap h e nou s n e rv e a p ar t o f wh ich o n d i s s e c t io n wa s fo un d
, , ,
i n th e s car an d t og e th e r wi th th e s car w a s e xci s e d i m m e dia te ly r e li e v

, ,
i n g th e p ain 3 F or n e ura.lgia o f t h
. e in fe rior d e n t al n e rv e o f fi ve y e ar s
s t a n ding t h e n e rv e wa s d ivi d e d j u st ab ov e t h e poin t o f e n tr a nc e in t o

.
t h e d e n t al fora m e n w h ich gav e r e li e f for t wo y e ar s

, T h e p ain h av ing .
r e t urn e d in an aggrava t e d for m an d la s t e d for a y e ar o n e inch o f th e , ,
n e rv e was r e se c t e d th e in fe rior d e n t al canal b e ing O p e n e d fro m th e

,
ou t s i d e t o p e rm i t i t ; i m m e di at e r e cov e ry fo llow e d 4 I n a m an s u f . .
fe rin g fro m e pil e p ti form n e ural g ia o f th e s i d e o f th e no s e an d fac e in ,
t h e p ar t s s uppli e d by th e in fra orbi t al n e rv e th e i n fr a orbi t al canal wa s -

,
-
e xpo se d an d th e n e rv e pull e d o u t o f i t a s far a s po s s ibl e an d d ivi d e d ;

,
th e p e rip h e ral e n d wa s th en dr awn up i t s br anc h e s d i s s e c t e d d own an ,
inch or m or e an d th e n d ivi d e d c o m pl e te r e li e f r e s ul ti n g ,
.
P r i m a ry N e r ve S u t u r e —Two ca s e s are r e por t e d b o th a ffe c ting th e

.
,
uln ar n e rv e b ut a s ye t th e y h av e h a d bu t n e gativ e r e s ul ts an d w e r e
, ,
un d e r ob s e rva t ion a t th e wri ti ng o f th i s pap e r .
R es ect i on a n a S u t u r e — I T h e m e d i an n e rv e w as c u t by a b ur s t ing
’
. .
bo ttl e r e s ul ting i n a lo s s o f s e n s a tion in th e m i dd l e an d for e fi ng e r s an d

,
th e p al m ar s ur fac e o f th e th u m b O n op e ra tion th e n e rv e wa s foun d .

,
in th e cica t ri x al m o s t s e v e r e d ; th e inj ur e d por tion was e xci se d an d th e ,
e n d s broug h t t o g e th e r an d s u t ur e d r e s ul tin g in r e cov e ry co m pl e te a , , ,
y e ar la t e r 2 T he m u s c ulo s piral n e rv e was d ivi d e d by a s t ab c au s

. .
-
,
N E R V0 U S A N D VA S C ULA R S YS TE M S .
5 19
in g wri s t d rop an d th e lo s s o f e x te n s ion in th e fi n g e r s al th oug h th e

- .
n e rv e e n d s w e r e u n i t e d a t th e pri m a ry op e ra t ion a m on th la t e r e ry ,
s ip e la s a n d e x t e n s iv e s uppura t ion O f th e w h ol e upp e r a rm c am e on ;
t h r e e m on th s la t e r th e r e b e ing n o r e t urn o f th e func t ion s o f th e m u s

,
culo s piral th e n e r v e wa s e xpo s e d in th e s car 1

-
, inch e s r e se c t e d a n d , ,
t h e e n d s s u t ur e d r e s ul t ing in co m pl e t e an d p e r m an e n t r e cov e ry a fte r

,
fo ur m on th s 3 T h e ulnar n e rv e h a d b e e n co m pl e te ly d ivi d e d by a
. .
p an e O f gla s s an d lo s s o f se n s ation in th e li ttle an d h al f o f th e ri n g

,
fing e r follow e d th e h e aling o f th e woun d on O p e ra t ion the e n ds O f th e ,
d ivi d e d n e rv e w e r e onl yfoun d a ft e r a pro lo n g e d d i s s e c t ion th e ir r e l a ,
t i o n s h avi n g b e e n con si d e rab ly al t e r e d an d th e d i s t al e n d r e trac te d

,
s o m e di s t anc e t h e y w e r e broug h t t og e th e r e n d t o e n d con s i d e rabl e , ,
t e n s i on on t h e U p p e r p or tion b e i n g n e c e s sary t o m ak e i t m e e t th e p e
r i h e ral p or t ion t h e e n d s fr e s h e n e d a n d s u t ur e d wi th n o appar e n t t e
p , ,
t u rn o f m o t or pow e r a fte r th r e e m on th s T h e wr i te r b e li e v e s th e .
m e t h o d o f s u t urin g th e S h e a th o f t h e t wo e n d s or in dir e c t m e th o d , ,
pr e fe rabl e t o th e m e th o d o f p a s si n g th e s u tur e s th rough th e n e rv e i t s el f ,
o r d ir e c t m e th o d —B os ton M ea a n d S u r
’
g f o u r O c t 21 .1 8 8 6 . . .
,
.
I I I A C a s e o f L i g a t u r e o f t h e C o m m o n I l i a c A r t e r y fo r
.
A n e u r i s m o f t h e E x t e r n al I l i a c ; D e at h o n t h e S e v e n t h
D a y fr o m A c u t e N e p h r i t i s By W I LL I AM F F LU H R E R M D
. .
,
. .
,
( N e w Y ork ) T h e p a t
. i e n t w a s a co lor e d l abor e r se t 3 5 wi t h a h i s , .
,
t ory o f s yp h ili s T h ir t e e n w e e k s pr e vi ou sly a s m all pu ls a ti n g tu m our

.
was ob s e rv e d in h i s l e ft gr oin w h ic h h a d s t e a dily incr e a s e d in s iz e an d

,
in th e s tr e n g th o f i ts p ul sation s An e uri sm of th e e x te rn al ili ac ar te ry

.
was d i a gno se d an d li g a t ur e O f th e co m m on iliac for i t s r e li e f wa s d e

,
ci de d up on Th e p a ti e n t app e ar e d t o b e in a fair p h ysi c i al con d i t ion

.
,
a n d th e e xa m ina t io n o f h i s urin e th e m orni n g o f th e O p e ra tion

, ,
s h ow e d n o th ing abnor m al T h e ab d o m e n wa s O p e n e d in th e m e dian

.
li n e skir ting th e u m bilicu s fro m a p oin t 2 i n ch e s ab ov e th e upp e r b o r

, ,
d e r o f th e p ub e s t o a p oin t , inch e s ab ov e th e c e n tr e o f th e u m
i
b ili c u s an d s ub s e qu e n tly e xt e n de d
, inch upwar d T h e s ur fac e s h ad .
p r e viou s ly b e e n r e n d e r e d a s e p t ic wi th m e rcu ri c bich lo ri de s olu ti o n s b ut ,
a s s oon a s th e ab d o m e n wa s O p e n e d a b o rO s alicyli c aci d s olu t i on was ,

-
5 20 I N D E X OF S U R GI CA L P R O GR E S S .
s ub s ti t u te d T he diagno si s h aving b e e n v e rifi e d by d igi t al e xplora tion

.
t h roug h a s m all o p e n i n g in th e p e ri t on e u m i t was op e n e d th e wh ol e
l e ng th o f th e woun d A pi e ce o f th in rubb e r sh e e ting S i m ilar t o th at

.
,
u se d by th e d e n ti s t s fo r th e rubb e r d am an d 2 7 x3 6 inch e s was rapi dly

,
s pr e a d ov e r th e ab do m e n i n s uch a way th at i t s m ain por tion

wa s on th e ri gh t o f th e b o d y a n d i t s l e ft e dg e ov e rlapp e d t h e m e
d ian lin e b ut ab ou t 5 inch e s ; th e n i t was flu sh e d wi th war m an t i

s e p t ic s olu tion an d th e s m a ll in t e s t in e d ra wn th roug h a s li t in th e
rubb e r wh ich was car e fully wrap p e d ab o u t th e m s o th a t t ow e l s

, ,
wrung ou t o f war m s olu tion b e ing k e p t con st an tly ab ou t th e b ag

, ,
’
th u s for m e d th e y w e r e k e p t w ar m m oi s t an d o u t o f th e op e ra t or s way
, ,
.
A di s in fe c te d s ilk lig at ur e wa s th e n appli e d at a poin t o f an inch
fro m th e t u m our a n d inch fro m th e bi furca t ion o f th e a or ta .
In abou t a m inu te a fte r tying th e v e s s e l th e ra dial p ul se wa s oh ,
s e rv e d t o b e s low e d t w e lv e or fi ft e e n b e a t s p e r m inu t e wi th a ,
m ark e d i n c r e a s e in volu m e Th e ab d o m in al wo un d wa s clo s e d wi th

.
a con tinuo u s s u t ur e o f ca tgu t for th e p e ri to n e u m a con tinuo u s s ilk ,
s u t ur e for t h e lin e a alb a an d in t e rrup te d s ilk s u tur e s fo r th e s kin

,
an d ,
d r e s s e d an ti s e p tic ally ; th e p a ti e n t was co m pl e te ly un d e r th e i n fl u
e n c e o f e th e r for t wo h our s Pa ti e n t r e a c te d w e ll fro m th e O p e ra t ion

. .
O n th e following d ay s y m p t o m s o f n e p h ri t i s w e r e O b s e rv e d wh ic h
, ,
con tinu e d un til on th e s e v e n th d ay h e s uccu m b e d t o th e pro foun d e x

h a u s ti on wh ich th e n e p h ri ti s i m p o s e d upon h i s w e ak e n e d con s t i t u tion .
T h e au t op s y s h ow e d o nly a s lig h t loc al p e ri t oni ti s a t o n e or t wo p oin t s
a n d goo d union at t h e p o in t o f lig at ur e T h e an e uri s m was fo un d

.
fill e d wi th a s oli d h o m og e n e o us cl ot T h e r e wa s al s o foun d an an

, .
e uri s m o f th e ab d o m inal a or ta ab ou t
5 inch e s in l e ng th T h e ki dn e y s
.
w e re s tr uct ur ally in goo d con di tion as i d e fro m th e l e s ion s o f th e a cu t e

n e p h ri ti s al th o ugh t h e y m u s t h av e s u ffe r e d fro m th e prolong e d a dm in
,
i s trati on o f io di de O f p o t a s s iu m giv e n fo r th e s yp h ili tic d i se a se ; th e

'
lapar o to m y m igh t h av e e x e r te d a d e pr e s sing e ffe c t upon th e m t o wh ic h ,
coul d b e add e d th e prolong e d e th e riz ation a n d th e ch ang e s in th e

r e n al circula tion i m p o se d by th e ch ang e in t h e c o ur s e o f th e b loo d .
I V Y Ill ea R ec
’
. . . . O ct . 2
3 .
H E A D AN D N E CK .
521
IV . n u c l e at i o n o f a N e u r o m a W h i c h S e e m e d t o D e
E ,
m an d R e s e ct i o n o f a N e rv e By M GU NN M D ( C hicago ) A
. .
, . .
, .
fi brou s t u m our in t h e c our s e o f th e u ln ar n e rv e wa s e xp o s e d ; an d i t
w a s fo u n d t h a t th e n e rv e fi br e s b e c am e lo s t i n th e m a s s a t th r e e
four th s O f an i n ch fro m t h e u pp e r ( ap p ar e n t ly s pr e ading o u t on th e
s ur fac e
) an d r e app e a r e d a t ab ou t th e s a m e d i s t anc e fro m th e low e r
e n d o f th e t u m our . On e xp lo ri n g th e m a s s by a lo n gi tu din al i n ci s ion

a t th e d e p th o f a co upl e o f li n e s i t wa s foun d th a t fro m th e c e n t ral
,
m ass cou ld e a s i ly b e s e p ar at e d a c a p s ul e O f th i s th ickn e s s co m po s e d ,
p ri ncip al ly o f n e op la s tic t i ss u e i n volvi n g an d co m pl e te ly ob s curing e x ,
c e p t a t e i th e r e x tr e m i ty th e wi d e ly s e para te d n e rv e fib e r s
, A fte r th e .
e nucl e a t ion o f th e c e n tr a l m ass t h e cap s ul e wa s l e ft con t i n uou s a t

,
e i th e r e n d wi th th e tru n k o f th e ul n ar n e rv e T h e r e s ul t w as a cur e
.
wi th fr e e d o m fro m all p ain an d i m p air m e n t o f function in th e par ts t o

wh ic h th e u lnar n e rv e was d i s tr ibu t e d Th e t u m our h ow e v e r re
.
, ,
curr e d i n a li ttl e l e s s th an four m on th s an d was r e se c te d ; an a tte m p t

wa s m a d e t o gra ft th e di s t al e n d O f th e ulnar n e rv e upon th e m e d i a n
a n d a gra d u al r e s t or a t ion o f func tion w a s occurri n g A r e p e t i tion o f .
t h e form e r O p e r ation in th i s ca s e wou ld prob abl y h av e b e e n u s e l e s s
owi n g to th e probabili ty o f r e curr e nc e a t a sh or te r in te rval T h i s c ase .
s h o w s h o w co m p le t e ly lo s t in n e opla s m n e rv e fi b r illae m ay b e co m e
,
wi th ou t i m pairi n g th e ir con d uc ti n g fun c tion an d h o w th e a dv e n ti t iou s ,
gro wth m ay i n s o m e ca s e s b e e nucl e at e d wi th ou t inj ury t o th e n e rv e .
j ou r . A m M ea A ss n
.
’
. . Oc t . 1 6, 1 886 .
H E AD AND N E CK .
I The u i o n r r h a g e a ft e r U v u l o t o m y By
.
Q e s t o f H m m o .
E TH E L BE R T C AR R O LL M O R G AN M D ( Wa sh i n g ton) ,
. . Th e au th or .
O p e n s h i s p ap e r wi t h a s e ri e s o f quo t a tion s fro m wri t e r s upon t h e s ub
j c e t b e gi n nin g wi th C e l s u s ( AD 1 8 8 5 ) an d e n din g wi th S ch e ch
.
th e g e n e r a l O pinion b e in g th at h ae m orr h a g e a ft e r uvulo t o m y i s un i m
por tan t an d to b e con troll e d by th e u s e O f styp tic s H e th e n r e l a te s a .
c a s e wh ic h c am e un d e r h i s car e o f a m an wh o s e uvul a h a d b e e n e x
,
c i s e d an d in w h o m in e ffe c t ual a t t e m p t s h a d b e e n m a d e t o con t rol th e

,
h ae m orrh ag e by s typ tic s fur th e r e ffor ts in th e s am e d ir e c tion t or s ion ,
an d an a t t e m p t t o fix th e b a s e o f t h e uvula by d oubl e s u t ur e ( th e r e
b e ing i n s u ffici e n t s t u m p t o h ol d a th r e a d) h aving prov e n un availing ,
h ae m os ta t i s was fina lly O b t ain e d by applica t ion o f a s m all s pring cla m p ,
s uch a s i s u s e d i n r e t ai n i n g s h ir t s l e e v e s in po s i t ion th e cla m p b e ing ,
l e ft in po s i tion for s e v e ral h o ur s A r e ci t a t i o n o f t we n ty ca s e s o f uvular

.
ob s tina t e h ae m orrh ag e m a n yo f th e m h i th e r t o u npubli s h e d follow s H e

, ,
.
the n conclu d e s th a t th e occurr e n c e o f th i s acci d e n t m ay b e influ e nc e d
by ( I ) an an om al ou s b loo d s upply —accor d ing t o Dwig h t probably an ,
abnor m ali ty o f th e a s c e n d i n g p h ary n g e al ar te ry—a n d ( 2 ) a pa th ological
con di tion o f th e uvula s uch a s e xc e s siv e h yp e r trop hy th e d e v e lop m e n t

, ,
o f a varico s e s t a t e o f i t s v e in s or th e e xi s t e nc e o f acu t e oe d e m a or ul
,
c e r at i o n ; e xclu di n g th e sn ar e th e galvano cau t e ry an d th e liga t ur e

,
-
,
h aem orr h ag e r e s ul t s e qually fro m th e u se o f v ario u s in s tru m e n t s

t roubl e s o m e h wm o rrh a g e i s n o t n e c e s s arily a tt rib u t abl e t o th e r e m ov a l
o f t oo m uch o f th e uvul a b u t th e b e s t prac tic e i s t o r e s t or e i t a s

,
n e arly a s po ssi b l e t o th e nor m al s ta te ; w h i le th e h ae m orr h a g i c dia th e s i s

woul d d ou b tl e s s h av e i ts i n flu e nc e n o s uch ca s e s h av e b e e n r e por te d
,
T h e h m m orrh a g e i f p e r s i s te n t i s n e arly alway s ar t e rial al th oug h v e

, , ,
nou s h ae m orrh ag e is occa sionally no t ic e d F ro m t h e s e s t u d i e s th e .
wri t e r conclu d e s I A fa t al or unc o n tr o llabl e h ae m orr h ag e h a s in o n e

.
in s t anc e foll ow e d uvulo t o m y 2 A p e r s i s te n t ob s tina t e or alar m ing

. .
,
h ae m orrh ag e i s only e nco u n t e r e d in t h e rar e s t i n s t anc e s 3 A m o d e ra t e . .
bl e e ding c e asing s pon t an e o us ly or by th e u se o f m il d s typ t ic s occ a

, ,
s i o n ally h app e n s 4 T h e lo s s o f a fe w d rop s o f bloo d a t th e ti m e o f

. .
O p e ra ting follow e d by s lig h t oozing

, i s o f co m m on o c curr e nc e
, 5 . .
Th e m o s t r e liabl e s urgical m e th o ds fo r con t rolling uvul ar h ae m orrh ag e
a re th e liga t ur e co m pr e s s ion by t h e cl a m p or forc e p s

, or by th e u s e ,
o f galv ano or a c t u al cau t e ry 6 T h e m o s t r e liabl e s typ tic s a re in t he

. .
or d e r na m e d s oli d s ilv e r ni tra te or iron p e r s ulp h a t e appli e d dir e c tly to

,
th e bl e e d ing s tu m p a n d s olu tion s o f gallo t annic aci d or alu m To th e s e

,
-
.
m a y b e a d d e d th e local us e o f i c e i c e wa t e r a n d vin e gar

, 7 The
- . .
m o s t r e li abl e s y s t e m ic m e an s are O piu m l e a d ac e t a te s ulp h uric a ci d

, ,
an d e rgo t A co m pl e te bibliograp h y o f th e acci d e n t i s app e n d e d —

. IV .
°
Y M erl
. .
f ou r . Oct . 1 6 an d 2 3 , 1 886 .
5 23
I n t u b a t i o n o f t h e L a r y n x a n d T r a c h e o t o m y By I H
II . . . .
H AN C E M D ( N e w Y ork) In conn e c tion wi th a re p ort Of fi ve c as e s

,
. .
, .
o f in t ub a t ion by th e m e th o d o f O D wye r th e a u th or t abula t e s th e

’
,
p oin t s o f s up e ri ori ty t o t rach e o to m y as follow s
I NTU BAT I O N OF TH E L A YNX

R . T R A CA E O I O M Y
’ ‘
.
T h e tu bp ro du ce
e s no s h oc k d u ri ng T h e tra c h e o to m y s o m e ti m e s p r o d uc e s
t h eir i n tr o d u c t i o n . fa tal s h cko .
T h e y are s
i n tan t a n e o u y i n t ro d uc e d sl . It re q u i re s fr o m t e n t o t i r ty m i n ut e h s
to o p en th e t ra c e a h .
T h ey are e a s ily i n tro d uc e d . I t is o fte n ti m e s a v e ry d i ffi c ult o p era
s
ti o n , e p e c i a y o n a c i d ll hl of fro m fo ur
to si x m on t hs o f ag e .
T h e y c au e n o s w o un d . It l v s ea e an e xt en si ve wo un d , w hi ch
is li b l t
a e o i n fec ti o n fro m di p t hh e r i ti c
s
p o i o n , e ry i p e a , e tc s l s .
T h e y c le an th e m selves . s
I t r e qui re c o n t an t c ar e s an d a tte n t i o n
to k e e p th e i n n e r tu b e l
c e an .
T h e i n p i re d s ai r is w a rm an d mo is t . Ar ti fi ci a lm e an s ss
a re n e c e ar
y to m a e k
s
i n p i re d a i r arm w an d m o i s t .
T h e re is no i n cr e a s e d ri s k of a c om T h e e c ap e o f s bl ood or ot h er fl ui d s
p li c a ti ng p n e um o n i a. i n to th e tr a c h ea i n c re a se th e ri sk of a
s e p ti c or lo b l u ar
p n e um o n i a.
T h e re i s n o afte rt r e a trn e n t . The wo un d r e qu i re s to b e tr e ate d

a fte r t h e re m o vl
a of th e tu b e.
—I V . Y M ed
. .
f ou r . O ct . 2, 1 886 .
J AM ES E P . I LC H E R (U . S Arm y)
. .
III . O p e r at i v e T r e a t m
n t o f G o it re b y Li gat i o n o f t h e e
A ffe r e n t A r t e r i e s BY Pro f A WO L F L E R ( Vi e nna) T h e v ariou s . . . .
m e th o d s o f tr e a ting goi t r e are s till m or e or l e s s op e n t o obj e c t ion Par .
e nch y m a t ou s inj e c t ion s are u s e l e s s in s o m e for m s ( e g in foe t al a d e n o . .
m a
) an d in
, s o m e ca s e s i m prac ti c abl e To t al e x t irp at ion m ay in d uc e a .
c e r t ain for m o f cach e xi a ( V A NNA L S O F S U R G v o l I pp 7 2 7 6 an d . .

, .
, .
, ,
v ol I I I p. th oug h th e nu m e rou s ca s e s O p e ra te d by Billr o th h a v e

, .
re m ain e d fr e e fro m m or e th an in dica tion s of th i s Par ti al r e se c tion m ay .

,
owin g t o s ub s e qu e n t h yp e r trop h y o f th e r e m ain de r prov e only a te m p o ,
r ary r e li e f Mikulicz s s o call e d r e s e c tion wi th liga t ur e o f s t u m p e n

’
.
-
m a ss e ( A NNA L S O F S U R C v ol III p i s t oo ne w a proc e d .

, .
, .
ure t o h av e an e s t abli s h e d p o s i t ion ; i t i s th e or e tic a l ly O p e n t o qu e s
t ion an d unl e s s in v e ry e xp e ri e nc e d h an d s t h e r e curr e n t n e rv e woul d

, , ,
5 24 [ NDEX OF S UR GI CA L P R O GR E S S .
be e n d an g e r e d Wo lfi e r h e r e con s i de r s th e m e th o d in dica t e d in th e
.
t i tl e ,
fir s t propo s e d by M uyr in 1 6 2 9 E arly th i s c e n t ury th e plan .
wa s follow e d in 3 1 k n own ca s e s b u t wa s giv e n up ( 1 ) fro m d e a th s d u e

, ,
t o th e inco m pl e t e woun d t r e a t m e n t o f th e ti m e ; ( 2 ) fro m i m p e r fe c t r e

-
s ult s owi n g t o th e fac t th a t th e i n fe rior th yroi d wa s n e v e r lig at e d at th e

,
s am e t i m e T h i s h ad b e e n d o n e i n b u t on e ca s e viz by Por t a in 1 8 5 0 ;
.
,
.
,
al th ough i t fin ally e n d e d in a co m pl e t e cur e ye t th e p a ti e n t n e arly di e d ,
o f p h le g m onou s in fla m m a tion an d la t e h e m orrh ag e In s e v e ral goi tr ou s .
do g s W ti e d th e ( in d og s) co m m on th yroi d ar te ry T h i s was follow e d

. .
in a fe w w e e k s by con si de rab le sh rinkag e o f th e on e h alf wi th ou t any -
g an gre n e .
W op e ra t e d in th i s m ann e r in O c tob e r 1 8 8 5 T h e p a ti e n t was a

.
,
.
m an o f 2 9 y e ar s wh o a t work or a sl e e p h ad m uch t roubl e in br e ath

.
, ,
ing b e cau s e of a ra th e r larg e colloi d goi tr e Th e righ t h al f wa s s o m e

, .
wh at th e l arg e r Bo th th e in fe rior an d s up e rior ar te ri e s on th i s s i d e

.
w e r e t i e d al s o ca s ually th e m e dian th yr oi d v e in T h e pa ti e n t coul d b e

, .
d i s ch arg e d nin e d ay s a fte r th e op e ra t ion — br e athing tr oubl e an d fe e lin g
o f oppr e s s ion w e r e con si de r ably r e li e v e d th e day aft e r , and grad u

ally s ub s i d e d co m pl e t e ly T h e di m inu tio n in s iz e o f th e n e ck h ow
.
,
ever di d n o t pro gr e s s at t h e s a m e ra t e
, A t th e fir s t r e dr e s s ing th e r e
.
wa s h ar d ly any c h ang e e i th e r on in s p e c tion or palp a ti on d e s o ite th e

, ,
s ubj e c t iv e i m prov e m e n t A w e e k p o th e m e dian circu m fe r e nc e h ad

. . .
d i m in i sh e d 2 c m an d 7 m on th s p o 6 c m
. wh e n th e rig h t s i de o f
. .
,
th e goi t r e h ad s h runk e n to on e h al f th e for m e r siz e an d b e co m e s o ft

-
, ,
h ar d an d no d ular ; e v e n th e le ft s i d e h a d d i m ini s h e d s o m e .
I n th e s e con d ar ticl e th e t e c h i q u e o f th e O p e r ation i s con s i de r e d A .
d ia gr am o f th e local ar t e rial circula ti on i s b orrow e d fro m J ae g e r T rur o th -
( S tr a s sb ur g Di s s e r t F ro m th i s a n d o th e r s ourc e s h e pr e s e n t s
.
,
fac t s in d ica t ing ( 1 ) th a t n e i th e r liga t ion o f b o th s up e ri or th yroi d s nor o f

,
th e in fe rior alon e can b e con s i d e r e d s u ffi ci e n t owing t o th e fr e e an as

, ,
t om o s e s I t i s a s ye t qu e s t ionabl e w h e th e r in larg e o n e si d e d goi

.
,
-
tr e s liga t ion of b o th t h yroi d s on th a t s i d e o ug h t t o b e acco m p an i e d by
lig ation o f th e oppo si te s up e ri o r th yroi d ; ( 2 ) T h a t lig a tion o f all four

th yroi d ar t e ri e s coul d h ar d ly l e a d t o g angr e n e o f th e goi tr e .
I t h as b e e n prop o s e d to li g ate th e v e in s in s t e a d of th e art e ri e s a nd

,
525
in on e ca s e ( Coar tes th e in fe rior th yr oi d v e in wa s t i e d th e goi

, ,
tr e s h rinking t o o n e h al f i t s volu m e
-
T h i s h ow e v e r i s m uch m or e dif
.
, ,
fi c ult th an liga t ion o f t h e ar t e ri e s unl e s s in ca s e o f th e s up e ri or v e in

,
wh i ch acco m pani e s th e corr e s pon d ing ar te ry .
Th e m e th o d r e co m m e n de d for fin d ing t h e s up e rior ar te ry i s n o t n e w .
T h e m or e d i fficul t t a s k o f fin d ing th e in fe rior h as b e e n s t u di e d by W .
on th e ca d av e r H e favor s a way l e s s liabl e t o involv e inj ury t o

.
th e l arg e v e s s e l s a t th e b a se o f th e n e ck t h an t h a t o f e i t h e r Ve lp e a u or
C M Lang e nb e ck
. . .
We sh oul d try t o ti e th e ar t e ry wh e r e i t t urn s fro m th e p e rp e n d icular

t o t h e h oriz on t al d ir e c t i on Th i s poi n t i s ab ou t on a l e v e l wi th th e t u
.
b e rc ulu m caro t icu m —o r a fi n g e r s br e a d th m e s ially b e low—an d

’
a l s o wi th th e cricoi d car t ilag e T h e inci s ion i s t o b e m a d e e x t e rnally

.
fr o m th e caro t i d b e t w e e n th e t wo p ar t s o f th e s t e rno cl e i d o t h oug h th i s -

,
m u s cl e in t h e goi t rou s i s broa d e n e d a n d d i s loca t e d Un d e r n or m a l .
con di tion s th e c u t s h oul d b e gi n ab ov e a t th e l e v e l o f th e cricoi d car til

,
a g e a n d r e ac h t o th e clavicl e
,
T h e low e r e n d o f th e c u t sh oul d fall b e
.
t w e e n th e inn e r an d m i d d l e th ir d s o f th a t p ar t o f th e clavicl e e x
t e n d ing fro m s ulcu s d e l t oi d e o p e c t orali s t o th e s t e rnal e n d o f t h e b on e

- -
.
T h e n follow s th e d ivi s ion o f th e pla ty s m a th e t ran s v e r s e s up e rfici al ,
v e in s an d th e d e e p fa s ci a—k e e ping t ow ar d s th e upp e r e n d o f th e inci

s ion I f m or e roo m i s n e c e s s ary th e s li t b e tw e e n th e t wo p or tion s o f th e
.
s t e rno cl e i d o m ay b e e x t e n d e d upwar d s
- T h e t e n dinou s p ar t o f th e
.
o m o h yoi d m u s cl e now app e ar s in th e m i d d l e o f t h e wo un d

- th i s c an
b e drawn ou t war d s an d upwar d s or d ivi d e d At th e p oin t wh e r e th i s

,
.
lay th e e xt e rn al b orde r o f th e j ugu lar i s to b e fr e e d a li ttl e an d drawn i n

w ar d s T h e vag u s a n d la te r al b or d e r o f th e c aro ti d can now b e s e e n
.
b a ck o f th e j ugular Th e r e trac t or now e xp o s e s th e s cal e nu s an ticu s

.
m u s cl e cov e r e d by lo o s e t i s s u e an d fa s cia w h ic h i s t o b e t orn t h roug h

, ,
on a d ir e c tor O n th e rig h t li e s th e p h r e nic n e rv e w h ich i s p u sh e d

.
,
o u t w ar ds I f th e ar te ry i s n o t now vi sibl e on th e inn e r b or d e r of th e

.
s cal e nu s m u s cl e th e l a tt e r can b e drawn

,
o u t war d s a li ttl e w h e n th e
b e n d in t h e ar te ry wi ll s ur e ly pr e s e n t i ts e l f I f unin te n tion ally th e inn e r
.
b or d e r o f th e in t e rnal j ugular h a s b e e n i s ola t e d th e ap pro ach o f th e ar ,
t e ry i s qui t e a s d ir e c t Wzen M ed Work 1 8 8 6 N o s 2 9 an d 3 0

’
. . . . . . .
W BR O WN I NG ( Bro k l yn ) . o .
ABD O M E N .
I . A Cas e I n t e s t i n a l O b s t r u c t i o n R e li e v e d b y L i b e r a t i n g
of
t h e O m e n t u m fr o m a n O m e n t a l H e r n i a Mr F A S O U TH AM . . . . .
T h e p a ti e n t a fe m al e se t 5 2 h a d h a d an irr e d ucibl e fe m oral h e rnia

"
.
, , ,
fo r s o m e t i m e b e for e sy m p t o m s o f s tr angula tion app e ar e d Sh e wa s .
O p e ra t e d on w h il e in a s t a t e o f collap s e Th e r e was no m ark e d di s .
t e n t ion of th e ab d o m e n b u t s e v e r e p ain in th e u m bilical r e gion wi th

, ,
t e n d e rn e s s on pr e s s ur e ; b e yon d an in d e fini t e fu ln e s s j u s t ab ov e Po u
p ar t s liga m e n t no th ing abn or m al coul d b e d e t e c te d i n th e ab d o m e n

’
, .
T h e fe m oral h e rnia was s o ft an d n o t t e n de r At th e O p e ra ti on only a .
fe w drop s o f cl e ar flui d e s cap e d fro m th e s a c a n d only a s m all pi e c e o f ,
h e al th y o m e n t u m wa s foun d in i t I t s p e di cl e wa s cl o s e ly a d h e r e n t t o
.
th e n e ck o f th e s a c all ro un d s o th at no knuckl e o f b ow e l co u l d po s s i
bly h av e b e e n r e c e n tly nipp e d th e r e .
T h e o m e n t u m wa s liga t ur e d an d r e m o v e d an d th e p e d icl e allow e d ,
t o s lip back in t o th e ab d o m inal cavi t y O n r e cov e ring fro m t h e a n

.
ae s th e s ia th e p a t i e n t a t onc e e xpr e s se d gr e a t r e li e f fr o m th e O p e ra t ion ,
th e ab d o m in al p ain h aving qui t e d i s app e ar e d Th e r e wa s no r e cur .
r e nc e o f th e s ickn e s s a n d h e nc e for th all w e n t w e ll wi th t he e xc e p tion

,
o f a t roubl e s o m e d iarrh oe a .
T h i s ca se h a s an in te r e s t ing b e aring on th e con tra s te d O pinion s e x

pr e s s e d by Mr Hol m e s an d Mr R u s h t on Park e r in th e Lanc e t ( Vo l
. . .
1 883 , an d Vo l . 11,
Th e ink s th a t in h i s ca se th e r e was e i th e r s trangula tion by

a u th or th
kinking of th e colon or e l s e th a t th e r e was co n s t ric tion o f s o m e o th e r

,
p or tion of th e b ow e l pr ob ab ly th e s m all in te s tin e by an o m e n t al ban d

, , ,
con ti nuou s wi th th e p e dicl e o f th e por ti on o f o m e n t u m p r e s e n t in th e

h e m i al s a c —La m et . 1 886 Aug 1 4 . . . .
II .I n t e r n a l S t r a n g u la t e d H e r n i a ; L a p a r o t o m y C u r e
“
. .
By M Q U E N U A wo m an aet 5 2 sh o we d s ign s o f in t e rn al s tra n gula

. .
, .
,
t ion Sh e h ad an old r e d ucibl e fe m oral h e rni a th e c o n d i t ion o f w hi ch was

.
,
qui te norm al Th e r e for e Q u enu in s te a d o f in te r fe ring wi t h t h i s m a de

.
,
( on th e fi fth d a y) an inci s ion in th e lin e a alb a H e fo un d th e abov e .
m e n t ion e d h e rnial ap e r t ur e fr e e b u t a li ttl e e x t e rnal t o t h e crural ri n g

, ,
CH E S T A N D A E D OM E N .
5 27
h e fe l t in t e s t in e t ig h tly nipp e d in ano th e r orifi c e H e e ffe c t e d re d uc .
t ion by pulli n g v e ry g e n t ly on t h e in t e s tin e a ss ur e d h i m s e l f th a t i t wa s ,
uninj ur e d a n d in tro d ucing h i s fing e r in t o th e s a c fro m wh ich h e h a d

,
j u s t wi th d rawn i t r e cogniz e d a s m all m ovabl e s ub p e ri ton e al s a c in d e

,
-
,
p e n d e n t o f th e or dinary apon e uro tic op e ning s o f th e r e gion A fte r .
h avi n g s t r e t ch e d upon h i s fing e r t h e orific e o f t h i s s m all s ac t o pr e v e n t ,
th e r e p e t i t ion o f analogou s acci d e n t s Q u e nu clo s e d th e ab d o m inal cav

,
i ty again T h e p a t i e n t r e cov e r e d b u t n o t wi th o u t pa s s ing th ro ug h a

.
,
p e rio d o f d a n g e r fro m s e rio u s p ul m ona ry cong e s tion wh ic h app e ar e d

s oon a ft e r th e op e ra t io n —R ev a es S ez fil ed J uly 1 5 an d B u ll S oc
’
’
. . . . .
,
XII N o 2 Pp 1 7 2 —1 8 0
'
de C/zzr . . . . . .
C B K E E TLE Y ( Lon d o n ) . . .
III I nt e s t i n al O b s t r u ct i o n
. Lap ar ot om y . R e c o v e ry . .
By Dr A B M I L E S ( N e w O rl e an s) Pa t i e n t a s t ou t m u s cul ar lab or e r
. . . .
, , ,
set 3 5 w a s a d m i tt e d t o t h e C h ari ty Ho s pi t al N e w O rl e an s wi th a h i s
.
, , ,
t ory o f in t e s t in al ob s t ruc t ion o f fi v e d ay s d ura t ion Wh e n a d m i t te d .
th e r e w as m a rk e d ab d o m inal fuln e s s wi th t e n d e rn e s s m or e e s p e ci ally ,
localiz e d in th e u m bilical r e gion a li ttl e t o th e l e ft o f th e ci ca tri x no
d e fini te t u m our t o b e m a d e o u t o n p alpa tion vo m i t s wh a te v e r i s giv e n
h i m al m o s t in s t an t ly th e m a t t e r s vo m i t e d n o t b e in g o ffe n s iv e ; p u ls e
,
full h ar d an d a cc e l e ra te d ; t e m p e ra t ur e a li t tl e ab ov e th e no rm al
, F or .
for ty e igh t h our s a t t e m p t s t o ob t ain r e li e f by larg e e n e m a t a o f warm

-
wa t e r s o ap a n d oil w e r e p e r s i ste d in wi th ou t avail All h i s pr e vi ou s

, ,
.
s y m p t o m s h aving b e co m e aggr ava t e d a n d th e vo m i t e d m a t t e r h a vin g

,
ass u m e d a s te rcorac e ou s c h ar a c t e r laparo t o m y wa s d on e Un d e r

, .
e th e r an in ci s ion fro m four t o fi ve inch e s was m a d e in th e lin e a a lb a b e
t w e e n th e u m bilicu s a n d p ubi s th e s kin fa s ci ae an d m u s cl e s d ivi d e d

, ,
an d th e p e ri t on e u m e xpo s e d ; a fte r all bl e e d in g h as s t opp e d t hi s lat ,
t e r wa s O p e n e d on a gr oov e d d ir e c t or an d s e arch m a d e for ob s t ru c ti o n .
To pr e v e n t th e bloo d oozing fro m th e e d g e s o f th e incis ion fro m e m

t e ring th e ab d o m inal cavi ty a t ow e l s oak e d in a s t rong an ti s e p t ic s o
,
luti on wa s m ade t o e nclo s e th e wh ol e th ickn e ss o f e ach s i d e of th e i n
c i s i o n in th e s a m e way a s th e cov e r o f a book e nc a s e s i ts sh e e t s .
A ft e r d ili ge n t s e arch m ad e m or e di ffi cult by adh e s ion s prob ab ly

, ,
5 28 1 N D E A Ol v
S U R GI C A L
fro m a for m e r ca se o f p e ri toni ti s th e ob s truc tion was fou n d a li ttl e t o

,
t h e l e ft o f t h e u m b ilicu s ; i t co n s i s t e d o f a cica t ricial b an d n o t m or e
th an 1 or lin e in th ickn e s s wh ich e ncircl e d th e w h ol e d ia m e te r o f

th e g ut lik e a ring a n d ob li t e ra te d e n tir e ly i t s calibr e ; th e in t e s tin e
ab ov e th i s ri n g wa s d ark a n d cong e s t e d an d na t ural b e low T h e ob .
s t ruc tion wa s d ivi d e d by th e s ci s s or s an d s o o n a ft e r t h e cong e s t ion d i ,
m ini sh e d T h e c ut e d g e s o f th e p e ri t on e u m w e r e s e w e d t og e th e r c ar e
.
fully wi th s m all ca tg u t t h e s kin a n d m u s cl e s w e r e broug h t t og e th e r b y

,
s ilv e r wir e s A s s oon as th e pa t i e n t r e cov e r e d fro m th e a n ae s th e t ic h e

.
was plac e d un de r th e influ e n c e o f m or p h i n e All vo m i t i ng c e a s e d .
fro m t h e t i m e o f O p e ra t ion T h e ca s e progr e s s e d favorably an d on

.
,
th e th ir d d a y h e h a d t wo goo d op e ra t ion s fro m t h e b ow e l s a n d th r e e
o n th e fi fth d a y ; t h e t e m p e ra t ur e a t no t i m e ro s e abo v e b ut
wa s g e n e rally m uch b e low th i s ; t h e s u t ur e s w e r e r e m ov e d i n s e v e n
d ay s w h e n a n accu m ula t ion o f p u s wa s foun d b e t w e e n th e m u s cl e s

,
un d e rn e a th th e s kin ; t h e p e ri t on e u m h ad uni t e d by fir s t i n te n ti on ; th e
p u s w a s pr e s se d o u t a t t h e s u t ural op e ning s an d t h e wo un d w a s so o h
he al e d —N ew Or lea n s M ed a n d S u rg f ou r No v . 1 886 . . . .
IV . P e n e t rat i n g ot W o u n d of t h e Ab do m e n I n
Gu n s h
v o lv i ng t h e Liv e r I n t r a p e r i t o n e a l H ae m o rr h a g e
. La p a r .
otom y R e c ov e ry
. By J W H E D D E N S ( S t J o s e p h
. . . Mal e .
, ,
ae t 3 0 r e c e i v e d a pi s t ol s h o t wo un d i n th e e piga s tric r e gion

.
,
-
e arly in ,
1 886 . T h e i m m e d ia t e r e s ul ts w e r e gr e a t p ain in th e rig h t s i d e an d
b ack a n d in th e righ t sh oul d e r wi th dysp n oe a Dr H b e li e ving

, , . . .
,
th a t th e r e wa s h ae m orr h ag e in t o th e ab d o m inal cavi ty p e r for m e d lap ,
a ro to m y by a n inci s io n e x t e n ding fro m

,
th e woun d d ownwar d s
in ch e s Th e co ur s e o f th e b ull e t wa s tr ac e d t o th e liv e r ; a pi e c e of
.
th e p a t i e n t s v e s t wa s foun d in t h e p e ri t on e al c a vi ty a n d r e m ov e d ;
’
,
ab ou t fo ur o unc e s o f b lo o d w e r e al s o r e m ov e d T h e woun d was d r e s s e d .
an ti s e p tically an d t h e p a ti e n t m a d e an unin te rru p te d r e cov e ry

,
.
Tr a n s a c M ed . S ta te of M i ssou r i
. May 1 8 8 6 . . .
V . C as e ot W ou n d o f th e S m all I nt e s t i n e an d
of P i s t o l- s h
M e s e n t e r y L a p a r o t o m y By C A J E R S E Y M D ( N e w Y ork ) A
. . . .
,
. . .
v e ry fl e sh y m an o f p oor p h y s i qu e ae t 44 h ad s h o t h i m s e l f wi th a 3 2 , .
,
9
calibr e pi s t ol ab ou t inc h e s t o th e righ t o f th e m e di an lin e a nd on e

,
inch ab ov e th e u m bilicu s an d s u ffe r e d gre a tly fro m sh o ck fro m wh ich

, ,
h e r e co v e r e d s lowly b u t h a d n o vo m i ting or m ov e m e n t o f th e bow e l s

,
nor any r e cogniz abl e sy m p t o m s o f in te rn al h ae m orrh ag e t w e n ty h our s

a ft e r a dm i s s ion t o h o s pi t al lap aro t o m y wa s p e rfor m e d ( an i nci s ion in
,
th e t r a ck o f th e b ull e t woun d h aving conclu s iv e ly prov e n th e e n t r anc e
o f th e b all in t o th e ab d o m i n al c avi ty in h e m e d i an lin e e x t e n d in g

) t ,
fro m ab ou t inch e s ab ov e t o abou t 4 inch e s b e low th e u m bilic us

s o m e bloo d y s e ru m a n d a fe w clo t s w e r e foun d in t h e a b d o m inal c av
i ty. S e v e n vi s c e ral woun d s w e r e fo un d four o f th e in t e s tin e a n d th r e e ,
o f th e m e s e n t e ry t wo o f t h e s e m e s e n t e ri c woun d s on ly b e ing p e n e
,
tra t in g ; all t h e woun d s w e r e s u t ur e d wi th ca t g u t an d d u s t e d wi th
io d o for m T h e foi lezi e o f th e p e ri t on e u m wa s p e r for m e d wi th car e an d

.
‘
t h e wou n d d r e s s e d wi th io d o for m d r e s s ing s T h e p a ti e n t r e cov e r e d .
s lowly fro m t h e s h ock o f t h e op e ra ti on w h i c h wa s s e v e r e a n d s u ffe r e d , ,
fro m con s t an t r e t ch i n g a n d vo m i t ing r e s tl e ss n e s s a n d l atte rly d e liriu m , ,
u n til d e a th on th e s e con d d ay Th e au t op s y r e v e al e d goo d h e aling in .
t h e in t e s t inal wo un d s a n d th e m e s e n t e ric abra s ion b ut th e e d g e s o f th e ,
m e s e n t e ric woun d s h a d s e para t e d an d th e ir s ur fac e s w e r e co ve r e d by a
black e n e d s o ft e n e d s lo ugh d i s ch arging p u s in t o th e p e ri t on e al cavi ty

, .
Th e a u th or in fe r s fro m th i s th a t th e p or t ion o f th e m e s e n te ry s urroun d
ing th e b ulle t h o le s s h oul d h av e b e e n inci s e d all th e con tu s e d bor d e r

-
,
r e m ov e d an d th e h e al th y s ur fac e s brough t t o g e th e r by s u t ur e s —XV Y . .
M ed R ec
. . Oct 1 6 . 1 886 .
VI u r g i c a l R e l a t i o n s o f t h e I l e o C aec a l R e g i o n By J
. S - . .
M c F GA S T O N M D ( A t lan t a Ga) A t h o r o u g h i n v e s t i g at i o n o f t h e '
. . .
, , ,
.
m orbi d co n d i t io n s o f t h e i le o c ae cal r e gio n l e a d s t o th e fo do wi n g con

-
c lu s i o n s 1 T h a t c e r t ai n m o difica tion s a re corr e c t e d s pon t an e o u s ly

.
or by th e proc e s s o f r e s olu ti o n un de r tr e a t m e n t 2 In th e e arly st ag e s . .
o f il e o c ae cal d i s or d e r s m e d icinal or m e ch a nic a l m e a s ur e s are a d va n

-
,
ta g e o u s 3 .T h a t t h e .e x t ra p e ri t on e al pun c t ur e s a n d inci s ion

-
s a re
b e n e fici al in c ae cal i nfla m m a t ion wi th or wi th ou t fae cal ab s c e s s 4 Di s , . .
or d e r s involving t h e p e r it o n e u m wh e n n o t pro m p tly r e li e ve d by g e n

'
,
'
e ral t r e a t m e n t warra n t e xplora t ory O p e ning o f t h e ab d o m e n

, 5 Im . .
p e di m e n ts o f th e in te s tinal canal or m o rbi d accu m u la tio n s in th e

ab d o m inal c a vi t y acco m p ani e d by m e t e o ri s m
, call for i m m e diate s ur ,
gi c al in t e r fe r e nc e wi th laparo t o m y 6 In c a s e o f s i m pl e s t e no s i s or
. .
m a lignan t grow th s involving th e il e o c ae c al conn e c tion s il e o colo s t o m y

-
,
-
i s in d ica t e d 7 Gangr e nou s p or tion s o f th e in t e s tin al canal n e c e s

. .
s i t a t e r e s e c t ion an d e i th e r d ir e c t r e s t ora ti on by s ut uring th e e n d s o f

,
th e in t e s tin e or th e for m a tion t e m porarily o f an ar t ifici al anu s

, 8 . .
Op e ra t iv e m e a s ur e s in il e o c ae cal d e rang e m e n t s sh oul d n o t b e d e

-
laye d un til th e p h y s ical pow e r s h av e b e co m e pro s t ra t e d b u t re ,
s or te d t o wh il e in cap a ci ty for r e a c tion o f th e vi t al forc e s — ou r Am

f . .
Mé d A s s n
. . . Oc t 9 . . 1 886 .
E XTR E M IT IE S .
1 . C as e of x t i r p at i o n o f t h e S c a p u l a t h e E x t e r
T o t al E ,
n a l T w o T h i r d s o f t h e C la v i c le a n d t h e E n t i r e A r m
-
By .
J LU C A S C H AM P I O NN I E R E M D ( Pari s) A m e ch a n i c h a d h i s l e ft arm
.
-
,
. .
cau gh t i n m ach in e ry an d t orn away in th e upp e r th ir d ; th e S kin was

d e s troy e d in fron t t o th e l e ft h al f o f th e th orax d e nu ding th e p e c t orali s ,
m aj or ; th e clavicular r e gion was e n t ir e ly d e nu d e d a n d th e e x t e rn al
h alf o f th e r e gion o f th e s c apula wa s r e li e v e d o f i t s S kin ; at th e low e r

.
p ar t of th e axilla a t ongu e o f S kin wi th i t s h air s was l e ft b u t i t wa s

, ,
s tripp e d o ff t o a gr e a t e x t e n t T h e m i dd l e o f th e h u m e ru s wa s d e
.
n ud e d an d pro tru d ing a m ong th e m u s cular m as s e s s urro un d ing i t ; th e
bic e p s m u s cl e was l ai d b are to th e s h oul d e r a s w e r e all th e o th e r ,
m u s cl e s o f th e p o s t e ri O
r e x te rn al a n d a n t e rior fac e s o f th e arm ;
, th e
upp e r par t o f th e arm s till r e m ain e d fir m ly a t t ac h e d by i t s li ga m e n t s .
Th e v e s s e l s w e r e al s o d rawn o u t th e brac hial ar t e ry b e ing s tr e tch e d

, ,
b ut i t s calibr e obli te ra t e d a t t h e e x t r e m i ty a n d no ar te ry s pur te d , ,
al th ough th e r e wa s :a g e n e ral oozi n g T h e n e rv e s s u ffe r e d th e s am e.
a s th e v e s s e l s Al th ough gr e a tly d e pre s s e d th e p a t i e n t wa s con s cio u s

.
, .
D uring th e follo wing th r e e d ay s h e gain e d in s t e n g th s o th a t on th e

four th d ay i t wa s p o s s ibl e t o s ubj e c t h i m t o th e r e m oval o f th e sh oul
de r wh ich h a d b e e n d e ci de d up o n b e cau s e th e i m m e n se e xp o se d s ur
,
fac e d e s tin e d t o s uppura t ion th e S l o ugh ing o f th e m u s cular m a s s e s

,
E X TR E M J TJ E S .
53I
an d th e n e cro s i s o f th e s ubj ac e n t b o n e s woul d prob ably h av e cau s e d

a fa t a l r e s ul t a ft e r a s e v e r e an d li n g e ring illn e s s wh il e th e long t i m e
,
r e quir e d for r e c o ve ry a n d th e n at ural s e qu e lae o f s o e x te n s iv e a cic

'
a t ri x
, woul d h av e r e n d e r e d a con s e rva t ion o f th e p ar t s e x tr e m e ly
un s a t i s fac t ory I t was d e ci d e d t o r e m ov e all o f t h e S h oul de r in
.
or d e r th a t th i s pr o m in e nc e b e ing r e m ov e d i t m igh t b e p o s s ibl e t o

,
d raw th e fl ap s o f th e s kin t h u s pro d uc e d ov e r th e e xpo s e d s urfac e

a n d clo s e t h e woun d ; t h e e x t e rnal t wo t h ir d s o f th e clavicl e w e r e
-
s aw e d o ff a n d t h e s ub clavian ar te ry liga t ur e d d ir e c tly wi th ou t th e
s cal e n i m u s cl e s th e n e rv e s o f th e brac h ial pl e xu s d ivi d e d a s h i gh a s

,
p o s sibl e a n d th e p e ct orali s m u s cl e c ut th rough ; th i s d on e th e sh o ul de r ,
was th r o wn o u t a n d th e s cap ula r e m ov e d wi th th e gr e a t e r p ar t o f i t s
m u s cl e s l e avin g th e s k i n in t ac t ;
, t h e h ae m orr h ag e wa s v e ry c o n s i d
e r ab le a t th i s s t ag e o f th e op e ra tion an d al th ough con troll e d by

, ,
h ae m o s t a t ic forc e p s di fficul t t o m ana g e b e cau s e o f th e d e p th o f th e

,
woun d ; p e r m an e n t h aem o s tat i s wa s s e cur e d wi th ca tg u t li ga t ur e s ;

th e woun d wa s clo s e d wi th d e e p an d s up e rficial s u t ur e s th e s kin o f th e ,
a n t e rior r e gion uni ting wi th d i fficul ty wi t h th a t o f th e po s t e rior r e
gion i n s pi te o f th e e n or m o u s los s o f s ub s t anc e ; th e s kin o f th e

'
axilla wh ich h a d b e e n pr e s e rv e d t o facili t a te th i s s te p o f th e op e r

,
a t ion was in b ad con di tion an d e v e n t ually b e cam e gan gr e nou s

,
alo n g i ts e d g e s th e wh ol e op e ra t ion wa s con d uc t e d un de r an ti s e p tic

irriga tion s a n d a n ti s e p tic d r e s s ing s appli e d ; gr e a t d e pr e s s ion r e s ul te d
fro m t h e O p e ra tion b ut th e p a t i e n t ralli e d w e ll an d i m prov e d p r o gre s
,
s i ve ly u n t il a final co m pl e t e cur e wa s ob t ain e d in e ig h t y e ig h t d a ys - .
T h e cica trix wa s 1 2 c e n t i m e tr e s in l e ng th by 9 in i t s gr e a t e s t br e a d th ,
at th e poin t w h e r e s loug h ing o f th e a x illary flap occurr e d Wi th an .
ar tifi cial li m b illu s tra t e d in d e t ail th e p a ti e n t i s abl e to p ur s u e h i s o r

, ,
din a ry avoca tion s —R evue de Cfi zr u rg ze J uly 1 8 8 6

' '
. . .
I I P a i n fu l A ff e c t i o n O f t h e F o o t By T G M O R T O N M D
. . . .
, .
( P h ila d e lp h i a ) T h i s a.ffe c t i on i s c h arac te riz e d by in te n s e p ain re fer ,
abl e t o t h e h e a d o f o n e o f th e m e t at ar s al b on e s m or e fr e qu e n tly th e ,
four th co n s e qu e n t upon an acci d e n t al s u dd e n t wi s t or s tr ain

, It .
s e e m s t o b e a n e uralgia o f o n e o f th e in t e rn al pl an t a r n e rv e s wh ich ,
a re d e e p ly lo d g e d in b e t w e e n th e t o e s an d w h ich are liabl e n o t o n ly t o

'
5 32 IN DE X OF S UR GI CA L P R O GR E S S .
be un d uly co m pr e sse d b u t pinch e d by a s u dd e n t wi s t o f th e an te ri or

p ar t o f th e foo t T h e tr ea t m e n t in dica te d i s in acu t e ca s e s wh e r e i t
.
,
i t h as e vi d e n tly b e e n in d uc e d by an inj ury local d e p le ti o n s ano d yn e , ,
applica t ion s an d r e s t a n d a s in t h o s e l e s s s e v e r e ca s e s w h ic h d o n o t
,
s e e m t o d e m an d O p e ra t ion a s ui t abl e broa d s ol e d s h o e , t h e gr e a te s t

-
co m for t an d o fte n e n tir e r e li e f i s a ff or d e d by th e us e o f a fi n e n arrow

fl ann e l b an d ag e cov e ring th e an t e rior p ar t o f th e foo t m o d e ra te ly
,
fi-r m ly s o a s t o giv e ab s olu t e s t e a d i n e ss t o all th e t o e s an d t ig ht

, ,
e noug h t o pr e v e n t any rol ling or m ov e m e n t s o f th e j oin t s or t o e s upon
o n e ano th e r I n ca se s o th e rwi s e b e yon d r e li e f e xci s ion o f th e j oin t

.
, ,
o f th e t oe in s ur e s a co m p l e t e an d p e r m an e n tly goo d r e s ul t —P /zi Z a .
M ed Ti m es
. . Oc t . 2 . 1 886 .
I D i g i t a l E x p lo r a t i o n o f t h e B la d d e r
. By W T B E L F I E L D . . .
,
M D ( Ch icago ) Th i s p ap e r i s a coll e c tion o f t e n ca s e s inclu ding

. .
, .
,
t wo p r o s t a t o m i e s a n d clo s e s wi th th e following r es u m e o f t he e s s e n t ial

,
pr e li m in ari e s to a d iagno s tic e xplora tion o f th e bla d d e r 1 I t Sh oul d .
n o t b e p e r for m e d as a d iagno s t ic m e a s ur e un til i t i s r e a s onably c e r t ai n
th at th e s e a t o f th e d i ffi cul t y i s in t h e bla dd e r or un t il all o th e r a n d l e s s

,
r ad ical d iagno s tic m e an s inclu d in g th e m icro s cop e h av e b e e n e xh au st

, ,
e d ; o th e r wi s e i t m ay yi e l d only d i s app oin t m e n t a n d r e gr e t t o bo th s ur
g e o n an d pa ti e n t F or i t m u st b e r e m e m b e r e d th a t an irri tabl e con di tio n

.
o f th e bla d d e r c an b e pro d uc e d by cau se s wi th ou t a s w e ll a s wi t h in th i s
vi s cu s s uc h a s s tric t ur e o f th e an t e ri or ur e th ra t ub e rculo s i s o f th e k i d
, ,
n e y p e lvi s e tc ,
In s uch ca se s th e m orbi d s y m p to m s m ay b e e xh ibi te d
.
ch i e fly or e xclu s iv e ly by th e bla d d e r wh il e th e l e sion li e s ch i e fly or e x

,
.
c lu si ve ly e l se wh e r e 2 T h e O p e ra tion sh oul d n e v e r b e p e r for m e d u n

. .
t i l th e bla d d e r h a s b e e n a ccu s t o m e d t o co m pl e t e e vacua t ion by ca th e
t e r or o th e r wi s e I f in con s e qu e nc e o f a tig h t s t ric t ur e or pro s t a tic

.
,
ob s truc tion th e bla dd e r i s m uch h yp e r trop h i e d m e m branou s ure

, ,
th ro t o m y i s d an g e rou s n o t fro m a probabili ty o f urinary e x trava s a tion ,
b u t s i m ply b e cau se a cy s t o py e li ti s o f m or e or l e s s gravi ty—p o s s ibly

-
e v e n a nu ria—u s ually follow s th e s u dd e n r e m oval o f t h e accu s t o m e d

5 33
h ig h pr e s s ur e in th e bla dd e r an d ki d n e y p e lvi s E xa m pl e s a re fou n d .
i n th e d aily in tro d uc tio n o f ca th e te r s fo r r e t e n tio n divi s ion o f tigh t ,

-
s tric t ur e s li th o t o m i e s e t c
, T h e r e for e b e fore th e bla dd e r i s e xp lor e d
, .
,
in a ca s e wi th t igh t s t ric t ur e pro s t a ti c e nlarg e m e n t or o th e r cau se o f

,
v e s ical h yp e r trop h y th e bla dd e r Sh o ul d b e gra d ually accu s t o m e d in t h e

;
co ur s e o f w e e k s t o co m pl e t e e vacua tio n ; th e s tric t ur e s h oul d b e e n

,
lar g e d or t h e pro s t a t ic ob s truc tion s h oul d b e ov e rco m e by th e h ab i t ual

,
u se o f t h e ca th e t e r u n t il all r e s i d ual urin e i s wi th d rawn T h e n a n d not .
t i ll th e n c an th e s urg e on r e s t a s s ur e d t h a t d igi t al e x p lora tion o f t h e
bla dd e r fro m th e m e m brano u s ur e th r a wh e th e r i t a ffor d m uch or li t tl e ,
b e n e fi t will a t l e a s t b e s a fe a n d d e voi d o f inj ury —f ou r A m M ed

, . . .
Ass n . S ept 4 1 886

. . .
II . S u b c u t a n e o u s D i v i s i o n of U re t h ral S t r i ct u re By .
C H M A S T I N M D ( Mobil e Ala) T h i s p ap e r i s op e n e d by a c o m
. .
, . .
, ,
.
p le t e h i s t orical s k e t ch o f the O p e ra t i on s d e vi s e d for th e r e li e f o f r e t e n

t ion o f urin e by organic s tric t ur e o f t h e ur e th ra H e e s t abli sh e s t h e .
following in dica t ion s for m aking an ar tifi cial v e n t fo r th e d i s ch arg e o f
th e co n t e n t s o f a d i s te n de d bla d d e r ( 1 ) T h e i m po s s ibili ty o f pa s sing

.
a s oun d in t o th e bla dd e r t hrough th e ur e th ral canal wh e n a fi rm or ‘
g a n i c co n t rac t ion bloc k s up th e ur e th ra an d prov e s r e b e lliou s e i th e r ,
t o d ila t a tion or in t e rnal ur e th ro t o m y T h e au th or h a s in s e v e ral .
ca se s o f th i s kin d h ow e v e r c ut d own t h rough th e axi s o f th e ur e th ra

, ,
in t o an d th rough th e s tric t ur e al th oug h i t was i m pa s s ibl e t o th e s m all

,
e s t in s t ru m e n t ( 2 ) Infil tra tio n o f urin e r e s ul ti n g in ab s c e s s n o t s u d

.
,
d e n ca s e s w h e r e fro m d ir e c t i nj ury th e ur e thra h as b e e n rup t ur e d an d
infil tra t ion i s th e con se qu e nc e b ut th o s e wh e r e a t igh t s tric t ur e h a s

,
e xi s t e d fo r a long t i m e an d a p e riur e th ral ab s c e s s h a s r e s ul te d fro m a

s m all O p e ni n g in th e ur e th ra gra d ual infil t ra t ion o f urin e h aving lig h te d
,
up infl am m a t ion to a d e gr e e s u ffici e n t t o for m a circu m s crib e d d e po si t

o f p us
( 3 ) Po s s ibly in c e r t ain ca s e s o f O ld tigh t s tric t ur e s co m p lica t e d
.
wi th urinary fi s t ula throug h wh ich a gr e a t p ar t o f th e urin e e s cap e s a t

e v e ry a c t o f m ic t uri t ion ( )
4 Th e m o s t i m p or t an t in d ica t i on i s t h e
.
rup t ur e o f th e ur e th ra by a viol e n t blow wh e n th e e ffe c t s o f th e inj ury ,

5 34 I N D E X OF S UR G I C A L P R O GR E S S .
are rapi d an d s e v e r e wh e r e e nor m ou s e xtrava s a tion o f bloo d occur s

,
i m m e dia t e ly an d r e te n tion t ak e s plac e ,th e wh ol e c e llular t i s s u e b e c om

ing infil tra t e d wi th uri n e ( 5 ) W h e r e a s tric t ur e h a s b e e n for m e d a s
.
t h e r e s ul t o f a d ir e c t i nj ury d o n e t o t h e ur e th ra ( 6 ) A larg e calculu s

.
i m pact e d in th e ur e th ra b e h i n d a s tric t ur e ( 7 ) W h e n e x trava s a tio n o f

.
u rin e h a s occurr e d fro m s u d d e n rup tur e o f th e ur e th ra an d in a S h ort

ti m e e x t e n s iv e s loug h ing h as t ak e n plac e fro m infil tra tion o f uri n e in t o
a dj ac e n t loo s e ti s s u e W h e r e th e s tric t ur e i s a t all p e rm e abl e th e

.
,
au th or b e li e v e s an i n t e rn al ur e th ro to m y t o b e alway s p o s s ibl e an d
pr e fe r abl e .
A fte r t h e di s cu s s ion of th e variou s m e th o d s o f ur e th ro t o m y h e d e ,
s crib e s th e op e ra t ion d e vi s e d by h i m s e l f a n d b a s e d up on t h e o ld m e t h o d
Th e p a t i e n t b e i n g d uly pr e p ar e d by O p en i n g t h e
‘
O f [ a bow on n i e r e
‘
.
,
b ow e l s fr e e ly wi th a n e n e m a an d by a h o t h ip b a th t o t ran quiliz e th e
-
n e rvou s s y s t e m i s plac e d upo n th e t abl e in t h e or d i n ary cy s t o t o m y

,
po s i tion an d an ae s th e t iz e d T h e t ub e o f B e niqu e a plai n S ilv e r t ub e

.
, ,
op e n a t b o th e n d s ab ou t 9 m m in d ia m e t e r an d fro m 6 t o 8 inc h e s in
, .
l e n g th i s p a s s e d d own th e ur e th ra ; th i s t ub e pro t e c t s t h e wall s o f t h e

,
ur e thr a an d pu t s th e fac e o f th e s tric t ur e on th e s tr e t ch T h e t ub e i s .
now fill e d wi th a b u n d l e o f s m all fi li fo rm wh al e b on e b ougi e s w hich are ,
car e fully p a s se d d own t o th e s trict ur e : by trying fir s t on e an d th e n

ano t h e r i t i s po s s ibl e t h a t o n e m a y e ngag e t h e op e n ing an d p a s s in to
,
t h e s tric t ur e T h i s b e ing acco m pli sh e d t h e d i s e nga g e d prob e s ar e re

.
,
m ov e d t og e th e r wi t h t h e t ub e a n d a ft e r s e curi n g th e prob e i n t h e bla d

,
d e r a W h e e l h ou s e s t aff d rill e d th roug h th e e n d i s carri e d d own ov e r i t

, ,
t o th e s t ric t ur e an d h e l d fir m ly a g ain s t th e coarc t a t io n by a n a s s i s t an t ,
whil e th e O p e ra t or O p e n s th e ur e thra in th e gro ov e o f th e s ta ff m aking ,
an inci s ion ab ou t h al f an inch in l e ng th Th e s ta ff i s th e n d rawn o u t

.
war d j us t s u ffici e n tly t o e nabl e th e w h al e b o n e prob e t o b e foun d a s i t

p a s se s through i ts e n d an d on in t o th e s tric t ur e ; th i s i s s e cur e d by
pa s sing a s m all b lun t h ook b eh in d i t a fte r wh ich th e s t a ff i s r e m o v e d
,
e n t ir e ly fro m th e ur e th ra a n d t h e d i s t al e n d o f t h e prob e d rawn o u t
th roug h th e li t tl e woun d wh ich h a s b e e n m a d e now ov e r th e prob e i s

pa s se d a li ttl e gorg e r e t ; th i s h as i t s bla d e dir e c t e d upwar d an d b e i n g ,
run along t h e prob e a s i t s gui de i t p a s s e s th rough th e op e ni n g i n t o

,
GE N I T O UR I N A R Y OR GA N S . 5 35
th e ur e t hra a n d d own th e s tric t ur e wh i ch i s c u t on i ts s up e rior fac e A

,
.
ca th e te r i s now p a s s e d alon g th e e n tir e ur e th ra in t o th e b la dd e r an d

th e urin e i s e vacua t e d a ft e r w h ich any b an d s r e m ainin g ar e c u t wi th th e
,
r e trogra d e ur e th ro t o m e o i Ci vi ale In ca s e th e in tro d uct ion o f a .
wh al e b on e prob e i s n o t p o s s ibl e in th e fir s t i n s t anc e a m o difica tio n o f ,
”
th e
“
Le e d s op e ra tio n i s u s e d t h e groov e d s t a ff b e ing carri e d d own t o
,
t h e s t ric t ur e a n d t h e ur e th ra O p e n e d j u s t ab ov e i t ; th roug h th e s t ric t
u re t h u s broug h t in t o vi e w a prob e p oin te d d ir e c t or i s pu sh e d an d ov e r

,
-
,
i t th e li ttl e gorg e r e t i s p a s s e d a s in t h e pr e c e ding ca s e ; th u s th e op e r

a tion i n e i th e r ca s e i s vir tually an in t e rnal s e ct ion T h e p ar ts ar e .
wa s h e d an ti s e p t ically th e lip s o f th e wou n d c o ap t a t e d an d h e l d by p in

,
s u t ur e s t h e s oun d wi th d rawn
, a n d i t s plac e occupi e d by a full s iz e d
ca th e te r p a s s e d d own t o th e pro s t a tic ur e th ra b u t n ot i n t o t h e bla dd e r ; ,
wh e n urina tion i s n e c e s s ary i t c an b e p u sh e d in t o th e bla dd e r an d a ft e r

,
war d d rawn b ack ; th i s i s u s e d o n ly fr o m t w e n ty four t o th ir ty s ix h our s - -

,
j u s t long e nough t o in s ur e th e pro t e c tion o f th e woun d fro m t h e p a s

s ag e o f urin e un t il i t h a s b e e n in a m e a s ur e glaz e d ov e r a n d t h e s tric t
u re d por t ion s o ft e n e d up b y th e pr e s e nc e o f t h e inlying ca th e t e r ; th e
pin s are wi thd rawn on th e four th t o s ix th d ay a n d th e pa t i e n t s oon

a fte r allow e d t o g e t up r e s um ing hi s for m e r voca tion s wi th in e igh t to
,
t e n d ay s a t o t al cur e b e in g ob t ain e d in fro m e ig h t t o t w e lv e d ay s T h e

,
.
a d van t ag e s o f th i s op e r a t ion are t h e S h or t p e ri o d o f confin e m e n t fo r th e
p a t i e n t fr e e d o m fro m h e m orrh ag e quick union by pri m ary a dh e s ion

, ,
a n d th e s m all a m oun t o f r e s ul t an t ci ca trici al t i s s u e wh i ch i s alway s ,
d e po s i t e d in gr e a t e r propor t ion th e lo n g e r th e h e aling proc e s s con
t in u e s —P r oceed i ng s Am . S m g Ass n
’
. . 1 88 6 .
J . E . P I L CH E R , (U . S Arm y)
. .
III . O n t h e Ch oi c e of O p e r a t i o n s fo r E xt ract i on of Ve s
i c a l C a lc u li ( c t io p e rin e ali s s e c t io al t a
se
) By P ro
, f K oNi G
( G O t . .
in g e n ) I t i s an o ld e xp e ri e nc e th a t n e w cura t iv e m e th o d s s ucc e s sful

. .
in a fe w ca s e s m ay for a ti m e qui te ov e r sh a dow old an d acc e p t e d

,
m e th o d s N o t in fr e qu e n t ly th e y a s rapi dly d i s app e ar l e aving s carc e ly

.
,
m or e th an th e ir na m e s T h e h i s t ory o f n e rv e s tr e t ch ing furni s h e s a

.
-
v e ry r e ce n t e xam pl e O p e ra t ion s on th e b la d de r h av e h ad a s i m il ar
.
e xp e ri e nc e Big e low s op e ra ti on d i s plac e d bloo dy m e th o d s for a ti m e

.
’
.
T h e n th i s wa s th ough t t o b e con trary t o t h e pri n cipl e s of an ti s e p s i s .
N ow owing t o Brown e 85 Gar s on s e xp e ri m e n t s an d Pe t e r s e n s applica

,
’ ’
t ion o f th e ir p rincipl e t o cys t o t o m y th e qu e s t io n i s a : t o th e s up e rior

,
or in fe rior inci s ion Th e S p e ak e r a s r e fe r e e

. o n t h e qu e s t ion pro
,
p o s e d by la s t y e ar s congr e s s s oug h t fir s t t o d e d uc e fro m h i s own e x

’ “
p e ri e n c e th e li m i t s for s e c t io al t a an d s p e ri n e ali s Proc e e d in g on

. .
th e ba s i s th a t t h e c h oic e b e t w e e n t wo op e ra t ion s h avi ng t h e s a m e
obj e c t d e p e n d s on two fact or s : d an g e r t o li fe on th e on e h an d an d

fe a s ibili ty on th e o th e r H e was o f t h e opinion th a t i n ca s e th e O bj e c t
.
coul d b e acco m pli s h e d by a l e s s d ang e rou s op e ra t ion t h oug h wi th ,
s o m e wh a t gr e a t e r d i fficul t y th i s m e th o d sh oul d h av e t h e pr e fe r e n c e
,
.
In applyi n g th i s principl e t o th e two O p e ra tion s ( s e ctio al t a s p e ri n e ali s) , .
—as s u m i n g th e d ang e r fro m h e m orrh ag e t o b e ab ou t e qual—d ang e r

t o li fe i s al m o s t nil fro m t h e p e rin e al wh il s t a s ye t fro m th e s uprapu b ic
,
i t i s fro m an a t o m ico m e ch an ical con d i t ion s n o t incon s i d e rab le— s e p t ic

-
pro c e s s e s o f t h e fro n t ab d o m inal wall s co s ti n g li fe i n a n u m b e r o f

ca se s.
H i s e xp e ri e nc e w e n t t o s h ow th e ab s e nc e o f d ang e r fro m t h e p e rin e al
O p e ra t ion .O f fi fty p e rin e al inci s io n s in t h e GOtt i n g e n cli n ic s inc e

1 8 7 6 for t y w e r e for ur e t h ral s t ric t ur e s
, N o t o n e o f th e fi fty d i e d fro m
.
th e con se qu e nc e s o f t h e O p e ra tion T hr e e di e d fro m th e ir t roubl e ; in

.
th em th e o p e ra tion h a d b e e n m a d e p ar t ly fo r cura t iv e par tly fo r d iag ,
no s tic p urpo s e s E xclu di n g th e s e th e r e r e m ain for ty s e v e n m e dian

.
-
i nci s ion s wi th o u t a d e a th T h e wou n d h e al e d t h ir ty s ix t i m e s wi th ou t

.
-
in te rrup tion al th ough S ix o f th e s e h ad b ulbou s h m m o rrh a g e at th e

,
op e ra tio n Urin ary fe v e r la s ting s e v e ral d ay s occurr e d in e i gh t e ry

.
,
s ip e la s in o n e T h e s e r e s u lts w e r e ach i e v e d al th oug h i n t w e n ty s e v e n a

.
-
s e ve r e purul e n t an d e i gh t t i m e s a s ti n ki n g p u t ri d ca ta rrh was

pr e s e n t F ro m th i s t h e co n clu s ion can b e d rawn th a t th e p e rin e al
.
m e th o d i s al m o s t non d ang e rou s a n d n o t m a t e rially in flu e nc e d by p ur

-
,
”
u le n t an d s t i n king u rin e S till th e s i g n ifican c e o f Bou tonni er e i s
.
n o t e quiva le n t t o th a t o f th e m d ian i n ci s io n as a for e ac t in t h e O p e ra

e
-
t i o n for calculu s H i s e xp e ri e nc e wi th O p e ra t ion s fo r calc ulu s e x t e n d s

.
t o th ir ty e ig h t ca s e s
-
T h e s e inclu d e t w e n ty two p e r in e als wi th s e v e n
.
-
GE N I T O UR I N A R Y OR GAN S .
S3 7
d e a th s fi v e s upra wi th fo ur d e a th s an d e l e v e n s t on e c ru sh i n g s
p ub i c s
-
,
-
wi th n o d e a th F ro m th e t w e n ty t wo p e rin e al li th o to m i e s two d e a th s
.
-
ar e t o b e d e d uc t e d
( 1 fro m ch loro for m 1 fro m ing e s tiv e pn e u m oni a , ,
a ft e r long ch loro for m vo m i ting ) T h e r e r e m ain fi ve fa t al ca s e s in .
t w e n t y or 2 ,
T h e fa t al c ase s all pr e s e n te d analogou s con d i tio n s .
T h e s t on e t ro ubl e h a d la s t e d long an d in m o s t o f th e m s e v e ral a t

-
,
.
t e m p t s h a d alr e a d y b e e n m a d e t o r e m ov e th e calculu s ; pu t ri d urin e
v e ry larg e calculi v e ry d i fficul t op e ra tion D e a th was pr e c e d e d b y

,
.
fe v e r m e n t al ob s cura t ion uncon s ciou s n e s s

, T h e au t op s i e s s h o we d
,
.
v e s ical ca t arrh o ld py e lon e p h ri ti s pn e u m onia an d fa t ty h e ar t As a

, , .
rul e th e y w e re old w e ak m e n in wh o m th e fr e sh in fe c tio n wa s a dd e d t o

,
th e old a n d wh o d i e d o f se p t ic urm m i c poi s oning

, T h e m e th o d o f
- .
O p e ra t ing was e vi d e n tly an i m p e r fe c t for e a c t I t m a d e t oo m any an d - .
t e d iou s a t t e m p t s a t r e m oval o f th e calculi n e c e s s ary .
A s t o d ura t ion o f cur e a fte r th i s O p e ra tion i t w a s—i f fro m t h e fi ft e e n

cur e d we l e av e o ut four v e ry s e v e r e ca s e s— e ig h t t i m e s co m pl e te d in
fi ft e e n d ay s O nly in on e p a t i e n t d id t h e c lo s ui g o f th e fi s t ula la s t
.
nin e ty d ay s I n o th e r ca s e s n o fi s tula r e m ai n e d
. N o t abl e i s th e .
rapi d cur e in ch il dr e n F o ur boy s w e r e d i s c h arg e d r e s p e c tiv e ly a fte r

.
t e n t w e lv e t h ir t e e n a n d fo ur te e n d ay s
, ,
O n e pa ti e n t fro m w h o m an .
,
e la s tic ca th e t e r wa s r e m ov e d co ul d b e d i s m i s s e d in e ig h t d ay s
, F ro m .
th e p e ri n e al inci s ion i t s e l f n o pa t i e n t d i e d .
T h e s t a ti s t ic s o f o th e r s urg e o n s al s o giv e v e ry goo d nu m b e r s fo r t h e

p e ri n e al c u t al th o ug h th e r e ar e no larg e s t a t i s t ic s o n t h e m e d ian O p e ra
,
t ion . We re wkin h a d ni n e d e a th s a m o n g 1 4 7 c h il d r e n O p e ra te d by
la t e ral li th o t o m y— th e la s t s e v e n ty two o f th e m wi th ou t a d e a th Th e -
.
i m prov e m e n t wa s owing t o i m prov e d a n ti s e p si s H e u si nge r coll e c te d .
2 2 2 ca s e s wi th fa t al Allar to n foun d 9 % a n d Be n fi e ld
.
We re wk in r e p ort s sixte e n m e dian s wi th o n e d e a th Min e r t e n ca s e s ,
wi th ou t a d e a th Lin d e m an ( R u s s i a) h ad r o —r 5 % ( Q) fa t al ca s e s a m ong
.
for ty -fi ve p e ra t e d
O .
T h e m o d e rn s e c t io al ta on t h e con trary h as d ang e r s n o t p e r t aining

, ,
t o t h e p e rin e al m e th o d But qui t e a s c e r t ainly i t h a s gr e a te r cap a

.
, ,
b i li t i e s T h e d ang e r t o li fe r e s ul ts fro m in fe c t ion o f th e woun d in th e

.
’
a b d o m inal cov e ring s T h i s i s sh own b y K s ca se s wh o s e r e s ults w e r e
.
,
5 38 I N D E X OP S UR OI CA L P R O GR E S S .
n ot qui te so poor s inc e on e o f th e fo ur d i e d fro m io d o for m a n d th e

,
o th e r th re e w e r e o ld p e r s on s wi th e nor m ou s calculi an d p u tri d urin e .
Bu t coll e c tiv e s t a t i s t ic s prov e th a t a r e lat iv e ly larg e nu m b e r o f p a ti e n t s

di e fro m s e p t ic in fe c tion o f th e ab d o m inal cov e ring s ; e g Ga rz i a s ’
. .
n i n e ty four ca s e s wi th
- d e a th s E v e n th oug h we d e d uc t lik e
.
,
Garzia t w e lv e on accoun t o f pr e viou s py e lon e p h ri ti s s till a larg e n u m

, ,
b e r o f ca s e s r e m ai n w h ic h t e r m i n a t e d fa t ally fro m t h e in fe c ti o n T u ffi e r .
foun d z 7 % o f d e a th s am o n g 1 2 0 c as e s th i rty four % o f th e d e a th s b e ing

, ,
-
d u e t o urinary infil tra t ion M e y e r al s o h ad e igh t o ut o f for ty on e ca se s

.
-
di e fro m urin e infil tr atio n E v e n acknowl e d ging th a t t h e r e s ul ts o f t h e

.
op e ra tion m ay owing t o m o de rn car e b e co m e s o m e wh a t b e tte r a s th e

,
O p e ra t ion i s i m prov e d i t will n e v e r b e p o s s ibl e t o e n t ir e ly d o away wi th

,
th e d ang e r s fro m d e co m po s e d urin e .
’
A s ye t Tr e n de l e nburg s m e th o d ( b e lly or la t e r al ab d o m inal po s i t ion
wi th rai s e d p e lvi s an d d rainag e ) app e ar s t o K th e s a fe s t th ough n o t . .
univ e r s ally availab l e ( e g n o t in o ld w e ak s ubj e c ts) T h i s i s m o s t

. .
,
.
l i k e ly t o avoi d ur i n e infil tra tio n O n th e o th e r h an d s u t ur e th oug h

.
,
wi th ou t d oub t th e m o s t i d e al m e th o d i s fo r th e pr e s e n t un s a fe a n d in
, ,
c e rt ai n p e r s on s ( v e ry fl e s hy ) s carc e ly av ailabl e a t all I t i s e vi d e n tly .
l e a st s e rvic e abl e w h e r e i t s u se woul d b e m o s t d e s irabl e i e wh e r e th e ,

. .
,
urin e i s v e ry p utrid .
In for ty on e ca s e s co ll e c te d by M e y e r th e s u t ur e d id n ot h ol d in
-
,
s e v e n t e e n a n d e ig h t d i e d o f wo un d s e p s i s
,
Wh e r e i t i s d e s ir e d t o
.
r e m ov e a larg e for e i gn b o dy th e s e rvic e abili ty o f th e s e c tio a l t a i s c e r

t ai n ly gr e at e r a n d th e m e th o d r e la t iv e ly l e s s d ang e rou s .
Calc uli in d iv e r t icula m ay b e m or e appro ach abl e fro m in fron t .
F inally h e e xpr e s s e s h i m s e l f v e ry favor a bly ov e r cru s h i n g —b ut a s s e r t s
th a t i t i s an a rt an d o n e n o t l e arn e d by e v e ry o n e A bri e f S k e t ch o f
.
e ach ca se clo s e s h is ar ticl e .
DIS CU SS I O N .
W R O S E R ( M arb urg) s pok e of two c a se s ( on e op e r ate d by G S i m on)

.
.
o f c alculi in d iv e r ticula op e ra t e d by t h e p e rin e al m e th o d B o th d i e d .
fr o m cy s ti ti s—owing t o prolong e d m anipula t ion I n o n e o f th e s e all .
t h e fr a g m e n t s coul d n o t b e e x t r a c t e d T h e h igh op e r at ion m i gh t h av e

.
GE N I T O UR I N A R Y OR GAN S .
5 39
sa v e d li fe an d m or e ov e r in S i m on s ca se th e larg e p olyp oi d pro s t a t e

, ,
’
lob e wh ich wa s s uch an i m p e d i m e n t m igh t al s o h av e b e e n c ut o ff fro m

, ,
ab ov e wi th s ci s s or s In a th ir d ca s e o p e n e d fro m ab ov e th e p a ti e n t
.
, ,
d i e d fro m a d iv e r t icl e ab s c e s s F ro m a s e ri e s o f ca se s R h a s foun d

. .
th a t u n i on a n d c i ca t r i c i a l eon l r a ezi on s do n ot occu r a s long a s l/ze u r i n e

‘
i s a lk a li n e T h e alkalini ty can n o t alway s b e ov e rco m e or a t le as t i n

.
, ,
ki dn e y s t on e an d py e li t i s i t alway s r e cur s A c e tic aci d irriga tion s .
a re h e r e m or e e ffe c t iv e th an b oracic aci d .
BE E R MAN N ( S t Pe te r s b urg ) op e ra te s u s ually by th e la t e ral m e th o d

.
,
a n d e s p e ci ally in c h il d r e n fro m 3 t o 1 2 y e ar s wi th goo d s ucc e s s Of .
thr e e c a s e s in p a t i e n t s o f 7 5 y e ar s t wo d i e d fro m pr e vi o u s e xh au s tion

, .
Taking all h i s ca s e s wi th ou t any cla ss ifi ca tion a s t o a ge co m plica tio n s

, , ,
’
e tc.
,h i s m or t ali ty wa s 1 t o 7 or Th o m p s on s coll e ct iv e la t e ral
,
O p e ra t ion s S h ow 1 t o T h e b e s t r e s ul t s o f b o th T an d E a r e b e . .
t w e e n 6 a n d 1 1 y e ar s At th e fir s t congr e s s o f t h e Mo s cow—S t Pe t e r s
. .
b urg M e d ical S o ci e ty Pro f S si n i tz in o f Mo s cow r e p or te d 1 5 4 li th o t o m i e s

.
in e ig h t y e a r s wi th s e v e n de a th s ( 1 t o 2 2 or ag e s 1 3 m on th s , ,
’
t o 5 6 y e ar s E b e rm ann s r e s ul t s in pa t i e n t s un d e r 6 0 w e r e ab o u t a s
.
fav orabl e S te rili t y a s a r e s ul t h e con s i de r e d a b ugb e ar

. .
I n s e v e ra l ca s e s in th e la s t th r e e y e ar s E h a d d on e th e m e d ian op e r .
at ion—n o b a d r e s ul t Wwe d e n s k y o f M o s cow r e p or te d 2 3 7 own ca se s

.
, ,
a t th e Pe t e r sb urg Congr e s s wi th m or t ali ty o f or 1 t o ( Allar

t on foun d 1 t o
M I N I N ( S t Pe t e r s burg) a n d E h av e coll e c te d fi fty th r e e ca s e s o f

. .
-
s e c tio al t a wi th s u t ur e o f th e bla d d e r — nin e o f t h e s e fa t al four fro m ,
infil tra ti on Willy M e y e r ( A NNA L S V i d e v ol ii p 8 4) h a d coll e c t ed

.
, ,
.
, .
for ty s i x -
.
A S CH M i Tz a t th e Pe t e r sb urg Congr e s s di s cu s se d r e s ul ts fro m th e

.
, ,
O l d e nb urg C h il dr e n Ho s pi t a l in S t Pe te r s b urg
- In th e for e an ti se p tic
. .
-
p e rio d m o rt ali ty wa s 1 t o ( se c tio al ta) s inc e th e n 1 t o cur e d , .
E b e rm a nn Pawlow an d Pro f Lucin h av e e ach op e ra te d ( onc e p re s um

,
.
,
’
a b ly Lu c in s ca s e wa s o n e o f t rau m a tic rup tur e o f th e fron t wall o f th e
,
b l add e r) by s t i t ch ing th e bla d d e r wall t o th e e x t e rn al wo un d for fi v e

d ay s or un t il pla s t ic un ion o f t h e ab d o m inal woun d was c e r t ain
, .
E a d voca t e d li th o t rip s y e sp e c i ally wh e re th e p a t i e n ts c a m e e arly

‘
.
,
to th e s urg e on H e h a d e m ploy e d i t t wic e s ucc e s s fully in 5 y e ar o ld

.
- -
c h il dr e n H e h ad th u s op e ra te d s t on e s up t o 7 0 gri n s S e v e r e v e s i c al
. .
a n d n e p h ri t ic t roubl e s cau s e d th e wor s t r e s u lt s H i s coll e c t iv e li th o .
t rip s y ca se s gav e b e t t e r s t a t i s t ic s th an any cu tt i n g m e th o d — S s i n i tz i n s

’
r e s ul t s e xc e p te d .
’
Th o m p s on s li th o trip s i e s 4 2 2 d e a th s 3 2 ( i t o 1 3
, , ,
’
K e i th s 1 1 8
( 1 to
,
'
’
E b e rm a nn s
( 1 to
Li th o tri ty i s con train d ica t e d in v e ry h ar d an d v e ry larg e s t on e s or ,
w h e r e th e y are in d ive r ti c uli al s o wh e r e t h e bla dd e r i s v e ry irri t abl e or

,
qui t e p aralyz e d ; al s o in v e ry narrow an d e x te n s iv e organic s tric ture s .
Li th o t o m y i s pr e fe rabl e in s e v e r e s upp ura tion s o f t h e urinary t rac t ,
T h e m e d ia n p e ri n e al i s th e l e a s t bloo dy O p e ra tio n b ut wh e r e th e s t on e ,
i s v e ry larg e a n d qui t e fill s o u t th e bla d d e r w h e r e i t S i t s in a d i ve rti c u

,
l u m ,
or w h e r e th e pro s t a t e i s gr e a t ly h yp e r t rop h i e d t h e s uprap ubi c i s ,
pr e fe rabl e .
V B E R G MANN ( pro fe ss or i n B e rlin ) con s i d e r e d li th olapaxy j u s tifi e d

.
,
in s o ft a n d fragil e calculi T h e d an g e r s a tt ribu t e d t o th e s uprap ubi c

.
op e ra tio n h e d id n o t acknowl e dg e in full T h e p e rin e al in ci s ion i s not

.
wi th ou t d ang e r fro m h ae m orr h ag e a nd e a s ily d e v e loping p e lvi c c e lluli ti s

inci d e n t t o cu tting th e pro s t a t e H e h a d p e rfor m e d n in e t e e n s e c tio
.
al t a s an d only o n e h a d p e riv e s ical c e lluli ti s d e v e lop —th e p a ti e n t re c o v

e ring .O n e only d i e d fro m h ae m orrh ag e fro m a n ulc e r o f t h e s t o m ach
, .
H e b e li e v e d p e lvic p h l e g m on co ul d b e avoi d e d by s u t ur e o f th e bla d

de r . H e d o e s n o t u s ual ly inclu d e th e v e s i cal m ucou s m e m bran e ;
p lug s th e ab d o m inal woun d wi th i o do for m gauz e fo r a w e e k I n o n e .
th ir d o f h i s c a s e s th e bla dde r woun d r e op e n e d - in th e r e m ain de r

t h e s u t ur e h e ld t h e fir s t th r e e t o e ig h t d ay s .
R e lap s e s m a y o ccur a ft e r li th olap axy a n d p e ri n e al e x t rac t ion e s p e ,
i a ll i f cru s h e d b e f or e r e m oval — h e nc ew h e r e p ye li t i s a n d p ye lo n e p h r o
c y
s i s a re pr e s e n t s e c t i o a lt a i s t o b e p e r for m e d s inc e t h e n all t h e calculi ,
can b e r e m o v e d La t e r o n Vo n B again urg e d s e c tio al t a wi th

. .
,
s u t ur e o f b la dd e r ; in fe c tiou s urin e i s t h u s k e p t a way fro m wo un d fo r a
fe w d ay s— w h e n i t c a n d o n o m o re h ar m .
Pi o f T R E N D E L E N BU R G ( Bo nn ) fav o r e d s e c t io al t a S inc e th e S i x s u c
. .
54 I
c e s s ful ca s e s p ubli sh e d by W M e y e r ( T s as s i s t an t) h e h a d p e rform e d

. .
’
i t four t i m e s ; th r e e o f th e s e —ae t 7 2 7 a n d 6 4 r e s p e c t iv e ly—w e r e

.
,
cur e d T h e four th a m an ae t 7 2 d i e d at th e e n d o f e igh t w e e k s T h e

.
, ,
. .
m a n h a d u s e d th e c ath e t e r for t en y e ar s ( v e ry larg e pro s t a t e H

) e re .
m ov e d for t y t wo larg e calculi an d c ut away th e larg e pro s t at e lob e

-
.
A fte r progr e s sin g w e ll a s inkin g ab s c e ss d e v e lop e d fro m th e r e m aining

fi s t u la T was s a ti s fi e d wi th h i s m e th o d ; th e r e c t al b allo on coul d b e
. .
d i s p e n s e d wi th ; p e ri t o n e u m wa s n e v e r inj ur e d .
”
VO LK MANN ( wi th K Oni g) s e para t e d s i m p le Bou t onni er e fro m ca se s
“
wi th inci sion o f pro s t a t e In ov e r 1 0 0 ca s e s o f th e for m e r—m aj o ri ty

.
c h il dr e n— h e h a d n e v e r s e e n p e lvic p h l e g m on O nly t wo d i e d dir e c tly .
fro m th e op e ra t ion o n e fro m h ae m orrh ag e o n e fro m s e p s i s

, ,
.
S C H E D E s t oo d by th e m e dian p e rin e al— four ca s e s m o s t ly in e l d e rly ,
p e opl e To s t op h ae m orrh ag e h e s e w s th e ur e th ral e d g e s t o th e e x te r

.
n al s kin H e d ila t e s th e p ar s pro s t a t ica wi th H e g ar s u t e rin e d ila t or

’
.
,
an d fo r s o m e d ay s l e a v e s fi n e r th ick T d r a inag e t ub e fo r d aily w a sh

-
g
ing out wi th b or wate r O nly on e ca s e o f urin e infil tra tion an d d e a th ;
-
.
o th e r s t ook goo d cour se .
S C H O N BO R N ( K onig s b e rg ) con s i d e r s li th olapaxy th e nor m al m e th o d

in s m all calculi b u t th e m e dian p e rin e al fo r for e ig n b o di e s Wi th th e
,
.
i m prov e d e vacu at or s r e curr e nc e can b e avoi de d i f th e b la dde r i s again ,
e x am i n e d a ft e r o n e or t wo w e e k s a n d la t e r th r e e or f our t i m e s a ye ar ,
t h u s a llowin g fo r r e m aining frag m e n ts grav e l fro m ki d n e y e t c , , .
S O N N E N BU R G ( B e rlin ) favor e d s e c tio a l t a A m ong s t i t s d i s ad van .
t a g e s h ow e v e r i f a urin ary fi s t ula r e m ain e d i t wi th s t oo d all a tt e m p t s at

, ,
cur e T h i s S h a s s e e n t wic e th e la s t y e ar In on e o f th e s e th e l) lad 1

. . .
d e r h a d b e e n s u t ur e d in th e o th e r—urin e b e ing alkalin e n o t

,
In th e .
fir s t ca s e ur e th ro t o m ia e xte rn a was d on e fo r p e r m an e n t drainag e o f th e

b l a dd e r wh e r e by two s m all s ton e s w e r e r e m ov e d on e con t aini n g a
, ,
S ilk s u t ur e T h e p at i e n t s oon d i e d
. Bla dde r an d p e ri t on e u m w e r e
.
m e d ially fir m ly a dh e r e n t t o th e ab d o m inal woun d ; an ab s c e s s cavi t y
wi th d i s co lor e d p u s in th e cavu m R e tzii b e h in d th e s y m p h y s i s wi th a ,
dir e c t co m m unica tion e x t e rnally an d v e ry in d ir e c tly wi th th e bla dde r .
S t ol d o f ano th e r ca s e lik e o n e o f Tili n g s m e n t ion e d in K r am e r s ar

’ ’
.
,
ti c le wh e r e th e p e ri t on e u m was b oun d t o t h e p o s t e rior s ur fac e o f th e

,
5 4 2 I N D E X OP S UR GI CAL P R O GR E S S .
y ph y s i s T h e p e ri t on e u m was c ut b ut i m m e dia t e ly s e we d up an d
s m .
fr e e d fr o m th e s ym p h y s i s wh e n th e bla dde r was op e n e d ; cur e wi th ou t
in t e rrup tion .
I SR A E L ( B e rlin) h a d al s o s e e n th e p e ri t on e al fol d a dh e r e n t t o th e
s ym p h y s i s an d fou n d fro m inv e s t iga t ion s on th e ca d av e r th a t b all o on
,
i n g th e r e c t u m d id n o t alway s p u s h up th e fol d o f p e ri t on e u m In a .
ca s e o f fi s t ula of fi ve ye ar s d ura tion I s m a d e t ran s v e r s e op e ning .
a bov e th e s y m p h y s i s c u t away th e fi s t s iz e d cica t ricial t i s s u e

,
- an d
s t i t ch e d ( s e w e d up h e b la dd e r Cur e only in t e rrup t e d by s o m e p a s

) t Z .
s ag e o f urin e th roug h w oun d on four th d ay In a ca s e o f v e s ical t u

.
m our an d pu tri d u rin e s t i t ch ing th e bla d d e r wall t o t h e ab d o m inal

, ,
t urn e d o u t w e ll .
Volk m ann ca s u ally ch ar a c t e riz e d s e c t io al t a a s m or e d a n g e rou s th an

ov a rio t o m y .
GU S S E N BAU E R ( Pragu e ) r e la t e d a ca se o f fi s t ula a fte r e picy s t o t o m y .
Pri m ary union o f th e s u t ur e d bl a dde r ; on r e m oval o f t h e s ilk s u tur e s
t wo w ee k s la te r th e y w e r e foun d m uch incru s t a t e d T e m p orarily th e

.
fi st ula woul d h e al t h e n br e ak o ut again Tr e a tm e n t i n vain by Vo n

,
.
Di tte l an d H ofm okl G i nci s e d th e bla dd e r wi th ou t fi n ding any th ing

. .
abnor m al b ut W
, i th ach i e v e m e n t o f s ub s e qu e n t cur e G f avor e d li th . .
o lap axy . Con train d ica tio ns fo r th i s an d th e o th e r O p e ra t i o n s lik e t h e

pr e viou s s p e ak e r s M e dian op e ra tion for ch il dr e n a n d s m all calculi
.
,
la te ral li th o to m y for larg e r calculi in fa t p e r s on s F o r e n or m ou s s t on e s

.
,
e tc th e s uprap ubic H e h a d onc e foun d th e p e ri t on e u m a dh e r e n t t o

.
s y m p h y s i s ; i t was acci d e n t ally inj ur e d a ft e r h aving b e e n pr e par e d o ff;
d e a th fro m p e ri t oni t i s a n d s e v e r e py e lon e p h ri t i s In ano th e r ca s e th e

.
s iz e o f th e s t on e co pl e t e ly filling bla d d e r co m p e ll e d h i m t o s e v e r
( m )
th e m m r e c t i ab d o m
. a t th e ir i n s e r t ion —
. c ur e d In a th ir d ca s e h e
.
foun d S ix s t on e s o n e in a d iv e r t iculu m — s low cur e

,
.
K U S T E R ( B e rlin ) r e m a rk e d t h a t co m pl e t e d igi t al e xa m i n a t ion o f t h e

bl ad de r was n o t po s s ibl e in all ca s e s thro ug h th e p e rin e u m s o t h a t in ,
th r e e ca s e s h e h a d h a d t o a dd s e c t io al t a H e t h oug h t no n e o f t h e o p
.
e r a t i o n s coul d b e d i s p e n s e d wi t h .
PE T E R S E N ( K i e l ) p oin t e d o u t th at r e curr e nc e o f s t on e m igh t n o t b e
th e faul t o f op e ra t or or m e th o d e g m igh t co m e d o wn fro m ki d n e y s

, . .
,
.
GE N I T O- UR I N A R Y OR GA N S .
5 43
S om vil s m igh t r e s ul t fro m hi s m e th o d o f r e c t al d i s te nt ion—at ony

e e
o f in t e s t in e a n d copro s t a s i s b ur st ing o f r e c t al wall fro m ov e r d i s t e n s ion

, .
In a s e ct i o alta fro m 1 8 7 6 th e cica trix brok e op e n s e v e ral ti m e s b ut ,
fin ally was se cur e d H e th ough t o n e cau s e o f fi s t ula m igh t b e th e

.
union o f ab d o m in al b e for e v e sical woun d .
H e wa s r e t urnin g t o li th olap axy o n e ca s e wi th cocain an a

Z e s th e s i a - - .
O r ig i n a l A bs l r a et i n C en tb l f . C /zi r . 1 886 . NO . 24 .
IV . M o de rn M o d i fi c ati o n s of th e O p e r at i o n s fo r C al
c u lu s By Dr K R AM E R ( Go t ti n g e n ) ( In tro d uct ory r e vi e w t o K O
. . .
e fe r s t o Big e low s op e ra t ion an d th e skill i t r e quir e s

’ ’
n i g s a r ticl e R
) . .
L a te r a l li lnofom y h as b e e n prac t ically giv e n up in Ge r m any ; in

R u s s i a s till fr e qu e n t ly prac tic e d e s p e cially on ch il d r e n , .
e tt ( M a a s D e u ts c h e G e s e ll f C h irg
( ) c
"
a T .
, 1 8 8 5) 1 0 6 ase s o f a ll . . .
,
ag e s wi th 3 d e a th s an d 3 r e curr e nc e s
,
.
( b ) Grub e ( Ch ar c ow R e f in C e n tb l f C h irg 1 8 8 2 N o 4 9 P
.
, . . . .
, , .
, .
7 9 9 ) 4 0 ca s e s wi th 3 d e a th s ( 2 fro m ki d n e y a ffe c t ion s a n d 1 fro m

,
s e p si s
) .
( )
c W e
. r e wk i n C e n tb l f
( C hirg 1 8 8 5 N o 8 ) 1 4 7 ca s e s wi th 9
. . .
, .
,
d e ath s b e s i de s 3 fro m acci d e n t al d i se a s e s

, A m ong s t hi s l as t 7 2 .
,
h ow e v e r no d e ath ( 1 0 h a d balano p o s th i t i s 9 e ry s ip e l as 2 orch i ti s

, .
-
, , ,
wh il s t o f th e 1 3 5 cur e d 7 h a d a fi s t ula a n d 2 incon t in e nc e o f urin e ) .
S e c t io m e d iana ( Bou t onni er e wi th d ila t a t i on o f ur e th ra an d s p h inc t e r ,
v e s ic ae) H e s i m ply m e n tion s for m e r s t a ti s tic s o f B e n s ing e r Be n fi e ld

.
, ,
e tc.
,w h ich gav e a m or tali ty o f 5 % t o Mor e r e c e n t colle c tion s
are : We re wk in ( l c ) 1 6 ca s e s in c h il dr e n wi th 1 d e at h and 1 fi s t ula ;
. .
,
Min e r ( r e ft in C e ntb l f C h irg 1 8 8 2 P 7 8 9 ) 1 0 ca s e s z

. . .
o f all a e s
g
.
, , .
wi th goo d r e s ul t ; M a as 1 d e a th fro m uraem i a ( a m o n g st , K in de

m ann R u s s ia ( M ag d e b urg Nat urfors c h an d Ae rz t e Ve rs a m m l ) in
, .
.
th r e e y e ar s 4 5 ca s e s wi th 1 0 t o 1 5 % m or t ali ty ; H e lfe r ic h M nic

, ,
( u h
M ile/z fli ed Woc h 1 8 8 6 N O S 2
. .
—
9 1 1 ) h a d 1 d e a th fro m s e p si s in
.
, . .
1 1 c as e s a n d A S ch m i tz ( Arch f klin C h irg Bd 3 3 P 4 8 2

, .
) 2 . . . .
, .
, .
,
d e at h s ( p e ri toni ti s p ye lon e p h ro si s) an d twic e fi s tul a am ong 1 4 ca se s

, .
R e c e n t ly a por tion o f th e Ge r m a n a n d F r e nch s urg e on s as a l s o ,
Th o m p s on h av e t urn e d m or e t o th e s uprapubi c Von Di tte l ’s in dica

, .
t i on s ( vi d e A NNA L S O c t 1 I n v e ry larg e s to n e s wh e r e the

, .
, .
5 44 I A D E X O P S UR GI CA L P R O GR E S S .
b la dd e r s pa s m o d ically e nclo s e s t h e s t on e s o t h a t n o i t in e rariu m can

b e in tro d uc e d b e t w e e n 2 W h e r e th e s t on e proj e c t s pip e lik e in t o th e
. .
-
ur e th ra 3 Wh e r e calculi ar e s o i m b e dd e d in div e r ticula th at th e y

. .
,
c an n o t b e e xpr e s s e d 4 In s t on e s o f s uch h ar d n e s s th a t th e y c an
. .
n o t b e cru sh e d 5 F o r for e.ign b o d i e.s th a t can n o t b e brok e n up nor
e x tr ac t e d 6 In c o e xi s t n e t ankylo s i s o f o n e h ip
. .
- .
Alb e r t ( Le h rb uc h 1 8 8 5 ) an d G arcin ( S t ra s sb urg

, h av e a c ,
ce p t e d t h e s e in dica t ion s th e la tte r a d d ing pro s t a tic h yp e r trop h y s t ric t

, ,
”
ur e o f th e ur e th r a irri t abl e bla dde r a n d m a t e rial al te rat ion s in th e
“
, ,
ki dn e y s .
M illi o t ( M e d ic Co n gr e s s o f Ly e n . ach i e v e d upw ar d di s plac e

,
m e n t o f t h e bla d d e r by inj e c t ing air in t o t h e r e c t u m Braun e a n d Gar .
s o n 1 8 7 8 follow e d wi th corrob ora tion a s k n own T h e n Pe t e r s e n 1 8 8 0 ;

, ,
.
,
Mannh e i m 1 8 8 4 an d F e h l e i s e n
, , .
Balloon in t h e r e c t u m fail e d in o n e ca se o f Ja n i s c z e ws k i o wing de ,
S pi t e d e e p narco s i s t o cra m p o f th e s p h inc t e r ani as clai m e d .
I n a v e ry fe w ca s e s th e p e ri t on e u m h a s b e e n O p e n e d ( Li s t e r We r ,
e wk i n How e on e m e n t ion e d i n th e di s cu s s ion

,
.
T h e propo s i tion o f Vi d al ( al s o Lang e nb u c h Alb e r t M ono d) t o d i , ,
vi d e th e s uprap ubic op e ra tion in t o two O p e ra tion s d o e s n o t s e e m t o

h av e b e e n prac tic e d ( P urpo s e o f t h i s w
. a s t o a voi d infil tr a t ion of
urin e) .
S inc e W M e y e r s s t at i s tic s o f 4 1 ca s e s o f s u t ur e o f th e bl add e r ( vi d e ;

'
A NNA L S J uly 1 8 8 5 ) a larg e nu m b e r o f s uch ca s e s h as b e e n p ubli sh e d

, , .
T h e plan h a s b e e n giv e n up by th e m aj ori ty unl e s s in e xc e p t ion al

c as e s an d d rain ag e th roug h t he bla dd e r woun d s ub st i t u te d
,
.
S t a ti s tic s o f t h e s uprapubic O p e ra tion in i t s m o d e rn for m h av e b e e n

'
coll e c te d by b o th Garcin an d T u ffi e r ( T Annal e s d e s M al d e s voi e s . .
urin 1 8 8 4 J un e G arcin s li s t a m oun te d t o 1 0 6 ca s e s

. . .
’
O f 9 4 ca s e s .
for s t on e or fo r e ign bo d y 2 3 d i e d ( 1 2 o f py e li t i s e ry s ip e la s e t c 7 fro m

, , , .
,
u r in e infil tra t ion o f w h ich la tte r in 5 th e bla d d e r h ad b e e n s u t ur e d ) .
A m ong s t hi s 2 7 ca se s b e t we e n 1 0 an d 2 0 y e ar s o f a g e b u t 1 d i e d
, , .
T uffl e r giv e s 1 2 0 ca se s wi th 2 7 % d e a th s S o m e op e r a t or s e m ploy .
th i s m e th o d in n e arly all ca s e s w h il s t o th e r s h av e r e co ur s e t o i t o nly

,
in v e ry di ffi cul t on e s th u s yi e l d ing un e v e n r e s u lts

, .
Von Be rg m ann ( 1 8 8 4 ) 1 0 ca s e s wi th n o d e a th s .
UL CE R S , A E S C E S S E S , T UM OR S . 5 45
Tr e n d e l e nburg ( c f W M e y e r ab ov e ) 6 ca s e s all c ur e s
. .
, , ,
E BOc k e l ( c f G arci n ) 3 cur e s a n d 3 d e a th s

. . .
M ikulicz 3 c a s e s on e dyin g fro m p n e u m oni a

,
.
V Di t te l 8 cur e s an d 5 d e ath s
.
,
Th o m p s on 6 ca s e s 1 d ying fro m e xh au s tion , .
Von I t e r s o n 1 2 ca s e s no d e ath , .
In F ranc e 1 9 wi th 5 d e a th s b ut onl y 1 ( 3 ) fro m th e O p e ration ,

.
We re wk i n 2 4 ch il dr e n 7 d e a th s ( fro m p e ri t o n i ti s)
, .
M ak aweje w ( R e f in C e n tb l f C h irg 1 8 8 4) 1 1 ca s e s wi th 2 d e a th s
. . . .
,
.
Tili n g 4 ca s e s no d e a th s , .
In s e v e ral o f th e a b ov e c as e s a v e ry in trac t abl e fi s tula r e m ain e d .
A r ed j . k li n . C/zi rg . 1 886 . Ed .
34 . H ft I . .
W . BR O WN I NG ( B ro o k ly
n ) .
U L C E R S —A B S C E S S E S —T U M O U R S .
I . T h e S u b i o di de of T re at m e n t o f U l c e r
B is m u th in th e
at io n s By A S I D N E Y R E YN O L D S M D ( Phil ade l ph ia) T h e s ub

. .
, . .
,
.
i o d i d e o f bi s m u th wou ld s e e m t o uni t e th e prop e r ti e s o f i o din e an d

bi s m u th ; th e for m e r ac ts upon ;granula tion ti ss u e s in d ucing an in ,
cr e a s e o f all nor m al p h y s iological proc e s s e s pro d ucing a pro t opl as m ic ,
e n e rgy or d inarily ob t ai n e d on ly by co n g e s t ion h yp e r ae m i a or i n fl am ,
m a t i on an d i n d uc e s a r e v e r s ion o f th e ti s s u e s t o an e m bryoni c s t a t e ;
,
i t i m par t s a for m a tiv e i n flu e n c e or forc e t o th e c e llular e l e m e n t s o f t h e
th r e e g e r m i n al or b la s t o d e r m ic lay e r s an d th e ir d e riva t iv e s , clo se ly a p
p r O X i m a t in
g t h e law s o f n or m al d e v e lop m e n t ; i t s S p e cifi c ac t ion in c e r
t ain d y s cra s i as a n d i t s an t i s e p t ic p ow e r i n h ibi t i n g g e r m d e v e lop m e n t in ,
th e propor t ion o f 1 t o a d d t o i t s e ffi ci e n cy Bi s m u th uni t e s wi th .
th e albu m e n for m ing an albu m ina t e wh ic h ac t s a s a s e d a t iv e a s e p tic

, , , ,
i m p e r m e abl e coa t i n g on th e gra n ulat io n s r e t ar ding th e e vaporat ion o f ,
th e c e llular m oi s t ur e m o d i fying th e for m a t ion o f a s t r i a t e d con n e c t iv e

,
t i s s u e fr o m th e g e la t inou s in t e rc e llu lar s ub s t anc e a n d pr e v e n t s th e ,
r e t rogra d e m e t a m orp h o s i s o f t h e wh i t e bloo d corp u s cl e s S u m m a .
r i z i n g t h e p h y s ical a n d t h e rap e u t ic prop e r t i e s o f t h e s ubio d i d e i t m ay ,
be s ai d t h a t ,
a . I t s ub d u e s th e infl a m m a t ory proc e s s .

46 I N D E X OF S UR GI CAL P R O GR E S S .
o It . ub s ti tu te s th e inflam m a to ry r e g e n e ra tion o f t i s s u e wi th a n e
s ,
Op la s ti c forc e wh ich clo s e ly s i m ula t e s nor m al e m bryoni c h i s t og e n e s i s

,
.
C I t i s by i t s ac tion a vi t al an t i s e p t i c s upp or ti n g li fe pro m o t ing nu

.
, ,
tri ti on an d m ain t aining t h e in t e g ri t y o f th e t i ss u e s .
d I t pr e v e n t s th e for m a t ion o f p u s
. .
e I t l e s s e n s d ir e c t an d r e fl e x irri t abili ty
. .
f I t i s so blan d an d unirri t a t ing th a t i t can b e u s e d on any s ur fac e

. .
Un d e r th e u s e o f s ubio di d e of bi sm u th ulc e r s wh ich u s ually h e al

~
,
by cica tr i z a tion a t th e ra te o f o n e h al f t o o n e lin e p e r day h av e b e e n

-
,
se e n t o d e rm at i z e a t t h e ra te o f th r e e t o fi v e lin e s p e r d ay ; th e ci c a
trix i s fl e s hy a n d fi rm an d i s b u t li ttl e d i s po s e d t o d e s truc tiv e i n fl a m

,
m a t io n s or s ub se qu e n t al te ra t ion s e v e n ov e r s yp h ili t ic s or e s C e r t ain .
ulc e r s o f p ar ticular origi n m ay r e quire s o m e ra d ical or S p e cifi c t r e a t

m e n t t o co n v e r t th e m t o s i m pl e for m s o f u lc e r or t o r e m ov e p a th o lo g
ic al e l e m e n t s wh ich woul d r e t ar d h e al th y ti s s u e for m a tion T h e d r e s s

, .
in g i s appli e d as a dry p ow d e r — M ed N ew s Oct 9 1 8 8 6

. . . .
, .
II . I n c i s i o n D i g i t al E x p l o r at i o n a n d D r a i n a g e o f
The ,
L u m b a r A b s c e s s e s —By E D M U N D A N D R E W S M D
.
( icago
C h ,
. .
, ,
F ro m a pr e t ty e x te n s iv e e xp e ri e nc e in th e variou s m e th o d s of
t re a tm e n t o f lu m b ar ab s c e s s wh ich h av e b e e n in vo g u e th e wri t e r
, ,
conclu de s : 1 S o m e lu m b ar ab s c e sse s r e cov e r si m ply by a s e ri e s o f

.
as pira tion s wi th or wi th ou t an t i s e p t ic wa s h i n g o u t
, T hi s m e th o d i s .
s i m pl e an d wh e re th e ch oic e o ffe r s i tse l f sh ould b e t e s te d fir s t

, ,
.
2 . I f th e a s pir at ion plan fa il s or i s in a pplicabl e in co n s e qu e nc e o f th e

,
ab s c e s s b e ing alr e a d y O p e n th e n fr e e inci sion e xplora tion an d c o m

, ,
p le te d i s in fe c tion sh oul d b e c arri e d o u t a t onc e 3 I f r e s i d ual a b . .
s ce s se s app e ar in th e co ur s e o f th e t r e a t m e n t t h e y S h oul d b e se rv e d i n ,
th e s am e way as th e p ri m ary o n e 4 T h e s u d d e n e v a cua tion o f a

. .
lar ge c avi ty fill e d wi th p us p r ovi d e d th e s ac i s i m m e dia t e ly d i s in fe c t e d

, ,
an d k e p t s o h as non e o f th e d ang e r s s uppo s e d by th e o ld au th or s t o

,
b e s e t th e ca se T h e s te p s o f th e op e ration vary wi th t h e loc ali t y

. .
Wh e n th e ab s c e ss p oin ts in th e lu m bar r e gion th e ori ginal focu s i s ,
alm o s t alway s in s i d e th e b o d y b ut b e h in d t h e p e ri t on e u m
, a sm all ori ,
fi c e a t the ou te r b or d e r o f o f th e co m m on m a s s o f th e e r e c t or e s s pi n ae
UL CE R S , A B S C E S S E S , T UM O R S .
5 47
m u s cl e s co n d uc ting th e p us ou twar d t o ano th e r broa d s a c wh i ch e x

,
p a n d s u n de r th e in te gu m e n t s In th i s ca s e n ot o n ly th e ou t e r fo cu s
.
,
m u s t b e e xp o s e d b u t th e inn e r o n e m u st b e e xplor e d th roug h t h e con

.
n e c t in
g op e n i n g u s ually foun d in th e groov e j u s t ou t s i d e th e b or d e r
,
o f th e co m m o n m a s s o f th e e r e c t or m u s cl e s b u t s o m e t i m e s lying in ,
th e angl e w h e r e th e cr e s t o f th e iliu m approach e s th e s kin N e cro s i s .
an d cari e s ar e t o b e tr e a t e d a s e l s e wh e r e Wh e n th e ab s c e s s poin ts .
ab ov e Poupar t s liga m e n t i t pr e s s e s aw ay th e p e ri t on e u m s o th a t th e r e
’
,
i s u s ually n o dan g e r in O p e n ing i t a li tt l e ab ov e th e ligam e n t an d in

‘
fron t o f th e s up e rior s pi n ou s proc e ss o f th e iliu m ; i f b e low a fr e e i n ,
c i s i o n i s m a d e t o a d m i t t h e fing e r
, T h e cour s e o f th e s i n u s i s t o b e
.
t r a c e d wi th a s oun d an d th e fo cu s th e n O p e n e d in th e lu m b ar r e gion ,
t h e ab s c e s s e vacua t e d th e cavi ty th oro ug h ly e xplor e d fo r d e a d bon e

,
wi th th e fi n g e r a n d prob e an d tr e a te d by an ti s e p ti c irri ga t io n T h e .
p ap e r i s acco m p ani e d by th e r e ci t a tion o f nin e ca s e s in wh ich th e au ,
t h or op e ra t e d by th i s m e th o d o f w h ich four p oin t e d in th e lu m b ar

,
’
r e gion o n e in th e ou te r s i d e o f th e l e ft th ig h an d thr e e ab ou t Poup ar t s
,
lig am e n t w h il e on e w a s an iliac ab s ce s s wh ich p oin t e d in th e lu m b ar

,
r e gion O f th e s e fi ve w e r e s i m pl e a b s c e s s e s an d four th e r e s ul t o f
.
Po tt s d i s e a s e All th e ca se s w e r e d oi n g w e ll a s long a s th e y coul d b e

’
.
k e p t un d e r ob s e rva tion e xc e p t on e in wh ich th e s y s te m h ad b e co m e

, ,
th oroug h ly in fe c t e d b e for e th e O p e ra tion a n d wh o d i e d o f a c e r e bral ,
a t t ack cau s e d prob ably by s e p ti c ae m i a —f ou r A m M ed A ss n O c t o . . . .
b er 23 , 1 886 .
III . F ibro o r S p i n d l e c e lle d S a r c o m a t o u s T u m o u r s

- .
By B A Wa t s on M D ( J e r s e y Ci ty N
. .
,
. . O p e ning wi th a g e n e ral
, .
d i s cu s s ion o f th e s e t u m our s giving a d e t ail e d a ccoun t of th e ir m acro

,
s copic an d m i cro s copic app e ar anc e th e wr i t e r no t e s th e gr e a t i m p or

,
t an c e o f t h e d i ffe r e n t i al d i agno s i s o f s arco m a an d c a rcino m a o f th e
br e a s t wh ich h e t ab ula t e s a s follow s

,
F I BR O S AR C O MA -
. C A R C I N O MA .
Co m ly d v l p s s low l y I Co m m ly d v l p s v pid y l
'
1 m on e e o v er
y , on e e o e ry ra
e s p ec i ally a t fi s t; r m ay r e m a i n s t a ti o n an d m ay t e rm i n a e t f t ll y w i t h i
a a n a ye ar .
ary fo r ye ar s .
2 R o u g , lo h b ula te d or lum p y; lu m p 2 hl
S li g t y r o u g h e n e d; no
g e lo u e s l ar b l
m ay be as larg e as a h en s
’
e gg ; tum o u r tu m o ur u u a s l l y s m ll a a n d fl a t t e n e d on th e
fi n ll y
a a tt a i n i n
g g re a t i s ze an d b e com i ng c h st
e .
p e d un c u a t e d l .
3 S in in k v lv o e d aft e r a lo n g i n t e rva l; 3 k b
S in e co m e s qu i c k ly a tt a c h ed to t h e
m c rb i d g r o h s th i t g wh t ap p ro a c e e n e u m or b id g w h ro t , is r e tr a c t e d , d ra w n i n, t h us
m en t whi h i
, g d ll y t h i
c d by s ra ua nn e as v
gi i ng ri s e t o th e a pp e aran c e of a qu i lt d e
an a b s ss d l s f q t ly m k d
ce , an a o re ue n ar e co v e r; l ar
g e v e in s not s een, b ut i n th i e r
wi t hl a rg e v e in s . s te a d th e r e m ay be o bs v er ed w h it l i e ne s ,
s o m e ti m e s ca ll ed l ym p h a ti c v s
a ri c e .
4 Nip p l e do e s n o t r e tr a c t a n d is not 4 N i p p le re tr a c t s an d i ts end s e em s to

o ft e n c h an
ged i n a
pp e aran c e . be a bs b or ed .
5 Ul c e ra ti o n o c c ur s
a ft e r th e l psa e 5 U l c e ra t i o n o c c ur s at an e ar ly d a te ;
of a lo n g p e r i o d ; in gi sk v e s w ay, o wi ng s ki n i s i n v ade d b y th e m or b i d g w th ro and
to ss
p r e u r e o n i t s i n te r n a l s urfa c e b y th e d e s t ye d ; ro b o rd e r is h k
t ic en ed, h ar d e n e d
lum p s , whi h b l c e on g to th e m or bid an d a d h e r e n t t o th e t u m o u r .
gro w th , b u t th e ”
l
u c e ra t e d b ord e r of th e
i n t e g um e nt i s t i n , lo o h se an d n o t a dh e r
en t t o th e t um o u r.
6 Co n s i s te n c e of th e tu m o ur v a ri e s 6 Co n sis t e n c e of th e tu m o ur n e v e r va
s t g e s o f th e di s s e ; f
i n th e d i ffe r e n t a ea i r st ri e s i n th e di ff e r e n t s tag e s . G e n e ra y fi rm ll _
h ard l t e s ft s p o ts m y b e fo u n d an d
, a r o a ,
e ve n li q u i d p a t s f o m th e cys t s w i t h i n i t
r r .
7 Th e m m m ry g l n d e m i n s d i sa a a r a 7 h s m b i d g w th f
T i or ro ro m th e fi rs
ti n c t fro m th e tu m u ; c o n s e q u e n t l y i t i s o r fu s s w i th th m m m y g l
e e a ar an d an d so on
n o t d s t o ye d b ut s i m p l y fl att e n e d an d
e r , s
d e troy i t s .
a tro
p i ed h .
8 S arc o m a doe s n ot b e com e adh e r 8 C arc i n o m a ad h e re s qu i c k ly to th e
e nt to th e d e e p s e at e d
p ar t s . deep s e a te d p a rt s esp
, e ci a ll y th e p e c t o ra
li s m u s cle .
9 D oe s not in v lvo e th e l ym p h a ti c 9 In v lv o e s th e lym p h a ti c s ys te m i n th e

sy s te m i n th e e ar ly s t a
g e of th e di se sea , e arly s t g a e of th e s se
di e a , whi h i lw c s a ays
a n d r ar e ly v e en i n th e l at e . s t di ly p
ea ro
gre ss i v e .
IO Th e m or b i d g w th ro r e t urn s i n th e IO Th e m or b i d g w h w i ll s ly
ro t ure an d
m a o ri ty o f c a e
j s s , c om m on ly i n th e s am e S
p e e di ly r e t u rn ; u u a s ll y i n to m e ot h erp art
org an , an d th s e e re a l ps es i n d i c at e a fi o f th e b o dy a n d a fa t a l t e rm i n a t i o n rap id y l
n al ly f t l a a t e rm i n a ti o n of th e d i e a s se . s up e r vene s .
11 T h e g e n e ra l e a t o f th e p ati e n t h lh II T h e g e n e ra ea t i s qui c y i m l h lh kl
o fte n r e m ai n
q u i te s
a ti fa c to ry, e e n s s v p a i re d , th e c a ch e x i a b e co m i n g e ry m ar e d v k
aft e r th e tu m o u r h as b e en re m o v e d s ev i n th e e arly tag e o f th e di e a e s s s .
e ral ti m es .
12 T h e p ro g re ss of th e di s e as e is 12 T h e p ro g r e o f th e d i ss s e as e is at
r ar e ly at t e n d e d w i t h m uc h p ai n . te n d e d w i t e e r e p ai n hs v .
R e fe rring t o th e d i fficul ty of d iagno s i s of th e se t m u our s in g e n e ral

B ON E S , j OI N TS , OR TH OP E D I C .
5 49
he r e m ark s th a t i t can n o t b e b a s e d up on any p ath ogn om oni c s ign b u t ,
by car e fully w e igh ing th e s y m p t o m s as a wh ol e a n d e v e n th i s in m any ,
ca se s d o e s li t tl e m or e th an s upply a s e riou s pr e s u m p t ion T h e prog .
no s i s i s v e ry grav e b e cau s e o f th e s t e a dy progr e s s of th e di s e a s e t owar d

a fat al t e r m i n a tion e i th e r by g e n e ral con t am in a ti on of th e s y st e m or
,
lo cal org anic d i s t urb anc e o f i m p o rt an t vi tal func tion s T h e t r e a t m e n t .
i s n e c e s s arily e n tir e ly s urgical a t th e e arli e s t p o s s ibl e m o m e n t r e m o v ,
in g e v e ry par ti cl e o f t h e t u m o ur n o t l e avin g a s ingl e m orbi d c e ll T h e ,

.
p ap e r conclu d e s wi th a r e p or t o f a ca se o f op e ra tion for s pin d l e c e ll e d -
s arco m a o f th e th i g h t h roug h th e low e r o n e t h ir d o f t h e low e r p or tion

,
-
o f wh ic h th e s ci atic n e rv e p a s s e d groovi ng d e e ply t h e upp e r t w o th ir d s ,

-
o f i t s po s t e rior s ur fac e S o m e t rac tio n was m a d e on th e n e rv e w h il e

.
,
lib e rat in g i t fro m th e t u mo ur i t was s ligh t ly inci s e d a t on e p oin t an d

, ,
was co m pl e t e ly d e t ach e d fro m all s urroun ding t i s s u e s th rough ou t th e
e n tir e le ng th o f t h e t u m our T h e O p e ra t ion wa s d on e un d e r s tric t

.
i
an t i s e p t c pr e cau tion s b ut w a s follow e d by rapi dly e x t e n di n g gangr e n e
,
o f th e li m b i n d uci n g d e a th a fte r th ir ty fo u r h our s

, T h e wr i t e r con -
.
s i d e re d th e gangr e n e a n d va s o m o t or d i s t urb anc e s t o b e d u e t o th e i n

-
v olv e m e n t o f th e n e rv e in th e m orbi d grow th an d i t s r e m oval — j oa r .
Am . M ed A ss n . .
, Oc t . 1 6, 1 886 .
BONE S , JO INTS , O R T H O P AE D I C .
I . B a c kw a r d D i s l o c at i o n i n ge r u p o n th e M e of th e F
t a c a rp u s By E O O T I S M D ( Bo s ton)
. . . H avi n g ob s e rv e d a ca s e
, . . .
’
o f irr e d ucibl e d i s loca tion o f t h e fing e r up on t h e m e t acarpu s t h e wri t e r s ,
att e n tion wa s a t trac t e d t o th e g e n e ral d i s r e gar d o f th e d i fficul ty o f re

d uc in g th e s e luxa tio n s a n d th e p ap e r b a s e d up on e xp e ri m e n t s upon
, ,
th e c a d av e r a n d a s t u dy o f th e ob s e rva t ion s o f Jalagui e r ( A r efi Gen .
de M ed F e b .
, i s t h e r e s ul t
. In b ackwar d di s loca ti on th e fing e r .
,
i s brough t in t o e x t r e m e e x t e n s ion wh i c h pro d uc e s a rup ture at th e ,
w e ak e s t p oin t in th e j oin t i e at th e m e t acarp al a tt achm e n t o f th e

,
. .
,
th ick d e n s e an d fi b r o c ar t ilaginou s a n t e ri o r or gl e noi d liga m e n t o f th e

,
-
m e t aca rp o p h alang e al j oin t ; th e h e a d o f th e m e t acarp al b on e e s c ap e s

-
th rough th e r e n t an d th e p h alanx wi th th e t orn li g am e n t h a nging t o i t

, , ,
as e c n d s th e d or s u m o f th e m e t acarpal b on e at th e s a m e ti m e t he ,
an t e rior fibr e s o f th e la te ral liga m e n t s ar e t orn t h roug h S c h ii lle r s ay s

.
th e s e a re n o t n e c e s s arily rup t ur e d b u t t h e wri t e r s e xp e ri m e n t s woul d

’
,
s e e m t o S h ow th e con t rar T h e d i sloca t ion b e i n g co m p le t e th e an t e

y .
,
rior p ar t o f th e ar ti cular fac e o f th e p h alanx r e s t s upon th e n e ck or

d or s al s ur fa c e o f th e m e t ac arp al b on e ; i t i s h e ld th e r e by th e fl e xor
t e n d on d e vi a t e d wi t hin by th e e x t e n s or t e n d on wh ich r ai s e s th e s kin
“
, , ,
and by th e r e m nan t s o f th e la t e ral liga m e n t s : th e gl e noi d li a m e n t wh i c h

g ,
h as follow e d th e p h ala n x i s in con t ac t wi th th e h e a d an d d o r s al s urfac e

,
o f t h e m e t acarp al b o n e i t s p al m ar s ur fac e h as b e co m e d or s al a n d cor

r e s pon d s t o th e an te rior fac e of th e d i sloca te d p h alan x wi th wh ich i t
for m s an a n gle Op e ni n g b e low ; i t s ar ticular fac e r e s ts upon th e n e ck or
e v e n up o n th e d or s u m o f th e m e t acarpal b o n e S uc h b e i n g th e di s
.
p o s i tion th e gl e noi d liga m en t m u st b e brough t in t o i t s p lac e a n d th i s

, ,
c an o n ly b e d o n e by u s ing th e p h alanx a s a l e v e r a n d p u s h ing b e for e
i t th e liga me n t w h ich follow e d i t in th e ac t o f d i s loca tio n th e t e ch n i qu e

,
b e i n g a s follow s : Carry b ack th e p h ala n x in forc e d e x t e n sion k e e ping ,
i t s b a se clo s e ly app li e d t o th e d or s u m o f th e m e t acarpal b on e th e n ,
S li d e i t s ar ticular s ur fac e u p on t h e d or s u m o f t h e fir m ly fix e d m e t a
—
carp al b on e un til i t r e ach e s th e h e a d o f th e la tte r an d finally fl e x th e

, ,
p h alanx wh e n th e r e d uc tion e n s u e s E xt e n s ion in a fl e x e d or s traigh t

, .
po s i tion al th o u gh i t m ay b e s ucc e ss ful incur s th e d ang e r o f m aking

, ,
th e d i s loca t ion irr e d ucibl e . I f th e m e th o d o f d or s al fl e xi o n fail s th e ,
d i s l o ca t ion i s prob ably wh a t Jalagui e r call s a co m pl e x o n e —th e gle

n o i d li g a m e n t b e ing r e v e r s e d an d in t e rpo s e d b e t w e e n th e t wo ar ticular
s ur fac e s—a con d i t ion rar e ly pri m ary b u t d ue t o t rac t ion m a de upon
,
th e fl e x e d p h alanx In th i s con di tio n th e r e i s a bar e ch anc e th a t th e

'
gl e noi d li gam e n t m ay b e di s e ngag e d an d th e di sloca tion ch ang e d to a

s i m pl e o n e by u s i n g th e m e th o d o f d or s al fl e xi o n t o an e x tr e m e d e gr e e ;
t h e p h alanx m u s t b e carri e d i f p o ssibl e

,
b e yon d an d b e h in d th e t orn
,
m e t ac arpal b or d e r o f th e gl e noi d liga m e n t an d s o e s t abli sh ing th e i m

,
m e d ia te con t ac t b e t w e e n th e ar ticular s ur fac e o f th e p h ala n x an d th e
d or sal fac e o f th e m e t aca rp al bo n e ; th e n th e p h alanx c an b e c a rri e d

forwar d p u s h i n g th e ligam e n t b e for e i t an d finally fl e x e d
, ,
T h i s fail
.
in g d o r s a l s ubcu t a n e ou s s e c t ion o f th e gl e noi d ligam e n t i s th e la s t

,
G YN / E C OL O GI CA L .
5 5 1
r e s or t ; th e only in s tru m e n t r e quir e d i s a s trong te no t o m e wi th a s h or t

bla de an d a ra th e r blun t p oin t T h e lan dm ark s for th e in d e x fi n g e r
.
a r e t h e po s te rior bor d e r o f th e gl e noi d cavi ty o f th e p h ala n x e a s ily fe l t ,
on th e d or s u m o f th e h an d an d th e e x te n s or t e n d on T h e e xac t s i t ua
,
.
t ion o f th e d or s al fac e o f th e m e t acarpal b on e m u s t a l s o b e d e t e r m in e d
in i ts r e la tion t o th e p h alanx to s e e i f th e t wo b on e s ar e in th e s a m e
,
a xi s a s th e y s h oul d b e in or d e r th a t th e m i dd l e o f th e g l e noi d liga m e n t

,
m ay li e upo n t h e m i ddl e o f t he d or s al fac e o f th e m e t ac arpal b on e ; th e
e xac t p o s i tio n an te ro po s t e riorly o f th e p h alanx d o e s n ot m ak e s o

,
-
,
m uc h d i ffe r e nc e b u t t h e t wo b on e s m u s t b e in th e s a m e axi s— p e r h ap s
,
t h e b e s t p o s i t ion of th e p h alanx b e ing th a t o f an ob t u s e or n e arly rig h t
a n gl e wi th th e m e t acarp al b on e In th e th u m b an d wh e n a s e s a m oi d
.
b o n e e xi sts in th e in d e x fing e r i t m u s t b e avoi de d T h e t e no t o m e i s

,
.
t o b e e n t e r e d abou t t wo c e n t i m e t r e s b e h in d th e b a se o f th e p h a lanx
a n d i m m e d ia t e ly o u t s i d e o f th e e x t e n s or t e n d on b e ing k e p t fl a t up on ,
th e d or s u m o f t h e h an d ; th e kni fe i s g li d e d un d e r th e i n t e gu m e n t un t il
th e a r ticular s ur fac e o f th e p h ala n x i s r e ac h e d ; th e n th e h an d l e o f th e
kni fe i s r ai s e d s o a s t o low e r th e p oin t an d b e aring d own h ar d up on ,
t h e d or s u m o f t he m e t a carp al b on e t h e s e c t ion o f th e gl e noi d liga m e n t

,
i s m a d e by wi thd rawi n g th e t e no t o m e ab o u t a c e n ti m e tr e In s o m e .
ca s e s i t i s n o t n e c e s s ary t o inci se th e wh ol e e x t e n t o f th e li ga m e n t a ,
s m all nick up on i t s t orn e d g e s e e m i n g t o b e s u ffici e n t t o allow th e h e a d
o f th e m e t ac arpal b on e t o s lip in t o plac e i f r e d uc t ion do e s n o t i m m e

,
d i a t e ly an d e a s ily follow th e kni fe m ay b e e n t e r e d a gain an d th e op e r

,
a t ion r e p e a t e d s o m e p or t ion o f th e gl e noi d lig a m e n t h aving p e rh ap s

,
e s cap e d inci sion in th e fir s t at t e m p t ; an t i s e p t i c pr e c a u t ion s s h oul d b e
u s e d an d t h e d igi t i m m obiliz e d aft e r th e op e r ation — B os ton M ed a n d

’
. .
S n rg f ou r S e p t 2 1 8 8 6
. .
, .
, .
J AM ES E . PI Lc HER ( U S Arm y)
. . .
I I n t o x i c a t i o n w i t h C o rr o s i v e S u b li m a t e i n C a s e o f L a p
.
a rot om y . By Dr K U E M M E LL ( H am b ur g) T h e n u m e rou s r e por ts

. .
,
wh ich h av e app e ar e d fro m ti m e to ti m e of c a s e s o f i n t oxic ati on occu r

,
ring afte r the us e o f corro s iv e s ubli m ate for di sin fe c t an t p urp o s e s

552 I N DE X OF S UR GI CA L P R O GR E S S .
d uring lar g e r p e ra tio n s h av e h ad th e wh ol e s o m e e ffe ct o f i n

O ,
t ro du c i n g th e e m ploy m e n t o f l e s s conc e n t ra t e d s olu tion s S uch ca s e s .
a r e nowa d ay s rar e ly h e ar d o f W h e n th e y d o occur th e cau s e m ay

.
g e n e rally b e foun d in s p e cial con di tion s pr e s e n t in th e a ffe c t e d in di

vi d ual Au th or h ad a m o n g h i s fir s t 1 7 0 larg e r Op e ra tion s wh e r e a
.
,
conc e n tr a te d s olu tion ( 1 s olu t ion was e m p loy e d b u t o n e ca s e wi th ,
s lig h t s y m p t o m s o f i n t oxic a t ion T h e r e s ul t s in s o m e 9 0 0 O p e ra tion s

.
s inc e t h e n h av e b e e n u n i for m ly s a t i s fac t ory

,
H e h as n e v e r ob se rv e d.
in an y of th e s e sy m p to m s wh ich coul d de no te a t o o l i b e ral e m ploy m e n t

o f th i s d i s in fe c t an t al th oug h m any o f t h e p a ti e n t s w e r e ch il d r e n an d i n
,
d i vi d ua ls wi th gr e a t ly r e d uc e d s tr e ng th Au th or d o e s n o t u s e th e car
.
b oli c s pray T h e s m o o th wall s o f th e op e ra t ing roo m a re th orough ly

.
s crubb e d wi t h s oap an d wa te r th e d ay b e for e th e op e ra tion The Op .
e ra t i n g t abl e i s al s o w e ll s crubb e d an d wa s h e d o ff wi th a 1 s olu tion
o f corro s i ve s ub li m a t e N i c k e l pla t e d in stru m e n t s m a d e e i th e r in on e

.
-
,
p i e c e or h aving nick e l or copp e r pla te d h an d l e s are e m pl o y e d Th e s e-

,
.
ar e h e a t e d t o R in an ov e n fo r o n e a n d a h al f h our s b e for e th e
.
op e ra tion an d ar e plac e d war m in a 5 % s olu tion carb oliz e d wa t e r

, , .
T h e S p o n g e s th o roug h ly cl e an s e d are k e p t in a 1
, s olu t ion o f corro
,
s iv e s ub li m a t e T h e y li e d uring t h e op e ra tion in a warm s olu tion of

.
t h e s ubli m a t e —
5 6 o o o a n d are w e ll pr e s se d o u t b e for e u s ing
, , , .
S ub li m a t e c at gu t i s u s e d for s u t ur e s liga t ur e s e t c T h e ab d o m e n o f
, , .
t h e pa t i e n t i s th o rou gh ly cl e an s e d wi th war m wa t e r s oap an d e th e r , ,
a n d al s o wi t h a 1 s olu t ion o f th e s ubli m a t e a s a r e al s o th e h an d s o f ,
t h e O p e ra t or an d h i s two a s s i s t an t s Un d e r th e s e an ti s e p tic p re c au
.
t io n s t h e au th or h a s ob t ain e d th e m o s t gra ti fyi n g r e s ul t s in s o m e nin e
t e e n ca s e s o f lapar ot o m y u n t il th e t wo following ca se s o f in t o xic ation

,
occurr e d a s h or t ti m e s inc e
,
Ca s e I Pa ti e n t ae t 3 0 Hig h ly an ae m i c con d i t ion M e n s e s r e gu

.
, . . .
lar S e v e ral nor m al c o n fi n e m e n t s F o r t wo y e ar s p a s t pro fu s e m en

.
.
s e s la s t ing fo r long p e rio d s Incr e a s e i n s iz e of ab d o m e n for six

.
m on th s pa s t E x a m ina tion r e v e al s th e pr e s e nc e o f an un e v e n m ova

.
b le t u m our o f th e u te ru s ab ou t t h e s iz e o f a c h il d s h e ad
, Diagno s i s ’
.
,
m yo m a u t e ri O p e ra tio n un d e r ab ov e d e s crib e d a n ti s e p t ic m e a s ur e s
.
A ft e r lap aro tom y h ad b e e n d on e an d an e la s tic liga t ure pa ss e d aroun d

G YN z E C OL O GI C AL .
5 S3
th e n e ck of th e u te ru s th e t u m our was e xci s e d U t e ru s clo s e d wi th

, .
th r e e row s o f s u t ur e s t h e p e ri t on e u m b e ing s e w e d s e para t e ly

,
Op er .
a ti on la s t e d h our s P ul se s t rong an d full 8 0

. D uring th e s a m e , .
d ay an d th e nig h t following vo m i ting s e v e ral t i m e s T h e n e x t d ay .
s ligh t e l e va t ion o f t e m p e r at ur e ; p ul s e 8 0 Ab do m e n r e lax e d an d .
p ainl e ss No vo m i ting S e v e ral s t ool s D uring th e ni g h t an d fol

. . .
lowing d ay s tool s m ix e d wi th bloo d G u m s s o m e wh a t s woll e n no ul .

,
c e ra t i o n s T e m p e ra t ur e on th e th ir d d ay abou t th e s a m e p ul s e 1 0 4
.
, .
Ab d o m e n p ainl e s s Collap s e D e a th e arly on th e m or n ing o f th e

. .
fourt h da y a ft e r O p e ra t ion Au t op s y sh ow e d th a t unio n o f th e woun d s

.
wa s progr e s s i n g w e ll In th e a s c e n d ing colon s e v e ral d e fe c t s in th e

.
m ucou s lini n g wi th s h arply d e fin e d e dg e s B e t w e e n th e s e w e r e .
group s o f e cch y m o s e s O th e rwi s e no thing abnor m al foun d

. .
Ca s e I I Pa ti e n t ae t 2 5 an m m i c in app e aranc e h a s alway s b e e n

.
,
.
, ,
h e al th y . M e n s e s r e gular F our y e ar s ago n o r m al con fi n e m e n t F o r

. .
p a s t s ix m on th s pain s in ab d o m e n d ue t o prolap s e o f p o s t e rior wall o f ,
vagi n a an d di s plac e m e n t o f u te ru s Th e s e d i s app e ar e d on th e in tro .
d uc tion o f a p e s s ary E xa m ina tio n r e v e al e d t h e pr e se nc e o f a t u m our

.
ab ou t th e S iz e o f an orang e e vi de n tly a tt ach e d t o th e righ t o vary F o r , .
p a st s ix w e e k s v e ry rapi d incr e a s e in s iz e o f ab d o m e n M e n s e s con .
t in n e r e gular Larg e s t circu m fe r e nc e o f ab d o m e n 1 0 2 c m

. O p e ra .
t io n . O n O p e ning th e ab d o m e n a lar g e e n cy s t e d a s ci t e s foun d cau s e d ,
by a larg e papillo m a o f th e rig h t ovary E xci s i on o f t u m o ur a n d .
ov ary Le ft ovary b e ing al s o di s e a s e d was e xci s e d Pa ti e n t ralli e d

. , .
w e ll a fte r op e ra t io n S o m e vo m i ting d uri n g th e d a y Pul s e 8 4 s t rong

. .
,
an d full Th e s a m e e v e ning gr e a t collap s e

. P a ti e n t r e s t or e d wi t h .
s ub cu t an e ou s inj e c t ion s o f e t h e r a n d ca m p h or F ollowing m or n ing .
gr e a t w e akn e s s p ul s e 1 6 0 ,
Ab d o m e n r e lax e d an d p ainl e s s N o
. .
vo m i ting B loo dy s t ool s I n fus ion o f

. gra m m e s o f a
. so
lu ti o n o f na t riu m in t o t h e b a s ili c v e in P ul se b e ca m e s trong e r a n d i t s .

,
fr e qu e ncy s an k fro m 1 6 0 t o 1 2 0 T h e n e x t d ay th e th r e a te ning s ym p .
t o m s h a d s ub s i d e d Bloo dy s t ool s for se v e ral d ay s Gu m s s woll e n

. .
an d ulc e r a t e d Co m pl e te r e cov e ry
. .
T h e clinical s y m p t o m s in b o th th e s e ca se s na m e ly t h e m oi s t t ong ue .
,
th e r e lax e d a n d p a in l e ss con d i t io n o f t h e ab d o m e n t h e a b s e nc e o f all ,

5 54 I N D E X OP S UR C I CA L P R O GR E S S .
sym p t o m s o f p e ri t oni ti s th e slig h t fr e qu e ncy o f pul se in th e pr e s e nc e

,
o f bloo dy s t ool s an d fur th e r m or e in th e fir s t ca s e

, th e r e s ul t s o f t h e , ,
au t op sy all p oin t t o in t oxi ca t ion wi th th e s ubli m at e n ot t o s e p s i s

, , .
T h e an wm i c s t a t e o f th e fir s t p a ti e n t wa s un d oub t e d ly t o a gr e a t e x ,
t e n t t h e cau s e o f d e a th a s m all quan t i t y o f th e t oxic di s i n fe c t an t

, ,
b e ing s u ffici e n t t o fa t ally i m p air th e r e d uc e d organi s m Au th or con .
c lu d e s h ow e ve r t h a t s olu t ion s o f t h e s ubli m a t e o f

, , 5 m ay
b e u s e d wi th ou t fe ar in ca s e s wh e r e th e s t r e ng th o f th e pa ti e n t i s n o t
t o o gr e a t ly r e d uc e d In an aem ic in divi d ual s h owe v e r an d in th o se
.
,
s u ffe rin g wi th ki d n e y a ffe c t ion s i t will b e a d vi s abl e t o for e go t h e u s e

,
o f t h i s m e an s o f d i s in fe c t io n e n t ir e l y —D en ls efi M ed Woollen No . . . . .
34 . Aug 2 6 1 8 8 6 .
, .
II . T w o Cas e s C ae s a r e a n S e ct i o n . S u t u re s of C at g u t
P re p a re d i n Ch r o m By Pro f LE O P O L D ( Dr e s
ic Acid R e c o ve r y
. . .
d e n ) Au th or h a s op e ra t e d e l e v e n t i m e s b e for e u s ing m o s tly s t rong s ilv e r

.
,
wir e for th e d e e p a nd th e fi n e s t s ilk for t h e s up e rficial s u t ur e s E x

, .
ri m e n t s wi th ca t gu t pr e p ar e d in J unip e ru s oil ( K o c h e r K s te r an d
p e u ) ,
in ch ro m ic aci d ( Mikulicz ) e n courag e d hi m t o t ry bo th ki n d s for s u

t ur e s in c a s e s o f laparo t o m y a n d pla s t ic O p e ra t ion s T h e r e s ul ts w e r e .
e n t ir e ly s a t i s fac t ory s u t ur e s o f ca t gu t p re p are d i n c h ro m ic aci d h ol d in g

, ,
w e ll for fourt e e n d ay s in ca se s o f ab d o m i n al woun d s In th e two fol

,
.
lowing ca s e s ( h i s XII an d XI I I ) s u tur e s o f th i s la tte r kin d w e r e e m

ploy e d .
M u lt ip a r a Tlzr ee d ea d
'
Ca se I . . efi zld r en . I I ig /z deg r ee of fl ai
i li e p elv i s Conj ug a za Pa t i e n t ,
‘ ‘
zen ed , r a eli . ve r a em . ae t . 24 .
Lab or b e gan J uly 4 P M F ir s t cranial po si tion ( a) F ollo wing

,
. . .
m o rning a t 1 1 o clo ck rup t ur e o f th e wa t e r s H e a d canno t e n te r ;

’
.
,
h e a rt b e a t s r e gular
’
At 4 o clock P M con d i t ion unc h ang e d
. Pain s . .
, .
v e ry s e v e r e Gre at de s ire fo r d e liv e ry O p e ra tion a t 5 o clock P M

.
’
. . .
Living ch il d w e igh ing gr a m m e s N o fe v e r Di s ch arg e d cur e d . .
in th r e e w e e k s th e u t e ru s b e ing e a sily m ovabl e an d w e ll r e d uc e d in

,
s iz e .
C a se I I . P rim ip a r a . D w a rf w i tfi r i ck ety p elvi s m u ck n a r r ow ed
a nd fl a ttened . D i ag on a l j
eon ug a ta em . Pa t i e n t ae t . 28 . Uni
G YN AE C OL O GI CAL .
555
v e r s al s i gn s o f rick e t s . Co m m e nc e m e n t o f lab or J uly 1 6 8 o clock A ,

’
.
M Wa te r s rup t ur e d at
. o clock P M O p e ra tion a t
’
. P
. M . .
Back o f ch il d on righ t s i d e b e h in d C e rvix fu lly di s te n d e d an d a loop

.
,
o f th e cor d lying in vagina Living c h il d w e igh ing

. gra m m e s .
T h e p at i e n t a m i s e rably n ouri sh e d in d ivi d ual h a d a S lig h t h ae m o r

, ,
rh age wi th s o m e w h a t quick e n e d pul s e i t h e d a y followi n g th e O p e ra t io n .
Sh e m a d e h ow e v e r a goo d r e cov e ry wi th ou t fe v e r
, , , I n b o th O p e ra .
t ion s th e m o d e o f proc ed ur e was a s follow s : A fte r lap aro t o m y h ad

b e e n d on e te m p orary s u t ur e s w e r e in tro d uc e d in t o th e ab d o m inal
,
wall s Th e u te ru s wa s th e n drawn o u t an d a rubb e r t ub e pa s s e d

.
ab ou t th e collu m an d fa s t e n e d wi th a cla m p Th e t e m por a ry s u t ur e s

.
w e r e t i e d a t th i s s t ag e th u s clo s i n g th e ab d o m in al cavi ty Inci s io n o f

, .
th e u t e ru s follo we d a n d e x trac t ion o f th e ch i l d A fte r th i s th e rubb e r .
t ub e wa s t ig h t e n e d or co m pr e s s ion wi th th e h an d m a d e on t h e collu m .
T h e u te rin e cavi ty wa s car e fully cl e an s e d o f all m e m bran e s a n d ,
t oil e tt e m a d e wi th carb oliz e d s p o ng e s S u t ur e s o f s t rong ca tgu t p r e

.
p ar e d i n ch ro m ic aci d w e r e n o w in tro d uc e d fo r clo s ing th e u t e rin e

woun d in th e fir s t ca s e ten in th e s e con d ca se t w e lv e b e ing u s e d
, , .
T h i s la tte r proc e d ur e occupi e d in th e fir s t ca s e t e n m i nu te s in t h e

, , ,
s e con d s ix t e e n m inu t e s
,
.
T h e s up e rfi ci al s u t ur e w h ich uni te s th e s e ro s a s h oul d b e an unin

, ,
t e rr up te d o n e Au th or giv e s th e following rul e s for th e p e rfor m anc e

.
o f th i s op e r a t ion 1 Co m pl e te clo s ur e o f th e ab d o m in a l cavi ty b y

.
pr e li m in ary s u t ur e a ft e r th e ut e ru s h as b e e n drawn forwar d 2 C on . .
t rolling o f th e h ae m orr h ag e a fte r inci s ion o f t h e u t e ru s 3 Car e f u l . .
cl e an s ing o f th e u t e rin e cavi ty 4 E xac t u te rin e s u t ur e 5 M a s s ag e

. . . .
o f t h e u t e ru s t o e xci t e con t r a c t ion .
W h e n t he u te ru s i s drawn for war d a s p ong e sh oul d b e plac e d u n

,
d e rn e a th i t r e s ting on th e in te s tin e s
,
Th e n th e t e m por ary s u t ur e s
.
b e ing s u ffi ci e n t) are t i e d T h e inci s ion in t h e u t e ru s s h oul d

( 6 t o 8 .
r e ach fro m th e fun d u s t o th e low e r s e g m e n t an d b e m a d e a s qui ckly ,
as p o s s ibl e .
Ma s s ag e ( accor ding t o C r e d e s m e th o d) i s e s p e ci ally r e co m m e n d e d

’
aft e r loo s e ning th e rubb e r co n s tri c t or Th e c at gu t i s pr e p ar e d in th e

.
following m ann e r : Coar s e ca t gu t l e ft in a 1 0 % s olu ti on o f c arboliz e d

glyc e rin e fo r for ty e igh t h our s i s t h e n allow e d t o r e m ain for fi ve h our s

-
,
in a s olu tion o f c h ro m ic aci d I t s h oul d b e pr e s e rv e d i n ab s o

.
lu te alco h ol D ea ls efi M ed Woollen N o 3 2 Aug 1 2 1 8 8 6

. . . . . . .
, .
C .
J . C O LLE s ( New Y or k) .
II I . T h e P r o g r e s s i v e ly
I n c r e a s i n g M o r t a li t y o f t h e C ae
s are a n O p e rat i o n i n t h e U n i t e d S t a t e s —By R P H A R R I S M . .
, .
D ( Phila d e lp h ia) T h e au th or t ab ula te s th e op e ra tion s for th e la s t

. .
fo ur d e ca d e s a s follow s ,
F ro m 1 8 46 to 1 855 i n clu s iv e
N u m b e r o f O p e ra tion s 2
5 C h il d r e n d e liv e r e d aliv e
, ,
Wo m e n s av e d ,1 2 C hil dr e n d e liv e r e d d e a d .
Wo m e n lo s t 1 3
-
F ro m 1 8 5 6 t o 1 8 6 5 i n clu siv e t e n y e ar s , ,
N u m b e r o f O p e ra ti o n s 2 5 C h il dr e n living
, ,
Wo m e n s av e d 1 2 C h il d r e n d e a d
, ,
Wo m e n lo s t ,
1
3
F ro m 1 8 6 6 t o 1 8 7 5 i n clu s iv e t e n y e ar s , ,
N u m b e r of op e ra tion s 3 6 C h il dr e n livi n g ,
Wo m n s av e d
e 1 0 C h il d r e n d e a d
.
,
Wo m e n lo s t , 26
F ro m 18 7 6 t o 1 8 8 6 inclu s iv e t e n a n d on e h al f y e ar s , ,
Nu m b e r o f op e r a tion s 3 7 C h il d r e n livi n g
, ,
Wo m e n s av e d , 8 C h il d r e n d e a d ,
Wo m e n lo s t , 2
9
l
W h i l e th e au th or s e e m s t o s u gg e s t d e lay i n op e rati ng for vari ou s
'
r e a s on s as th e ch i e f cau s e for th i s m or t ali ty i t woul d app e ar th at th e ,
i n cr e a se i s appar e n t ra th e r th an r e al a n d d u e t o th e fact th at a larg e r

propor tion of fa t al ca s e s h av e b e e n r e por te d r e c e n tly th an for m e rly
ca s e s w h ich fo r m e rly woul d n o t h av e b e e n r e por te d at all —M d N ew s .
,
Oct . 1 6, 1 88 6 .

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Ab d o m in al w all F i bro m a t a o f 3 6 , , 0 . m a tic 1 64 ra c m o u m cu r d b y

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A m put a ti o n a t hi p 1 8 5 o f nti r m a nd , e e ar S c arp a ) C o m p r i o n o f inn o m in a t

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Gun h o t w o und o f ab d o m n La p aro t o y

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