The modern small bullet causes few surface indications as to the amount

of damage done within, as in the thorax. A careful consideration of

the location of the wounds of entrance and exit will indicate the

probability of perforation, especially of the hollow viscera. The

appearance of blood, either in the mouth or from the rectum or urethra,

the recognition of a rapidly accumulating amount of fluid, the presence

of gas in the abdomen, are all significant indications of perforating

injury. Several years ago Senn advised the insufflation of hydrogen gas

into the colon, on the theory that its escape from the intestine into

the abdominal cavity and thence out of one of the abdominal wounds,

where it could be lighted as it passed through a small tube, would

afford a certain and unmistakable test as to perforation of the bowel,

and such is undoubtedly the case. Nevertheless, it is not one which

is always easy or even possible of application, and no time should be

wasted in waiting for a supply of hydrogen for this purpose.

The safest course and the most life-saving one is _exploration_ when

there is any doubt as to the nature of the injury. This means an

operator possessed of good judgment, a suitable environment, rigid

antiseptic precautions, and a small incision to begin with, with

the finger as the best of all probes. The escape of bloody fluid,

bloody urine, or fecal matter will immediately justify a much more

extended incision through which complete orientation may be obtained.

The first incision may be best made as an enlargement of the bullet

wound, but any extensive operation within the abdominal cavity can

be made through a sufficiently long median incision. Only in this

way can the source of hemorrhage be ascertained. Thus the intestines

may be systematically gone over inch by inch. When perforations are

found they may be either dealt with as they appear--each opening being

closed transversely--or the entire intestinal canal may be exposed.

Contused spots will eventually slough, and should be treated as if

they were perforations. Injuries, therefore, of short portions of the

intestines might justify the removal of several inches. Instead of

making multiple resections, it would be better to remove _en masse_ the

involved portion of the bowel, and then make lateral anastomosis or

an end-to-end suture. Perforations of the mesentery as well as tears

in the omentum should be carefully closed. Everything which is not

vitally necessary and which has been injured should be removed. The

posterior surface of the stomach, the lesser cavity of the omentum, the

region of the gall-bladder and pancreas, the kidneys and ureters, and

the bladder should be examined, in order that injury may be detected.

After operations of this kind the abdominal cavity may be flushed with

sterile salt solution; while the question of drainage should be decided

upon the individual merits and indications of each case, as it is safer

to drain the contaminated peritoneal cavity than to rely upon mere

cleansing and drying.

If the _spleen or kidney_ be injured, it is safer to make a primary

removal of them; if they are not removed, posterior drainage should be

made.

In uncertain cases of abdominal wounds the back as well as the abdomen

should be scrubbed in order that if posterior drainage be necessary it

can be made without delay.

The _after-treatment_ of such patients does not differ from that of

non-traumatic cases. Abstention from stomach feeding, the judicious use

of salines, dependence upon hypodermoclysis and rectal nourishment, and

the use of opiates are all matters of importance.

When the _bladder_ has been injured there is usually more or less

injury of some of the other pelvic organs. An empty bladder will

escape more often than one which is full; while the latter will nearly

always leak into the peritoneal cavity or along the bullet track, thus

infecting one or both. The appearance of blood in the urine is one

of the indications of bladder injury, and sometimes the bladder will

fill with blood clot, which will produce the phenomenon of retention.

Such a case may rapidly succumb to infection if relief be not promptly

afforded, and this may come through abdominal section or a combination

of it with exploration through the perineum. Particles of clothing and

bone and even the bullet itself have been removed from the cavity of

the bladder. It is advisable to open the bladder from below and insert

a self-retaining drainage tube, by which, especially when combined with

the method of drainage by siphonage, as described in the chapter on

Surgery of the Bladder, a satisfactory and continuous emptying of the

organ may be maintained.

CHAPTER XXIII.

PREVENTION AND CONTROL OF HEMORRHAGE; SUTURES; KNOTS.

The first requisite after the infliction of a wound is to arrest

and control the hemorrhage. In many operations upon the extremities

precautions are taken to avoid its occurrence, and the so-called

bloodless method of operating, which is effected by the use of an

elastic bandage of pure rubber, is frequently employed and generally

gives satisfactory results. The pure-gum bandage was first introduced

into surgery by Martin, of Massachusetts, and its combined use both as

an elastic bandage and tourniquet was so promoted by Esmarch that it is

generally known as Esmarch’s bandage, and Martin has failed to receive

the credit due him.

The _elastic bandage_ used for this purpose should be about three

inches in width and five or six yards in length, and made of pure

rubber. The operator begins by applying this to the tip of the

extremity which is to be made bloodless. It is wound around the limb

in spiral turns, with sufficient force to press out the blood from

the tissues and to empty the vessels into those of the trunk. It is

continued above the site of the operation, and then the limb is either

constricted with a _tourniquet_ of the old type or with one of the

rubber appliances used for this purpose. A few turns of the rubber

bandage may be passed more tightly about the limb at this point and

secured with forceps. The rest of the bandage is then unwrapped from

the limb, which will be found pale and bloodless. Operation may then

be practised without the loss of more than a few drops of blood. All

divided vessels should be secured before the constriction is removed

and the wound closed.

In septic, tuberculous, and malignant conditions no such pressure

should be made, as harmful elements might be forced into the

circulation. In such cases the elastic tourniquet is applied high up

and no attempt is made to force the blood out of the limb. The limb

should be elevated so that its veins may empty before the bandage is

applied, and a certain amount of blood will thus be saved.

Care should be taken in graduating the tightness of the constricting

band, as well as its narrowness, and in preventing undue pressure upon

nerve trunks. Cases are on record of temporary and even permanent

paralysis, due to too vigorous application of the tourniquet, and

except upon large and stout limbs it is not often necessary to apply

it as tightly as is often done. Moreover even a wide rubber bandage

when stretched taut becomes little better than a rubber cord or rubber

tube and sinks into the tissues. A sterile towel should be folded into

a strip and wound around the limb, and then a tourniquet should be

applied over it so that pressure may be more equably distributed and

danger of paralysis reduced.

Exigencies may require the application of the elastic tourniquet as

high as it can be possibly used, either upon the shoulder or the hip.

This necessity is usually observed in amputations at those joints,

and the special methods required will be more fully dealt with when

speaking of these procedures. (See Chapter LVII.)

The elastic bandage should have been unrolled and sterilized with the

rest of the surgical equipment required, and even when so protected it

would be well to cover the limb with wet sterile towels before applying

the bandage, which is usually done at the last in order to avoid

contamination. When this is not done the final scrubbing should not be

effected until the bandage has been placed, the tourniquet applied, and

the bandage again removed.

[Illustration: FIG. 60

Illustrating forced flexion for control of hemorrhage.]

_The first measure, then, in the treatment of a wound is to prevent

loss of blood._ This may be done in various ways, and the method

should depend upon the circumstances of the case. In emergency cases

it may be accomplished either by direct pressure, by constriction of

the limb above the injury, or in some instances by mere position. If

it be possible to make direct pressure through the medium of some

clean--preferably sterile--dressing or material, this of course

would be desirable. In all civilized armies soldiers are now equipped

with a package of sterile dressing by which an emergency pad for

this purpose can be promptly applied. Railroads and steamers are now

providing emergency outfits. In injury of the arm or leg advantage may

be taken of position, _i. e._, forced flexion, which is maintained by

any measure or material which can be made available for this purpose

(Fig. 60). _Digital compression_ over a main vessel may also serve a

good purpose. Mere elevation of the part, as, for example, the head,

when not otherwise contra-indicated, or a hand or foot, will do much

to check venous or arterial flow. Moreover, in these positions reflex

contraction of arteries occurs, even in those of the head when the arms

are elevated. For this reason in cases of serious nose-bleed it is

often advisable to keep the arms raised high above the head.

Of other means resorted to may be mentioned:

1. =Extremes of Heat and Cold.=--Water at a temperature of 130° to 160°

F. is a powerful hemostatic. It stimulates contraction of the muscular

coats of the vessels and produces coagulation of the albuminous

portions of the blood upon the surface to which it is applied, and

in this way plugs the capillaries and small arteries and so prevents

oozing. Heat with pressure will be serviceable in many instances.

Cold may be employed by means of ice or iced water and may be made

serviceable in cavities like the mouth, the vagina, or the rectum,

after patients have recovered from the anesthetic and at a time when

hot water could not be borne. Cold has more of a constringing effect

but less coagulating property.

2. =Pressure Directly Applied.=--This may be made with a tampon in

some cavity, or by a graduated absorbent dressing whose effect may be

regulated by pressure of a bandage or an elastic bandage. Care should

be always given that pressure be not too long nor too firmly made, and

it should be released as soon as there appears edema of the part below

or any evidence of insufficient circulation.

3. =Styptics and Chemical Agents.=--There are many substances which

contract vessels and cause more or less coagulation of blood, and

at one time there were many of these in general use, but they have

been supplemented by other products, _i. e._, cocaine, antipyrine,

and adrenalin. The effect of cocaine is temporary, but sometimes is

sufficient in the urethra or the nasal cavity. Antipyrine, in 5 to 10

per cent. solution, alone or with cocaine, has a similar effect, but

is more lasting. Some years ago the writer stated that by mixing 10

per cent. solutions of antipyrine and tannin there was precipitated a

gum-like material of extraordinary tenacity. This will check oozing

from any part to which it may be applied, but it may adhere so tightly

as to make it difficult to later remove the tampon. Of the hemostatic

drugs, adrenalin has the most marvellous properties. It can be procured

in solutions of 1 to 1000. A solution of this strength, somewhat

diluted, may be spread or applied upon an oozing surface with almost

instantaneous effect.

_The use of gelatin in checking hemorrhage_ has given some satisfaction

upon the Continent, but has not found much favor in this country. It

consists of a solution of 2 parts of pure gelatin to 100 parts of

normal salt solution, which should be thoroughly sterilized. It is

injected subcutaneously to increase the coagulability of the blood, and

has also been injected directly into an aneurysmal sac or its immediate

vicinity to induce coagulation. It is likely that if the surgeon have

a patient with the hemorrhagic diathesis the combined use of gelatin

in this way and of calcium chloride internally would give satisfactory

results.

A styptic has recently been introduced by Freund under the name

“_stypticin_.” It is a product of the oxidation of narcotin, one of the

opium alkaloids, and is a yellowish powder of bitter taste. Chemically

it is cotarnin hydrochloride. It has been used especially in the

treatment of uterine hemorrhage, with a certain degree of success,

regardless of the cause of the hemorrhage. It may also be given in

cases of too profuse menstruation. The average dose is 2 to 3 Gr. (0.15

to 0.20) at intervals of two or three hours. When a speedy result is

desired twice the above amount in 10 per cent. solution may be given

subcutaneously.

4. =Destructive Methods= may include the use of the sharp spoon,

chemical caustics, or the actual cautery. The curette is usually

employed for removal of surfaces which have attained a spongy or easily

bleeding condition, as the interior of the uterus, bleeding ulcers

in other cavities, etc. When fungoid tissue is scraped to a base of

healthy tissue there is usually a cessation of further hemorrhage.

Occasionally there are cases of fungating cancer which bleed upon the

slightest touch. The most radical way in which to deal with these for

temporary purposes is to destroy the spongy tissue which bleeds so

frequently. The gross part may be done with the sharp spoon and the

cautery may be made to finish the work. Bleeding piles, when it is not

permissible to treat them more radically, should be touched with the

actual cautery, with stretching of the sphincter. The cautery knife

should not be made too hot, as it may act similar to a sharp blade

instead of merely searing by its heat.

5. =Mechanical Means.=--When vessels of considerable size or masses

of tissue containing them can be made accessible, the best means of

control of hemorrhage are those which can be applied directly to the

vessels. When this is not possible they should be tied _en masse_. A

method formerly in use was acupressure. To effect this a needle was

passed through the overlying skin beneath the vessel and out again, and

around this a suture was tied to make pressure. Since the introduction

of absorbable materials this method has been supplanted by the use of

catgut sutures, which may be tied, cut short, and left to absorb.

Under the term “forcipressure” is included the method of seizing

vessels before, or as they bleed, in small forceps, which are variously

shaped and constructed, and grouped under the name of _hemostats_.

Small vessels seized between the blades of such an instrument will have

their walls so crushed that blood clot is so quickly entangled that the

forceps can be removed in a few moments with little or no danger of

subsequent bleeding. Larger vessels should be ligated.

_Torsion_ is a substitute for ligature, especially with the smaller

vessels, and denotes a twisting of the vessel end after its seizure,

breaking up its inner coat, and effectually sealing its lumen. Some

surgeons rely on torsion for the large vessels.

_Angiotribe_ is the name applied to strong crushing forceps, by which

a pressure of several hundred pounds can be made through a lever

mechanism. In this a mass of tissue, as the broad ligament, can be

secured and such tremendous pressure brought to bear that its vessels

are crushed and destroyed beyond possibility of bleeding. Downes has

improved upon this mechanism by adapting to it an electrocautery

arrangement, by which not only pressure but also heat is brought to

bear. His instrument is called an _electrothermic clamp_. To all of

these instruments there are at least theoretical objections, in that

they are more or less clumsy or unwieldy and require special equipment.

They devitalize a considerable amount of tissue, all of which has

subsequently to be removed either by a process of sloughing or by

active phagocytosis; but they serve perhaps a useful purpose in the

crushing treatment of hemorrhoidal tumors. They have been used only by

a few, and have not found wide acceptance.

6. =Ligatures.=--These are also mechanical means of controlling

hemorrhage, but deserve to be grouped by themselves. Ligation of

vessels may be preliminary or may be performed as needed during an

operation.

By a _preliminary ligature_ is meant taking such precaution as tying

the carotid before operations on the face, the brain, or the femoral

artery before amputation at the hip. There is also the method of

temporary ligation of vessels by the application of a ligature which

should not be drawn too tightly, but simply serve the purpose of gentle

constriction for the half-hour or so during which it may be needed,

after which the vessel is promptly released. If this ligature has not

been too tightly applied the vessel walls will not have been injured

and circulation is restored. Crile has effected the same purpose with

the carotids by a small clamp whose pressure may be regulated by a

thumb-screw.

Ligation of large trunks is made for the purpose of influencing

nutrition by diminishing blood supply, as when the femoral is tied

for elephantiasis of the leg, or the carotid is tied or excised, as

suggested by Dawbarn, to cut off the blood supply from cancer of the

face or neck.

Ligatures are usually made of absorbable material, such as catgut,

chromicized or not, as may be desired, or of silk, which disappears

after a time, but which is not regarded as absorbable. For special

purposes other material has been used at times, such as strips of ox

aorta. The surgeon has his choice of these, whether he intends to

ligate the end of an artery or tie a vessel in its continuity. For

the latter purpose the ligature is threaded into an artery needle, or

a specially devised curved forceps known as the “Cleveland” needle.

When tying the exposed end of a bleeding vessel it is desirable to tie

near the cut end, so as not to leave tissue which should be absorbed,

and for the same reason to not include unnecessary tissue. One of the

forms of knot similar to the “reef” knot, which will not slip, should

be used. Silk has the advantage over catgut in that a knot tied with it

will rarely become loose, whereas catgut knots, unless carefully tied,

will occasionally slip. The ligature knots should be left as short as

is consistent with protection against slipping.

=Fate of Ligatures.=--Silk or celluloid thread are the most

unabsorbable of ligature materials ordinarily used. Even these usually

disappear after the lapse of time. Absorbable ligatures of catgut

disappear after a few days or weeks, according to the method of their

preparation. Absorption is practically a matter of phagocytosis, the

end of the vessel or tissue beyond the ligature disappearing with the

latter by the process of tissue digestion.

When vessels of large size are ligated the blood supply is taken up by

the collateral circulation. On the possibility or practicability of the

latter will depend the success of such operations as ligation of large

trunks for the cure of aneurysm. Should the collateral supply prove

insufficient, gangrene, beginning at the tip of an extremity, is an

assured fact.

The effects of the ligature on the vessel wall will depend upon the

security with which it is tied. The damage done to the inner and middle

coats by a ligature tied for permanent purposes is usually sufficient

to rupture them, after which they roll up inside the outer coat, while

the blood contained in that part of the vessel coagulates, the clot

extending to the first vessels above and below. This quickly organizes,

becomes infiltrated with cells, and brings about the complete

obliteration of that part of the vessel and its transformation into a

fibrous cord. This can only occur, however, when asepsis has prevailed.

Should the ligature prove septic the patient is exposed to two dangers:

that of secondary hemorrhage by ulceration and breaking down of the

clot instead of organization, and the ordinary dangers of septic

infection.

There are circumstances under which it may be well to modify the

ordinary methods of ligation and not to tie knots too tightly--_i.

e._, when the vessels are greatly weakened by extensive disease, or so

stiffened by calcareous degeneration as to cause them to snap under

rough handling. It has been suggested to use pieces of ox aorta to

prevent these accidents.

The dangers of _secondary hemorrhage_ pertain mostly to septic

conditions. In an absolutely aseptic wound, properly cared for,

secondary hemorrhage is almost impossible, but as soon as germ activity

begins lymph barriers are broken down, tissues softened, and weakened

vascular walls may give way.

Secondary hemorrhage may call for ligation of a main trunk not

previously attacked, but in a majority of cases will demand reopening

of the wound and further search for bleeding points. Should the

patient’s condition be materially weakened the effects of position and

of pressure may be tried in suitable cases. But the pressure which may

be effective to check the hemorrhage may be sufficient to completely

shut off circulation from parts beyond, and such pressure should,

therefore, be judiciously practised and its effects carefully watched.

The _signs of secondary hemorrhage_ will vary with the location of its

source. Occurring on or near the surface it will usually stain the

dressing; occurring deeply, as in the pelvic or abdominal cavities, it

will produce prompt symptoms of shock, _i. e._, lowered blood pressure,

whose degree will indicate the extent of the blood loss. In these

cases, unless the patient’s condition contra-indicate the measure, the

wound should be opened under anesthesia, and the source of the bleeding

sought out and mastered. The surgeon should never overlook the fact

that after the gradual restoration of the force of the heart’s action,

as the patient recovers from anesthesia and becomes uncontrollably

restless, vessels may bleed which upon the operating table scarcely

emitted a drop of blood. Experiences of this kind teach the value of

hemostasis during operation, and even of absolute rest induced by an

opiate, immediately after.

There are certain conditions in which the surgeon is led by experience

to anticipate liability to unusual hemorrhage; such as cases of

hemophilia, or anything that savors of it or of scurvy. In patients

who claim to be “bleeders,” the surgeon should be extremely chary and

careful during his operative work. There are, furthermore, certain

toxemias, especially that of cholemia, during which the blood is slow

in coagulation. When the time for preparation is afforded no cholemic

patient should be operated without a few days’ previous preparation by

four or five daily doses of calcium chloride, 20 to 30 grains given in

plenty of water. This is known to greatly increase blood coagulability,

and thereby to measurably protect the patient against the danger of an

oozing of blood difficult to control.

The other measures needful in the treatment of secondary hemorrhage are

those described in Chapter XVIII.

TREATMENT OF WOUNDS.

The general consideration of wounds in the previous chapters

necessarily included many suggestions concerning their treatment. The

first essential in the treatment of open wounds is exact hemostasis;

the next is the removal of dirt and foreign material of all kinds,

_i. e._, visible and invisible. Accidental wounds are practically

never received upon surgically clean surfaces, and it may be always

assumed that the possibility of infection is present. It becomes then a

question to what extent the surgeon should go in removing or avoiding

danger. Obviously all visible foreign material should be carefully

removed and all dirt should be scrupulously washed away. Emergency

treatment of a bleeding injury in a well-regulated hospital is one

thing, and the exigency of a railroad accident or casualty away from

civilization is quite another. The canons of antisepsis and asepsis

have been elsewhere sufficiently well laid down to indicate what should

be done at the time when it can be done.

The protective vitality of the human tissues permits them to

bear frightful injuries or resist infection in a surprising way.

But occasional escapes from severe accidents by no means justify

carelessness when caution can be taken, and cannot be held as excusing

the surgeon for any neglect in antisepsis.

A _bruise_ or _contusion_ accompanied by a slight abrasion may seem a

trifling injury, and yet by virtue of the injury the resisting powers

of the tissues may be rendered insufficient to protect them from

infection through a break of the surface. No relatively small lesions

of this kind can be safely neglected, but should be cleaned and covered

with an antiseptic compress, either wet with some suitable solution

or smeared with a protective ointment, or used dry with a suitable

antiseptic powder, as, for example, bismuth subiodide. Injuries

followed by considerable swelling should be treated according to the

time which has elapsed since their reception. If, for instance, a

bruise or sprain be seen early and before much swelling has occurred,

ice-cold applications can be made in the hope that, by limiting the

flow of blood, the outpour of fluids may be prevented. This effort

should be seconded by position, and perhaps by gentle pressure.

Conversely when a case is seen late, after the tissues have become

waterlogged with fluids, heat should be applied in order that by

stimulating the circulation reabsorption may more speedily take place.

In this case, also, suitable pressure may be of service.

When there is actual _hematoma_, and the exuded fluid fails to

disappear, an incision properly made and in the right place may

permit the clot to be turned out, and then speedy recovery secured by

coaptation with sutures and pressure.

_Poultices_ are nauseous applications to make to the human body. By

their indiscriminate use much harm has been done and suppuration

encouraged or brought about, which but for them would not have

occurred. There are occasions when a hot flaxseed poultice may be

of use, but they are very few and far between. With regard to such

remedies as arnica, witch-hazel, etc., the best that can be said of

them is that they may be of some use by virtue of the alcohol which

they contain; they serve the purpose, then, of a diluted alcohol and

nothing else.

There is virtue in the use of a _cold wet pack_, or compress,

especially in the treatment of chronic affections of the joints, and

their value can be perceptibly enhanced by using solutions of sodium,

or preferably ammonium chloride, and the addition of a little alcohol.

Absorbent material wet in such a solution, wrapped around the part,

covered with oiled silk or some impervious material, while the part is

kept at rest, will render valuable service in conditions of this kind.

In regard to the relative worth of heat and cold for relief of pain,

the alleviating effect of heat is more promptly manifested, but that

of cold is more permanent, and especially is this true of chronic

affections of the joints and bones.

In the _treatment of open wounds_, bleeding having been first

controlled, all the surrounding parts, as well as the wound itself,

should be sterilized. In a scalp wound the scalp should be shaved as

well as scrubbed. All particles of visible dirt should be carefully

picked out, and every particle of tissue whose vitality is so

compromised that it apparently cannot live should be excised. The wound

may then be irrigated or washed out with hydrogen peroxide, and not

until all this is done should the operator consider how he may best

close it, as well as whether he needs to provide for drainage. A ragged

line of tearing will leave a jagged and more unsightly scar, especially

on the face; therefore the margins of such a lacerated wound should be

trimmed before coapting them.

The method of closure will depend on the degree of tension necessary

for the purpose. Parts that come together easily may require but slight

suturing, and with fine catgut which will loosen of itself within two

or three days; the intent in such cases always being to assist the

sutures by proper support of the external dressings.

Buried sutures will serve a useful purpose in many instances, and

upon the face or exposed parts of the body a subcutaneous suture of

fine silk or horse-hair may be so applied as to be easily removed by

a single pull and leave but trifling disfigurement. Female patients

will be doubly grateful if the surgeon can leave but a minimum of

unsightly scar. Fasciæ will sometimes retract widely. They should be

brought together by distinct separate catgut sutures. Before closure of

a wound it is important to determine that no such structures as nerves

or tendons have been divided, or, if such injuries have occurred, to

reunite their ends by fine silk or catgut sutures. The writer prefers

silk for most of these purposes, although in a nerve a fine formalin

catgut suture would perhaps be the most ideal.

There are occasions when it seems impossible with the means at hand to

tie or secure in any way a deep bleeding vessel which has already been

seized with a hemostat. In such case the forceps may be left _in situ_

for thirty-six to forty-eight hours. This may be done, for instance,

in the groin, in the axilla, in the depths of the neck, and about the

cranial sinuses. Life may be occasionally saved by this procedure which

would be lost from hemorrhage without it. At other times a firm tampon

of gauze may be forced into the depths of a wound for the same purpose,

and maintained there by position, or by the pressure of secondary

sutures, which serve the same purpose and require removal in two or

three days. These measures refer rather to wounds of veins than of

arteries.

If one can be absolutely sure of his asepsis, he may close even an

extensive wound with little or no provision for _drainage_; but unless

he is certain regarding it he should provide at least for escape

of fluid by omitting a suture occasionally, or by drainage with a

tube or a cigarette drain. In compound fractures not only must such

provision be made, but the treatment of the wound may also include the

introduction of wire sutures through bone ends or the use of other

mechanical expedients.

The further and equally important treatment of wounds consists largely

in maintaining physiological rest of the injured part, as well as

the general welfare of the patient. _Pain_ which becomes unendurable

causes the patient to lose self-control and to disturb not only the

dressings but apposition of wound surfaces. Pain, therefore, should

be controlled by the mildest expedient that may suffice to master it.

Elimination must be maintained, because the circumstances attending

the injury may act to disturb it. A patient who shows no irregularity

of pulse, temperature, elimination, or general comfort may be assumed

to be doing as well as could be expected, and the dressings need not

perhaps be changed for several days. On the other hand, with rise of

temperature or pulse, increase of restlessness, swelling of the parts,

or discomfort in the vicinity of the wound, the dressings should be

promptly changed. It may be necessary to make such change at the end

of forty-eight hours in order to permit the removal of the drain. The

second dressing may then often remain a week, but any dressing which

becomes saturated, even with blood, may dry and adhere to the skin, and

should be removed.

It would be best to inspect the wound in all cases when the temperature

and pulse are rising or when there is any disturbance in the wound. The

accumulation of blood in an aseptic wound may cause much discomfort,

and by its presence interfere with primary union. Should, therefore,

a wound be found pouting or its edges reddened and swollen it may be

safely assumed that there is something wrong, and as many sutures

should be removed as may be necessary to reveal its condition and

permit of its treatment.

_Wounds which are foul_ or septic when they come under surgical

observation should be treated differently. Here the first attempt

should be at antisepsis. In some cases continuous immersion in warm

water will give the best results. I have never found anything so

prompt, however, in cleaning up a sloughing area as brewers’ yeast.

When this can be obtained it should be used in sufficient abundance to

get the diseased surface thoroughly wet with it. In sloughing cases

moist dressings are usually preferable, and the best are the two above

mentioned. This is true of those cases where part of the wound is

granulating satisfactorily, while part is acting badly. Dressings in

all of these cases require to be frequently changed, that they may be

kept effective.

I have elsewhere called attention to the value of granulated sugar as

an emergency antiseptic material of great value.

SUTURES AND KNOTS.

=Sutures.=--There are many varieties of sutures which have found

favor. Until the surgeon becomes expert by long practice he should

confine himself to few sutures and knots. _Primary_ sutures include

_continuous_, _interrupted_, _plate_ or _modified plate_, _quill_

or _modified quill_, _chain_, and _transfixion_ sutures, and also

certain forms of suture used in intestinal surgery. The above forms are

illustrated in Figs. 61 to 66. Several of them may be used in making

what are known as buried sutures, _i. e._, those which are tied deeply,

whose ends are cut off below the surface and left either permanently or

for later absorption.

The purpose of a suture is to bring the parts into accurate apposition

and so maintain them. It is a mistake to employ a superficial suture

alone, which may leave a “dead space” beneath it. If but one suture

is used, as in closing an abdominal wound, it should pass through the

tissue layers of the abdomen and bring each layer into contact with the

corresponding layer on the other side. Unless this can be done a series

of sutures should be used uniting the tissues layer by layer. If these

be made of formalin or chromic gut they will remain _in situ_ for a

length of time sufficient to serve their purpose. Some prefer silk for

this purpose, but it may work out later; if sterile and freshly boiled

just before using it will rarely cause this trouble. In closing a thick

and fat abdominal wall four or five tiers of buried sutures may be used

and their effect may be reinforced by the addition of a modified plate

or quill suture, as shown in Figs. 63 and 64.

Fine wire is preferred by some operators, and horse-hair by others.

Success pertains rather to the perfection of the method than to the

material used. The primary feature of all wound sutures should be

_prevention of tension_ and protection against it. Further support in

the same direction can be made by the use of adhesive plaster after

fastening the dressing upon the wound, thus taking off strain.

Certain expedients have been resorted to in superficial wounds, some

of which include the affixion of a strip of plaster on either side of

the wound and then the application of the suture material through the

plaster rather than through the skin. Plasters with small hooks have

also been applied, and then a shoelace suture applied over the hooks,

thus lacing the wound margins together. Such measures are convenient

for certain cases, although they make the maintenance of strict asepsis

difficult or impossible. Fine-wire clips have also been introduced,

by which skin margins may be held together for three or four days,

or until they have had time to unite with some firmness, after which

they may be removed. These little implements can be sterilized and

repeatedly used.

[Illustration: FIG. 61

Continuous suture.]

[Illustration: FIG. 62

Interrupted suture.]

[Illustration: FIG. 63

Modified plate suture, using gauze instead.]

[Illustration: FIG. 64

Modified quill suture, using gauze.] ] [Illustration: FIG. 65

Billroth’s chain-stitch.]

[Illustration: FIG. 66

Transfixion suture.]

[Illustration: FIG. 67

Reef knot.]

[Illustration: FIG. 68

Granny knot.]

[Illustration: FIG. 69

FIG. 70

Clove hitch.]

[Illustration: FIG. 71

Staffordshire knot.]

When an absorbable suture will serve the purpose it is desirable to

use it, since the necessity of subsequent removal is thereby avoided.

Inasmuch as every point through which a suture is passed will show

its own minute scar, it is desirable for cosmetic purposes to use a

subcutaneous suture, which may be made of chromic gut, silk, or fine

wire. If of catgut it may be left to disappear spontaneously; but a

silk or wire suture should be left with ends protruding from the wound

so that after a few days it may be withdrawn by steady traction in the

proper direction.

Secondary sutures are those which are placed at the time of the

operation, but either not drawn so as to unite the wound edges, or are

tied with a bow-knot, so that they may be untied and utilized later.

They are useful when either hemorrhage or suppuration is anticipated,

and when it is compulsory to pack a cavity with gauze.

_Every suture which has failed of its purpose or ceased to be effective

should be removed._ Ordinarily they are left in place from four to ten

days. They should be removed by dividing upon one side of the knot,

which should be seized with forceps and pulled upward and to the other

side. The suture should be cut at a point where it is moist, so that

only its flexible portion may be drawn through the parts which it

has held. Moreover the buried portion is more likely to be sterile.

Secondary sutures are usually made of silkworm-gut, celluloid thread,

or wire. So soon as they are found unserviceable they also should be

removed.

=Knots.=--The purpose of a knot is not achieved if it slips, and the

“surgeon’s knot” is best for the purpose, since in the first formation

one end is carried twice around the other before being tied in the

opposite direction. It requires more force in making it taut, but it is

safer than the ordinary reef knot (Fig. 67).

Figs. 69 and 70 illustrate the clove-hitch, which becomes firmer

the tighter it is pulled. It is rarely used in ordinary sutures or

ligatures, but may be made exceedingly valuable. The Staffordshire knot

(Fig. 71) serves especially for securing pedicles, which are first

transfixed with a double thread, the loop thus formed being slipped

over the stump and secured between the two loose ends of the ligature,

one end being placed over and the other under it; each is pulled

tightly and secured by an ordinary knot. When properly applied it is

effective. When knots are improperly applied none of them should be

trusted.

When wire sutures are used it is sufficient to twist the ends, unless

very fine wire is used, when it may be tied.

CHAPTER XXIV.

ASEPSIS AND ANTISEPSIS; TREATMENT OF WOUNDS.

The medical student of the present generation has no conception of

the contrast between the results of today and those of a generation

ago, or before the introduction of antiseptic technique and its later

perfection, asepsis. Under the term “_antiseptic_” should be included

those measures intended to combat sepsis, or surgical infection, from

without. The term _asepsis_ is of later date, and was introduced when

it was found that the prevention of infection was better than measures

calculated to overcome it, or atone for its presence. A perusal of

former surgical horrors will afford but an insufficient comparison as

to the incalculable benefits for which we are indebted to a small group

of men, of whom Lister is the most important; although the names of

Pasteur and of Ogston should ever be held memorable in this connection.

The two great nineteenth century achievements in surgery were

anesthesia and antisepsis, both of Anglo-Saxon origin, one American,

the other British.

It was the recognition of the parasitic, _i. e._, the germ nature of

surgical infections, which led to Lister’s first attempts to exclude

and combat the infecting agents. And while the original technique

which he introduced has been changed in nearly every particular,

the correctness of the views upon which it was based has been ever

broadened and strengthened. We have learned that simple measures may

be as effective as those more complicated, and the principal changes

which have been made in three decades have tended toward simplicity

and prevention. Thus heat has been made to take the place formerly

occupied by carbolic acid. And we have learned that parts made clean

need little antiseptic protection. We have learned that healthy tissues

are endowed with large powers of self-protection, and also that this

self-protection is interfered with by causes over which the surgeon

has sometimes but little control. _A wound in a body loaded with toxic

products is by no means protected against infectious agents by mere

external agencies._ The appearance of pus in a wound is a reflection

upon the surgeon. The ideal aseptic technique will include many days of

local and constitutional protection, as has been stated in the sections

on Auto-intoxication and on the Preparation of the Patient.

The methods of either antiseptic or aseptic technique include as a

fundamental basis the necessity for perfect sterilization of everything

which may come in contact with the wound, so far as the surgeon can

control it. The atmosphere contains in suspension bacteria, but their

contact is no longer dreaded, because of reliance upon the germicidal

powers of the fluids and tissues of the body. It is known, however,

that in accumulation of fluids there is danger as well to the tissues,

either from rude handling, application of large pressure forceps, the

insertion of too many stitches, or whatever else may lacerate or impair

the circulation.

There are parts of the body where no precautions can afford complete

freedom from germ activity, as in the mouth, the vagina, the rectum.

Here the surgeon must be cleanly in his work, assuring himself that

he introduces nothing new from without. Furthermore, after operation

upon these parts he must ensure his precautions by the use of

mouth-washes, douches, etc. On the other hand, ample opportunity should

be afforded for sterilization of the field of operation, of the hands

of the operator and his assistants, the instruments, ligatures, and

dressings--everything which may come in contact with the raw surface.

_Heat_, moist or dry, is the simplest of all sterilizing methods. It

is used in dry and in moist form. The most resistant spores are those

of anthrax, which is supposed to be a laboratory germ, one not seen in

practice. Most of the imported catgut is made from the intestines of

sheep, and sheep die frequently (on the Continent) of anthrax; it will

thus be seen that the danger of an anthrax infection is not so remote

as might first appear, and that no precautions are sufficient which

do not include a degree of heat and length of exposure sufficient

to kill these germs. In the operating-room, as in the laboratory,

has been introduced the method of “fractional,” _i. e._, _repeated

sterilization_. Most of the materials thus exposed may be left in

superheated steam under pressure from thirty to sixty minutes. They

are then exposed once or twice more to the same heat at intervals of

twenty-four hours. In order to make heat thoroughly useful its effects

should permeate everything which it is expected to so sterilize; hence

the addition of steam _under pressure_, especially when dressings,

towels, etc., are folded. It is well to have a form of sterilizer that

permits steam to be turned off and drying to be accomplished slowly by

the aid of dry heat.

Next to steam thus utilized is _boiling water_, in which nearly

everything can be sterilized. Silk sutures and silkworm-gut may also

be sterilized in this way; animal suture does not permit of it unless

previously hardened. The effectiveness of boiling water is increased by

adding to it 1 per cent. of sodium bicarbonate, by which its boiling

point is raised.

Dry heat is employed in an oven, or its equivalent, preferably in some

apparatus by which temperature can not only be measured but maintained.

In such a mechanism it is well to have the temperature raised to 300°

F. for at least half an hour, and then let its contents cool slowly.

Another method of sterilization is by using _volatile_ or easily

volatilized _chemicals_, such as formalin in its fluid form, or its

equivalent called paraform, which comes in crystals or may be had in

tablets ready for use. Formalin is a powerful bactericidal agent, and

if used in such form as to be sure of its penetration, good results may

be expected. Some materials and instruments which are injured by steam

or dry heat may be kept in an atmosphere of paraform, or sterilized

by exposure to formalin vapor, being then subsequently protected

against exposure in a sealed package. Catheters which have been boiled

or cleansed can be thus exposed, as Hutchings has shown, and can be

regarded as safe for use. They can, moreover, be resterilized in the

same way. Naphthalene has similar properties, but is not quite so

strong. The writer is accustomed to use one or the other of these in

jars or receptacles containing dry dressings, catheters, and rubber

gloves.

If aseptic methods are practised there will be but little use for the

employment of any antiseptic, either in solution or in any other form.

Boiled water and sterile salt solution should be available for all

purposes. It is customary, however, to have a solution of mercuric

chloride on hand, which is colored in order that it may not be mistaken

for any other, in which to rinse the hands, especially after they have

been in alkaline solution.

The first thing to be sterilized should be that part of the body upon

which operation is to be made. In some cases, as about the feet,

the mouth, etc., this preparation should be begun two or three days

beforehand; in other cases twelve to twenty-four hours will suffice.

Preparation should be begun with soap, nail-brush, and razor, the parts

being thoroughly cleansed and shaved. It is then customary with most

operators to keep a moist and antiseptic dressing applied upon surfaces

thus cleansed, which should be protected from drying by a covering of

oiled silk or rubber tissue. Green soap is usually employed, which may

have added to it a small percentage of carbolic acid or lysol. The

mercurial preparations are too irritating to the skin. Carbolic acid

has the reputation of being absorbed rapidly. On tender skins and in

certain parts of the body it is impossible to make such applications,

especially of soap poultices. Under these circumstances repeated

washings and some protection should be practised. Feet upon which

operations are to be made should be soaked repeatedly and scrubbed.

Twenty-four hours previously to operating on the head the scalp should

be shaved--preferably forty-eight hours--and prepared as above. For

operations in the mouth the tooth-brush and antiseptic mouth-washes

should be frequently used. For those in the vagina, douches, etc.,

should be frequently administered.

The preparation of the field of operation includes a final scrubbing,

with a washing of alcohol or alcohol and ether. The hands and external

clothing of the surgeon and his assistants should be sterilized, also

the towels, suture materials, instruments, and dressings.

Lawson Tait was the first to teach the great value of absolute and mere

cleanliness. This applies in large degree to the hands of the chief

operator and of the assistants. With a large amount of scrubbing and

cleansing of the hands it is not possible to put them into a condition

of ideal sterilization. This is perhaps more true of the hands of

some than those of others. A realization of this fact has led to the

introduction of _gloves_, either thin rubber or cheap cotton. The

former may be used repeatedly. The latter are sterilized by repeated

boiling and may then be used again. Rubber gloves may be sterilized

by steam or boiling water, and may be cleansed with soap and water or

one of the stronger antiseptic solutions. The introduction of rubber

gloves has brought great improvement in results. The gloves, however,

constitute an impediment to some of the finer work and the easy

recognition of tissue. Not the least important of the advantages of

rubber gloves is the protection they afford to the surgeon’s hands and

to other patients. Many accidental infections may be saved the operator

if his hands can be kept out of pus, while the use of gloves permits

the operator to pass from a pus case to a clean one without exciting

fear. A snugly fitting glove is best drawn upon the dry hand by the aid

of sterilized talcum. But the hand which it encloses should have been

previously thoroughly sterilized so that it will not be a source of

danger should the glove be pricked or torn. The operator can keep his

hands in more favorable condition by using gloves dry in this way than

by macerating his hands inside of wet ones.

_The question of hand sterilization_ is an important one, whether the

gloves are to be worn by some or all of the operating staff. There

are occasions when it is important to make the hands absolutely clean

because no gloves can be procured. Even the hands encased in gloves

should be thoroughly prepared, as there is no knowing when the glove

may tear and the surgeon’s bare hand come into contact with the

patient’s tissues. Running water is preferable to a basin filled with

it, for while it runs it carries away such material as may be detached

by soap or nail-brush. If it be not possible thus to wash the hands,

then repeated basins of sterilized water should be used, and all the

crockery or metal ware used in the process should be sterilized, so

that the hands will not be contaminated by handling unsterilized

material. Nail cleaners are essential agents, to be vigorously used,

and nail-brushes should be sterilized after each using, and there

should be a separate brush for each operator. The common soaps and even

the officinal green soap are not sterile. The former should be relied

on only for the first cleaning, and the latter should be sterilized

before use. A dirty hand should not be thrust into a receptacle

containing freshly sterilized green soap. The outside coating of dirt

should first be removed by an ordinary soap. Vegetable fiber has been

recommended by many, but it is not as good as ordinary corn-meal, which

should be sterilized before using. It is not as gritty nor as keen as

sand, and yet it is sufficiently rough to serve admirably the purposes

of a curry-comb. A first scrubbing with common soap and a nail-brush,

followed by green soap with corn-meal, and this by a thorough use of

the nail cleaner and a clean nail-brush, will ordinarily serve to put

the hands in a reliable condition. It is the practice of some to add

antiseptics to the soap, _e. g._, lysol and thymol. A number of years

ago I introduced ordinary _mustard flour_ for this purpose, basing

its use upon the fact that the essential oil of mustard is one of the

most potent of the vegetable antiseptics, in addition to its power as

a deodorizer. (Parenthetically it may be said that when unpleasant

odor attaches to the unprotected hands after making a postmortem

examination, or opening an offensive collection of pus, the use of

mustard will quickly remove the taint.) Even mustard is not absolutely

reliable, nor is anything else which can be tolerated by the human

skin. A method much in vogue a few years ago was to wash the hands in a

solution of potassium permanganate, and then to decolorize the skin in

another strong solution of oxalic solution. This method was at one time

regarded as an effective one, but it is severe upon the skin. Another

method in use at present combines commercial chloride of lime with

saleratus; here free chlorine is supposed to be the active agent.

The bacteriological side of this subject has been investigated by

numerous observers, particularly Dr. E. R. McGuire, attached to the

Buffalo Surgical Clinic, who reached the following conclusions:

Absolute sterility of the hands is unattainable, but as toward this

result nothing takes the place of long and vigorous mechanical

scrubbing under aseptic precautions; the use of antiseptics on the skin

is of questionable value and often distinctly harmful; the operator

whose hands perspire freely should wear gloves in every case; the use

of rubber gloves is not ideal, but gives the nearest approach to it.

No material should be used which is so harsh that it will injure or

destroy the epithelial cells either upon the operator’s hands or upon

the patient’s skin.

Solutions of gutta-percha in its different solvents, or of collodion

in acetone, have been suggested as forming a covering for the hands

by quickly drying upon the skin. The merit of these preparations is

questionable, and the length of time required to dissolve the coating

makes them impracticable. They have found little favor among surgeons.

Next to the sterilization of the parts to be operated, and the

hands, may be considered _treatment of septic tissues or fluids_ and

_protection against further infection_. Clean and uninfected tissues

need no other precautions than those already described, _plus_ extra

care in hemostasis, in order that there be no clot left in which germs

may find a nidus, and the careful closure of the wound in such a way

that no cavities or “_dead spaces_” may be left in which blood may

later collect. Surgeons generally agree that the less clean tissues are

handled and the less contact they undergo with foreign materials the

more readily they heal. The ideal fluids with which to cleanse parts

or to wash away blood clot are sterile salt solution and boiled water.

Antiseptic solutions should not be used upon healthy tissue; but when

abscess cavities have been opened and when pus or other infectious

material have come in contact with fresh raw surfaces, every effort

should be made to overcome its effects. It is customary in abdominal

operations to “wall off” the site of a pus focus so that contamination

of adjoining surfaces may be avoided, by placing gauze packing around

it. Other expedients, _e. g._, the use of a rubber dam in any of its

modifications, which will aid in this purpose, should be adopted.

Upon brain surfaces, as upon the ruptured perineum, and in vaginal,

rectal, and numerous other operations, a continuous fine stream of salt

solution may be directed with great benefit.

An _abscess_ of any kind, no matter where located, should be

_thoroughly cleansed_, its cavity disinfected, and easy access made

to the outer wound. The interior of such cavities should be scraped

with a sharp spoon. After curetting, a thorough washing or swabbing,

often with the use of hydrogen dioxide, will often prove serviceable.

Even a treatment of this kind does not afford as complete disinfection

as may be secured by free application of pure carbolic acid or of a

strong solution of zinc chloride (50 per cent.). The effect of this is

not only to more completely sterilize, but to so sear the cauterized

surfaces as to make them incapable of absorption. Excess of the

caustic should be wiped away, or antidoted, in the case of carbolic

acid by further swabbing with alcohol, or in the case of zinc chloride

by merely washing out. Such a surface should heal naturally after

sloughing, yet it is rarely safe to completely close such a cavity. A

light packing of clean gauze, or, as the writer is fond of using it, of

gauze sopped in balsam of Peru, will permit such a cavity to quickly

close by the granulation process without further disturbance. Bone

cavities, especially, are well treated with zinc chloride, it being

difficult to so thoroughly disinfect such a focus that it may be safely

closed without drainage; or they may be filled with bone chips or

paraffin.

Visible tissue which is sure to slough should be removed with scissors

or the sharp spoon, in order to save valuable time. Sometimes the

actual cautery may be used to great advantage, as in chancroidal

buboes, where every particle of raw surface will be infected by the pus

which flows over it, and where it is advisable to cauterize not merely

the suppurative focus, but everything which may come in contact with

its pus.

=Instruments.=--Instruments are now all made of metal, usually

nickel-plated, which will stand at least a certain amount of exposure

to heat. It is not sufficient, however, to sterilize instruments

alone, but basins, irrigator nozzles, and everything else which may be

wanted during the course of an operation should be equally prepared

for it. Inasmuch as hard rubber does not well stand even boiling

water, instruments should be made, so far as possible, of metal or

of glass. Boiling water, or “live” steam, are universally employed

for this purpose; while to the water is often added 1 per cent. of

ordinary washing soda, which enhances its serviceability. Fifteen to

twenty minutes’ actual boiling, or its equivalent, will be sufficient

for ordinary purposes. All instruments, such as knives and scissors,

deteriorate after repeated use in this way and need to be frequently

sharpened. Catheters also may be sterilized by boiling and should be

constantly kept exposed to some volatile antiseptic, such as formalin

(see above). Sterile material should be used upon the inhalers, and the

metal parts of these, as well as mouth-gags, hypodermic syringes, and

the like, should all be boiled.

=Dressings, etc.=--Not only the dressings which are to be employed

after an operation, but the gauze, the cotton, or the sea-sponges

which may be used during the same should have been twice sterilized

either by dry heat or steam, in order to ensure security. No absorbent

material should be packed tightly if it is to be subjected to steam, as

it is not easily penetrated, even under pressure. Moreover, not only

these materials but the sheets, gowns, aprons, towels, splints, and

everything which may come into near approach or actual contact with the

wound should be prepared in the same way. After sterilization all these

materials should be enclosed in germ-proof, sterile wrappers of some

kind or in sterile jars or boxes.

As a postoperative precaution, all materials which can be destroyed

after use in a septic case should be _burned_. If this be not

practicable, they should be soaked for twenty-four hours in a strong

solution of corrosive sublimate, say 1 to 500. At the conclusion of

operation there should be no opportunity left for dissemination of

infection.

=Sponges.=--In place of sponges, gauze or absorbent cotton wrapped

in gauze are now generally in use, prepared as above. There are some

purposes for which sea-sponges are very convenient if they can be made

reliable. Those which are received fresh from the dealer should be

freed from sand by beating in a mortar, placed in a solution of 1 to

500 of potassium permanganate, and then transferred to a solution of

sodium sulphite containing 5 per cent. by volume of pure hydrochloric

acid; in this they remain until they are bleached out, which will take

but a few minutes. They are then thoroughly washed in sterile water and

stored in 5 per cent. carbolic solution.

=Suture Materials, etc.=--Wire, silkworm-gut, horse-hair, and silk or

linen thread may be sterilized, if not rolled too tightly, by twice

boiling for a half-hour, and then being allowed to dry, or preserved

in 5 per cent. carbolic solution or in sterile alcohol. Disappointment

often comes from rolling these materials so tightly upon spools that

sterilization of the deeper layers is not complete. This is true of

catgut as well as of the other animal sutures.

=Catgut.=--_Catgut_, so called, is usually made from the intestine of

the sheep, and must be freed from anthrax germs or spores. It should

be rolled loosely on spools or rods, each layer separated from that

beneath by a piece of gauze. The writer prefers to free it from animal

fat by a preliminary soaking in ether or benzene. After this it may

be sterilized by boiling in alcohol, preferably absolute, which must

be in a container not tightly closed. This is placed in water, raised

gradually to boiling, and should boil for two hours. This process

should be repeated at least once after the expiration of twenty-four

hours. This is the simplest of all procedures and generally proves

reliable. Other methods are those of exposure, for instance, to cumol,

a volatile paraffin oil, in which it is boiled under pressure in a

special apparatus, the temperature being raised considerably above

the boiling point of water (300° F.). When the receptacle is opened

the cumol is drawn off or evaporates and the catgut is left dry and

sterile. It should be either kept dry in a sterile jar or in alcohol.

Some prefer to add to the latter a small amount of oil of juniper,

which has a little hardening effect upon the animal material.

Catgut should be tested repeatedly to be assured of its sterility.

Special methods of preparing catgut are as follows:

=Formalin Gut= is prepared by placing the gut, wound as mentioned, in a

3 per cent. formalin solution for three hours. If the sterility of that

which is used be not assured, then this preparation should be boiled in

water for fifteen minutes. Catgut of large size should be immersed in

a solution stronger than the above. It will probably be sufficient to

give this a final boiling at the time of operation. This is almost as

lasting as chromicized gut.

=Chromicized Gut.=--Gut to be thus prepared should be wound in single

layers on spools and immersed in a solution of potassium bichromate

1.5 to 2.5, carbolic acid and glycerin each 10, and water 1000 parts.

It is allowed to remain in this solution for twenty-four hours, then

dried and boiled in water, or in alcohol under pressure, in which it

is subsequently stored. According to the length of exposure and the

strength of the solution, this gut will resist absorption from ten to

thirty days.

=Iodine Gut= is growing in favor with some surgeons. It is prepared by

immersing catgut in a 10 per cent. solution of iodine, in which it is

kept for a week. After removal it is allowed to dry and is stored dry,

but should be kept protected from exposure.

=Silkworm-gut= may be boiled in a 2 per cent. lysol solution for one

hour, which makes it pliable. Sometimes it is convenient to have it

stained black in order that the sutures may be better distinguished

when removed. In this case it is allowed to stand in a 1 per cent.

silver nitrate solution for from twelve to twenty-four hours. This

gives it an almost black stain, but tends to make it more brittle. It

may be kept in alcohol, or dry in a sterile receptacle.

=Silk.=--Silk should be spooled loosely, boiled in a similar solution

for one-half hour, and again in plain water just before using. It may

be stored dry or in alcohol. It may be also stained black.

=Celluloid Thread.=--This should be washed and scrubbed in green soap

and hot water, after which it is spooled, and then boiled for thirty

minutes. It may be stored dry or in alcohol. This is a linen thread

covered with a film of celluloid.

=Kangaroo and Reindeer Tendons= are prepared essentially as is catgut,

but if boiled in alcohol they must be kept covered with the fluid, as

they tend to disintegrate.

=Drainage Tubes= of rubber should be boiled in soda solution for

fifteen minutes, and may then be stored either in 1 per cent. formalin

solution, or dry in a suitable tube.

=Oiled Silk and Rubber Tissues= are first prepared by washing in 1 to

500 sublimate solution, then dried, and exposed in an air-tight jar to

the vapor of formalin or paraform.

The above are the methods usually in vogue in the writer’s clinic, and

may be relied upon. These materials should be frequently tested by

dropping fragments into culture tubes and watching the result, but only

after taking the precaution to precipitate or neutralize the antiseptic

previously used in their preparation.

=Antiseptic Solutions, Applications, etc.=--In well-regulated clinics

sterile salt solution is always at hand. As has been stated the old

six per mille solution may be improved by adding 1 part of potassium

chloride and 2 parts calcium chloride. For emergency purposes tablets

are now prepared which will permit the rapid preparation of these,

of any desired strength. To this a little corrosive sublimate may be

added without producing decomposition. When sublimate is used alone,

or in other combinations, a little vegetable or mineral acid, such as

tartaric or hydrochloric, should be added, as most of the water used

contains lime.

When a maximum of bactericidal effect is desired with a minimum of

irritation, the _silver salts_, either the lactate or the citrate,

will probably afford the best results. The former may be used as

strong as 1 to 300, the latter 1 to 500. The writer has frequently

used these solutions for washing out the peritoneal cavity, in cases

of tuberculous peritonitis, where they serve their purpose admirably.

For washing out tuberculous joints and many other abscess cavities,

solutions of silver nitrate of 1 to 1000 to 1 to 2000 are most

serviceable; or, for the same purposes, boiled water, to which has been

added sufficient tincture of iodine to give it a mahogany color. In

caring for such cases it is good practice to alternate the solutions,

using them on alternate days.

_Antiseptic powders or applications in dry form_ are useful for many

purposes. At one time iodoform was very popular; it was supposed to act

by virtue of the iodine set free in the presence of decomposing organic

material. It is now seldom used, partly because of its tell-tale odor,

and partly because of the disappointment which its use often brings. It

is, moreover, an active toxic agent of itself, and has many times given

rise to symptoms of intoxication, such as mental depression, delirium,

nausea, and anorexia. Under all these circumstances free iodine can be

detected in the urine.

There are numerous substitutes for iodoform, many of which are

superior to it in antiseptic properties, while most of them are free

from odor and toxic qualities. Two substances, however, are used

extensively--_naphthalene_ and _bismuth subiodide_ or red iodide. The

former has a marked odor and is more or less volatile, which makes it

particularly valuable. The latter is odorless, non-toxic, and of much

greater value as an antiseptic than most of the others, because it will

give off free iodine under favorable circumstances. A good plan is to

use it in the preparation of gauze and dressings, as well as for a

dusting powder upon the skin.

The absolute value of these local applications is questionable, because

a wound will sometimes heal under the protection of a piece of foil or

gutta-percha tissue as well as when dressed in any other way. This is

true only of wounds in part surgically clean.

=Drainage.=--Drainage has been resorted to, more or less

intermittently, since earliest historical times. It is provided for

the _removal of deleterious fluids or of superfluous exudates or

transudates_. _It is a recognition sometimes of a necessity, at other

times a confession of fear_ which may or may not be justified. It is

bad practice to cover a focus of previous gangrene or suppuration

in such a way that the infected cavity is closed to the escape of

accumulating fluid. This may be prevented by the use of a suitable

drain. At times a clean operation may be made, and yet in such loose

tissue, or to such an extent, that it is preferable to provide for the

escape of blood rather than let it occur and force apart surfaces which

should be in close contact. A drainage tube may serve as a vent through

which blood may escape that has oozed after closure of the wound.

After pelvic operations provision should be made for the withdrawal of

accumulating fluid which might serve as a culture medium for germs.

Drainage is therefore necessary in many instances.

It will suffice sometimes to suture loosely a part or the whole of

a wound, so that should tension occur from retention there may be

spontaneous escape. This may be termed _indirect drainage_, and

sometimes has to be made still more complete by leaving out some

sutures, or by placing _secondary sutures_, which are only utilized

some days later, when previously infected surfaces have become healthy

and are granulating, so that they can be brought together.

By _direct drainage_ secretions and fluids are guided toward the

dressings, which should be absorbent or so arranged as to provide

for their accommodation; thus in drainage of the gall-bladder or

of the urinary bladder the tube may be connected with a suitable

receptacle by siphonage. _Capillary drains may be_ made of a few

strands of silkworm-gut, which is non-absorbable, or of catgut, which

is absorbable, and to which, perhaps, no further attention need be

paid. This will answer for conducting away small amounts of fluid

which exude. Gauze, or its equivalent in the shape of some form of

wicking, affords an excellent material for removing fluid by osmosis.

The thinner the fluid the more perfectly it serves this purpose. The

gauze must be changed frequently, as these lesions may become filled

with coagulated material, in which case it would act merely as a plug.

The so-called _cigarette drain_ consists of folds of gauze, or a small

roll of it, surrounded by sterilized oiled silk or gutta-percha tissue,

in which are cut numerous holes. The same purpose may be achieved, but

often not so well, by a piece of rubber tubing split down one side. The

gauze drains by osmosis, and the rubber prevents any adhesion to the

wound margins and any pain in the removal of the drain; while a certain

amount of fluid may escape around and outside the smoother surface.

When the fluids to be removed are more dense--_e. g._, pus--_tubular

drains_ should be provided. These vary in size from that of a

lead-pencil to that of the finger. A tube which is too small becomes

easily plugged. They are perforated with numerous openings for the

ready entrance of fluid save in those cases, like the gall-bladder or

the pelvis, where it is desirable to drain only the depths of a cavity.

These tubes are usually made of rubber, the purer forms of gum being

preferable. For some purposes, especially in the pelvis, tubes of glass

or aluminum are used; these are non-collapsible. They may be emptied

by a capillary drain, or by the frequent use of a small syringe with a

long nozzle, by which they are pumped out at regular intervals. Metal

and glass tubes can be resterilized and used again. All other drainage

material should be burned as soon as removed. There are occasions

when it is well to use a _dressed drain_--_i. e._, a tube surrounded

by absorbent gauze, and this again by rubber tissue or oiled silk. In

many instances it is well to prevent the loss of a drainage tube by

passing through its outer end a safety pin, or by stitching it to the

margin of the skin wound. Tubes have been lost, especially within the

thoracic cavity after operating for empyema, more often than is perhaps

generally known, and for a lack of precaution in this respect.

Tubes of _decalcified chicken bone_ have been used and are occasionally

serviceable. They are made by cleaning the cooked bones of the

fowl, soaking them in 20 per cent. hydrochloric acid solution until

decalcified, trimming the ends, cleaning the interior, and are then

sterilized by boiling in a saturated solution of ammonium sulphate.

They are then washed in sterile water and preserved in alcohol. They

correspond to catgut, and will ordinarily last in the tissues for about

eight days. They may be chromicized, as is catgut, in which case they

endure considerably longer.

CHAPTER XXV.

PREPARATION OF PATIENTS FOR OPERATION AND THEIR AFTER-TREATMENT.

At the risk of some repetition it is proposed to epitomize here a

few directions on a subject of great importance, to which, as well

in theory as in practice, too little attention is often paid. For

present purposes patients may be divided into two classes: those who

have sustained accidents or sudden surgical diseases, where no time is

afforded for preparation; and those who, having chronic conditions,

are subjected to surgical measures which are, however, sometimes made

abrupt by sudden decision. In the former case the surgeon is compelled

to work hastily; for the latter, time for preparation should be

always afforded. Experience teaches that a few days, sometimes even

a few weeks, may be well spent in preparing a patient for a surgical

operation.

In emergency cases, aside from the usual scrubbing and shaving, there

may be several matters to which it is well to give attention. The

stomach should be washed out just before the administration of the

anesthetic, or soon afterward. If there be time the rectum should be

emptied, and the bladder always; too much care cannot be given to these

performances. The degree of shock should be estimated and appropriate

treatment given, according to principles stated in the chapter on Shock.

Foresight will often dictate the _preparation of some part of the body

not directly involved_ in the field of injury; for example, in any

gunshot or stab wound of the abdomen or in a case of acute pancreatitis

the back should be scrubbed and cleansed and the patient laid upon

sterilized material, so that should posterior drainage be required it

may be promptly made without waste of time required for preparation.

In head injuries, if the scalp or cortex of the skull be involved,

the entire head should be shaved. In preparation of patients for

operation upon the mouth, tonsils, or stomach an antiseptic mouth-wash

should be used in order to avoid, so far as possible, contamination

from these germ-laden regions. It Is especially in cases undertaken

for the chronic pathological conditions that time can be afforded for

careful preparation. It may be assumed that every patient suffering

from a chronic surgical malady has been so disabled, in at least some

function, that elimination has been interfered with. The emunctories of

the body comprise essentially the skin, the lungs, the intestines, and

the kidneys. Every one of these should be made to perform its work more

fully.

The skin should be stimulated by _hot-air baths_, for which purpose

patients may be sent daily to the Turkish baths, while others should

take their sweats in cabinets or in bed. If it be possible after the

skin has been made to perspire profusely the patient should be put into

a hot bath and the skin thoroughly scrubbed.

The _lungs_ may be stimulated partly by improving the heart’s action,

partly by certain exercises, and by getting the patient out into the

open. The intestines should be made to perform their work, preferably

by the mildest measures that may prove effective. Mercurials are

agents of great value, as they not only stimulate secretions but are

antiseptic in their effects. Sodium phosphate is useful when something

stronger is not required.

Many patients who are found in this class will have _impaired

digestion_, for which a regulated diet should be supplied; and such

cases may call for _lavage_, as well as for a careful examination of

stomach contents, in order that appropriate aids to digestion may

be given. Most patients suffer from intestinal torpor, especially

of the large intestine, and the daily administration of a high-up

_colon wash_, with the patient in the knee-chest position, will give

gratifying results.

It has been suggested that in all operations upon the upper alimentary

canal it would be of great advantage to feed the patient during the

previous forty-eight hours upon sterilized food.

_A careful study of the urine_ should be made, both quantitative

and qualitative. The gross measurement of the amount excreted in

twenty-four hours is of importance. It is necessary to know what amount

of solids is being daily excreted, as well as the amount of fluid.

_Renal insufficiency is one of the difficulties_ with which the surgeon

has often to deal, and caution should be used when operating upon a

patient suffering from this condition. Extra work is thereby imposed

upon other emunctories. A depraved blood circulation through the brain

will often impair its function and lead to delirium in mild or serious

form. The heart’s action will be impaired and septic infection is made

more possible, in spite of every precaution included in antiseptic

technique. In the chapter on Infection it was stated that certain cases

of surgical sepsis commence as infections from within, due to failure

in unloading the body of its content of disease germs.

_Hyperacidity_ should be also corrected. In order that this may

be properly done, the urine should be tested by a more accurate

method than by litmus paper. The restlessness and consequent wound

disturbances which may ensue after operation may be due to _failure in

the elimination of uric acid_ and the oxalates; alkaline diuretics,

therefore, are an important feature in the preparation of many surgical

patients.

_The blood and circulation_ should not be neglected in these cases.

These patients are frequently anemic. A high degree of anemia is

recognized by methods described in the chapter on the Blood. Much may

be done, even in a short time, to improve the quantity and the quality

of the blood, by attention to nutrition and elimination. By these same

measures the heart’s action will be also greatly strengthened, but much

can be accomplished in this direction by the use of digitalis, cactus,

or other of the heart stimulants, and by the administration, preferably

subcutaneously, of strychnine. This is usually given in too small

doses. Two hypodermic injections of ¹⁄₃₀ Gr. (0.002) a day will have a

pronounced effect. While the heart is thus fortified as against shock

before the ordeal, adrenalin will prove the most effective agent during

it and after it is passed.

_Intestinal fermentation_ or decomposition is a prominent feature of

many of these cases. If it be possible to select a drug which has

antiseptic properties that may be effective in the intestine and in

the kidneys, it will come near to being the ideal in this respect. The

attendant has here to choose from many remedies, and his choice will

depend largely on his personal experience. It is better to use a few

remedies and use them well than to be indiscriminate.

Salol, benzosol, betanaphthol, sodium sulphocarbolate, and the salts

of mercury and arsenic will furnish sufficient compounds from which to

select. When the urine is alkaline, as it often is in certain kidney

and bladder diseases, urotropin may be advantageously combined with one

of the others.

In the way of general preparation of those patients who have to undergo

operations upon the _mouth_, _the nasopharynx_, _the esophagus_,

_trachea or larynx_, _and upper alimentary canal_, they should be sent

to the dentist in order that their teeth may be put in good condition

and accumulations of tartar removed, and then use an antiseptic

mouth-wash, or, when necessary, a nasal spray, in order that there

may be avoidance of infection from the bacteria which abound in these

parts. Patients often have diseased and carious teeth, and, in hospital

patients especially, the mouth is often in a dirty condition. So long

as any wound surface is so situated as to be in danger of contamination

from these sources, this should be minimized as far as possible.

=Prevention of Peritonitis.=--Experiments have been made by Mikulicz

with regard to the value of _nuclein_ in producing an _artificial and

protective leukocytosis_ before abdominal operations, hoping thereby to

accomplish more or less in the way of prevention of peritonitis. The

procedure is based upon the well-known property of nucleinic acid, or

nuclein, to produce a prompt but transitory increase in the number of

leukocytes. To take advantage of this, 3 to 5 Cc. of nuclein solution

is administered beneath the skin, say twelve hours and again six hours

previous to the operation. Should any septic agent be introduced or

liberated during its performance, the leukocytes will be present

in additional numbers to act as phagocytes and exert their active

protective powers.

AFTER-TREATMENT.

The care of patients _after_ operation is a factor in a surgeon’s

success and calls for discrimination and judgment. The fact that the

odor of chloroform or ether persists about the patient and in his

breath for hours after their administration shows to what extent they

have been dissolved and are circulating in the blood. If elimination

have already been attended to, and so far improved as to permit

the emunctories of the body to do work up to their capacity, these

anesthetics may be promptly eliminated. The longer they circulate in

the blood the greater the disturbance to other functions and the more

difficult it is to get normal function equalized.

The things especially to be guarded against, so far as one may prevent

them, are _nausea_, _vomiting_, _extreme restlessness_, _pain_,

_inactivity of the bowels_, _insufficiency of the kidneys_, and the

toxic action of any antiseptics or drugs which may have been used, _e.

g._, iodoform.

_Nausea_ and _vomiting_ after operations are due not so much to mere

reflex activity as to the elimination of the anesthetic by the stomach

and its irritant action. No matter how produced, such vomiting is of

itself most depressing, mentally and physiologically, and is injurious

in a large proportion of cases, and efforts should be made to prevent

it. So long as it was regarded simply as a reflex act drugs were

theoretically sufficient for its treatment, but with the appreciation

of its actual causation it will be seen that the irritating material

should be removed. This may be done with the minimum of discomfort

and the maximum of advantage by means of the stomach tube. Lavage,

therefore, constitutes the most rational and effective treatment in

cases of postoperative vomiting.

That the anesthetic reaches the stomach by way of the circulation and

is excreted by the gastric mucosa has been proved by the studies of

Türck. He showed that the same is also true of morphine. He showed,

moreover, that the stronger anesthetics disturb the metabolism of

the cells and that toxic products are thereby produced which, being

reabsorbed, cause an auto-intoxication reducing vital resistance of

the blood serum and the tissues. Thus during anesthesia there occurs

an atony of the stomach walls with the escape of the anesthetic into

the stomach, which, acting as an irritant, leads to an increased amount

of toxin production. The discoloration of the gastric mucosa and the

capillary hemorrhage which take place, as shown _postmortem_ in cases

where persistent vomiting is a feature, illustrate the disturbing

effect of the stronger anesthetics upon the stomach itself. This

furnishes, then, the reason for _washing out the stomach immediately

after stopping the anesthetic_ and before the patient leaves the

operating table. It cannot be said that by this measure postoperative

vomiting will be abolished, but its frequency will be materially

lessened.

Lavage may also be practised to great advantage not merely immediately

after the operation, but during the ensuing twenty-four hours, or

later should vomiting recur or come on late. On the other hand, where

time has not been afforded in which to suitably prepare a patient

for operation, it is advantageous to wash out the stomach before

administering the anesthetic as well as after. This is recommended as

a general measure, and without special reference to those cases where

operation is directed to the stomach itself or to the intestinal tract,

where it has become an established part of the preparation to carefully

cleanse these viscera.

Several points in the performance of lavage will be of great service

to patient and operator. It should be performed quickly in order to

reduce the length of the discomfort, and the water used should be warm,

at least 110° F. If the throat be previously sprayed with weak cocaine

solution (2 per cent.), or if a cocaine lozenge be dissolved in the

mouth, the tube can be introduced with less gagging and difficulty. The

lubricant should be flavored with wintergreen or some other aromatic.

Where vomiting continues in spite of lavage it is advantageous to give

a full dose of chloral with a little starch-water in the rectum; 2

or 3 Gm. of chloral, with as much sodium bromide, to which, in case

of severe pain, a little opiate may be added, may be profitably used

in cases where the patient is restless and where sleep is fitful

or perhaps impossible. This will be more beneficial than drugs

administered by the mouth. It is seldom rejected, and is very soothing.

_Extreme restlessness_ is undesirable from every point of view. In

some cases when it comes on early it is an evidence of insufficient

oxygenation and may be combated by the administration of oxygen gas. It

frequently accompanies shock and constitutes one of its most disturbing

features. It may be combated by a subcutaneous dose of morphine or

heroine, or chloral in doses of 2 Gm., with as much sodium bromide,

thrown into the rectum with salt solution. The effect may not be as

prompt, but it is often much better. Restlessness is not always a

symptom of pain, but is occasionally an uncontrollable reflex nervous

phenomenon.

_After operations physiological rest of the operated part is necessary_

for the process of prompt repair. After abdominal operations,

especially when restlessness and vomiting are combined, much harm may

be done if the patient cannot keep the parts quiet.

_Pain_ will often accompany restlessness, and frequently accentuate

it, especially when patients have not yet fully returned to

consciousness. It may be relieved by warm or cold applications. In

some cases an ice-bag may be used as soon as the patient is placed in

bed--for example, after breaking up an ankylosis. In mild cases the

use of chloral in the rectum, as above, with an opiate added, may be

sufficient. When pain is severe hypodermics of _morphine_ or _heroine_

should be given. Secretion should not be disturbed by such drugs as

these, yet as between them or permitting patients to suffer intensely,

my opinion is that opium should be given judiciously, providing it

prove sufficient. In extreme cases morphine seems to be the only

medicament upon which complete reliance can be placed. When the opiates

seem to produce nausea the difficulties are heightened. It may be

decided in some cases to push the opiate to the point of narcotism,

preferring to keep the patient in this semistupefied condition for two

or three days and until the series of early dangers have been passed.

Opiates should be given with great discretion lest the opium habit be

encouraged if not formed.

Lately there has come into use a remedy which has little or no

unpleasant after-effects, and upon which a good deal of reliance can be

placed, namely, _aspirin_, which may be given in 1 Gm. doses, repeated

as necessary. If it be combined with phenacetin, in doses of half that

amount, the combination will be more effective than either alone. This

will often prove a serviceable substitute for opiates in any form.

After operation upon the lower bowel, or in any part of the pelvis,

patients may complain of pain, sometimes severe, referred to the

_rectum_. Relief may be obtained by throwing into the rectum, through

a flexible tube, one-half to one pint of warm linseed oil. This will

often take the place of an anodyne or a suppository.

The next question is one of _catharsis_. If the alimentary canal have

been properly emptied, as it should have been before the operation, the

bowels may be allowed to rest for the ensuing forty-eight hours. At

the expiration of that time the lower bowel should be emptied. Whether

this be done with laxatives administered by the mouth or by enema will

depend on the character of the case and the reliability of the stomach.

When vomiting is distressing little can be accomplished from above.

In most cases the first effort is to be made by the administration of

a thorough colon wash, or by the use of an enema, which may perhaps

best consist of ox-gall, glycerin, and a saturated solution of Epsom

salt. If this be thrown up high, and retained a while, it will in all

probability be effective. Should the operation have been one upon the

rectum extra care will be needed for the patient’s comfort, and just

preceding the stool a small amount olive oil should be administered

through a tube. Many patients will complain of gaseous distention or

other discomfort, due apparently to fermentation, and partly perhaps

to the air which they have swallowed during the act of vomiting, or

because of nausea. No matter how produced it will afford relief to get

rid of this gas, and while this may be partly accomplished by an enema,

it will be more thoroughly effected by a mercurial, given by the mouth,

to be followed by a saline laxative. In order that flatus may escape

without effort, a rectal tube may be inserted, which later may be

utilized for the administration of an enema. Save in rare instances it

is a mistake to allow accumulation of fecal matter, as the stercoremia

thus favored may easily lead into a more profound form of poisoning by

its interference with elimination and vital resistance.

Attention should be also given to the _bladder and to the urine_.

_Renal insufficiency_ is one of the great dangers pertaining to the

use of anesthetics. This may be combated by 2 Gr. doses of sparteine

sulphate every three hours (McGuire).

Many patients are unable to void urine after operations, particularly

after those upon the female genitalia, and _the use of a catheter_

is often necessary. This should be used with antiseptic precautions,

both as to the patient, the instrument, and the operator’s hands.

Much of this difficulty can be avoided by injecting 20 Cc. of a 2

per cent. sterilized boroglycerin solution through a catheter in the

evening after the operation. Its action is usually prompt, and in five

to ten minutes the patient spontaneously empties the bladder without

unpleasant after-effects.

After abdominal and pelvic operations the patient should not be allowed

to urinate, but should be systematically catheterized. The bladder

should never be allowed to become distended. The amount and character

of urine passed should be carefully noted. In serious cases the amount

of solids eliminated should be estimated, in order that it may be

kept up to the necessary standard. In fact, efficient and sufficient

elimination is more necessary after the prolonged administration of an

anesthetic than after almost any other event. When sufficient fluid to

keep up the standard cannot be administered by the stomach, it should

be introduced into the rectum or given beneath the skin. Two or three

enemas of salt solution should be administered each day, and in urgent

cases the normal solution should be thrown beneath the skin, and this

should be repeated as often and as long as may be necessary. When the

patient begins to show evidence of what is vaguely described as uremia,

_i. e._, _the toxemia of renal insufficiency_, not only should warm

water be used in these ways, but hot-air bed baths should be given

twice a day if necessary, in order that some of the work of the kidneys

may be assumed by the skin. Hot-air baths stimulate the kidneys as

well, and these measures will prove more effective than most of the

diuretics, although digitalis and pilocarpine by the skin may be of

assistance.

Patients frequently complain of excessive _dryness in the mouth_. This

may be relieved by occasionally dropping beneath the tongue one-half

of an ordinary hypodermic tablet of ¹⁄₁₀ Gr. pilocarpine; also by

mouth-washes which contain a little glycerin, and by keeping the lips

moistened with glycerin. _Excessive sweating_ can sometimes be relieved

by giving a hot-air bed bath or a hot mustard foot bath, as the extra

action of the skin thus induced checks the spontaneous drain.

_Delirium and acute mania_ occasionally supervene after operations. It

should first be made clear that these are not due to any antiseptic

or drug. Iodoform is less frequently used than formerly. Children and

aged people become delirious with less provocation than do those in

middle life. Such delirium is generally an expression of a toxemia,

and, in addition to such other measures as may be necessary, calls for

control and restraint and more active elimination, as in so-called

uremia. In proportion to the degree of mania must be the restraint

prescribed. A restraining sheet or a strait-jacket may be sometimes

needed. When these conditions arise in surgical patients more harm will

come from the violation of the principle of physiological rest than

from the drugs which may be needed to secure it. The milder measures

should be first used, abstaining as far as possible from opiates,

which are probably the least desirable of all, but which may be

occasionally demanded. Chloral, the bromides, cannabis indica, alone or

in combination, may be made to render more valuable service. Hyoscine,

in doses of ¹⁄₁₀₀ to ¹⁄₅₀ Gr. beneath the skin, will often control when

other remedies fail; it may prove invaluable. When delirium tremens

complicates a case it may be treated as suggested in the chapter on

Various Intoxications.

Part V.

SURGICAL AFFECTIONS OF THE TISSUES AND TISSUE SYSTEMS.

CHAPTER XXVI.

CYSTS AND TUMORS.

GENERAL CONSIDERATIONS.

A tumor _is a new formation, not of inflammatory origin, characterized

by more or less histological conformity to the tissue in which it has

originated, and having no physiological function_.

By the above definition it is intended to separate the new-growths

from a distinctive class of neoplasms which are of inflammatory (_i.

e._, of infectious) origin, to which the generic term of _infectious

granulomas_ has been given. (See Part II.)

Exceedingly vague notions have prevailed concerning the _nature_ and

_origin_ of tumors, and, while the clinical observations of writers in

the past will never lose their value, the ideas which have prevailed

concerning their pathology constitute interesting reading in a

historical sense, but are now of small value. Accurate notions scarcely

prevailed until Virchow demonstrated that tumor cells nowise differ

from cell types which are met either in embryonic or in adult tissues.

Tumors, like all other parts of the body, are built up of cells, and

the points concerning which we need most light regard the influences

which determine cell overproduction in these characteristic forms.

Concerning the views that have prevailed, this is scarcely the place

in which to offer an epitome. I shall therefore take up but few of

the explanations which have been offered to account for tumor growth,

and will emphasize that, according to our present light, there is no

explanation sufficient to cover all cases, but that it is now one cause

and now another which may determine this peculiar form of cell activity.

=Irritation and Trauma.=--The effort is often made to explain the

presence of tumors upon the hypothesis or the known fact of some

previous injury. Frequently tumors appear in sites where there have

been previous traumatisms, but this sequence of events by no means

proves a definite relation of cause and effect. On the other hand,

there are forms of irritation which are often followed by tumor

formations. Probably no woman escapes without one or more bumps or

bruises upon the breast, yet they do not produce tumors in more than

a trifling proportion of cases. _Per contra_, upon the lower lip of

inveterate clay-pipe smokers and the scrotum of chimney-sweepers there

develop certain forms of malignant ulcer (epithelioma) which so often

and so significantly follow upon the irritation thus produced that it

is impossible to avoid conviction that one is the cause of the other.

Should events prove the parasitic nature of any of these growths they

will also prove that the irritation causes surface lesions through

which infection easily occurs. In regard to the relative frequency

with which cancer in some form follows trauma we should not forget the

well-known fact that traumatism usually diminishes tissue resistance.

If cancer be an expression of infection, as many (including the writer)

believe, the possible relation between trauma and malignant disease may

be better appreciated.

=Inflammation.=--This refers to inflammation in the sense in which it

has been used in the past, implying a variable condition, sometimes

including and sometimes excluding infection, the term covering a

confused mixture of irritation, hyperemia, and infection. In so far as

it concerns inflammation as considered in the present work it should

not be here included, since inflammation (_i. e._, infection) produces

neoplasms of a class considered in Part II and is distinctly ruled out

from present consideration (_i. e._, the infectious granulomas).

If inflammation in the former sense be more than hyperemia it may be

regarded as predisposing to cell activity, but not necessarily to tumor

formation as distinguished from hypertrophy of a given part or tissue.

If it refer to irritation, this has been acknowledged as a factor

in the etiology of tumors, but as an uncertain one. Cancer of the

gall-bladder or liver, which occasionally results from the irritation

of a gallstone, or the cancer of the breast that follows eczema of the

nipple, may be regarded in this light as additional illustrations if

it is preferred to interpret them in this way. If by inflammation be

meant the infectious granulomas, they have already been considered. As

the term “inflammation” can scarcely mean anything except hyperemia,

irritation, or infection, we seem to have completely ruled it out from

consideration as by itself an active cause leading to tumor formation.

=The Embryonal Hypothesis of Cohnheim.=--This in its ingenuity and in

its applicability is a fascinating explanation, which is undoubtedly

sufficient for at least a certain number of instances. According

to Cohnheim, only one causal factor for tumors exists--_i. e._,

_anomalous embryonic arrangement_. He regards them as _entirely of

embryonal origin_, no matter how late in life they may develop and

appear. Briefly summarizing his views, they are to the effect that

in the early stages of embryonal development there are produced more

cells than are necessary for the construction of a certain part, so

that a number of them remain superfluous. While these may remain very

small, they possess, on account of their embryonal nature, a potent

proliferating power. This superfluous cell material may be distributed

uniformly, in which case it will develop whole system arrangements,

like supernumerary fingers, etc., or it may remain by itself in one

place, and will then develop a tumor. In the latter case the tumor may

appear early or not until late in life, according to the time at which

the cell collection receives the necessary stimulus, or because of

its suppression by resistance of surrounding structures. It may be an

irritation or an injury, such as above alluded to, which shall give it

this stimulus; as, for example, it is reasonable to think that certain

nevi and other congenital conditions which develop later into cancers

do so in accordance with this view. Surgeons generally find little

fault with Cohnheim’s hypothesis, except that as yet they decline to

see in it an explanation for all cases. Nevertheless for dermoid and

teratomatous, and for all heteroblastic tumors, it seems to afford the

only tenable explanation. Thus chondromas of the parotid and of the

testicle are most easily explained in this way, and that cartilaginous

islands occur in the shafts of adult bones is well known.

=Heredity.=--In regard to heredity being a factor in the etiology

of neoplasms there is reason to believe that a favorable tissue

disposition may be inherited, but there is nothing to show that it

permits the actual transmission of the disease.

=Parasitic Theory.=--The _parasitic theory of tumor formation_ has

only within a few years taken definite form and shape, as a result

of evolution from vague suggestions and scattered observations. It

implies that tumors, and they are mainly of the malignant type, are

due to irritation produced by extrinsic agencies, _parasites of some

kind_, which, introduced from without, act as do bacteria in the now

well-known infectious granulomas. While this theory, perhaps, does not

afford an absolutely satisfactory explanation of all the phenomena of

malignancy, it nevertheless comes nearer to it than does any other

hypothesis now before the profession, the arguments in favor of it

being scientific and positive, and those against consisting mainly of

mere negations. Summed up these arguments may be stated as follows:

1. =Comparative Pathology.=--The argument from _comparative pathology_

begins with the lower forms of life. Tumors in trees and plants are

well known to vegetable pathologists and botanists as of frequent

occurrence. They vary in size from the most trifling galls to those

large woody masses known as xylomas, which are essentially tree

cancers, since they tend to the destruction of the tree. These are

known to be invariably due to extrinsic agencies, such as insects,

fungi, etc. As water freezing in the bark of a tree may crack it open

and thus leave opportunity for subsequent infection, so may injuries

upon the body surface make trifling lesions which predispose to

subsequent infection and cancer in man and animals. Exclude parasites

from such traumatic lesions on plants and there will be no xylomas.

[Illustration: PLATE XIV

Adenocarcinoma with Young Parasites. (Parasites blue. Plimmer’s method.)

This plate is introduced to illustrate the _presence_ of parasites,

whose minute and actual character is not yet positively determined, but

whose existence is undeniable.

From Gaylord’s paper in the Third Annual Report of the New York State

Pathological Laboratory of the University of Buffalo.]

[Illustration: PLATE XV

Rapidly Growing Carcinoma of Breast.

The parasites herein demonstrated are still subjects of careful and

minute study. It would therefore seem premature to make detailed

statements concerning their exact nature.

From Gaylord’s paper in the Third Annual Report of the New York State

Pathological Laboratory of the University of Buffalo.]

[Illustration: PLATE XVI

FIG. 1. Parasites, at one time called Russell’s Bodies, at Periphery of

Epithelioma of Tonsil. (Oil immersion.)

FIG. 2. Same in Lymph Node before Epithelial Invasion. (From N. Y.

State Path. Lab. Rep.)

FIG. 3. Papillary Adenocarcinoma of Ovary, showing Intracellular

Ameboid Forms of Parasites. (From N. Y. State Path. Lab. Rep.)]

2. =The Analogy Afforded by the Infectious Granulomas.=--These are

universally conceded to be of parasitic origin, while their clinical

course and behavior in every respect make many of them almost as

malignant as the true cancers become.

3. =Metastasis.=--This is in every other disease considered to be one

of the most significant expressions of infection, yet until recently

few of those who have willingly accorded to metastasis its now common

interpretation in tuberculosis have been willing to give it the

same dignity as a factor in the spread of cancer and an important

explanation of its nature. Why should every other disease characterized

by metastasis be everywhere viewed as parasitic, and cancer, in which

occur some of its most positive expressions, be denied? _Metastasis has

the force and significance of an inoculation experiment performed under

favorable circumstances._

4. =Evidence of Local Infectivity.=--The involvement of a part which

has lain in contact with a cancerous lesion, as about the mouth or the

vulva, and in many other ways and places of which medical literature

is now full, and the instances of cancer following the knife wound,

especially following the track of the trocar used for tapping a case

of cancerous ascites, stamp the disease as having an infectivity which

cannot be explained on any inherent property of its own.

5. =Microscopic Appearances.=--While it is true that but few observers

have been able to agree upon a definite cancer parasite, it is also

true that many of the best observers have seen, described, and figured

bodies that do not belong in the cells of a cancerous growth except

they are there in the roll of active agents, and the appearances which

have been described by Pfeiffer, Plimmer, Gaylord, Calkins, and others

are not to be explained away as mere artefacts, but must be given a

place in our estimation which they would attain of themselves, as

exciting suspicion, were there no other facts corroborating the views

that they are in some way actively connected with the production of the

disease. (See Plates XIV, XV, XVI.)

6. =Inoculation Experiments.=--No feasible plan has been devised for

practising inoculation experiments upon human beings. It is known,

however, that the disease may be transmitted in some cases among

animals of the same species, and the transfer has been made in a few

instances from man to the lower animals. In the Gratwick Laboratory

(Buffalo) the disease has been thus transmitted through hundreds of

mice, and has thus afforded the best means of studying it in its varied

phases, albeit in small animals, ever yet enjoyed. But cancer does

occur in animals and has proved to be capable of inoculation, and,

therefore, has responded to one of the severest tests of the value of

the theory. Moreover the facts cited above (under 4) are essentially

successful auto-inoculation.

7. =Clinical Observations.=--Add to the features already mentioned

above those impressions which come from accurate observation and

correlation of the phenomena attending many cases of cancer, and a

plausibility is thus lent to the parasitic theory which it can never

gain from study in the dead-house or through the microscope. The

resemblance between it and other known infections, the local and

general alterations of tissues and fluids, the chemical changes by

which the cachexia of the disease is brought about--these with other

features all conspire to give the keen observer of cases of cancer an

impression of parasitism or infectiousness which nothing can efface.

Add to these its endemic, sometimes almost epidemic occurrence, its

apparent transmission by contact, and the fact that it is but little

influenced either by nutrition or drugs, and the argument is still

strengthened. As against these arguments little has been advanced save

denials or negations.

In thus upholding the parasitic theory, the writer would not wish to be

understood as claiming either that the parasite has yet been discovered

or its nature positively made out, nor that it is a question of one

organism alone; rather, on the contrary, he feels that it is probably

a question of several agents, probably of protozoan character, perhaps

too small to be recognized with the lenses of today, perhaps belonging

to some as yet unstudied class of organisms, making themselves known,

however, as do the hypothetical parasites of syphilis and scarlatina,

by their effects. To accept the parasitic view is to reconcile many

discrepancies of earlier times and to give an entity to the disease

by which, and until something better be found, we may be more safely

guided in its management.

The parasitic theory lends plausibility to the statement which the

writer wishes to emphasize, that cancer, like many of the other

infectious diseases, is at first a local condition, that it is not

transmitted by inheritance, and that there is a time in the history

of every cancer when, _if_ it could be recognized sufficiently early,

and _if_ it were also accessible and thoroughly removed, _it could be

cured_.

=Nomenclature.=--The nomenclature of tumors has been much confused, and

if some new terms are introduced it is perhaps better than to cling

to some which have prevailed in the past. Various systems have been

followed of naming them according to their supposed nature or their

evident tendency, or according to some purely arbitrary classification;

thus there is the distinction into _homologous_ and _heterologous_

or _heteroplastic_, according as they are similar to or variant

from that tissue in which they seem to originate; or they have been

referred to as _benign_ and _malignant_ according to the disposition

which they evince; and these terms are in sufficiently frequent use

to demand acceptance. The distinction between benign and malignant is

convenient and in some respects accurate, implying little in regard to

histological structure, but much in regard to their effect upon the

individual.

So far as _method of classification_ goes, the _anatomical_ (_i. e._,

the _histological_) has proved far the most satisfactory, and is that

which is now generally adopted. It is the basis for the classification

followed in the ensuing pages. But even here it is impossible to

maintain abrupt or always accurate distinctions, because tumors are

frequently of mixed type, and it is required, if desired to express

their composition by their names, to sometimes combine words in an

awkward fashion.

By common consent that tissue which predominates furnishes the

concluding portion of the compound term, while by prefixing other terms

we endeavor to imply the composite character of the neoplasm.

Thus we have _osteochondroma_, _fibromyoma_, _myofibroma_, etc.,

and it is necessary often to reduplicate terms in order to be

accurate in description. While this complicates phraseology, it

nevertheless furnishes to the reader a reliable clue as to the

general character of such a growth; and if one reads, for instance,

of a _myxochondrosarcoma_, he promptly infers therefrom that thereby

is meant a tumor essentially a sarcoma, in which both myxomatous

degeneration and cartilaginous formation have taken place.

In the same way the prefix _cysto_ is frequently used to imply a

combination of originally solid tumor which had undergone cystic

changes in whole or in part.

The old term _cele_ is frequently used as a suffix, implying neoplastic

changes in an organ, or at least the formation there of a tumor. Thus

we have _bronchocele_, _hydrocele_, and _cystocele_. Again, certain

terms are used in a different sense from that originally intended. Thus

the term _sarcoma_ has a definite significance, whereas originally it

had little meaning and was applied inadequately and indiscriminately.

Old terms also, like _fungus hematodes_, are now used rather in a

descriptive sense, because for any such tumor we can find, on accurate

examination, a proper term taken from descriptive pathology. Therefore

the student of today should read the works of the older writers,

especially concerning neoplasms, with a certain amount of intelligence,

as well as of apology for the inaccuracy and misnomers of the past.

TREATMENT OF TUMORS.

The results of treatment of tumors leave much still to be desired,

particularly when dealing with those of malignant nature. So far as

purely internal treatment is concerned, we have not yet discovered

drugs which with any certainty influence cell growth to the extent of

making them reliable or effective. In the past, and even at present,

numerous remedies have been advocated as having more or less power in

this direction. Of them all it is probable that arsenic in some form

is more efficacious than any other. This is true in the case of the

disease elsewhere spoken of as _malignant lymphoma_, or _Hodgkin’s

disease_, which partakes much of the character of some of the other

neoplasms. But to say that arsenic alone or any other known remedy can

be relied upon at all times is making a bold assertion.

=Operable Tumors.=--The _treatment of operable tumors_ is _essentially

surgical_ (_i. e._, _operative_), although to a large extent results

are based upon the essential character of individual cases. But it

can be stated that to be successful in the removal of any tumor its

complete extirpation is imperative. Even the most benign growths will

return if only partially removed. This is true even of innocent cysts,

which will be often reformed if a portion of the cyst wall be allowed

to remain. Complete extirpation is ordinarily a simple measure when

tumors are _encapsulated_, as are often many of the innocent tumors.

On the other hand, the performance of some of these operations is

made difficult and hazardous by the location of the tumor, as in many

large uterine fibroids, tumors of the thyroid, etc. But when dealing

with malignant tumors the secret of success is to extirpate them,

sacrificing everything which may appear to be involved unless, like a

large bloodvessel or important organ, it be essential to the life of

the part or of the individual. These statements are made when speaking

of tumors in a general way. More specific directions will be given

when dealing with particular forms or in the chapters on Special and

Regional Surgery.

CLASSIFICATION OF TUMORS.

Following custom in large degree, yet being guided by undeniable facts

concerning histological structure, tumors will be classified and

considered as follows:

1. Cysts.

2. Dermoids.

3. Teratomas.

4. Tumors of connective-tissue type.

5. Tumors of nerve elements.

6. Tumors derived from epithelium.

1. =Cysts.=

A cyst may be defined as a _tumor containing one or more cavities

filled with fluid or semifluid contents_. This specifies nothing with

regard to the location nor the character of the cyst wall nor the

nature of the fluid contents. Following Sutton, I divide cysts into

four groups:

_Retention cysts._

_Tubulo cysts._

_Hydroceles, or distention cysts._

_Gland cysts._

=Retention Cysts.=--These imply a previously existing cavity whose

outlet is obstructed and whose contents consequently accumulate, often

to such a degree that the original character of both containing wall

and contained fluid is entirely altered. When this occurs in glands

or gland ducts there is usually complete atrophy of gland tissue,

providing sufficient time have elapsed. Such cysts are due either

to permanent or temporary arrest of flow. In _hydronephrosis_, for

example, there is obstruction of the renal outlet and dilatation of

its pelvis, with partial or complete atrophy of the kidney structure,

until a cyst of enormous size may be present. When a similar condition

obtains in the uterus, as by obstruction of the cervix, perhaps due to

injury done during labor, we have a condition known as _hydrometra_,

seen occasionally in women, often in the lower animals, and

particularly in those having a bicornate uterus, causing a condition

often mistaken for an enormously dilated Fallopian tube. Similarly,

when the common bile-duct is obstructed, which may be due to impacted

gallstones, to inflammatory lesions or tumors, there may be such

backing up of bile in the gall-bladder as to produce the condition

known as _hydrocholecyst_.

Under any of these circumstances pyogenic bacteria may produce

infection which will be more or less promptly followed by suppuration;

and then, instead of _hydronephrosis, ydrometra_, _hydrosalpinx_,

_etc._, we have _pyonephrosis_, _pyometra_, and _pyosalpinx_.

=Tubulo Cysts.=--These are _cystic dilatations of certain functionless

ducts and obsolete canals_ which no longer serve a useful purpose. They

comprise:

1. =Cysts of the Vitello-intestinal Duct.=--Cysts originating from this

functionless duct occupy the umbilical region, sometimes projecting

externally, sometimes internally. They are usually lined with mucous

membrane furnished with villi and columnar epithelium. Such a cyst

may be confounded with an umbilical hernia. These cysts occasionally

open at the umbilicus and discharge irritating material, sometimes

fecal matter. Cystic dilatation of the portion of the duct originally

connected with the ileum is also sometimes seen.

2. =Allantoic Cysts.=--These are connected with the urachus, which

should ordinarily be found as a fibrous cord, but which occasionally

persists in a pervious condition, in whole or in part. At birth it is

often traversed by a narrow canal lined with epithelium continuous with

that of the bladder. The urachus lies outside the peritoneum, and may

be dilated at any point between its two extremities. When the entire

urachus is pervious urine is discharged from the navel.

3. =Cysts Connected with Remains of the Wolffian Body.=--The Wolffian

body, or the mesonephros, is intimately related with the development

of the kidney, the ovary, and the testis. In the two latter locations

glandular elements may be met, persisting in adult life.

In the male the _tubules_ persist as _excretory ducts from the testis_,

but in the _female_ they persist, in a vestigial condition, as the

_parovarium_ and _Gärtner’s ducts_. The ovary proper consists of the

_oöphoron_ and the _paroöphoron_, the former being the egg-bearing

portion, the latter receiving the tubules from the adjoining structure

known as the parovarium. The _paroöphoron_ gives rise to cysts which

burrow deeply between the layers of the broad ligament, make their way

alongside the uterus, and raise the peritoneum. It is a peculiarity of

these cysts that their inner walls often become _papillomatous_, and

may even develop such a crop of warty outgrowths that these make their

way through the cyst wall and protrude into the abdominal cavity, where

they sometimes become detached and are dropped as loose bodies into

the peritoneal sac. The condition is also often accompanied by warty

growths upon the peritoneal surfaces. These need give rise to no alarm,

because they usually disappear spontaneously with removal of the tumor.

_Paroöphoritic cysts_ are to be distinguished from _parovarian cysts_,

which develop from the parovarium, this latter consisting of a number

of tubules situated between the layers of the mesosalpinx, composed of

an outer series known as _Kobelt’s_, an inner set, about a dozen in

number, known as the _vertical_ tubules, with a straight tube, running

at right angles to these through the broad ligament to the vagina,

known as _Gärtner’s_ duct, which is homologous with the vas deferens

in the male. Cystic dilatation of Kobelt’s tubes is often seen, these

cysts being very small and having no clinical importance. Cysts arising

from the vertical tubules are usually transparent until they attain

considerable size, when their walls thicken. Their contained fluid

is not harmful, and after rupture of such cysts internally the fluid

is absorbed. Such cysts may rupture and refill several times. _As

between the paroöphorous_ and _parovarian cysts_ the latter are easily

enucleated, carry the ovary upon one side, and have the Fallopian tube

stretched over them without communication.

The internal sections of _Gärtner’s duct_ are more often involved in

animals than in women, but excellent illustrations of cystic dilatation

of its various portions have been observed, usually in the walls of the

vagina.

Corresponding to the above-mentioned conditions in the female there

are in the male, as the result of changes in the Wolffian body,

two conditions--_encysted hydrocele of the testicle_, and _general

cystic degeneration_ of the same. Like the ovary, the testicle is a

complex organ with remnants of the mesonephros persisting among its

ducts, while only a few of the Wolffian tubules remain. True encysted

hydroceles arise sometimes in the efferent tubes of the testis and

sometimes in Kobelt’s tubes (the same structures which in the female

give rise to parovarian cysts), the two conditions, therefore, being

analogous and homologous. These cysts, though closely associated with

the testis, lie outside its tunica vaginalis. Their contained fluid is

usually clear or of a milky whiteness, due to fat globules. Sometimes

it contains spermatozoa. Another variety is cystic dilatation of one

or more of _Kobelt’s tubules_, which is often described as involving

the _hydatid of Morgagni_.

_General cystic disease of the testis_, known also as adenomatous

degeneration, was formerly referred to as hydatid disease of the same

organ. The multiple cysts appear to originate in the remnant of the

mesonephros still persisting, known as the _paradidymis_. The cavities

are lined with epithelium, and _papillomatous intracystic_ formation

is not uncommon. These tumors have been called by a number of improper

names, such as “cystic sarcoma,” etc.

=Hydroceles.=--The term hydrocele has covered numerous conditions. At

present, when no other locality is designated, hydrocele of the tunica

vaginalis is understood. (The term implies a _collection of watery

fluid in a previously existing serous cavity_.) This is the most common

form.

Possibility of its formation depends upon the prolongation of the

peritoneal cavity which takes place in advance of or along with

the descending testicle, and which in many of the lower animals

remains connected with the general cavity throughout life. In men

only is it expected to close, even before birth. When the portion

which extends along the spermatic cord is not completely obliterated

there is _encysted hydrocele of the cord_, or _funicular hydrocele_,

which is not common. The common form of hydrocele is constituted by

serous effusion into the tunica vaginalis, and occurs usually without

recognizable exciting cause. It will be treated more fully in its

appropriate place.

The corresponding process of peritoneum in the female is known as the

_canal of Nuck_; and, when persistent, this also becomes distended

with fluid and forms a cyst known as _hydrocele of the canal of Nuck_,

occupying the inguinal canal.

In many of the lower animals the ovaries are contained within a serous

sac derived from the peritoneum, which is so connected with the opening

of the Fallopian tubes that when the ova escape from the ovary they

enter these tubes and pass to the uterus without entering the general

peritoneal cavity. This ovarian sac is subject to serous distention,

and constitutes a condition called by Sutton an _ovarian hydrocele_.

An homologous condition occurs sometimes in the human female, by

pathological adhesion, and such cysts may attain large size. They

project from, and are intimately connected with, the posterior layer of

the broad ligament.

=Hydroceles of the Neck.=--Hydroceles of the neck, so called, are

cystic collections of congenital origin found in the cervical region,

due to dilatation of ducts or clefts which should have disappeared at

or before birth. The forms of cyst to which the name “hydrocele of the

neck” are usually limited are recognizable at or soon after birth, and

constitute fluctuating tumors, often extending beneath the clavicle

into the axilla or down upon the thorax. They may occupy the entire

lateral region of the neck, and may be unilateral or bilateral--may be

single or multilocular, and may even intercommunicate.

They originate always beneath the deep fascia. Some of these cysts are

undoubtedly due to dilatation of lymph spaces. This is particularly

true of the multilocular forms. There is noted in many of them a

tendency toward spontaneous recovery, but many again require operative

measures for their eradication. Occasionally their walls are extremely

vascular, even to the degree meriting the term _nevoid_.

Some of these cysts are considered by Sutton to be essentially examples

of the laryngeal saccules which are met with as diverticula from the

laryngeal mucous membrane, which undermine the deep cervical fasciæ of

certain monkeys. These air chambers, which are normal in the monkey,

communicate with the larynx through the thyrohyoid membrane, and

occasionally run down beneath the upper border of the thorax. Many of

the cysts having this resemblance are closely related to the hyoid bone

and to the larynx, and there is much to substantiate the view thus

quoted.

=Glandular Cysts.=--_Ranula_ is an altogether too comprehensive term

which has long been used in surgery, alluding to cysts in the floor

of the mouth, and not indicating minutely their character nor their

exact location. At present this term should either be restricted

in signification or be eliminated. If used, it should be confined

to retention cysts due to obstruction of the _submaxillary_ or

_sublingual_ ducts. Such obstruction is often caused by salivary

calculi impacted in the duct orifices. In other instances it is due

to cohesion of the margins of the outlet. A similar condition in the

parotid duct is known, but is less common. Aside from this, certain

other cysts originate from minute beginnings in and about the floor of

the mouth, being due to dilatation of the mucous glands, particularly

one near the tip of the tongue, sometimes known as _Nuhn’s gland_.

Dermoid cysts in this locality are not uncommon. Formerly cysts of the

floor of the mouth were described as _ranula_.

_Pancreatic cysts_ correspond in large degree to salivary cysts,

the pancreatic duct becoming dilated by retention when its orifice

is obscured; and, indeed, the condition has been referred to as

_pancreatic ranula_. Sometimes the canal is dilated in distinct

portions, so that the condition resembles a string of cysts; at other

times it is the terminal portion which is most enlarged. Such cysts

attain large size and contain mainly mucoid material. Examples have

been reported showing that they have attained a capacity of two gallons.

In the mesentery there sometimes develop cysts which are known as

_chyle cysts_, whose sacs appear to be formed of separate mesenteric

layers, their cavity being occupied by fluid identical with chyle. Such

tumors also sometimes attain great size.