WY M787c 1316 *-X>: Jad ft* ■ ■ • •••X.vxy.'.rr .-■ .-.■yyAy^fA it :>-£>:?xt 'miiiiu\mim SAv '.v".r:< V ii iftiiiiiiiiiiiiiiil WY 161 M787c 1916 54710910R NLI1 D5EfifiTlD 5 NATIONAL LIBRARY OF MEDICINE =H= mi SURGEON GENERAL'S OFFICE LIBRARY. Section No. 113, W.D.S. G.O. m.%lJ:2.2J 3—513 NLM052889105 I I CARE OF PATIENTS UNDERGOING GYNECOLOGIC and ABDOMINAL PROCEDURES BEFORE, DURING, AND AFTER OPERATION / BY E. E. MONTGOMERY, A.M.,M.D.,LL.D.,F.A.C.S. Professor of Gynecology in Jefferson Medical College; Gynecologist to Jefferson and St. Joseph's Hospitals; Consulting Surgeon to the Philadelphia Lying-in Hospital, the Jewish Hospital, the Kensington Hospital for Women, and the American Oncologic Hospital ILLUSTRATED PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1916 ^ A &% ^ C/) O ~—' :«„«•; =5 t-^ ^ *^ 3 u ^ 2 H u C u E T3 C » 03 1> 11 2 3 a u T3 "o JS u U x a M ■2 t i '3 _u 3 U be a o N ^S- rt T3 3 03 a H w v: u bi O O E £ ■2 E •2 0J .2f a. ■*-> >2 .2 ~ is H 3. dus reached, the fingers should hug it closely, and thus secure a line of cleavage which will permit separation, and after- SALPINGECTOMY—SALPINGO-OOPHORECTOMY 69 ward permit the posterior surface of the broad ligament to be followed, setting free the infected tubes and ovaries. By pressing the uterus downward and drawing upward upon the intestines, bands of adhesions may be cut without in- jury to the viscera. Pus, blood, and inflammatory exudate should be kept wiped away as the operation proceeds, so that infection shall not be distributed through the abdomen. Not infrequently openings will be found in the intestine through which drainage has taken place. Even where no such discharge has occurred, careful inspection should be made to see that no softened points exist where perforation wras about to occur. Openings in the intestine should be pared and closed at once. The opening should be raised up, its edges pared or freshened with curved scissors, and then sutured with a round-pointed curved needle threaded with sterile silk, and the intestine folded over this line of suture with a fine chromic catgut suture. Where the ovaries and tubes are broken down with infection, they should be re- moved, but an ovary or part of one should always be retained if possible to maintain the balance of internal secretions. Ragged omentum should be tied and the ends cut off. The intestine must be carefully inspected for injuries and also to ensure separation of the coils, so that subsequent obstruction may not occur. Where the intestine is severely injured, has been the seat of extensive inflammatory thickening, so that its permeability is threatened, it may be wise to resect it. Last year I had a patient in the ward who had some years previously undergone an abdominal operation, and as a 70 CARE OF GYNECOLOGIC PATIENTS result came into the house suffering from obstruction. The abdomen opened disclosed a knuckle of small intestine coiled about a section of the descending colon so that its caliber was completely closed. I was able to separate the intestines so that the canal was no longer obstructed, but the descending colon formed so large a loop, loosely attached, with a meso- colon so long as to permit a volvulus to recur readily, that I decided to remove the redundant portion. It was separated from its mesocolon and about 18 inches of the intestine removed. The procedure was as follows: The amount of intestine was estimated by bringing the surfaces together, showing the amount that could be spared. Intestinal clamps were applied at these points, and after the mesocolon had been tied and severed in sections between the points, the in- testine was divided between forceps, the surrounding sur- faces previously protected with gauze pads. The peritoneum of the cut ends retracting, the muscle and mucous membrane were tied, closing the open end, carbohzed, and after squeez- ing off the superfluous acid the peritoneum was sutured over the end. The ends of the intestine were then overlapped and a lateral anastomosis done. With a fine chromic catgut (No. o) suture the surfaces were united for a distance of 6 cm., then, having pushed their contents back, clamp for- ceps were applied and the surfaces carefully protected with gauze pads, each portion of the intestine opened the length of the suture, and the raw edges of the adjacent portions sutured with a continuous silk suture. This was continued around the remaining edges of the opening, and when the SALPINGECTOMY—SALPINGO-OOPHORECTOMY 71 intestinal communication was complete the catgut suture was resumed, completing the external row of suturing. The clamps were removed and the patency of the communica- tion determined, the cavity carefully examined, and all for- eign bodies removed. The removal of the tube alone is salpingectomy. The removal of tube and ovary is salpingo-oophorectomy. The ligation of the pedicle in the latter operation, where the broad ligament is infected and filled with exudate, may be attended with some difficulty as the broad Hgament is short- ened and held down. Sometimes it is better to incise the peritoneum and draw out the infected tube from its sheath. The assistant must be ready with a hemostat to seize any bleeding vessels. The application of a ligature is difficult and is likely to cut out. The better plan is to suture the surfaces with a continuous suture of catgut which should not be drawn so tight as to cut through. In cases of ex- tensive pelvic infection there is quite frequently extensive oozing and the possibility that collections may form to be- come infected from the surrounding tissue, or from its rela- tion to the coils of intestine, so that it is preferable that vaginal drainage shall be employed. A split rubber drain may be carried through the pelvis into the vagina, and when the pelvic peritoneum is much broken it may be supple- mented by gauze packing, one end of which is carried into the vagina. The gauze thus used keeps the intestines from coming in contact with the injured surfaces until the perito- neum has had opportunity to re-form. It is wise to employ 72 CARE OF GYNECOLOGIC PATIENTS such drainage when the intestine has been injured and sutured, especially where there has been a previous drain- age into the intestine, for the intestinal wall in such instances is not very resisting and may break down. If no vent has been provided, the pelvis is infected by the drainage of fecal matter, which, if nothing worse occurs, will make its exit through the abdominal wound, infecting its full length. Fig. 13.—Salpingostomy. The rule of surgical procedure should be to remove struc- tures which are in so diseased a condition as to ensure con- tinual infection where retained, but in chronic conditions where infective processes have subsided and result in closure of the abdominal end of the tube, it should not be sacrificed, but should be opened. Unless the fimbria can be set free by separating adhesions about the abdominal end of the tube, a fistula should be formed by a longitudinal incision on its convex border. The circular fibers hold open the incision OVARIOTOMY 73 and evert its mucosa. This procedure is known as salpin- gostomy (Fig. 13). OVARIOTOMY This is the term employed for the removal of tumors of the ovary (Fig. 14). For instruments and preparations, see Fig. 15. These tumors may attain to a very large size, may be single or multiple; the contents may be thin, or thick and viscid, Fig. 14.—Woman with large ovarian cyst. with fatty matter, teeth, hair, and bones. The growths may be benign or malignant. Unless the tumor is of enormous size it is better to make the incision large enough that the sac can be turned out without being opened. This is par- ticularly true in the dermoid growths, in which the contents 74 CARE OF GYNECOLOGIC PATIENTS are frequently fatty acids, so irritating that contact of the m o OJ OJ o a 3 c/i id H u ro OJ 3 o T3 u OJ p. a 3 o X. ,3 OJ Tl O t~ ■n is 3 fluid with the peritoneum is sure to set up inflammation and be followed by peritonitis. In malignant growths, the soiling OVARIOTOMY 75 of the peritoneum with the contents may be followed with secondary implantation and the recurrence of the disease. In a unilocular cyst a short incision may be succeeded by puncture and evacuation of the cyst and the withdrawal of its sac through a small opening. The intern should be di- rected to place his hands on either side of the upper abdomen and press the sac of the tumor into the incision, and under no circumstances to let up on the pressure. The operator with a knife punctures the cyst, when with cyst or Ochsner forceps he seizes its edges at the puncture and draws it out. The sac thus forms its own funnel and the soiling of the cavity is prevented. When the tumor is removed unopened, it should be held by the intern and not be allowed to drag on its pedicle; the latter should be clamped with large and strong forceps and be cut between the forceps and the tumor (Fig. 16). As the tumor is withdrawn, adhesions of the intestines must not be overlooked. These adhesions when recent are easily separated, but old adhesions may be so firm as to require the employment of scissors to separate them. They may be so intimate as to require a portion of the cyst wall to be removed with them to save the intestine from in- jury. The secreting surface should be removed from all such portions. The tumor may not always have a pedicle and may have to be enucleated. The tumor may be intra- ligamentary, and in its development spread out the broad ligament, causing the ureter to lie over a portion of its sur- face. The situation of the ureter should be determined in all intraligamentary growths. Such a tumor may have so 76 CARE OF GYNECOLOGIC PATIENTS spread out the uterus upon its surface as to require the re- moval of the organ to secure the extirpation of the growth. In the removal of the unopened tumor I would advise that a pair of forceps be applied to its pedicle. This is tied with chromic catgut. The operator, having such a suture threaded in a needle, passes it through the pedicle and ties it in two Fig. 16.—Ovarian tumor which was removed without puncture. portions, and finally carries one of the ligatures around the stump and ties again. The peritoneum is sutured over the stump with fine chromic catgut suture to prevent a coil of intestine becoming adherent to the raw surface. The peri- toneum is carefully inspected for bleeding points and for injuries, all of which should be covered in. HYSTERECTOMY—SUBTOTAL HYSTERECTOMY 77 HYSTERECTOMY—PANHYSTERECTOMY—SUBTOTAL HYSTERECTOMY Hysterectomy is indicated for cancer of the cervix and body, for fibroid growths, and in inflammatory cases where the uterus is so infected that it cannot be retained without prejudice to the health and even life of the affected individual. It means the removal of the organ in whole or part. The partial removal is known as hysterectomy subtotal or supra- vaginal, and should not be practised when the uterus or any portion of it is invaded by malignant disease. The entire re- moval of the organ is known as panhysterectomy, and may or may not be accompanied by the removal of the ovaries and tubes. For instruments and preparations, see Fig. 17. The median abdominal incision is preferable, inasmuch as it affords more room. The intestines are packed back and the myoma screw inserted, by which the uterus and growth are drawn up. This instrument should not be used in malignant disease of the body. The uterus is drawn to- ward the umbilicus, the anterior surface exposed, and the self-retaining retractor inserted. The intern makes trac- tion on, the uterus, when the operator with tissue forceps picks up the peritoneum above the bladder and incises it outwardly on each side to the round ligament. The round ligaments are tied and cut; a ligature is passed through the broad ligament between the ovary and uterus in fibroids, and external to the ovary in cancer, tied and cut; the mass is then raised up, the uterine arteries exposed, clamped, and cut. 78 CARE OF GYNECOLOGIC PATIENTS In partial hysterectomy the uterus is cut across at this point, leaving the stump of the cervix (Fig. 18). The uterine arteries are tied. The nurse hands a curved needle, armed with catgut ligature, which is passed through the posterior HYSTERECTOMY—SUBTOTAL HYSTERECTOMY 79 peritoneum, carried alongside the stump through the perito- neum in front near the round ligament; then with a hemostat the intern holds the stump of the broad ligament so that the Fig. 18.—Exposing the cervix in subtotal hysterectomy. (Montgomery, "Practical Gynecology.") ligature is tied over it, thus ensuring against hemorrhage by a second ligature, and making the stump of the ligament support the cervix and vagina against subsequent prolapse 8o CARE OF GYNECOLOGIC PATIENTS (Fig- 19). The same course is followed on the other side, and the intervening peritoneal edges closed with a continuous suture. Panhysterectomy.—Following the course indicated above, the uterosacral ligaments are clamped and cut, which per- mits the uterus to be raised, attached to the vagina alone. Fig. 19.—Stumps of the broad ligament sutured to the cervix. Peritoneum closed over them on the left side. The latter may be opened behind, in front, or on the side, and separated from the cervix. When the operation is done for malignant conditions it is important to guard against reim- plantation of the disease, so that the vagina should be care- fully mopped out, clamped below the cervix, and the canal cut across below the clamps. I think an equally effective HYSTERECTOMY—SUBTOTAL HYSTERECTOMY 81 procedure is to open the vagina in front, push a gauze pad through the opening into the vagina, which is subsequently to be withdrawn through the vulva, pack some gauze over the cervix, and complete the section. The tissues are thus protected from contact with diseased tissue. Sutures are passed on either side of the pelvis, picking up the perito- Fig. 20.—Method of fixing stumps in panhysterectomy. neum, posteriorly carried forward along the edges of the vagina and including the vesico-uterine peritoneum. The stumps of the broad ligaments are drawn inward and the ligature suture tied over each. The intervening peritoneum is secured by a continuous suture (Fig. 20). 6 82 CARE OF GYNECOLOGIC PATIENTS INTESTINAL RESECTION AND ANASTOMOSIS Excision of a portion of the intestine may be demanded for injuries during the progress of an operation for inflam- matory conditions, or extensive adhesions in ovarian or uter- ine neoplasms where the destruction of the intestinal walls or the injuries to vessels have been so extensive as to im- peril the future vitality of the intestine. The primary purpose of the operation may have been to resect the intestine for obstruction from malignant disease; for volvulus; for intussusception, or strangulation from con- stricting bands, or from hernia; for redundant condition of the descending colon or sigmoid; for prolapsus of large por- tions which are frequently an intussusception of the sigmoid and colon through the anus. Resection and anastomosis have of late been suggested by Lane for intestinal stasis and toxemia, where he partially or completely removed the colon. For instruments and preparations, see Fig. 21. The abdomen is opened in the median line, whether the procedure is primary or secondary. In the latter the in- testinal work follows the removal of the inflammatory struc- tures or growths, as the case may be. The intestine affected is raised, its contents pressed or milked downward where there is no opening, but where one exists it is brought out of the wound and the intestine emptied through it, exercising care that the contents do not enter and soil the peritoneal cavity. Clamps are applied to the intestine beyond the points at which excision is proposed and a pair of forceps at each end of the portion of the gut to be removed. The intestine INTESTINAL RESECTION AND ANASTOMOSIS 83 is cut between forceps at either end of the proposed resection, ■o ^ X. p p 5. S. „ ^ h o - — 00 — - 3- cr w m re 9r re ^ p a. H and the excised portion separated from its mesentery or mesocolon, as the case may be, and the vessels clamped as 84 CARE OF GYNECOLOGIC PATIENTS the separation proceeds. Care is exercised to make this separation hug closely the bowel, so that large branches shall not be injured, and thus imperil the vitality of extensive por- tions of the intestine. The nurse hands a suture ligature of chromic catgut No. i, threaded in a round-pointed needle, and the mesentery is secured with a continuous suture occa- sionally interlocked by passing the needle and suture be- neath the preceding loop. After tying the end of the suture, the surface should be inspected to make certain that all bleed- ing is controlled. The proximal and distal ends of the re- sected gut are carefully cleansed when cut. The muscle and muscle layer of each are now seized with forceps, drawn out from the peritoneum, tied with silk, having the forceps slowly loosened as the knot is tied, the external portion carbolized, dried, and the peritoneum sutured over it. The intestinal clamps are placed some 3 inches from the distal and proximal ends of the intestine, the contents having been pushed beyond the clamps before they are applied. The intestinal ends are overlapped and the peritoneal surfaces sutured for a space of 3 to 4 cm. An incision is made in each end the length of the sutured portion, when the field having been protected by gauze, the edges of the incision are united by a continuous, occa- sionally interlocked silk suture, tied on the inner surface. When the opening is completely closed the catgut suture is resumed, uniting the peritoneal surfaces over the silk suture (Fig. 22). The clamps are removed, the certainty of the communication established by pressing the gas and con- tents of the upper intestine downward through the opening. INTESTINAL RESECTION AND ANASTOMOSIS 85 The wound in the mesentery is closed by a continuous catgut suture. The same course is pursued in resection for non- traumatic conditions. When done because of strangulation, the precaution must be exercised to make certain that the resection has extended beyond the devitalized portion. In operations for carcinoma or prolapsus of the rectum it may be necessary to loosen the peritoneum, and resect the Fig. 22.—Intestines united by lateral anastomosis. bowel below the latter, where it is not feasible to apply clamps to the lower portion. The sphincter should have been pre- viously divulsed and the wound cleansed from below. Where the bowel is opened a gauze pad should be pushed into the lower segment, to be withdrawn by the anus, and the pelvis carefully protected from soiling by gauze packing. The resection may be so low in the pelvis as to make even an end- to-end anastomosis difficult. In such cases the better pro- 86 CARE OF GYNECOLOGIC PATIENTS cedure is to draw the proximal portion of the intestine through the anus. Its ends should have been ligated temporarily to ensure protection of the pelvis from soiling. The abdominal wound should be temporarily packed with gauze while the end of the intestine is being stitched to the skin about the anus. The hands are washed, or the gloves changed when they are worn, and the peritoneum sutured in the pelvis about the intestine, following which the abdominal wound is closed. The intussuscepted portion of the intestine sloughs and is dis- charged through the anus. It is better to fasten a rubber drain through the anus into the intestine for a few days to prevent gaseous distention of the lower bowel. GASTRIC OPERATIONS Operations on the stomach consist in measures for its support in prolapsus; its exploration for removal of foreign bodies and the treatment of ulceration; its resection in cancer and extensive ulceration, and its drainage in narrowing of the pyloric opening or in marked prolapse and dilatation. The incision should generally be made above the umbilicus, in the median line or through the left rectus. The incision should be a free one, for a large incision can be closed more expeditiously and with less injury to the structures than when the operation is done through a small and insufficient opening. As it is quite impossible to absolutely predict in advance the character and extent of an operation, it is a matter of prudence to be provided with all the necessary paraphernalia for any emergency. GASTRIC OPERATIONS 87 For instruments and preparations, see Fig. 23. Fig. 23.—Instruments and preparations for gastric procedures: i, Scalpel; 2, scissors, curved and straight, sharp and blunt pointed (4): 3, hemostatic forceps (12); 4, long hemo- static forceps (Bland's) (4); 5, large gastroenterostomy clamps (2); 6, small gastroenteros- tomy clamps (2); 7, large clamp forceps (2); 8, combined retractors (self-retaining); 9, broad blade retractors (2); 10, abdominal retractors (2)- n, small retractors for holding open the stomach (4); 12, ligature carriers (right and left); 13, tissue forceps, toothed (2), serrated (il; 14, needle-holder; 15, towel clips (6), 16, needles, curved, round-pointed (4): 17, needles, long and curved, cutting edge (4); 18, Paquelin cautery; 19, tubes of silk for sutures, Nos. o, 1, 2; 20, tubes of catgut, chromic, Nos. o, t, 2; 21, tubes of catgut, plain, Nos. 1, 2; 22, pack- ages containing sterile gowns, sponges, packs, dressings, towels, sheets, cover pad, and abdom- inal binder. Plaster in strips with tapes attached for retaining dressings. Gastropexy.—In gastroptosis the stomach is supported by folding the gastrohepatic omentum, as suggested by Beyea, or attaching the great omentum to the anterior ab- 88 CARE OF GYNECOLOGIC PATIENTS dominal wall. The patient is placed in the dorsal position, with the upper part of the table slightly elevated, or the table may be broken about the middle of the back, or a sand pillow or inflated rubber pillow placed under the patient, so that the upper abdomen is more prominent. A median Fig. 24.—Beyea's operation for gastroptosis—the first layer of sutures (Moynihan). incision from the ensiform cartilage to just above the umbili- cus is made through all the tissues above the peritoneum. The latter is held with tissue forceps by the operator and intern and opened between them. The operator then, with blunt straight scissors, incises the peritoneum the length of GASTRIC OPERATIONS 89 the wound, protecting the abdominal contents with two fingers of the other hand. He raises up the stomach, trans- verse colon, and omentum, and with a pack handed him by the nurse walls off the small intestine. The intern and a nurse hold the wound open with a broad retractor on either Fig. 25.—Beyea's operation for gastroptosis—the first layer of sutures completed; the second and third being introduced (Moynihan). side (Figs. 24, 25). The operator carefully examines the stomach, pylorus, and gall-bladder, after which he shortens the gastrohepatic omentum by inserting three rows of sutures, using No'. 1 chromic catgut, threaded in a curve-pointed needle, exercising great care not to include large vessels in the sutures. go CARE OF GYNECOLOGIC PATIENTS The Coffey operation consists in stitching the omentum to the anterior abdominal wall, this forming a sort of shelf on which the stomach shall rest (Fig. 26). The omentum just below the colon is secured by interrupted sutures to either side and to the wound as it is closed, exercising the precau- Fig. 26.—Gastropexy; Coffey's operation. The suture of the omentum to the anterior abdominal wall (Moynihan). tion that there shall remain no opening through which a loop of the small intestine may be forced and become strangu- lated. Where the omentum is very heavy and fat this oper- ation may very wisely supplement the Beyea procedure to take the drag from the gastrohepatic sutures. GASTRIC OPERATIONS 91 Gastrotomy.—Probably the most frequent cause for surgical interference with the stomach is occasioned by gastric or duodenal ulcers. These ulcers may render life unendurable through the severe pain, or endanger it by pro- fuse hemorrhage or rupture, and the escape of the stomach contents into the peritoneal cavity. Persistent ulceration associated with nature's efforts at repair through cicatriza- tion may result in contraction and pyloric obstruction. The recognition of an ulcer of the stomach does not necessarily demand resort to surgery, for many patients under a care- fully directed medical regimen recover, but in numerous in- stances delays are dangerous, and it may be questioned whether in the majority of instances recovery would not be expedited by early surgical interference. For instruments and preparations, see Fig. 23. The incision has been made. The stomach is drawn out and carefully examined. The ulcer is most frequently found near the pyloric end and the lesser curvature, although it may affect the greater curvature, the anterior or posterior walls. It consequently may be readily accessible or be so situated that the stomach has to be opened to reach it. The procedure is known as "gastrotomy." The operation is done for exploration of the stomach where a hardness or indura- tion is situated upon its posterior wall, to explore the mucosa for ulceration where there is a history of hematemesis with- out presenting any evidence of cicatrization, and for the pur- pose of removing foreign bodies. A perforation is best treated by searing its surface with a thermocautery knife 92 CARE OF GYNECOLOGIC PATIENTS and suturing the opening with a double row of sutures. An accessible ulcer attended with induration may be wisely made a perforation with the cautery, and then closed as in ordinary perforation. In suturing these openings the first row of sutures should be silk, while the second may be chromic catgut. The inaccessible ulcer requires an incision of the stomach through its anterior wall which may be longitudinal or vertical. Retractors are inserted and the cavity inspected. The abdomen is carefully protected from soiling by gauze packing. An ulcer may be inverted through the opening, be cauterized with the cautery, and sutured from within with silk sutures, ensuring the contact of a thick layer of peritoneal surfaces. The gastric incision is then closed by continuous or interrupted silk sutures, and this line of suture covered by a row of chromic catgut suture which may be continuous. All gauze packing is effectually removed before closing the wound. The nurse in care of gauze pads must keep an ac- count of the pads used, and in this as in all abdominal pro- cedures be certain that all pads used are in sight. Gastro-enterostomy.—The term employed for a com- munication between the stomach and the small intestine (Fig. 27). It may be called a gastroduodenostomy when the first part of the small intestine, or a gastrojejunostomy when the second part is utilized. The operation may be an anterior or posterior gastro-enter- ostomy. The latter is the one most frequently preferred. Anterior gastro-enterostomy is made between the stomach and the jejunum. A coil of the latter has its contents pressed GASTRIC OPERATIONS 93 out and is grasped by one of the clamp forceps, generally with the blades covered with rubber. The other pair is placed upon a fold of the anterior surface of the stomach near its greater curvature. The point of the forceps is directed across the stomach or toward its lesser curvature. A roll of gauze is placed between the two pairs of forceps, and with a No. i chromic catgut suture the long diameter of the intestine is sutured to the transverse diameter by a continuous suture for Fig. 27.—Gastroduodenostomy. Kocher's method. (Keen's "Surgery.") about 3 to 4 cm. With the surfaces carefully protected an incision \ to 1 cm. from the sutured line is made into the stomach and intestine. The purpose of making it so low in the former is to make sure there will be no undrained portion. The raw edges of stomach and intestine are united with a continuous suture of silk (Fig. 28), which should interlock about every third or fourth turn, and should completely en- circle the opening. When the opening is thus closed the clamps 94 CARE OF GYNECOLOGIC PATIENTS may be removed and the second row of suture (catgut) be resumed until it completely covers the silk suture. As these cases sometimes suffer from a vicious circle, the contents of the jejunum, consisting of food which still passes the pylorus, the bile, and pancreatic secretion, enter the stomach at the corn- Fig. 28.—Anterior gastrojejunostomy. Showing the correct position (a) and the incorrect position (b) for the anastomosis. (Keen's "Surgery.") munication and are vomited, this condition has been met by making an anastomosis between the surfaces of the jejunum, so that the contents of the latter will not reach the communi- cation with the stomach. Posterior gastro-enterostomy is the operation of preference, the anterior being done where it is not feasible (Fig. 29). The GASTRIC OPERATIONS 95 latter is done when the mesocolon is too short to permit carry- ing the stomach through it, or the posterior wall is fixed by adhesions or is the seat of cancer. In the posterior procedure the colon and omentum are turned upward, an opening through the mesocolon avoiding large vessels, and a portion of the Fig. 2g— Posterior gastro-enterostomy. The inner suture nearly completed. The mucosa being turned outward, not inward (Moynihan). posterior wall of the stomach drawn through and clamped. A loop of the jejunum is also secured with another clamp in its course from left to right. Mayo emphasizes the importance of avoiding a reverse turn in uniting the intestine. As in the anterior operation, a pad of gauze is placed behind the forceps, the peritoneal sur- 96 CARE OF GYNECOLOGIC PATIENTS faces sutured with chromic catgut, the desired length being 3 to 4 cm., an incision is made into each fold while the abdomen is carefully protected from soiling. The edges of the united flaps, including the mucous membrane, are sutured by con- tinuous silk (No. 1) suture, and this suture is continued, occa- sionally interlocking it, until the union of the stomach and in- testine is completed by closure of the opening. The clamps are removed and the catgut suture resumed and continued, completing the second line of suture. The opening in the meso- colon is closed about the anastomosis. Neglect of this pre- caution has occasioanally led to a hernia of the small intestine through the opening and to a serious obstruction. Gastroduodenostomy and pyloroplasty are methods employed in pyloric obstruction, but it is unnecessary to more than men- tion them here, as they do not require additional technic. Gastrogastrostomy may be employed in hour-glass contrac- tion. Pylorectomy and partial gastrectomy are required in gastric carcinoma, when the disease is so circumscribed as to afford a reasonable probability of recovery, or rendering more com- fortable the remaining span of life for the sufferer. As the supply of blood to the stomach comes from the celiac axis the extent of the structure removed will depend upon the vessel destruction. The field involved is carefully inspected for evi- dences of transmission to the lymphatic nodes in this region, and when such have occurred the advisability of a radical operation is questionable. The gastric branches in the gastro- hepatic and large omentum are tied and cut through the length GALL-BLADDER OPERATIONS 97 of the proposed resection. The wall of the stomach is clamped by the stomach forceps well external to the disease, while a second large pair of forceps is applied close to the disease struc- ture, and the incision with scalpel or scissors made between them. The same course is followed upon the pyloric side. The surfaces are carefully protected by gauze from soiling during the resection and the surfaces carefully sponged upon its completion. The operator closes the open surfaces first with a continu- ous silk suture, bringing the peritoneal surface in contact, and reinforces this with a suture of chromic catgut externally. Where but a small portion of the stomach has been resected, an anastomosis may be made between the lower end of the gastric incision and the pylorus, but in all cases where the tension would be great the wounds should be closed and communica- tion established between the most dependent portion of the stomach and the jejunum. GALL-BLADDER OPERATIONS Operations on the gall-bladder are most frequently occa- sioned by obstruction of the bile tracts by concretions known as gall-stones. They most frequently form and accumulate in the gall-bladder. They may vary in number from one to several hundred, and in size from the calculus as large as the end of a thumb to the millet-seed size in great numbers. They1 may be rough, strawberry-like, or perfectly smooth where they attain to considerable size, and where many are packed to- gether they are facetted. They may exist in large numbers in 7 Fig. 30.—Instruments and preparations for gall-bladder operations: 1, Scalpel; 2, scissors, straight and curved, sharp and blunt pointed (4); 3, hemostatic forceps (12); 4, long hemostatic forceps, Bland's (4); 5, tissue forceps, toothed and serrated (2); 6, forceps for seizing gall-stones; 7, glass syringe (2 to 4 oz.); 8, gall-stone scoop; 9, long probe; 10, retractor (self-retaining); 11, retractors, long and curved (2); 12, towel clips; 13, needle-holder; 14, needles, curved, long and short, round pointed and cutting edged (8); 15, bottle and tube for drainage; 16, rubber tubing; 17, gauze wrapped with rubber tissue; 18, right-angled tube for common duct drain; 19, tubes of silk, Nos. 1, 2; plain and chromic catgut, Nos. o, 1, 2, for sutures and ligatures; 20, packages containing sterile packs and sponges, dressings, gloves, gowns, sheets, and towels; abdominal binder and plaster strips with tapes attached. GALL-BLADDER OPERATIONS 99 the gall-bladder and produce no characteristic symptoms. The patient frequently complains of a sense of discomfort and burning, which is attributed to dyspepsia. When the con- cretions enter the cystic duct in their course toward the intes- tine the patient may suffer violent attacks of colic attended with nausea and vomiting. Where the calculus passes into the common or hepatic ducts, not only does the patient suffer severe pain, but becomes profoundly jaundiced, and is affected by more or less morbid toxemia. Infection of the gall- bladder may result from coli bacillus, the bacillus of la grippe, or typhoid, and be favored by the continued irritation of the gall-stones. The gall-bladder may be thickened and con- tracted or greatly distended, forming a large sac, the walls of which are fragile, rupturing in the efforts at separating it, or even under manipulation prior to operation for purposes of diagnosis. The patient prepared for abdominal operation is placed upon a table which is broken so that the chest lies above the break. This position can be accomplished by a sand-bag or inflated rubber bag under the back. The incision may be made in the median line, parallel with the ribs, or in the right semilunar muscle, S shaped as suggested by Bevan, as the operator may prefer. The grid-iron opening, in which the various muscles are split and held apart, may be utilized where a large opening will not be required. A vertical opening will generally be most satisfactory, as an opportunity is afforded for the extension of the incision when required. The abdomen opened, the self-retaining retractor is placed, the intestine IOO CARE OF GYNECOLOGIC PATIENTS walled off, and the condition of the gall-bladder and its rela- tions determined by sight and touch. The exigencies of the conditions found may require resort to one of the several procedures. Cholecystotomy is opening of the gall-bladder for the evacuation of gall-stones and in- flammatory collections. SugIi an opening may be at once closed. In cholecystostomy the opening is maintained for a length of time for drainage, as in infections of the gall-bladder Fig. 31.—Sectional cut showing the gall-bladder and tube in position. (After Binnie.) and bile-ducts, and for inflammation of the pancreas (Fig. 31). Cholecystectomy is done when the changes in the gall- bladder from inflammation and gangrene render its retention dangerous. Choledochotomy is done when the common duct has to be opened, as for the removal of impacted gall-stone. Choledochostomy when this opening has to be maintained for a length of time. Choledochectomy when a portion of the common duct has to be removed. The condition of the bile- GALL-BLADDER OPERATIONS IOI ducts may further require choledochoplasty, as for the closure of a biliary fistula, or cholecystogastrostomy, cholecystoduod- enostomy, cholecystojejunostomy, cholecystoileostomy, and cholecystocolostomy, respectively a communication between the gall-bladder and stomach, duodenum, jejunum, ileum, or the colon, as the changes of the structures may demand. Ad- hesions of the omentum and intestines to the gall-bladder are carefully separated and the intestines walled off from the field by gauze packing, while the exposure is made complete by re- tractors held by the intern or nurse. When the gall-bladder is distended it can be drawn out by hemostats and cut between them, and its contents, whether bile, pus, or calculi, evacuated without danger of soiling the peritoneal cavity. While the intern holds the opening, the operator should pass his hand along the common and hepatic ducts and endeavor to coax any calcuh which have entered them back into the gall-bladder to secure their evacuation. Where the gall-bladder is not easily brought up it may be partially separated from the liver, or where this is not sufficient, the abdomen about it should be packed with gauze to absorb the discharges which may follow its opening. The removal of small stones and the detritus or sand may be facilitated by syringing out the tract with warm salt solution. The removal of large calculi, or those impacted, may be facilitated by the employment of the scoop or forceps. The impaction of a large stone in the common duct may de- mand the incision of the duct for its delivery. The operator should never neglect to make certain that no calcuh remain in the common and hepatic ducts, for otherwise relief will be in- 102 CARE OF GYNECOLOGIC PATIENTS complete and the surgery be justly censured. Where the gall- stones have been completely evacuated and the gall-bladder shows no evidences of inflammation and thickening, the gall- bladder wound can be closed by a double row of sutures. In the majority of cases demanding operation it will be advis- able to insert a drain; a section of f- to ^-inch rubber tubing is inserted into the bladder, the opening sutured about it with chromic catgut, and the latter carried into the tube to insure its remaining. Unless there has been extensive perivesical inflammation no drainage of the tube will be required. When the calculus has required the incision of the common duct, accompanying infection or contraction may demand that the common duct shall be drained, or the condition of the gall- bladder may demand the removal of the latter. In these in- stances drainage of the abdomen may likewise be required. The drain for the common duct should be a right-angled rubber tube, constructed in one piece, sutured into the common duct. The abdomen may be drained by a separate rubber drain or by cigarette drains of gauze and rubber tissue, or the field, when there have been extensive adhesions, may be walled off by sterile or iodoform gauze and the ends brought out of the wound about the tube. When the bladder only is drained, the tube may be brought out through the wound, or when more closely related to the peritoneal surface, through a stab wound just over the bladder. It is unnecessary to suture the bladder to the peritoneum, as traction on the tube draws it into the stab wound. Care should be exercised that the bladder does not come next the skin surface, otherwise the continuity of THE SPLEEN 103 mucosa to the skin prevents the closure of the fistulous tract. When gauze is used for drainage unenveloped by rubber tissue it should be left for five or seven days before removal or until it can be easily withdrawn. It is a filthy method of drainage and is followed by extensive adhesions, so that it is better avoided. The rubber drain after the wound is closed may be inserted into a flat bottle buried within the dressings, or be con- nected with another tube, the end of which is carried into a bottle suspended from the side of the bed. The end of the tube should be immersed in a 5 per cent, solution of carbolic acid to prevent the aspiration of germ-laden air into the abdomen through the tube. Traction on the tube from time to time after the end of a week will soon bring about its with- drawal, when the sinus, unless the canal is obstructed, will promptly close. THE SPLEEN The spleen may become injured by falls, blows, or stab wounds, and in severe cases may demand its removal. The instances in which the removal of the spleen is indicated are infrequent. In addition to the already indicated injuries, the spleen is removed for malignant disease, marked material en- largement, splenic enlargement, and when the organ is very movable (Fig. 32). Operation.—The incision is generally made in the median line, although in large tumors the incision through the left semilunaris may afford more ready access to the pedicle, and additional room may be secured by cutting across the rectus. The wound opened and vessels secured, the extent of adhesions 104 CARE OF GYNECOLOGIC PATIENTS should determine the course, those to the diaphragm and pan- creas generally affording the greatest difficulty. The omental adhesions may be separated between ligatures. The spleen OPERATIONS UPON THE KIDNEY 105 raised and carefully delivered through the wound. Great care must be exercised that the friable organ is not torn. Trac- tion upon the vessels of the pedicle may cause severe shock. Where they are not securely tied, a vessel may retract, causing a quickly fatal hemorrhage. As the spleen is raised and brought out of the wound, the intestines are packed back with gauze to keep exposed the pedicle of the spleen. It is very important to make certain that every vessel is ligated, and they should be tied with No. 1 chromic catgut, but not so tight as to endanger cutting through the vessels. It is unwise to tie a large pedicle in mass, for the retraction of a vessel is not infrequently attended with a fatal hemorrhage. Where adhesions are broad the chain-interlocking suture should be employed. In adhesion to the pancreas, the removal of a portion of the latter may be necessary. Wherever possible, peritoneum should be sutured over denuded areas. All gauze packs should be removed and the wound closed without drainage unless extensive areas have been denuded, when either a wick or gauze packing should be employed. OPERATIONS UPON THE KIDNEY Surgical relief may be demanded for traumatic or dis- eased conditions of the kidney. The latter are the more frequent, and vary from mobility, interfering with the com- fort and safety of the patient, to extensive destructive conditions which demand incision and drainage or complete extirpation. The position of the incision depends upon its purpose. In 106 CARE OF GYNECOLOGIC PATIENTS all procedures for disorders unattended by marked increase in size the oblique lumbar incision is preferable (Fig. 33). A table with an arrangement for breaking it. Where the latter arrangement is not present, there should be provided sand OPERATIONS UPON THE KIDNEY 107 pillows or a rubber cushion (Edebohls). The patient should lie in a semiprone position on the left side where the right kidney is the one affected, over the break or pads, so that the ribs and crest of the ileum shall be widely separated. The field after previous preparation is painted with 3! per cent. iodin solution and enveloped with sterile sheets and towels held in place by towel clips. Fig. 34.—After section of latissimus dorsi. Cross showing position of incision of the aponeurosis of the transverse muscle. (Greene and Brooks.) An oblique incision is made outward and downward, from the point where the twelfth rib emerges from beneath the erector spinae muscles to a point one fingerbreadth above the crest of the ileum. This incision carried through skin, super- ficial fascia, and latissimus dorsi (Fig. 34). The oblique can be drawn forward and the fascia of the transversalis cut, thus ex- posing the fascia directly over the kidney. The ilio-inguinal and the iliohypogastric should be pulled aside; where this is io8 CARE OF GYNECOLOGIC PATIENTS impossible, the nerves should be cut and sutured at the close of the operation. I have seen relaxation of the abdominal muscles of the affected side follow the operation and lead to the diagnosis of hernia. This relaxation or paralysis is due to innervation fqllowing cutting the iliohypogastric nerve. In movable kidney the incision described admits anchoring of the kidney. It is called "nephropexy." The enveloping perineal fat is opened, the kidney separated from it, and the surrounding structures, especially the colon and peritoneum, by blunt dissection, and is then drawn out of the wound by a finger thrust beneath the kidney, or the investing fatty capsule may be seized with a hemostat near the lower pole and raised, when the organ can usually be easily drawn out. Should there be difficulty, a pair of concave-bladed fenestrated forceps, by which the organ can be seized and drawn up without danger of injury by compression, should be used. There should be no difficulty in the delivery of a freely movable kidney. Thus delivered, the capsule is opened, a grooved director passed under it, and the capsule divided the length of the convex border. It is then pushed forward and backward toward the kidney pelvis, exposing about one-half the kidney surface. Two sutures are introduced in the folded capsule on each of the anterior and posterior surfaces, parallel to the long axis of the kidney. These sutures are passed through the muscle and aponeurotic layers, but not through the skin, and tied. They carry the kidney into tjie incision. The muscle and fas- cia are closed with chromic catgut sutures, turning the raw sur- face of the quadratus lumborum muscle in contact with the OPERATIONS UPON THE KIDNEY 109 raw kidney surface. The skin may be closed by a continuous catgut suture. Nephrotomy.—With the preparation indicated, and through a similar incision, the kidney may be opened for the removal of pig 3S-—Opening kidney with silver wire. (Ernest K. Cullen, in "Surg., Gyn., and Obst.") a calculus, the evacuation of a pus collection, or the exploration of its pelvis and calices. The kidney may be opened, extend- ing through its convex border, but the incision with a knife is no CARE OF GYNECOLOGIC PATIENTS often attended with frightful hemorrhage. Cullen and Derge advocate doing nephrectomy with a silver wire (Nos. 3 or 4). The wire is threaded into a long, round-pointed or liver needle, and carried the distance desired for the opening (Fig. 35). The capsule of the kidney is incised over the desired course; the two ends of the wire are drawn upon by a sawing motion until the opening has been accomplished and without much bleeding. The direction of the incision should be determined by the dis- tribution of the vessels and its purpose. The position of the renal incision for the removal of a calculus will depend upon its size and situation. If it occupies the calices of the kidney, the incision should be either longitudinal or vertical. If it is situ- ated in the pelvis, and especially when small, the opening should be through the membranous wall, exercising care not to injure the vessels. Where it is desirable to maintain drainage, the opening in the kidney may be sutured to the abdominal wall, thus constituting a nephrostomy. The cavity may be packed with gauze or have a rubber tube sutured in. When the opening is in the membranous structure of the pelvis the drainage should consist of a small roll of rubber tissue. Nephrectomy.—The degeneration may be so extensive as to demand the removal of the entire kidney. The kidney is brought up in the manner described. The condition demand- ing the operation may be revealed by the incision into its structure. Its pedicle is exposed, the ureter divided between ligatures, the arteries and veins either ligated or clamped and cut, releasing the kidney. If the vessels have been clamped they should now be ligated, and preferably after isolation OPERATIONS UPON THE KIDNEY ill rather than en masse. The cavity is carefully inspected, and then, after insertion of drainage or the employment of gauze packing, the wound is partially closed. For Large Renal Tumors. - When the kidney is occupied by growths of considerable size, or is greatly enlarged by pus col- lections and accompanying inflammatory changes, the oblique Fig. 36.—Lumbar iliac incision for nephro-ureterectomy. (Greene and Brooks, after Pierre Duval.) lumbar incision is insufficient. The incision may extend from the lower end of the oblique incision described, around the crest of the ileum, and downward in the corresponding flank to the edge of the rectus muscle. This incision is the one usually recommended for nephro-ureterectomy (Fig. 36). The majority of the operations for removal of the kidney 112 CARE OF GYNECOLOGIC PATIENTS will not require so extensive an incision. An alternative pro- cedure is to open the abdominal wall external to the rectus muscle corresponding to the affected side, exposing the peri- toneum without opening it, and then push it from the ab- dominal wall outwardly until the kidney within its perineal fat is exposed (Fig. 37). If the surrounding structures are Fig. 37.—Abdominal incision for removal of kidney. (Hartmann.) not too extensively involved in the inflammation or infiltra- tion, it may be completed as a retroperitoneal operation. In the,, majority of large tumors of the kidney, whether from inflammatory or neoplastic changes, the mass will project into the abdominal cavity, and so ultimately connect with the en- veloping peritoneum that it will have to be removed with the kidney. In the latter cases the condition of the circulation of OPERATIONS UPON THE KIDNEY 113 the adjacent portion of the colon must be determined. When the peritoneum is dissected off only the outer surface of the colon is exposed and its circulation is unaffected. The peri- toneum pushed back exposing the kidney, the intestine is wailed back with gauze and retractors are employed to main- tain the exposure. The kidney is separated from its bed, the ureter is exposed, ligated with a double hgature, and cut be- Fig. 38.—Nephrectomy. (Greene and Brooks, after Berger and Hartmann.) tween them. The vessels are isolated if possible and ligated separately with chromic catgut, and upon completion of the ligation the kidney mass is removed (Fig. 38). If the ureter is infected, especially with tuberculous disease, it should be removed throughout its entire length. The retention of such a focus endangers the extension. The employment of the pro- longed oblique incision affords the best exposure. The dis- section should be accompanied without traction on the ureter, 8 ii4 CARE OF GYNECOLOGIC PATIENTS for where thickened by inflammation it is easily broken and the spread of infection is thus endangered and its complete removal rendered difficult. If it becomes healthy near the bladder, a ligature can be applied and the ureter cut externally. When the disease involves the lower portion, its vesical orifice should be excised and the opening closed with a double row of chromic catgut sutures. The treatment of the wound will be con- sidered later. Where it has been necessary to open the peritoneum, it should be closed or gauze packing should be employed, to prevent contact of the peritoneal-covered intestines with the raw surfaces. When the peritoneum can be left a closed sac, the wound, which is usually a large one, should be drained with a series of split rubber tubes, ropes of gauze covered with rubber tissue, or iodoform gauze packed in the pelvis. The muscle and fascia should be accurately closed with chromic catgut sutures except where vents for drainage are necessary. In dressing the wound a considerable quantity of gauze should be applied and this covered with pads of cotton and gauze. The dressing should be changed as soon as there is an indication of its being soiled. Saturated dressings should not be allowed to remain, as they afford ready entrance for infection. VAGINAL OPERATIONS After the removal of the hair from the lower abdomen and a hot bath, the nurse washes the abdomen and genitalia with soap and hot water and administers a vaginal douche of a solution of mercuric bichlorid (i : 2000) or iodin (Lugol's solution, \ dram to 1 quart of hot water). These douches should be given three times in the twenty-four hours preced- ing operation, and in the intervals the vulva kept covered with a sterile gauze pad. When the patient comes to the table for operation she should have the vagina and the ex- ternal parts, including the buttocks and the inner surface of the thighs, thoroughly scrubbed with tincture of green soap and hot water. For this purpose the fingers should be wrapped with sterile gauze. The superfluous soap should be washed away with hot sterile water, and, finally, the parts scrubbed with a 50 per cent, alcohol solution, dried, and painted with 3.5 per cent, solution of iodin. The patient is placed on her back, with legs flexed and supported by leg- holders. The feet and legs are covered with sterile dressings and the vulva isolated with sterile towels, which should be held in place by towel clips. The principal operations done on, or through, the vagina are dilatation and curetment, excision of growths, plastic operations on the anterior and posterior vaginal walls, repair "5 116 CARE OF GYNECOLOGIC PATIENTS of the cervical canal, known as "trachelorrhaphy," ampu- tation of the cervix, closure of the fistulous openings be- tween the vagina and bladder, or the vagina and rectum, and hysterectomy. DH.ATATION AND CURETMENT The patient has been prepared as directed for vaginal operations, the perineum retracted and held back by a weighted speculum; two tenacula are inserted in the anterior lip and held with the left hand of the operator. The direc- tion of the canal having been previously determined by care- ful bimanual examination, the graduated bougies, of which there are two on each central handle, are introduced, begin- ning with the smaller size, one after another, until the de- sired dilatation has been accomplished (Fig. 40). The in- tern hands the bougies, with the smaller instrument directed toward- the cervix. The nurse connects the curet to the douche-bag and is ready to open it as soon as the dilatation is completed. The douche fluid washes away the scrapings and mucus as the instrument is carried by long swTeeps over the anterior, posterior, and lateral walls of the uterine cavity, and is finally carried across the fundus from one opening of the fallopian tube to the other. The nurse has ready a small pledget of sterile absorbent cotton which she has satu- rated with iodoform solution, and the operator carries this to the fundus, and as it is withdrawn the contents are squeezed off, the ether evaporates with the temperature of the body and leaves a coating of iodoform. In some instances the DILATATION AND CURETMENT 117 cervical glands are filled with secretion and have been con- verted into cysts by closure of the ducts by inflammation. These cysts are opened with a bistoury, and the cavity painted n8 CARE OF GYNECOLOGIC PATIENTS with tincture of iodin to set up sufficient inflammation to obhterate the cavity. When the cureting follows an abortion the bleeding may be free, and it is then better to swab the uterine cavity with an iodin solution and pack it with iodo- form gauze. In recent uterine inflammation, or following an abortion, or at the site of a flexion the wall of the uterus may be softened and be readily perforated by the bougie. This accident does not necessitate opening the abdomen, but the curet should be used without the douche and no irritant medi- TRACHELORRHAPHY 119 cation be made to the canal. The uterus should be packed with gauze and care should be exercised that it does not project through the perforation. TRACHELORRHAPHY This is the designation given to the operation designed by Emmet for the various lacerations of the cervix. The patient is brought to the end of the operating-table, with her feet supported in leg-holders and enveloped in sterile coverings. The vulva is isolated with sterile sheets and towels held in place with towel clips. The vagina has been cleansed as in all vaginal operations, and the cervix is exposed by the weighted speculum. The intern, standing to the right of the operator, who sits at the foot of the table, holds with his right hand a double tenaculum in the anterior lip, and with his left makes traction when necessary upon the speculum. A nurse to the right, with her left hand holds a tenaculum placed in the posterior lip, and with her right mops the blood from the field of operation. The denuda- tion may be made on one or both sides, according to the ex- tent and character of the laceration. Even in bilateral lacer- ation, unless the tears be deep, it is better for the future drain- age of the canal that the repair be limited to one side, espe- cially to the side in which it has been most extensive. Where the repair is to be confined to one side, the cervix should be drawn to the opposite side, and if deep and the uterus fixed, it may be necessary to employ a lateral retractor to expose the apex of the tear. If it is decided to confine the denuda- 120 CARE OF GYNECOLOGIC PATIENTS tion to the right side of the cervix, the assistants should reverse their hands in holding the tenacula. The uterus should always be cureted as a prehminary to the operation. TRACHELORRHAPHY 121 Beginning on the posterior lip, the operator seizes the tissue near the point for the new os and outlines the portion to be removed by an incision from the inside of the canal and another on the vaginal side (Fig. 42). The tissue or flap thus outlined is lifted toward the apex of the tear and left in position while the denudation on the anterior lip is followed in the same manner. When the operation is bilateral a similar course is pursued on the other side of the cervix, tak- Fig. 42.—Denudation for trachelor- Fig. 43.—Bilateral laceration of the rhaphy. (Montgomery, "Practical Gy- cervix and sutures introduced for union necology.") of denuded surfaces. (Montgomery, "Practical Gynecology.") ing care to preserve a central undenuded portion on each lip for the future cervical canal. The denudation completed (Fig. 43), the nurse hands a needle threaded with No. i chromic catgut, and the first suture is introduced from the vaginal side of the anterior right lip of the cervix, and brought out on its inner surface within the denudation at the margin of the cervical membrane; the left suture is introduced from the posterior Hp and brought out on the anterior. These sutures 122 CARE OF GYNECOLOGIC PATIENTS are situated on either side of the new os and temporarily secured with forceps; the tenacula are removed, and these sutures are used as retractors. Their introduction and em- ployment thus ensures the union of the lips at a uniform length, otherwise it would be difficult to ensure their being properly brought together. The other sutures are intro- duced on either side to ensure the proper coaptation of the lips, each suture being carried to the margin of the cervical flap, but none entering it. A suture entering the cervical Fig. 44.—Wound closed. (Montgomery, "Practical Gynecology.") mucosa prejudices the result in two ways: first, by approxi- mating the two mucous surfaces it diminishes the surface for union; and, second, its presence acts as a seton which may result in a cervicovaginal fistula, an abnormal opening which will be a source of annoyance subsequently. The sutures in place, the surfaces are separated, all blood-clots removed, and the sutures tied without undue pressure, just securely enough to ensure proper apposition (Fig. 44). If tied firmly the included tissue will slough out and the laceration recur, AMPUTATION OF THE CERVIX 123 or the increased cicatricial tissue will be a source of irritation. The nurse hands a section of iodoform gauze, about 4 inches long, cut from a fold of yard-wide roll, and this is packed against the cervix. AMPUTATION OF THE CERVIX The cervix is amputated when the laceration has existed for some time, is accompanied by hypertrophy, eversion of the mucous membrane, or glandular degeneration and erosion. The patient prepared for a vaginal operation and the vulva isolated with sterile dressings, the perineum is re- tracted with a weighted speculum (Fig. 46). The cervix, after the uterus is cureted, is held by a tenaculum in each hp, and with a scalpel the operator encircles the opening of the cervical canal, cutting through the mucosa and part of the muscular layer. The tenaculum is removed from the posterior lip, and with tissue forceps the surgeon holds it while with the knife he outlines and removes a flap extend- ing from one side of the cervix to the other, following the junction of the cervical and vaginal mucosa. He then re- moves the tenaculum from the anterior lip, and, after plac- ing it on the posterior, has it held by the intern while he fol- lows the same course in removing a flap from the anterior lip. In both instances the denudation is at the expense of the internal surface. The removed tissue should include all eroded and diseased structures unless the posterior lip is too extensively eroded (Fig. 47). The important consideration 124 CARE OF GYNECOLOGIC PATIENTS is to secure an unconstricted canal for uterine drainage. The cfl /, V o S rt 1 3 OJ ,3. T3 tfi 1 OJ J~ ^ & • rt o 3 id •. M 75 "O 3 • > h/l 3 '3 a 3 w n O X a x) 3 3 -1 u o 0 £ a n, rn 0 TJ u u T3 . o ^ •- D nJ aj ° y e o g C ~—' ■" O O. cu "0 o X! --a S 3 - »1 u J .3 ^ 3 « > U V C O C 3 "5 a P o P o x (Q. R7" ft M O " -<* o. o 3 a- P 3 re ° " D* « p n fc 3 0. C (1 1 J. Cm 3 3 It' <^ n m o1 re 0 p g 3 &. 3 ^ylU,v the soihng of the vagina and the wround with the secretions or discharges. The instruments thus applied serve as trac- 134 CARE OF GYNECOLOGIC PATIENTS tors, and if necessary the assistant on each side can still further aid in the exposure by the use of a vaginal retractor. The operator, holding the cervix with the tenacula, sweeps around it with the scalpel, severing it from the vagina, and then with a gauze-wrapped finger pushes the vagina and bladder back in front and the vagina laterally and posteriorly. Fig. S3-—Procidentia with gravity sores on the cervix. The nurse hands the surgeon a needle in grasp of needle- holder, threaded with No. i chromic catgut; while the in- tern holds the cervix firm with the fixation forceps he passes the ligature from above downward against the finger which has been placed beneath the under side of the lower part of the broad ligament, and when tied this ligature secures the uterine artery of that side. The vessel of the other side is VAGINAL HYSTERECTOMY 135 secured in the same way, and when the tissue is cut between the ligature and cervix the organ is easily brought to a lower level. If the vesico-uterine fold of the peritoneum has not already been opened, it should be now, and the fundus brought down, the carrier again threaded, the upper portion of each ligament is tied, and before cutting is secured by a strong hemostat. The ligatures are cut short to prevent any possi- bility of being pulled on, and thus possibly permit the retrac- tion of a vessel which would be difficult to again secure. The uterus is cut away from the remaining tissue, the in- tern being ready with a hemostat to secure any spurting vessels. The uterus removed, careful inspection is made for any bleeding vessels, and ligatures substituted for clamps except the two on the upper portions of the ligaments. The assistant on either side draws upon the broad ligament with the forceps, while the operator applies another hemostat to the peritoneum covering the bladder, a suture is passed through the inner (which is the upper) surface of the left broad ligament, then gathers up the peritoneum of the lower margin of the bladder and carries the needle downward through the upper surface of the right ligament (Fig. 54). A second suture is carried backward through the left liga- ment, gathers up the peritoneum of the posterior vaginal wall, and passes forward in the right ligament. These two sutures when tied close the peritoneum from the vagina and ensure that any bleeding occurring shall be outside the ab- dominal cavity. A third suture, carried from the left ligament, picks up the bladder wall near its base, and backward, 136 CARE OF GYNECOLOGIC PATIENTS through the right ligament tied, supports the bladder on the ligaments. The stumps are then sutured so that the end of one overlaps the other, and the ligaments are made to sup- port the bladder and rectum. The vault of the vagina is exposed by a retractor held by the intern beneath the sym- Fig. 54.—Uterus removed and sutures introduced for closing the peritoneum. physis, and the surgeon sutures the lateral points of the vaginal vault to the ligamental stump and closes the upper part of the vagina by anteroposterior sutures. The raw surface on the anterior wall, made by excision of the pro- truding vagina, is closed by transverse sutures, which pick VAGINAL HYSTERECTOMY 137 up also the vesical wall, and this portion is closed in a vertical hne with interrupted chromic catgut sutures (Fig. 55). The method of closing here described is particularly apphcable to the cases in which the operation has been done for pro- lapsus, and presupposes that a flap has been removed from Fig. 55-—Sutures introduced closing the vagina. the anterior vaginal wall in the separation of the vagina from the cervix. In cases in which the vagina is not so distorted, the stump of each broad ligament may be secured outside the peritoneum by passing a purse-string suture through the anterior and posterior peritoneal folds around the one stump and tying 138 CARE OF GYNECOLOGIC PATIENTS it over the other. This ligation secures against hemorrhage. The vaginal surfaces should then be united by interrupted catgut sutures. The operation thus performed leaves no raw surface within the peritoneal cavity nor within the vagina, and the recovery is rapid. The vagina is sponged free of blood, the fine of incision painted with the diluted iodin, and a pledget of iodoform gauze packed against the vault. The packing holds the vault at a higher level, allows the hgaments to contract, and by cicatrization ensures a longer and more fixed vagina. PERINEORRHAPHY; POSTERIOR COLPORRHAPHY; RECTO- VAGINAL INTERPOSITION OF THE LEVATOR ANI MUSCLES This procedure is generally supplementary to other operations. It is rare that the surgeon would confine the procedure to the perineum only. It may terminate repair operations on the cervix, and particularly should follow ante- rior colporrhaphy and the removal of the uterus for prolap- sus. The procedure may be required for relaxation of the floor or for extensive laceration through the sphincter and the rectovaginal septum. The procedure then involves not only the support afforded by the pelvic floor, but also the restora- tion of the control of the contents of the intestine, whether liquid or gas. The preparation of the patient will depend upon the ex- tent and purpose of the operation. The bowel should be always effectually evacuated, especially when laceration ex- tends through or into the sphincter. The patient should I PERINEORRHAPHY; POSTERIOR COLPORRHAPHY 139 have been restricted in her diet to food with httle waste material, as meat broths, and should not take any milk after the purgative has been administered. The evenmg preceding the operation she should be given an enema of 140 CARE OF GYNECOLOGIC PATIENTS soapsuds and the vulvar hair should be removed as weU as that about the anus. This is best done with a depilatory, as thus any possibility of injury and infection of the skin is avoided. When the operation is done for relaxation and eversion of the posterior wall and to ensure subsequent Fig. 57-—Incomplete laceration of the perineum. effectual support, the vulva is separated by the employment of the Bland retractor (Fig. 57). This instrument has two blades, separated by a spring with a tenaculum point pro- jecting from each blade. The instrument -is introduced into the vulva, with the blades closed, and placed with a point against the remains of the hymen, known as the caruncula, PERINEORRHAPHY; POSTERIOR COLPORRHAPHY 141 on either side the vulva, and the pressure released when the vulva and orifice of the vagina is widely separated. A double tenaculum picking up the summit of the vaginal eversion, the outlines of the denudation are indicated. The action of the instrument lifts the vaginal wall away from the rectum, and an incision can be easily made from the tenaculum above to the margin of the commissure posterior and carried outward to the end of the retractor on either side, which outlines flaps for excision that can be quickly lifted with the scalpel and removed. This dissection exposes the rectum above and the muscular layer below, while on either side can be exposed the edges of the separated levator ani muscles. With a curved needle armed with No. 1 chromic catgut suture, held in a needle-holder, the surgeon lifts the edge of the vaginal wall on the left s de, passes the needle through the belly of the levator ani, carries it downward through the fascia covering the rectum, upward on the other side, beneath the levator ani, and clamps the ends of this suture with a hemostat. Traction on this suture lifts up the levator ani and renders the subsequent sutures more easily placed. Three sutures are generally sufficient to ensure the approximation of the muscles. The retractor should be removed before these sutures are tied (Fig. 58). After tying the sutures the vaginal wound is closed by super- ficial sutures. The result is, the levator muscles are brought in front of the rectum, thus effectually preventing the re- formation of rectocele and overcoming the tendency to pro- lapse. The ease with which the bowels can be evacuated 142 CARE OF GYNECOLOGIC PATIENTS is enhanced. This procedure brings the posterior segment of the pelvic floor in contact with the anterior and sup- ports it. In cases where there is a weakened condition of the upper vaginal floor, and the peritoneum has been pushed down between the rectum and vagina, tight lacing or con- stipation may lead to a protrusion or hernia of the upper vagina, which will cause the patient to feel the rectocele is Fig. 58.—Rectovaginal interposition of the levator ani muscles. recurring. Where such a condition is possible, it is wise to cut through the vaginal wall, push back the peritoneum, and make a wider approximation of the levators. The cicatriza- tion thus produced is the most effective resistance to further trouble. Complete Laceration.—In this form of laceration the most important consideration is the restoration of the func- tion of the sphincter (Fig. 59). The Bland retractor should PERINEORRHAPHY; POSTERIOR COLPORRHAPHY 143 Fig. 59.—Complete laceration associated with cystocele. Fig. 60.—Suture of the ends of the sphincter muscle. 144 CARE OF GYNECOLOGIC PATIENTS be placed with a point at the extremity of the tear at either side, and will thus render tense the line of the septum, which should be split and anterior and posterior flaps formed. The posterior flaps are sutured, preferably by the Lauenstein suture, to form the anterior wall of the rectum. The ends Fig. 61.—Operation completed. of the torn sphincter which have been exposed by the dissec- tion are united by two chromic catgut sutures (Fig. 60), and then the levator ani muscles and the vaginal wall and skin surfaces united, as in the previous operation (Fig. 61). The surface should be cleansed with alcohol and water and the line of incision painted with the diluted iodin. A sterile PERINEORRHAPHY; POSTERIOR COLPORRHAPHY 145 pad should be kept over the vulva and the surface irrigated after the evacuation of the urine, and particularly when the bowels have been moved. The procedures described present the principal operative measures performed upon and through the vagina, and afford the principles which should govern any operation on this tract. 10 INDEX Abdominal hysterectomy, 77 operations, 62 pain and tenderness, 48 After-care, 29 Amputation of cervix, 123 Anastomosis, intestinal, 82 Anterior colporrhaphy, 128 gastro-enterostomy, 92 Catheterization, 32 Cervix, amputation of, 123 repair of, 119 Cholecystectomy, 100 Cholecystocolostomy, 101 Cholecystoduodenostomy, 101 Cholecystogastrostomy, 101 Cholecysto-ileostomy, 101 Cholecystojejunostomy. 101 Cholecystostomy, 100 Cholecystotomy, 100 Choledochectomy, 100 Choledochoplasty, 101 Choledochostomy, 100 Choledochotomy, 100 Colporrhaphy, anterior, 128 posterior, 138 Curetment, 116 Depilatory, 12 Dilatation, 116 Drainage, 24 Dressings, 25 Fecal fistula, 60 Field, preparation of, 12 Fistula, fecal, 60 Gall-bladder operations, 97 Gastrectomy, partial, 96 Gastric operations, 86 Gastroduodenostomy, 96 Gastro-enterostomy, anterior, 92 posterior, 94 Gastro-gastrostomy, 96 Gastropexy, 87 Gastrotomy, 91 Hemorrhage, 42 Hypodermoclysis, 40 Hysterectomy, abdominal, 77 subtotal, 77 vaginal, 132 Ileus, 58 Incision, 15 median, 17 Pfannenstiel, 19 Instruments, 16 for amputation of cervix, 124 for anterior colporrhaphy, 129 for dilatation and curetment. 117 for gastrotomy, 91 for hysterectomy, abdominal, 78 vaginal, 133 for intestinal anastomosis, 83 for intravenous inj'ection, 39 i47 148 INDEX Instruments for operations on Fallo- pian tube, 68 on gall-bladder, 98 on kidney, 106 on spleen, 104 for ovariotomy, 74 for perineal operations, 139 for salpingectomy, 68 for shortening round ligaments, 63 for trachelorrhaphy, 120 Intern, duties of, 11 Intestinal anastomosis, 82 Intestines, resection of, 82 Kidney operations, 103 Laceration, complete, of perineum, 142 Levator ani muscles, rectovaginal interposition of, 138 Ligaments, round, shortening of, 62 Nausea, 41 Nephrectomy, no Nephropexy, 108 Nephrotomy, 109 Nourishment, 34 Nurse, duties of, 11 Operations, after-care, 29 cervix, amputation of, 123 repair of, 119 Fallopian tube, 67 gall-bladder, 97 gastric, 86 kidney, 105 renal tumors, in levator ani muscles, 138 ligaments, shortening of, 62 Montgomery's modification, 62 Operations, ovary, 67 pelvic floor, 138 perineum, complete laceration of, 142 spleen, 103 uterus, 77-132 dilatation and curetment, 116 vaginal, 114 Watkins', 130 Ovariotomy, 73 Pain, abdominal, 48 Panhysterectomy, 77, 80 Partial gastrectomy, 96 Patient, care of, after operation, 29 during operation, 27 on admission, n Pelvic floor, repair of, 138 operations, 62 Perineorrhaphy, 138 Perineum, complete laceration of, 142 Peritonitis, 49 Phlebitis, 56 Posterior colporrhaphy, 138 gastro-enterostomy, 94 Pylorectomy, 96 Pyloroplasty, 96 Rectovaginal interposition of leva- tor ani muscles, 138 Round ligaments, shortening cf, 62 Salpingectomy, 67 Salpingo-oophorectomy, 67 Salpingostomy, 72 Sepsis, 52 Shock, 36 Spleen, 103 Subtotal hysterectomy, 77 Supravaginal hysterectomy, 77 INDEX 149 Tenderness, abdominal, 48 Trachelorrhaphy, 119 Tympanites, 45 Vaginal hysterectomy, 129 operations, 114 Vomiting, 41 Uterus, dilatation and curetment of, 116 ! Watkins' operation, 130 vesicovaginal interposition of, 130 Wound, closure of, 21 SAUNDERS* BOOKS ----------- on ----------- Practice, Pharmacy, Materia Medica, Thera- peutics, Pharmacology, and the Allied Sciences W. B. SAUNDERS COMPANY West Washington Square Philadelphia 9, Henrietta Street Covent Garden, London Our Handsome Complete Catalogue will be Sent You on Request Medical Clinics of Chicago Issued serially, one octavo of 200 pages, illustrated, every other month. Per Clinic Year (July to May), six numbers: Cloth, $12.00 net. EXCLUSIVELY INTERNAL MEDICINE These bi-monthly publications are devoted exclusively to Clinical Internal Medicine in all its departments. They give you the bedside and amphitheater teachings of leading Chicago.internists, representing such large hospitals as Mercy, Cook County, St. Luke's, Michael Reese, and Sarah Morris Memorial. The widest variety of cases is included, bringing out forcibly every feature of history-taking, diagnosis, treatment, and general management. The cases are illustrated with x-ray pictures, photographs, pulse-tracings, and temper- ature charts; the technic of all laboratory tests is given in detail, and every aid that can serve to make the diagnosis and treatment of the cases thoroughly clear to the general practitioner is emphasized. These publications are clin- ical in the strictest sense—they are an exposition of diagnosis and treatment as actually practicedat the bedside and in the amphitheater. 2 SAUNDERS' BOOKS ON Musser and Kelly on Treatment A Handbook of Practical Treatment. By 82 eminent specialists. Edited by John H. Musser, M. D., and A. O. J. Kelly, M. D., University of Pennsylvania. Three octavo vol- umes, averaging 950 pages each, illustrated. Per volume : Cloth, $6.00 net; Half Morocco, $7.50 net. THE TREATMENT THAT IS ALL TREATMENT Every chapter in this work was written by a specialist of unquestioned authority. Not only is drug therapy given, but also dietotherapy, serumtherapy, organotherapy, rest-cure, exercise and massage, hydrotherapy, climatology, electrotherapy, x-ray, and radial activity are fully, clearly, and definitely discussed. Those measures partaking of a surgical nature have been pre- sented by surgeons. The Medical Record "The most modern and advanced views are presented. It is difficult to pick out any one topic that deserves special commendation, all parts fully covering their particular field, and written with that fulness of detail demanded by the every-day needs of the practitioner." Thomson's Clinical Medicine Clinical Medicine. By William Hanna Thomson, M.D., LL. D., formerly Professor of the Practice of Medicine and of Diseases of the Nervous System, New York University Medical College. Octavo of 667 pages. Cloth, $5.00 net; Half Moroc- co, #6.50 net. A RECORD OF 50 YEARS This new work represents over a half century of active practice and teach- ing. It deals with bedside medicine—the application of medical knowledge for the relief of the sick. First the meaning of common and important symp- toms is stated definitely; then follows a chapter on the use of remedies and a classification of them; next the section on infections, and last a section on diseases of particular organs and tissues. An important chapter is that on the mechanism of surface chill and "catching cold," going very clearly into the etiologic factors, and outlining the treatment. The chapter on remedies takes up non-medicinal and medicinal remedies and vaccine and serum therapy. The infectious diseases are taken up in Part II, while Part III deals with diseases of special organs or tissues, every disease being fully presented from the clinical side. PRACTICE OF MEDICINE 3 Tousey's Medical Electricity, Rontgen Rays, and Radium Medical Electricity, Rontgen Rays, and Radium. By Sinclair Tousey, M. D., Consulting Surgeon to St. Bar- tholomew's Hospital, New York. Octavo of 1219 pages, with 801 illustrations, 19 in colors. Cloth, #7.50 net; Half Morocco, ^9.00 net. NEW (2d) EDITION, RESET The revision for this edition was extremely heavy ; new matter has increased the size of the book by some 100 pages. About 50 new illustrations have been added. The new matter added includes : Diathermy, sinusoidal currents, radiography with intensifying screens, rontgenotherapy, the Coolidge and similar Rontgen tubes and the author's method of dosage, and radium therapy. The book has been enriched by including several of Machado's tabular classifications of electric methods, effects, and uses. Throughout the entire work everything concerning electricity, Jtr-rays, and radium in medicine, as well as phototherapy, is explained in detail—nothing is omitted. It tells you how to equip your office, and, more than that, how to use your apparatus, explaining away all difficulties. It tells you just how to apply these measures in the treatment of disease. The chapters on dental radiography are particularly valuable to those interested in dental work. Abbott's Medical Electricity Medical Electricity. By George Knapp Abbott, M. D., Dean and Professor of Physiologic Therapy and Practice, College of Medical Evangelists, Loma Linda, Cali- fornia. i2mo of 132 pages, illustrated. Cloth, $1.25 net. This new work gives the nurse the essentials of this subject. Dr. Abbott's style has made the difficult simple. The text is illustrated. 4 SAUNDERS' BOONS ON Gant's Work on Diarrhea Diarrhea, Inflammatory and Parasitic Diseases of the Gastrointestinal Tract. By Samuel G. Cant, M. 1)., LL.D., Professor of Diseases of the Sigmoid Flexure, Colon, Rectum, and Anus, New York Post-Graduate Medical School and Hospital. Octavo of 604 pages, with 181 illustrations. Cloth, $6.00 net; Half Morocco, #7.50 net. ILLUSTRATED This new work is particularly full on the two practical phases of the subject —diagnosis and treatment. For instance: While the essential diagnostic points are given under each disease, a fuller description of diagnostic methods is given in a special chapter. The differential diagnosis of diarrheas of local and those of systematic disturbances is strongly brought out. There is a special chapter on nervous diarrheas and those originating from gastrogenic and enterogenic dyspepsias. You get the psychotherapy of psychic diarrheas. You get reliable methods of simultaneously controlling associated constipation and diarrhea. You get a complete formulary—prescriptions from Dr. Gant's own practice. There is a chapter on hookworms, tapeworms and round worms, and on the diarrheas caused by them and other parasites. This chap- ter contains many excellent illustrations. The limitations of drugs are pointed out, the dangers of their use emphasized, and the indications for surgical intervention given. You get the technic in detail of all surgical procedures indicated—fully illustrated. Gant's Intestinal Stasis (Constipation and Obstruction) This work is medical, non-medical (mechanical), and surgical, the lat- ter really being a complete work on rectocolonic surgery. The chapters on therapeutic gymnastics and massage are the outgrowth of Dr. Gant's personal experience. You get practical articles on diverticulitis, peri- diverticulitis, pericolitis, perisigmoiditis {Jackson's membrane), Lane's kink, and affections of the ileocecal valve. Octavo of 575 pages, with 250 illustrations. By Samuel G. Gant, M. D., LL. D., New York Post-Graduate Medical School and Hospital. Cloth, £6.00 net ; Half Morocco, $7.50 net. "The best and most complete treatise on these subjects."—Medical Record. DIAGNOSIS AND TREATMENT 5 Cabot's Differential Diagnosis Differential Diagnosis. Presented through an analysis of 385 Cases. By Richard C. Cabot, M.D., Assistant Professor of Clinical Medicine, Harvard Medical School. Two octavos of 750 pages each, illustrated. Per volume : Cloth, $5.50 net; Half Morocco, $7.00 net. VOLUME I [New (3d) Edition—Just Out] : Headache, pain in various regions, fevers, chills, coma, convulsions, weakness, cough, vomiting, hema- turia, dyspnea, jaundice, and nervousness—21 symptoms and 385 cases. VOLUME 2 (Just Out): Abdominal and other tumors, vertigo, diarrhea, dyspepsia, hematemesis, enlarged glands, blood in stools, swelling of face, hemoptysis, edema of legs, frequent micturition and polyuria, fainting, hoarse- ness, pallor, swelling of arm, delirium, palpitation and arhythmia, tremor, ascites and abdominal enlargement—19 symptoms and 317 cases. Morrow's Diagnostic and Therapeutic Technic Diagnostic and Therapeutic Technic. By Albert S. Morrow, M.D., Adjunct Professor of Surgery, New York Poly- clinic. Octavo of 830 pages, with 860 original line drawings. Cloth, $5.00 net. NEW (2d) EDITION^ Dr. Morrow's new edition is decidedly a work for you—the physician en- gaged in general practice. It is a work you need because it tells you just how to perform those procedures required of you every day, and it tells you and shows you by clear, new line-drawings, in a way never before approached. The information it gives is such as you need to know every day—transfusion and infusion, hypodermic medication, Bier's hyperemia, exploratory punc- tures, aspirations, anesthesia, etc. Journal American Medical Association " The procedures described are those which practitioners may at some time be called on to perform." 6 SAUNDERS' BOONS ON Garrison's History of Medicine History of Medicine. With Medical Chronology, Biblio- graphic Data, and Test Questions. By Fielding H. Garrison, M. D., Principal Assistant Librarian, Surgeon-General's Office, Washington, D. C. Octavo of 763 pages, illustrated. Cloth, $6.00 net; Half Morocco, $7.50 net. THE BAEDEKER OF MEDICAL HISTORY The work begins with ancient and primitive medicine, and carries you in a most interesting and instructive way on through Egyptian medicine, Sumerian and Oriental medicine, Greek medicine, the Byzantine period; the Mohamme- dan and Jewish periods, the Medieval period, the period of the Renaissance, the Revival of learning and the Reformation ; the Seventeenth Century (the age of individual scientific endeavor), the Eighteenth Century (the age of theories and systems), the Nineteenth Century (the beginning of organized ad- vancement of science), the Twentieth Century (the beginning of organized preventive medicine). You get all the important facts in medical history; a biographic dictionary of the makers of medical history, arranged alphabetically; an album of medical portraits; a complete medical chronology (data on dis- eases, drugs, operations, etc.); a brief survey of the social and cultural phases of each period. McKenzie on Exercise Sz! Exercise in Education and Medicine. By R. Tait McKenzie, B. A., M. D., Professor of Physical Education, and Director of the Department, University of Pennsylvania. Oc- tavo of 585 pages, with 478 illustrations. Cloth, $4.00 net. D. A. Sargent, M. D., Director of Hemenway Gymnasium, Harvard University. " It cannot fail to be helpful to practitioners in medicine. The classification of athletic games and exercises in tabular form for different ages, sexes, and occupations is the work oi an expert. It should be in the hands of every physical educator and medical practitioner " Carter's Diet Lists Diet Lists of the Presbyterian Hospital of New York City. Compiled, with notes, by Herbert S. Carter, M. D. i2mo of 129 pages. Cloth, $1.00 net. Bonney's Tuberculosis Second Edition Tuberculosis. By Sherman G. Bonney, M. D Professor of Medicine, Denver and Gross College of Medicine. Octavo of qz c paees with 243 illustrations. Cloth, #7.00 net; Half Morocco, #8 50 net ' THE PRACTICE OF MEDICINE 7 Anders* Practice of Medicine A Text=Book of the Practice of Medicine. By James M. Anders, M. D., Ph. D., LL. D., Professor of the Practice of Medicine and of Clinical Medicine, Medico-Chirurgical Col- lege, Philadelphia. Handsome octavo, 1332 pages, fully illus- trated. Cloth, #5.50 net; Half Morocco, $7.00 net. NEW (I2th) EDITION The success of this work is no doubt due to the extensive consideration given to Diagnosis and Treatment, under Differential Diagnosis the points of distinction of simulating diseases being presented in tabular form. In this new edition Dr. Anders has included all the most important advances in medicine, keeping the book within bounds by a judicious elimination of obsolete matter. A great many articles have also been rewritten. Wm. E. Quine, M. D., College of Physicians and Surgeons, Chicago. " I consider Anders' Practice one of the best single-volume works before the profession at this time, and one of the best text-books for medical students." DaCost&'s Physical Diagnosis Physical Diagnosis. By John C. DaCosta, Jr., Asso- ciate Professor of Medicine, Jefferson Medical College. Octavo of 589 pages, with original illustrations. Cloth, $3.50 net. NEW (3d) EDITION In Dr. DaCosta's work every method given has been carefully tested and proved of value by the author himself. Normal physical signs are explained in detail in order to aid the diagnostician in determining the abnormal. Both direct and differential diagnoses are emphasized. The 243 original illustra- tions are artistic as well as practical. Henry L. Eisner, M. D., Professor of Medicine, Syracuse University. " I have reviewed this book and am thoroughly convinced that it is one of the best ever written on the subject. In every way I find'it a superior production." SAUNDERS' BOOKS ON Sahli's Diagnostic Methods Edited by Nath'l Bowditch Potter, M.D. A Treatise on Diagnostic Methods of Examination. By Prof. Dr. H. Sahli, of Bern. Edited, with additions, by Nath'l Bowditch Potter, M.D., Assistant Professor of Clinical Medicine, Columbia University. Octavo of 1225 pages, pro- fusely illustrated. Cloth, $6.50 net. SECOND EDITION, RESET Lewellys F. Barker, M. D. Professor of Medicine, fohns Hopkins University " I am delighted with it, and it will be a pleasure to recommend it to our students in the Johns Hopkins Medical School." Friedenwald & Ruhrah on Diet Diet in Health and Disease. By Julius Friedenwald, M. D., Professor of Diseases of the Stomach, and John Ruhrah, M. D., Professor of Diseases of Children, College of Physicians and Surgeons, Baltimore. Octavo of 85 7 pages. Cloth, $4.00 net. NEW (4th) EDITION Dietetic management in all diseases in which diet plays a part in treat- ment is carefully considered, the articles on diet in diseases of the digestive organs containing numerous diet lists and explicit instructions for administra- tion. The feeding of infants and children, of patients before and after anes- thesia and surgical operations, are all taken up in detail. = W." l\ S6emS l° r?e„that, y?u have Prepared the most valuable work of the kind now avail- SSii EcTOK feLS %£^J&3££r*of different kinds°f &F- Eggleston's Prescription Writing This new work is a crystallization of Dr. Eggleston's long experience m teaching this subject. It covers the entire field in a most practical way taking up grammar, construction, dosage, vehicles, incompatibility ad- ministration, etc. J' &fv%^lJtf&^W%%& I™ «» Pharmacology „ PRACTICE OF MEDICINE 9 Kemp on Stomach, Intestines, and Pancreas Diseases of the Stomach, Intestines, and Pancreas. By Robert Coleman Kemp, M. D., Professor of Gastrointes- tinal Diseases at the New York School of Clinical Medicine. Octavo of 1025 pages, with 377 illustrations. Cloth, $6.50 net; Half Morocco, 88.00 net. NEW (2d) EDITION It is the practitioner who first meets with these cases, and it is he upon whom the burden of diagnosis rests. After the diagnosis is established, the practitioner, if properly equipped, could frequently treat the case himself instead of transferring it to a specialist. This work is intended to equip the practitioner with this end in view. The Therapeutic Gazette *' The therapeutic advice which is given is excellent. ^ Methods of physical and chemical examination are adequately and correctly described." D&stedo's Materia Medica, Pharmacology, Therapeutics, and Prescription AWriting By W. A. Bastedo, M. D., Associate in Pharmacology and Therapeutics at Columbia University. Octavo of 602 pages, illustrated. Cloth, #3.50 net. THREE PRINTINGS IN SIX MONTHS Dr. Bastedo's new work has the distinct advantage of presenting the subjects from both the laboratory and the clinical sides. Dr. Bastedo for many, years devoted his entire time to laboratory work. Now, however, he is strictly a clinical man. He gives you the practical, daily application of that information he gleaned at first hand in the laboratory—facts you can use in your bedside practice. Because of this early laboratory training you are assured that his book is correct according to laboratory standards. Being now a strictly clinical man, you know that his book is modeled with the common purpose of all medical practice : The treatment of the sick. IO SAUNDERS' BOOKS ON Faught's Blood-Pressure Blood=Pressure from the Clinical Standpoint. By Francis A. Faught, M. D., formerly Director of the Laboratory of Clinical Medicine of the Medico-Chirurgical College of Phila- delphia. Octavo of 475 pages, illustrated. NEW (2d) EDITION Dr. Faught's book is designed for practical help at the bedside. It meets the urgent needs of the general practitioner, who heretofore had no book to which to turn in case of emergency. Every effort has been made to provide here a practical guide, full of information of a clinical nature, and presented in a way readily available for daily use by the busy man. Besides the actual technic of using the sphygmomanometer in diagnosing disease, Dr. Faught has included a brief general discussion of the process of circulation. The practical application of sphygmomanometric findings within recent years makes it imperative for every medical man to have close at hand an up-to-date work on this subject, Anders and Boston's Medical Diagnosis A Text-Book of Medical Diagnosis. By James M. An- ders, M.D., Ph.D., LL. D., Professor of the Theory and Prac- tice of Medicine and of Clinical Medicine, and L. Napoleon Boston, M. D., Professor of Physical Diagnosis, Medico-Chirur- gical College, Philadelphia. Octavo of 1248 pages, with 466 illustrations. Cloth, $6.00 net. NEW (2d) EDITION This new wor£ is designed expressly for the general practitioner. The methods given are practical and especially adapted for quick reference. The diagnostic methods are presented in a forceful, definite Way by men who have had wide experience at the bedside and in the clinical laboratory. The Medical Record " The association in its authorship of a celebrated clinician and a well-known labora- tory worker is most fortunate. It must long occupy a pre-eminent position." PRACTICE OF MEDICINE u Deaderick & Thompson's Endemic Diseases of South Endemic Diseases of the Southern States. By William H. Deaderick, M. D., Member American Society of Tropical Medicine; and Loyd Thompson, M. D., Charter Member American Association of Immunologists. Octavo of 546 pages, illustrated. Cloth, $5.00 net; Half Morocco, $6.50 net. This new work is really a collection of monographs on malaria, blackwater fever, pellagra, amebic dysentery, hookworm disease, and other intestinal parasites. Diagnosis, prophylaxis, and treatment are gone into in detail, giving you every aid to the correct interpretation of the symptoms presented, and every modern means of value in the prevention and treatment of the diseases discussed. Smith's What to Eat and Why Second Edition What to Eat and Why. By G. Carroll Smith, M. D., Boston. 12mo of 377 pages. Cloth, $2.50 net. With this book you no longer need send your patients to a specialist to be dieted— you will be able to prescribe the suitable diet yourself, just as you do other forms of therapy. Dr. Smith gives 'the why" of each statement he makes. It is this knowing why which gives you confidence in the book, which makes you feel that Dr. Smith knows. Ward's Bedside Hematology Bedside Hematology. By Gordon R. Ward, M. D., Fellow of the Royal Society of Medicine, London, England. Octavo of 394 pages, illustrated. Cloth, #3.50 net. Slade's Physical Examination & Diagnostic Anatomy Physical Examination and Diagnostic Anatomy. By Charles B. Slade, M. D., Chief of Clinic in General Medicine, University and Bellevue Hospital Medical College. i2mo of 146 pages, illustrated. Cloth, $1.25 net. 12 SAUNDERS' BOOKS ON Stevens* Therapeutics Fifth Edition A Text-Book of Modern Materia Medica and Therapeutics. By A. A. Stevens, A.M., M.D., Lecturer on Physical Diagnosis in the University of Pennsylvania. Octavo of 675 pages. Cloth, $3.50 net. Dr Stevens' Therapeutics is one of the most successful works on the subject ever published. In this new edition the work has undergone a very thorough revision, and now represents the very latest advances. The Medical Record, New York " Among the numerous treatises on this most important branch of medical practice, this by Dr. Stevens has ranked with the best." Butler's Materia Medica Sixth Edition A Text-Book of Materia Medica, Therapeutics, and Pharma- cology. By George F. Butler, Ph.G., M.D., Professor and Head of the Department of Therapeutics and Professor of Preventive and Clinical Medicine, Chicago College of Medicine and Surgery, Medical Department Valpariso University. Octavo of 702 pages, illustrated. Cloth, $4.00 net; Half Morocco, $5.50 net. For this sixth edition Dr. Butler has entirely remodeled his work, a great part hav- ing been rewritten. All obsolete matter has been eliminated, and special attention has been given to the toxicologic and therapeutic effects of the newer compounds. Medical Record, New York " Nothing has been omitted by the author which, in his judgment, would add to the completeness of the text." Sollmann's Pharmacology Second Edition A Text-Book of Pharmacology. By Torald Sollmann, M.D., Professor of Pharmacology and Materia Medica, Western Reserve Uni- versity. Octavo of 1070 pages, illustrated. Cloth, $4.00 net. The author bases the study of therapeutics on systematic knowledge of the nature and properties of drugs, and thus brings out forcibly the intimate relation between pharmacology and practical medicine. J. F. Fotheringham, M.D., Trinity Medical College, Toronto. "The work certainly occupies ground not covered in so concise, useful, and scien- tific a manner by any other text I have read on the subjects embraced." Amy's Pharmacy Principles of Pharmacy. By Henry V. Arny, Ph. G., Ph. D., Professor of Pharmacy, New York College of Pharmacy. Octavo of "75 Page% with 246 illustrations. Cloth. #5.00 net. George Reimann, Ph. G., Secretary of the New York State Board of 1 liarmacy. " I would say that the book is certainly a great help to the student, and I think it ought to be in the hands of every person who is contemplating the study of pharmacy.' THERAPEUTICS AND MATERIA MEDICA 13 Hinsdale's Hydrotherapy Hydrotherapy : A Treatise on Hydrotherapy in General; Its Application to Special Affections; the Technic or Processes Employed, and the Use of Waters Internally. By Guy Hinsdale, M. D., Fellow of the Royal Society of Medicine of Great Britain. Octavo of 466 pages, illustrated. Cloth,$3-50 net. The Medical Record " We cannot conceive of a work more useful to the general practitioner than this, nor one to which he would resort more frequently for reference and guidance in his daily wcrk." Kelly's Cyclopedia of American Medical Biography Cyclopedia of American Medical Biography. By How- ard A. Kelly, M. D., Johns Hopkins University. Two octavos of 525 pages each, with portraits. Per set: Cloth, $10.00 net; Half Morocco, $13.00 net. Dr. Kelly, in these two handsome volumes, presents concise, yet com- plete biographies of those men and women who have contributed notewor- thily to the advancement of medicine in America. Dr. Kelly's reputation for painstaking care assures accuracy of statement. There are about one thousand biographies included. Swan's Prescription-writing and Formulary Prescription-writing and Formulary. By John M. Swan, M.D., Director Glen Springs Sanitarium, Watkins, N. Y. l2mo of 185 pages. Flexible cloth, $1.25 net. Stewart's Pocket Therapeutics and Dose- book New (4th) Edition Pocket Therapeutics and Dose-book. By Morse Stewart, Jr., M.D. 32mo of 263 pages. Cloth, $1.00 net. Bohm and Painter's Massage Massage. By Max Bohm, M. D., of Berlin, Germany. Edited, with an Introduction, by Charles F. Painter, M. D., Professor of Orthopedic Surgery at Tufts College Medical School, Boston. Octavo of 91 pages, with 97 practical illustrations. Cloth, #1.75 net. 14 SAUNDERS* BOOKS ON GET A w^^S **•>*• THE NEW the best imllieriCan STANDARD Illustrated Dictionary The New (8th) Edition, Reset The American Illustrated Medical Dictionary. By W. A. Newman Dorland, M. 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