Papers read 
BEFORE THE 
State Medical Society of Arkansas, 
—BY— 
<J. T. JELKS, 1XL. ID., 
—OF— 
HOT SPRINGS. 
LITTLE ROCK: 
Mitchell & Bettis, Printers, 
1889, A CASE OF TUBERCULOSIS OF KNEE JOINT WITH PERIARTIC- 
ULAR ABSCESS. 
In the winter of 1888, I was called by Dr. M. G. Thompson to see Mr. lllank. 
I found him suffering very much with his right knee, which was greatly swollen, 
the swelling extending up the thigh and down the leg, and from a small opening over 
the joint puss was exuding. Temperature 102 deg.; some cough. Leg and knee 
had been poulticed with flax seed meal. The small opening in the joint had been 
made by some previous medical attendant. The internal condyle of tibia was 
enlarged and painful: had been so for several years; pain in the joint also all 
this time. In autumn of 1887, he received a fall. Since that time patient has 
been worse; pain in the knee more severe. 
Diagnosis—Tuberculosis of head of tibia with secondary infection of the joint 
and periarticular abscess. 
The abscess was opened freely and scraped out with a Simon spoon in several 
places. The patient previously having his leg shaved, scrubbed with soap and 
water and Bichloride 1-1000, and lastly by sulp. ether. Large rubber drainage 
tubes, calibre % inch were carried down to the bottom of all the recesses of the 
abscess, cut off even with the skin and transfixed with safety pins. More than a 
pint of pus was evacuated from the leg and thigh. It had burrowed to the mid- 
dle of the thigh and also down near the middle of the leg. The drainage tubes 
I used had been kept constantly in a jar, in 5 per cent, solution of carbolic acid. 
The leg was now dressed with moist gauze, sublimated into the solution of the 
sublimate, some tartaric acid having been dissolved to render the bichloride 
stable. Over the gauze sublimated cotton, and over that more gauze. 
During the entire operation, the patient’s legs, feet and body were wrapped in 
antiseptic towels. 
The dressings were made abundantly large to absorb the discharges from the 
large cavities, and were changed once a week. In a few days temperature was 
normal. Improvement ceasing, it became a question of amputation or resection 
of the knee. Recent involvement of apex of right lung in the tubercular process 
rendered an operation imperative. By reason of his emaciated condition, the 
involvement of the lung and the rapidity with which he could be gotton into the 
fresh air decided amputation. 
After thorough antiseptic precautions as above described, with an Esmarch 
constrictor applied, amputation was performed at junction of middle with upper 
third of thigh by Dr. M. G. Thompson. Three vessels ligated, ligatures cut 
short and wound united with catgut sutures. Chloroform was used as an anaes- 
thetic, and we were twice compelled to stop its exhibition on account of respira- 
tion ceasing. After operation, bottles of hot water applied around the patient, 
he rallied slowly, and was well of the operation in about one month. I resected the ends of the tibia and femur and now present them to the society 
for inspection. 
You will notice several small cheesy masses on the surface of the bones, and 
also that the entire articular surface has been destroyed. These cheesy masses 
are tubercular, and from one or more of them an entrance was made into the 
joint. Secondary infection of the joint by the pus microbe followed, and the 
joint was thus destroyed. . 
He died about one year after the operation, from tuberculosis of the lungs. A 
few years ago these patients were all subjected to amputation or left to die a mis- 
erable, protracted death. It may be safely put down as a law that if only one 
lung is involved in the tubercular infection, resection is the remedy. If both 
lungs involved, amputation. By reason of antiseptic surgery, these patients get 
well after resections, whereas, formerly amputation was their only hope. 
Primary infection of a joint with tuberculosis bacilli is a rare affection. The 
microbes are usually stopped in the epiphesis of the long bones, thence find their 
way into a joint, produce a peculiar inflammation characterized by granulation 
tissue, more or less effusion into the joint, the masses of granulations giving the 
old name, “fungus degeneration.” 
From a vast number of experiments with this granulation tissue it has been 
clearly demonstrated that it is tubercular in character. The bacilli of tubercu- 
losis have invariably been found in them, and when the material has been inocu- 
lated on guinea pigs they have all died of tuberculosis. Again, this material in- 
serted into proper localities has always produced the so-called scrofulous gland 
disease. Again, material from these enlarged glands introduced into a joint, or 
into the peritoneal cavity invariably produces a tubercular joint affection, or a 
general tuberculosis, thus demonstrating beyon the shadow of a doubt the iden- 
tity of scrofula and tuberculosis. Again the bacillis of typhus has the same color 
reactions to aniline as that of tuberculosis, and when the microbe of lupus or 
lupus tissue is introduced into the peritoneal cavity of the guinea pig, tubercular 
peritonitis and general tuberculosis result, demonstrating that lupus is a tuber- 
cular skin disease. 
3 
GASTRO-ENTEROSTOMY FOR CANCER OF PYLORUS. 
In July 1888, Geo. F. aged forty years, laborer and student, consulted me for 
what he called dyspepsia. He had been treated for indigestion for several years 
without much benefit. For a year or more he had had frequent attacks of vom- 
iting after meals, the material being very acid. When I saw him he had been in 
bed for a week or ten days but complained of no pain. A few weeks prior to this 
time and for months before, he had suffered with great pain in the epigastric 
region. He was greatly emaciated, retaining his food for two or three hours 
only, when it was invariably vomited, the material frequently containing a “dark 
coffee ground” looking material. These symptoms together with slight tumor in 
the right of epigastric region led me to make the diagnosis of cancer of the 
pylorus. 
I told the patient what my diagnosis was, and that death from starvation was a 
certainty in a few weeks. With pencil and paper I drew for him a diagram of his stomach and the diseased portion and proposed resection of the pyloric end 
as holding out a slight hope. He declined to have anything done. For ten days 
I tried to sustain him with peptonized milk, though he took only a very small quan- 
tity, water being the only thing he could retain on his stomach. He had been 
starving for more than a month prior to consulting me. At the end of ten days 
he asked for, and urged me to attempt resection of the pylorus. Explaining to 
him both the resection and gastro-enterostomy, if the former could not be per- 
formed by reason of adhesions or the amount of tissue involved. He left me free 
to act as I thought proper when the stomach was reached. 
With the assistance of Drs. J. H. Gaines and M. G. Thompson and J. H. 
Carpenter I proceeded to do the operation. 
The room was prepared by being scrubbed with solution bichloride of mercury 
i-iooo and the walls and ceiling washed with the same; the instruments boiled 
for one hour in a 3 per cent, solution of carbolic acid. Each of the assistants 
and myself were bathed in a solution of sublimate 1-5000, care being taken to 
bathe the head and whiskers, the latter wrapped in carbolized towels and clean 
operating gowns donned. 
The patient was prepared for the operation by having a bath all over the day 
previous to the operation. At the time of operation the abdomen was shaved, 
scrubbed with soap and water then with bichloride solution 1-2000 this followed 
by the parts being washed in ether and again in boiled water. This being done 
the abdomen was opened in the linea alba from the umbilicus to the ensiform 
cartilage. All hemorrhage was checked with compression forceps before the per- 
itoneum was opened. When this membrane was opened on the grooved director 
the lower edge of the liver, presented also a portion of the stomach. With a little 
traction the latter organ was brought into the opening when it was ascertained 
that the anterior wall was involved in the cancerous deposit for nearly if not quite 
half its extent, including the pylorus and a portion of the duodenum and a large 
extent of the smaller curvature. The great omentum had about one hundred or 
more small secondary deposits. So much of the stomach was involved that I 
decided to make gastro-enterostomy instead of pylorectomy. 
Before opening the stomach and jejunum they were stitched together on what was 
to be the posterior part of the opening, a hole three-fourths of an inch made into 
both the stomach and jejunum and the parts united by continuous catgut sutures. 
During the operation, from time to time, patient required hypodermic injections of 
brandy and atropia by reason of great collapse. Time of the operation, one hour 
and fifty minutes, and he was so collapsed that all the details of the dressing were 
not carried out. Toilette of peritoneum was made, the abdomen stitched with in- 
terrupted suture of silk which had been previously boiled in three per cent, car- 
bolic acid and before the operation dropped into a one to twenty solution of same. 
Patient came out from the ether very weak. Hypodermic injections of brandy 
and atopia repeated. He was brought to bed and bottles of hot water placed 
around him, his head being lowered slightly. He talked some to his wife but 
died in a few hours. 
Three hours after death a post-mortem was held, body very much emaciated. 
Opening the abdomen I removed the pyloric end of the stomach. 
One of the greatest difficulties of the operation is the length of time required for 
4 5 
its performance. The patients being so weakened from loss of flesh and prev- 
ious enforced fasting they can not stand the long anaesthesia required for so many 
stitches. Thanks to Dr. Senn, of Milwaukee, the operation may now be per- 
formed in fifteen to thirty minutes by the use of decalcified bone plates. When 
the opening in the stomach is made one of the plates is slipped into it and the 
organ transfixed with the threaded needle, the bowel treated the same way, four 
knots tied and the work is done. It has been my pleasure to be with Dr. Senn 
in some of his experimental work in intestinal surgery and to witness the simplic- 
ity and effectiveness of the bone plates. I would urge upon those who have not 
done so, to purchase “Senn’s Intestinal Surgery.” 
REPORT OF CASES. 
Case /.yA--Mrs. M., while driving with her daughter was thrown from the bug- 
gy into the middle of the road and received a large scalp wound extending from a 
point between the eyes to the juncture of the parietal and frontal sutures, thence 
curving downward over the temple to a line drawn from the lowest point of the 
wound on forehead to the centre of the left ear over the seam. The scalp was cut 
to the bone—peeled from the same throughout its entire length and breadth—the 
flap resting on the left cheek. The entire surface of wound was covered with 
fine sand and gravel from the road-bed, much of it being ground in and re- 
quiring an hour for its removal. When this was accomplished the scalp was 
shaved for some distance around the wound, the entire part washed with three per 
cent, solution carbolic acid after it, the scalp, had been bathed with soap and 
water. After this the flap was adjusted, fastened with adhesive plasters, a pad of 
antiseptic cotton applied—over all a well adjusted bandage. Under the flap a 
few threads of antiseptic silk were drawn to act as drainage tubes. She was now 
removed to her house. The dressing was not disturbed for a week, and when re- 
moved the wound was found healed without one drop of pus, and scarcely a line 
shows where the wound was. 
Case 2nd.--l was called to attend a boy aged 14 years. Found him with a com- 
pound comminuted fracture of the head of the third metacarpal bone, from gun-shot 
wound. The ball entered on palm of hand, passing through and making its exit 
on back of wrist. There had not been very much hemorrhage. His hand was 
thoroughly scrubbed with soap and water, then with a solution of sublimate 
1-1500, after this the wound was injected with solution of iodoform in ether, the 
hand wrapped in sublimated cotton and an aseptic bandage applied. 
The wound healed under this one dressing without the presence of either pus or 
inflammation. It remained in place about three weeks. 
Compound fractures, or compound comminuted fractures, have until recently 
been the dread of all surgeons, but under the modern antiseptic and aseptic man- 
ner of dressing them, they heal as kindly and readily as any other wounds, and 
without suppuration. It may be put down as a fact that there is no such thing as 
“laudable puss” about which we used to hear so much. There is no pus without 
the pus microbes, and if they get into a wound it is through the negligence or ig- 
norance of the surgeon. When called to a wounded man we should not interfere 6 
in any manner whatever with the wound until we are prepared to do it aseptic- 
ally. If patient is suffering from collapse, administer to that symptom, get him to 
his home and go deliberately to work to render the patient, his wound, the person 
and hand of the surgeon aseptic. If it is a compound fracture never attempt to 
reduce the fracture until the patient is ready for the permanent dressing. After 
his conveyance to his home then thoroughly scrub the parts about the wound with 
an antiseptic solution, either of a three per cent, solution of carbolic acid or a 
i-1500 of corrosive sublimate. If it is a compound fracture the ends of the bone 
should be well washed with it, before reduction is attempted. I emphasize these 
antiseptic precautions to which I attribute the success of modern surgeons, be- 
cause I have recently seen or known of men who pretended to considerable sur- 
gical skill, operate without much preparation. I have seen a surgeon while en- 
gaged in a dangerous operation scratch his arms and then go ahead with his 
work. Is it any wonder such an operator has pus in his wounds? Again I have 
seen an assistant who was presumably well drilled, and who had cleaned up thor- 
oughly, put the needles into his mouth and then use them on the wound. To those 
of us who know that the mouth of the ordinarily healthy man contains twenty or 
more different varieties of microbes and among the number, the staphlococcus 
aurius and albus, it is no wonder that an operator does not always succeed when 
he has such an assistant. Another surgeon I have known to get ready to syringe 
out a uterus, supposed to contain retained menstrual blood, by putting his syringe, 
taken I suppose from the dusty and dirty drawer in his office, on the soiled carpet 
of an ordinary hotel room. Such practice is criminal in its negligence or ignor- 
ance. Another surgeon prepares for an amputation by placing his saw on the 
floor by his side, presumably for convenience. Another covers the table on which 
are his instruments, with the ordinary newspaper, possibly it had been lying in 
anything but a clean office for weeks. Other surgeons I have seen use an old 
dusty, velvet lined tray as an instrument tray, the bottom of the tray covered with 
a slip of newspaper, during some operation. I noticed an assistant with a soiled 
looking sponge with which he was endeavoring to remove some blood from a 
facial wound. The patient vomited, the assistant’s sponge rested on the vomit- 
soiled face and was from time to time pressed into the wound. And yet such 
operators cry out against antisepsis in surgery. Another surgeon will blow his 
nose on a soiled handkerchief, put this back in his soiled and dusty pocket and 
then proceed with his operation as though the catarrhal secretions from his nose 
did not contain thousands of pus microbes, either the stapholococcus aurius, or S. 
albus, or the streptococcus pyogene. Of course, the hands become soiled by 
such proceedings and should never be allowed to touch a wound surface until they 
have been thoroughly cleaned. Neither should an operator allow his hands to 
scratch his head or beard or touch or handle a chair or any article of furniture in 
the room, or even his own or the patient’s clothing. If he does he is not aseptic. ARTHROTOMY OF KNEE JOINT FOR FLOATING BODY AND 
SYNOVITIS. 
7 
I was asked by Dr. M. G. Thompson to see Mrs. B. She was a large, fleshy 
woman, about forty years old; has complained of pain and swelling in the knee 
joint for some years. When walking the streets would be suddenly attacked with 
the pain and be as suddenly relieved of it. She has been treated for years for 
rheumatism of the joint. Upon examination, I found a swollen, tender joint, with 
fluctuation and enlargement of the quadricep bursae. Upon careful handling of 
the joint, I detected a loose substance on the exterior of the joint at the point 
where the condyles of the femur and tibia come together. This was soon lost to 
be again found after some manipulation. I diagnosed loose cartilage and advised 
arthrotomy for it. Patient consented, and on the 7th day of April, with Drs. 
Barry and Thompson assisting me, I operated on the case. My hands and arms 
were thoroughly scrubbed with a brush, and sublimate solution 1-1000, special 
care being used to render the under surface of the fingernails clean with the pen- 
knife, and then soaking them for two or three minutes in alcohol. Then they 
were well scrubbed with Bichloride 1-1000 for five to ten minutes. All the 
knives, forceps, safety pins and needles were passed through the flame of an alcohol 
blow-pipe or lamp and then dropped into a 5 per cent. sol. carbolic acid where 
they remained until needed. Cat gut sutures were used, prepared after the 
manner of Kocher. They were also dropped into the carbolic acid solution. 
The patient having previously had a bath, she was moved into a room from which 
the carpet had been taken up, and the floor of which had been well scrubbed 
with a 1-1000 solution of Bichloride of mercury. Her right leg was then well 
shaved from midway the leg to midway the thigh, washed with sulphuric ether to 
remove the fatty matters of the skin, then washed with soap and water, the 
scrubbing brush being freely used. After this, the leg was scrubbed with 
Bichloride, 1-1000, the feet of both legs and the bed were covered up in towels 
wrung out of Bichloride solution. She was anaesthetized with chloroform and the 
joint opened, on what we thought was the loose cartilage, but when we got into 
the joint it had again disappeared. I then passed my index finger into the 
joint and searched all it recesses, but the one behind the femur, and failed 
to find the substance we had operated for, but in the joint were several tufts of 
floating fringes, we might call them. After a dilligent search, I withdrew my 
finger and turned my head away to look for some instruments, and Dr. Thompson 
said it came out with a gush of synovial fluid. A small drainage tube was then 
iuserted so that its inner end just penetrated the capsule of the joint. The 
latter was united by a continuous suture of cat gut. Then the fascia was also 
united and finally the skin, but I forgot to put a safety pin through the drainage 
tube. The knee was now wrapped up in absorbent gauze which had been boiled 
for one hour, and then boiled for another hour in Bichloride of mercury, I-10000. 
Over this gauze, several layers of absorbent cotton, dry, were wrapped, and over 
the cotton a bandage of sublimated gauze and over that a sheet of rubber tissue 
was placed, and the whole leg then incased in a plaster of paris bandage. Let 
me say, that before the wound was closed, I irrigated the knee joint with 5 per 
cent, solution of carbolic acid, and then again with Bicloride solution 1-2000. Patient came out from under the chloroform very nicely indeed. During the 
afternoon next day she had a slight elevation of temperature, I believe as high as 
ioo, but after the second day her temperature and pulse remained normal. 
Wound was dressed on the seventh day under the same antiseptic precautions as 
had characterized the operation. The drainage tube was found somewhat buried 
in the tissues, but by opening the wound it was extracted without difficulty. 
April 17th the knee was redressed by Dr. M. G. Thompson and found healed 
with exception of a small granulating surface. Motion in the joint good and pain- 
less, swelling all subsided and patient expresses herself as feeling well. This 
last dressing was made without the plaster paris covering, and was retained in 
place for one week or ten days when she was allowed to get up and go around 
the house. 
May 4th, 1889, when last heard from, the patient was at her home, in Indiana, 
very well indeed. 
8