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Full text of "The American journal of surgery. Quarterly supplement of anesthesia and analgesia (American journal of anesthesia and analgesia) Oct. 1914-Apr. 1926"

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american 
Journal of Surgery 

WALTER M. BKICKNER, B.S., M.D., F.A.C.S. JOSEPH MACDONALD, Jr., M.D. 

Editor-in-Chief Managing Editor 

JAMES P. WARBASSE, M.D., F.A.C.S., Special Editor 
ERWIX REISSMAN, M.D., Assistant Editor 

Associate Editors: 

ELI MOSCHCOWITZ, A.B., M.D., HAROLD HAYS, A.M., M.D., F.A.C.S., 

Surgical Pathology Surgery of the Throat and Ear 

IRA S. WILE, M.S., M.D., SAMUEL M. BRICKNER, A.M., M.D., 

Surgical Sociology Gynecology and Obstetrics 

HYMEN R. MILLER, B.S., M.D., ISADOR C. RUBIN, M.D., 

General Surgery Gynecology and Obstetrics 

MURR.AY H. BASS, A.B., M.D., 
Pediatric Surgery 

ALICE CHADWICK (N. Y. Public Library), Index Editor 



Quarterly Supplement of Anesthesia and Analgesia 

[American Journal of ^Vnesthesla and Analgesia} 

F. HOEFFER McMECHAN, A.M., M.D. (Cincinnati.) 

Editor 

Associate Editors: 

JAMES TAYLOE GWATHMEY, M.D., CHARLES K. TETER, D.D.S., M.D., 

New York, N. Y. Cleveland, O. 

WILLIS D. GATCH, M.D., F.A.C.S., CARROLL W. ALLEN, M.D., F.A.C.S., 

Indianapolis, Ind. New Orleans, La. 

ARTHUR E. HERTZLER, M.D., F.A.C.S., E. I. McKESSON, D.D.S., M.D., 

Kansas City, Mo. Toledo, O. 

DUDLEY W. BUXTON, M.D., M.R.C.P., PROF. YANDELL HENDERSON, Ph.D., 

London, Eng. New Haven, Conn. 

JOHN D. MORTIMER, M.D., F.R.C.S., ISABELLA C. HERB. M.D., 

London, Eng. Chicago, 111. 

W.M. HARPER DeFORD, D.D.S., M.D., 
Des Moines, la. 



VOLUME XXIX 



1915 . C^% ' 



COP\T«IGHT. 1915 

By Thf. Surgery Publishing Co., 

NEW YORK 



THE SURGERY PUBLISHING CO. 

93 \\'iLLi.\M Street 
NEW YORK, U. S. A.. 






Contributors to v olume XXIX 



[Those marked with an * have made editorial contributions.] 



ALBEE, FRED H. 
ASCH, JOSEPH T. 
ASHHURST, AStLEY P. C 

BALDWIN, J.F. 
'BASS. MURRAY H. 
BEATES, HENRY. Jr. 
BEER; EDWIN 
BERENS, T. PASSMORE 
BISHOP. ERXEST S 
BIZOT. A. R. 
BOOKMAN. MILTON R. 
BREESE, E. S. 
♦BRICKNER. SAMUEL M 
*BRICKNER. WALTER M. 
*BROWN, ROSE 
BUERGER, LEO 
BURDICK. W. P. 
BURROWS, ARTHUR 

CAMPBELL. WILLIS C. 
CARSTENS. L H. 
CLINTON. MARSHALL 
COON, CLARENCE E. 
CONNELL, KARL 
COTTON, F. J. 
CROHN, BURRILL B. 

DABNEY, S. G. 
DARRACH. WILLIAM 
DEA\'OR, T. L. 
DeFORD. WM. HARPER 
DENMAN. IRA O. 
DOWNEY, J. H. 
DuBOSE, F. G. 

EMBLEY. EDWARD HENRY 
ESTES. W. L. 
EVANS. C. A. 

FARR, RE. 
FORT. F. T. 
FOSTER. G S. 
FOTHERGILL. W. E 
FRANK. LOUIS 
*FRANK. ROBERT T 
FULD. JOSEPH E. 
FUNK, V. A. 

GATCH. \\-. D. 
GEWIN. W. C. 
GIBSON. CHARLES L. 
GINN. Cl'RTISo 



[ 
Pi 



^ 



.i^ 



GOODMAN, S. J. 
GRANT, H. HORACE 
GREEN, MAURICE 
GUEDEL. ARTHUR E. 
GWATHMEY, JAMES TAYLOE 

HAAS, SIDNEY V. 
HARTMAN. W. LOUIS 
HAYNES, IRVING S. 
*H.\YS, HAROLD 
HELLMAN, ALFRED M. 
HERB. ISABELLA C. 
HERRMAN, CHARLES 
HOGAN. JAMES J. 
HOLDING, ARTHUR F. 
HYMAN, A. 

JACKSON. JABEZ NORTH 
L\COBSON, J. H. 
JACKSON. REGINALD H. 
JOHNSTON, RICHARD H. 
JONAS, A. F. 

KAUFMAN. LOUIS RENE 
KAEMPFER, LOUIS G. 
KAKELS, M. S. 
KOHLMANN. W. 

LANE. SIR WILLIAM ARBUTHNOT 

LEVINGS. A. H. 

LEWISOHN. RICHARD 

LIEB. CHARLES 

LILIENTHAL. HOWARD ■■ •• 

LINK. GOETHE 

LONG. JOHN WESLEY 

LONG. WILLIAM HAMILTON 

LUCAS. H. A. 

LYDSTON. G. FRANK 

LYNCH. JEROME M. 

McKESSON, E. I. 
*McMECHAN. F. HOEFER 
M.^cMILLAN. HUGH W. 
MAGRUDER. ERNEST P. 
MANGES. MORRIS 
MARCY, WILLIAM H. 
MASSEY, G. BETTON 
MAYER. EMIL 
MEYER. WILLY 
MIERS. E. M. 
*MILLER. HYMEN R. 
MOORHEAD. TOHN J. 
MORRIS. ROBERT T. 



MORSE, DOUGLAS H. 
MOSCHCOWITZ, ALEXIS V. ' 
♦MOSCHCOWTTZ, ELI 

*NEUHOF, HAROLD 
NIFONG, FRANK G. 

PARSONS, ALBRO L. 
PIRRUNG, J. EDWARD 
POLLITZER, SIGMUND 
POWERS. CHARLES A. 
PRICE, JOHN W. 

RAVOGLI, A. 

RICKETTS. BENJAMIN MERRILL 

ROBERTS. W. O. 

ROETHKE, R. W. 

*RUBIN, ISADOR C. 

SACKETT. H. R. 
SCHAPIRA. S. WM. 
SECOR. WM. LEE 
SEFF. ISADORE 
SHERMAN. WM. O'NEILL 
SMITHIES. FRANK 
SONDERN. FREDERICK E. 
SQUIER, J. BENTLEY 
STETSON. H. G. 
STEWART, WILLIAM H. 

TAYLOR. .HOWARD C. 
TETER. CHARLES K. 
THOMA. KURT H. 
TOVEY, DAVID W. 

VANCE. AP MORGAN 
VANDER VEER. EDGAR A. 
VIRDEN, JOHN E. 

WALKER. JOHN B 
*WAREASSE. lAMES P. 
WARE. MARTIN W. 
WARNER. A. R. 
WASHBURN. BURTON A. 
WIGHT. I. SHERMAN 
nVILE. IRA S. 
WOGLOM. WM. H. 
WOLFE. C T. 
WOLLHEIM. J. L. 
WRIGHT, THEW 

YOUNG. JAMES K. 

ZIMMERMAN. B F. 



Index to v olume XXIX 



[Titles printed in sm.^ll capitals 
to editorial articles. * before a page 

PAGE 

A 

Abdomen, .^cute 194 

— Gi;nshot Wounds. See ZI^f- 

MERMAN. 

Abdominal Incision, Transverse. 

See also Farr. 
Abortion and Labor, Production of 195 
Ab.scess. Au-eolar. See Thoma. 

— Parapharjngeal 463 

—Subpectoral 231 

Accident Pre\-ention. A Bulletin 

o'' .• 386 

Accide.vts, Industrial; Alcohol- 
ism and J. __ 4151 



refer to original articles; those in lower case to abstracts, and those in italics 
number refers to .the Anesthesia Supplement.] 



PAGE 

Acid Cryst.^l. Pure ; A New 
Method of Applying. — Vance. . . 410 

Actinon.ycosis 464 

AiNHUM ; A Case Report. — Kauf- 
man 221 

ALBEE. FRED H.— The Inlay 
Bone Graft \'ersus La.ve Plates 
IN THE Treatment of Fractures 77 

.Alcoholism and Indu.strial Aca- 
DENTS 415 

.■Minientary Tract, Roentgen Ray 
Examination 411 

Alkaloidal MEDIC.^TI0N IN Rela- 
tion TO Anesthesia and Anal- 
gesia. — Herb : .*141 



page 
.'\mencan Association of Anesthe- 
tists *58, *89, *93, *160 

American Medical Editors' Associa- 
tion 

.Amputate, Where, When and 
How to; with Treatment of 
Gas Baollus Infectio.v. — H.\rt- 

MAN 

Amputation. Great Toe 

-Amputation.s. Revision 463 

-Amputations, War 357 

-Analgesia, Nitrous O.xid and Oxv- 

gen. in Obstetrics ..*128 

.Anastomosis, Bloodx^essel; with 
Especial Reference to the Use 
OF Canula-Forceps. — Price 431 



349 



451 
463 



PAGE 

Anastomosis. Arteriovenous, 359; 
Epiclidymis-vas, 462; Intestinal.. 167 

Anesthesia, Damages for Hot-water 
Bottle Burns Under *86 

— Fr.\ction.\l Rebreathing in. See 
McKesson. 

— KiDNEV Function .-xno. — Hog.'Kn. *75 

— Music in. See Burdick. 

— Nausea after, 72; Posture in.... *64 

— The Proper Depth of. — G.atch . . *38 

— For Fearful Patients, *62; in 
Operative Dentistry *94 

— A Full-Fledged Speci.\lty.- — 
Long *114 

Anesthesm, General; Resuscita- 
tion During Threate.ved F.'Vtal- 
iTiES Under. — Emblev *69 

Anesthesia, Local; in Gastro- 
enterostomy. See Breese. 

IN Major Surgerv ; with II- 

lustr.\tive Cases. — Du Bose .... *72 

— — in Dentistry, *166; in Major 
Operations, *63; Preventive of 
After-Pain and Shock *95 

— Oral, in the Surgery of Chronic 
Alveol.ar Abscesses. — Thoma . . . *79 

— Peridental : Intraosseous Meth- 
od, *160; Sacral *95 

Anesthesi.^, Nitrous Oxid: Color 
Changes and the M.^rgin of 
Safety in.— Morse *133 

— Nitrous-Oxid Oxygen Dosage in. 
— Connell *39 

— Oil- Ether Colonic. — Gwathmey *66 

— Oil-Ether Colonic, *166; Novo- 
cain *167 

— \'„por, and Resuscitation Appara- 
tus *161 

Anesthesia and Analgesia, The Fu- 
ture of I *88 

Anesthetic, Alleged Negligence in 
.'\dministering to a School Child. *86 

— Non-Abortive; Death from a *59 

Anesthetic Administered by Layman, 
Liability of Employer for Death 
or Employee under Operation... *60 

— ■ — — Medical Student. Surgeon 
Not Liable for Death Due to *59 

Anesthetics, Coroners' Inquests of 
Deaths Under *S7 

Anesthetist, Crumbs for the *1SS 

—Worthy of His Hire *5S 

—Dental: A Reprehensible Propa- 
ganda Against *1SS 

— Expert, and Analgesia *120 

— Unlicensed: The American Col- 
lege of Surgeons and *120 

.Aneurism, Traumatic, of the Ex- 
TER.N.^L Iliac Artery. — Clinton. 454 

Angioma, Tongue, 232 ; Uvula 232 

Angiomata, Cavernous ; Boiling Wa- 
ter Injections in the Treatment 
of 313 

Ano-Rectal Operations 411 

Anoci-Association, *61 ; in Dental 
Operations *159 

.Antiseptics Used in the Trea"!-- 
MENT OF Infections of the -Gen*- 
ito-LTrin.ary Organs, A Consid- 
ER-\TI0N of the. — R.WOGLI 14 

Anus and Rectum. Defects 320 

.Appendicectomy, Single Stitch 420 

Appendicitis, Acute; A View of 
114 Consecutive Operations, 
Without Mortality. — Wright. . 1^ 

.Appendicitis, 419, 4<51 ; Diagnosis,' ' 
30; Symptoms !^l^:._.^ 

— Gastric Ulcer and Choli.cystiusJl 4i§t) . 

Appendix Forceps. — Fulp' ..,'. . . . .'. ^B^ 

Arthritis. Multiple, 72; Pn^einnocQC-, , ,: 
cic, 392; Rheumatoid .f/l'y/. . i . .1. 232 

—Hands ..,.\fl . .W-^-.- . 72 

Arthroplasty of Elbow .391 



■ ■ P.^GE 

ASCH, JOSEPH J.— Acute Gon- 
orrheal Epididymitis and Its 

Treatment . . . ; 200 

.Asepsis. Some Benefits of 353 

ASHHURST, ASTLEY P. C— 
The Prevention of the Disabil- 
ities Following Fr.\ctures of 
the Limbs 114. 132 

B 

Bacillus. Boas-Oppler 194 

Back. Painful 463 

Backache in Ge.\ito-Urin.\ry Dis- 
eases. — Wollheim 406 

Banti's Disease 160 

HALDWIN, J. F.— Shockless 

Operations 281 

BEATES. HENRY.— a Report of 
Practic.\l Experience with Nar- 

co-Anesthesia 345 

BEER, EDWIN.— E.\RLY Recogni- 
tion of Malignant Dise.\se of 
THE Bladder and of the Pros- 
tate; OpER.'VTm: Therapy 247 

BERENS, T. PASSMORE— Am- 
bulant Otitic Meningitis 147 

BISHOP, ERNEST S.— Prelim- 

IN.^RY C0NSIDER.\TI0NS OF DrUG 

Addiction in Surgic.\l Cases... 435 

BIZOT, A. R.— FiBRO-LiPOMA 292 

Bladder. Gummatous Ulceration 

of. — schapira 213 

— Rupture, 30; Papillomata, 318; 

Tumors 185, 229 

— Tuberculosis vs. Adenoma 435 

— Tumor vs. Adenoma 455 

Bladder a.xd Prost.ate, E.\rl\' Rec- 
ognition OF Malignant Disease 
of; Operative Therapy.— E. 

Beer 247 

Blastomycosis of the Bones 450 

Blood Platelet E.xtr.\ct, a Physi- 
ological He.mostatic, in Nose 
AND Thro.\t Surgery". A Pre- 
limin.^ry Report. — Kaempfer . . 401 
— Transfusion. See Transfusion. 
Bone, An Oper.^tion for the Elon- 

G-^TioN OF. — Wight 18 

Bones, Alignment by Foreign Bodies 110 

BOOK REVIEWS: 

Abbott Laboratories. — Federal 
Narcotic Record Book 193 

Allen, C. W.— Local .Anesthesia.. *60 

Annals of Surgerv — General In- 
dex. Vols. 51-60 *122 

Bacon, C. S. — Obstetric Nursing; 
a Manual for Nurses and Stu- 
dents 156 

Bainbridge, W. S. — The Cancer 
Problem 69 

Barber, Edward S. — Practical An- 
esthetics with Nitrous Oxid and 
Oxygen *90 

Barnes. H. A. — The Tonsils; Fau- 

cial. Lingual, and Pharyngeal . . 28 
'Berkeley, C. and V. Bonney.^ 
The Difficulties and Emergen- 
cies of Obstetric Practice. 2d 
edition 156 

Braun. H. — Local Anesthesia : Its 
Scientific Basis and Practical 
Use. Translated and edited by 
P. Shields from the 3rd German 
edition *61 

Bradford, E. H.. and R. W. Lov- 

■ ett. — Orthopedic Surgery. Sth 

edition 459 

j Brewei*.! G. E.. and others. — A 
! Textbook of Surgery for Stu- 
'■■ 1 .Ments and Practitioners. 3d 
edition 418 

Brown. W. L., and J. K. Mur- 
ray. — -The Practitioner's Ency- 
clopedia of Medical Treatment. 459 



page 

Bruce, H. A. — Sleep and Sleep- 
lessness 354 

Bulkley. L. D. — Cancer : Its Cause 
and Treatment ^50 

Burghard, F. F. — A System of 
Operative Surgery. 5 voU. New 
edition 27 

Cameron, S. J. — A M: 

Gynecology for Students umi 
Practitioners 386 

Cannon, W. B. — Bodily Changes 
in Pain, Hunger, Fear and 
Rage *158 

Coriat, I. H. — The Meaning of 
Dreams 460 

Comet. Cy.— Acute General Mili- 
ary Tuberculosis ; Translated by 
F. S. Tinker 69 

Crile, G. W. — The Origin and Na- 
ture of the Emotions 317 

^Anemia and Resuscitation *121 

— -Anoci-Association *119 

Crossen, H. S. — Operative Gyne- 
cology 316 

Delorme. E. — Precis de Chirurgie 
de Guerre 28 

DeNormandie, R. L.^Case Histo- 
ries in Obstetrics 28 

De Swietochowski. G. — Mechano- 
Therapeutics in General Prac- 
tice 419 

DePuy. G. M.— The Stretcher 
Bearer 459 

Faught, F. A. — Essentials of 
Laboratory Diagnosis. Sth edi- 
tion 354 

Fischer. G. — Local Anesthesia in 
Dentistry. With Special Refr 
erence to the Mucous and Con- 
ductive Methods *89 

Gant, S. G. — Diarrheal. Inflamma- 
tory, Obstructive, and Parasitic 
Diseases of the Intestinal Tract 386 

Garrison, F. H. — John Shaw Bil- 
lings 316 

Gates, Eleanor. — ''Swat the Fly"; 
a One-act Fantasv 193 

Hegner. R. W.— The Germ-Cell 
Cycle in Animals 28 

Hirschman, L. J. — Hand-book of 
Diseases of the Rectum. 2d 
edition *15" 

Horsley. J. S. — Surgery of the 
Blood Vessels 417 

The International Medical An- 
nual. Year 33 387 

Kno.x. R.— Radiography; X-Ray 
Therapeutics and Radium Ther- 
apy 459 

Krause, F.. and R Heymann. — 
Text-book of Surgical Opera- 
tions. Translated and edited bv 
A. Ehrenfried. Vol. 1 '. 317 

Lederer. W. J. — The Principles 
and Practice of Tooth Extrac- 
tion and Local Anesthesia of 
the Maxills *121 

Lederle Antitoxin Laboratories. 
— Modern Biologic Therapeusis 460 

Lewis. B.. and E. G. Mark. — Cys- 
toscopy and LTrethroscopy 418 

Lewis. T. — Lectures on the Heart 227 

Maclennan. A. — Surgical Materials 
and Their Uses 69 

Mayo Clinic. Rochester, Minn., 
Collected Papers, edited bv Mrs. 
M. H. Mellish. Vol. 6. 1914. 

317. 355 

Mortimer. J. D. — Anesthesia and 
.Analgesia *6! 

Moynihan. Sir B. — Abdominal 
operations. 2 Vol. 3rd edi- 
tion 28 



PAGE 

Operations of Surgery (Jacob- 
son). Sixth edition by R. P. 
Rowlands and P. Turner. 2 
vol 459 

Oxford War Primers 459 

Park, R. — Selected Papers; Sur- 
gical and Scientific, from the 
Writings of Roswell Park, with 
a Memoir by C. (j. Stockton.. 29 

Park, W. H.. and A. \V. Wil- 
liams. — Pathogenic Micro-or- 
ganisms. Sth edition 28 

Parke, Davis & Co. — Collected 
Papers from the Research Lab- 
oratory. Vol. 3 387 

— A Manual of Biological Thera- 
peutics 69 

Polak, J. O. — A Student's Manual 
of Gynecology 156 

The Practical Medicine Series. 
Vol. II, General Surgery. Ed- 
ited by J. B. Murphy *1S7 

Preston, M. E. — Fractures and 
Dislocations 417 

Progressive Medicine. Edited by 
H. A. Hare and L. F. Apple- 
man 69, 193, 387 

Putnam, J, J. — Human Motives.. 418 

Robinson. W. J. — Fewer and Bet- 
ter Babies ; or, The Limitation 
of Offspring 317 

Royal Society of Medicine. — Sec- 
tion of Anesthetics; Proceed- 
ings. Vol. 7, 1913-14 *89 

Savidge, E. C. — The Philosophy 
of Radio-Activity or Selective 
Involution 156 

S c h o 1 1, T. — Balneo-Gymnastic 
Treatment of Chronic Diseases 
of the Heart 69 

Scudder. C. L. — The Treatment 
of Fractures. Sth edition 316 

Shattuck. G. C. — A Synopsis of 
Medical Treatment. '2d edition 387 

Starling, E. H. — Principles of Hu- 
man Physiology, 2d edition... 418 

Stewart, F. T.— A Manual of 
Surgery. 4th edition 417 

Sutherland. G. A.— The Heart in 
Early Life 156 

Swanberg, H. — The Invertebral 
Foramina in Man 387 

Tanton, J. — Fractures 417 

Taylor. H, C. — Cancer; Its Study 
and Prevention 386 

Text-book on Nervous Diseases. 
By G. Aschaffenburc; [a n d 
others]. Authorized English 
edition, edited by C. W. Burr. 
2 vols 354 

Thoma, K. H.— Oral Anesthesia. *90 

Todd. A, H.— A Practical Hand- 
book of Surgical After-Treat- 
ment 417 

Towns, C. B.— Habits that Handi- 
cap 459 

Tyson. J. — Selected Addresses on 
Subjects Relating to Education. 
Biographv. Travel, etc 156 

Walker, J. W. T.— Surgical Dis- 
eases and Injuries of the Gen- 
ito-Urinary Organs 27 

Wiggers. C. J. — Modern Asiiects 
of the Circulation in Health and 
Disease 418 

Williams. E. H. — The Question of 
.Mcohol 69 

Zinnscr, H. — Infection and Resist- 
ance. With a Chai>ter on Col- 
loids and Colloidal Reactions by 

S. W. Young '. 28 

BOOKMAN, MILTON R.— Com- 
plete Torsion of thk Great 

Omentum 304 

Bowel Injuries from Shell and bul- 
let 72 



PAGE 

— Surgery, Local Anesthesia in *158 

Bowels, After Rectal Operations.. 400 

Brain Surcerv, Anesthesia fur. — 
Teter *144 

Breast, Cancer, 318; Precancerous 
Changes 382 

—Hypertrophy; Senile Paren- 
chymatous. — Powers 446 

BREESE, E. S. — Gastro-Enteros- 
ToMY Under Local Anesthesia. 
Case Report 64 

BRICKNER, WALTER M.— 
Traumatic Forward Subluxa- 
tion OF the Shoulder: a Clin- 
ical Entity 51 

BUERGER, LEO. — Concerning 
Certain Problems in Urethro- 
VESicAL Diagnosis and Treat- 
ment (WITH DeSCRINTION UF A 

New Instrument) 54 

BURDICK, W. P.— The Use of 
Music in Local and General 

Anesthesia *107 

Burns, Management 356 

— A Note on the Proper Method 

OF Treating. — Herrman 63 

— Treatment by Exposure to .Air. 

—Haas 61 

BURROWS, ARTHUR.— The Ra- 
dium Treatment of Cancer of 

the Cervix of the Uterus 296 

Bursitis, Subacromial 157 

Bursopathy, Luetic 358 

C 

Catalase, Urinary 159 

Calculi, Ureteral 229 

Calculous Obstruction 229 

Calculus. See Gall-Stones. 
CAMPBELL, WILLIS C— Amber 
Color of Spinal Fluid with Co- 
agulation en Masse. Report of 

Case 348 

Cancer, AnotlKr "Treatment" ZZ^ 

— Delay in 255 

—Diagnosis; the General Prac- 
titioner's Responsibility in the 
Early. — Manges 377 

— — L.vboratory Aids and the 
Early. — Sondern 370 

— The Early Treatment of 278 

— Its Treatment by Physical 
Methods with and without Sur- 
gery. — Holding 1 

— Mammary Involution and 277 

—Mortality 262 

— A Plea. See Carstens. 
— Pre-Cancerous Lesions and 
Transition Types of Malignant 
Disease of the Tongue and 
Their Rei ation to Syphilis ; 
with Rem.arks on Early Diag- 
nosis and Operation, — Lydston. 33 

— Surgery. — Gibson 374 

— Symptoms, Ignorance of 298 

Cancer, Colloidal Copper in 359 

— Oxyproteic Acid in 360 

Cancer, Bladder, 250 377 

— OF THE Bladder ; the Early Di- 
agnosis OF. — Squier 248 

Cancer, Breast, 160. 246 318 

— OF THE Breast. — L. Fr.'Vnk 244 

— — The Imperative Necessity of 
Early Diagnosis and Early Op- 
eration IN Cancer of the 1'"e- 
male Breast. — Jackson 241 

— Cervix 301 

— OF the Cervix of the Uterus; 
Radium Treatment of. — Bur- 
rows. 

— Esophagus 318 

— OF the Esophagus, The Early 

Diagnosis of. — W. Meyer 252 

— Female Genital Organs, — Tay- 
lor 371 

—Gastric 379 



page 
— OF the Penis. Report of Two 

Cases. — Massey 299 

—OF THE Rectum, The Early 

Diagnosis of. — Lynch 274 

— OF THE Skin. — Pollitzer 330 

—Skin, 301; Surface 382 

— OF THE Stomach, The Early 

Di.\gnosis of. — Haynes 263 

— — The Early Diagnosis of: A 
Study of 921 Operatively and 
Pathologically Demonstrated 

Cases. — Smithies 255 

— OF THE Upper Air Passages, The 
Early Recognition of. — E. 

Mayer 251 

— L'terine, The Early Detection of. 279 

—Uterus, 422; Radiotherapy in 390 

Cancer and the Simple Life 155 

— See also Carcinoma. 

Carcinoma of the Uterus, Early 

Diagnosis. — R. T. Frank 238 

— See also Cancer. 
CARSTENS, J. H.— H.we "Can- 
cer ON THE Brain": A Plea.... 276 

Chest, Injuries to the. — Fort 395 

Childbirth, Painless, in France: 
.\ Note LIpon the Use of Toca- 

nalgi.ne. — Hellman 9 

Chloroform Toxicity and Hepatic 

Necrosis *62 

Cholecystectomy. See Gewin. 

Cholecystitis 189, 303 

Cholecystostomy. See Gewin. 
CLINTON, MARSHALL.— Trau- 
M.\Tic Aneurism of the Exter- 
nal Iliac Artery 454 

Cocaine Solutions; Asx. They In- 
jured BY Boiling? — Verden 288 

Coloptosis and Prostatic Disturb- 
ance 189 

Conjunctiva, Sarcoma of. See 

Wolfe. 
CONNELL, KARL.— Nitrous-Ox- 
id Oxy'gen Dosage in Anes- 
thesia *39 

COOK. F. WILLIAM.— The First 
Major Operation Under Ether 

IN England *98 

Coolidge Tube 458 

COON, CLARENCE E.— Bone 

and Joint Syphilis 211 

Consultation in Surgical Cases, 

The Question of. — Lilienthal,. 364 
COTTON, F. J— Hip Fr.^ctures . . . 96 
CROHN, BURRILL B.— The 
Early Diagnosis of Carcinoma 
iiF THE Bile and Pancreatic 

Ducts 270 

Cyst. Bone. 222 ; Ovarian 159 

Cystitis. Electrolysis for 30 

— Tubercular 391 

Cystography 30 

Cysts of the Neck. Congenital. — 
Funk 288 

D 

DABNEY, S. G.— Intr.\-Ocular 
Neoplasms. Clinical Report 
WITH Subsequent History Cov- 
ering Five to Twenty Years... 185 

Damaged Goods 25 

DARRACH, WILLI.AM.— Non-Re- 
ducing Operations for Frac- 
tures AND Dislocations 85 

Dkafness, Catarrhal. See Hays. 

DEAVOR. T, L.— Some Dangers 
Attending the Unguarded Use 
of Ether ; Observations Con- 
cerning Its Inflammability.... 286 

— Transfusion of Blood — Some 
Recent Orserv.\tions 10 

Decennial, Our 124 

DfI'OKD, WM, harper.— Con- 
tinuous Analgesia and Anes- 
thesia with Somnoform — The 
Technic of Administration +34 



PAGE 

DEKMAN, IRA O,, and E. I, Mc- 
KESSON. — Tonsillectomy: The 
FoKUARi) Inclin'eii Sitting Pos- 
ture Under N;0-0 Anesthesia, 
AND Other New Features 181 

Dentin, Anesthesia of, with Albar- 
gin *62 

Dentistry, Ethyl Chloride in. 
See Green. 

Diabetics, Preparation for Opera- 
ti.in 360 

Disinfection, Gasoline and Iodine 

415, 454 

DisPENs.VRY Problems, Some 68 

DOWNEY, J. II.— Fr.utures ok 
THE Lower E.xtremity and Their 
Treatment 98 

Drug .Xduiction m Surgical Cases, 
1'reliminary Considerations of. 
Bishop 435 

Du 150SE, F. G.— Local Anes- 
thesia IN Major Surgery; with 
Illustrative Cases *72 

E 

EDITORIALS: 

The American College of Sur- 
geons and Unlicensed Anesthe- 
tists :*120 

Another Cancer "Treatment". .. . 224 
Are the Ordinary Herniae Ever 

Traumatic f 223 

Blood Transfusion Still Further 

Simplified 383 

Boiling Water Injections in the 
Treatment of Cavernous Angi- 

omata 313 

The Congenital Theory of Hernia 

E'c'otces an Argument 352 

Crumbs for the Anesthetist *156 

The Cure of Vesico-Vaginal Fis- 
tula 384 

Damaged Goods 25 

The Early Detection of Uterine 

Cancer 279 

The Early Treatment of Cancer. 278 
The Morphine Addicted Surgical 

Patient 456 

Epidural Injection 464 

E.Xpert Anesthetists and Analge- 
sia *120 

Fractures 124 

The Future of Anesthesia and 

Analgesia *88 

Herniae and Damage Claims 413 

The McBurney Incision 25 

The Medical Pickti.'ick 65 

Nitro.vid Anesthesia — a Sugges- 
tion *120 

Our Decennial 124 

The Physician and Acute Osteo- 
myelitis 24 

Pyelography 312 

The Quadricentennial of Andreas 

Vcsalius 66 

Refusal io Submit to Anesthesia 
and Operation in Respect to 

War Pensions *I56 

The Removal of Needle Frag- 
ments from the Skeletal Mus- 
cles 191 

A Reprehensible Propaganda 

Against Dental Anesthetists *155 

Simple Methods of Blood Trans- 
fusion 153 

A Surqeon's Philosophy 412 

Trvilight Sleep ". 351 

The Unsettled Problem of Pyloric 

Occlusion ' 24 

W orth\< of His Hire 

EMBLEY, EDWARD HENRY.— 
Resuscitation During Threat- 
ened Fatalities Under General 
Anesthesia *69 



PACE 
Embryo, Human, Ninc-niillimeler. . 230 

Empyema 232, 319 

Epididymectomy 228 

tipididyniitis 30, 421 

— Acute Gonorrheal, and Its 

Treatment. — Ascii 200 

Epididyniotomy 421 

Epileptic Seizures, Cess.vito.'^ 
Akter Removal of Prepuce and 
I'lBROMA Imbedded in Urethra: 

Case Report. — Washburn 23 

Epithelioma, Radium in 410 

Erysipelas 300 

Esophageal Stenosis, A Review. — 

Roberts 1 72 

EsTES, W. L. — Fractures of the 

Femur 103 

Review of Fractures to Date 438 

Ether, Closed, and a Color Sign. . .*1(j() 
ii,ther. The First Major Opera- 
tion Under, in England, — Cook. *9^! 
— Some Dancers Attending the 
Unguarded Use of; Observa- 
tions Concerning Its Inflam- 

.M ability. — Deavor 286 

Etherization in Tuberculous Perito- 
nitis *94 

Ethmoiditis, Classilication 31 

Ethvl Chloride, Fifteen Years' 
Experience with It as an Anes- 
thetic. — Ware *1 12 

— — AS A General Anesthetic in 
Dentistry. — Green *117 

EYANS, C. a. — Unlocalized In- 
tracranial I NJ URIES 441 

F 

Factory Inspector.s, Medical 26 

Fallopian Tube, Congenital Ab- 
sence OF. See Grant. 

— — Hematoma in. A Case Re- 
port. — MiERS 151 

FARR. R. E. — The Transverse Ab- 
dominal Incision 347 

Fibro-Lipoma. — BizoT 292 

Fibroids, Ovarian 319 

[•'inger Injuries 360, 402 

First Aid Corps, The Value of 
Their Organiz.\tion and In- 
struction Along Railway Lines. 
—Lucas 329 

— — Teams, Socializing Through 192 

Fissures, Anal 410 

Fistula. Anal 320 

— Vesico-Vaginal, The Cure of 384 

Fistulae, Fecal ; A Method of 

CoNSKRviNG Nutritive Values 

IN High Lying. — Jackson 411 

Foot, Weak 423 

Forceps, An .Appendi.x. — Fuld 382 

FORT, I*". T. — Injuries to the 
Chest 395 

— — The Local Employment of 
Iodine in Suppurative Peritoni- 
tis 59 

FOSTER. G. S.— A Steel Pin 
Ope.n Method of Treating Frac- 
tures 321 

FOTHERGII.L. W. E— Anterior 
Colporrhaphy and Amput.ation 
OF the Cervix Combined as a 
Single Operation in the Tre.\t- 
MENT OF Genital Prolapse 161 

Fracture, Infected Compound, of 
the F'emur into the Knee Joi.nt. 
Treat.ment by Conservative Sltr- 

CERY. — LiLIENTHAl 118 

— Oper.\tions. Results of Some. 

— La ne 7i 

— Specialists 381 

Fractures. 124. 3')1 ; Alignment, 

118; Bone Transplantation in.... 127 



PACE 

—Classification of. — Walker .... 86 

— Conservative Treatment, 128; Dis- 
ease vs. Age in. 84; Fi.xation in 
0|)en Treatment 127 

— The Inlay Hone Graft versus 
Lane Plates in the Treatment 
OF. — .'\LI!KE 77 

—Lane Plate 86 

^The Operative Treatment of. — 
Long 214 

— Operative Treatment. 195; Radi- 
ography in, 102; Repair after.... 32 

I-'racturks, Review to Date. — 
Estes 438 

—Some Social Phases of 126 

— .Some Medico-Legal Features of. 
Marcy 121 

— .\ Steel Pin Open Method of 
Treating. — Foster 321 

—Treatment OF. — Zi.mmermann .. 90 

l''r;u'tures. Compound and Sup|)U- 

rating. at the Seat of War 128 

-Simple ; h'i.xation 157 . 

1-'raiti;res About the Anki.e. — 
PiRRUNG 110 

—.Ankle 158 

— OF THE Clavicle, The Abduction 
Treatment of. — Moorhead 120 

—Elbow 127, 158, 195 

— of THE 1'"emUR. — EsTES 103 

— Femur; .Imputation for, in the 
.\ged.— Link 218 

369; 15v Gunshot, 158; Both 

Femurs. 319; Neck of Femur. 32, 127 

— Hip. — Cotton 96 

— Humerus ; Birth 462 

— Larger Bones 77 

— of the Limbs, The Prevention 
AND Treatment of the Disabili- 
ties Following. — .Ashhurst. 114. 132 

— OF the Lower Extremity and 
Their Treatment. — Downey ... 98 

— IN the Neighborhood of Joints. 
— Young 115 

—Radius and Ulna 128 

— Tibia: Compression, 213; Un- 
united 157 

Fractures and Dislocations, Non- 
Reducing Operations for. — Dar- 
rach 85 

FR.A.NK, LOUIS.— Cancer of the 
Breast 244 

FR.\NK, ROBERT T.— The E.arly 
Di.\gnosis of Carcinoma of the 
Uterus 238 

FULD, JOSEUH E.— An Appen- 
dix Forceps 382 

FUNK, V. .A. — Congenital Cysts 
OF the Neck 290 

Furuncles 160 

G 

Gall-Bladder Disease. Cholecys- 
tostomy or Cholecystectomy i.v. 
— Gewin 219 

Gall-stones. 194; Roentgen Diagno- 
sis 159 

— See also Calculi. 

Gangrene. Extremities 359 

— Gas, 463; Experimental 463 

Gas Pains 29 

Gastric Operations. Roentgen Stu- 
dies .After 460 

Gastroenterostomy I'nder Local 
.\nesthesia: Case Report. — 
Breese 64 

GATCH. W. D.— The Proper 
Depth of .Anesthesia *3? 

Ge.vito-Urinary Infections, .Anti- 
septics I.v. See Ravocli. 

Tract. The Latest Method of 

Examining with the Roentgen 
Ray. — Stewart 404 



Page 
GEWIN, \V. C— Cholecystostomy 
OR Cholecystfxtomy in Gall- 
bladder Disease. A feviEW 219 

— — Ray.vaud's Disease; with a 

Report of a Case 188 

GIBSON, CHARLES L.-Cancer 

Surgery 374 

GINN, CURTISS.-Uterus"'Uni: 

coRNis— A Case Report 301 

Glands, Mesenteric; Tulx-rcular. 

194 ; Sublingual ' 424 

Goiter in Children ' . ' 15g 

— Exophthalmic 494 

GOODMAN, S. J.-The Teaching 
OF Obstetrics to Nurses: How 
Extensive Should Such a 
Course be Made ? 326 



58 
32S 



307 



Gorgas Medal 
Grafts, Bone . . . 

GRANT, H. HORACE.— Congen- 
ital Absence of Left Ov.xry and 
Fallopian Tube; Report of a 
Case, with a Survey of the Lit- 
erature 

GREEN, MAU RICE.— Ethyl 
Chloride as a General Anes- 
thetic IN Dentistry *117 

Growths, Fulguration Treatment... 160 

— Metastatic 237 

GUEDEL, ARTHUR E.— Nitrous 

OxiD in Obstetrics *109 

Gunshot Wounds of the Abdo- 
men. — Zimmerman 366 

Knee, 357; Spine 23' 

GWATHMEY, JAMES TAYLOE. 
Oil-Ether Colonic Anesthesia *66 



61 



H 

HAAS, SIDNEY V.— The Treat- 
ment OF Burns by Exposure to 

Air 

Hand, Nerves of; Sequelae of Mi- 
nor Injuries Incompletely Sev- 
ering.— Neuhof 143 

—Infections. See P.^rsons. 
Hare-lip, Club-foot and Syphilis 67 
HARTMAN, W. LOUIS.— When. 
Where and How to Amput.^te; 
WITH Treatment of Gas Bacil- 
lus Infection 451 

Have "Cancer on the Brain": A 

Plea. — Carstens 276 

HAYNES, IRVING S.— The Ear- 
ly Diagnosis of Cancer of the 

Stomach 263 

The Significance of Pyloric 

Spasm 

HAYS, HAROLD.— The 'Surgery 
OF the Posterior Tip of the In- 
ferior Turbinate; the Relation 
of the Posterior Tip to Catar- 
rhal Deafness and Tinnitus.. 
Head Injuries, Common.— Miers. . 
Health Officers, The Training 

of 

HELLMAN, ALFRED "m!—Anal1 
GEsiA. Anesthesia, and Amnesia 

IN Obstetrics *138 

— — Painless Childbirth in 
France: A Note Upon the Use 
OF Tocanalgine 9 



HERRMAN, CHARLES.— A Note^^'^^ 
ON THE Open Method of Treat- 
ing Burns 53 

Hernia, The Congenital Theory 
Evokes an Artjument 3S2 

—The Indications and the Con- 

TRA-INDIC.\TI0NS FOR THE OPERA- 
TIVE AND Truss Tre.\tments of. 

— A. V. MoscHcowiTZ 197 

— Local Anesthesia in 285 

—Pelvic. 371; Umbilical 230 

—Ventral; A Note on the Em- 
ployment OF the Transverse 
Fascia Imbricating Operation 
for Post-operative Ventral Her- 
nia.— Tovey 380 

Hernlae and Damage Claims 413 

—Are the Oniiuary Herniae Ever 

Traumatic :' . . . 2^3 

HOG AN, JAMES J^-kVdney 

Function and Anesthesia . . 7^ 
HOLDING, ARTHUR F.— The 
Treatment of Cancer by Phys- 
, ical Methods with and without 

Surgery j 

Hydrocephalus, Internal 196 

HVMAN, A.— The Application of 
Modern Urological Methods in 
the Diagnosis of Surgical Con- 
ditions OF the LIrinary Tr.-\ct.. 204 
Hypertension and Hypotension, Ar- 
terial *61 

Hyperthyroidism 159, 424 

Hysteria and Pelvic Disease 323 



JACOBS ON, J. H.-An all-metal^'^''^ 
Syringe for Use in Local Anes- 
thesia 349 

Jackson Veil 72 

JOHNSTON, RICHARD H.— To- 
tal Rhinoplasty. A Case Re- 
port 149 

Joint, Paralytic Flail.!!!!!!.!!!!.'.' 423 

— .\dhesions 353 

— Infections 462 

JONAS. A. F.—Surgic!v'l " 'Con- 
science. The Duty of Aseptic 
Technic 34] 



426 



20 
399 

354 



220 



Hematuria 

Hemorrhage from Middle Menin 
GEAL Artery Due to TRA^JM.^- 
tism; Hemiplegia. Motor Apha- 
sia ; Osteoplastic Flap for Liga- 
tion OF Vessel; Recovery.— 
Kakels 16 

—Gastric Ulcer, 337; PuVmonarv! 
390 ; Uterine .' . 230 

Hemorrhoids, The Advantagks of 
Combined Anesthesia in the 
Operative Treatment of.— Seff *44 

HERB. ISABELLA C— Alkai.oi- 
DAL Medication in Relation to 
Anesthesia and Analgesia *14l 



Incision, The Transverse Abdom- 

i NAL. — Farr 347 

—Transverse Abdominal 461 

Ileo-colic Glands, Inflammation 424 

Ileum, Terminal; A Note Con- 
cerning THE Surgical Relation 
OF THE Blood Supply of the. — 

ToTCY 300 

Infections, Genitc-ciu.vary. See 

Ravogli. 
—Hand. The Choice of Incisions 

IN. — Parsons 6 

— Pyocyaneus 302 

Inflamniation, Subdiaphragmatic . . 356 
Inhaler. Pharyngeal, for Anesthesia 

in Jaw Operations *16S 

Insufflation, Intratracheal. — 

RiCKETTS ■*147 

Insurance. Health 458 

Interstate Association of Anesthe- 
tists *90, *122 

Intestinal Adhesions, 419; Anasto- 
mosis, 167: Obstruction 193,230 

—Obstruction, Acute and Chron- 
ic. — Levinc,- 164 

— Resection 167 

Intestine, Large; Malignant Disease 387 
Intestines. See also Obstruction, 

Stasis, etc. 
Intracranial Injuries, LInlocal- 

iZED. — Evans 441 

Intralaryngeal Operation, Direct 

Method 32 

Intraoral Oper.'\tions. The Use of 
Conductive Anesthesia in. — 

MacMillan *130 

Intraurcthral Oi)erations 420 

Iodine in Peritonitis. See Fort. 

J 

JACKSON. JABEZ NORTH.- 
Tiie Imperative Necessity of 
Early Diagnosis and Early 
OpFRATioN IN Cancer of the Fe- 
male Breast 241 

JACKSON, REGINALD H.-!\ 
Means of Conserving Nutritive 
Values in High Lying Fecal 
Fistulae 41] 



KAEMPFER, LOUIS G.— Blood 
Platelet Extract, a Physiolog- 
ical Hemostatic, in Nose and 
Thro.\t Surgery. A Preliminary 
Report 401 

KAKELS, M. S.— Hemorrhage 
from Middle Meningeal Artery 
Due to Traumatism ; Hemiple- 
gia, Motor Aphasia; Osteoplas- 
tic Flap for Lig.\tion of Vessel; 
Reco\try 16 

KAUFMAN. LOUIS RENE.— Ai'n- 
hum: a Case Report 221 

Kidney, Hematogenous Infections.. 228 

— Pelvic — Pyonephrosis with 
Stones: A Case Report.— Kohl- 
mann 

—Function and Anesthesia. — Ho- 

GAN 

— Tests. Functional 

Kidney and Ureter, Stones in. 

KOHLMANN, W.— Pelvic Kid- 
ney — Pyonephrosis with 
Stones : A Case Report 



190 

*75 

71 

4^)1 



190 



Laboratory vs. Clinical Determina- 

ti"" 411 

LANE. SIR WILLIAM ARBUTH- 
NOT.— Results of Some Frac- 
ture Operations 73 

Lane Plate 86 

Laparotomy. Elevation of Patient 
After, 337; Stomach Dilatation 

During *168 

LEVINGS, A. H.— Acute ' ' 'and 
Chronic Intestinal Obstruc- 
tion 164 

LEWISOHN, RICHARD.— Blood 
Transfusion with One 20 ccm. 

Syringe 36I 

LIEB. CHARLES.— Treatment 'of 

Post-opkrative Shock *47 

LILIENTHAL, HOWARD.— In- 
fected Compound Fracture of 
THE Femur into the Knee Joint. 
Treatment by Conservative Sur- 
gery £18 

— — The Question of Consulta- 
tion IN Surgical Cases 364 

LINK. GOETHE.— Amput.\tion 
for Fracture of the Femur in 

THE Aged 218 

Lipoid. Brain ! 464 

Little's Disease 196 

Liver, Adenoma, 419; Traum.itisni! 356 
—Traumatic Rupture of the. — 

Stetson 334 

Localization, Fluoroscopic 118 

LONG, JOHN WESLEY.— The 
Operative Treatment of Frac- 
tures -714 

LONG. WILLIAM H'AMiL'fdN. " 
— .\ne,sthesia: a Full-fledged 

Specialty *] 14 

Louisville Society of Anesthetists. *124 
LUCAS, H. A. — The Value of the 
Organization and Instruction 
of First Aid Corps Along Rail- 
way Lines 329 



PAGE 

LVDSTON, G. FRANK.— Pre-can- 
CEROus Lesions and Transition 
Types of Malignant Disease of 
THE Tongue and Their Relation 
TO Syphilis; with I^makks on 
Early Diagnosis and Operation 33 

LYNCH, JEROME M.— The Early 
Diagnosis of Cancer of the 
Rectu m 274 

M 

McAllum, D. C. In Mcmoriam *I19 

McBurney Incision, The 25 

McKESSON, E. I. — Fractional 
Rebreathing in Anesthesia — 
Its Physiological Basis, Tech- 
Nic AND Conclusions *51 

MacMILLAN, HUGH W.— The 
Use ok Conductive Anesthesia 
IN Lntraoral Operations *130 

MAGRUDER. ERNEST P.— A 
Glimpse into Present-day Mili- 
tary Surgery. A Letter from 
THE Late E. P. Magruder, Gev- 
GELijA, Serbia 304 

MANGES, MORRIS.— The Gen- 
eral Practitioner's Responsibil- 
ity IN THE Early Di.^cnosis of 
Cancer 377 

MARCY. WILLIAM H.— Some 
Medico-Legal Features of Frac- 
tures 121 

MASSEY, G. BETTON.— Cancer 
OF THE Penis. Report of Two 
Cases 299 

MAYER, EMIL.— The Early Rec- 
ognition OF Cancer of the Upper 
Air Pass.\ges 251 

Mediastinum. Growths 160 

Medical Picku'ick. The 65 

Medication. Alkaloidal, in Rela- 
tion TO Anesthesia. See Herb. 

Medico-Legal Aspects of Anes- 
thesia AND Analgesia *59. *86 

Megacolon and Microcolon 230 

Meningeal Hemorrhage. See 
Kakels. 

Meningitis, Ambulant Otitic. — 
Berens 147 

Mesenteric Occlusion. Some Ob- 
serv.ations on. — Nifong 168 

MEYER. WILLY.— The Early 
Di.AGNOsis OF Cancer of the 
Esophagus 252 

MIERS, E. M.— Common Head In- 
juries 399 

• — Hematoma in the Fallopian 
Tube with Prolonged Uterine 
Hemorrhage. A Case Report.. 151 

MOORHEAD. JOHN J.— The Ab- 
duction Treatment of Fracture 
of the CL.wacLE 120 

MORRIS. ROBERT T.— The Sur- 
geon's Reput.\tion 22 

MORSE, DOUGLAS H.— Color 
Changes and the Margin of 
Safety in Nitrous Oxid Anes- 
thesia *133 

Mortality Rates. 1913.. 2^7 

MOSCHCOWTTZ. ALEXIS V.— 
The Indicatio.vs and the Con- 
tra-indications for the Opera- 
TH'E and Truss Tre.atments of 
Hernia 197 

Mu.ic. Its Use in Local and Gen- 
eral .'\nESTHESIA. — BURDICK . . . .*107 

Myositis. Gluteal 35,9 

N 

Nnrco-anesthesia, a Report of 
Practical Experience with. — 

Be.ate? 34s 

Nau=pa. Popt-anesthetic 72 

Xcrdic Fracjiucnts. Removal from 
the Skeletal Muscles 191 , 



PAGE 

Needles, Extraction, 196; Localiz- 
ing 391 

Neoplasia, Modern Aspects of the 

Problem of. — Woglom 233 

Neoplasms. Intra-ocul.vr. Clin- 
ical Report with Subsequent 
History Covering Five to Twen- 
ty Years. — Dabney 185 

Xeplirectomy 228 

Xc'-hrotomies, Hemorrhage After. . 70 
Nerve Blocking in Nose Operations. *I27 

—Defects. Repair, 391; Suture 357 

Xeuralqia. .-Mcohol Injections in... 31 
XEUHOF. HAROLD.- Sequelae 
OK Minor Injuries Incompletely 
SiA-ERixG Nerves of the Hand. 

Their Surgical Treatment 143 

X. \. Medical Reserve Corps Asso- 
ciation. Gorgas Medal 58 

XIFONG, FRANK G.— Some Ob- 
servations ON Mesenteric Oc- 
clusion 168 

Niiroxid Anesthesia — a Suggestion .*\2Q 
Nitrous-oxid for Dental Use, *62 ; 
Manufacture. *124; in Obstetrics, 
see Guedel; 13.000 Administra- 
tions *63 

— Manufacture of. for Use in 

Hospitals.— Warner *124 

Nitrous Oxid-oxygen Analgesia .'\p- 

paratus *163 

Dosage, See Connell. 



Obstetrics. Analgesia, Anesthe- 
sia AND Amnesia in. — Hellman.*]38 

—Nitrous Oxid in. — Guedel *109 

— Teaching to Nurses: How Ex- 
tensive Should Such a Course 

be Made.?— Goodman 326 

Obstruction, Intestinal 389 

Ome.ntum, Great; Complete Tor- 
sion OF the. — Bookman 304 

Opkrations, Shockless. — Baldwin 281 

Osteitis Fibrosa 128 

Osteochondritis. Hip 462 

Osteomyelitis, Acute ; The Physician 

and 24 

— Joint Contracture 411 

Ossicular Rigidity, Misuse of Cath- 
eter in 152 

Ovaries, Cyst, 159; Fibroids 319 

Ovary and Fallopian Tube. Con- 
genit.m. Absence of; Report of 
a Case, with a Sur\-ey of the 

Literature. — Grant 307 

Oxygen Injections 72 



Pains. Post-operative Gas 222 

Palate. Cleft 463 

Pancreatic Disease 356 

Panillomata. Bladder 318 

PARSONS. ALBRO L— The 
Choice of Incisions in Hand In- 
fections 6 

Pelvis. Contracted 422 

Pelvis and .Abdomen. Sub-infection 

from 388 

Penis. Cancf.r. .See Massey. 
Pensions. War; Refusal to Submit 
to •Anesthesia and Operation in 

Resf'cct to *156 

Peritonitis. Pneumococcus 21 

—Suppurative: The Local Em- 
ployment OF Iodine in — Fort... 59 
Pharyngeal and Intratracheal Anes- 
thesia .'Apparatus *164 

Phenolsulphonenhthnlein Test .... 70 

'^li'hsophv. A Surgeon's 412 

Phlegmons. Gas, 196. 424; Early 

Diacmosis bv .r-rav. 330; Joint. 196 
PIRRUNG. J. EDWARD— "Frac- 
tures .About the .Ankle" 110 

Placenta Previa 230 



PAGE 
Pneumonia, Post-operative. Let- 
ter TO Editor, by J. D. Morti- 
mer 125 

Poliomyelitis 423 

POLLITZER, SIGMUND.— Can- 
cer OF THE Skin 330 

Popliteal Suppuration 16 

Pott's Disease 98, 379 

POWERS, CHARLES A.— Senile 
Parenchymatous Hypertrophy 

OF the Breast 446 

Pre-cancerous Lesions of the 

ToNGlJE. See I.YDSTON. 

Pregnancy, Ovarian Tumors in, 
195; Tubercular Infection Com- 
plicating 196 

PRICE. JOHN W.— Bloodvessel 
Anasto.mosis : with Especial 
Reference to the Use of Can- 

ul.vforceps 431 

Prolapse, Genital,- .Anterior Col- 
roRRHAPHV and Amputation of 
the Cervix Combined as a Sin- 
gle Operation for Use in the 

Treatmknt of. — Fothergill 161 

Prostate. Maligna.nt Disease of. 

See Beer. Edwin. 
Prostatectomy, 420; Suprapubic. 71, 229 
Prostatic Suppuration, 358; Ob- 
struction 158 

Pruritis, Radium in 416 

Puncture, Corpus Callosum 392 

Pyelitis, Chronic 70 

Pyelography 312 

— Damage by 70 

Pylephlebitis" 230 

Pylorectomy and Partial Gastrec- 
tomy 159 

Pyloric Occlusion, The Unsettled 

Problem of 24 

— Spasm, The Significance of. — 

Haynes 426 

— Stenosis 29 

Py'onephrosis with Stones. See 
Kohl MANN. 

Q 

Quinine After Operation 392 

R 

Rebreathing. Fractional, in An- 
ESTHESi.\ — Its Physiologic Basis. 
Technic and Conclusions. — Mc- 
Kesson *51 

Renal Infection. 152; Permeability. 420 

Radiography, Inestinal 363 

Radiotherapy in Surgical Affections 32 
Radium in Malignant Tumors. .32. 374 
R.A\^OGLI. A. — .A Consideration 
OF THE Antiseptics Used in the 
Tre.\tment OF Infections ok the 

Genito-Urin.'ujy Organs 14 

Raynaud's Disease; with a Re- 
port OF A Case. — Gewin 188 

Red Cross Seals 457 

Renal Pain 462 

Rhinoplasty, Total. A Case Re- 
port. — Johnston 149 

Rib Mobilization 319 

RICKETTS. BENJAMIN MER- 
RILL. — Intr.\tracheal Insuf- 
flation *147 

ROBERTS, W. O.— Esophageal 

Stenosis: A Rewew 172 

ROETHKE, R. W.— A Modifica- 
tion of Podalic Version 23 

RUBIN, I. C— Foreign Body Crep- 
itus in the Uterus. .An U.n- 
usuAL Sign in Gynecological 
Examination. Wnn a Case Re- 
port 403 

S 

SACKETT. H. R— Major Points 
IN Minor Surgery 339 



PAGE 

Sarcoma ok the Conjunctiva, A 

Case of. — Wolfe 303 

Sarcoma. Myeloid 318 

Scapula Flexed 359 

Scars, Radium Treatment 320 

SCHAPIRA, S. WM.— Gumma- 
tous Ulceration of the Bladdkr 213 
Sciatica. Perineural Infiltration in.. *96 

bcoliosis 296 

Scottish Society of Anestlietists. . . *91 
SECOK. \VM. LEE.— Minor Points 
IN M.\joR Surgery that Insure 
A Smoother Convalescence and 

Better End Results 393 

SEFF, ISADORE.— The Advan- 
tages OF Combined Anesthesia 
in the Operative Treat.ment of 

Hemorrhoids *44 

Sesamoids, Flexor Brevis Hallucis 463 
SHERMAN, WM. O'NEILL.— A 
Standardized Treatment ok 
Wounds: Report of 77,000 Casks -l-IS 
Shock, 464; Peripheral Origin of. 

*64; Post-operative 424 

— Post-operative Treatment of. — 

LiEB *47 

Shockless Oper.\tions. — Baldwin. 2cSl 
Shoulder, Traum.vtic Forward 

SUBLUX.\TI0N of THE: A CLINICAL 

Entity. — W. M. Brickner 51 

—Disability 71, 231 

■ — Dislocation, Recurrent 217 

Sinus, Frontal, Suppuration. 357; 

Sphenoid, Opening of 232 

Sinuses, Accessory, Disease 35<* 

Skull Defects 464 

SMITHIES, FRANK.— The Early 
Diagnosis of Cancer of the 
Stom.\ch : A Study of 921 Oper- 
ATi\-ELY and Pathologically 

Demon str.'^ted Cases 255 

Soldiers, Crippling ; Twelve Com- 
mandments to Avoid 194 

Somnoform, Continuous Analge- 
sia and Anesthesia with. The 
Tech NIC of Administr.\tion. — 

DeFord *34 

SONDERN, FREDERICK E.— 
Laboratory Aids and the Early 

Diagnosis of Cancer 370 

SURG SUP INDEX— 9 
HUMPHREYS— TUESDAY 
Spinal Fluid, Amber Color of;, 
with Coagulation en masse. 

Report of Case. — Campbell 3AH 

Spine, Lesions 32 

Spleen, Extirpation, KiO; -Surgerv 

of '. 35(1 

See also Banti's Disease. 

Splenectoinv 389 

SQUIER, ' J. BENTLEY.— The 
Early Di.\gnosis of Cancer of 

the Bladder 248 

Stasis, _ Intestinal 356. .388 

Stenosis, Pyloric 2*) 

Sterility, Relief of 30 

STETSON, H. G.— Traumatic 

Rupture of the Liver 334 

Stumps, Amputation 231 

STEWART, WILLIAM H,— The 
Latest Method of Examining 
THE Genito-I'rinarv Tkai t vvnii 

THE Roentgen Ray 404 

Stomach. Symptoms. 430; Syphilis. 356 
— and Duodenum, Benign Lesions.. 388 
Surgeon, Railway; His Relation 
TO THE Patient. — Vander Vekr. . 338 

—The Useful 188 

Surgeon's Reputation, The. — Mor- 
ris 22 

Surgery, American. 349; Bone, 319; 

Bone and Joint 127 

— Brain. See Teter. 
— Cancer. See Gib.son. 



PAGE 

— Major: Minor Points th.\t In- 
sure A Smoother Convalescence 
AND Better End Results. — Secor 393 

—Military *167 

— Minor 385 

Major Points in. — Sackett.. 339 

— Surgery, Orthopedic 227 

— Silver Lea f in 360 

Surgical Conscience. The Duty 

OK Aseptic Technic. — Jonas .... 341 

SURGICAL SOCIOLOGY.. 26, 68, 126, 

155. 192, 226, 314, 353, 385, 415, 457 

SURGICAL SUGGESTIONS ..25,67, 

125, 154, 192, 226, 280, 314, 353, 384, 

415. 

Syphilis, Bonk and Joint. — Coon. 211 

— Stomach 356 

Syringe, An All-metal, for Use 
IN Local Anesthesia. — Jacobson 349 

T 

Tachycardia and Uterine Growths.. 63 
TAYLOR. HOWARD C— Can(er 

OF the Fe.male Genital Organs. 371 
Tkchnic, .A-septic. See Jonas. 
TETER, CHARLES K.— Anes- 
thesia FOR Brai.n Surgery *144 

Tetanus, 232, 360, 392; Treatment. 160 
THOMA, KURT H.— Oral Anes- 
thesi.\ in the surgery of 
Chronic Alveol.\r Abscesses.... *79 
Thrombosis and Embolism, 359; 

Post-operative 363 

Thyroid Enlargement 63, 358 

tocanai.cine in childbirth. see 

Hellman. 
Tongue, Malignant Disease of. 

See Lydston. 
Tonsillar Fossae, Post-operative 

Treatment 358 

Tonsillectomy: The Forward In- 
clined Sitting Posture Under 
N-O-O Anesthesia, and Other 
New Fe.\tures. — Denman and 

McKesson 181 

TOVEY. D.WID -W.- a Note 
Concerning the Surgical Rela- 
tion of the Blood Supply of the 

Terminal Ileum 300 

A Note on the Employj-ent 

of the Transverse Fascia Imbri- 
cating Operation for Po.st-oper- 

ative Ventral Hernia 380 

Transfusion. Blood 359 

Danger in 455 

— — Siint^Ic Mi-llwds of 153 

Some Recent Observations. — 

Dewor 10 

Still Further .Simplified.... 383 

WITH One 20 ccm. Syringe. — 

Lewisohn 361 

Transplantation, Bone. 319; in Frac- 
tures, 127: in Pott's Disease.... 98 
— Gastric M'.icous Membrane .... 1.59 
Tuberculosis. Surgical. .390; Uri- 
nary, 20; Uterine .'\ppend.agcs. . . . 421 

Tuberculous Exposure 464 

Tumors, Bladder, 185 : Papillary in 
Bladder. .382; Radium in, 195; 
Multiple Pulsatina;, 229 ; Ovarian, 

in Pregnancy. 195; Uvula 232 

Turbin.\te. Lnkerior; The .Surgery 
OF THE Posterior Tip ; the Rela- 
tion OF the Posterior Tip to 
Catarrhal Deaf.ness and Tin- 
nitus.. — Hays 20 

Twilight Sleep 414 

TunliaUt Slccf< .351 

U 

Ulcer, Dieulafoy's 20 

— Duodenal, 64; Gastric, 21, 315. 
.382 and Duodenal. .320; Leg, 160- 

Radiou-ranhv in 217 

Ulnar Nerve Trouble 231 

llrcter. Stones in 461 

Urethra, Prostatic; Growths of... 462 



page 
Urethrovesical Diagnosis and 
Tre.\tment, Concerning Prob- 
lems I.N, with Description of a 
New Instrument. — Buerger ... 54 

Urine, Retention, in Infants 5 

Urological Methods, Modern ; 
Their Application in the Diag- 
nosis OF Surgical Conditions of 
THE Urinary Tract. — Hvman.. 204 

Uterus, Adenocarcinoma 195 

— Cancer of Cervix. See Burrows. 
— Carcinoma, See R. T. Frank. 

—Fibroids 421, 422 

— Foreign Body Crepitus in the. 
An Unusual Sign in Gyneco- 
logical Examination, With a 

Case Report. — Rubin 403 

— Retroversion 230 

— Unicornis — A Case Report. — 

GiN.N 301 

Uvula, Angioma, 232; Tumors 232 

V 

\ANCE, AP MORGAN.— a New 
Method of Applying Pure Acid 
Crystal 4IU 

\'ANDER VEER, EDGAR A.— 
The REL.fVTioN of the Railway 
Surgeon to the Patient 338 

Version, Podalic: A Modification 
OF. — ROETH ke 23 

Verumontanum, Removal 158 

I'csalius, Andreas: The Quadrieen- 
tcnnial of 66 

Vesical Malignancy 349 

\TRDEN, JOHN E.— Are Cocaine 
Solutions Injured by Boiling?. 288 

W 

WALKER. JOHN B.— Classifica- 
tion OF Fractures 86 

WARE, MARTIN W.— Fifteen 
Years' Experience with Ethyl 
Chloride as an Anesthetic. .. .*112 

WARNER, A. R.— The Manukac- 
TURE OF Nitrous Oxid for Use in 
Hospitals *124 

WASHBURN, BURTON A.— A 
Boot for Injuries Involving the 
Wrist 409 

— — CESS.A.TI0N of Epileptic Seiz- 
ures after Removal of Prepuce 
AND Fibroma Imbedded in Ure- 
thra : Case Report 23 

WIGHT, J. SHERMAN.— An 
Operation for the Elong.ation 
of Bone. Report of a Case.... 18 

WOGLOM. WM. H.— Modern As- 
pects of the Problem of Neo- 
plasia 233 

WOLFE, C, T.—K Case of Sar- 
coma OF THE Conjunctiva 303 

WOLLHEIM, J. L.— Backache in 
Genito-LTrinary Diseases 406 

Workmen's Compensation Act, 
The Federal 26 

Wound Surfaces, Irrigation 464 

Wounds, X Standardized Treat- 
ment : Report of 77,000 Cases. — 
Sherman 448 

Wounds in Battle, 357; in Flanders 29 

WRIGHT, THEW.— A View of 
114 Consecutive Operations for 
.\cuTE .Appendicitis, without 
mortality 129 

Wrist, K Boot for Injuries In- 
volving THE. — Washburn 409 

X 

X-Ravs in Malignant Disease 389 

Y 

YOUNG, JAMES K.— Frvctures 
IN THE Neighborhood of Joints. 115 
Z 

ZIMMERMAN, B. F.— Gunshot 
Wounds of the Abdomen 366 

— — Treatment of Fractures.... 90 



AMERICAN 



JOURNAL OF SURGERY 



Vol. XXIX. 



TAXUARY, 1915. 



Xo. 1 



THE TREATMENT OF CANCER BY PHYSI- 
CAL METHODS WITH AND WITH- 
OUT SURGERY. 
Arthur F. Holding, M.D., , 
New York. 

(From the Physical Laboratory of the Huntington Cancer 
Commission, General Memorial Hospital, N. Y. City.) 



The electrical methods employed in the follow- 
ing series of cases were deep Rontgentherapy, ful- 
guration (De Keating-Hart) desiccation (Clark), 
and diathermy (Nagelschmidt). These therapeutic 
agencies were combined with surgery, radium, tox- 
ins, and vaccines, when such adjuvants were indi- 
cated. The results obtained were due, not so much 
to any originality of method, as to the correlation of 
several ver)' excellent methods, already described, 
but little understood, and seldom used by the profes- 
sion at large. Inasmuch as we have been treating 
these cases only during the past ten years, suffi- 
cient time has not elapsed to warrant any final 
statement concerning the successful cases, other 
than that they are now syinptomatically well. 

For our purposes malignant lesions may be di- 
vided into three classes, viz., those in the first, sec- 
ond, and third degrees of malignancy. 

1. THE FIRST DEGREE OF MALIGNANCY. 

(a) Cases having superficial skin lesions tending 
to extend out from the skin rather than into the 
underlying structures, (b) Those which do not 
extend more than one cm. beneath the skin. These 
are characterized by slow growth, long duration, 
and a tendency not to metastasize early. 

Histological characteristics. Growths of this 
class of malignancy in our series showed the his- 
tological formation of papillary epithelioma, basal- 
celled epithelioma, mycosis fungoides, and pre- 
epithelial keratoses. 

Prognosis. The prognosis of such casfes treated 
by the above methods is 100 per cent. good. They 
can be cured by physical methods, without surgery, 
pain, hemorrhage, opening up the lymph channels, 
danger of infection, implantation of malignant cells, 
or hospital confinement, and with the best cosmetic 
results. 

Thereapentic methods. These cases should not 
be treated by cutting operations. The physical 



methods indicated in the order of their preference 
are: (a) Massive doses of Rontgen rays; (b) 
desiccation; (c) radium; (d) destructive caustics, 
provided the more expensive equipments are not 
available. 

If improperly treated or neglected, these cases 
may develop into the second or third degree of 
malignancy. 

2. THE SECOND DEGREE OF MALIGNANCY. 

(a) Those operable tumors, characterized by 
rapid growth, and tend to extend rapidly into the 
deeper structures, and to metastasize early. Car- 
cinomata of the breast and operable sarcomata are 
very good examples of this class. 

Histological characteristics. Growths of this 
class of malignancy in our series of cases showed 
the histological formation of basal-celled epitheli- 
oma, and alveolar and medullary carcinoinata of 
the breast. 

Therapeutic methods, (a) Preoperative massive 
doses of Rontgen rays; (b) thorough radical 
operation; (c) fulguration at the time of operation; 
fd) post-operative deep Rontgentherapy or radio- 
therapy. By the use of these adjuvants to surgical 
treatment, the percentage of recovery in this class 
of patients has been materially increased. 

3. THE THIRD DEGREE OF MALIGNANCY. 

Inoperable superficial and deep malignant condi- 
tions. 

Prognosis. These patients, as a rule, cannot be 
cured by any method of treatment, and are unde- 
sirable subjects, as the ultimate prognosis is 100 
per cent. bad. Despite this fact, in our series of 
116 cases of the third degree of malignancy, 6 
cases (5.8 per cent.) to date remain symptomatically 
well : 24 ^20 per cent.) showed marked primary im- 
provement after massive Rontgen ray treatment 
was instituted. This in itself is sufficient to demon- 
strate even to the most conservative that deep 
Rontgenotherapy has an action on malignancy 
which might well be called inhibitory. This in- 
hibitory action, shown in these hopelessly advanced 
cases, is the same action which becomes annihila- 
tory in less advanced cases. 

Therapeutic methods. The symptoms can usu- 
ally be improved by electrical methods and radium. 



American 

joL-RNAL OF Surgery. 



Holding — -Cancer. 



January, 191S. 



The results obtained in all three classes of cases 
have been noticeably better .since the installation of 
the Coolidge tube. We have operated the Coolidge 
tube with a parallel spark gap of 10 inches, with 
miliamperage of 5, getting 15 X through filters of 
3 m.m. of aluminum and a filter sensitized paper in 
3 minutes. 

The foregoing division of all cancers into three 
classes of malignancy, is valuable for determining 
both the prognosis and the treatment. Cases of the 
first degree of malignancy can be cured; cases of 
the second degree of malignancy may be cured : 
cases of the third degree of malignancy, as a rule, 
cannot be cured. The majority of cures of malig- 
nancy referred for treatment by physical methods 
are cases of third degree of malignancy, and this 
accounts for the poor results frequently obtained. 
Much time mav be lost in cases of the second and 




Before treatment. .\fter treatment. 

Fig. 1. — First degree of malignancy. 
Superficial epitfielioma of the forehead. Complete recovery 
under massive Rontgen therapy. 

third degree of malignancy, and the patient's life 
endangered, if one is deceived by the well-known 
superficial healing properties of radium as well as 
of the .I'-rays. The fact that lesions of the second 
degree of malignancy appear at first to improve, 
under treatment indicated only for cases of the 
first degree, gives a false sense of security, and re- 
sults only in therai>eutic procrastination, and the 
development of second degree cases into a malig- 
nancy of the third degree while under a form of 
treatment suited only to cases of first degree 
malignancy. 

Of the first degree of malignancy, we have thir- 
teen cases, nine of which have been symptomatically 
cured under massive doses of .r-ray, four of which 
are symptomatically cured with radium, and one. 
symptomatically cured under the combined treat- 
ment of both massive doses of .t'-ray and radium. 

Of the second degree of malignancy, we have a 
total of ten cases; four of epithelioma of the skin 



and si.x of carcinoma of the breast, all treated by 
a combination of massive doses of .r-ray, radical 
operation, and fulguration. followed by massive 
doses of .r-ray or radium. Three of these patients 
are still under treatment ; five have been discharged 
symptomatically cured; and two have discontinued 




Fij::. J. — Fir^t 'iegrec 'il iiiali^^tiancy. 
Case of mycosis fungoides, in which the lesion on the right 
temporal region was treated by surgical removal and skin graft- 
ing. The lesion on the left temporal region was treated by mas- 
sive Rontgen therapy. The lesions on the cheeks and neck were 
treated by desiccation. 

treatment. All of those patients who have con- 
tinued the treatment are symptomatically well, al- 
though sufiicient time has not elapsed to warrant 
the statement that they have been completely cured. 
In the third degree of malignancy we had 116 




Fi^. 2a. — Mycosis fungoiiles after treatinent. 
The best cosmetic results were obtained by radium, desiccation, 
atid massive Rontgen therapy. In the lesions treated by dessic- 
cation there has since been recurrence. Other mycosis lesions 
have appeared in other parts of the body. All these lesions are 
now being treated by radium or .r-rays. 



cases, divided into 
panying table : 

No. of 
Diagnosis. Cases. 

Fpithelionia 21 

Carcinoma of breast 22 

Lymphosarcoma 11 

Round celled sarcoma J 

Spindle celled sarcoma 9 

Chondrosarcoma 1 

Melanosarcoma 2 

Miscellaneous sarcomata 7 



;roups according to the accom- 



.Synip'v Im- 


I'nini- 




Well. 


proved. 


proved. 


Uea 





4 


10 


S 


1 


3 


9 


6 


1 


4 


3 


3 


I) 











1 


3 


' 3 


1 


1 


I 


n 





(1 


II 


1 


1) 





3 


3 






Vol. XXIX, No. 1. 



Holding — Cancer. 



American 
Journal of Surgery. 



Hodgkin's disease 5 2 3 2 

Chronic lymphatic leukemia... 10 10 

Carcinoma ot uterus t... 10 2 2 2 

Miscellaneous tumors 25 5 15 

116 6 24 38 3" 

Percentage 5.8 20. 32.22 32. 

On account of the extravagant exploitations of 
radium by the profession, as well as by laymen, a 
statement as to the relative value of this thera- 
peutic agent as compared with other physical meth- 
ods may be valuable. 

Radium has been fortunate in many respects in 
its exploitation. In the first place, it is so rare and 
expensive that it has been placed only in the hands 




Fig. 2b. — Photomicrograph, case of mycosis fungoides. 

of well-known physicians, surgeons, or scientists, 
who have felt in duty bound to test it extensively 
and report upon its properties. Their results are not 
nullified by a great multitude of mediocre or un- 
reliable results promulgated by inexperienced ob- 
servers who happened to have a few hundred dol- 
lars that they were willing to invest in the new 
agent, as was the case when .r-ray machines were 
put on the market. Consequently, radium has been 
taken much more seriously than its predecessor in 
the radio-active field, the .t'-rays. Electricity of any 
kind in medicine is not taken very seriously by the 
profession as a rule, largely because of the unsci- 
entific character of the majority of men who have 
exploited it. It is a singular fact that the radium 
workers, who are more scientific as a whole, do 
not seem to be familiar with the therapeutic ef- 
fects obtained by means of .r-rays in efficient work- 
ers' hands. Several of the best known radium 
workers have pointed with pride to their results in 
treating epitheliomata, the various leukeinias, 
Hodgkins' diseases and exophthalmic goiteis, for in- 



stance, and have shown surprise when infonned 
that .f-ray workers reported the same results years 
ago, and that successful treatment of these condi- 
tions is a routine occurrence in the practice of good 
Rontgentherapists. In personal conversation with 




Fig. 3. — Second degree oi malignancy. 
Case of epithelioma of the nose in a patient suffering from ex- 
tensive lupus (non-ulcerative). The tumor developed on the nose 
after a local treatment of the lupus with carbon dioxide snow. 
The epithelioma was removed surgically, the base fulgurated (De 
Keating-Hart), followed by massive Rontgentherapy. The lupus 
was treated by massive Rontgentherapy, the resistant edges being 
controlled by desiccation (Clark). An artificial nose has since 
been fitted and the patient makes a very presentable appearance. 

some of the most noted radium workers in this 
country, they have looked skeptical, even when they 
refrained from expressing skepticism, when as- 
sured that -r-rays properly administered will con- 
trol all the symptoms complained of in exophthal- 




Fig. 3a. — Photomicrograph, case of epithelioma of nose. 

mic goiter except exophthalmos, and that the blood 
counts and lymphatic enlargements in leukeinias 
and pseudo-leukemias can all be controlled at least 
temporarily. These results are established facts at- 
tested bv numerous authentic references in medical 



American 
Journal of Surgery. 



Holding — Cancer. 



January, 1915. 



literature. Whether these results obtained by 
radium will be more permanent than those obtained 
by -f-rays cannot be stated at the present time, as 
the radium cases are too recent to warrant any con- 
clusion. There really should be little or no rivalry 
between these two agents at the present time, as 
they are similar agents that can be used as tre- 
mendous assistants in the surgical relief of cancer. 




Fig. 4. — Third degree of malignancy. 
Case of primary lymphosarcoma of the tonsil, involving the 
cervical glands. Treated at first by toxins with slight, if any, 
improvement. Within forty-eight hours after the first massive 
dose of deep Rontgentherapy, the size of the tumor had dimin- 
ished fifty per cent. Under the combined treatment of toxins 
and .r-rays, the patient steadily improved to the condition shown 
in the "after treatment" illustration. He subsequently relapsed 
and failed to respond to any treatment. This is commonly the 
history in cases of lymphosarcomata. Hodgkin's disease, leukentia, 
and allied conditions, i. c marked primary improvement pro- 
pressing often to apparent recovery, but, as a rule, these patients 
die sooner or later of the condition despite all changes in the 
technic, including raying of the long bones. In this class of 
cases every effort should be put forward to make permanent the 
initial good results. 

In comparing the relative value of the various 
physical methods, six points may well be consid- 
ered : 




Fig. 4a. — Photomicr 



.sil anil 



Case of lymph 
metastasis. 



'Sarcoma of the ton- 



1. — Cost. 
Radium is far more expensive than any of the 
other methods. Massive .r-rays, electric desiccation 
and ultra-violet rays come next in expense. Sur- 
gery and caustics are the cheapest. 

2. — Ease of Application. 
As to ease of application, much depends upon the 
training of the individual who administers the treat- 



ment. Each therapeutist will naturally do the best 
work with the greatest ease by employing that agent 
with which he is most familiar. Other things be- 
ing equal, radium and caustics are easier to apply 
than the other agents in question. 

3. — Time Consumed in Treatment. 

Radium applications are much longer in duration 
than any of the other methods. They require hours 
while the other treatments require minutes. 
4.— Pain. 

Radium, .I'-ray, and ultra-violet light treatments, 
cause no pain. Electric desiccation and carbon 
dioxide snow cause slight pain. Surgery and cau- 
terization are very painful and require a local anes- 
thetic. Chemical caustics are the most painful. 
5. — Cosmetic Effects. 

Cosmetic effects are best after radium, A'-rays, 
ultra-violet light, desiccation, and carbon dioxide 
snow, and poorest after surgery or cautery. 




Fig. 5. — Third degree of malignancy. 
Case of myxolymphosarcoma. Extensive tumor of the right 
thigh and large mass, filling half of the abdomen on the left side. 
It was impossible to remove all the tumor tissue from the thigh 
at operation, and no surgical removal of the abdominal mass was 
attempted. Post-operative deep Rontgentherapy caused the com- 
lete disappearance of all evidence of both the tumor masses. 
_n this class of patients a regular system of prophylactic treat- 
ments should be instituted to guard against recur-ence. (Since 
this was written, the patient has returned with a recurrence in 
the thigh. -As yet there is no evidence of a return of the ab- 
dominal tumor.) 



?, 



6. — Dangers. 

With a proper technic there are no dangers in 
any of these methods. Poor technic is a de facto 
contra-indication for the use of any agent, for it 
will need the combined energies of the advocates of 
both forms of radio-activity to persuade the sur- 
geons of today to admit that there is any efficacy 
in either method. 

The electric cautery of Percy seems to have made 
some impression on the surgical mind, but the vir- 
tues of desiccation, diathermy and fulguration are 
hardly known and seldom practiced by surgeons. 
It is to be hoped that the propaganda of radium, 
associated with the timely invention of the Coolidge 
tube, will call to the attention of the medical profes- 
sion the value of electrical methods. This can 
hardly result in a large vogue for these methods 
unless championed by prominent surgeons. 



Vol. XXIX. No. 1. 



Holding — Cancer. 



American 
Journal OF Surgery. 



MALIGNANCIES OF THE GASTRO-INTESTINAL TRACT. 

The only hope for the rehef of internal growths 
is to diagnose them in their incipiency. By the 
proper use of the Rontgen rays, a positive or nega- 
tive diagnosis of carcinoma or ulcer of the gastro- 
intestinal tract can be made in the earliest stage's 
of the involvement. Furthermore, its size, shape, 
and position can be determined, painlessly and with- 
out shock or danger. This accurate information 
affords an opportunity for the early and successful 
removal, by surgical operation, of the cancer or 
ulcer bearing area, moreover reducing the time re- 




Fig. 5a. — Photomicrograph of case of my.xo-lympho-sarcoma. 

quired for surgical examination and operation, and 
consequently the amount of shock entailed, so that 
the precentage of recoveries after surgical removal 
is increased. 

The problem of handling malignancy to-day re- 
solves itself, therefore, into: 

1. The proper treatment of external cases of the 
first degree of malignancy, lest they develop into 
cases of the second and third degree of malignancy. 

2. Increasing the palliative effects possible for 
external tumors of the second and third degrees of 
malignancy, so that they may be regarded as ac-, 
tually remedial. 

3. The diagnosis and early surgical removal of 
ulcer-bearing areas and malignant conditions of the 
gastro-intestinal tract in their incipiency. 

CONCLUSIONS. 

1. Incipient surface cancers can be cured: (a) 
if superficial, by physical methods; (b) if deep, by 
physical methods and surgery. 

2. The physical methods employed include mas- 



sive .I'-ray doses, desiccation (Clark), fulguration 
(Dc Keating-Hart), diathermy (Nagelschmidt), 
and radium. 

Beginning cancer of the gastro-intestinal tract 
can be diagnosed with accuracy by recently im- 
proved .i--ray methods. 

4. Advanced cancer, either internal or external, 
cannot be cured by any known method. 

5. The successes herein reported are due not to 
the discover}- of any one new factor, but rather to 
the combined application of the best and most ef- 
fectual electro-physical technic, both in early diag- 
nosis and prompt treatment, the results of which, 
if permanent, are invaluable. 

6. The methods herein advocated are very costly. 
I am grateful to the members of the Commission 

and the staff of the General Alemorial Hospital for 
their co-operation, and particularly to my assistants 
in the electro-physical department for their faith- 
ful and painstaking work. 

BIBLIOGR.\PHY. 
A description of the technic employed in the treatment 
of these cases will be found in the following literature : 

1. Clark, W. L. : A Preliminary Report Upon the De- 
struction of Surface and Cavity Neoplasms by Dessication, 
Nezv York Medical Journal. June 10, 1911. 

2. Idem : High Frequency Dessication ; Second Report, 
Monthly Cyclopedia and Medical Bulletin, .\ugtist, 1912. 

3. Idem: Electrical Dessication as an Adjunct to Sur- 
gery, with Special Reference to the Treatment of Cancer, 
Surgery, Gynecology and Obstetrics. August. 1912. 

4. Idem : The Dessication Process of Tissiie Destruc- 
tion as Applied to Certain Pathological Conditions, Penn- 
sylvania Medical Journal, February, 1913. 

5. Hart, De Keating: Un nouveau mode de traitement 
du cancer, Congres international d'electrologie et de radio- 
logic, Milan, 1906; Annales d'Electro-Biologie, 1907. 
Trois cas de cancer recidive traite avec succes par la ful- 
guration — Paris chirurgical. IV, 946, 57, 1912, Presen- 
tation d'un cas de lymphosarcomatose generalisie avec 
legers splenomegalie. traite par un mode nouveau de 
radiotherapie — Bulletin de I'association frangaise pour 
letude du cancer, IV, 312. 14, 1912. 

6. Holding, A. F. : Technic in Roentgenotherapy, with 
Especial Reference to Deep Therapy as Practised at Frei- 
burg by Kroenig and Gauss, Medical Record, Februarv 21, 
1914. 

7. Ifem: Simplified Technic of Deep Therapy, Archives 
of the Roentgen Ray. 

8. Kroenig. Gauss, and Lembke : Roentgentiefenthera- 
pie. 1912. 

9. Nagelschmidt. Franz : Lehrbuch der Diathermie f iir 
Aertze und Studieren, 1913. 



Retention of Urine in Infants. 
Retention in the newly born babe may be due to 
one of several causes for which, when a doubt ex- 
ists, the infant should be examined: (1) Imper- 
forate meatus urinarius, either glandular or prepu- 
tial; (2) marked phimosis simulating imperforate 
preputial meatus; (3) cyst of the sinus pocularis; 
(4) impacted mucus or calculus within the urethral 
canal; and (5) atresia. — T. C. Stellwagen, Jr., in 
The Pennsxlvania Medical Journal. 



American 
Journal of Surgery. 



Parsons — Hand Infections. 



January, 1915. 



THE CHOICE OF INCISIONS IN HAND 

INFECTIONS.* 

Albro L. Parsons, M.D., 

Louisville, Ky. 



In this paper only infections of the palmar aspect 
of the hand will be discussed. Infective lesions 
involving the dorsal surface are infrequently en- 
countered. 

I have examined the literature of hand infections, 
and find only three contributions of importance 
published during the last ten years. First, and of 
greatest value, is the classical monograph of Kana- 
vel, of Chicago, "Infections of the Hand"' (edition, 
1914), to which I am indebted for many of the 
data here presented. Second, is an article by White, 
of England, which appeared in the London Lancet 
a few months after publication of the first edition 
of Kanavel's monograph. White's article is exten- 
sively quoted by DaCosta in his recent book on 
surgery. The third contribution is by a French- 
man, Picque. 

The subject of hand infections is so extensive 
that my remarks will be principally confined to one 
phase, i.e., the sites of the several incisions which 
will best drain the infected hand with the least dam- 
age to the other tissues. Furthermore, I shall dis- 
cuss only acute and subacute infections that involve 
the tendon sheaths and fascial spaces of the palmar 
surface. 

To briefly review the anatomy of the palmar 
tendon sheaths: Those of the index, middle and 
ring fingers extend from the base of the terminal 
phalanx to "Kanavel's line," i.e., a line drawn be- 
tween the radial end of the proximal phalangeal 
crease and the ulnar end of the distal palmar crease, 
roughly a thumb's breadth above the web. These 
sheaths pass near the proximal interphalangeal 
joint, and this fact may account for its more fre- 
quent involvement than the metacarpophalangeal 
joint from which the sheaths are well separated. 
The sheath of the flexor longus pollicis pursues 
relatively the same course, excepting that nineteen 
times out of twenty it does not temiinate at the 
root of the thumb, but continues upward into the 
radial bursa, which in turn extends to a point one 
inch above the annular ligament between the pro- 
nator quadratus and the flexor tendons. The little 
finger sheath imitates its fellows until it reaches 
the hand. From this point in about half the cases 
it extends into the ulnar bursa, which also passes 
above the annular ligament upon the pronator 
quadratus, "hugging" the ulnar side of the super- 



•Read before the Society of Physicians and Surgeons of Louis- 
ville, November. 1914. 



ficial and deep tendons of the wrist with prolon- 
gations extending between them. In approximately 
half the instances a communication exists between 
the radial and ulnar bursae. 

Four fascial spaces are embraced within the 
scope of this paper: The first is what may be called 
the terminal phalangeal space — the site of felons. 
This space is composed of the fatty cushion at the 
finger end, and is divided into numerous compart- 
ments by fascial bands which extend roughly from 
bone to skin. Alongside of this space are the blood- 
vessels that nourish the shaft of the terminal 
phalanx, and obstruction of the blood supply by 
pressure explains the frequent necrosis of that por- 
tion of the bone in felons. Next are the web 
spaces, i.e., those between the fingers. Infection in 
this loose tissue may extend to the dorsum, to the 
adjacent fingers, or along the lumbrical muscles to 
either of the two spaces to be next described. 
These, the thenar and mid-palmar spaces, may be 
best described together. They occupy the palm 
below the tendons and lie upon the interossei and 
adductor muscles. The third metacarpal bone indi- 
cates the point of their separation, excepting at the 
wrist, where at times the two spaces communicate. 
Below, these spaces are continuous with what may 
be called the lumbrical canals. Above, the mid- 
palmar space terminates near the annular ligament, 
upon the pronator quadratus. The deep palmar 
arch is dorsal to these spaces, whereas the super- 
ficial arch is palmar to them. Infection may occur 
in all of these spaces and tendon sheaths, or in any 
one of them singly. More often, however, the pa- 
tient is seen only after the infection has invaded 
other sheaths or spaces. 

In order to properly locate the necessary inci- 
sions for drainage, it is important to understand 
just what combinations are likely to be encoun- 
tered. Terminal phalangeal infections tend to be- 
come localized, unless neglected, when the infection 
may extend either by the fascial spaces to the web, 
or upward along the tendon sheath, both of which 
will be specifically mentioned later. Infections of 
the sheaths of the index, middle and ring fingers 
may rupture through the skin. The proximal inter- 
phalangeal joint is frequently involved, with subse- 
quent necrosis of the middle phalanx. Most often, 
however, rupture occurs at the proximal end of the 
sheath, the pus gravitating into the finger web and 
thence by way of the lumbrical canal to the thenar 
space if the inde.x finger be involved, and to the 
mid-palmar space where the middle and ring fingers 
are implicated. Rarely does middle finger infec- 
tion invade the thenar space. Little finger in fee- 



Vol. XXIX, No. 1. 



Parsons — Hand Infections. 



American 
Journal of Surgery. 



tions behave in like manner, where the sheath is 
not connected with the uhiar bursa, otherwise the 
infection rapidly extends to the forearm under the 
profundus. Thumb sheath infections invade the 
foreann through the radial bursa. Pus in the the- 
nar space may invade the mid-palmar space, and 
vice versa. In either event the webs are prone to 
involvement by way of the lumbrical canals. Pus 
in the mid-palmar space oftentimes invades the 
forearm. \\'eb infections may rupture anywhere 
upon the dorsal or the palmar surface. Both the 
thenar and mid-palmar spaces are frequently in- 
fected. To illustrate the structures which may be 
infected in regular sequence, I may mention that 
inflammation of the little finger sheath may extend 
to the ulnar bursa, to the mid-palmar space, to the 
radial bursa, to the thumb sheath, and the thenar 
spaces, each in turn becoming involved. Distally, 
the finger webs may be infected with possible rup- 
ture upon the dorsum. Proximally, the infection 
may pass upward along the forearm, under the pro- 
fundus and over the pronator quadratus, and still 
further extension in the connective tissue of the 
foreann around the vessels and nerves probably 
explains the paralyses and trophic changes which 
super\-ene in certain cases. 

The foregoing comprise the more frequent struc- 
tures invaded. In addition there may occur osteo- 
myelitis of any of the bones, invasion of the wrist 
joint, rupture of the mid-palmar space through the 
dorsum, and a host of other complications. 

In operating upon a felon. Kanavel advises a lat- 
eral incision, supplemented at times by a counter 
opening. Thus he claims to more thoroughly divide 
the fascial bands which traverse the terminal pha- 
langeal space, and also avoids placing the scar on 
the palmar surface. Babcock (Journal of the 
A. M. A., June 14, 1913), from personal experi- 
ence with this incision, states that the sense of 
touch is impaired, and recommends the time-hon- 
ored median incision. Dorrance {Journal of the 
A. M. A., May 10, 1913) "goes Kanavel one better" 
and joins the distal ends of two lateral incisions 
around the end of the finger. I have never used 
this latter incision. Certainly the old median inci- 
sion left something to be desired, in that it often- 
times had a tendency to prematurely close. In my 
experience the Kanavel incision has given entire 
satisfaction, especially when two openings are made, 
and I have had no complaint of impairment in tac- 
tile sense. 

Infections of the sheaths of the first, second and 
third fingers should be attacked from the side. 
The incisions are made upon the lateral palmar 



aspect of the two proximal phalanges, and if the 
infection is severe these incisions are joined over 
the proximal interphalangeal joint. The sheath 
should be freely opened by extending the incision 
the full length of the infected area. This holds 
true even over the joint, but in such cases the finger 
must be dressed in extension to prevent tendon 
prolapse. White warns against incision over the 
joint for fear of tendon sloughing. This has not 
been my experience, if the finger is properly 
dressed. 

Infections of the little finger sheath are treated 
as described in the foregoing paragraph. One must 
carefully ascertain whether infection has extended 
to the ulnar bursa, and if not that structure must 
not be exposed. It is advisable to proceed from the 
known infected area to the unknown, for, as Kan- 
avel suggests, the hitherto uninfected sheath even 
if opened first would probably become contami- 
nated from the lymphatics. I believe White's 
method of aspirating the sheath before opening, so 
lauded by DaCosta, is only of theoretical value. If 
the ulnar bursa is involved, it should be incised 
through the palm on a director to the ulnar side 
of the sheath. If the infection has invaded the 
forearm, the incision may be carried around the 
uncinate hook and the annular ligament may be 
sacrificed if necessary. Kanavel advises this in 
some instances, and states if the wrist is dressed in 
extension no harm results. Probably a better pro- 
cedure would be to terminate the incision at the 
distal border of the annular ligament, and drain 
the space under the profundus tendon at the wrist 
into which sheath the ulnar bursa is almost certain 
to rupture. This is accomplished by incising the 
wrist on the lateral palmar aspect of the ulnar 
above the joint. Forceps are introduced so that all 
structures save the bones and the pronator quad- 
ratus are palmar to them, and a counter opening is 
then made upon the radial side. If the infection 
has extended further upward, invading the fore- 
arm around the ulnar vessels, it may be attacked by 
an incision between the ulna and the flexor carpii 
ulnaris. 

Thumb sheath infections must be opened along 
the proximal phalanx and through the thenar mus- 
cles to a point one thumb's breadth distal to the 
lower border of the annular ligament. The reason 
for terminating the incision here is to avoid divid- 
ing the motor nerve to the thenar muscles. As the 
upper end of the radial bursa is always infected and 
usually ruptures, it must be drained by lateral inci- 
sions in the wrist which lead to the "anterior wrist 
space" already described. Kanavel warns against 



8 



American 
Journal of Surgery. 



Parsons — Hand Infections. 



January, 1915. 



mistaking subcutaneous collections of pus upon the 
anterior aspect of the wrist of lymphatic origin, for 
the more important pus pockets under the tendons. 
Drainage of these spaces will not drain the anterior 
wrist space. 

The frequency with which infections of the little 
finger and thumb sheaths and their respective bursae 
are associated induced Picque {Journal de Chirur- 
gie, October, 1913) to make four incisions, one 
each along the little finger and thumb, one from the 
root of the little finger to the radial side of the 
uncinate hook, and one from the root of the thumb 
to the base of the thenar eminence. If the infec- 
tion extends above the annular ligament, he makes 
two incisions, one on either side of the flexor ten- 
don group which lead downward to the upper ends 
of the ulnar and radial bursae respectively. 

Web infections are treated by incisions upon 
either the dorsal or palmar aspect of that structure, 
or by splitting the web. The superficial transverse 
ligament at the distal border of the hand may be 
divided without danger, but the deep interosseous 
ligament must be spared to preserve the integrity 
of the hand. On the palmar surface the incision 
may be extended to the Kanavel line, which is dis- 
tal to the superior arch. As web infection so often 
extends along the lumbrical canals, the incision 
should be located over the lumbrical muscle. This 
has an added importance in regard to the webs of 
the middle, ring and little fingers, as the mid-palmar 
space is almost certain to participate in their in- 
fection, and the best way to drain this space is by 
passing forceps through the incision around the 
dorsum to the lumbrical muscle and thence into the 
space, as suggested by W. C. Dugan in 1906. 

The thenar space rests immediately upon the 
transversus adductus, and the shortest route thereto 
is by incising the dorsum of the index-thumb web 
just radial to the middle of the index metacarpal 
bone and level with its palmar surface. Forceos 
are made to pass along the palmar as])cct into the 
thenar space, but never beyond the middle meta- 
carpal bone for fear of infecting the niid-i)alniar 
space. 

The method of attacking infection of the upper 
ends of the ulnar and radial bursae and the ante- 
rior wrist space recommended by White (Lancet, 
February 24, 1906) is interesting. Severe infec- 
tion of the ulnar bursa, wliich is usually found rup- 
tured, he opens by a lateral ulnar incision which 
drains the anterior wri.st space. Tie makes no coun- 
ter radial opening as does Kanavel. Less severe 
ulnar bursa infections (unruptured) he drains by 
an opening between the flexor tendon and the flexor 



carpii ulnaris in the same manner as Picque. The 
radial bursa he finds less often ruptured into the 
anterior wrist space, and instead of completing the 
rupture and draining the space as recommended 
by Kanavel, he drains anteriorly between the radial 
artery and the flexor carpii radialis. If he fears 
pressure upon the artery, he excises one inch of the 
vessel and covers the stumps. He avoids the ulnar 
side of the flexor carpii radialis for fear of pres- 
sure upon the median nerve. Kanavel mentions 
this point of drainage, but prefers to rely upon the 
lateral wrist incision. 

Picque does not recognize the spaces designated 
by Kanavel as the thenar and mid-palmar spaces. 
He deals with palmar abscess as a whole and drains 
through two incisions which begin near together at 
the proximal end of the adductor crease and radiate 
distally, one being directed toward the web between 
the little and ring fingers, and the other toward the 
web between the index and middle fingers. Such 
incisions must sever the superior palmar arch, and 
furthermore the pus is drained through the tendon 
group. The first of these incisions opens the mid- 
palmar space, but how much better is Kanavel's 
method of drainage — over the involved lumbrical 
canal, away from the tendons and distal to the ar- 
teries. The second Picque incision opens the inner 
end of the thenar space. Kanavel drains by a 
shorter route, traversing the tissue of the dorsum — 
the usual site of overflow when the thenar space 
ruptures, l-'urthermore, by the latter method in- 
jury to the palmar structures is avoided. 

Although the scope of this paper does not include 
specific methods in the treatment of hand infec- 
tions, I cannot forego tlie mention of a few general 
points, with the correctness of which I had become 
convinced before reading the monograph of Kana- 
vel so frequently quoted herein. 

(1) In operating for hand infections a general 
anesthetic should be employed. In uncomplicated 
felons this rule may sometimes be disregarded. 

(2) ]\Iake the field bloodless by the employment 
of a suitable tourniciuet. 

(3 For drainage use gutta percha tissue (not 
tubes) or gauze saturated with balsam of Peru and 
oleum recini. Kanavel recommends gauze impreg- 
nated with vaseline. 

(4) As a rule wet dressings are continued too 
long. 

(5) The operation should be slowly performed, 
the various structures being identified as encoun- 
tered, remembering that the procedure is not so 
simple as the opening of a boil. 



Vol. XXIX, No. 1. 



Hellman — Painless Childbirth. 



Amebic AM 
Journal of Surgery. 



PAINLESS CHILDBIRTH IN FRANCE: A 

NOTE UPON THE USE OF 

TOCANALGINE. 

Alfred M. Hellman, M.D., F.A.C.S., 

New York. 



In 1847, a few months after the discovery of 
ether, Deschamp in Paris wrote an article entitled 
"Ether in a Case of Application of Forceps," and 
in the same year Dubois wrote on "Application of 
Ether in Labor." So from the very earliest days 
France was alive to the need of easing, wherever 
possible and safe, the pains of childbirth. In 1854 
appeared articles on chloroform in labor from the 
pens of Pajot, of Perrin, and many other French- 
men. The "Sleep a la Reine" was much in vogue 
after its discovery by Simpson, of Edinburgh, espe- 
cially after he had used it when royalty was in 
labor. 

In 1878, Pinard wrote a most elaborate and able 
monograph entitled "The Comparative Action of 
Chloroform, Chloral, Opium, and Morphine on 
Women in Labor," and most of his deductions still 
hold. He felt that chloral was of little value, 
and that while morphine was frequently useful its 
results were not as satisfactory as those of chlo- 
roform. Chloral stopped the labor every time; 
morphine only at times. 

In 1885, Doleris, working with Dubois, attempted 
the local use of cocaine in solution and in salves 
applied to the genital tract, to make labor less pain- 
ful, but with little result. 

Later Tuffier and Malartic and others tried spinal 
cocanization in obstetrics. But aside from its dan- 
gers the anesthesia lasted only two hours. Shortly 
after, stovaine was discovered, and that, too, was 
used intraspinously, but it in turn had to be dis- 
carded. 

When Kroenig and Gauss first reported their re- 
sults with scojxilamine and morphine, Le Lorier 
working on the service of Dessaignes, tried this 
method with the same difficulties that confronted 
many others at that time, — difficulties due, I should 
say, to the fact that the Freiburg recommendations 
were not followed in detail and also to the instabil- 
ity and unreliability of the drug, as then prepared. 

But the great need of something to alleviate the 
sufferings of childbirth and to encourage a possible 
increase of the birth rate in this age being ever 
present in France, Prof. Ribemont Dessaignes of 
the University of Paris gladly sought the oppor- 
tunity to try tocanalgine when the virtues of that 
drug were proclaimed by the chemists Laurent and 
Paulin. 



This drug is obtained by the action of living fer- 
ments on the clilorhydrate of morphine. The liv- 
ing ferments resemble those used in beer leaven- 
ing. Morphine is almost entirely transformed into 
a substance which crystallizes in a very regular 
way. So we see that the drug closely resembles 
the oxydimorphine of Marne ; it seems to be a 
product of hydration and hydrogenation of mor- 
phine. But, strangely enough, it possesses not one 
of the chemical reactions of morphine itself and 
is only one-fifteenth as toxic. 

It was in July, 1914, that Prof. Ribemont Des- 
saignes reported to the Paris Academy of Medicine 
his results with tocanalgine. He tried it in 112 
cases without a single bad result. The drug acts 
on the nervous centers of the brain and sympa- 
thetic system where it is brouglit from the point of 
injection by the circulatory system. The pains dis- 
appear in from 3 to 15 minutes after the adminis- 
tration of the drug; rarely it takes 30 minutes. As 
a rule the patients sleep between pains but are 
easily aroused by asking them a question. Those 
who do not sleep are apt to be excited and talkative 
and, though conscious of uterine contractions, they 
perceive no sensation of uterine pain. Eighty-four 
of his 112 patients had complete analgesia. Twen- 
ty-four of the women, finding sufficient relief from 
one injection, refused further treatment, though 
they still had some slight pain. Only four very 
nervous women seemed refractory to the drug. 
Though they claimed that they had no relief, their 
complaints and screams became less noisy. 

The length of the analgesia is very variable, the 
extremes being 30 minutes on the one hand to 12 
hours on the other. There was not a single ill ef- 
fect on the mother during labor or the puerperium; 
and though the hysterograph showed the uterine 
contractions to be unaltered, the second stage of la- 
bor was somewhat lengthened, probably due to the 
lessened use of the abdominal muscles following 
the injections. Often in cases of rigid cervix the 
first stage is shortened. 

The 112 labors resulted in 115 babies, 77 of 
whom at once cried out ; 28 were born dazed, like 
Cesarian section babies, but they had good color, 
regular forcible cardiac action, normal reflexes. 
This meant that after a little artificial respiration 
they would all breathe nonnally and they did. One 
child died during labor, but the fetal heart sounds 
were inaudible on admission to the hospital. All 
others, after respiration was established, had the 
same chances as other new-born infants. 

This drug tocanalgine is given in doses oi lyi 



10 



American 
JouRNAi- OF Surgery. 



Deavor— Blood Transfusion. 



January, 1915. 



ccm. for the first injection and Yz to J4 ccni. for 
succeeding doses. 

Due to existing international conditions I could 
obtain only a small quantity of this drug to date 
and have so far tried it in only three cases with the 
following results : 

All three patients were primiparce — one was 36 
years old. Two cases received 2 injections, one 
case 3 injections. Unfortunately, all three were 
given pituitrin. Two of tlie patients were entirely 
relieved of suiTering, one very much relieved. 

One mother suffered from thirst and frequent 
micturition. There were absolutely no other un- 
toward symptoms in the mother during labor or 
puerperium. The women were not exhausted at 
the end of labor, the uterus involuted promptly, 
convalescence was in every way smooth, the flow 
of milk was as it should be. There were no head- 
aches, nausea or vomiting or other uncomfortable 
sensations, at any time. The second stage of labor 
was certainly prolonged in all three cases. It does 
not seem that the uterine contractions were stopped, 
but they were certainly lessened in frequency and 
intensity, necessitating, as I have stated, or at least 
so my house gynecologist thought, pituitrin in the 
three cases. 

One baby cried out at once, one took 4 minutes 
to cry out and one 8 minutes. But after that thev 
all did perfectly well and at the end of the twelfth 
day left the hospital weighing more than at birth. 

In conclusion let me say a few words compar- 
ing this "tocanalgine obstetrique" with scopolamine- 
morphine. They both act on the central nervous 
system. Tocanalgine works in 15 minutes ; scopola- 
mine takes 1 to 3 hours to establish amnesia. Both 
fail in a small percentage of cases. Both are harm- 
less to the mother in labor and puerperium. Both 
prolong the second stage of labor, but if this pro- 
longation is not excessive it is rather a benefit than 
a harm. Both cause oligopnea in a certain iiuni- 
ber of babies, but that should not deter us from the 
use of either drug. Though I am delighted with 
the results I have obtained to date in over 30 cases 
of "twilight sleep," I would welcome a drug that 
was just as safe to mother and child as scopolamine- 
morphine, and easier of manipulation. In the 
Freiburg method the memory test, not always easy 
to employ, must be the main guide and must be 
repeated every few minutes and the mother and 
child must be constantly watched. With tocanal- 
gine the return of pain means that the effect of the 
drug has worn off and the patient needs another 
injection, and the first or a repeated dose can be 
given near the end of labor, as it works promptly 



and promises rapid relief. Although my three cases 
were not everything to be desired, they were much 
more successful and much more encouraging than 
were the first attempts in the method of Kroenig 
and Gauss. 
2 West 86x11 Street. 



TRANSFUSION OF BLOOD— SOAIE RECENT 

OBSERVATIONS.* 

T. L. Deavor, M.D., 

Syracuse, N. Y. 



Aluch has been written about blood transfusion. 
Many attractive theories have been advanced. In- 
teresting articles have appeared, from time to time, 
dealing with almost every phase of the subject, espe- 
cially of technic, and describing new instruments, 
some of which are so complicated and so stamped 
with the genius of the inventor as to be of little 
practical value to the busy general surgeon. 

Although the indications for transfusion are nu- 
merous, it must be that new conditions will con- 
tinue to arise, as we come to understand the blood 
more fully. By the introduction of new blood into 
the veins, some persons, though suffering from an 
incurable malady, have no doubt been given a few 
months longer to live, notably so in pernicious 
anemia and in the anemia of malignant disease. I 
have seen both these conditions apparently benefited 
by transfusion, but it must be done early, and re- 
peated if necessary. Transfusion for acute infec- 
tions in plctlioric individuals is unwarranted. Long- 
standing infectious processes, attended by anemia, 
show improvement in some instances. The action 
of transfused blood in these cases is still theoretical. 
There is good reason to believe, however, that it 
increases phagocytosis and raises the opsonic index. 

Not all anemic individuals are good subjects for 
transfusion. Each case must be carefully studied, 
especially as to the heart condition. If the second 
sound of the heart is not easily defined, and the 
pulse thready and irregular, one should transfuse 
cautiously, if at all. Accidental hemorrhage, for 
which we would perform a transfusion, sometimes 
occurs in the presence of certain constitutional con- 
ditions — diabetes, leukemia, nephritis — in which the 
heart muscle has been rendered unable to withstand 
the strain incident to sudden increase in the volume 
of the circulation. In case of fatal hemorrhage, 
death is probably not due to loss of blood per sc, 
but rather to rapid deterioration of the heart muscle, 
the heart dying along with the rest of the body 



•Re.id before the Syracuse Academy of Medicine, November 
17, 191-1. 



Vol. XXIX, No. 1. 



Deavor — Blood Transfusion. 



American 
Journal of Surgery. 



11 



from lack of nutrition. We must not forget, also, 
that hemorrhage is sometimes beneficial. Some of 
our superiors still remember the magic effects of 
venesection, as practiced years ago. These splendid 
results were due largely to relief of tension upon 
the vasomotor centers, giving to the heart muscle 
a period of respite from fatigue. In the presence 
of marked blood impoverishment, and in great re- 
duction of the blood volume by acute hemorrhage, 
the danger of hematolysis should not be overlooked. 
Hematolysis occurs in something like 2b per cent, of 
cases, and yet a long and extensive experience may 
not encounter a single instance. It is a mark of 
good surgical judgTuent, however, not to transfuse 
unless the blood of both individuals is found to be 
compatible. Some years ago when the study of the 
circulation was creating new interest, the opinion 
was held that death from hemorrhage was due to 
a sudden diminution in the quantity of blood and 
not to loss of red corpuscles, that no matter how 
sudden or severe the hemorrhage, the loss of serum 
was invariably out of proportion to tliat of the cel- 
lular elements, there being always enough red cells 
left to carrj' oxygen to the tissues, and further- 
more, on such occasions, the mere introduction into 
the veins of sufficient normal saline solution to re- 
store equilibrium would also save life. We know 
now, however, that while this theory was largely 
correct, it did not express the whole truth. There 
are instances in which, after serious loss of blood, 
saline instillation fails to save life. The heart rallies 
for a short time, it is true, only to again lose its 
grip. Something else is needed. Whole blood 
seems to supply this need. After abortions in tall, 
slender, relaxed individuals, with the uterus empty 
and hemorrhage persistent, sometimes for days, 
transfusion acts unusually well. Of course, there 
are other effectual means of treatment. But trans- 
fusion controls the hemorrhage by shortening the 
coagulation time, and supplies new blood. 

By far the greater number of transfusions is done 
for some form of anemia, in which the patient's cir- 
culation has been either suddenly depleted by hem- 
orrhage, or more gradually effected, as in the stilli- 
cidium of uterine fibroids, persistent epistaxis, hem- 
orrhage of the newborn and frequent attacks of 
hematemesis. Then there is the group of cases in 
which some disease or foreign substance has altered 
the character of the blood. In this group are the 
malignancies, cirrhosis of the liver, illuminating gas 
poisoning, pernicious anemia and hemophilia. Be- 
sides these more common conditions, all of which 
have responded to transfusion, another indication 
is found in those diseases of obscure pathology of 



which idiopathic epilepsy is an example. The pa- 
tient's circulation should first be depleted by phle- 
botomy. If one will transfuse these cases occa- 
sionally, perhaps twice a year, and note the effect, 
he will find that many of them will be relieved of 
epileptic seizures for a number of months each lime. 
Since there is, as yet, no cure for epilepsy, trans- 
fusion ought to be tried. This applies more par- 
ticularly to the individual case, in which there is a 
desire to relieve domestic tension and improve the 
environment. In institutional work, where hun- 
dreds of cases are treated, transfusion would hardly 
be feasible. 

Like all other surgical procedures, methods of do- 
ing transfusion will continue to multiply until one 
or more are perfected which combine simplicity 
with rapidity and safety. Crile's method is used 
extensively. Brewer's tubes have given satisfaction. 
McGrath's rubber bulb apparatus should receive 
further trial. The same author's forceps-canula 
seems very simple in its application, but here again 
the matter of turning back a vascular cuit is tedious 
and often difficult. None of these methods provide 
any special means for measuring the blood. While 
it is not necessary to be so accurate about the 
amount transfused, yet it would seem best to oper- 
ate within the limits of safety, noting carefully the 
effect. Some patients require only small amounts ; 
others, inore. A slender person should be selected 
as donor, if possible, whether arterial or venous 
blood is to be used. Healtliy relatives are to be pre- 
ferred, for legal as well as social reasons. Section 
of the radial artery, while exposing the donor to a 
slightly longer convalescence, is quite devoid of 
danger, only a small incision being necessary, when 
the simple canula, presently to be described, is used. 
Results are more certain also because of the driv- 
ing power of the heart back of the column of blood. 
Of course, when an artery is severed, instantly its 
walls contract and retract, a wise provision of Na- 
ture in controlling hemorrhage. But this is offset 
by the fact that venous blood clots more readily 
than arterial, the coagulation time being shorter. 
The more tedious the process, anyway, the greater 
are the chances of failure. 

In the Nezv York State Journal of Medicine, July, 
1911, I described a method of direct transfusion, 
with a simple means of ineasuring the blood. Since 
then I have used this method in a considerable num- 
ber of cases with very good results. It is effective, 
quickly applied and requires only a reasonable 
amount of dexterity. However, when the donor is 
a stout individual with a large wrist, as is too often 
the case, tliere is some difficulty in making the artery 



12 



American 
Journal of Surgery. 



Deavor — Blood Transfusion. 



January, 1915. 



reacli the vein without undue tension. On this ac- 
count, I conducted a series of experiments to de- 
termine how this could be overcome. Without go- 
ing into a close description of the many devices in 
use, it is safe to say that the two disturbing fea- 
tures which have occupied the attention of experi- 
menters everywhere are hematolysis and early co- 
agulation of the blood. The disposition of the first 
is in the hands of the operator. Evidently, many 
surgeons believe that whatever contrivance is used 
to convey the blood from one individual to another, 
its inner surface must, in some way, approach in 
character that of the living vessel (Crile), or be 
lined with paraffin, herudin or some other protective 
substance (Brewer, Percy, Satterlee and Hooker). 
While this may be desirable, I have not found it 
to be an absolute necessity. The great trouble with 
many of the finely adapted instruments for transfu- 
sion is that their application often is not possible 
in every case on account of inability to procure 
them. Lack of assistance and of skilled hands, also, 
being important considerations. Consequently, 
many persons, greatly in need of transfusion, are 
deprived of its beneficient influence. 

After a number of tests covering all these points, 
I found that arterial or venous blood will flow al- 
most indefinitely through an unlined rubber tube 
or a combined metal and rubber tube, if air is ex- 
cluded and the conducting medium is kept at the 
body temperature by means of hot saline sponges; 
also, that blood collected from the canula does not 
coagulate any more readily than if taken directly 
from the vessels, the same conditions prevailing in 
both instances. Mere contact with a foreign sub- 
stance, therefore, is not the main feature in the 
production of clotting. Exclusion of air and gentle 
manipulation are likewise essential. Paraffin seems 
to be unnecessary. As a matter of fact, the blood 
forms its own lining, as effectually protective as 
paraffin, by rapidly coating the inside of the tube 
with senim. This can be demonstrated by opening 
a tube through which blood has been passing for 
some seconds. The serum which adheres to the 
tube does not seem to favor coagulation, nor does 
it show a tendency to break up into particles to be 
carried along as emboli. On the strength of these 
findings, I now use two small canulre connected by 
a piece of rubber tubing (fig. 1). The flexible rub- 
ber connection permits of rapid and more accurate 
adjustment. 

We learned, however, that several things are 
necessary for easy and satisfactory work. The en- 
tire tube, or transmitter, should be as short as pos- 
sible, not over five inches, and free from sharp 



curves and angular processes.' A long tube (Ave- 
ling) means failure. When ready to make the anas- 
tomosis, the blood should not be exposed to the air, 
the vessels and tube having been kept warm and 
covered by hot saline sponges. Air does not easily 
penetrate a wet sponge. If blood is to be collected 
in the small graduate for estimating the amount to 
be carried over, it requires but a few seconds, after 
which the tip of the canula is wiped off and the hot 
sponges re-applied. The caliber of the tube should 
compare well with that of the vessels to be used. 
A very small tube produces too much tension, and 
one of large caliber permits undue commotion, of 
the blood stream, both of which favor fibrin forma- 
tion and clotting. 

The parts having been cleansed, the artery and 
vein, or both veins, are dissected clear and kept 
warm by moist sponges. Nerve fibers are carefully 
avoided. Provisional ligatures are thrown around 
the vein and artery in order later to fix the canula, 
and close the vessels when through. The artery is 
then severed, its distal end clamped or ligated, and 
the canula inserted and tied in. While the blood 
is flowing into a hot sponge, the vein is opened 
and the other end of the canula introduced and 
fixed. When the vessels used are both veins, they 
need not be divided. For obvious reasons, their 
distal and proximal segments, respectively, are con- 
nected with the canulae. The anastomosis should 
be made quickly and with the slightest amount of 
traumatism. Air must be excluded. Even while 
the vein is being opened for the second canula, the 
artery, or other vein, should bleed into a hot sponge 
to prevent coagulation. The tip of the canula is 
wiped off before insertion. 

We still employ the "spurt" method, referred to 
previously, to determine the amount of blood used. It 
is estimated in this way : When ready to make the 
connection, a small sterilized graduate is provided 
and the blood allowed to spurt into it till the drachm 
mark is reached, or any other point which may be 
decided upon. If five spurts are required to fill 
the graduate to the drachm mark, each spurt will 
contain twelve drops. A pulse of eighty, therefore, 
will discharge two ounces of blood a minute. This 
quite simple device is also sufficiently accurate. A 
trifling allowance is made for loss during the oper- 
ation. 

Arterial hemorrhage is a continuous flow, charac- 
terized by sharp, spurt-like exacerbations, due to sys- 
tolic force modified by vascular tension. Blood com- 
ing from a vein has a long, open, undulating curve, 
comparable to a very slow pulse. The estimation, in 



Vol. XXIX, No. 1. 



De.wor — Blood Transfusion. 



American 

JOUKNAL or S l'KGERY. 



13 



either case, however, can be made as above de- 
scribed. 

There is no mysterj' about blood transfusion, al- 
though blood itself is a rather mysterious fluid. We 
analyze it, and determine pretty well the nature of 
its many constituents, but its physiology is not 
clear. No one knows just how it is that the same 
blood stream, rushing on like a mighty torrent, is 
equally able to construct bone and muscle, and to 
keep alive and keenly active the delicate brain 
cell. Hence the question has been raised as to the 
final destiny of blood transfused, whether it under- 
goes change, or immediately fulfils all tne require- 



Fig. 1. 

ments of the patient's own circulatory medium. In 
our experiments we could find no particular altera- 
tion except a tendency to enrichment. The reci- 
pient's blood, examined before and after transfu- 
sion, showed, in the latter instance, only an increase 
in normal constituents. I also tested a mixture of 
the two bloods, patient's and donor's, at the body 
temperature, both before and after transfusion, 
with the same results, except in the cases of perni- 
cious anemia ; here, of course, the abnormal ele- 
ments remained in evidence. From my more re- 
cent work along this Hne, I have reached the follow- 
ing conclusions : 

(1) That blood may be carried from one indi- 
vidual to another through unlined metallic or rub- 
ber tubing, maintained at the body temperature, 



without danger of clotting, if the anastomosis is 
made promptly. Long exposure of the field to the 
air and tedious manipulation are to be discouraged. 
The tube must be kept scrupulously clean. The 
blood serum adequately lines the tube. 

(2) That the amount of blood passing over from 
the donor to the recipient may be accurately de- 
termined by knowing the donor's pulse rate, and 
the quantity discharged by a series of ventricular 
contractions. 

(3) That the field of application should be en- 
larged to include any condition which might be 
benefited, even to a small degree. All things con- 
sidered, the indications for transfusion may be left 
to the judgment of the operator, who should know 
something of bloodvessel surgery. 

(4) That, in the absence of hemolysis, blood, 
after transfusion, is immediately taken up by the 
recipient and utilized as blood. If any change oc- 
curs, it is a gradual one, which has not, as yet, been 
determined. Further study of the blood is greatly 
needed. 

(5) That our experience with whole blood 
preferably arterial, has been so satisfactory, that we 
have not often had to resort to the more compli- 
cated process of defibrination. 

(6) That the method to be recommended is the 
one which requires the fewest assistants, creates 
the least excitement, fulfils the desired purpose and 
can be applied with the slightest disturbance to the 
blood contents. 

(7) That blood transfusion is not, strictly speak- 
ing, a cure for any pathological condition, but rather 
a therapeutic help to other means of treaunent. Its 
indication may even be replaced, occasionally, by 
saline instillation. Yet, there have been times 
when, death being imminent, when transfusion has 
seemed to be the one link in the chain of events 
without which a life would surely have been sac- 
rificed. We. therefore, cannot take the unusual po- 
sition held by some and dispose of transfusion as a 
useless procedure, nor vie with the enthusiastic 
worker, and recommend its practice too freely; but, 
with an open mind, as if searching for truth, we 
should carefully consider each case, in full view of 
the fact that blood is a complicated tissue about 
which there is yet much to be learned. 

(8) That transfusion of blood is not devoid of 
danger; and while frequent performance improves 
the dexterity and skill of the operator, it does not 
relieve him of the peculiar responsibility which at- 
tends this apparently trivial operation. 



14 



American 
Journal of Surgery. 



Ravogli — Antiseptics. 



January, 1915. 



A CONSIDERATION OF THE ANTISEPTICS 
USED IN THE TREATMENT OF IN- 
FECTIONS OF THE GENITO- 
URINARY ORGANS. 
■• •, A. Ravogli, M.D., 

- ' Cincinnati, Ohio. 



Infections of genito-urinary organs occur from 
different sources and from different causes, and in 
consequence there are different kinds of infections. 
Gonorrheal infection is the most common, the most 
persistent, and often the starting point of urinary 
troubles. Other infections occur, frequently, how- 
ever : for instance, in chronic cystitis, between the 
enlarged folds of an inflamed mucous membrane 
through the irritation of an alkaline urine, ulcera- 
tions are found which are very easily infected. 
The infection may be brought by continuity to the 
ureters and to the pelvis, causing pyelitis and pye- 
lonephritis. An enlarged prostate is the cause of 
congestion of the mucous membrane of the bladder, 
and it often contains infectious materials in all de- 
grees of inflammatory process, causing and spread- 
ing infection. 

The infection may be limited to one part of the 
genito-urinary apparatus, or it may spread to the 
whole apparatus, from the urethra to the kidney. 

Many pathogenic bacteria are found in the uri- 
nary tract, which, according to R. Kraus,^ can be 
divided into two groups: In the first group are: 
1, bacterium coli ; 2, proteus Ilauser; 3, staphylo- 
coccus pyogenes; 4, streptococcus pyogenes; 5, gon- 
ococcus Neisser ; 6, tubercle bacillus ; 7, bacillus 
typhi. The second group consists in the bacillus 
pyocyaneus, diplococcus Fraenkel and Weichsel- 
baum, and some anaerobic bacteria referred to by 
Albaran and Cottet. In some cases those bacilli 
which in the normal circiunstances are saprophytes 
do not produce any trouble, but in the presence of 
pathological alterations may become of a pathogeni': 
influence, staphylococcus ureae (Rovsing), staphy- 
lococcus and micrococcus liquefaciens, flugge dip- 
lococci Bastianelli, and many others, which in some 
circumstances more or less will produce infection in 
the urinary organs. 

Infection often is carried from outside by the in- 
troduction of instruments in the urethra either not 
at all or not sufficiently sterilized. In many cases 
the instruments, although perfectly sterilized, may 
stir uj) mucus or muco-pns in the posterior urethra 
and cause infection. 

When a urethra has been infected with gon- 
orrhea, this condition has much greater influence in 
the i)roduction of other infections. 



Infections may occur by the way of the lymph 
and of the blood. In these cases pathological bac- 
teria, which are found in those fluids, when car- 
ried to an hyi>eremic or inflamed mucous mem- 
brane of the urinary organs, may find good ground 
for their develof)ment in the mucous membrane it- 
self and in the residual urine. The lymphatics 
from the intestines in close proximity to the urinary 
organs may carry a rich mess of bacteria and pro- 
duce infection. Colon bacillus in urinary infections 
is more frequent and much more stubborn than at 
first considered. Adams" referred to sixty cases of 
infection of the urinary tract where colon bacillus 
was present. The results of this infection is bacil- 
luria, which often causes pyelitis, chronic cystitis, 
and at times, pyelonephritis. On account of the 
stubbornness of these bacteria, there is a tendency 
to relapse, and more often to recrudescence. 

The most important point before the treatment 
of infections of the genito-urinary organs is the pre- 
vention. When the rules of asepsis are strictly en- 
forced infection can be avoided. When, however, 
we are in the presence of infection, it must be 
treated. We make use of two kinds of antiseptics, 
those which are taken by the stomach ( internal an- 
tiseptics) and those which are used locally to wash 
and to cleanse the mucous membranes (local an- 
tiseptics). 

The general internal antiseptics are those which, 
administered by the mouth and excreted with the 
urine, produce such a change as to convert it into 
a germicidal fluid. Salicylic acid has been used for 
many years, and more especially its derivate salol, 
which is still used with good results. Salol, de- 
composing in the upper intestinal tract into salicylic 
acid and carbolic acid, is thus absorbed and excreted 
in the urine, rendering it antiseptic. 

On account of its being hard on the stomach, 
salol has been replaced by urotropin, which has to- 
day just attained great popularity. It is hexa- 
methylene tetramin [(C H 2) 6 (N H 2) 4] and is 
obtained from ammonia and formaldehyde. Al- 
though having antiseptic properties, it is non- 
jioisonous and non-irritant. It was introduced into 
urological practise by Nikolaier under the commer- 
cial name of urotropin. From the same base, com- 
bined with other antiseptics, we have helmitol 
(Bayer), and borovertin, when combined with boric 
acid : hetralin, cystopurin, cystogen, aminoform, are 
all the same thing under difterent names. All come 
from the same preparation and have in common the 
property to set free formaldehyde in the urine, 
which disinfects the urinary tract. In small doses 
it prevents the production of bacteria, while in 



Vol. XXIX, No. 1. 



Ravogli — Antiseptics. 



American 
Journal of Surgery. 



15 



large doses it destroys those already existing. To a 
certain extent, hexamethylenamin has been recom- 
mended as diminishing pain and also as a uric acid 
solvent. Camphoric acid has also been proposed 
as a urinary antiseptic, and it has been combined 
witii hexamethylin-tetramin in a preparation that 
has been recently highly recommended by Remete'' 
as much more effective in producing disinfection 
and producing no irritation. In a series of cases 
where the urine was foul and full of bacteria, after 
using this drug it was found not altered and the 
bacteria were greatly diminished. 

So far, at the present time, urotropin is the ex- 
ponent of a large series of urinary antiseptics. 
Pfoundler and Schlossmann consider it a sovereign 
remedy for cystitis and pyelitis. Indeed, in chronic 
cystitis in the second stage together with the local 
treatment hexainethylenamin, as internal disinfect- 
ant, finds its right indication. Holt praises urotropin 
as an important remedy in the treatment of phos- 
phaturia in children of all ages. 

Thompson claims that urotropin alone is not so 
well tolerated, but associated with benzoate of 
sodium is much more effective. Indeed, Thompson, 
Still. Pardoe, and others, in cases of infection from 
bacillus coli, have not much confidence in the value 
of hexamethylenamin and they recommend the use 
of alkalies. In those cases wliere hexamethylenamin 
had been of great benefit, it had been administered 
in association with potassiimi citrate. Moreover, 
it is usually much more effective in chronic urinary 
infections than in acute cases, where the use of 
alkalies, antipyrin, salol. and the old chinin have 
proved of great value. 

The use of the vaccines, especially in the gon- 
ococcic and colon bacillus infections, has been 
greatly praised. In my experience it requires much 
more study, and many more accurate observations. 

The most reHable treatment for the genito- 
urinary infections is the local treatment, by means 
of irrigations or instillations, with local antiseptics. 
Irrigation is a powerful means to combat infections 
in the urinarv' tract. It is necessary to recommend 
perfect asepsis for the instruments and for the fluid 
to be injected, which has to be boiled before using. 

By means of a Janet irrigator one can send into 
the bladder large quantities of an antiseptic solu- 
tion, without any necessity of insertihg catheters. 
If we do not need to send the fluid into the bladder, 
the application can l)e limited to the urethra by fill- 
ing the canal, securing an even distension : when 
the inflow- is stopped the fluid leaves the urethra 
by its contraction. 

In my practice I am using, in cases of acute 



cystitis, irrigations with 2% solution of biborale of 
sodium; with its mild alkalinity it dissolves the 
mucus, cleanses the mucosa, diminishes the irrita- 
tion, and at ihe same time has antiseptic properties. 
In many cases it is found useful in bladder irriga- 
tions, as it has no irritating property. 

Where more powerful antiseptic applications are 
required, potassium permanganate is an excellent 
antiseptic. It is a powerful oxidizing agent be- 
cause of the ready disengagement, in the presence 
of oxidizable matters, of a portion of the oxygen 
of the permanganic acid. P.y this property it 
promptly destroys fetor and putrid materials. In 
solution of from 1 to 5000, to 1 to 3000, it has a 
light claret wine color. When injected in these 
strengths into the bladder and the posterior urethra 
it is soon changed and is expelled as a grayish dirty 
fluid. The muco-purulent secretion is coagulated 
and is expelled as masses of dirty brownish strings. 
In my practice a mild solution of potassium per- 
manganate has been found tlie most effective to 
combat infections of any kind. Formaldehyde in 
solution from 1 to 1000. to 1 to 500. is frequently 
used for irrigations with good results. 

Picric acid, with its derivate picratol, has been 
used in solutions from 1 to 1000. to 1 to 500, in 
inflammatory gonorrheal urethritis, and in cystitis. 
It is an astringent and also a mild antiseptic. The 
results, however, have not been such as to warrant 
its use. 

Aluminum acetate has been pointed out by Dr. 
KolP as a useftfl antiseptic, especially in colon 
bacillus infection. With a series of experiments on 
the colon bacillus series and on the staphylococci, 
he could prove the bactericidal action of the drug 
in the strength of 2 per cent, solution. Clinically 
it 'gave good results in his cases; and in my service 
in two cases of severe chronic infectious cystitis, 
irrigations with 2 per cent, acetate of aluminum 
gave the most satisfactory results. 

For instillations I have used solutions of 1 to 3 
per cent, protargol, but more often of 20 per cent, 
argyrol. With an Ultzmann syringe only a few 
drops of argyrol are instilled in the prostatic 
urethra. ArgjTol has a powerful coagtflating prop- 
erty, and by it the muco-pus is coagulated in thick, 
string}- masses, which are easily removed by irriga- 
tions. Silver nitrate is also highly praised, but it is 
very irritant and painful, and in the ordinary cases 
argv-rol gives good results. 

Bichloride of mercury I find very irritating, even 
at the dose of 1 to 50.000. At this dose in mv pa- 
tients it has not produced any discomfort at the mo- 
ment of the irrigation, but after a while it was fol- 



16 



American 

Jqurnai- of Surgery. 



Kakels — Meningeal Hemorrhage. 



January, 1915- 



lowed by severe pain and vesical tenesmus, and I 
have entirely abandoned its use. A great many of 
tlie recommended antiseptics under different trade 
names have as their base bichloride of mercury and 
it is better to be on guard in their use. 

In concluding a short review of the modern anti- 
septics it must be said, again, that no antiseptic will 
have much value unless means to remove the source 
of infection are used. A good drain is obtained by 
the catheter left permanently in the bladder. A 
ratheter left permanently in the bladder, draining 
infected urine, diminishes and removes fever, if 
present, and its beneficial effects are seen also in 
the ureters and on the renal pelvis. Through the 
catheter the bladder and the urethra are washed 
with the disinfectant solutions. 

The removal of infected secretions from the pros- 
tate and from the spermatic vesicles by means of 
digital massage is often of great benefit, as in those 
organs infections are maintained and the urine 
spreads infection to the bladder and to the other 
parts of the genito-urinary tract. Likewise, if stric- 
tures are present, they must be dilated or cut. 

As stated above, in cases of deep infection, the 
old stand-by, chinin (quinine), surpasses any other 
internal antiseptic, and repeated irrigations vi'ith so- 
lutions at dift'erent strength of potassium permanga- 
nate excel any otlier local applications. 

References. 

'Kraus, R. : Die Bacterien der gesunden und Kranken 
Harnwege. Handbuch der Urologie, Band, I., p. 440. 

'Adams : Australian Med. Jour., ref. Urologie & Cutan. 
Review, Oct. 13, p. 525. 

'Remete, Eugene : Uber die Antisepsis der Harnwege. 
Pester Med. Chir. Presse, 1912. No. 10-11. 

*KoIl, Irwin S. : An Experimental and Clinical Study of 
Colon Bacillus Infection of the Gcnito-Urinary Tract. 
Trans. .A.ni. Urolog. Ass., 1912. 



Popliteal Suppuration. 
Pus escapes easily from the posterior chamber 
of the knee-joint along the azygos vein into the 
popliteal space. In the popliteal space it is shut 
in by the dense, tough popliteal fascia which fonns 
a roof over it, causing it to travel by the way of 
least resistance up to the thigh under the hamstring 
muscles and down the leg under the gastrocnemius. 
The overlooking of the escape of pus or any in- 
fective material from the knee-joint into the pop- 
liteal space is very easy and its results, owing to its 
deep extensions, are very disastrous, often leading 
to the loss of the limb or to pyemia. I would 
strongly urge that it is better to make even an un- 
necessary incision in the popliteal space than run the 
risk of overlooking this escape. — Edred M. Corner 
in the J. A. M. A. 



HEMORRHAGE FROM MIDDLE MENIN- 
GEAL ARTERY DUE TO TRAUMATISM ; 
HEMIPLEGIA, MOTOR APHASIA; 
OSTEOPLASTIC FLAP FOR LIGA- 
TION OF VESSEL ; RECOVERY.* 

M. S. Kakels, M.D., F.A.C.S., 
Surgeon to Lebanon Hospital ; Consulting Surgeon 
Rockaway Beach Hospital, 

New York. 



to 



Intracranial hemorrhage from rupture of the 
middle meningeal artery or its branches, due to 
traumatism, is a condition demanding serious con- 
sideration which the surgeon must be prepared to 
meet when least expecting it. 

The diagnosis is not difficult if one has a clear 
history of traumatism and is able to watch or 
elicit symptoms from the time of injury until mani- 
festations of cerebral compression are apparent. 
Occasionally, though, patients suffering from this 
condition are brought to the hospital with little or 
no evidence of trauma to the skull, in a state of 
stupor or coma, that many of the facts of the pre- 
ceding history that might lead to an interpretation 
of the cause of the symptoms cannot be elicited. 
Fortunately for the patients, the physical signs, 
namely, effects of cerebral compression, which de- 
mand operative intervention, are so characteristic 
that they hardly admit of error. 

A violent injury to the skull sufficient to cause a 
laceration of any of the intracranial vessels is gen- 
erally followed by symptoms depending upon the 
situation and extent of the extravasation. This ex- 
travasation may be intracerebral or extracerebral. 
If intracerebral it may involve important centers 
and cause rapid death without giving symptoms of 
compression. If extracerebral, due to extravasa- 
tion from the middle meningeal artery or its 
branches, a peculiar and characteristic sequence of 
symptoms follows the traumatism, namely: 1st, con- 
cussion ; 2nd, free or conscious interval ; 3rd, focal 
symptoms; and finally, 4th, symptoms indicative of 
general pressure such as (a) stupor, (b) uncon- 
sciousness, (c) slow pulse, (d) rise in blood pres- 
sure, (e) respiratory symptoms. 

The focal symptoms are commonly at first irri- 
tative, shown by twitching of the face or arm due 
to the situation of the hematoma, generally over the 
lower end of the Rolandic area where the centers 
for the face and arm are situated. Furthermore, 
if the hemorrhage is on the left side motor aphasia 
is another characteristic sign. 

Besides, from a laceration of the middle menin- 



•Presented before the .Surgical Section of the N. Y. Academy 
of Medicine, December 4. 1914. 



Vol. XXIX, No. 1. 



Kakels — Meningeal Hi 



M' iRRII \r,K 



American 
Journal of Scrcery. 



17 



geal or its branches extradural hemorrhages may 
take place from injury to the veins, sinuses, peri- 
sinoidal sinuses or emissary veins, the symptoms 
depending upon the amount, the site and the 
effects of pressure of the extravasated blood. The 
symptoms of pressure resulting from extravasation 
of blood may be of insidious or of rapid onset. 
The manifestation of compression occur when the 
extravasation has attained sufficient size to compro- 
mise the brain in the cavity of the cranium. When 
the extravasation takes place slowly there is a time 
— the free or conscious interval — which may be of 
short or long duration before symptoms of com- 
pression manifest themselves. Great importance 
must be attached to this classical and typical con- 
scious interval between concussion and onset of 
symptoms of compression, as it is one of the most 
characteristic signs we have of middle meningeal 
hemorrhage. 

On the other hand, the extravasation may be so 
rapid that coma occurs almost immediately without 
a free internal. The irritative symptoms may pro- 
gress to those of local paralysis of the same centers 
and if the clot is large enough to extend to the cen- 
ters of the lower extremity, which are situated 
higher up on the hemisphere, hemiplegia may re- 
sult. This, however, is extremely uncommon. 
Gushing states that "instance of actual hemiplegia 
from an extradural hemorrhage must be rare, since 
the centers or the lower extremity lie so far away 
from the primary point at which an extravasation of 
this sort is likely to arise that a iclot large enough 
to implicate the upper ridge of the hemisphere 
would in all probability either lead to such deep 
coma that symptoms of hemiplegia could not be 
appreciated, or else would cause death before they 
were apparent." 

The patient whose case is here presented had a 
lesion of this type, of w4:ich there are not many 
recorded. 

In spite of the progress made in the localization 
of cerebral affections there are some conditions in 
which it puzzles the operator to decide upon the 
exact place to open the skull. To determine the 
particular branch of the middle meningeal artery, 
anterior or posterior, which has been injured, is 
almost impossible, although schemes have been de- 
vised for finding points of election (Kronlein) for 
trepanation in hemorrhages from the different 
branches, should such be diagnosed. One can ob- 
viate this difficulty and uncertainty by making a 
large osteoplastic flap with its center over the main 
trunk. This seems quite rational, as it afford? an 
excellent view for exploration for hemorrhage from 



the main trunk of the artery as well as its branches. 
With such an opening we can lift the brain and 
thereby expose the middle fossa of the skull, thus 
giving a good view for basilar inspection and re- 
moval of clots. In elevating the brain, there need 
be no fear, as the opening in the skull is sufficiently 
large to admit of dislocation of the brain with little 
danger of compression effects. 

To one conversant with all the details of cranial 
surgery such a radical method is without danger 
and no more serious than exploration of the abdom- 
inal or any other cavity of the body. By follow- 
ing this plan in quite a number of cases we find 
this procedure a most efficient one for lesions in 
the fronto-temporal or tempo-parietal regions. 

A male, 45 years of age, was admitted to my 
service at the Lebanon Hospital on October 11, 
1914, with the history that two hours before, w-hile 
watching a baseball game, he was accidentally hit 
with a ball. After being struck he felt dizzy, but 
quickly recovered therefrom and walked to his 
home, where after an hour he became unconscious, 
and the whole right half of his body, including his 
face, was found completely paralyzed. He had 
vomited a large quantity of dark material. When 
brought to the hospital there was a small hematoma 
over the left parietal region, but no depression 
could be felt. The right half of his face was 
smooth and lifeless. The left pupil was markedly 
dilated and did not react to light or accommoda- 
tion. The right upper and lower extremity were 
paralyzed. Knee jerks, Babinski reflex, and ankle 
clonus were present on the right side. The left 
upper extremity was negative. On the left side 
the knee jerk was present, but only slight ankle 
clonus. The patient was unconscious. Lumbar 
puncture revealed sanguinous cerebro-spinal fluid 
under increased pressure. The pulse was slow and 
irregular. Respiration stertorous. Blood pressure 
220 m.m. The histor\- and classical train of symp- 
toms, namely, traumatism, concussion, free inter- 
val, then compression symptoms, were typical of a 
rapid and large extradural hemorrhage, due prob- 
ably to laceration of the middle meningeal artery 
or one of its branches. Accordingly a horseshoe 
incision w'as made in the left temporal region down 
to the bone. The skull was trephined in four places 
and the openings connected by means of the Gigli 
saw. The osteoplastic flap was dislocated down- 
wards and a large clot, the size of the palm of the 
hand and over an inch in thickness, was removed. 
A fissure-fracture of the temporal bone was found 
close to the base of the skull. The bleeding was 
co-.p.ing from the main trunk of the middle menin- 



18 



American 

Journal of Surgery. 



Wight — Elongation of Bone. 



Januaxy, 191S. 



geal and it and a small vessel on the dura were 
ligated. The hemorrhage from these vessels was 
checked. The brain was seen to pulsate. There 
was no subdural hemorrhage over the exposed 
area, still there was considerable blood welling up 
from beneath, probably from laceration of some 
emissary veins, although no distinct point of hem- 
orrhage could be discerned. The brain was gently 
lifted and considerable clots removed from the base 
of the skull. The space was gently packed with 
iodoform gauze to check the persistent oozing; 
the osteoplastic flap was replaced and the scalp 
was loosely sutured. 

Forty-eight hours later, under narcosis, the old 
incision was laid open, the osteoplastic flap again 
reflected and the packing carefully removed. There 
was no more oozing. A small rubber tissue drain was 
inserted underneath to the base of the brain and 
brought out through one of the trephine openings. 
The flap was replaced to the original site and scalp 
permanently sutured. The rubber tissue drain was 
removed on the seventh day, when the wound was 
found healed by primary intention. 

It was very interesting to watch the fall of the 
blood pressure during the operation. As soon as 
the bone flap was elevated the blood pressure grad- 
ually decreased so that when the operation was 
completed it had fallen from 220 m.m. to 110 m.m. 

The clot was so large and thick that when it was 
removed one could plainly see the depression left 
in the region of the brain occupied by the hema- 
toma. 

On recovery from the stupor the motor aphasia 
and hemiplegia were markedly in evidence. From 
the time of the second operation these manifesta- 
tions gradually disappeared, so that at the end of 
two weeks they were hardly noticeable. The pa- 
tient was then discharged, fully recovered except 
for a slight headache. 

The early operative intervention — about six hours 
after the injury — no doubt was the most impurt-'Tii 
factor in this recovery. Had the hemorrhage con- 
tinued and the clot extended so as to compress the 
important centers of the medulla, the outcome 
would not liave been so successful. Indeed, one 
week later in an almost similar case, where I per- 
formed the same operation for an almost identical 
lesion, the outcome was not so favorable, as the 
hemorrhage was so rapid and the clot so extensive 
that the patient died six hours later from compres- 
sif)n of the medullary centers. The autopsy showed 
a large clot underneath the base of the brain press- 
ing on the medulla oblongata. 

The prospects of relief from a hemiplegia due to 



epidural hemorrhage are in inverse relation to the 
time elapsed from the traumatism to the operation 
interference, because the sooner the pressure on the 
delicate nerve centers is removed, the better chance 
of permanent recovery from the hemiplegia. 
35 East Sixtv-first Street. 



AN OPERATION FOR THE ELONGATION 

OF BONE. 

Report of a Case. 

J. Sherman Wight, B.S., M.D., 

Associate Surgeon to the Long Island College Hospital, 

Brooklyn, New York. 



The normal asymmetry of the lower extremities 
is about one-half an inch. The dilTerence is in 
favor of one side about as often as it is of the other, 
though most tables find that the right is the longer. 




Fig. 1. 

The |)clvis tilts and compensates for even a greater 
difl^erence between the two sides. From these facts 
we may conclude that the loss of an inch on the 
longer side when this was the longer by half an 
inch Ix'fore injury, does not interfere with a good 
result, provided the fragments have united in line, 
since the normal difference has been preserved. 
However, one-half an inch would give rise to limp- 



Vol. XXIX, Xo. 1. 



Wight — Elongation of Bone. 



American 
journai. ok surgerv. 



19 



ing when the fracture occurs in the shorter limb 
under similar conditions. Oblique fractures with 
overriding and an angular displacement give even 
worse results in the shorter limb. A bone graft 
centrally placed is the best method which has been 
employed to bridge defects and lengthen the long 
bones. Much of the new bone that fills in and re- 
inforces in this method of repair must go through 
the intermediate stage of cartilage formation, which 
is a rather long-drawn-out process of bone repair. 
This method requires absolute fixation of the 
fragments, as even slight motion would tend to 
cause absor[)tion and prevent union. While this 




Fig. 2. 

method covers a wide range of cases, the method 
which I am about to describe has proven very satis- 
factory in selected cases of angular deformity and 
shortening of long bones as a result of fracture. 
The following case illustrates this operation. 

E. B.. seven years old, family history negative. 
She broke her left leg at five and a half years of 
age ; the bone united readily. While playing in 
the street three months ago, she fell and broke her 
right thigh : this was put in a splint and union took 
place with deformity. When I saw her three months 
after the injury, she walked very lame. The right 
leg measured one and a half inches shorter than the 
left and showed an angular defonnity. The lower 
fragment turned inward, making an angle with the 



upper fragment of 15 degrees; there was also some 
rotary displacement. Figure 1 shows the deformity 
with the fragments overriding about an inch. 




i?... 



-ytq 



I made a linear incision over the outer side of 
the thigh and carried it down to the bone at the 
point of fracture, and freed the bone from the soft 
tissues. The saw shown in figure 2 was used to 




Fig. 4. 



20 



American 
Journal of Surgehy. 



Hays — Inferior Turbinate. 



January, 191S. 



make the section of the bone. It is so constructed 
that the blade can be set at any angle with the 
plane of the frame. In this case it was set at 67^ 
degrees. 1 made the bone incision, shown in figure 
3, a.c.d.b.e.f.g. The fragments a.b.c and c.d.e.f. 
were removed. The bone was re-set and its frag- 
ments fastened together with the screw "s" cut oft' 
close to the bone (figure 3). This also shows 
spaces a.c.c'. b. and g'.e'. e.g. filled with new bone. 
All the instruments used in this operation are shown 
in figure 2. The wound was closed and the leg 
was placed in a long plaster cast which was removed 
at the end of five weeks. The skin stitches were 
then removed; and union was firm. Both extremi- 
ties measured the same and there was no appre- 
ciable deformity. I'lgure 4 shows the final result. 
The screw has caused no trouble, so it has been 
left in place. The child now walks without a limp. 



Dieulafoy's Ulcer. 
Profuse gastric hemorrhage in the young with 
previous symptoms of ulcer is not uncommonly due 
to mucus erosions or hemorrhagic gastritis. The 
cause and pathology of these so-called Dieulafoy's 
ulcers are not clearly understood, but clinical expe- 
rience shows that it is an acute condition, not ordi- 
narily fatal, tending to clear up spontaneously and 
often followed by no sequelae of any kind. Gas- 
troenterostomy has been advocated for this condi- 
tion, but the evidence, in my opinion, does not 
warrant its use in every case. On the other hand, 
massive hemorrhage from the erosion of a vessel 
in the base of a chronic ulcer is a very dangerous 
condition and urgently calls for intervention,. At 
the same- time it is not wise to operate upon the 
patient in an exsanguinated state. The first hem- 
orrhage rarely kills and with proper treatment some 
reaction may be expected. On the other hand, re- 
action with the rise of blood pressure is apt to 
excite a fresh hemorrhage which is more likely to 
be fatal than the first. It becomes a question of 
nice surgical judgment, therefore, to decide when 
to operate. — John B. Deaver in the Long Island 
Medical Journal. 

Urinary Tuberculosis. 
Remember that most cases appeal to the general 
practitioner and, if he wastes their time and his 
efTort in useless bladder washing, he is surely al- 
lowing the best time for cure to slip by. Where 
frequency of urination is complained of and pus 
is present in the urine, do not give urotropin and 
do not wash out the bladder tmless you are sure 
the condition is not tuberculous. — G. S. Whiteside 
in Northwest Medicine. 



THE SURGERY OF THE POSTERIOR TIP 
OF THE INFERIOR TURBINATE; THE 
RELATION OF THE POSTERIOR 
TIP TO CATARRHAL DEAF- 
NESS AND TINNITUS. 

Harold Hays, M.D., F.A.C.S., 
New York City. 



It is well appreciated that anything that inter- 
feres with the proper action of the tubal muscles, 
or anything that causes a chronic irritation to the 
Eustachian tubes, or anything that causes obstruc- 
tion to the passage of air into the Eustachian tube, 
will have a tendency to bring about a progressive 
deafness and the accompanying distressing condi- 
tion — tinnitus. ■ ■ , • ^ 

Among the various factors that cause a pro- 
gressive diminution of hearing on account of their 
action on the Eustachian tube (mainly by causing 
a stenosis) may be mentioned a chronic hyper- 
trophy of the mucous membranes associated with 
chronic intranasal conditions, i. e., sinus disease, 
polypi, chronic hypertrophic rhinitis, deviated sep- 
tum, etc. ; in the throat and nasopharynx, hyper- 
trophied and diseased tonsils, adenoids, and ad- 
hesions in the fossa or Rosenmiiller. 

I believe that those dealing with the treatment 
of deafness seldom appreciate the importance of 
the role that the posterior tip of the inferior tur- 
binate plays in the causation of this condition. It 
is on account of that important role that I desire 
to explain briefly a simple operative procedure for 
the removal of this posterior tip. 

One must first understand thoroughly the anat- 
omy and pathology of the inferior turbinate. 
Anatomically, the inferior turbinate is situated 
along the floor of the nose and is attached 
anteriorly to the superior maxillary bone, posteriorly 
to the inferior turbinated crest of the palate bone, 
and its middle portion articulates with the lacrymal 
bone and the superior maxillary. It extends from 
just within the free margin of the nostril almost 
to the nasopharynx, and is covered with a thick 
heavy mucous membrane of ciliated epithelium. 
The apparent size of the bone varies from time 
to time, due mainly to the action upon its mucous 
membranes of various irritants. This mucosa fre- 
quently becomes hypertrophied to such an extent 
as to cause interference with breathing, and this is 
particularly so of its anterior and posterior tips. 
The posterior tip is liable to undergo various forms 
of degeneration, mainly forming itself into a mul- 
berry mass, which extends into the nasopharynx 



Vol. XXI.X, No. 1. 



Hays — Inferior Turbinate. 



American 

JoUBNAl. OF SUBCimY. 



21 



and often encroaches upon the orifice of the Eus- 
tachian tube. 

One can well sec that a mass of this char- 
acter, in this location, very often becomes edem- 
atous and, if sufficiently enlarged and irritated, 
that it can cause trouble to the various surround- 
ing tissues. Not only does it act as an obstruction 
to the Eustachian tube, but it is very liable to cause 
an excess of secretion of thick mucus, which in 
itself may lodge in the tubal orifice and cause in- 
flammation or obstruction. 

According to the ordinary methods, unless one 
is very skilled, it is extremely difficult to remove 
the posterior tip. Many operators make it a point 
not to use adrenalin in these cases, for the edem- 
atous mass is liable to shrink to such an extent 
that it is difficult to remove. However, if one 
uses the technic which I am about to outline I 
am sure that he will not meet with many difficulties. 

The nostril is first sprayed with a dilute solu- 
tion of cocain and adrenalin. Two pledgets of 
cotton are soaked in this solution. One is placed 
underneath the turbinate against its attachment to 
the maxillary wall, and pushed back with an ap- 
plicator. The other is placed over the entire mucous 
membrane of the turbinate. These are left in place 
for ten to fifteen minutes, and when they are re- 
moved the ■ mucous membrane is sufficiently 
shrunken so that one can often see into the naso- 
pharynx. By doing this, of course, the posterior 
tip is also much smaller. It is then our object to 
increase the size of this to such an extent that it 
can be well seen. A fine needle three inches long 
is attached to an ordinan.^ hypodermatic s)Tinge 
into which is placed equal parts of one-quarter of 
one per cent, cocain and adrenalin (1-1000). The 
injection of this solution is begun at the posterior 
two-thirds of the turbinate and is extended well 
back into the posterior tip. On account of the 
looseness of the tissue in this region one can bal- 
loon this area out sufficiently so that it can be 
readily seen. 

An angular scissors is introduced, closed, beneath 
the turbinate and between it and the maxillary wall 
as far back as possible. By grasping the handle 
of the scissors firmly in one hand and placing the 
other hand on the top of the patient's head the 
closed blades are rotated inward until the entire 
turbinate is fractured from its attachments, when 
it will stand out at right angles. The closed scissors 
is now withdrawn and an incision is made into the 
turbinate at its posterior third deep enough to 
engage the tip of a wire snare. The snare is then 
introduced through the nostril to the nasopharynx, 



and the w-ire rotated outward until it is seen to 
pass over the posterior tip. It is then drawn slightly 
forward, the shank of the snare being pressed firmly 
into the incision formerly made. By closing the 
wire the posterior lip is firmly grasped and snared 
off. I have found Wright's pistol snare the best 
for this procedure. The rest of the turbinate is 
then placed in its former position, and a small strip 
of bisnuuh subnitratc gauze placed in the nostril, 
firmly against the cut surface. 

Post-o()erative treatment is very simple. The pa- 
tient is told to rest for the remainder of the day, 
iced cloths are put around the neck to stop the 
hemorrhage, and tlie following morning the gauze 
in the nose is saturated with liquid albolene until 
it comes out very readily. The patient is then given 
a spray of adrenalin and Dobell's solution. 

I have seen the pathological [lart of a posterior 
tip present in many cases of lieginning deafness, and 
have noted considerable improvement in this condi- 
tion when the above outlined operative procedure 
was followed. 

II West 81st Street. 



Treatment of Acute Pxeumococcus 
Peritonitis. 
When a patient is seen suffering from acute dif- 
fuse pneumococcus peritonitis, every effort should 
be made to support the patient, and with procto- 
lysis or continuous hypodermoclysis. Fowler's posi- 
tion, camphor stimulation, and the withholding of 
all fluids and solids by mouth, an attempt to tide 
him over until the acute stage passes. The local- 
ized abscess, whether subdiaphragmatic, pelvic, 
lumbar, or between loops of intestine and the ab- 
dominal wall, may be opened with comparative 
safety and effectively drained. — L. Miller K.\hn 
in the Nezc York Medical Jounial. 



Gastric Ulcer. 
A plan which I have recently followed success- 
fully appeals to me as sufficiently rational. After 
opening the abdomen and locating the ulcer, the 
stomach should be opened and the base of the ulcer 
inspected. If the vessel is seen it may be ligated 
directly by transfixion. If, as is more commonly 
the case, no erosion or artery is seen, a stitch of cat- 
gut should be whipped aroimd the base as well as 
the edge of the ulcer with the object of occluding 
the vessels supplying it. The stomach may then be 
closed and a gastroenterostomy quickly performed. 
I liken this procedure to hysterotomy, of which I 
am a strong advocate. — John B. Deaver in the 
Long Island Medical Journal. 



22 



American 
Journal of Surgery. 



Morris — Surgeon's Reputation. 



January, 1915. 



THE SURGEON'S REPUTATION.* 

Robert T. Morris, M.D., 

Professor of Surgery, New York Post-Graduate Medical 
School and Hospital. 

New York. 



One wlio worries about his reputation knows in 
his lieart that he ought to worry about it. The 
reasons are apparent to him. Furthermore he can- 
not help himself in the matter. Explanation serves 
only to complicate matters. The situation is hope- 
less and dislieartening, nothing being left for him 
excepting to continue worr}'ing. On the other 
hand, one who worries about his character is in the 
midst of opportunities for helping himself daily, 
and the worry is transitory in duration. 

There is a tendency always to be more jealous of 
reputation than of character. In the professions 
we are inclined to be jealous of each other and 
properly so, because of our high ideals, but our 
worry should be less about personal reputation than 
about personal character. 

Recognition of a young practitioner comes first 
from colleagues and fellow workers. Those who 
are very close to a man are the ones best able 
to understand the significance and degree of his 
accomplishments. Public speaking and publication 
of ideas come next in order for giving a wider 
recognition, if one can make himself interesting 
without undue self-advertisement. A reputation 
that endures is based upon the foundation of ap- 
preciation on the part of colleagues, rather than 
upon ideas gained by a professional lay clientele. 
The superstructure of reputation never gets far 
above a base which can support it. 

Practice is not to come from some indefinite 
imaginar)' point as many young men in the pro- 
fession imagine. It is to come chiefly through old 
acquaintances, and in proportion as one has merited 
the respect of such close acquaintances. The three 
greatest social powers in the world are love, ora- 
tory, and propinc|uity, and of these the greatest is 
propinquity. The young physician who places him- 
self near to objects of his ambition is apt to find 
himself drawn along without his conscious knowl- 
edge, toward the goal which he seeks. 

When one first takes up the responsibilities of 
caring for human life and hai)piness it is apt to 
make him sleepless at night. He cannot do the 
best work after missing a good night's rest. Real- 
izing that fact, I stopped being sleepless in 1883, 
when serving on the Piellevue staff as house sur- 
geon. This is easily accomplished by one in normal 

• Advance papt-?. from a book entitled '*Way.side Notes" to be 
published by Doubleday Page & Company, New York. 



health as a matter of the will, if he determines to 
stop all thinking upon retiring at night. It is best 
to take a lesson from the French doll. When one 
assumes a recumbent position his eyes naturally 
fall shut automatically like those of a French doll, 
and he may then remain like the doll until the next 
morning. 

IMembers of the visiting staff at Bellevue were 
theoretically responsible for all of the people under 
my care, but practically my own responsibility was 
so great, with daily opportunity for mistakes in 
judgment that might cause death and suffering, that 
I found it difficult to rest. A little experience 
showed that the patients who were the cause of 
this worry had slept better than I during the night. 
An eft'ort of the will was then brought to bear 
upon cessation of all thought at a certain hour, and 
this was accomplished without real difficulty. 

We used to hear in former times about surgeons 
who "walked the floor late into the night" before 
doing some important operation. This kind of tem- 
perament is absolutely "impossible" for a surgeon 
of the present day. The patient should have been 
the one to walk the floor while the doctor was get- 
ting a good night's rest. The surgeon must be 
securely calm in his knowledge of what he is about 
to do, — or else turn the patient over to someone 
who is calnv Surgical work is almost certain to 
be done badly by anyone who carries a perturbed 
spirit into the operating room. Deaths are more 
often due to little errors in technic than to applica- 
tion of wrong principles. 

Fame brings many complicated problems that re- 
quire time for their adjustment. I would rather 
enjoy my pliant trout rod and the song of the hennit 
thrush, the fragrance of moist cedars and the beauty 
of a white violet in the soft green moss, than any 
combination of joys that fame can bring. I would 
not care to be great, because that incidentally takes 
up inuch time. Greatness is desirable in Nature's 
plan. No one admires great or famous men more 
than I do — if they are honest men — but personally 
it seems pleasanter to allow other people to have 
these things, which take up time that is precious 
for my own studies. I would rather be called plain 
Bob Morris by my friends than to be called anv 
sort of a genius. 

As one continues to maintain a position in the 
profession, the tendency is for more and more posi- 
tions of trust to be placed upon him, and he must 
be constantly on guard against accepting too many. 
The desire for leadership is a matter of tempera- 
ment, and brings responsibilities requiring a certain 
type of mind. Wlien circumstances have placed me 



Vol. XXIX, No. 1. 



W.\siiburx^Remov.\l of Prkih'cf.. 
Rdethke — PoDALic Version. 



.'Xmekican 
Journal of Surgery. 



23 



ill po.'^itions that led step by step toward leadership, 
I ha\e made an elTort to escape. This plan would 
naturally not be followed by men oi a ditterent 
temperament. If a young man has (|ualitications 
and taste for leadership, duty will indicate that 
he follow that bent and play a most necessary part 
in atTairs. 

The time comes wh.en one has added so many 
responsibilities to his list that it is practically im- 
possible for him to take on one more, and yet it 
is difficult to avoid shouldering more than he can 
really manage well. I find the only way for ob- 
taining mental relief is to emulate the guinea-hen, 
and she is now my symbol. A guinea hen will find 
a choice corner in the brush lot and soon has forty 
eggs in her nest. She cannot hatch all of them 
but she sits in the middle of the nest and hatches 
out all of the eggs that she can. and lets the rest 
go. The lesson taught by the guinea hen caine to 
me as a great comfort. 



CESSATION OF EPILEPTIC SEIZURES 

AFTER REMO\^\L OF PREPUCE AND 

FIBROMA IMBEDDED IN URETHRA: 

CASE REPORT. 

B. A. Washburn, M.D., 
Paducah, Ky. 



Male, aged 52, weight 180 lbs. Had been under 
treatment for epilepsy for fifteen years. His 
seizures were from one to six a month, accompanied 
bv involuntary micturition. 




His sight was good ; he was constipated and had 
occasional headaches. No history of injury. 

The foreskin, covering the meatus, was adherent 
on the right side behind the corona glandis. In the 
fossa navicularis the urethra was narrowed to tlie 
size of a filiform bougie by a tumor growing into 
it from the prepuce. 

The foreskin was removed with the attached 
growth, which was found to be a fibroma (see pho- 
tograph). Since this operation, two years ago, 
there has been no recurrence of the epileptic attacks. 



A MODlFlC.\TION OF PODALIC VERSION. 

R. W. ROETIIKE, M.D., 

Professor of Obstetrics, Marquette University. 

Milwaukee, Wis. 



The modification of podalic version here described 
is not applicable to all cases requiring version. It 
has been tried in about a dozen cases and they have 
partially proved the theory, but the method must 
stand the test of general usage. The idea was in- 
duced by the loss of time, frequent prolapse of the 
umbilical cord and consequent deaths to babies dur- 
ing version in a certain class of cases. 

The cases where version is still practical but 
where there is enough of disproportion to necessi- 
tate considerable traction on the child's body for 
extraction are the ones referred to here. The ordi- 
nary procedure under such circumstances is to ex- 
tract one leg and when it is found that much trac- 
tion is necessary the accoucheur's hand is again in- 
serted and the other leg is brought down. In this 
way the umbilical cord is often brought down and 
much time is wasted. The hand is introduced into 
the uterus when the lower segment is already under 
too great tension due to the head of the child be- 
ing doubled against the body and the baby's other 
thigh and leg increasing the bulk. The head does 
not slip up well because of this and both external 
and internal manipulations are dangerous for the 
same reasons as pressure and friction on a tense 
perineum. 

To partially correct the faults of the above meth- 
od the following is submitted : Instead of bringing 
down one leg, the operator takes time to carefully 
straighten out both and to separate the cord from 
between the thighs. He then grasps both ankles 
with a finger between them, rotates them to the 
side or the anterior oblique diameter and draws 
carefully down in the pelvic direction. In this way 
much time is saved and the tension of the lower 
uterine segment is much lessened, due to the ab- 
sence of the second thigh. For the same reason the 
head slips up more easily and no further internal 
or external manipulations are necessary. The cord 
does not come down because it is not looped around 
the child's thighs or legs. The extra time is taken 
during a comparatively safe stage. The objection 
that this method does not dilate the cervix as well 
as the other must receive consideration in the pre- 
liminary stretching of the birth canal. 



Never apply an elastic ligature about the arm 
without first interposing a towel. This may obvi- 
ate subsequent paralysis. 



24 



American 

Journal of Surgery. 



Editorials. 



January, 1915. 



Am^rtrau dinurual nf ^urg^rg 

SURGERY PUBLISHING CO. 

J. MacDONALD, Jr.. M. D., President and Treasurer 

92 William St., N. Y., U. S. A. 

to whom all communications intended for the Editor, original 

articles, books for review, exchanges, business letters 

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We cannot hold ourselves responsible for non-receipt of the Journal 
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C7- SPECIAL NOTICE TO SUBSCRIBERS "a 
The "American Journal of Surgery" is never sent 
to any subscriber except upon a definite written order. 
Present and prospective readers please note this. 

WALTER M. BRICKNER, M.D., Editor 

New York, January, 1915. 

THE UNSETTLED PROBLEM OF PYLORIC 
OCCLUSION. 

Experiences with gastro-eiiterostomy for pyloric 
stenosis due to ulcer constitute very apt illustrations 
of the remarkable tendency in the human body 
towards reformation of a physiological lumen. It 
has been found that, when food has been deflected 
through the new gastroenteric stomach for some 
time, the pylorus becomes patent again in not a few 
cases. The unused stoma tlien closes, in part or 
entirely, irritation of the ulcer at the pylorus re- 
sults in a second stenosis, and the patient's symp- 
toms recur. This rather schematic outline of the 
mechanics of some of the reported cases suffices 
to indicate the reason for, and tlie importance of, 
the many efforts made to permanently occlude the 
pylorus. Of course the ideal method is to resect 
the pylorus with the ulcer-bearing area. Even when 
feasible, however, this procedure is not always de- 
sirable because it adds considerably to the risk of 
the operation. The same may be stated for the 
operation consisting in division of the pylorus and 
suture and inversion of the cut luniina. 

The first efforts towards simple occlusion of the 
pylorus consisted in the ligation with stout silk 
thread. It was soon found that the silk worked its 
way into the interior of the stomach and that the 
pylorus became patent in many instances. .Although 
more successful, the method consisting in crushing 
and ligating the pylorus was also found unsatis- 
factory. This is not the place to review all the 



methods that have been employed to occlude the 
pylorus permanently. It is sufficient to state that 
none of them has had the full measure of success. 
Some recent encouraging efforts should be men- 
tioned. Basing his work on uniformly satisfac- 
tory experimental results, Wilms performed pyloric 
occlusion, in several cases, with strips of fascia 
lata and reported completely successful pyloric 
closure. The operations have been performed at 
too recent a time to decide finally upon the method ; 
unfortunately, however, an unsatisfactory result 
has already been reported by another observer. In 
a recent contribution,* Strauss describes ideal re- 
sults, in a series of experiments observed during 
a considerable period of time, by shelling out the 
pyloric mucosa (through an incision of the mus- 
cularis) and ligating it with a strip of fascia. It 
is very doubtful, however, if this operation will 
have any great practical possibilities, for it presup- 
poses normal pyloric tissues and a quite bloodless 
layer of cleavage between mucosa and muscularis. 
It is evident, however, that the very important 
problem of securing an adequate and permanent 
occlusion of the pylorus is still far from solved. 
Perhaps its solution will be found by some simple 
modification of already proposed operations. — 
H. N. 



THE PHYSICIAN AND ACUTE OSTEOMY- 
ELITIS. 

The surgeon has visited upon the head of the 
physician much blame for his tardiness and tem- 
porizing in cases of appendicitis. The physician 
has merited all of the criticism that has been heaped 
upon him, and even then he was, perhaps, let off too 
lightly. 

The same may be said of the physician's relation 
to gastric ulcer, duodenal ulcer, perforating typhoid 
ulcer, apoplexy, empyema, metrorrhagia, and "rheu- 
matism." Indeed, as we look over the catalogue of 
human ills, it is difficult to find one in the treat- 
ment of which the surgeon might not render aid. 

In some of these diseases, conditions develop 
vvhicli surgery would cure, but which without the 
surgeon often go on to healing. In others the 
treatment which the surgeon applies results disas- 
trously. Still, in all of these conditions if modem 
surgery were applied the chances of recovery are 
better than without it. 

Acute osteomyelitis belongs in a class by itself. 
It is wholly surgical. The physician has no busi- 
ness with it for a single minute. This can scarcely 
be said of any other disease. Even cancer is not 



*Journ. of the A. M. .\, 



Vol. XXIX, No. 



Editori.vls .\nd Surgical Suggestions. 



American 
Journal of Surgery. 



wholly surgical; the surgeon often can do nothing 
more than the physician. But with acute osteomye- 
litis the surgeon can always do something. 

There is but one treatment for this disease. As 
soon as the infection occurs and begins to make 
pressure within the bone, the damage begins. To 
relieve the pressure in the medullary cavity and 
secure drainage through its bony sheath is impera- 
tive. Unless this is done promptly, the infection 
and inflammation, confined under the pressure of 
non-yielding bone, cause necrosis of more medulla, 
death of the bone, and absorption into the general 
system of the products of the infection. Alost 
important among the latter are the infective or- 
ganisms themselves. Metastatic foci develop, and 
to the local destruction is added a virulent general 
infection which threatens the bones, joints, the 
valves of the heart, and every other structure in 
the body. 

These are the cases which come to the surgeon 
from the physician after having been treated for 
"rheumatism" or what-not. Necrotic bone, metas- 
tatic abscess, arthritis, and endocarditis have all 
developed often before the surgeon sees the case. 
If modern surgery is applied as soon as the disease 
is recognizable, a simple trephine opening into the 
bone suffices to cure the disease. .Without this the 
case goes on ; and loss of bone, crippling of limbs, 
invalidism or death may be expected. . i i ■ ; 

The diagnosis of most surgical conditions may 
fail even in experienced hands. !Many surgical 
conditions recover without surgery. Some are ag- 
gravated by surgery. But acute , osteomyelitis is 
most easy of diagnosis, even in its earliest stages. 
It invariably does badly unless treated surgically. 
Its treatment is so simple that surgery at its worst 
cannot do as much harm as the disease. — T- P- W. 



THE McBURNEV INCISION. 
The still popular gridiron incision is quite satis- 
factorj' for a simple appendicectomy ; but one can 
never be sure that a presumably simple appendicec- 
tomy will not eventuate as a much more extensive 
operation requiring liberal exposure. Nor does the 
McBurney incision lend itself well to exploration 
of the gall-bladder, pylorus, etc., which cases of 
presumed chronic appendicitis so often require. To 
be sure almost any intraabdominal operation can be 
performed through any incision if it is large enough, 
and, of course, the McBurney incision can be en- 
larged in various ways. Those who use it as a 
routine, however, must often encounter otherwise 
avoidable technical difficulties and must often over- 
look conditions that would be obvious through the 
right rectus incision. — W. !M. B. 



D.\M.\GED GOODS. 
Brieux' play, "Damaged Goods" (Les .Avaries), 
has been splendidly instructive to the public of the 
widespread dissemination of syphilis and of its 
subtle dangers to the innocent. The medical data 
it presents are for the most part accurate and well 
chosen. There is one statement, however, in the 
first act, that is wholly incorrect. To his recently 
infected patient, insistent upon marrying within a 
few months, the doctor says that the children of 
syphilitics are apt to have hare-lip, club-feet and 
congenital hip disease. (We know of no "con- 
genital hip disease." Probably congenital disloca- 
tion of the hip is meant.) 

Such fetal malformations as hare-lip, club-feet, 
and dislocation of the hip are not stigmata of syph- 
ilis and have no relation to the disease. Mothers of 
children bearing these abnormalities, who read or 
hear of this unfortunate passage in the play, will 
probably suspect that their husbands and their off- 
springs are s}-philitic. In the interest of the peace 
of mind of such motliers, even more than for the 
mere sake of accuracy, this passage should be cor- 
rected.— W. M. B. . ..; 



Surgical Suggestions 



Hard nodules in the prostate due to calculi may 
be mistaken for carcinoma. The routine radiog- 
raphy of prostatic cases will obviate this error. 



After perineorrhaphy it is in most, if not in all, 
cases unnecessary to bandage the thighs together, 
as is so often done. 



Inversion of the appendix stump into the bowel 
within a pursestring suture is unnecessary. Quite 
as safe and at least as free from the chances of 
forming local adhesions, is the quicker procedure of 
merely tightly ligating the base of the appendix 
with catgut, and cauterizing the surface and lumen 
of the stump with pure phenol. 



The midline (linea alba) incision into the abdo- 
men is always inadvisable (especially in the hypo- 
gastrium of multiparous women, whose tissues here 
are stretched and thinned), since, even when no 
drain is used, a hernia often results. Except 
when a hemorrhage or other emergency demands 
great haste the opening should be made to one side 
of the linea alba, i.e., through the rectus sheath, re- 
tracting or splitting the muscle. 



26 



American 
Journal of Surgery. 



Surgical Sociology. 



January, 1915. 



Surgical Sociology 

Ira S. Wile, M. D., Department Editor. 



Medical Factory Inspectors. 
The protection of workers in industrial establish- 
ments requires a high degree of enlightenment on 
the part of employers and employees. The mere 
promulgation of laws fails to secure the results 
intended. Industrial hygiene involves an interpre- 
tation of sanitation, hygiene, and medicine in the 
light of persona! health, home environment, and 
industrial conditions. The type of factory inspector 
which has existed is hardly sufficient to guarantee 
thoroughgoing medical inspection of industrial 
establishments. While it may not appeal at the 
present time to the medical profession as a type 
of employment offering possibilities, there is little 
question that in the future medical factory inspec- 
tors will be needed. 

At the present time, England and Belgium main- 
tain separate medical divisions in their factory in- 
spection departments (Bull. 42 U. S. Dept. of 
Labor). Their services are required for the pur- 
pose of making investigations of occupational dis- 
eases, supervising medical work in dangerous trades, 
and doing specialized work in industrial hygiene. 
In addition, there is a supplementary group of 
physicians whose function it is to examine minors 
and children, investigate industrial accidents, and 
control dangerous trades. 

While medical factory inspection is virtually an 
undeveloped department of activity in most of the 
foreign countries, factory inspection itself is re- 
garded as a special vocation and of high profes- 
sional standard. The preparation for this work 
must necessarily be rigid and thorough for the 
preparation for such a life profession involves edu- 
cation and responsibility equal to that of law, medi- 
cine, or engineering. 

In our country, owing probably to its youth and 
freedom, state service is not regarded as as highly 
desirable as in the older and more socially devel- 
oped European countries. To serve the state is 
one of the ambitions of foreign youths. In this 
country, it is for the most part regarded in the 
nature of a supplementary resource or a transitory 
employment until some better position presents it- 
self. 

The assumption of medical work in various de- 
grees and kind by municipalities, the states, and the 
federal government is all too frequently regarded 
by physicians as an encroachment upon their pre- 
rogatives and finances. It has not yet been recog- 
nized that civic medicine is opening the doors to 
unusual opportunities for medical men ; and our 
medical institutions are failing to call attention to 
the vast number of collateral occupations that are 
now open to physicians who are willing to serve 
in emplovments requiring a medical education and 
that are as legitimately the practice of medicine 
as the daily attendance upon a small group of in- 
dividuals regarded as private patients. 



The activity of medicine and surgery is assuming 
a public aspect of wider significance than ever be- 
fore. The entrance of medical men into public 
careers is to be hailed with delight. It means more 
efficient service, more educated public servants, and 
more scientific attainment in the field of civic hy- 
giene which is so essential for the promotion of 
public welfare. 



The Federal Workmen's Compensation .^ct. 

The enactment of compensation acts to justly 
lessen the burdens of injured workingmen has al- 
ready been recognized in twenty-four states. The 
first act in the United States was the Federal Law 
of 1908. It has now completed the first five years 
of its operations and the report of its services is 
detailed in Bulletin 155 of the United States De- 
partment of Labor. 

About 95,000 persons are covered by the pro- 
visions of this act, and there have been 42,290 
accidents reported during the five years, of which 
1,006 were reported as fatal. It is noteworthy that 
the mortality during each of these five years has 
been lower than in the preceding years, which is 
clearly indicative of the fact that the mere fact 
of compensation for injuries not due to negligence 
or misconduct tends to increase the care of work- 
men rather than to make them more careless. 

Over one million eight hundred thousand dol- 
lars have been paid out as compensation. While 
all accidents are reported, provided that they cause 
disability for longer than one day, compensation is 
given only for accidents causing a disability in ex- 
cess of fifteen days. Negligence or misconduct of 
the injured workmen prevented the compensation of 
only 109 injured workmen in five years. 

The basis of compensation is the wages of the 
injured workmen, the amount awarded being the 
same as the rate of such wages during the period 
of disability not exceeding one year. In fatal cases, 
the amount of payment is equal to one year's wages 
of the deceased workman. Nearly one-half of the 
accidents compensated occurred to men in the em- 
ploy of the Isthmian Canal Commission with its 
25,000 largely unskilled employees working under 
conditions of unusual hazard. 

The full worth of the Federal Law cannot be 
readily determined by reason of the fact that com- 
pensation for non-fatal accidents terminates as 
soon as the injured person has recovered sufficiently 
to permit him to resume work. Therefore, few 
data are available with reference to the results of 
accidents because of permanent partial disability. 
Similarly, there is little infomiation as to the effects 
of accidents causing a disability for a period be- 
yond one vear. It is unfortunate that the Federal 
Law does not treat the problem of permanent par- 
tial disability on a different basis from disability 
from wdiich complete recovery is possible. It is 
obvious that under such circumstances inadequate 
compensation must frequently result. For exam- 
ple, in the case of the loss of a right arm, the 
workman might receive less than $50, and in three 



Vol. XXIX, No. 1. 



Book Reviews. 



.'\mekican 
Journal of Subcery. 



27 



cases wherein the loss of both legs resulted, the 
average compensation was only $377.40. 

Regardless of its shortcomings, however, the 
Federal Compensation Law has been of immense 
benefit to a large number of injured employees and 
their families. Furthermore, this law served proi> 
erly as a stimulating, practical act for the reason- 
able consideration of the value of workmen's com- 
pensation acts to the states of the Union wherein 
such Icgislatiion had not been formulated. Future 
amendments will undoubtedly serve to correct the 
defects already noted and will tend to provide for 
an extension of the provisions of the act to all fed- 
eral employees of whom three-fourths are not in- 
cluded under the provisions of the law. 

In extensive social legislation along lines of com- 
pensation, this government is far behind the stand- 
ards existent in foreign countries. Furthermore, 
state legislation has advanced so that at present 
many of the states of the Union have wider and 
more just laws relating to workmen's compensation 
than provided for in the Federal bill. It would 
seem to be a function of national government to 
point out the way for the various states to make 
adequate provision for the protection of employees. 
The recognition of the obligations of society to 
lessen the burdens from accidents might well be 
pointed out by the national government through 
adequate attention on its part to its numerous civil- 
ian workers. In the organization of our govern- 
ment with the sovereignty of states recognized as 
it is. it becomes difficult to establish uniform legis- 
lation. Probably, there is an advantage in this fact, 
inasmuch as each state presents its own problems 
and its legislation grows out of the educational 
enlightenment of its population. Wherefore, there 
are numerous social experiments constantly being 
developed, the outcome of which may lead to the 
formulation of the type of enactment which will 
afford the greatest justice to. and protection of. the 
industrial workers throughout the countrv. 



Book Reviews 



Surgical Diseases and Injuries of the Genito-Urinary 
Organs. By J. \V. Thompso.x Walker, M.B.. CM. 
Ed.. F.R.C.S. Eng., Hunterian Professor of Surgery 
and Pathology, Royal College of Surgeons of Eng- 
land (1907), etc. Octavo; 879 pages; 45 plates (24 
in color) and 279 text illustrations. New York ; 
Funk & \V.-\gnalls Co., 1914 
Thompson Walker's eminence as a urologic surgeon is 
sufficient to attract, and the excellence of this work is 
sufficient to hold, deep interest in his new book on 
genito-urinary afifections. 

With certain exceptions (vide infra) it covers the en- 
tire field of the diseases, injuries and malformations of 
the male and female urinary tract and of the male genital 
organs. It is not. however, encyclopedic in any sense, 
and is intended as a text-book rather than as a treatise 
in its broader meaning. The author therefore makes no 
pretence to. include all the literature, but bases his work 
chiefly on selected recent publications and on his per- 
sonal experiences. Indeed, he makes his own observa- 
tions serve largely as the substance of his text, which is, 
after all, the desideratum in all practical medical text- 
books of authoritative origin. Also quite in keeping with 
his text-book plan. Walker has adopted the anatomical 



rather than the pathological classification of diseases, 
and one must agree with him that this is better for the 
purpose intended. 

One of the most striking and most helpful features of 
the book is its wealth of excellent original illustrations, 
including numerous beautiful colored plates. These assist 
the text in presenting what the author has carefully 
aimed to supply, clear pictures of the "living pathology." 

In a review of the first edition of so important a book 
it is fair to our readers, and helpful to the author, to 
point out some of its shortcomings rather than to deal 
only in general description. 

.•Vppended to each subject is a selected bibliography. 
Since this list is in each case admittedly incomplete the 
references to the author's own publications appear unduly 
numerous. We note, too, that not sufficient care has been 
taken in the spelling of proper names; thus we find Caut- 
Zi'cll for Cantwell, McMurty for McMurtry and Mosch- 
koiK^it: for Moschco'dAtz. 

In the chapter on bladder tumors there is not the 
slightest reference to Beer's treatment of vesical papilloma 
with the "high-frequency" spark. This method, now 
widely practiced, has been before the profession for about 
live years. We are forced to conclude that Thompson 
Walker has no experience with, perhaps no knowledge of, 
one of the most important of recent contributions to 
urologic surgery. 

Neither in the section of undescended testis, nor in 
the appended literature, appears the name of Bevan, al- 
though the operation as described includes the principle 
feature of the procedure that usually bears his name. 
The fixation operation described by the late Keetlcy of 
London and. a little subsequently, by Torek of New York, 
is not referred to; but perhaps the author, like many 
other surgeons, does not approve of it. 

The section of cystoscopy is too brief for a work in- 
tended for students and novitiates. We cannot quarrel 
with the author for preferring his own irrigating and 
catheterizing cystoscope. but we believe that he should 
have described and compared a few of the other com- 
monly used instruments. 

The results of castration for testicular neoplasms are 
given from the statistics of Chevassu and of Russell 
Howard, without reference to the morphology of the 
tumors. This is confusing and unsatisfactory. More de- 
tailed data are available. 

Acute and chronic gonorrhea are dealt with in consid- 
erable detail; so is syphilis of the bladder, of the kidney 
and of the testis; so, too. are balanitis and herpes prepu- 
tialis. Yet chancre and chancroid are not described. This 
is an inconsistency, a strange incompleteness. 

The clinical value of the work would have been en- 
hanced, we believe, by the inclusion of separate chap- 
ters dealing with the routine differential diagnosis of 
renal and bladder affections : special preparations for 
major urologic operations ; operative methods in general ; 
the after-care and complications of major operations. 

These, then, are some of the defects in a generally 
excellent, very interesting, altogether practical and. pic- 
torially and typographically, exceedingly attractive book. 

A System of Operative Surgery. By various authors. 
Edited by F. F. Burgh.\rd, M.S. (Lond.). F.R.C.S. 
(Eng.), Teacher of Operative Surgery in King's Col- 
lege. London, etc. Sew Edition. In five large octavo 
volumes; illustrated. London: Oxford Medical Pub- 
lications. Henry Frowde and Hodder and Stoughton, 
1914. 

As compared with the four-volume first edition of 1909 
this edition does not show a general revision. .\ change 
has been made in some of the authors and corresponding 
sections have been re-written. In Volume I, The Prin- 
ciples and Technique of Asef^tic Surgery is now contrib- 
uted by Percy S.\rgent; in Volume II. Operations upon 
the Tongue is now written by H. J. Wari.ng, Operations 
upon the Tonsil by George E. Waugh. Operations upon 
Malignant Disease of the Pharynx by Wilfred Trotter. 
Volume III appears the same in iDOth editions. Volume IV 
is devoted to the surgery of the eye. ear. nose, larynx 
and trachea. It shows minor changes made to include 



28 



American 

Journal of Surgery. 



Book Reviews. 



January, 1915. 



recenl adv.snctis. ■ Gynecologic operations, wliich formerly 
also fippij-arcd in \'olume IV, now constitutes Volume V, 
and tliis section has, indeed, been largely recast. Formerly 
writtci|i,.hi', Bl.and-Sutton and John Phillips, they now 
share the, work with Andrews, Leedham-Green, Bonney. 
Jellett, Bell, M.\x\vell and Le.\. 

Abdominal Operations. By Sir Berkeley Moynih.an, 
M.S. (London). F.R.C.S., Leeds, England. Tliird Edi- 
tion. In two large octavo volumes of about 500 pages 
each ; 371 illustrations. Philadelphia and London : W. 
B. S,\unders Co., 1914. 

The second edition of this standard work, in one 
volume, was published eight years ago. In the preparation 
of this two-volume edition the entire text has been thor- 
oughly revised and modernized, and considerably en- 
larged. It shows a careful study of all the recent literature 
and the inclusion of such of it as is important. Thus 
the index of names lists about 900 authors referred to. 

Although entitled "Abdominal Operations," the work 
concerns itself, as before, only with operations on the 
stomach and intestines, the peritoneum, the pancreas, the 
spleen, the liver and biliary tract, and the subphrenic 
space. Operations on the urinary tract, the pelvic organs, 
the abdominal wall (other than for penetrating wounds), 
and herniae are not included. Nor is resection of the 
rectum described. In short. Moynihan devotes his work 
to those operations or types of operation that he prac- 
tices. 

The preliminary chapters, dealing with operative meth- 
ods. pre])aration, after-treatment, etc., have been revised 
with the others, and include a brief description of Crile's 
anoci-association technique, which Moynihan has adopted. 

Precis de Chirurgie de Guerre. By Edmond Delorme, 
Medical Inspector General of the French Army. 
Duodecinw; 218 paues. Paris: M.^sfON et Cie 1914. 
Price, 4 fr. 50. 

Of timely interest is this compact yet comprehensive 
volume on war surgery. The offensive and defensive 
types of war im])lements are all dealt with and the casual- 
ties produced are tabulated according to the region in- 
volved: the prognosis, course and treatment of the injury 
are then discussed briefly and clearly. Delorme dwells 
at considerable length upon the bone lesions. These he 
classifies according to the type and severity of the injury, 
presenting simple and adequate illustrations to explain the 
rnechanism of fractures. He has employed with satisfac- 
tion simple and apparently satisfactory metallic splints 
for which he claims a particular usefulness in fractures 
of long bones near or involving joints. The condensed 
chapters on wounds of the thorax, the abdomen, the spine, 
the upper and lower extremities shed no new light, but 
their subject matter is well arranged and written with 
authority. Delorme has comparatively little to say about 
amputations, but he lays stress on the importance of com- 
bating hemorrhages, primary and secondary. 

The volume is agreeably free from overburdening 
statistics. The appended charts for statistical and case 
study are well planned. 

The Tonsils, Faucial, Lingual and Pharyngeal With 
some account of the posterior and lateral Pharyngeal 
Nodules. By Harry A. Barnes, M.D.. Instructor in 
Laryngology, Harvard Medical School ; Surgeon in 
the Department for Diseases of the Nose and Throat, 
Boston Dispensary; Assistant Laryngologist, Massa- 
chusetts General Hospital; Member New England 
Laryngological and Otological Society; Member 
American Laryngological, Rhinological and Otolog- 
ical Society. Octavo; 168 pages; 39 illustrations. 
St. Louis: C. V. Mosby Co., 1914. Price, $3.00, net. 

Barnes' monograph on the tonsils takes up in a very 
simple and complete manner the modern views concern- 
ing tonsils and the surrounding tissues of Waldeyer's 
ring. We agree with the majority of his conclusions, al- 
though in a few instances we might take issue with him. 
The most import.-mt chapters are those which deal with 
the development of the tonsil and its anatomy and his- 
tology. 



The volume is profusely illustrated with excellent cuts, 
and forms a valuable addition to the various new works 
on the nose and throat. 

Infection and Resistance. An Exposition of the 
Biological Phenomena Underlying the Occurrence of 
Infection and the Recovery of the Animal Body from 
Infectious Disease. By Hans Zinnser, M.D., Profes- 
sor of Bacteriology at the College of Physicians and 
Surgeons, Columbia University, New York, formerly 
Professor of Bacteriology and Immunity, Leland 
Stanford University, California. With a chapter on 
Colloids and Colloidal Reactions, by Prof. SiEW.'UtT 
W. Young, Professor of Chemistry, Stanford Uni- 
versity. Octavo ; 546 pages. New York : The Mac- 
millan Co., 1914. 

Amidst the wealth of new works upon infection and 
immunity that have been published in recent years, this 
work stands conspicuous. It is the best that we have 
seen. It is a combination of lucidity and comprehensive- 
ness such as we meet but rarely in any medical work. 
By writing each chapter as a separate unit, Zinnser affords 
a complete and indelible picture of those under discus- 
sion. At the same time, the critique of the vast literature 
which the author commands so easily is so admirable 
that the reader is never left in doubt as to what is fact 
and what is still debatable. The chapter on colloids is 
short, but sufficient to enable the reader to note the close 
relations between the reactions of immunity and of col- 
loids. 

Pathogenic Microorganisms. A Practical Manual for 
Students, Physicians and Health Officers. By Wil- 
liam Hallock Park, M.D.. Professor of Bacteriol- 
ogy and Hygiene, University and Bellevue Hospital 
Medical College, and Director of the Bureau of Lab- 
oratories of the Department of Health. New York 
City, and .\nna W. Williams, M.D,. .Assistant Di- 
rector of the Bureau of Laboratories. N. Y. Health 
Department; Consulting Pathologist, N. Y. Infirmary 
for \\'omen and Children. Fifth Edition. Octavo: 
6S4 pages ; 210 engravings and 9 plates. New York and 
Philadelphia : Lea axd Febiger. 1914. 

This much-used manual is an outgrowth of the lab- 
oratories of the N. Y. City Department of Health and was 
published first under the title Bacteriology in Medicine and 
Surgery. 

Part I. Principles of Microbiology, deals with the va- 
rious microorganisms in general and with laboratory 
methods. Part II considers the individual pathogenic or- 
ganisms in detail. Part III is devoted to .Applied Micro- 
biology, viz. the bacteriology of milk, water, air, the soil; 
disinfection; water contamination and putrefaction; milk 
sterilization; the disposal of sewage; and bacteria in in- 
dustries. 

The Germ-Cell Cycle in Animals. By Robert W. Heg- 
NER. Ph.D., .Assistant Professor of Zoology in the 
Ufniversitv of Michigan. New York; The Macmil- 
i.AX Co., 1914. Price $1.75. 

To those interested in the problems of heredity, genetics, 
of animal breeding and hybridization the morphological 
studies of the changes in the germ cells as set forth in 
this book, cannot fail to prove of the deepest interest. The 
maturation of germ cells receives less attention than the 
segregation of the germ cells in the developing egg which 
from the author's viewpoint deserves greater emphasis. 
Not a small feature is the appended bibliography of more 
recent literature bearing on the subject treated to which 
the author has richly contributed. 

Case Histories in Obstetrics. Groups of Cases Illus- 
trating the b'undamental Problems which arise in Ob- 
stetrics. By Robert L. De Normandie. A.B., M.D., 
Assistant in Obstetrics. Harvard Medical School, etc. 
Octavo ; 516 pages. Boston : W. M. Leonard, 1914. 

This book is written by one who has been accustomed 
to teach obstetrics at the bedside. The case reports em- 
brace practically all the usual experiences of a well- 



Vol- XXIX. No. 1. 



Progress in Surgery. 



Ameku:as 
Journal ot Sl'kcerv. 



19 



trained obstetrician and set mrtli in a very lucid manner 
the important and vital considerations in the management 
of normal and abnormal pregnancies, labors and the puer- 
peral state. It is no book lor the student, but it is a dis- 
tinct aid and consultant for the beginner in tlie practice 
of obstetrics. For the reader who may have a large per- 
sonal e.xperience in obstetrics there is much in the pages 
of this book that may serve to check up observations, 
elucidate certain points or even stimulate clinical interest, 
for the author has succeeded in presenting so many living 
cases from his private and hospital work. 

Selected Papers. Surgical and Scientific, from the 
writings of Kosuell 1'.\rk, late Professor of Surgery 
in the University of Buffalo and Surgeon-in-Chief to 
the Buffalo General Hospital. With a memoir by 
Charles G. Stockto.n. M.D. Octavo: 381 pages. 
BulTalo: The Courier Co., 1914. Price, $3.00, net. 

This is a handsomely printed memorial to an eminent 
surgeon an<l gifted teacher, consisting of a selection from 
his many published articles, chiefly surgical, and a memoir 
written by his friend and university colleague. Stockton. 



Progress in Surgery 

A Resume of Recent Literature. 



Note on the Wounds Observed Dtiring Three Weeks' 
Fighting in Flanders. G. H. M.^kins, Lancet, No- 
vember 21. 1914. 

The wounds are in the main of very severe type; this 
appears to be dependent on the fact that they have nearly 
all been received at the short distance of about the 20O 
yards which separates the opposing trenches, and that 
many bullets ricochet and acquire irregularity of flight 
by striking the margin of the trenches. The type of 
entry and exit wounds is somewhat varied from those 
produced by the older Mauser and Lee-Metford bullets ; 
there is certainly more irregularity in form and size. 
One especially striking form is that in which the central 
round wound has a slit passing from opposite sides, sug- 
gesting that the original opening has been enlarged with 
a knife for purposes of exploration ; such wounds are 
seen mainly on prominent points of the bodj', such as the 
margin of the patella or over an outstanding tendon. 
The number of large stellate exit wounds is also great. 
the most typical of all being those on the dorsum of the 
hand. The difficulty of being convinced as to the produc- 
tion of large explosive wounds by rifle bullet, shrapnel 
bullet, or fragment of shell respectively is very great. 
The patients positively state many wounds to have been 
produced by rifle bullets, which offer no resemblance 
to any type wound. 

The presumption that the occurrence of gangrenous 
cellulitis might become rare with the establishment of 
more rapid means of transport has not been substan- 
tiated. 

It has also proved that this condition may develop as 
the result of a simple rifle bullet wound, and when this 
is the case the absence of the safety vent afforded by 
the larger shell wounds may render the extension of the 
infection a still more rapid process. With regard to the 
influence of delay in transport on the development of 
gangrenous cellulitis, this affects only the extent to which 
the process may have reached when the patient comes 
under treatment, and can hardly be assumed to favor its 
actual origination. Experience of the same disease in 
civil practice needs only to be recalled to emphasize the 
rapidity with which the infection gains ground and the 
unlikelihood that any local antiseptic treatment could ef- 
fectually cut it short. 

The influence of the mechanical factor in favoring the 
spread of the process is well illustrated by the fact that 
while it spreads readily from wounds involving the deep 
planes of the limbs, the condition is not observed to de- 
velop in wounds of the thoracic parietes, of the ab- 
dominal wall, the neck or the scalp. In the latter cases 



the wounds afford sufficient vent to prevent the develop- 
ment of the tension which favors the extension of the 
process. 

The advent is not heralded by serious general symp- 
toms, neither the temperature nor pulse-rale rises very 
high, and there is little pain. The most striking features 
in the later progress are sleeplessness, the development 
of extreme anemia, and a peculiar slackness in the ten- 
sion of the pulse. The patients meanwhile make little 
complaint. 

Locally the lirst signs arc rapidly increasing edema; 
at first white, later large patches of bronzy redness of 
unequal depth of tint develop, while at the upper limit 
of the discolored area crepitation is palpable. The bub- 
bles of gas are often sufficiently large to raise an eleva- 
tion which suggests on inspection a small varix of a 
vein ; this is often seen in the areolar tissue over Scarpa's 
triangle. The glands of the axilla or groin enlarge early, 
but they are hard, not very tender, and never reach a 
large size or suppurate. 

After two or three days the portion of the limb distal 
to the wound becomes cold, pulseless, and gangrenous. 
The distal gangrene is of the arterial type. The limb in 
cases which survive long enough mummifies, and a very 
sharp line of demarcation develops. Some of these limbs 
are intensely black in color. 

No satisfactory method of treatment has been dis- 
covered. Multiple incisions at the limit of advance of 
the process check it and bring it to a standstill, and some 
benefit has been claimed from the method of injecting 
hydrogen peroxide in the same region, although Makins 
has seen little to support the opinion. The adoption of 
this method, however, lands the surgeon in a serious dif- 
ficulty, since in spite of the arrest of the gangrenous 
process the perished limb persists as a source of sep- 
ticemia, hectic develops, anemia becomes extreme, and the 
patient succumbs before the opportunity for the perform- 
ance of a secondary amputation arrives. A considerable 
difference exists in this respect, however, between the 
treatment of the upper and lower extremities. In the 
former a considerable proportion of the cases survive, 
while of the latter the large majority of the patients die 
from shock and septicemia during the next 36 hours if 
the amputation needs to be made through the thigh. 

The Relief of Gas Pains After Appendicectomy. T. A. 

Kexefick, New York, Ara' York Mcdxcai Journal, 
November 7, 1914. 

In fifteen successive cases. Kenefick has obtained com- 
plete relief by the following method : He administers 
20 grams of acetyl salicylic acid ester, with fine grains 
of bicarbonate of soda and one grain of calomel, in two 
or four ounces of water the afternoon preceding the 
operation. This is followed by an enema the next morn- 
ing. The dose varies with the age of the patient. If 
signs of distension appear after the operation, ten grains 
can be given the next day. 

Experimental Pyloric Stenosis. W. W'. H a Ji burger 

and J. C. Friedm.ax, Chicago, Archives of Internal 
Medicine, November 15. 1914. 

1. Moderate pyloric stenosis in dogs (ligature around 
pylorus tied loosely) causes little or no change in stomach 
mobility, acidity or size. 2. Marked obstruction causes 
motor insufficiency, continuous secretion (hyper-acidity) 
and hypertrophy and dilatation of the stomach. 3. Com- 
plete occlusion results in inanition, vomiting, convul- 
sions and death of the animal in from 48 to 120 hours. 
4. The pyloric ligature (stenosis) results in motor insuf- 
ficiency with food retention, which in turn sets up a con- 
tinuous secretion with the constant presence of free hy- 
drochloric acid. S. Pyloric obstruction with resulting 
motor insufficiency and continuous secretion are probably 
the most important factors in the production of chronic 
experimental ulcer. 6. While the foregoing results con- 
cern experimental chronic ulcer, it is more than likely that 
primary partial pyloric stenosis (from whatever cause) 
with secondary motor insufficiency and continuous secre- 
tion are largely responsible for the progression and de- 
layed healing of chronic ulcer in man. 



30 



American 
Journal of Surgerv 



Progress in Surgery. 



jAxi.-ARy. 1915. 



A New Diagnostic Sign of Appendicitis. (Zitr diag- 
nose tier iiffcnduitis). C. Huk.n, Zcntralblatt fiir 
Chirurgie, October 3, 1914. 

Horn's sign consists in pain caused by pulling the right 
spermatic cord. This sign lie rated in 12 out of IS cases. 
In obtaining the sign, it is necessary to avoid pressure 
upon the testis ; the cord is grasped above the testis and 
gently pulled. The pain, according to the author, is due 
to irritation of the peritoneum in the neighborhood of 
the internal inguinal ring. 

The Relief of Sterility by Means of Permanent Epi- 
didymostomy With the Formation of an Artificial 
Sac for the Storage of the Sperm. V. D. Lespi- 
NASSE, Chicago, Journal of the American Medical As- 
sociation, November 28, 1914. 

Lespinasse says that the types of sterility in a male are 
all cases of obstruction of the vas above the internal 
abdominal ring and almost all cases of obstruction of the 
ejaculatory ducts. His work represents seventy-nine 
operations. To try to relieve patients he experimented 
in three ways to make a sac to contain the glandular se- 
cretion ; first by making the sac of the tunica vaginalis 
and then covering the cut surface of the epididymis and 
the contiguous surfaces of the testicle with a piece of 
thin rubber sheeting. Second, by making the sac en- 
tirely of this rubber sheeting sewed to the reflected cap- 
sule of the epididymis. Third, by removing the tunica 
vaginalis completely and placing the entire testicle and 
epididymis in a rubber bag. The technic is described as 
follows : "The tunica vaginalis is exposed as for an 
ordinary operation for hydrocele. The parietal layer of 
the tunica vaginalis is then cut. thus exposing the testicle 
and the epididymis. Epinephrin is now injected beneath 
the capsule of the epididymis, commencing at the top 
of the globus major and continuing down to the junction of 
the globus major with the body of the epididymis. An in- 
cision is made in the center of the epididymis commencing 
at the top of the globus major and continuing down to the 
junction of the globus major with the body of the 
epididymis. The epididymal capsule is now dissected off, 
thus exposing the epididymal tubules. The tops of these 
tubules are now cut off or hair threaded through them. 
The sac is made as follows : The rubber sheeting or 
tunica vaginalis is sewed to the reflected capsule of the 
epididymis in such a manner as to form a closed sac. 
The testicle is now replaced in the scrotum and suitable 
dressings applied. With the above-described technic we 
can produce a sac into which the sperm will discharge 
and continue to live. This sac can be tapped whenever 
sperm are desired for impregnating purposes. This opera- 
tion will relieve all cases of male sterility in which there 
is a functionating testicle." 

Operative Treatment of Acute Epididymitis. D. O. 

.Smith and B. H. Fr.wser, Canal Zone. Annuls of 
Si(rgcry. December, 1914. 

Acute epididymitis warrants early surgical interference, 
these authors assert. Moreover, they claim that the ex- 
tent of damage to the tubules is decreased by operation, 
that pain is relieved at once, and that recovery is made 
more rapid and complete. The evidences of a frank in- 
fection in acute epididymitis is so well marked in its 
local and systemic manifestations tliat there should be no 
hesitation to operate. 

They advocate an incision in the tunica vaginalis, exter- 
nal and parallel with the epididymis, and large enough to 
deliver the testis. Multiple punctures are made in the 
inflamed parts of the epididymis with a blunt probe. 
These parts are gently massaged, wa.shed with warm 
■saline solution, and the testicle returned to the scrotum. 
A small gauze drain is used. A suspensory bandage is 
employed for support. The after treatment is simple. 

[For many cases a small incision directly over the epi- 
didymis will suffice. A slender piece of rubber tubing 
makes a more satisfactory drain. The usual hot rectal 
irrigations should not be neglected. A "Bellevue" adhe- 
sive plaster bridge gives convenient support for the 
scrotum.) 



Concerning Cystography. ( Vebcr Zystograpliie) O. 
Zuckerk.\.\ul, Miincheiier Medizinische IVochen- 
schrift, No. 35, 1914. 

The use of the X-ray for determining the presence of 
tumors within the bladder has, according to Zuckerkandl, 
not been popular owing to the simpler diagnostic help of- 
fered by the cystoscope. There are cases in which the 
cystoscope cannot be introduced into the bladder and 
others where no definite picture is elicited by the cystoscopy. 
In such cases Zuckerkandl has found the injection of col- 
largol most serviceable. Inasmuch as the collargol shadow 
often embraces the tumor masses and conceals them, 
Zuckerkandl first radiographs with collargol in the blad- 
der, then empties the latter and refills it with air. A 
second X-ray picture is taken with the bladder inflated 
and the contrast is most striking and instructive. Villous 
polypi of the bladder, pedunculated tumors of the blad- 
der — infiltrating carcinomata and hypertrophied prostates 
are in this way brought into strong relief. In certain 
cases of large diverticulation when the cystoscope does not 
give complete pictures, this method can be supplemented. 

Further Results in the Electrolysis Treatment of 
Cystitis. C. Russ, London. Lancet, October 31. 1914. 

"After the urine is voided a special catheter is passed 
into the bladder, but no lavage is undertaken. A few 
ounces of fluid are then passed in, and the catheter with 
a glass tube attached is fixed upright by a clamp; this 
makes a fluid system of the bladder, the catheter, and the 
tubing. The upper level of the fluid is seen through llie 
glass tubing to rise and fall with respiration. .\ lint- 
covered metallic belt encircles the lower trunk at the hip 
level and is connected to one wire of the battery. The 
other wire (platinum) is passed down the catheter and 
conveys the current through the fluid to the interior of 
the bladder. Radiating from the perforations around the 
catheter eye numerous electric streams pass in all direc- 
tions through the bladder and lower trunk to reach the 
metallic core of the belt. In this way we have an electro- 
chemical action penetrating the bacteria and the entire 
vesical tissues. Tliis action goes on for an hour or 
an hour and a half at each treatment. While the treat- 
ment proceeds the bladder is being gradually distended 
by the incoming urine and its recesses become exposed to 
the forces at work. The patients are unaware of the 
current's flow and recline at their ease, being occupied 
in reading and often also enjoy a smoke. If any pain 
or discomfort is felt it is certain that something in the 
arrangements needs readjustment." 

There is gradual diminution of pus in the urine, with 
disappearance of the bacteria. Subjectively, there is di- 
minished frequency of urination. As far as the experience 
of the author goes, the results are permanent. Russ be- 
lieves the action of the electrolysis depends on a slow 
destruction of bacteria, with phagocytosis following con- 
gestion of the bloodvessels of the bladder. Its effect is 
therefore comparable to the Bier treatment of inflamma- 
lions. 

Extraperitoneal Rupture of the Bladder; Its Surgical 
Management. Eugene Fuller. New York. Journal 
of the A)nerican Medical dissociation, December 12. 
1914. 

Severe violence in the suprapubic or perineal region 
may cause CKtraperitoneal rupture of the bladder, and the 
worst cases are those associated with fracture of the 
pelvis. It generally occurs in the region of the trigo- 
num under the space of Ketzius. less frequently above and 
at the side of the vesical neck. The injury is usually 
single and, if slight, may be treated expectantly, leaving 
the patient with nothing more than a corresponding area 
of pericystic sclerosis with slight or severe symptoms, ac- 
cording to the extent and position of the lesion. In most 
cases, however, expectant treatment invites a fatal result 
on account of the extravasation and burrowing of urine, 
which may involve the perinephrilic region or even the 
thigh. There are no strikingly characteristic symptoms, 
and often the injury remains undetected until the inflam- 
matory symptoms or burrowings attract attention. Hema- 
turia follows the accident and may he slight or extensive. 



Vol. XXIX, Xo. 1. 



Progress in Surgery. 



American- 
Journal OK S'JKGEKV. 



31 



In the former case there is sometimes no retention of 
urine. There is always pain, sometimes severe, on urina- 
tion, but it may be masked by other pains following the 
traumatism. There is apt to be marked febrile disturbance. 
When seen promptly the dilTerential diagnosis is between 
anuria, intraperitoneal and extraperitoneal rupture. In 
a case indicating bladder rupture seen at once the patient 
should be instructed to urinate, and if he can do so nat- 
urally and it sliows no blood the chance is that the bladder 
is not injured, but if he cannot urinate a sterile catheter 
should be passed. If no urine appears, the probability is 
of an anuria from shock. The abdomen should be care- 
fully watched, however, and after a little time the sterile 
catheter should be reintroduced and a measured amount 
of sterile normal saline solution be injected. If this is 
caught on the return flow, well and good ; if not, the abdo- 
men should be promptly opened and an intraperitoneal 
rent looked for and closed, if found. If not found, extra- 
peritoneal injury should be looked for. a catheter intro- 
duced and the distention of the bladder watched. The ad- 
dominal wound should then be closed and the bladder 
opened suprapubically and drained. If the bladder con- 
tains blood-clot, or if there is retention due to involvement 
of bladder neck or deep urethra, suprapubic cystotomy 
should be promptly performed, and if there is then any 
indication of rupture involving the peritoneum, any rents 
should be closed. If suprapubic cystotomy discloses extra- 
vesical rupture, and there is reason to believe that there 
is no great degree of urinary extravasation as yet. nothing 
further need be done than the drainage. In most cases 
prompt surgery has not been available, and if the burrow- 
ing has been enough to show externally it will be found 
that the bladder has been opened suprapubically or perine- 
ally, or perhaps both. An incision is usually made, drain- 
ing off the pent-up fluid, and probably may save life, but it 
does not cure, as the drainage is only partial. .-Another 
error is in cases in which the burrowing point is far from 
the bladder and suppuration is then falsely diagnosed as 
local. Formerly Fuller has advised drainage of such 
pockets, and after this dissection to reach that pocket. He 
now reverses that process and dissects first. All these 
extravasations tend to point to the most dependent part 
and that should first be opened. It will then be found a 
much simpler matter to trace the track of the burrowing, 
and. when the limit of extension is located, an external 
incision can be made down on the end of a probe and 
drainage tubes introduced. More than one external con- 
necting incision may be necessary if the burrow-ings have 
extended in more than one direction. Each step of the 
operation in these cases is described at length and illus- 
trated in his paper. Three cases are reported. 

Some Experiences with Alcohol Injections in Trigemi- 
nal and Other Neuralgias. Wilfred H.\RRif. Lon- 
don. Journal of the America)! Medical Assncialion. 
November 14, 1914. 

Harris reports his experience with alcohol injections in 
neuralgia. He cautions against injection directly into a 
mixed nerve, such as the sciatic, on account of the motor 
as well as sensory paralysis it will produce. Many pa- 
tients who have been thus operated upon have escaped 
paralysis by their good luck in the operator missing the 
nerve trunk and injecting around its sheath. He gives a 
case of his own experience which is instructive as regards 
this point. He has had experience with some two hun- 
dred cases of chronic trigeminal neuralgia. The first 
division is seldom involved alone, the second is usually 
also implicated. The supraorbital is the only branch of 
the first division Harris attacks. Attempts to reach the 
infraorbital branches he thinks dangerous and needless. 
The second division or superior maxillary nerves can be 
reached with advantage either at the foramen rotundum 
in the sphenomaxillary fossa, or at the exit of the intra- 
orbital nerve on the cheek. In a majority of cases the 
pain is referred to the upper jaw and the nerve must be 
attacked at the foramen rotundum ; this is difficult, while 
the other injection is easy. Harris uses two routes for 
this posterior injection: the first, and preferably, through 
the cheek in front of the coronoid process and behind the 



superior maxilla. If the coronoid process of the mandible 
comes too far forward or the antrum bulges backward, it 
niay be hard to direct the needle between these part.s and 
in front of the external pterygoid plate so as to enter the 
sphenomaxillary fossa. In such cases he tries to reach the 
nerve from behind the coronoid process, passing the needle 
through the cheek about 4 cm. in front of the middle of tlie 
internal auditory meatus on the line drawn from the 
incisura notch to the bottom of the ala nasi so as to pass 
over the bottom of the sigmoid notch on the lower jaw. 
With this the needle passes slightly upward and forward 
and the pterygoid plate is felt for. The injection of the 
third division at the foramen ovale is much more certain 
and easy. b"or this he uses roughly Levy and Baudouin's 
line. Full details of these methods are given, too minutely 
to be abstracted, as is also the injection of the gas-serian 
ganglion and the anatomical exceptions to the usual con- 
ditions provided for. In over sixty cases in which he has 
injected this ganglion he has seen in one slight diplopia 
due to sixth nerve weakness appear immediately and last 
for three month.s. In another case there was temporary 
vertigo and nystagmus for which he cannot easily account. 
Almost always Harris finds loss of taste occur immedi- 
ately after injections of the third division of the fifth nerve 
confined to the anesthetic half of the tongue in proportion 
to the depth of the anesthesia. This lasts as long as the 
anesthesia and he has seen it two years after injection. 
This occurs immediately, proving that taste fibers from 
the tongue pass along to the gasserian ganglion via the 
third division. He has encountered two patients who suf- 
fered from paroxysmal neuralgia in which the paroxysms 
began in the throat or posterior palatal region on one side 
and spread into the ear and in front of the ear on to the 
cheek and down the side of the neck. In each case no 
relief was given by an injection of the third division of 
the fifth, and Harris considers these cases of geniculate 
neuralgia such as are described by Pierce. Clark and Tay- 
lor. Post-therapeutic neuralgia should never be treated by 
alcohol injection or any other operative measures, as it 
makes the cases worse even if they may appear at first 
to be relieved. He has seen decided benefit in chronic 
fibrositis and brachial fibrositis from alcohol injection. 
Migrainous neuralgia is rarely benefitted, but the post- 
influenza of periodic supra-orbital neuralgia may be some- 
times completely cured by a single injection. It is in 
chronic trigeminal neuralgia that most cures are obtained. 

Clinical Classification of Ethmoiditis. E. M. Holmes, 
Boston. Jotir)ial of the .-hiterican Medical Association 
December 12. 1914. 

Holmes, discusses the clinical classification or ethmoidi- 
tis. It is needful, he says, that we should remember the 
important function of the ethmoid and middle turbinate in 
regulating the temperature of the respiration. When for 
any reason the middle turbinate and lower wall of the 
ethmoid have been sacrificed, it practically puts the patient 
in the condition of a mouth breather. In treating the 
ethmoiditis the most important thing is "to ascertain, so 
far as possible, the degree and extent of the existing 
pathologic conditions, to learn of the duration of the dis- 
ease and whether there have been previous attacks, to con- 
sider the inconvenience of the existing ethmoid disease to 
the patient, the degree of extension into other structures 
and the inconvenience as well as the danger due to this 
e.xtension. It is likewise of great importance to consider 
the patient's general condition, his hygienic surroundings, 
his habits and previous treatment, if any. After having 
gone over the individual case, unless we are sure that 
the whole ethmoid structure is beyond repair, I believe 
it is our duty to make the patient understand that it will 
give better results in his case to save all the nasal struc- 
tures possible and tell him that in trying to obtain this final 
result several operations may be necessary." With this 
understanding we should do what seems necessary, even 
to the most thorough radical operation. \\"e have to con- 
sider carefully the condition of the frontal and sphenoid 
cells and the effects of irritation from associated nerve 
filaments, especially the dental. Holmes first divides 
ethmoid disease into two classes : the purulent and the 



32 



American 

Journal of Surgery. 



Progress in Surgery. 



Ja.s-uary, 1915. 



non-purulent. The latter may be either an acute or a 
chronic intlammatory condition, a degenerative, a syph- 
ilitic, a tuberculous or a ncopIa.stic. The purulent may be 
either acute or chronic. Both types may occur independ- 
ently or be associated. The acute inflammations arc very 
common and usually associated with attacks of acute 
rhinitis, and in the majority of cases are self-limited. They 
are often difficult to diagnose, and when the drainage is not 
materially obstructed the symjitoms are slight. If tliere 
is an associated purulent secretion coming from some of 
the ostia, the diagnosis is easier. While the majority are 
self-limited, some may become chronic, and we should be 
on the lookout. The general condition of the patient should 
be attended to, the gastro-intestinal tract kept right and the 
patient protected from exposure or fatigue. Locally much 
can be gained for diagnosis by a systematic application 
of cocain about the ostia, carrying it on a small-tipped 
applicator saturated with 5 or 10 per cent, solution directly 
to the anterior portion of the middle fossa under the tip 
of the middle turbinate. If this gives only slight or no 
relief, the next application should be made at the posterior 
end of the middle fossa, and after this the floor of the 
nose can be anesthetized and a thorough examination made. 
In an acute case in which the first application establishes 
drainage, the repetition of the treatment with the addition 
of argy-rol is usually sufficient to cure the patient in a 
short time. There are cases in which this cannot give 
relief and more radical treatment is required. Chronic 
suppurations vary much in degree and severity of symp- 
toms. The pus that flows backward into the pharynx may 
be distressing and very disagreeable when it forms decom- 
posing crusts. Sometimes disturbances within the orbit 
may occur and pain be felt externally over the nose and 
in the temple region. Polypoid formation may exist for 
years without purulent manifestations. Unless there is 
thorough removal of the growth it is almost sure to re- 
turn, and in advanced cases radical exenteration is re- 
quired. Syphilitic disease may show the signs of a purulent 
ethmoiditis, and this should be kept in mind and, when 
discovered, operation deferred until specific treatment has 
been given. Neoplasms of the ethmoid are very rare and 
frequently beyond treatment when discovered. Any soft 
vascular tumor within the nose should arouse suspicion 
and receive immediate attention. 



The Direct Method of Intralaryngeal Operation. 

C'Htv.M.iER T.vcKsoN. Pittsburg, Jounial of tlic Aincr- 
ican Medical Association, November 28, 1914. 

According to Jackson, the direct method is the only 
one for operating on the larynx in children ; the in- 
direct or mirror method is applicable only to adults. The 
difficulties of the direct method require long and constant 
practice in the operator but not nearly to the same ex 
tent as in the mirror method. No one method can be 
said to be best for all cases and all operators. The 
laryngologist should try all methods and instruments to 
learn which is the best for him to use. No anesthetic, gen- 
eral or local, is necessary for operations on the larynx 
in children. Cocain is dangerous in any case and gen- 
eral anesthesia is absolutely contra-indicated in all cases 
with even the slightest degree of laryngeal stenosis. Lo- 
cal anesthesia should be used in adults. General an- 
esthesia, preferably ether, being required only when cocain 
is contra-indicated or when the ischemia accompanyin.g 
its use causes the growth to shrink so as to hinder ac- 
curate removal. 

A New Physical Sign in Certain Lesions of the 
Lumbar Spine. I.eon.vri) VV. Ely. San Francisco. 
.■liiicrican Jnurnal of Orthopedic Surgery, October, 
1914. 

In various lesions of the lumbar spine, inflammatory and 
traumatic, if the patient be laid upon his face, when his 
knee is flexed his pelvis on that side will rise from the 
table. The exact reason for this phenomenon is some- 
what difficult to understand, but it helps to differentiate 
lumbar from sacroiliac lesions, having possibly in the 
former the same value as Kernig's sign has in the latter. 



Fractures of the Neck of the Femur; Its Treatment. 

John B. W.xlker, New York, New York State Jour- 
nal of Medicine, December, 1914. 

1. Fracture of the neck of the femur occurs under 
fifty years of age more frequently than was formerly 
believed. 

2. Any injury to the hip followed by disability should 
suggest the possibility of a fracture of the neck, and 
requires an expert examination aided by an x-ray photo- 
graph. 

3. Reduction of the deformity with complete im- 
mobilization of the fracture during the period of repair 
by means of a plaster spica bandage is advised in all 
suitable cases. 

4. This is to be followed by early gymnastic move- 
ments, active rather than passive. 

5. All weight-bearing upon the fracture is to be 
avoided for from four to six months, in some cases 
even longer. 

A New Method of Hastening Repair After Fracture. 

H. J. Kauffer, New York, New York Medical Jour- 
nal, November 21, 1914. 

KaufTer suggests the use of powdered bone mixed with 
petrolatum to the consistency of bismuth paste, which 
is injected between the divided ends of the fracture with 
the object of stimulating more rapid bone formation. 
The author has not tried his method in human beings, 
but in experimental work upon animals he claims that 
he has obtained more rapid formation of bone than in 
control animals. 

Penetration Radiotherapy in Surgical Affections, with 
Special Reference to Surgical Tuberculosis. (Zur 

Rontgcnticfentheral'ie bci chirurgischcn Krankhciten, 
mil besonderer Beriicksichtung der chirurgischen 
Tuberkulose). J. Oehler, Miinchener Mcdicinische 
Wochenschrift, No. 40, 1914. 

Formerly the X-ray was employed only casually in in- 
operable malignant tumors, in recurrences and after in- 
complete operations. Now the X-ray is used systematically 
in such circumstances and also in a great variety of other 
surgical diseases. The author has had favorable results 
in treating bone and joint tuberculosis, in abdominal 
and gland tuberculosis and tuberculosis of the epididymis; 
also in one case of actinomycosis of the jaw. Strumata 
were also favorably influenced in some cases, though the 
result was not as satisfactory as in tuberculous affections. 
Concerning malignant growths, those that are inoperable 
should and must be rayed ; recurrences should likewise 
be treated by radiotherapy But operable cases should 
and must be treated surgically whether it be carcinoma 
or sarcoma. The only exception is the superficial can- 
croid of the face, which is very amenable to the ray 
treatment. 

Experiences in the Treatment of Malignant Tumors 
by Radium. Rich.«lRd Sparmann, Vienna. Annals 
i>{ Surgery, November, 1914. 

Sparmann reports his chief's, von Eiselsberg's, experi- 
ence with radium in malignant tumors. Only inoperable 
cases were treated. In the beginning large doses of 
radiutn irradiation were employed ; later much smaller 
doses, since it was found that the large doses produced 
destruction of healthy tissues in the tumor zonj and that 
the patient's general condition suffered measureably. Of 
52 cases treated, curatively as well as preventively, only 
11 remained free from tumors. The writer is clear in 
his emphasis that recurrences were sometimes hastened 
by post-operative irradiation, that the general ill-effects, 
such as tachycardia, weakness, vomiting, were often dis- 
tressing, finally that the dangers of hemorrhage or per- 
foration of a hollow viscus were by no means negligible. 
For these reasons the author believes that the hopes 
placed in radium as a new and successful method of 
treating malignant tumors were not realized. 



American Journal of Surgery 

QUARTERLY SUPPLEMENT of 
ANESTHESIA CQ, ANALGESIA 



[Ainerif-an Journal of Anosihosia and Analgesia] 



OFFICIAL ORGAN 



American Association Providence (R. I.) Society Scottish Society of 
ol Anesttietists of Anestlietists Anesthetists 

EDITOR 
F. HOEFFER McMECHAN, A.M., M.D. 



ASSOCIATES 

JAMES TAYLOE GWATHMEY. M.D.. 
DUDLEY W. BUXTON, M.D.. M.R.C.P., 
WILLIS D. GATCH. M.D.. F.A.C.S.. 
JOHN D. MORTIMER, M.D., F.R.C.S.. 
PROF. C. BASKERVILLE. Ph.D., F.C.S., 
ARTHUR E. HERTZLER, M.D., F.A.C.S., 
WM. HARPER DEFORD. D.D.S.. M.D., 



CHARLES K. TETER, D.D.S., M.D., 
PROF. DR. GUIDO FISCHER, 
CARROLL W. ALLEN, M.D., F.A.C.S., 
EDWARD H. EMBLEY, M.D., M.R.C.P., 
TORRANCE THOMSON, M.D., 
PROF. YANDELL HENDERSON, Ph.D., 
E. I. McKESSON, D.D.S., M.D., 



ISABELLA C. HERB. M.D. 



Vol. I. No. 2. 



JANUARY 



1915 



CONTENTS OF THIS ISSUE 



CONTINUOUS ANESTHESIA AND ANALGESIA WITH 
SOMNOFORM. (Illustrated) ----- 



PROPER DEPTH OF ANESTHESIA. - - - . 

NITROUS OXID-OXYGEN DOSAGE IN ANESTHESIA. 
(Illustrated) ---------- 

COMBINED ANESTHESIA IN THE OPERATIVE TREAT- 
MENT OF HEMORRHOIDS. (Illustrated) - - - - 

TREATMENT OF POSTOPERATIVE SHOCK - - - . 

FRACTIONAL REBREATHING IN ANESTHESIA. (Illustrated) 



Win. Harper DeFord, 
Des Moines, la. 



Willis D. Gateh, 
Indianapolis, Ind. 



Karl Connell, 
New York Cit.v 



Isadure Seff, 
New York City 

Frof. Charles Lieb, 
>'e\v York City 

E. I. McKesson, 
Toledo, O. 



34 
38 

39 

44 
47 
51 



DEPARTMENTS 



EDITORIALS - 
BOOK REVIEWS 



58 MEDICO-LEGAL ASPECTS 

60 INDEX AND ABSTRACTS - 



59 
61 



34 



American Journal of Surger> 
Anesthesia Supplement 



DeFoRD SOMNOFORM Ax ALGESIA. 



January, 1915. 



CONTINUOUS ANALGESIA AND ANES- 
THESIA WITH SOMNOFORM— THE 
TECHNIC OF ADMINISTRATION. 

\Vm. H.vrper DeFord, A.M., D.D.S., M.D., 
Des Moines, Iowa. 



The use of lijghly volatile and rapidly eliminated 
anesthetics has immeasurably broadened the scope 
.of the expert anesthetist's work in rendering the 
routine operative procedures of dentistry, minor 
surgery and the specialties, painless. Also the same 
agents and methods of administration serve equally 
well for brief periods of surgical narcosis, without 
the dangers incident to ether or chloroform and the 
occurrence of untoward post-anesthetic complica- 
tions. 

While ethyl chloride has been available as a gen- 
eral anesthetic for a number of years, its use for 
continuous analgesia and anesthesia by nasal ad- 
ministration has been deferred, owing to the lack of 
a suitable apparatus for its administration. The 
DeFord inhaler, devised and developed for the ad- 
ministration of ethyl chloride in combination with 
methyl chloride and ethyl bromide — Somnoform 
now provides the expert anesthetist with a simple, 
efficient and easily portable device for continuous 
.analgesia or anesthesia. 

Description of App.\r.\tus. 
The essential parts of the device, as illustrated 
(Fig. 1) are (1) a Capsule Chamber, in which the 
.ampoules containing the anesthetic are fractured : 
(2) a Gauze Chamber to prevent the entrance of 
shattered glass into the apparatus; (3) a Rubber 
Bag to hold the volatized anesthetic; (4) a Regu- 
lating \'alve, controlling the volume of the anes- 
thetic vapor and the admixture of air; (5) a Nasal 
Cover, with a sponge rubber cushion to render it 
air-tight and adaptable to varying physiognomies, 
and an Expiratory Valve, controlled by a milled cap, 
b}- the turning of which rebreathing may be gov- 
erned ; and finally, (6) a Mouth Cover, used during 
the induction of analgesia or anesthesia, to avoid too 
great dilution of the anesthetic vapor by oral breath- 
ing. Attached to the tube leading from the anes- 
thetic bag to the nasal cover, is a support to render 
the apparatus more stable, when strapped to the 
head, and allow the operator the freedom of both 
his hands. The mouth' cover is adjusted to the 
proper position by means of an adjusting rod and 
■set screw, and it may be put out of the way by let- 
ling it fall back into a slip-joint on the nasal cover. 

Adjusting the Appar.-\tus. 
.^ssemble the appliance with the exception of the 




Fij;. 1. The DeFord Inhaler and lu Various Parts. 

mouth cover. See that the lever regulating the 
valve is pulled down as far as it will go, this pre- 
vents the anesthetic from escaping. With the gauze 
chamber lightly packed, place an ampoule of somno- 
form in the breaking device, replace the top of 
breaking device and press upon it until a slight ex- 
plosion is heard. The sonmoform is now locked 
in the appliance and cannot escape till liberated. 

For operations on the teeth under analgesia the 
mouth cover is not needed. For removing aden- 
oids, tonsils, etc., under analgesia the mouth cover 
is important. 

For extraction of teeth, removing tonsils, aden- 
oids, etc., under anesthesia the mouth cover is neces- 
sary. 

Now adjust the appliance by placing it over the 
nose, fasten the strap around the head, and arrange 
the extra support to stabilize the apparatus. 

When the mouth cover is to be used, with the 
mouth prop m position, slip the mouth cover over 
its retaining pin, adjust it on the rod so it covers the 
mouth accurately, and tighten the thumb screw. 
With the exhaling valve open to its fullest extent, 
anesthesia induction may now begin. 

The Induction of An.xlgesia. 
It is advisable to complete the painless part of all 
operative procedures before beginning the induc- 
tion of analgesia. When all is in readiness the pa- 
tient is allowed several breaths of air, then the lever 
of the regulating valve is raised slowly, and the anes- 
thetic gradually admitted in increasing volume. The 
lever is raised until the lazy winking of the patient's 
eyelids indicates the onset of the anesthetic's ob- 
tunding effect. Only several more inhalations will 
then be necessary for an analgesia of brief dura- 
tion. It is not desirable for the patient to lose con- 
sciousness. .\t this stage operating may be com- 
menced, increasing the pressure and speed of the 
bur if no pain is felt. When a plane of satisfactory 



Vol. 1, No. 2. 



DeFoRD SOMNOFORM ANALGESIA. 



American Journal of Surgery 
Anesthesia Supplement 



35 



analgesia has been reached, the regulating lever 
should be pressed down to shut oft" all or nearly all 
of the anesthetic. The beginner will do well to ex- 
clude all Soinnoform at intervals, admitting a fresh 
supply of the vapor as needed. The expert, with 
increasing experience will be able to manipulate the 
regulating valve to admit just the required amount 
of fresh vapor to make the analgesia smoothly con- 
tinuous. During continuous analgesia the depth of 
the obtunding etifect is controlled, not only by the 
regiilating valve, but also by the tidal volume of the 
patient's respiration. It is surprising how quickly 
patients accustom themselves to co-operate with the 
dentist, by lightening or deepening the plane of 
analgesia by increasing or diminishing their res- 
piratory excursions. Also, when operating without 
the rubber dam, the lips may be closed at intervals 
to offset the dilutent effect of oral breathing. The 
supply of Somnoform vapor is renewed by fractur- 
ing fresh ampoules in the capsule chamber. 

THE IXDUCTIOX OF .VNESTHESI.X. 

To induce complete surgical anesthesia, the anes- 
thetic vapor is gradually admitted by raising the 
lever of the regulating valve. The rapidity with 
which this can be done will depend entirely on the 
reflexes of the mucous membrane in accepting the 
gradually concentrated vapor of the anesthetic. If 
the patient manifests no uneasiness, the lever may 
be rapidly advanced until the patient is breathing 
pure Somnoform vapor and exhaling it through 
the expiratory valve. Continuous anesthesia may 
require various degrees of rebreathing, which is ac- 
complished by closing the expiratory valve entirely 
or partially, and by allowing the rebreathing of 
pure anesthetic vapor to and fro from the bag, or 
admitting varying percentages of air as the ex- 
igencies of the narcosis may require. The anes- 
thetist who has acquired considerable skill in the 
use of Somnoform for short administrations will 
find the DeFord inhaler and the nasal technic a 
very satisfactory method of conducting anesthesias 
lasting upward to 15 or 20 minutes. Continuous 
anesthesia is preferable to repeated administra- 
tions, particularly if hemorrhage can be controlled 
and the patient kept from swallowing blood : a com- 
plication which usually results in nausea and car- 
diac depression from the diaphragmatic spasm dur- 
ing the efforts at vomiting. In the event of re- 
peating the administration at the same sitting, suf- 
ficient time should elapse for the patient to fully 
recover from the first administration, and this in- 
terval should be used to cleanse the mouth and 
control hemorrhage to avoid spasm of the glottis 
from the weight of the accumulated blood. The 



aspirator is a valuable adjunct to satisfactory con- 
tinuous anesthesia in all instances in which there 
is troublesome bleeding. The assistant should move 
it across the base of the tongue to keep a clear, 
bloodless field for the operator. 

SIGNS OF ANALGESI.\ -XND ANESTHESI.V. 

During analgesia the patient merely feels drowsy, 
the eyelids w-ink lazily, and there is some tingling 
and numbness of the extremities. The patient can 
talk, aiul is conscious of everything that is being 
done, but is insensible to the pain of light oper- 
ating. He is able to assist the operator by mov- 
ing the tongue or jaws, and clearing the mouth. 
With the onset of anesthesia there is loss of con- 
sciousness, muscular relaxation usually supervenes, 
the eyeballs roll upward, while the pupils notice- 
ably dilate, and breathing becomes rhythmic and au- 
tomatic as in sleep. As anesthesia deepens the dila- 
tation of the pupil becomes marked, and the eye- 
balls become fixed, while the corneal refle.x is lost 
and snoring or sterterous respiration supervenes. 
These signs denote the ultimate plane of surgical 
narcosis that is compatible with safety. Anesthesia 
continues to deepen for some 15 seconds after the 
last inhalation of the anesthetic vapor, and then 
elimination begins and is generally completed in 
about one minute, although there is a workable 
period of analgesia during recovery, which may 
be utilized to good advantage. 

UTILITY OF SOMNOFORM ANALGESIA AND ANES- 
THESIA IN DENTISTRY AND SURGERY. 

The progressive dentist is finding an ever broad- 
ening and more profitable field for the use of anal- 
gesia in the painful operations of dentistry, such as 
lancing abscesses, pyorrhoea technic, excavating 
sensitive dentine and removing pulps. Analgesia 
is sufficiently painless for all dental operations ex- 
cept the extraction of teeth and the removal of 
vital pulps surgically. Also it is invaluable not only 
in sparing the patient pain and nervous tension, but 
also in saving the dentist's time and enabling him 
to do more thorough work. Dental operations fail, 
not so much because dentists do not understand 
correct cavity preparation, proper tooth and root 
formation for crowns and abutments, and the ne- 
cessity of thoroughly removing all calcarious con- 
cretions in pyorrhoea, but zmthout analgesia patients 
many times will not endure the pain necessary to 
perform the operation thoroughly. 

Somnoform anesthesia is also very serviceable in 
such operations of minor surgery as the opening 
of abscesses, tenotomies, removal of tonsils and 
post-nasal adenoids, aural, nasal and uterine polypi; 



36 



American Journal of Surgery 
Anesthesia Sujiplement 



DeFoRD SOMNOFOR.M ANALGESIA. 



January, 1915. 



the application of the actual cautery, passive move- 
ments of stiff muscles and joints ; eversions of toe 
and linger nails, removal of external piles, drain- 
■dga tubes; in curetage, dilating urethral strictures 
and reducing dislocations. While the use of a 
mouth-prop during analgesia is optional with the 
operator, a patient should never be surgically an- 
esthetized with Somnoform for such operations as 
the extraction of teeth or the enucleation of tonsils 
and adenoids, without a mouth-prop being inserted 
between the teeth in advance of the induction of 
narcosis. Occasionally spasm of the masseter mus- 
cle is met with, and this complication may prove 
very annoying, even dangerous, unless this precau- 
tionary measure to conserve an open airway has 
been adopted. .-Mso it is important for the tyro 
t(; remember that the regulating valve of the ap- 
paratus must be closed before fracturing a fresh 
ampoule in the capsule chamber, otherwise the pa- 
tient, already anesthetized, would inhale an over- 
whelming volume of the anesthetic vapor. After 
the bag has been filled with the new supply of 
vapor, the lever of the regulating valve is gradually 
raised until the required percentage of anesthetic 
vapor and air admixture has been reached. 

PRELIMINARY STUDY AND PREPARATION OF THE 
P.\TIENT. 

The dentist or expert anesthetist, who is to ad- 
minister any general anesthetic, may, with advan- 
tage, cultivate the habit of gathering for himself 
valuable information as to the patient's physical 
condition without the patient's knowledge. He may 
detect at a glance whether the patient is young 
or old, thin or corpulent, feeble or robust, nervous 
and excitable or calm and without dread, temperate 
or alcoholic, showing shortness of breath or normal 
respiration. Even serious impairment of the heart 
or kidneys may be suspected by the careful ob- 
server. 

It is always profitable to note the degree of nerv- 
ous tension, since this may influence the patient's 
conduct during anesthesia or analgesia. This is 
particularly true when fear leads to muscular rigid- 
ity, gripping the chair, locking the jaws, and oppos- 
ing the anesthetic. Signs of intoxication in even 
mild degree should be carefully looked for, since 
anxiety leads many patients to take "a bracer" be- 
fore entering the office : and even a small amount 
of alcohol may necessitate the use of much larger 
quantities of Somnoform to control the excitement 
stage of narcosis. Again, patients are met with 
who are in an absolute state of exhaustion from 
pain and insomnia, and in these analgesia and anes- 
thesia may be readily induced, and occasionally 



persons in this condition pass into a profound nat- 
ural sleep, after recovery from the anesthetic, from 
which they are with ditticulty aroused, and which 
is very disconcerting to the anesthetist. 

The extremes of age are no contra-indications 
to Somnoform analgesia or anesthesia, except that 
in the presence of arteriosclerosis due care must 
be e.xercised not to allow any imperiling degree of 
respiratory embarrassment to supervene, which 
might precipitate a stroke of apoplexy. Elderly per- 
sons who show prominent veins in the neck and 
temples must be anesthetized very gradually with 
plenty of air in the early stages. The same is true 
for plethoric and obese patients, who seem to re- 
(|uire excessive oxygenation in comparison w^ith 




\- 



:n 




Fig. 



Moutli Cover EIe\atfil to Pcriiiit C)iiL-r;aive Proce<liires. 



anemic individuals. Nervous and frightened pa- 
tients cause the anesthetist more anxiety and are 
really more hazardous risks than the frail and deli- 
cate subjects who present pathological complica- 
tions, but have no dread of the anesthetic. During 
the induction of narcosis nervous individuals are 
subject to imperiling drops in blood pressure, due 
to psychic impressions, and their idiosyncrasies must 
be humored until the plane of light anesthesia has 
been reached. Should there be any question in 
the anesthetist's mind regarding the safety of ad- 
ministering analgesia or anesthesia to any particular 
hazardous- risk, the respiratory test of Stange and 
the differential blood-pressure test of McKesson 
should be used to definitely determine the pres- 
ence of acidosis and dangerous cardiac conditions. 
It should be understood without constant repiti- 
tion that in preparing a patient for analgesia or 



Vol. 1. 



DeFoRD — SOMNOFORM ANALGESIA. 



American Journal of Surgery 
Anesthesia Supplement 



37 



anesthesia any tight clotlies. collars and corsets 
should be removed. Women patients' statement 
that the corset is loose or has been loosened should 
not be accepted, but the nurse attendant should see 
that it is. It is also advisable that about three 
hours should have elapsed since the last meal. 

The expert anesthetist will persuade the patient 
to yield without opposition to the induction of anal- 
gesia or anesthesia. The amount of self-control 
exerted by patients will be largely determined -by the 
amount of confidence the operator is able to in- 




Fig. 3. Rubber Dam in L'^e Iiislti^d of Mouth Cover. 

spire. Nothing will so quickly place the patients 
at their ease as the realization that the operator 
knows exactly what he is to do and how to do it. 
Pleasant, diverting conversation also plays an im- 
portant part in putting patients in a proper frame 
of mind for the ordeal of anesthesia. 

POSITIOX OF THE PATIENT. 

For many minor surgical operations and prac- 
tically all dental operations the semi-reclining up- 
right position answers all purposes. The head-rest 
should be so fixed as to tip the head slightly back, 
without stretching the neck or embarrassing respira- 
tion. The feet should rest comfortably on the foot- 
rest without the legs being crossed. The hands 
should lie limp, unclasped in the lap, so that they 
may be raised by the patient to indicate pain dur- 
ing analgesia or by the operator to determine re- 
laxation at the onset of anesthesia. Providing that 



breathing is not interfered with, the patient should 
be put in that position which facilitates access to 
the field of operation. For operations, in which 
etherization is used as an adjunct to Somnoform, 
the horizontal posture is advisable : although with 
proper precautions and the use of the French chair- 
table, patients may be anesthetized in the horizontal 
and then operated on in any other desired posture. 
The use of the aspirator to prevent the swallow- 
ing of blood during dental and oral operations has 
already been advocated, and it is also imperative 
for the operator to prevent anything else from drop- 
ping into the throat during anesthesia. Deaths in 
the chair from s\ich accidents have occurred and 
I >perators, under the circumstances, have been 
mulcted of heavy damages. 

CARE OF THE PATIENT DURING RECOVERY FROM THE 
ANESTHETIC. 

Keeping the patient sitting back in the chair dur- 
ing recovery from anesthesia, and talking quietly 
and soothingly, will frequently overcome any ten- 
dency toward excitement and will prevent nausea. 
The patient should not sit up to wash out the mouth. 
It is more advisable to use the aspirator or to 
swab out the mouth. Also the patient may be al- 
lowed to rinse the mouth without raising the head. 
The patient should remain in the semi-reclining 
position until all effects of the analgesia or anes- 
thesia have worn off and there is but slight ten- 
dency to nausea. 

ACCIDE.NTS. 

Somnoform analgesia and anesthesia have been 
singularly free from the usual accidents of general 
narcosis. It is very comforting, however, for the 
administrator to know exactly what to do in case 
any untoward accidents should occur. Experimental 
research has determined that in laboratory fatali- 
ties respiration has ceased several moments before 
the heart did. Consequently in clinical instances of 
embarrassed breathing immediate efforts should be 
made to re-establish respiration. The apparatus 
should be withdrawn, and sudden sharp pressure 
exerted on the abdomen. This stirs up the solar 
plexus and in most instances is sufficient to re- 
establish breathing. If not, rhythmical traction of 
the tongue, associated with artificial respiration by 
lifting the arms, and lowering them with compres- 
sion of the chest, should be instituted, about 18 
times a minute, and continued until spontaneous 
respiration returns. Meanwhile 1/100 gr. of nitro- 
glycerin may be dissolved under the tongue, and 
amyl nitrite or aromatic spirits of ammonia held to 
the nose. 



38 



American Journal of Surgery 
Anesthesia Supplement 



Gatch — Proper Depth of Anesthesia. 



January, 1915. 



In cardiac collapse 8 or 10 drops of adrenalin in 
the conjunctival sac will usually cause a prompt and 
resuscitative circulatory response. Massaging the 
precordial area and lowering the patient to the hori- 
zontal or slight Trendelenburg posture will mate- 
rially assist in accomplishing resuscitation. 

CARE OF THE APPARATUS AFTER USE. 

As soon as the operation is over, the gauze in 
tlie inhaler should be removed and thrown away, 
and the rubber bag and sponge cushion sterilized 
by exposure to dry heat or immersion in an anti- 
septic solution such as lysol, bichloride of mercury 
or carbolic acid. Both sides of the bag should 
be thoroughly dried and powdered with soapstone ; 
all excess of the powder being then removed. Un- 
less this is done the rubber bag and sponge cushion 
will rapidly deteriorate. All metal parts of the 
apparatus may be sterilized by boiling. Steriliza- 
tion of the apparatus is an imperative prophylactic 
measure against the transmission of communicable 
diseases. 

Flynn Building. 



THE PROPER DEPTH OF ANESTHESIA. 

W. D. G.\TCH, M.D., F.A.C.S., 

Indianapolis, Ind. 



The purpose of this paper is to present evidence 
for the belief that the lightest possible anesthesia 
which will suffice for a given operation is the best. 
The injurious effects of general anesthesia may be 
grouped under two heads, (1) direct injuries due 
to the toxic action of the anesthetic upon the tissues, 
and (2) indirect injuries caused by the interference 
of the state of narcosis with physiologic processes. 
The most important of the indirect injuries are due 
to asphyxia and to muscular relaxation. 

The harmful effects of asphyxia, the causes of 
this condition, and the means of preventing it are 
so generally known that it is needless to discuss 
them here. The same is not true of the harmful 
efifects of muscular relaxation. In fact, many sur- 
geons regard this as desirable, since it facilitates the 
performance of their work, and, as they believe, 
prevents so-called "surgical shock." 

That full relaxation facilitates somewhat the per- 
formance of certain operations, especially laparoto- 
mies, we are prepared to grant, though we must 
deny that it is necessary. Instead of preventing 
"shock," we believe that muscular relaxation is an 
extremely potent means of producing it. 

Before proceeding further let us explain what 
we mean by "light" anesthesia. To make this plain 
we shall describe our own practice. This has been 



developed gradually and largely through experience 
with nitrous-oxid-oxygen anesthesia. It was this 
which taught us the advantages and possibilities of 
a light narcosis. 

Thirty minutes before the anesthesia is begun a 
hypodermic of morphia and atropine is given (aver- 
age dose for adults : morphine gr. 1/6, atropine gr. 
1/100). When the services of a skilled anesthetist 
are to be had we use nitrous-oxid and oxygen, 
otherwise, ether, given drop by drop on a mask 
which fits the face closely, is heavily covered with 
gauze, and has a considerable dead space. We in- 
sist that the patient be anesthetized without his be- 
coming cyanotic or struggling. If his respiratory 
reflexes are so active that they render the main- 
tenance of an open air way difficult, the anesthesia 
is gradually deepened till the anesthetist has his 
patient's respiration under control. 

Difficulty in keeping an open air way is the only 
contraindication to light anesthesia, and it is sur- 
prising how seldom this is encountered, when the 
patient has been properly prepared. A short time 
after the patient has ceased to respond to questions 
the operation is started. Great care is exercised not 
to make sudden or violent traction on the tissues, 
and to employ sharp dissection whenever possible. 
The effect of each manipulation upon the patient 
is noted, and if necessary the operation is delayed 
a few moments until the anesthesia can be deepened. 
As far as possible the anesthetist is kept informed 
concerning the steps of the operation and the re- 
quirements of anesthesia. For example, during a 
laparotomy involving a resection of the intestine, 
once the segment to be resected has been located, 
very little anesthetic is administered till we are al- 
most ready to close the abdomen. Then after the 
peritoneum has been closed no anesthetic is given 
during the remainder of the operation. We insist 
that the patient be practically awake before he 
leaves the operating room. 

The foregoing description applies largely to the 
use of ether. When nitrous-oxid-oxygen is used 
there is no danger that the anesthesia will be toO' 
deep, provided cyanosis is guarded against. The 
depth of anesthesia which we employ corresponds 
to that of the ether "Rausch" of the Germans. 

Post-operative ill effects from this light anes- 
thesia, either from ether or nitrous-o.xid, are al- 
most entirely absent. Vomiting rarely occurs. 

Nearly every patient except those who have 
undergone laparotomy is ready to take nourishment 
three or four hours after operation. In fact, we 
believe that an unprejudiced observer would say 
that the post-operative condition of these patients 



Vol. 1. No. 2. 



CoNNELL — Nitrous Oxid-Oxygen Dosage. 



American Journal of Surgery 

Anesthesia Supplcniciu 



39 



is as good as that of similar cases operated upon 
under local anesthesia. 

Our experience with this technic has now been 
of over six years' duration. We have found it to 
be adopted to all patients except the small class 
mentioned, and to most of these once they are 
got under control. \\'e believe that it is so safe 
that its use renders unnecessary the combination of 
local and general anesthesia as a routine procedure. 

Having thus explained what we mean by "light" 
anesthesia and having incidentally given the clinical 
results of the same, we must now return to our 
original questions, which are the consideration of 
the ill effects of muscular relaxation and the in- 
fluence of deep anesthesia upon the production of 
so-called "shock." 

It is a well known fact that the blood vessels are 
capable of holding several times the entire amount 
of blood. Since the arteries nuist always be full, 
it is evident that the veins and capillaries are not, 
and it is also evident that the mechanism by means 
of which the blood is prevented from accumulating 
in the latter vessels must be essential to life. That 
muscular contraction is the chief force involved in 
doing this is proved by the follow'ing considerations : 
(1) The veins of the limbs are provided with valves 
situated at short inter^-als apart and arranged so 
that every force that compresses the veins forces 
the blood toward the heart. When the valves be- 
come incompetent serious venous dilatation occurs, 
as in varicose veins of the leg. The mechanism just 
described is powerful enough to raise the blood 
pressure in the veins to several times the height of 
the arterial blood pressure, as we have showm by di- 
rect experiment. (Gatch — The Effects of Lapar- 
otomy on the Circulation. Trans. Am. Gyn. So- 
ciety, 1914; in press.) (2) The intra-abdominal 
veins are destitute of valves, and since these vessels 
alone can hold more than all the blood in the body, 
something must prevent their filling. This is usually 
supposed to be accomplished by the vaso-motor 
mechanism. But that this alone is incapable of pre- 
venting a fatal stasis of blood in the abdominal 
viscera is shown by the following experiment : A 
dog is etherized till muscular relaxation is pro- 
duced. Its arterial blood pressure is recorded. 
That its vaso-motor mechanism is acting well is 
shown by the maintenance of a normal blood pres- 
sure, and by a rise of blood pressure during as- 
phyxia. The dog is now placed in a vertical head- 
up posture. The blood pressure rapidly falls and 
is soon almost to the base line. On placing the 
animal in the head-down posture its blood pressure 
quickly reaches the normal level. Salt solution is 



now injected into the animal's peritoneal cavity till 
its abdominal walls are distended. If the animal 
is now placed in the vertical head-up posture, little 
or no fall of blood pressure occurs. Similar re- 
sults may be obtained by the use of curare. This 
experiment clearly shows: (1) The inability of the 
vaso-motor mechanism to prevent a fatal stasis of 
' blood in the abdomen, and (2) the ability of an 
adequate intra-abdominal pressure to do so. Since 
this pressure is normally due to muscular contrac- 
tion, the role of the latter is evident. Thus it is 
possible to produce fatal "shock" by deep anes- 
thesia combined with the head-up posture. When 
we abolish muscular tone there is an accumulation 
of blood on the venous side of the circulation, and 
the effect of this is practically that of hemorrhage. 

The writer is convinced from both clinical and 
laboratory experience that operating for ten min- 
utes with the patient under profound anesthesia 
may do him more harm than operating for an hour 
under light anesthesia. During a prolonged period 
of complete muscular relaxation so much blood may 
be withdrawn from the circulation that all the tis- 
sues suffer from a diminished blood supply. This- 
fact must be taken into account in estimating the 
toxic action of an anesthetic. This indirect action 
of the drug may be much more harmful than its 
direct toxic action. 

1440 Centr.xl Avenue. 



NITROUS-OXID OXYGEN DOSAGE IN 

ANESTHESIA.* 

By Karl Connell, M.D., F.A.C.S., 

Assistant Surgeon Roosevelt Hospital. Instructor in Sur- 
gery College of Physicians and Surgeons, Columbia 
University, 

New York. 



PROPORTION OF G.^SES IN TID.AL .MR THE ONLY AVAIL- 
ABLE STANDARD OF QUALITATIVE DOSAGE. 

The intensity of the anesthetic action of nitrous 
oxid is in a measure inversely as the quantity of 
oxygen with which it is administered. The effect 
varies from a blunting of pain sense, obtained by 
administration with percentage of oxygen exceed- 
ing that of nomial air. down through increasingly 
anesthetic action, obtained by a percentage of oxy- 
gen half that of normal atmosphere: thence down 
through an increasingly anesthetic and asphyxial ac- 
tion, until finally, with a percentage of oxygen 
about one-third that of normal air, the asphyxial 
effect renders the mixture so dangerous that it 
may be termed unrespirable. The effect of dosage 



•Read by proxy, courtesy of Dr. L. S. Booth, .\nestht list to 
Roosevelt Hospital, during the Second .\nnual Meeting of the 
American Association of Anesthetists, Atlantic City, June. 1914. 



^ '^■"Anes?hj5"a''supplem?nr''*' CONNELL— NiTROUS OxiD-OXYGEN DoSAGE. 



January, 1915. 



may therefore be tabulated within certain limits, ac- 
cording to the relative percentage of the two gases 
maintained for respiration. 

GAS TENSION AS A FACTOR. 

Additionally the anesthetic action of nitrous oxid 
is in a measure directly proportional to the tension 
of the gas dissolved in the arterial blood and central 
nervous system. Indeed any appreciable dilution of 
the anesthetic mixture by an inert gas such as 
nitrogen so lowers the volumetric proportion of 
normal atmospheric pressure sustained by nitrous 
oxid in the lungs and results in such low gas ten- 
sion of nitrous oxid dissolved in the blood, that 
satisfactory anesthesia cannot be induced. In this 
connection the well-recognized increased anesthetic 
efficiency of nitrous oxid administered under a few 
millimeters of positive pressure can scarcely be 
cited as an illustration, since the clinical advantage 
accruing in this instance is no doubt due to the 
exclusion of air, which so often finds ingress into 
the apparatus through leaking joints, rather than to 
additional nitrous oxid dissolved in the blood. It 
is difficult to imagine that 5 millimeters of posi- 
tive pressure would add an amount clinically ap- 
preciable to the 680 millimeters of tension, more 
or less, of nitrous oxid in the central nervous sys- 
tem of the anesthetized patient. 

AN ACCURATE STANDARD AVAILABLE FOR THE 
HYDROCARBON ANESTHETICS. 

With the lipoid solvent anesthetics, decreased 
■oxygen supply is a secondary factor in the depth 
of anesthesia, the determining one being the actual 
vapor tension of such agents as ether, dissolved in 
the neurone. Therefore with these anesthetics, 
ether and chloroform, it would seem desirable, as 
urged by Boothby, to adopt a nomenclature of 
dosage referring to the barometric pressure exerted 
"by the vapor in the lung and the tension under 
which it is held dissolved in the neurone. 

NITROUS OXID STANDARD OF QUALITATIVE DOSE. 

With nitrous oxid on the other hand since its 
efficiency is in larger measure proportional to the 
deprivation of o.xygen, it seems desirable, until fur- 
ther work on the nitrous oxid tension of the blood 
has been done, to measure and tabulate dosage in 
terms of relative volumes of nitrous-oxid to oxygen 
in the inspired tidal volume. 

LIMITATION OF THE QUALITATIVE DOSE STANDARD 
FOR NITROUS-OXID. 

It must be recognized that the proportion of 
gases in the tidal volume is only an approximate 
index of the proportion of available gases which 
reach the central nervous system. Oxygen is per- 



ishable in the body, and must be constantly re- 
freshed, whereas with nitrous-oxid, no loss being 
sustained, a partial clinical balance of blood and 
neurone with alveolar gas is established within six 
minutes, an almost complete balance within 15 min- 
utes, and a complete physical balance within about 
40 minutes, if analogy may be drawn from observa- 
tions on carbon dioxid. Therefore, after a time 
it makes no difference with the amount of nitrous- 
oxid circulating in the blood what the tidal volume 
of respiration may be, so long as an equal gas pres- 
sure is maintained in the lungs. But for the oxygen 
of the blood to maintain a balance and the anes- 
thetic state to remain in equilibrium, the oxygen 
intake in the tidal gas of respiration must remain 
constant in quantity within certain limits, no mat- 
ter what the percentage may be. In other words, 
the percentage of oxygen must be raised to com- 
pensate for small tidal volume, thus upsetting the 
tidal proportion standard of dosage. 

A second factor to upset the accuracy of dosage 
gauged by the relative proportion of gases in the 
tidal volume is an altered capacity of the blood to 
transfer oxygen. Any diminished rate of blood 
flow or diminished o.xygen carrying power in the 
hemoglobin must be compensated for by increase 
in o.xygen relative gas pressure both in the tidal 
volume and the alveolar air for the nerve cell to 
remain in anesthetic equilibrium. 

Clinically it is found that the requirement of in- 
dividual patients toward higher percentage of oxy- 
gen in the tidal volume is common when there is 
present any marked diminution of tidal volume or 
of quality or rate of blood flow. The tidal volume 
is often diminished by obstruction, by breath-hold- 
ing, by acapnoea and by over-anesthetization. 

The o.xygen-carrying capacity of the blood is 
diminished by low hemoglobin content and by 
decreased rapidity of blood flow; or the carry- 
ing capacity of the blood for oxygen is much 
diminished by anemic and septic conditions ; also the 
relative capacity seems to be lessened and the ne- 
cessity for a higher per cent, of oxygen is evident 
in rapidly growing children and in patients of rap- 
idly-increasing weight. The carrying capacity be- 
ing in direct ratio to the rate and volume of the 
blood flow is lessened in asthenic states, such as 
old age, cardiac decompensation and conditions of 
disease. Any of these factors which decrease the 
oxygen intake by a lessened tidal volume, or de- 
crease the oxygen carrying capacity of the blood by 
lessened hemoglobin capacity or rate of blood flow 
must be compensated for by increase of oxygen in 
the mixture administered to that patient. 



Vol. 1, No. 2. 



CoNNELL — Nitrous Oxid-Oxvgen Dosage. 



American Journal of Surgery 
Anesthesia Supplement 



41 



As previously stated, the only practical place 
to measure the relative proportion of gases is at the 
intake in the inspired volume, however much this 
measurement may leave to be desired. 

Yet in normal man of average tidal volume the 
effect of a given proportion of gases can be fore- 
told to a nicety, and in the exceptions noted above 
the proper level is very quickly found. By the 
use of a measuring instrument of precision for 
quantity of each gas as it flows to the patient the 
administration for a given depth of anesthetic be- 
comes almost a rule of thumb and an automatic 
procedure. 

ZONES OF ANESTHESI.\. 

If it is conceived for purpose of observation and 
tabulation that the various stages of nitrous-oxid 
anesthesia, from slight blunting of pain sense to 
profound asphyxia may be plotted as on a surface 
into continuous areas, each marked by definite phy- 
sical reactions and each induced and maintained 
by definite proportion of nitrous oxid and oxygen, 
then these areas may be termed Zones of Anes- 
thesia. 

The following chart I have tabulated as the 
average for normal man of good tidal volume. The 
mixtures and measurements were first made very 
accurately and automatically by a carefully cali- 
brated anesthetometer, working on nicely balanced 
gas pressures. Later this was abandoned for a 
less exact but more practicable measurement by the 
writer's instantaneous gas flow gauges. For guid- 
ance in tabulating the slightly asphyxial zones I 
am indebted to Dr. Walter M. Boothby, for the 
analgesic zones to Dr. Charles K. Teter. The pro- 
foundly asphyxial zones were determined in part 
by Dr. James T. Gwathmey and myself on the 
dog. The remaining zones were tabulated from 
operative cases in routine anesthesia at the Roose- 
velt Hospital, New York. 

These zones were all determined without sup- 
plemental narcosis. It may be mentioned in pass- 
ing, as a point frequently overlooked or understood 
by the more fanatical devotees of nitrous oxid, that 
without supplemental narcosis for resistant sub- 
jects no zone exists in the range of true nitrous- 
oxid anesthesia, which is surgically desirable. 

UTILITY OF THE ABOVE ZONES. 

The Lethal Zone: Equilibrium can never be said 
to be established in this zone, as fatal asphyxia 
supervenes in from 3 to 6 minutes. While the 
percentages of this zone are in common use for 
short operations, such as extraction of teeth, yet 
the asphyxial mixtures of this zone should be aban- 
doned for those which induce anesthesia more 







ZONtS OF NITROUS OXlDt -OXYGEN ANAESTHESIA 
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OENTISTHY 



Fig. 1. 

slowly and safely. Anesthesia induced by the per- 
centage mixtures of the lethal zone subject the pa- 
tient to severe cardio-vascular strain, and carry him 
to W'ithin a minute or two of death from asphyxia. 

The Profound and Deep Zones also have no 
proper surgical indication. They are frequently 
invaded by error during the routine administration 
and are rapidly retreated from by raising the per- 
centage of oxygen when oncoming asphyxia is ob- 
served. By intratrachael insufflation of the mixture 
a dog may be kept alive in the profound zone for 
half an hour. ^lan may be carried in the deep 
zone if the tidal volume be large and no asphyxial 
obstruction or thoracic fixation presents, yet the 
margin of safety is small. 

The Medium Zone: The percentage of mixture, 
even in this zone is advisable only for the first 
few minutes of induction, as the zone yields an un- 
desirable degree of asphyxia characterized by a 
slight cyanosis, occasionally muscular rigidity, by 
stertor, and by cardio-vascular strain. Some an- 
esthetists utilize the physiologically disadvantageous 
asphyxia of this zone erroneousl}- for additional de- 
gree of relaxation in resistant subjects. Relaxation 
cannot be secured in this zone in resistant subjects, 
but can only be secured by raising the percentage 
of oxygen and by supplemental narcosis ; such nar- 
cosis as is attained by a small addition of ether. 

The Light Zone: This is the one of greatest 
utility for abdominal surgery. The perfect relaxa- 
tion of the hydrocarbon anesthetics is never pres- 
ent. Reflex muscular and respiratory reaction to 
trauma is always evident unless blocked by local 
analgesia or by a more effective general anesthetic 
such as small doses of ether or a large dose of 
morphine. 

The Very Light Zone: This is the desirable one 
for surface surgery such as amputation of the 
breast. Both this and the subconscious zone may 
serve for all degrees of operative work when sup- 



42 



American Journal of Surgery 
Anesthesia Supplement 



CoNNELL — Nitrous Oxid-Oxygen Dosage. 



January, 1915. 



plemented by ether. In fact these are the ideal 
zones physiologically, since in these zones the blood 
pressure is not raised, the color is normal or even 
rose pink, the breathing is not exaggerated and 
there is no asphyxia present. 

On the usual volume of delivery of from eight 
to ten litres of gases per minute, the percentages 
of oxygen in the gases delivered must be about 
two per cent, higher than that charted in Figure 
1 on account of dilution with expired gases from 
which the oxygen has been in part absorbed. In 
patients who are anemic or toxic from disease or 
whose respiratory volume is small, or who have 
diminished blood flow, a higher percentage of oxy- 
gen is required to maintain the same oxygenation 
of the tissues. The percentages of oxygen needed 
in the inspired gases is approximately in direct ratio 
to the degree of anemia, or intoxication. For ex- 
ample, a patient with 50 per cent, hemoglobin or 
half the normal oxygen-carrying capacity requires 
for the zone of light anesthesia 18 to 20 per cent, 
of oxygen in the tidal volume of respiration, in- 
stead of the 11 per cent, mixture required by nor- 
mal man. 

The stimulus of operative trauma elevates the 
blood pressure 10 to 30 millimeters in all zones, 
even in the zone of profound anesthetic-asphyxia. 
Nitrous-oxid has not the slowly induced ether ef- 
fect in blocking efferent sensations of the somatic 
nerves by direct action on the nerve ends. Nor 
does it compare in efficiency as to central nerve cell 
•disassociation with full ether anesthesia. The maxi- 
mum nitrous-oxid effect is about equivalent to 
the ether eft'ect obtained by 30 millimeters of ether 
tension. Whereas full anesthesia under ether with 
complete disassociation of all the central nervous 
system from the great primative medullary centres 
is accomplished by 50 to 52 millimeters of ether 
tension in the central nervous system as has been 
shown in the anesthetic tension investigations of 
Boothby. Therefore, nitrous-oxid provides no zone 
which protects against harmful stimuli of opera- 
tive trauma as do the hydrocarbon fat-solvent an- 
esthetics. Nitrous-oxid should therefore be em- 
ployed only with the gentlest manijuilation of tissue 
by the operator, or where there is supplemental 
blockage of centripetal stimuli by local analgesia or 
by a more effective general anesthetic such as ether, 
or deep narcosis by morphine or scopolamin. 

quantitative dosage. 

A consideration of dosage would be incomplete 

where a large avenue of excretion has been utilized 

and in part blocked, were not also the refreshing 

of the dose considered. In practice it is found that 



a re f resiling of the gas at a rate about equivalent 
in bulk to the normal tidal volume suffices. I have 
never observed any ill effects from exceeding this 
rate, such as are alleged to arise from over-excre- 
tion of carbon dioxid. Excessive volume, however, 
is monetary waste. 

A satisfactory level of anesthesia cannot be main- 
tained unless the gaseous excrements such as carbon 
dioxid are washed out at a comparatively normal 
rate. No smoothness of anesthesia can be main- 
tained on less than six litres per minute, and, in 
fact, 8 litres per minute (120 gallons per hour) 
should be placed as the minimal delivery, or to 
active individuals 10 litres per minute. The in- 
terrupted flow method, as set forth by Gatch and 
others, suffices for unconsciousness with intervals 
of exaggerated breathing (unless the respiratory 
center is desensitized by morphin), together with 
moments of asphyxia ; but to maintain a definite 
level of anesthesia the supply of gases should be in 
continuous flow by the Boothby, or Teter method. 

The working method which I prefer is to set 
the nitrous-oxid flowing through a Connell instan- 
taneous gas flow gauge, at the rate of 8 litres per 
minute, the oxygen is set to ^ litre per minute for 
induction. As soon as slight cyanosis appears, the 
oxygen is raised to 1 litre and in about 5 minutes 
to 1J4 litres. After 15 minutes it can usually be 
raised to lyi litres per minute. If the patient is 
one requiring larger percentage of oxygen in the 
tidal air to establish anesthesia in the proper zone, 
this fact is promptly evident and the oxygen is 
increased. Rarely is more than 2 litres of oxygen 
per minute required. 

NITROUS-OXID anesthesia ADJUVANTS. 

Owing to the intrinsically light character of 
nitrous-oxid oxygen anesthesia as previously stated, 
it must usually be supplemented for general surgery 
by alkaloidal narcosis or light ether anesthesia or 
both. Morphin with atropin or hyoscin is the rec- 
ognized alkaloidal adjuvant. Without these ad- 
juvants it is impossible to hold in surgical anes- 
thesia robust, athletic individuals, and those of al- 
coholic, tobacco, and other narcotic habits without 
dangerous degrees of asphyxia. 

ALKALOIDAL NARCOSIS SUPPLEMENTAL TO NITROUS- 
OXID. 

Preliminary alkaloidal narcosis renders the 
course of nitrous-oxid anesthesia smoother, in- 
creases the depth of anesthesia, allows an increase 
of 1 to 3 per cent, in the oxygen percentage, and 
renders the necessity for ether less frequent. How- 
ever, these narcotics desensitize the respiratory cen- 
ter and increase the danger of respiratory collapse 



Vol. 1. No. 2. 



CoNNELL — Nitrous Oxid-Oxygen Dosage. 



American Journal of Surgery 
^Anesthesia Supplement 



43 



from asphyxia. Scopolamin or hyoscin also occa- 
sionally exercise rapid, powerful depression on the 
circulatory mechanism. Indeed, I can name a dozen 
surg-ical and medical associates who, working amid 
the human derelicts of the large New York hos- 
pitals, have seen this drug in their individual ex- 
periences, administered in recognized therapeutic 
dose, kill like the blow of a slaughter-house sledge. 

ETHER ANESTHESI.\ SUPPLEMENTAL TO NITROUS- 
OX ID. 

By proper combination of ether with nitrous- 
oxid the best points of both of these anesthetics 
may be secured. By combining the very light or 
the subconscious zone of nitrous-oxid anesthesia, 
11 to 14 or 14-16 per cent, of oxygen, with the 
light subconscious zone of ether anesthesia, a vapor 
pressure of 15 to 25 millimeters, a physiologically 
ideal state of general anesthesia may be induced, for 
the light transitory anesthesia of nitrous-oxid is se- 
cured, together with the relaxation, sensory nerve- 
end paralysis and post operative analgesia of ether. 
The asphyxial zones of nitrous-oxid may be avoided 
on the one hand, while on the other there is no 
such concentration of ether vapor as actively stimu- 
lates mucous secretion in the bronchi, the dosage 
remaining well below the disassociation level of the 
vomiting center, present at about 25 m.m. of ether 
tension, nor do the after effects exceed those of 
unsupplemented nitrous-oxid administration. 

TECHNic /.• Supplemental A^arcosis by ether 
when required. At any time during the course of 
nitrous-oxid oxygen anesthesia, when it becomes 
necessary to secure more efficient anesthesia or to 
establish relaxation, the administration of ether is 
desirable. This is a far safer procedure than to 
persist in attempting to subdue the patient by un- 
supplemented nitrous-oxid anesthesia, by reducing 
the oxygen supply. 

About 86 millimeters of ether vapor pressure, 65 
drops of ether per gallon of gas. is necessary to es- 
tablish an efficient state of anesthesia within rea- 
sonable time, from 3 to 5 minutes. When relaxa- 
tion is secured, the ether is discontinued or re- 
duced to minimal dosage, 20 m.m. of vapor pres- 
sure or 15 drops of ether per gallon of gas. 

TECHNIC ^: Routine Relaxation by Ether Vapor. 
The patient is primarily anesthetized by nitrous- 
oxid oxygen. Ether is now slowly added increas- 
ing the vapor pressure to about 86 millimeters by 
adding about 65 average size drops of ether for 
each gallon of gas, usually two drops per second. 
At the same time the oxygen percentage may be 
increased to 12 per cent. When anesthesia is com- 
plete and general relaxation has been established. 



usually within 6 minutes, the anesthetic state may 
be readily continued by nitrous-oxid oxygen alone, 
usually without further recourse to ether. 

TECHNIC J.- Routine Relaxation by Oil-Ether 
administered by Rectum. The metliod of Gwath- 
mey would seem one of great future ]5romisc, 
namely, very light preliminary ether narcosis by 
rectal administration of small dose of a weak oil- 
ether mixture. To obtain the desirable menial con- 
fusion or subconsciousness and the analgesia and 
relaxation of the light subconscious zone of ether 
anesthesia, 15 to 2S m.m. of ether tension; prob- 
ably a mixture of ether 50 per cent, in oil, half 
an ounce to each 20 pounds of body weight will 
suffice administered by the Gwathmey rectal 
method, J^ hour before operation. 

TECHNIC -/.■ Routine Combination of Ether Nit- 
roHs-Oxid Anesthesia. The Best Method. By 
starting the administration of ether immediately in 
nitrous-oxid administration, adding less than 22 
drops of ether per gallon of gas, the dosage of 
ether vapor may be kept constantly below 30 milli- 
meters of ether vapor pressure. The oxygen con- 
tent in the tidal gas may be gradually increased 
to 15 per cent. Thus the safest, most satisfac- 
tory state resultant from any general anesthetic is 
obtained : a state combining the light subconscious 
zone of both ether and nitrous-oxid into one of 
deeper yet controllable anesthesia. A proper ether 
flow is a drop every two seconds for the first half 
hour ; thereafter a drop every three seconds. The 
gases are best delivered continuously, 9 to 10 litres 
per minute. Thirty grams of ether per hour and 
150 gallons of gases should be used. 

SUMMARY AND CONCLUSIONS. 

1. The eti'ect of a given nitrous-oxid-oxygen 
mixture is constant on normal man. 

2. The anesthetic effect is in a degree inversely 
as the proportion of oxygen. 

3. The ultimate gas tension which the drug es- 
tablishes is not at present an available gauge of 
dosage. 

4. The only available gauge of qualitative dosage 
is the proportion of oxygen with which the drug 
is administered. 

5. The action may be differentiated into con- 
secutive levels or zones of anesthesia, according to 
the average amount of oxygen present in the tidal 
gases. For analgesia in normal man the propor- 
tion of oxygen in the tidal gases of breathing may 
exceed 20 per cent. Below this the consciousness 
becomes gradually abolished until at 16 per cent, 
the patient slowly becomes unconscious. From 14 



44 



American Journal of Surgery 5j.pp COMBINED ANESTHESIA FOR HEMORRHOIDS. 

Anesthesia Supplement 



January, 191S. 



to 11 per cent, there is sufficient anesthesia for 
surface operations; from 11 to 8 per cent, there 
is sufficient anesthesia for abdominal surgery, asso- 
ciated, however, with slight asphyxia and without 
proper muscular rela.xation. Below 8 per cent, 
the mixtures are useful only for induction of an- 
esthesia, and below 6 per cent, they become so 
highly asphyxial that tliey should not be used even 
for tooth e.xtraction. 

6. Higher percentage of oxygen is required 
when the tidal volume is below the average, or the 
oxygen-carrying capacity of the blood is dimin- 
ished. 

7. At least 6 litres of fresh gases per minute 
are required for smooth anesthesia and to estab- 
lish normal excretion of carbon dioxid and other 
gaseous waste products; preferably 8 to 10 litres 
per minute of a uniform mixture is supplied in a 
continuous flow. 

8. By continuous flow and known dosage with 
accurate and constant measurement and control the 
level of each patient may rapidly be found, and 
after the first 15 or 30 minutes anesthesia may 
run continuously without further adjustment. 

9. Unsupplemented nitrous-oxid-oxygen anes- 
thesia is ineffective to block the centripetal stimuli 
of operative trauma. 

10. Nitrous-oxid-oxygen anesthesia is most ad- 
vantageously supplemented by ether. 

11. Light ether anesthesia, the light subcon- 
scious zone of ether, a tension of 15 to 25 m.m. in 
conjunction with the subconscious or light subcon- 
scious zones of nitrous-oxid-oxygen anesthesia, 
14-16 or 16-20 per cent, of oxygen is physiologically 
the most advantageous of all anesthetic states. 

12. Owing to present complexity and inaccuracy 
of administration, the average nitrous-oxid anes- 
thesia, even when effectively supplemented, pos- 
sesses no practical advantage over properly induced 
and well-maintained ether anesthesia. 

Roosevelt Hospital. 



THE ADVANTAGES OF COMBINED ANES- 
THESIA IN THE OPERATIVE TREAT- 
MENT OF HEMORRHOIDS.* 
Isadore Seff, M.D., 
Adjunct Attending Surgeon, Beth Israel Hospital, 
New York. 



FEATURES IN THE AP RIL SUPPLEM ENT 

RESLLSCITATION IN THREATENED 

FATALITIES DURING GENERAL 

ANESTHESIA. 

E. H. EMBLEY, M.D., M.R.C.P., 

Melbourne, Australia. 

KIDNEY FUNCTION IN ITS RELA- 
TIONS TO GENERAL ANE.STHESIA. 

JAMES J. HOGAN, M.D., M.R.C.P., 

San Francisco, Cal. 

PROCEEDINGS OF THE SCOTTISH 
SOCIETY OF ANESTHETISTS. 



Routine operative methods that have been de- 
vised for the treatment of external and internal 
hemorrhoids under local or general anesthesia are 
invariably followed by post-operative pain and dis- 
comfort entirely out of proportion to the gravity 
of the condition. 

To operate under local anesthesia in rectal cases 
is usually a tedious procedure, and in a majority 
of the cases is accompanied by severe pain. Under 
general anesthesia graver difficulties are experi- 
enced, especially during dilation of the sphincter. 

A large number of sufferers with hemorrhoids 
refuse operation, not on account of the length of 
time necessary for a cure, but because of the severe 
pain and discomfort tliat persist for several days 
after the operation. 

It is the object of this paper to outline a method 
that not only eliminates [)ost-operative pain, but 
also accomplishes relaxation of the sphincter zt'ith- 
out manual dilatation. It excludes all difficulties 
in the administration of the general anesthetic; the 
patient's color remains good and the breathing reg- 
ular throughout the entire operation. 

NERVE SUPPLY OF THE ANAL REGION. 

In order to better understand the method used 
in accomplishing the foregoing results, a brief re- 
view of the nerve supply of the anal region is 
necessary. .' .'> 

The nerves supplying the anus are derived from 
both the cerebro-spinal and the sympathetic nervous 
systems. Those originating from the former come 
from the fourth sacral nerve, and those from the 
latter from the hypogastric plexus. The muscles 
of the anal region are supplied by branches of the 
sacral nerves, while the superficial perineal branch 
of the internal pudic supplies the levator ani and 
skin in front of the anus, antl the inferior hem- 
orrhoidal branch inervates the lower end of the 
rectum and anus. 

It can readily be seen that since the anus is sup- 
plied by the fourth sacral nerve and the branches 
of the internal pudic. severe local pain and wide 
distribution of reflex pain will be experienced as 
the result of operative trauma. Because of the 
close nervous association between the anus and 
the outlet of the bladder, we note, on the one 



•From the surgical .service oT Dr. Chas. Gnodm;in. 



Vol. 1, No. 2. 



Seff— Combined Anesthesia for Hemorrhoids, •'^"'ya.cria'su'ppiemenf"'' 



45 



hand, the frequent desire to urinate as a result of 
anal irritation and, on the other hand, temporary 
retention of urine due to the vesical spasm that 
follows trauma to the anus. 

DIFFICULTIES UNDER ANESTHESIA. 

In the usual operations for hemorrhoids under 
general anesthesia, we have all seen how difficult 
it is to keep the patient fully relaxed and in a 
safe plane of surgical narcosis. As soon as dilata- 
tion of the sphincter is begun, the patient becomes 
cyanosed and the breathing stertorous. Not infre- 
quently at this time we witness struggling of the 
patient on tlic table, due to reflex cerebral stimula- 
tion. 




manipulation would have no elTect upon the course 
of the anesthesia, nor would the patient be sub- 
jected to the markedly severe pain and discom- 
fort that always follow operations for hemorrhoids. 
With these objects in view I have utilized the prin- 
ciples of Crile's method of anoci-association anes- 
thesia. 

THE NEW METHOD OF COMBINED ANESTHESIA. 

The method that has been practiced in a series 
of 16 cases is as follows: The preparation of the 
patient is the usual method of thoroughly evacu- 
ating the bowels. Three-quarters to one hour be- 
fore the induction of general anesthesia, a hypo- 
dermatic injection of morphine sulphate 1/6 of a 



Fig. 1. — Case 13. Showing anus before injection. 

Dilatation of the sphincter is often completed too 
rapidly, and as a result of this unnecessarily rough 
manipulation the mucous membrane is torn and 
very frequently a hematoma is produced in the 
rectal wall. Tears in the mucous membrane may 
become the focus of infection, or give rise to fis- 
sures. Hematomas, ultimately, may cause ulcera- 
tion of the rectal mucous membrane by pressure, 
with continual bleeding or late secondary hemor- 
rhage. 

The excruciating post-operative pain usually per- 
sists for 24 to 72 hours. Temporary retention of 
urine almost always occurs, so that catheterization, 
with its attendant dangers, becomes necessary. 

Realizing that the anal region has been endowed 
•with a large nerve supply, it occurred to me that if 
I could obtain complete relaxation of the sphincter 
without manual dilatation and block oflf the nerve 
impulses during the operative procedure, then the 




Fig. 2. — Case 13. Showing the amount of relaxation of the anal 
opening after the injection of novocain and quinine and urea 
hydrochloride. Allison forceps in position. 

grain and atropine sulphate 1/150 of a grain is 
given. Ether by the open drop method is the anes- 
thetic used. The patient is never placed in the 
lithotomy position until well under the effects of 
the narcotic. The skin area about the anus is 
painted with a three and a half per cent, solution 
of tincture of iodine. Four points are selected 
about the circumference of the anus, one-half to 
three-fourths of an inch from the muco-cutaneous 
junction, corresponding to 12, 3, 6 and 9 on the 
dial of a clock. A solution containing two parts 
of a one-half per cent, solution of novocain and 
one part of a 1/600 solution of quinine and urea 
hydrochloride is injected into the internal sphincter 
of the anus at each point. The course of the needle 
is guided with a finger in the rectum, so that one 
may be absolutely certain that the needle is in the 
sphincter and not in the lumen of the bowel. 



46 



''''"^Anesth°s'iI"sUtlem'/nf''''^''-''''— '^Q^^I^'ED ANESTHESIA FOR HEMORRHOIDS. 



January, 1915. 



Almost immediately after the .solution is injected 
the guiding finger feels the sphincter relax. After 
waiting a minute or two it is possible to insert the 
breadth of four fingers into the anal opening with- 
out any resistance whatever. Also there is no re- 
flex contraction of the sphincter. The hemorrhoids 
are very readily rolled into view, by placing four 
Allison forceps at opposite points at the muco- 
cutaneous junction, as seen in Figures 2 and 4. The 
hemorrhoids are thus easily exposed and whatever 
method is selected for their removal can be prac- 
ticed without any difficulty. I have used the clamp 
and cautery method without putting either a tube 
or packing into the rectum. The average amount 





o 



ing the anesthetic fifteen to twenty minutes be- 
fore completion of the operation. On recovery 
from the effects of the anesthetic fifty per cent, 
of the patients have been entirely free from post- 
operative pain, according to our charted results. 
The remaining number have required but one dose 
of an hypnotic throughout the entire post-operative 
period. 

PROLONGED OBTRUDING EFFECT OF QUININE ..\ND 
UREA. 

I attribute the prolonged relaxation of the sphinc- 
ter and the absence of the post-operative pain to 
the continued anesthetic effect of the quinine and 




l-'ig. 3. — Case 16. Shows ami- ait-l hL-ninn li.ii.ls before injection. 



Fig. 4. — Case 16. Shows relaxation of the anal opening, and 
liemorrhoids brought into view, after the injection of tlie novo- 
cain and quinine and urea hydrochloride. 







Chart: 


Combined Anesth 


esia in the 


Operative Treatment of Hemorrhoids. 




Case 


Discharge 


Date of 


Date of 


Date of 


Internal or 


Hypnotic 


Cathet- 


No. 


Number • 


Admission 


Operation 


Discharge 


E.xternal Piles 


Given 


erized 


1 


118" 


3/31/14 


4/3/14 


4/10/14 


int. 


none 


no 


2 


\22i 


4/10/14 


4/11/14 


4/16/14 


ext. 


none 


no 


3 


1246 


4/13/14 


4/15/14 


4/19/14 


int. 


none 


no 


4 


1264 


4/13/14 


4/15/14 


4/22/14 


both 


once 


no 


5 


1358 


5/1/14 


5/2/14 


5/8/14 


int. 


once 


no 


6 


1418 


5/10/14 


5/11/14 


5/16/14 


ml. 


once 


no 


7 


1490 


5/17/14 


5/18/14 


5/25/14 


both 


none 


no 


8 


1535 


5/18/14 


5/20/14 


6/1/14 


int. 
anemia 


none 


no 


9 


1538 


5/26/14 


5/27/14 


6/1/14 


int. 


once 


no 


10 


1614 


6/3/14 


6/3/14 


6/10/14 


both 


once 


no 


n 


1629 


6/2/14 


6/3/14 


6/12/14 
7/9/14 


int. 


once 


no 


12 


1832 


7/6/14 


7/7/14 


both 


none 


no 


ij 


1847 


7/13/14 


7/15/14 
7/7/14 


7/25/14 


int. 


none 


no 


14 


1864 


7/6/14 


7/14/14 


both 


once 


no 


15 


1878 


7/7/14 


7/8/14 


7/17/14 


both 


once 


no 


16 


1962 


7/24/14 


7/25/14 


7/28/14 


ext. 


none 


no 





of novocain and quinine and urea hydrochloride so- 
lution used was 15 to 20 c. cm. for each case. The 
patients maintain a good color and breathe quietly 
throughout the operation. The amount of ether 
used in each case has been one-third to one-half the 
amount necessary under general anesthesia alone. 
In a number of the cases we have discontinued giv- 



urea hydrochloride, and furthermore, I feel assured 
it is this agent that blocks the impulses that cause 
reflex spasm of the neck of the bladder. In our 
entire series of cases all patients have voluntarily 
urinated, showing that the method eliminates the 
danger of infection of the bladder by catheteriza- 
tion. 



Vol. 1, No 



LiEB — Postoperative Smock. 



American Journal of Surgery' 
Anesthesia Supplement 



47 



For purposes of comparison, I have operated on 
four cases for hemorrhoids under purely local 
analgesia, using the solution of two parts of a one- 
half per cent, novocain and one part of the 1/600 
quinine and urea hydrochloride, and injecting this 
solution into the sphincter ani in the same manner 
as with the method of combined anesthesia. Al- 
though perfect relaxation of the sphincter is ob- 
tained, and the cautery causes no pain, it is never- 
theless a very tedious procedure to keep entirely 
within the bounds of the analgeric area. The in- 
jection into the sphincter renders the skin area 
analgesic only for a short distance around the muco- 
cutaneous junction of the anus. The pain from 
the insertion of the needle into the sphincter is 
severe in itself. Only two of these four cases 
urinated voluntarily, and all received more than 
one hypodermatic injection of morphine. With 
combined anesthesia we have entirely eliminated the 
necessity for catheterization in every case, and 
when an hypnotic was necessary one dose sufficed. 

ADV.\XT.-\GES OF THE COMBINED METHOD. 

The disadvantages of both local analgesia or gen- 
eral anesthesia are entirely overcome by the com- 
bined method. The advantages of this method 
may be summed up as follows : 

1. Aiicstliesia. Profound anesthesia is not neces- 
sary to secure the proper relaxation of the sphincter. 
Untoward symptoms such as cyanosis and stertor- 
ous breathing are entirely eliminated. The amount 
of general anesthetic used is reduced from one-half 
to one-third that required under general anesthesia 
alone, and therefore post-anesthetic general se- 
quelae are reduced to a minimum. 

2. Exposure of Hemorrhoids. The ease with 
which the hemorrhoids are brought into the field 
of operation eliminates unnecessary manipulative 
trauma, and its direct and indirect complications. 

3. Post-operatk-e Pain. Fifty per cent, of the 
patients are without pain after the operation: while 
the pain in others is reduced, so that but one dose 
of an hypnotic is necessary to carry them through 
the entire post-operative period. 

4. Post-operative Catheterization. Since ca- 
theterization, even under the strictest aseptic pre- 
cautions, is attended with the dangers of trauma to 
the urethra, infection of the bladder and even 
ascending infection of the urinary tract, the re- 
moval of this danger alone establishes the great 
value of the combined method of anesthesia in the 
operative treatment for hemorrhoids. 

1945 Seventh Ave. 



TREATMENT OF POST-OPEKATUE 
SHOCK.* 

Bv Prof. Ch.\rles Lieu, 
Coluiiilna University. 

New York City. 



The successful prevention and treatment of shock 
.depend uj)on an accurate conception of its nature 
and causation. Numerous theories have been of- 
fered to explain the phenomena of shock, but when 
put to the clinical lest they have all proved disap- 
pointing. Thus, the vasomotor center is not ex- 
hausted ; the heart is not primarily involved ; acap- 
nia is not necessarily present ; oligemia is not 
usually demonstrable ; over-inhalation has not been 
proved : adrenal insufficiency is not generaly ad- 
mitted; the disappearance of the Xissl bodies from 
the cells of the cerebellum and the region of the 
fourth ventricle is not constant. 

Despite the painstaking and brilliant investiga- 
tions which have been made in the attempt to solve 
the problem, we know little or nothing about the 
nature of shock. \\"e have learned, however, the 
direct exciting cause of shock. In the last analysis, 
shock is always due to afferent impulses — impulses 
which may arise at the periphery or within the cen- 
tral nervous system itself. It is upoti this scant 
foundation that the treatment of shock must be 
built. 

The prophylatic treatment has been so carefuly 
perfected by Crile and has proved so successful 
when properly carried out, that it need not detain 
us. The one essential is the prevention of the 
development, or at least of the transmission, of 
noci impulses. 

The treatment after shock has once developed is 
governed by the same principles. The wound or 
injury should be physiologically isolated from the 
central nervous system by means of cocaine, novo- 
caine, or urea-quinine hydrochloride, and mental 
anxiety allayed by the use of morphine. The im- 
portance of thus staying the further progress of 
shock cannot be overemphasized. 

The relation between afferent impulses and 
shock is so firmly established that no plan of treat- 
ment is worthy of consideration that does not in- 
clude protection of the central nervous system from 
incoming stimuli. The further treatment of shock 
is more difficult, more unsatisfactory, more per- 
plexing. The symptoms are familiar, but nothing 
is known of the pathological changes of which these 
symptoms are the clinical expression. We can 



*Read during the Second Meeting of the .\mericaa Associatioa 
of .Anesthetists, at .-Mlantic City. June 22, 1914. 



48 



American Journal of Surgery 
Anesthesia Supplement 



LiEB — Postoperative Shock. 



January, 1915. 



treat the symptoms, but the utter uselessness of 
such therapy is only too often apparent. 

Because the circulation is easily studied, undue 
prominence has been given to pulse rate and blood 
pressure. It is generally admitted, however, that 
neitlier the blood itself, nor the heart, nor the vaso- 
motor center is the primary cause of shock. In- 
deed, the patient may be in profound shock and yet 
heart rate and blood pressure may be normal. Nev- 
ertheless, treatment, as ordinarily carried out, con- 
sists essentially of circulatory stimulation. 

Since the treatment of shock is purely sympto- 
matic, the measures employed should be at least 
harmless; that is, they should neither aggravate the 
symptoms nor intensify the degree of shock. This 
is the test to which the therapy of sliock must be 
submitted. All measures that fail to meet this 
standard are certainly contraindicated. 

The retlex stimulants form the first group of 
drugs to which I wish to call your attention. The 
group includes the "refle.x stimulants" in the nar- 
rower sense, as well as alcohol, ether, and the nu- 
merous proprietary preparations which have alco- 
hol or glycerine as solvents. Before absorption, any 
effect which they roduce is of reflex origin. By 
their direct irritation of the nerve endings, with 
which they come into contact, they initiate a stream 
of centrifugal impulses; these reaching the central 
nervous system, produce changes identical with 
those arising in a wound or injury. Qualitatively, 
these impulses are as shock-producing as any other 
afferent impulses. 

Camphor should also be included in this group. 
It, too, is a local irritant, and the effects which fol- 
low its injection are partly reflex and partly cen- 
tral in their origin. The stimulation of the central 
nervous system is subordinate to the local action, 
and camphor is as much contradindicated as any 
other irritating drug. 

Not only are all shock-producing drugs contra- 
indicated, but that group which facilitates the trans- 
mission of impulses within the central nervous sys- 
tem must also be avoided. 

So much has been written about the danger of 
using strychnine in the treatment of shock that it 
is not necessary for me to condemn it further. I 
wish, however, to remind you of the way in which 
strychnine acts upon the central nervous system. 
It opens new paths along which the afferent im- 
pulse may travel freely up and down the cord, af- 
fecting an abnormally large number of cells. The 
response to a given stimulus is therefore stronger 
and more widespread than normal. A subminimal 
impulse becomes effective. In other worcls, it may 



be said that strychnine increases the force of each 
afferent stimulus by raising the shock-value of the 
impulse and by lowering the shock resistance of the 
individual. 

Caffeine, however, is said to have a proper place 
in the therapeutics of shock. When it is remem- 
bered that caff'eine has the same effect upon the 
cord as strychnine, its position immediately be- 
comes untenable. Stimulation of the psychic areas, 
an important function of caffeine, tends to arouse 
the patient and to add psychic shock to the existing 
surgical shock. It may be claimed that the circu- 
latory stimulation outweighs the disadvantage con- 
sequent on stinuilation of the central nervous sys- 
tem. Caffeine, however, has not proved a powerful 
circulatory stimulant, and no marked benefit can 
be expected from its administration. Large doses 
possess all the disadvantages of strychnine and 
probably e.xert, in addition, a depressant action 
upon the heart. 

The use of hot black coffee in the form of an 
enema is so frequently recommended that an analy- 
sis of its action may prove of value. The effect is 
due partly to the caff'eine ; more important are the 
empyreumatic oils, the pint of water, and the heat. 
Any action of the aromatic oils will be the result of 
a reflex, a method of treatment that has already 
been condemned. The hot fluid, which is the only 
advantage possessed by coffee over strychnine, can 
be administer to much better purpose in the form 
of a luit saline irrigation. 

In discussing the drugs which act directly upon 
the circulation, we may consider first those which 
lower blood pressure. These may be divided into 
the cardiac depressants and the arterial dilators. 

Aconite and veratrum viride are the most impor- 
tant members of the first group. They lower blood 
pressure by slowing and depressing the heart. If 
shock were due to acceleration of the heart — as has 
been claimed — these drugs would be indicated, de- 
spite the fall in blood pressure which they produce. 
The acceleration of the heart, however, is the man- 
ifest:ition of the attempt on the part of the heart 
to maintain an efficient circulation, and any slow- 
ing thereof is reflected in a slowing of the circula- 
tion — a reaction which is most certainly undesirable. 

The nitrites lower blood pressure by dilating the 
blood vessels. The most serious symptom of shock, 
from a prognostic point of view, is a low blood 
pressure, and any attempt to lower that blood pres- 
sure further regularly results in deepening the de- 
gree of shock. We conclude, then, that no drugs 
that lower pressure are called for. 

Of the drugs which raise blood pressure, epi-" 



Vol. 1, No. 2. 



LiEB — Postoperative Shock. 



American Journal of Surgery 
Anesthesia Supplement 



49 



nephrin, piiiiitiiii, and possibly strophanlliiii, are 
tlie most important. The snbcutaneous or intra- 
venous injection of atropine is frequently followed 
by a rise in blood pressure, the extent of which 
varies directly with the tonus of the vagal center. 
Only when the tonus is such that the heart is beat- 
ing slowly does atropine produce a considerable 
rise in blood pressure. The rise is secondary to 
the augmented output of the accelerated heart and 
not to vasomotor stimulation. In shock, vagal tonus 
is slight or absent. The heart has escaped from 
vagus control, and one neither expects nor finds a 
rise in pressure after atropine. 

Clinically, epinephrin has proved to be the most 
efficient drug in combating the low blood pressure 
of shock. The method of administration is ex- 
tremely important. Neither subcutaneous or intra- 
muscular injection is followed by the slightest rise 
in pressure. Only when the drug is injected 
directly into a vein are the vessels constricted. 

The injection of a few minims of epinephrin is 
followed by a very small, evanscent rise in pres- 
sure. In order to obtain a more marked and more 
prolonged eitect, the drug must be given in con- 
junction with a saline infusion. The rise in blood 
pressure outlasts the infusion but a very few min- 
utes. It is necessary, therefore, to be sparing both 
of the saline and of the epinehprin. The free use 
of the salt solution soon leads to hydremic ple- 
thora and the heart becomes embarrassed. If too 
much epinephrin is employed, the rise in blood pres- 
sure becomes excessive and the work of the heart is 
unnecesharily increased. Accordingly, the epi- 
nephrin-saline infusion is continued until blood 
pressure is approximately normal. The infusion is 
then interrupted, to be resumed when the blood 
pressure falls dangerously low. 

In the laborataory, at least, pituitary extract has 
a distinct advantage over epinephrin. The rise in 
blood pressure which follows its intravenous injec- 
tion is maintained for hours rather than minutes. 
Like epinephrin, the subcutaneous or intramuscular 
injection of pituitrin is not followed by any im- 
provement in the circulation. This effect is pro- 
duced only when the drug is given intravenously, 
and may be increased by the simultaneous admin- 
istration of a saline infusion. The side effects on 
urinary secretion and on the intestine are inde- 
pendent of the effect on blood pressure. 

Clinically, the drug has proved somewhat disap- 
pointing and is not employed so frequently as a 
few years ago. 

The digitalis preparations when administered by 
mouth affect the circulation only after the elapse 



of from twenty-four to forty-eight hours. This 
prolonged latent period precludes their oral admin- 
istration in the treatment of shock. 

None of the official or proprietary preparations 
is fit for intravenous injection. Hence, if a digi- 
talis effect is desired, strophanthin should be em- 
ployed. Administered in doses of not more than 
1 mg. in twenty- four hours it produces within half 
an hour a considerable slowing and strengthening 
of the heart and a rise in blood pressure. This 
effect frequently persists for eighteen hours. The 
value of this drug as a circulatory stimulant has 
not been recognized by the surgeon. 

Of the mechanical means of raising blood pres- 
sure, gravity is of the utmost importance. The 
head-down position assures a fair blood supply to 
the higher divisions of the central nervous system 
and materially assists the return of the blood to 
the right heart. The saine advantages may be ob- 
tained by the use of pressure, particularly when 
applied to the limbs and abdomen. 

The quantity of fluid within the blood vessels 
can be increased, temporarily at least, by a saline 
infusion. A far better method is to transfuse, be- 
cause the rise in pressure is much longer main- 
tained. 

The betterment of the circulation which follows 
any of these procedure leads to improved nutrition 
of the central nervous system and all the other or- 
gans, and frequently assists in the recovery of the 
patient. Again I wish to emphasize that circu- 
latory failure is only one of the symptoms of shock 
and is rarely the direct cause of death. Probably 
90 per cent, of the cases die from respiratory 
paralysis. 

Whether the respiratory failure is due to the 
asphyxia secondary to the low blood pressure, or 
whether it is due to the absence of the normal hor- 
mone, has not been determined. It is necessary, 
therefore, to maintain a fairly efficient circulation 
and to conserve or administer carbon dioxide dur- 
ing shock. 

What drugs may be used to stimulate the re- 
spiratory center? 

Measured by the standard already set, drug stim- 
ulation of the respiratory center is limited. It has 
already been shown that neither reflex stimulation 
nor caffeine nor strychnine may be employed. Atro- 
pine is probably the only drug which may be used. 
I venture to suggest that even this drug is contra- 
indicated because further investigation will prob- 
ably prove that its action on the central nervous 
system resembles closely that of strychnine or caf- 
feine. 



50 



American Journal of Surgery 
Anesthesia Supplement 



LiEB — Postoperative Shock. 



January, 1915. 



Surgical shock may be complicated by: 

(1) Hemorrhage. The only modification of the 
treatment necessary is prompt restoration of the 
fluid lost, either by saline infusion or by a trans- 
fusion. 

(2) Toxemia, particularly that caused by the an- 
esthetic. Chloroform is a powerful ciculatory de- 
pressant and renders the patient more susceptible to 
surgical, traumatic, and hemorrhage shock. 

There are two forms of chloroform death, de- 
pending upon the strength of the vapor inhaled. 
Concentrated mixtures of chloroform and air para- 
lyze the heart and kill the patient before anesthesia 
is established. In these cases respiration continues 
after the heart has stopped. 

Very dilute solutions of chloroform and air cause 
a progressive lowering of blood pressure and weak- 
ening of the heart from the moment their inhala- 
tion is begun. When death occurs under these 
conditions it is due to respiratory failure ; the heart 
continuing to beat after breathing has ceased. 

The first type of chloroform poisoning may be 
prevented by avoiding the use of a too concentrated 
anesthetic mixture. If the heart has stopped, arti- 
ficial respiration should be at once instituted. The 
Sylvester method has the advantage that during 
the compression of the chest the heart is massaged 
and the chloroform-laden blood is expelled from 
its chambers. 

Chemical stimulation of the heart is absolutely 
necessary. The surest method of bringing a drug 
into direct contact with the cardiac muscle is by 
perfusing it through the coronary arteries. Ac- 
cordingly, an artery is exposed and a cannula is 
inserted pointing towards the heart. The saline 
infusion is then begun, and epinephrin is injected 
through the rubber tubing just above its connec- 
tion with the arterial cannula. The epinephrin- 
saline infusion is thus passed through the coronary 
arteries ; the closed aortic valves preventing its en- 
trance into the cavity of the left ventricle. This 
method of cardiac resuscitation is successful in 
about 30 per cent, of the cases. The chief difficulty 
is in estimating the quantity of epinephrin that is 
to be used. If too much is injected, it causes a 
powerful constriction of the blood vessels and a 
tremendous rise in blood pressure. The heart, al- 
ready weakened by the chloroform, contracts once 
or twice against this enormous resistance, then 
passes into fibrillation and permanent death. 

When chloroform causes respiratory failure, ar- 
tificial respiration is usually sufficient to revive com- 
pletely the patient. If necessary, an intravenous 



injection of epinephrin may be employed to support 
the heart. 

Ether rarely causes circulatory depression. 
Death after ether is always due to paralysis of the 
respiratory center, and should never be permanent. 
The heart continues to beat after breathing has 
stopped and its death is due to asphyxiation. Arti- 
ficial respiration and an intra-arterial infusion, such 
as was described under chloroform, will almost in- 
variably revive such a heart. 

SUMMARY. 

The treatment of shock as usually carried out is 
empiric. A rational treatment must be established. 
It must be based upon what has actually been 
learned about the causes and nature of shock. 
Shock is directly due to afferent impulses. The 
rational treatment of shock must therefore be 
directed against the exciting cause. The rest of 
the treatment is purely symptomatic. It must not 
increase, directly or indirectly, the susceptibility to 
shock. 

The rational treatment of shock comprises: Pro- 
tection of the central nervous system from aft'erent 
impulses, by (a) physiological isolation of the 
wound; (b) allaying mental anxiety by means of 
morphine. 

This shielding of the central nervous system, to- 
gether with the head-down position and the appli- 
cation of external heat, constitutes the nucleus, if 
not the whole rational therpay, of shock. It assists 
nature by working with her, and interpsoses no 
obstacle to recovery. If applied early this treat- 
ment will prevent the development of shock; if car- 
ried out after shock is present, it will assist in the 
recovery. A transfusion is unquestionably the 
most promising method for supporting the circula- 
tion. If a donor is not at hand, an epinephrin- 
saline infusion may be given. Since neither of 
these measures attacks the exciting cause of shock, 
too much cannot be expected of them. 

Carbon dioxide should be administered in the 
presence of a definite history of hyperpnoea. 

Under no circumstances are reflex stimulants to 
be employed. Caffeine, strychnine, cardiac depres- 
sants, and the nitrites are absolutely contraindi- 
cated. 

There is, I believe, a real danger in overdoing 
stimulation, so that we retard rather than assist the 
recovery of the patient. The only completely suc- 
cessful treatment of post-operative shock may be 
summed up in the word — prophylaxis. 

Columbia University. 



Vol. 1, No. 2. 



McKesson — Fractional Rebreathing. 



American Journal of Surgery 
Ancslliesia Supplement 



51 



FRACTIONAL REBREATHING IN ANES- 
THESIA—ITS PHYSIOLOGIC BASIS, 
TECHNIC AND CONCLUSIONS. 
By E. I. McKesson, M.D., 
Toledo, Ohio. 



Ill a preliminary report attention was called to 
this method in 1911. Since that time 1 have used 
the method continuously, and all cases have been 
charted as to the amount of rebreathing, the systolic 
and diastolic blood pressures, pulse rate, respiration 
rate and volume, the percentages of gas and oxy- 
gen used, and the quantity of ether used, when the 
latter has been employed as a supplemental anes- 
thetic. These determinations have been made prior 
to anesthetization in each case, and at five to ten- 
minute inten^als, or oftener, in some cases, through- 
out the entire period of anesthesia. 

HISTORICAL CONSIDERATIIONS. 

Since Priestly discovered nitrous oxid in 1772, it 
has been used to produce peculiar sensations and 
strange mental effects. For years after its dis- 
covery this property made it a popular means of 
entertainment quite similar to present day exhibi- 
tions of hypnotism. During these exhibitions on 
many occasions people fell and painlessly sustained 
injuries. As early as 1800 Sir Humphrey Davy 
suggested its use in surgery, but nothing was done ' 
clinically to clinch his opinion. 

Henry Hill Hickman, of Ludlow, Shropshire, 
England, between 1820-28, set about to discover 
some means of relieving pain during his operations. 
Experimenting on animals, he first produced semi- 
asphyxia by excluding air (by rebreathing CO„), 
and later by using NoO with success. He was not 
able to interest his profession at home or in Paris, 
however, and died in 1829 without applying his dis- 
covery to the human subject. 

Horace Wells, a dentist of Hartford, Conn., in 
July or August of 1840, in a conversation with 
Linus Brockett, M.D., said: "I believe a man may 
be made so drunk by this gas (nitrous oxid) or 
some similar agent, that dental or other operations 
may be performed upon him without any sensation 
of pain.'" Wells w^as already thinking about anes- 
thesia, and when Prof. C. Q. Colton four years 
later gave an exhibition with nitrous oxid in Hart- 
ford on the evening of December 10, 18-14, the oc- 
currence of another accident, in which one of the 
subjects was painlessly injured, further substan- 
tiated the opinion of Wells, who was one of the 
spectators at the exhibition and had also taken the 
gas. The next morning Wells conversed with Prof. 
Colton upon the subject of painless injuries, of the 



possibilities of nitrous oxid in dentistry, and sug- 
gested that Prof. Colton come to his office and ad- 
minister nitrous oxid to him while he had an upper 
third molar extracted under its influence. 

Accordingly the appointment was made. Dr. 
John M. Riggs was called to do the extraction, and 
quoting Dr. Riggs' own words: "Dr. Wells, after 
seating himself in the operating chair, took the bag 
and inhaled the gas, he threw back his head and I 
extracted the tooth. It was a large molar in the 
upper jaw, such as is sometimes called a 'wisdom 
tooth.' It required great force to extract it. Dr. 
Wells did not manifest any sensibility to pain. He 
remained under the influence of the gas for some 
time after, and immediately upon recovering from 
it he swung his arms and exclaimed : 'A new era 
in tooth pulling.' He remarked that he did not feel 
any pain from the operation." 

Wells was so certain of the nature of his dis- 
covery and fearless in its application that he. Dr. 
Riggs and other dentists at once began using nitrous 
oxid in their practices, and even went so far as to 
set apart a day when teeth would be extracted with- 
out pain. 

In an endeavor to bring his discovery of anesthe- 
sia to the notice of the medical profession at large, 
he went to Boston and gave a public demonstration 
on one patient. The result was unsatisfactory be- 
cause the gas bag was removed before the patient 
was thoroughly under. "The patient howled some- 
what during the operation, but on his return to 
consciousness, said he felt no pain whatever." 
Wells, however, was denounced as an impostor, al- 
though during this stay, at Boston he successfully 
anesthetized a group of medical students for their 
own instruction. 

The one case, usually referred to as a failure, 
especially by those who, a few years later, tried to 
rob Wells of the honor of having discovered anes- 
thesia, was not in reality a failure, nor did it retard 
the use of gas, which was soon employed in many 
places for operations of various kinds. 

It is noteworthy that Wells' apparatus consisted 
of only a large bag and a mouth tube to breathe 
through. The patient rested the bag of gas in his 
lap, took the tube into his mouth, and inhaled the 
gas while the nose w^as held with one hand. It is 
obvious, therefore, that the first application of gas 
as an anesthetic was by the rebreathing method 
since there were no check valves to prevent it. 

Wells had considered ether as an anesthetic, but 
on account of its odor and the nausea it produced, 
which were well known from the "ether frolics,"' 
common in those days as a means of entertainment, 



52 



American Journal of Surgery 
Anesthesia Supplement 



-McKesson — Fractional Rebreathing. 



January, 1915, 



he preferred nitrous oxid, which in his opinion was 
more like air and safer. 

Willi iru T. G. Morton, who had been a student 
of Wells, and for a short time also a partner in his 
office, 1846, or nearly two years after Wells' dis- 
covery, publicly demonstrated ether, and later at- 
tempted to appropriate the honor of having discov- 
ered anesthesia. Morton first sprinkled the ether 
on a handkerchief, but later it was placed in a flask 
having two openings to breathe through ; one open- 
ing was placed to the patient's mouth by means of 
a tube, and the patient inhaled to and fro through 
the flask, picking up the ether vapor. In this way 
rebreathing was also early established in the admin- 
istration of ether. But this apparatus had to be 
improved because of the inadequate supply, or con- 
centration of ether vapor for some cases, especially 
the heavy breathers. 

Next came the type of apparatus which was de- 
vised by Clover and variously modified and imitated 
by a host of others. It consisted essentially of 
Morton's flask, with the additional means of con- 
trolling the amount of air coming into contact with 
the ether, and also a bag to increase the rebreath- 
ing. This bag was the principal improvement, since 
it retarded the elimination of ether from the blood, 
thereby making etherization easier. This is known 
as the "closed method," wliile Morton's flask was 
a "semi-closed method," since the amount of re- 
breathing in the latter was partial and always con- 
stant, and depended upon the dead space in the 
flask and upper air passages. 

The Clover method was used for years, but finally 
fell into disuse with most American surgeons, be- 
cause of incompetent administrators. This simple 
but inaccurate apparatus required a high degree of 
skill for its proper management ; as a result, pa- 
tients were often allowed to breathe to and fro 
from the bag until they were quite asphy.xiated and 
overcharged with ether and COj before fresh air 
was administered. 

Although many have held to the closed method, 
the so-called open method has largely displaced it 
in this country. The latter, in reality, is not open, 
but semi-open, since air is not freely accessible 
through the many layers of gauze or toweling ordi- 
narily used. With some "open" masks and the 
usual amount of gauze, rebreathing is excessive, 
since 200 to 400 c.c. of alevolar gases are thus re- 
tained and rehreathed ; a study of the symptoms 
alone shows it. 

With ether we have had three eras. The first 
two have purposely employed rebreathing: the 
third, the open-method era unintentionally employed 



considerable rebreathing; and it now appears that 
the fourth is beginning. The coming era will give 
us accuracy in dosage of ether vapor, accurate re- 
breathing, the return of apparatus for its admin- 
istration, and more restrictions in its use. 

When Wells chose nitrous oxid in preference to 
ether as his anesthetic agent he did not know that 
he had selected an agent which, to this day, remains 
the most difficult to administer; an agent requiring 
the most accurate mechanical control of the gases 
to produce uniformly good results. It was this fact 
which gave ether, and later chloroform, their oppor- 
tunity to practically supplant NoO in general sur- 
gery, and this retarded for years the perfecting de- 
tails that we now recognize as imperative in perfect 
NjO-O anesthesia. The professional anesthetist 
now taking his place in the operating room is mas- 
tering NjO-O anesthesia and bringing it into gen- 
eral use. 

In the '90s there was some discussion tending to 
show that rebreathing exhaled gases, especially 
CO,, was liable to poison the patient, when a con- 
siderable proportion of gas users adopted the valved 
inhalers which would not permit rebreathing. Dur- 
ing the same period chloroform had gained suprem- 
acy over "closed ether," being administered by the 
open method — a fact which also may have influ- 
enced the two professions against rebreathing in 
nitrous oxid. 

We must not pass the year 1868 without at least 
mentioning the fact that Andrews of Chicago dem- 
onstrated the value of oxygen with NjO, the appli- 
cation of which, by others, has made major surgery 
uniformly practicable with NoO anesthesia. 

The first successful attempt to administer nitrous 
oxid and oxygen at ordinary atmospheric pressure 
by means of an apparatus capable of regulating the 
proportions of the two gases was made by Hil- 
lischer, of X'ienna. and it was the report of his 
investigation that attracted Hewitt's attention to 
the subject. In 1886 this master administrator 
commenced a series of experimental administra- 
tions at the Dental Hospital in London, giving im- 
partial attention to all known methods of nitrous 
oxid anesthesia, using it alone, concurrently with 
air, or in combination with oxygen, in varying per- 
centages, and finally with rebreathing of the gases. 
These clinical researches resulted in the develop- 
ment of the Hewitt apparatus, which for years was 
the most efficient device obtainable for nitrous oxid 
oxygen anesthesia. At this time Hewitt succeeded 
in maintaining a non-asphyxial type of nitrous oxid- 
oxygen narcosis for periods of 35 minutes, for such 
operations as Syme's amputation, lithotrity, re- 



Vol. iv No. 2. 



McKesson — Fr.\ctional Rebreatiiing. 



American Journal of Surgery 
.-Xncstlicsia Supplen^ c ii t 



53 



moval of the breast, excision of varicose veins, vari- 
cocele, resection of the patella, several intra-uterine 
operations, and numerous minor surgical operations 
and the dressing of ivounds and readjustment of 
splints. 

The first systematic endeavor to administer 
nitrous oxid and air for prolonged anesthesia was 
made by Bush, of Brooklyn, who employed an ap- 
paratus with a sliding valve, so arranged as to admit 
atmospheric air according to the requirements of 
the patient and the narcosis. Operations lasting 
upward of one hour were performed under the in- 
fluence of the anesthesia thus produced, but the 
method could not compete with the perfected gas- 
oxygen technic, although it has a few advantages 
even at the present time. 

In 1892, Clover renewed interest in prolonged 
nitrous oxid anesthesia by continuing the narcosis 
induced in the usual manner by passing the gas 
through a metal tube into the mouth. In 1898, 
Coleman revived the use of the nasal inhaler, which 
Patterson in 1899 modified and adapted to his im- 
proved apparatus. In 1902, Kilpatrick improved it 
by adding an expiratory valve, which could be 
thrown in or out of action as desired. In the same 
year Hillard used endo-pharyngeal nitrous oxid an- 
esthesia by means of soft rubber tubes passed 
through the nares into the naso-pharynx. Teter has 
since improved the nasal technic by using oxygen 
and a pressure regulated expiratory valve. 

PHYSIOLOGIC B.\SIS OF REBRE.MHING. 

After years of work, physiologists generally agree 
that animals that have died in air-tight confinement 
in which oxygen was supplied and CO, removed, 
death was not due to poisoning from rebreathing 
exhaled gases, but to ammoniacal decomposition of 
urine and feces in the cage, and that there is no 
organic substance in exhaled gases, which is toxic. 
Herman, Haldane, and Smith have pointed out that 
CO, may reach a 4 per cent, concentration in the 
air before stimulating respiration. Hill and Flack 
found that COj up to 35 per cent, in the air breathed 
stimulated respiration, while higher percentage ten- 
sions depressed it ; that percentages up to 22 pro- 
duced a rise in blood pressure, while greater per- 
centages depressed it. They further stated that 
"the effects of COj on the heart can always be 
quickly recovered from, even if the blood pressure 
has sunk to zero." When it is remembered that 
there is from 40 to 45 volumes per cent of CO, 
normally in the blood, such statements as the above 
are not startling, and CO,, except in fair concen- 
tration, cannot be regarded as poisonous. 

Henderson, in 1908, began the publication of his 



work on acapnia and shock. He brought forward 
experiments to support his contention that CO, in 
the blood regulates blood pressure and respiration, 
and that by rapid or deep respiration the CO, con- 
tent of the blood is reduced, a condition which he 
termed "acapnia." He further contended that acap- 
nia is the cause of surgical shock, and produced it 
in dogs by over-ventilating the animal's lungs and 
blood by means of a pump or bellows. He then suc- 
cessfully relieved the shock and apnea by adminis- 
tering oxygen to sustain the heart until sufficient 
CO, had accumulated in the blood to reestablish 
respiration. This required several minutes. Respi- 
rations were more quickly restored when CO, was 
administered. His conclusions favored the use of 
rebreathing in anesthesia as a means of avoiding 
over-ventilation and shock. 

Catch, then of Johns Hopkins, was among the 
first to put Henderson's theories of acapnia and 
hypercapnia to the crucial test of clinical applica- 
tion, and at the sixty-second Annual Session of 
the American Medical Association, at Los .Angeles, 
reported on a series of 2,500 nitrous oxid-oxygen 
and nitrous oxid-oxygen-ether anesthesias, in Hal- 
stead's clinic, by a method of rebreathing, using an 
apparatus which he had personally devised for ac- 
complishing the technic. The apparatus was sim- 
plicity itself. Catch had the patient exhaust the 
residual air in the lungs by breathing a mixture of 
nitrous oxid and oxygen through valves. The bag 
was then refilled and rebreathing of nitrous oxid 
with an unmeasured quantity of oxygen was al- 
lowed for from five to eight minutes, when the bag 
was emptied breath by breath through the expira- 
tory valve, and the same process was repeated in- 
definitely. The amount of oxygen supplied was 
gauged entirely by the patient's apparent require- 
ments, his condition and the necessar\- depth of the 
narcosis. For purposes of relaxation ether was 
added by dropping it upon drip plates, where the 
ether, heated by rebreathing, quickly evaporated, 
and was rapidly absorbed into the blood because of 
the increased pulmonary ventilation. 

This technic of rebreathing, while efficient in the 
hands of an exceptionally skilled administrator, is 
inaccurate for routine purposes, and prone to pro- 
duce hypercapnia, followed by an increase of blood 
pressure, slowing of the heart and nausea, on the 
one hand; or acapnia, if the bag is filled too fre- 
quently, on the other. 

A great impetus to the rebreathing method, how- 
ever, occurred and anesthetists generally began 
using it again. 

Until 1910, rebreathing had always been accom- 



54 



American Journal of Surgery 
vVnesthesia Supplement 



McKesson — Fractional Rebreathing. 



January, 1915. 



plished as Wells, Clover, Hewitt, or Gatch had 
practiced it — by allowing the patient to breathe to 
and fro for a certain time into a bag of anesthetic 
vapors which was larger than the patient's tidal 
respiration. This is total rebreathing, since the 
whole breath is stored and rebreathed. 

FRACTIONAL REBREATHING. 

In 1910, I devised the fractional method of re- 
breathing and constructed a special bag for that 
purpose. The bag is cylindrical, of thin rubber, and 
attached to a gas tight ring which slips over a cylin- 
drical tube with a perforated bottom. By moving 
the ring and bag up or down, the capacity of the 
bag is decreased and increased. The tube being 
graduated in 100 c.c. divisions, the capacity of the 
bag is known at all times and may be accurately 
adjusted as desired. I have termed this the "frac- 




FiK. 1. 
Method. 



McKesson Adjustable Rebreathing Bag for the Fractional 



tional rebreathing bag," since in use, only a portion 
of each breath is retained for rebreathing. The 
bag is attached to the gas-oxygen or other apparatus 
between the supply bags and the inhaler so that 
on exhalation the rebreathing bag is first filled and 
the latter part of exhalation escapes from the ex- 
haling valve on the face mask. On inhalation the 
bag is first emptied and the remainder of the inha- 
lation comes from the fresh gases in the supply 
bag. In this way the action is automatic, accurate, 
and free from danger of asphyxia, from lack of 
control or experience — always a danger when total 
rebreathing is used. 

As a means of determining hozv much of each 
breath should be retained and rebreathed the bag 
is used to measure the tidal respiratory capacity of 
the patient from time to time during anesthesia. 
This is accomplished by moving the ring and bag 
down until the bag is just large enough to be filled 



and emptied with each breath. The graduation on 
the tube in cubic centimeters represents the tidal 
volume. 

PHYSIOLOGIC BASIS OF THE FRACTIONAL METHOD. 

A brief review of some facts in the physiology of 
respiration will show the importance of this method. 

The average lung capacity in forced inhalation 
is about 3,700 c.c, but the amount of air inhaled 
and exhaled at an ordinary breath is only about 
500 c.c, called the tidal volume. 




Fig. 2. A Rebreathing Bag .Vdapted to the McKesson Apparatus. 

The tidal respiration may be divided into two 
portions : the first, which fills the tubes and pas- 
sages leading to tlie alveoli ; and the second, which 
occupies the smaller bronchioles and alveoli where 
the exchange of gases actually takes place. 

The quantity normally contained in the upper air 
passages and bronchial tree, in which there is no 
CO;, is 140 c.c, while the second, or alveolar por- 
tion, amounts to 360 c.c. and represents the volume 
of gases actually engaged in respiration. 

In selecting the part of the exhalation to be re- 
breathed, I constructed the apparatus to retain the 
first portion in order to save the 140 c.c. of unused 
gases. Since this 140 c.c. contains no carbon dioxid 
it could be of no other use than the saving of ap- 
proximately one-fourth of the gases consumed by 
the patient, and, therefore, represents economy. 
Moreover, this 140 c.c. has lost none of its nitrous 
oxid or oxygen to the blood and, therefore, should 



Vol. 1, No. 2. 



]\IcKesson — Fractional Rehkicathing. 



American Journal of Surgery 
Anesthesia Sup[>lcmcnt 



55 



not be wasted. If this were all that one would wish 
to be rebreathed, a 140 c.c. bag to catch these gases 
only would be simplicity itself. But we must usually 
be able to save more than 140 c.c. of each exhalation 
if we are to prevent over-ventilation. The amount 
actually used for rcbreathing must be adjustable 
and based upon the ventilation of the lungs. 

What is the normal ventilation of a sleeping 
adult? It is the product of the rate of respiration 
by the volume of gases taken at a breath. This 
normally amounts to from 7,000 c.c. to 8,000 c.c. 
per minute for 15 respirations X 500 c.c. = 7,500 
c.c. per minute. But the patient in anesthesia often 
breathes rapidly, 30 times per minute of 500 c.c. or 
15,000 c.c. per minute. In other words, he has 
doubled his ventilation, or over-ventilates. Now, 
to reduce the ventilation of this patient to normal 
by means of fractional rebreathing, the bag is set 
to catch 250 c.c; half of each breath to be taken 
at the following inhalation together with fresh 
gases, to the amount of 250 c.c. At each breath 
this accurate selection is automatically accom- 
plished, and so long as the respiratory rate or vol- 
ume does not change, no further adjustment is re- 
quired, and the patient actually exhales but 7,500 
c.c. per minute, although the respiratory movements 
would doube this amount if half of each breath 
were not rebreathed. 

Rapid breathing in anesthesia, especially' with 
NjO, is probably due to restricting oxygen in the 
nerve cell to amounts capable of supporting life 
functions only. This oxygen restriction sets up a 
protective train of impulses resulting in rapid 
respirations, for it is common knowledge among 
NjO-O anesthetists that a rich oxygen mixture for 
two or three breaths will invariably slow, and some- 
times even stop, respiratory efforts for several sec- 
onds, but as the surplus of oxygen is consumed, the 
patient soon resumes rapid respiration. With ether, 
the oxygen restriction is probably of a chemical 
nature. 

The rate of respiration in N„0-0 anesthesia de- 
pends largely upon the oxygen content of the mix- 
ture administered, increasing as the oxygen is de- 
creased until such a point is reached that anoxemia 
begins to produce convulsive movements. 

These rapid respirations, resulting in over-ventila- 
tion, eliminates more CO, from the blood than 
normal, which in some patients causes a decreased 
volume of respiration, thus partially correcting the 
over-ventilation. In the majority of patients, how- 
ever, associated with this rapid respiration, other 
symptoms indicative of shock appear, such as in- 
creasing pulse rate, weakened heart contractions, as 



shown by the decreased pulse [pressures, as well as 
decreased systolic and diastolic blood pressures. 

While over-ventilation is only one among the 
causes of surgical shock and not even as important 
as trauma, it is almost invariably associated with 
shock from any cause and may always be a con- 
tributing factor when present. It is, therefore, of 
importance that this cause be carefully eliminated 
in each case. 

There are variations in the production and elimi- 
nation of CO„ by the body, notably in the variable 
amount of muscular contraction, food taken, etc.; 
but under the conditions usually encountered on the 
operating table with the patient properly prepared 
for operation, these variations are not so wide. 

In clinical practice, therefore, we may prevent 
over-ventilation by allowing the patient to exhale 
between 7,000 and 8,000 c.c. of gases from the ap- 
paratus per minute, the normal for sleeping condi- 
tions. Thus the elimination of an excessive amount 
CO„, and in so far as this augments shock from 
any cause, it may be prevented. 

TECHNIC. 

The rate of respiration is determined, then the 
tidal volume is obtained by setting the rebreathing 
bag where it is just large enough to hold an ex- 
halation and to accommodate inhalation. The vol- 
ume of the bag now represents the tidal respiration 
and the position of the ring on the graduations in- 
dicates the volume in c.c. Then the bag is de- 
creased in cajiacity by elevating the ring as much 
as it is desired the patient shall obtain of fresh 
gases, and also exhale alveolar gases at each breath. 
The balance is to be rebreathed. 

Respiration Fresh gas to be inhaled and Normal 

rate. -Alveolar gases to be exhaled. ventilation. 

15 X SCO c.c. 7500 c.c. 

20 X 375 c.c. 7500 c.c. 

25 X 300 c.c. 7S0O c.c. 

30 X 250 c.c. 7500 c.c. 

35 X 210 c.c. 7500 c.c. 

40 X 185 c.c. 750O c.c, 

45 X 166 c.c. 7500 c.c. 

50 X 150 c.c. 7500 c.c. 

Referring to the table, suppose the patient 
breathes 25 times per minute, and that the tidal vol- 
ume is found to be 550 c.c. at a breath ; then the 
amount of fresh gases to be taken and alveolar 
gases to be eliminated at each breath to maintain a 
normal ventilation would be 300 c.c. The bag is, 
therefore, decreased by raising the ring 300 c.c. 
from 550 c.c. ; then the amount to be rebreathed 
would be the amount above the ring, or 250 c.c. 
With each breath the patient thus inhales 250 c.c. 
from, and empties the rebreathing bag, while the 
remainder of the inhalation, 300 c.c, comes from 
the supply bags filled with fresh gases. On exhal- 



56 



American Journal of Surgery 
Anesthesia Supplement 



McKesson — Fractional Rebreathing. 



January, 1915. 



ing, the rebreathing bag catches the first 250 c.c. 
to leave the air passages, but as soon as it is filled 
the latter portion of exhalation, or the following 
300 c.c. escapes automatically from the valve at the 
inhaler, and is thus eliminated from the apparatus. 
To repeat, the fractional method permits us to accu- 
rately limit the amount of gases actually exhaled 
per minute to the normal sleeping elimination of 
7,000 c.c. to 8,000 c.c. 

Since using the fractional method of rebreathing, 
I have found that with a tidal volume of less than 
300 c.c. the resulting anesthesia under nitrous oxid- 
oxygen is often unsatisfactory, doubtless due to an 
inadequate exposure of the gases in the alveoli for 
absorption. This fact may account for the efforts 
made by earlier investigators to improve nitrous 
oxid-oxygen anesthesia by its administration under 
increased atmospheric pressure ; and it explains 
Gwathmey's conclusion that: "Five m.m. of mer- 
cury- pressure in the rebreathing bag have been 
found a very great help in those subjects usually 
considered unsuitable for nitrous oxid-oxygen." 
The increased pressure under these circumstances 
restricts ventilation in the alveoli and through the 
CO, retention, stimulates larger respiration, which 
increases the absorption of gases and thus deepens 
anesthesia. It is not probable that such a small in- 
crease in the gaseous pressure would in itself mate- 
rially increase absorption. 

When an adult patient has a tidal volume of 300 
c. c. or less, the rebreathing bag should be set so 
that a considerable portion of this is rebreathed for 
a minute or so until enough COj is thus retained 
to increase the depth of respiration to about the 
normal, or 500 c. c. When the normal volume is se- 
cured, the rebreathing bag is readjusted on the basis 
of the rate of respiration previously described. Gen- 
erally, the volume may not be increased above the 
nomial without stimulating the rate of respiration, 
which is usually undesirable. The increased volume 
of respiration exposes more gas-oxygen to the blood 
for absorption, and a deeper anesthesia is obtained 
without changing the mixture of gases. Within 
certain limits rebreathing may be used to stimulate 
the depth of respiration, while the rate may be 
varied somewhat by the proportion of oxygen in 
the mixture. The latter, however, is less suscepti- 
ble of manipulation. 

An exceptionally valuable feature of the frac- 
tional rebreathing device is that it automatically 
selects those gases coming from the upper air pas- 
sages to be retained for rebreathing and eliminates 
from the apparatus most of the latter portion of 
exhalation, coming from the deeper and alveolar 



portions of the lungs, which contains 6 per cent, of 
carbon dioxid and is poor in anesthetic properties. 

That rebreathing will favorably influence the pre- 
carious condition of hazardous risks has been abun- 
dantly proven in Catch's experience and my own. 

The manner in which rebreathing may be used 
to influence the condition of a patient is shown in 
the accompanying chart of one of my cases. 

" 4581 AMSthHis(% Chart SiSSz 

PHYSCAI. UPPEMliliCE !o^*T9--rt ^ COMPIPUO* --^"^ 

lUNGt "yLe.^ . . 



"gSi 



nc *r»M^ — Z-^ 



2S2K 



110 [- 


•^ Efi -; ;-;- 7-;- 


— -^ — 


tf- 




-^-w^ -^ ^^ 




: — 


\'M- 


Q--: - : 




- — 


ir^ 






^ — 


s n. 

- 10 


— ^ 




— _^ 


1 

S 

i 


if J ' 


T"'T TT- 

1 


■^ 



R::ovE^t of cosiCiOusMi;- iii.jKi / 
POiT OFEHATivf v3M;rir.C __'-"*-'^.-«'~' 

Fig. 3. Illustrative Chart. 

Case I. Shortly after beginning this anesthesia for an 
appendectomy, the tidal respiration was but 300 c.c. In the 
second five-minute interval, rebreathing was set for 300 c.c. 
as shown by the dotted hne in the middle section of the 
chart. In two or three minutes the tidal respiration began 
to increase until it reached SCO c.c, when the rebreathing 
bag was set for 250 c.c, as the rate of respiration was 
30 per minute, indicated by the broken line. This chart 
also illustrates the slowing of the respiratory rate when 
the oxygen percentage is increased ; also, the influence 
of rebreathing in maintaining blood pressure, and thereby 
acting as a prophylactic measure against the insidious 
onset of shock. 

The occasional necessity of administering ether 
with nitrous oxid and oxygen usually caused by 
faulty preparation of the patient, mistakes of the 
anesthetist, or roughness by the surgeon, does not 
interfere with the routine use of fractional re- 
breathing. In fact, an extraordinarily safe and effi- 
cient nitrous oxid-oxygen anesthesia with fractional 
rebreathing may be readily maintained with an ex- 
ceedingly small amount of ether. 

Excessive ether percentages which were a con- 
stant factor in the older methods of etherization 
by closed cones with rebreathing have been shown 
by Ladd and Osgood to have been responsible for 
the occurrence of acetonuria in 88 per cent, of pa- 



Vol. 1. No. 2. 



McKesson — Fractional Rebreathing. 



American Journal of Surgery 
Anesthesia Supplement 



57 



tients thus anesthetized. With the open drop 
method of etherization this percentage falls to 25. 
In nitrous oxid-oxygen-ether anesthesia with ' frac- 
tional rebreathing of post-anesthetic acidosis is neg- 
ligible. 

The following case from my practice illustrates 
the value of rebreathing and oxygen in collapse: 

Case 2. Following an abdominal operation of ordinary 
severity, the patient, a man of moderate build, in the 
twenties, who had been anesthetized with ether, apparently 
"fainted." The patient had been in bed about one hour, 
had regained consciousness and seemed so well that his 
relatives had left the hospital half an hour before the 
incident occurred. 

The nurse's failed to revive him by their usual treat- 
ment for fainting. The pupils were widely dilated, pulse 
imperceptible, pallor and perspiration marked, with no 
eftort at respiration. They began artificial respiration and 
sent word to the operating room. It was ten minutes be- 
fore I was able to leave the patient I was then anesthetiz- 
ing, but shortly alter that found the patient as above de- 
scribed, but cyanosed slightly, still making no voluntary 
respiratory efforts. 

I then inflated the lungs with pure oxygen three times 
in about ten seconds to make sure that the supply of oxy- 
gen was adequate to support the heart. I then held the 
mask against the face and waited half a minute by the 
watch. There was no respiratory effort, but the cyanosis 
faded slightly. His lungs were again inflated with oxy- 
gen and another half-minute wait still failed to develop 
the slightest respiratory effort. And so the O inflations 
were continued as described for six and a half minutes be- 
fore feeble respiratory efforts began. In the meantime the 
pupils gradually began to contract, although still large, 
when respirations resumed. The pulse w-as still imper- 
ceptible at the wrist. 

During the next fifteen minutes he quite rapidly in- 
creased the volume of respiration under the stimulating 
influence of rebreathing. The rebreathing bag was kept 
within 50 c.c. of his tidal volume, so that but a small por- 
tion of each breath escaped. When the pupils were nor- 
mal, the pulse strong, and the patient was again rational, 
the method was discontinued. The patient made an un- 
eventful recovery after this collapse. 

During the period while we were waiting for respira- 
tion to be started by CO: in the blood, o.xygen was admin- 
istered to save the heart from anoxemia, taking care that 
the ventilation would be well below normal, and thus allow 
CO2 to accumulate. The oxygen by the rebreathing 
method, I believe, saved the patient. If a high percent- 
age of COj had been thrown into the lungs and circulation, 
would it have started respiration as it did when the heart 
was sustained while CO2 gradually accumulated in the 
blood? I do not know. It might quite easly overcome 
the tendency to respiration if administered in too strong 
concentration. How strong should CO2 have been if it 
had been used? Under the conditions of the circulation 
I believe it quite impossible to judge. I prefer rebreath- 
ing and pure oxygen, w-hich has also given me good results 
in several illuminating-gas asphyxias. In most of these 
latter cases, breathing was reestablished within ten min- 
utes, and if the case was seen early, complete recovery 
followed in five to thirty minutes. 

Rebreathing during the administration of nitrous 
oxid-oxygen will not only control the tendency of 
preliminary alkaloidal medication to decrease the 
rate and the volume of pulmonary ventilation, but 
will also, in association with over-ventilation with 
oxygen and carbon dioxid, combat the effect of 
morphin in preventing the elimination of ether from 
the system, if ether is used. 

In conclusion, it may be stated that rebreathing 



is a perfecting detail in the administrative technic 
of nitrous oxid-oxygen anesthesia, and that the 
fractional method of rebreathing made possible by 
the fractional rebreathing bag: 

(1) Affords a practical means of measuring the 
tidal respiration. 

(2) Selects automatically those gases coming 
from the upper air passages to be retained for re- 
breathing, and eliminates from the apparatus the 
latter portion of the exhalation coming from the 
alveolar portion of the lungs, which contains 6 per 
cent, carbon dioxid, and is poor in anesthetic prop- 
erties. 

(3) Controls the tension and elimination of con- 
comitant etherization when employed. 

(4) Prevents the rapid breather from using more 
gas, per minute, than he would use of air, if nor- 
mally asleep. 

(5) Makes the light breather increase the depth 
or volume of respiration, thus securing a better 
absorption of the anesthetic and a more satisfac- 
tory plane of narcosis. 

(6) Reduces gas consumption to accuracy, and 
to an economic basis, which puts the technic within 
reach of all. 

2233 Ashland Avenue. 



FEATURES IN THE APRIL SUPPLEMENT 

OIL-ETHER COLONIC ANESTHESIA, 
THE LATEST TECHXIC. 

JAMES T. GWATHMEY, M.D., 

New York Citv. 



PROCEEDIYGS OF THE AMERICAN 
ASSOCIATION OF ANESTHETISTS. 



MEDICO-LEGAL ASPECTS OF ANES- 
THESIA AND ANALGESIA. 

(^Concluded) 

^ M the time of going to press, the SUPPLE- 
Ji MENT is in receipt of a communication that 
it has been made the Official Organ of the 
PROVIDENCE (R. I.) S O C f E T Y OF 
ANESTHETISTS. 

^][ Editorial arrangements are in progress to 
jl secure a number of articles from well-known 
authorities on the HISTORICAL EVOLUTION 
OF ANESTHESIA AND ANALGESIA. These 
articles will be based on original researches and 
documents, and will serve to correct many errors 
that have become traditional, on account of constant 
repetition, without any warrant of fact. 



58 



American Journal of Surgery 
Anesthesia Siipj^lenient 



Editorials. 



January, 1915. 



Amrrirau dinurual nf ^itrurru 

QUARTERLY SUPPLEMENT of 
ANESTHESIA and ANALGESIA 

-^ Surgery Publishing Co. -^ 

J. MacDONALD, Jr., M.D., President and Treasurer 
92 William Street - New ^■oRK, U. S. A. 

Original Articles, Clinical Reports and Experinicntal 
Researches on the Theory and Practice of Anesthesia 
and Analgesia, as ivell as pertinent Society Transactions, 
are solicited for exclusive publication in this Supplement. 
Typewritten Manuscripts facilitate Editorial Rez'ision and 
avoid errors. 

Subscribers Changing Address should immediately notify 
the publishers of their past and present locations. 
Half-tones, Line-etchings and other Illustrations viill be 
furnished by the Publishers when Photographs or Draxv- 
ings are supplied by the Author. 

F. HOEFFER McMECHAN, A.M., M.D., Editor 

Cincinnati, Ohio, U.S.A. 



Vol.1. No. 2. 



JANUARY. 



1915 



"Even as a surgeon minding off to cut 
Some cureless limb, before in use he puts 
His violent engines in the victim's member, 
Bringeth his patient in a senseless slumber, 
And griefless then, guided by use and art, 
To save the whole, saws off the infested part." 

Dubartas. 1593. 



WORTHY OF HIS HIRE, 

While the Committee of the Ohio State Medical 
Association has found that the awards paid to phy- 
sicians and surgeons by the Ohio Industrial Com- 
mission, under the provisions of the Workmen's 
Compensation Law, are higher than those sched- 
uled in New York or any other state, there is still 
room for improvement, notably in respect to the fee 
paid the anesthetist. 

The Ohio Industrial Commission has arbitrarily 
fixed the anesthetist's fee at five dollars ($5.00) 
irrespective of the inherent hazard of the case, the 
time and skill of the administrator and the method 
of anesthesia involved. 

It is conceivable that a fee of five dollars may 
be a remuneration of sorts for local analgesia in the 
operative procedures of minor surgery, or a brief 
ether rausch, but when life hangs by a thread, and 
the anesthetist is called upon to prevent the occur- 
rence of an operative death, involving an award of 
several thousand dollars, the five dollar fee is ridic- 
ulously inadequate in comparison with the impor- 
tance and value of the services rendered. 

Moreover, such an arbitrary, minimal fee pre- 
cludes the use of nitrous oxid-oxygcn anesthesia 
for extra hazardous risks, as the anesthetist would 
have to furnish the apparatus and gases required 
and do the work at a personal pecuniary loss. Hos- 



pitals cannot and will not stand for this additional 
drain out of the five dollar fee allowed for oper- 
ating room expenses. 

The Ohio Industrial Commission is to be com- 
mended for promulgating the following rule : 

"Fees covering scrzices rendered by internes connected 
with a hospital shall not be paid from the state insurance 
fund." 

This regulation not only saves the victim of an 
accidental injury from being anesthetized by an in- 
competent tyro, but reserves the work for the ex- 
pert to whom it rightfully belongs. 

The preceding rule is further emphasized in the 

following regulation : 

"Fees covering services rendered by an assistant or an 
anesthetist shall not be paid from the fund unless such 
services are performed by a physician, and a separate fee 
bill covering such services presented by him. The neces- 
sity for the services of a consultant, assistant or anesthetist 
must be clearly apparent from the nature and extent of the 
injury before fees for such services shall be approved for 
payment from the state insurance fund." 

This regulation effectively disposes of the nurse 
anesthetist in workmen's compensation cases, and 
the separate fee bill prevents the penurious surgeon 
from now treating the anesthetist as a charitable 
adjunct of the operating room stafif. Those sur- 
geons who, through a mistaken sense of economy, 
persist in having their anesthetics administered by 
others than licensed practitioners, would do well to 
reflect on the decision of the Supreme Court of the 
State of Louisiana in the case of Nations vs. Liid- 
ington, Wells & J 'an Shaick Lumber Co., in which 
it was held that employing a non-medical anesthet- 
ist, however experienced, with no emergency exist- 
ing, constituted negligence, and the damages 
awarded by the trial court to the plaintiff were 
increased to $10,000. 

Be that as it may, if the anesthetist is at all wor- 
thy of his hire, it would seem that the question of 
the anesthetist's fee under the provisions of re- 
cently enacted Workmen's Compensation Laws is a 
matter for the immediate attention of the Ameri- 
can Association and New York Society of Anes- 
thetists. 

The New York Society of Anesthetists is alreay 
displaying commendable activity in the matter and 
at the November meeting of the organization a leg- 
islative committee of three members was appointed 
to investigate the question and report on a solution 
for the problems involved. — F. H. M. 



THE AMERICAN ASSOCIATION OF AN- 
ESTHETISTS WILL HOLD ITS THIRD AN- 
NUAL MEETING DURING THE PANAMA- 
PACIFIC EXPOSITION, AT SAN FRAN- 
CISCO, JUNE 19, 1915. 



Vol. 1, No. 2. 



Medico-Legal Aspects. 



American Journal of Surgery 
Am-stlicsia Supplement 



Medico - Legal Aspects of 
Anesthesia and Analgesia. 



Editor's Xotc. — Periodically the Supplement lirill review 
American and Continental Court decisions im'olving the 
relations of Anesthetists and Surgeons to Anesthesia, 
Analgesia and the Lata. 



SURGEON NOT LIABLE FOR DEATH DUE 

TO ANESTHETIC ADMINISTERED BY 

MEDICAL STUDENT. 

The deceased in this suit of Levy (Adminis- 
trator) vs. Vaughaii, was an over-weight hazardous 
risk, who was anesthetized by a medical student, 
who, while he had witnessed anesthetics adminis- 
tered in a large number of cases, had actually ad- 
ministered ether, before, in but eight or ten cases. 
The open-drop method with an Esmarch mask was 
the technic employed. The induction of anes- 
thesia was attempted in the anesthetic room, under 
the general supervision of two house-physicians, 
who were in an out of the room during the 35 min- 
utes required to get the patient under the influence 
of the anesthetic ; about 3 ounces of ether being 
used. No complications presented until after the 
patient had been lifted on the operating table, when 
he was noticed to be cyanotic. The defendant felt 
the patient's pulse and immediately instituted arti- 
ficial respiration, which proved tempiorarily benefi- 
cial, and the patient was returned to the ward, un- 
operated. Cyanosis persisted and, despite the use 
of resuscitative measures, the patient succumbed. 
Autopsy revealed fatty degeneration of the heart. 

The Court of Appeals of the District of Columbia 
held that a verdict for the defendant had been prop- 
erly directed, and affirmed judgment with costs. 
The court held that there was no evidence whatever 
of negligence, either in the preliminary examination 
of the patient or in the administration of the ether, 
by a student of the description given ; as the evi- 
dence in behalf of the plaintiff showed that two ex- 
perienced house-physicians were present, generally, 
during the induction of narcosis, in a supervisory 
capacity. That they were employed by the hos- 
pital and had not been provided by the defendant, 
was wholly immaterial, as was the fact that these 
interns were licensees of a state other than the Dis- 
trict of Columbia. They were not practicing medi- 
cine in the District, but were employed in the hos- 
pital and had been shown to be competent. 



DEATH FROM A NON-ABORTIVE ANES- 
THETIC. 

In State of Ohio vs. Tippic, the Supreme Court 
of Ohio held that: 

"Whoever, with the intent to procure the miscar- 
riage of a woman by the use of an instrument or 
other means, administers to her a non-abortive drug 
as an anesthetic preparatory to the use of such in- 
strument or other means of procuring an abortion, 
and the woman dies in consequence of the admin- 
istering of such drug before the use of instruments 
or other means by such person to procure such mis- 
carriage, and it does not appear that such contem- 
plated miscarriage is necessary to preserve her life, 
or that the procuring of such miscarriage was ad- 
vised by two physicians to be necessarv- for that pur- 
pose, is guilty of a violation of the provisions of 
Section 12412, General Code. 

"Lender such circumstances ever}' act done and 
performed in furtherance of such unlawful purpose 
is an integral part of the whole unlawful transac- 
tion ; and the fact that death ensues before the final 
act in the contemplated crime can be accomplished, 
is not a defense to an indictment charging a viola- 
tion of this section. 

"If it appear that a non-abortive drug is admin- 
istered to a woman as an anesthetic to enable a duly 
authorized and practicing physician fully and care- 
fully to examine into the woman's actual condition 
for the purpose of determining if it be necessary to 
produce a miscarriage in order to save her life, and 
the woman dies from the eft'ect of the drug so ad- 
ministered, and no miscarriage is performed, nor in- 
tended to be performed unless the examination dis- 
closes that it is necessary to preserve the woman's 
life, no offense has been committed within the pro- 
visions of Section 12412, General Code. 

"Evidence tending to show that no secrecy is 
maintained in the transaction, that a second physi- 
cian is called in to administer the anesthetic, that 
while the woman is in a state of anesthesia the at- 
tending physician makes an examination for the pur- 
pose of determining whether the fetus is alive or 
dead, and upon such examination does determine 
that the fetus is stih alive and that it is not neces- 
sary to procure a miscarriage in order to preserve 
the woman's life, and having so detennined. makes 
no use of any instrument or other means to procure 
a miscarriage, but immediately desists from fur- 
ther efiforts in that direction, and directs that the 
woman be restored to consciousness, is proper evi- 
dence to be admitted for the purpose of showing 
the absence of criminal intent in administering the 
anesthetic." (lOf, N. E. R. 75.) 



60 



American Journal of Surgery 
Anesthesia Supplement 



Book Reviews. 



January, 1915. 



LIABILITY OF EMPLOYER FOR DEATH OF 
EMPLOYEE UNDER OPERATION, WHEN 
LAYMAN ADMINISTERS THE ANES- 
THETIC. 
In the case of A^atioiis vs. Ludington, Wells & 
Van Schaick Lumber Co., the patient, a laborer, 
died from the effects of the anesthetic before the 
operation was begun. The Supreme (Appellate) 
Court of the State of Louisiana held that employ- 
ing a non»-medical anesthetist, with no emergency 
existing, constituted negligence, and increased the 
damages, awarded by the trial court to the plain- 
tiff, to $10,000. The Supreme Court was emphatic in 
its declaration that in the case adjudicated, one con- 
templating minor surgery only, a physician should 
have been employed to administer the anesthetic, 
although the officiating anesthetist was experienced 
in this line of work, and administered the anes- 
thetic in the presence and under the direction of the 
surgeon. (Medical Record, February 28, 1914.) 
{To be continued.) 



Book Reviews 



A carefully selected library is essential to a thorough 
knowledge of the science and practice of a specialty. 

Local Anesthesia. By Carroll W. Allen, M.D., F.A.C.S. 
Instructor in Clinical Surgery at Tulane University 
of Louisiana. With an introduction by Rudolph 
Matas, M.D., F.A.C.S., Professor of Surgery at Tou- 
lane University. Octavo of 625 pages, with 255 illus- 
trations. W. B. Saunders, Publishers, Philadelphia, 
1914. Price, cloth, $6.00. 

In the revival of interest in general anesthesia and in 
local and regional analgesia, the tide of contemporaneous 
literature has swung from the continent to America. 

Allen's volume, just off the press, is a complete and in- 
dividual exposition of the various phases of local and re- 
gional analgesia. The historical evolution, principles, 
physiology, toxicology and technic of the subject are ex- 
haustively covered and handled in a masterly manner. To 
enable the reader to secure a clearer insight into the 
causality of pain, a chapter is devoted to the nerves of 
sensation, their areas of distribution and association with 
the sympathetic system. Valuable advice is suggested re- 
garding the psychic control of pain. 

The principles of osmosis and diffusion, of various anal- 
gesics in combination and solution, on which the effective- 
ness of local and regional analgesia depend, are adequately 
considered and explained. Especial attention is devoted 
to cocain and novocain, their action on the nervous system, 
the control of their toxicity and the value of adrenalin as 
an adjuvant. Also the peculiar obtunding effects of qui- 
nine and area, the magnesium salts and potassium sulphate 
are dilated upon. 

Perhaps the most valuable feature of this volume is 
the minute detail with which the technics for spinal and 
epidural analgesia, paravertebral, parasacral, intrarterial, 
and intravenous anesthesia are described. These technics 
are amplified by numerous illustrations of exceptional 
merit in explaining difficult injections, and illuminating 
routine procedures. 

Crile's latest accomplishments in anoci-association and 



his method of adrenalin-saline transfusion are included 
as valuable aids in obtunding sensitive tissues and opera- 
tive areas, and in preventing the occurrence of shock or in 
treating the condition once it has supervened. 

The scope of Allen's book can only be fully appreciated 
when it is realized that he has detailed and illustrated all 
the various methods of local and regional analgesia as ihey 
apply to rectal, genito-urinary and gynecological surgery 
and to operative procedures upon the head, eye, ear, nose 
and throat as well as the extremities. 

Even the subject of dental anesthesia is exhaustively 
considered. 

While .^llen has scoured the world's literature to en- 
compass his subject, his volume emphasizes the value of 
those methods and details of technic, which from personal 
experience he has found to be the easiest and most efficient. 

Local Anesthesia: Its Scientific Basis and Practical 
Use. By Prof. Dr. Heinrich Braun. Chief-of-Staff 
and Director of the Royal Hospital at Zwickau. Ger- 
many. Translated and edited by Percy Shields, 
M.D., A.C.S., Cincinnati, O., from the Third German 
edition, with 215 illustrations in black and colors. 
Octavo : 399 pages. Price, $4.25. Lea & Febiger, 
Philadelphia, 1914. 

Attention has already been drawn to the fact that the 
American edition of this work cost the translator his life; 
but it was worth the effort and it fulfills in a most effi- 
cient manner Dr. Shields' purpose, as expressed in the 
preface, written just before his untimely death: 

"My object in placing Braun's work at the command of 
the English speaking surgical profession is to systematize 
the -'ague, erratic and unsatisfactory efforts "vhich have 
been made in this field for many years, by offering a log- 
ical procedure, based upon scientific facts, and having an 
e.vact and undeinating technic." 

This volume of Braun's may be truly termed a classic, 
and it stands as another monumental achievement of a 
medical genius' infinite capacity for taking pains. This 
third edition records not only a widespread popularity for 
the hook itself, but an intrinsic development of the sub- 
ject that has put analgesia on a secure and scientific basis, 
and rendered it adaptable to practically every known oper- 
ation of surgery and its co-related specialties. 

While Braun has had exceptional opportunities for de- 
veloping the scope of local analgesia, both in general 
surgery and the specialties, he has not hesitated to incor- 
porate the best work of the master-minds of both conti- 
nents on analgesia, and he graciously acknowledges an 
especial indebtedness to the cooperation of Prof. Schwarz 
and Dr. Viereck. 

Braun's review of the historical evolution of analgesia 
up to the discovery of cocaine is, to say the least, as inter- 
esting as it is exhaustive. His consideration of the os- 
motic tension of watery solutions and tumefaction and 
dehydration analgesia lays a basic foundation of physiolog- 
ical principles for the technics of infiltration and conduc- 
tion anesthesia. 

.\fter extensive experiments with all known analgesic 
agents, Braun now utilizes, almost exclusively, novocain 
amplified by suprarenin. Hertzler's and Crile's notable 
successes with quinine and urea hydrochloride as an im- 
portant adjunct to local analgesia seem entirely to have 
escaped Braun's observation. 

Braun describes in detail not only the many novelties of 
his instrumentarium and the routine percentage solutions 
of the analgesic agents, but also gives the minutest direc- 
tions regarding the general technic of infiltration and con- 
duction analgesia, in respect to cutaneous cataphoretic, sub- 
cutaneous, peri, endoneural, lumbar, sacral, epidural, para- 
vertebral, venous and arterial anesthesia. 

The latter half of the book is devoted to the practical 
application of the technics of infiltration and conduction 
anesthesia to every conceivable sort of operative procedure. 
Readers of the previous German editions will be surprised 
by the number of new illustrations that have been added. 
They are especially striking because the photographs were 
taken during the course of actual operations, and the ab- 
sence of any expression of pain on the faces of the pa- 



Vol. 1, No. 2. 



Index and Abstracts. 



American Journal of Surgery 
Anesthesia .Supplement 



6) 



tients is a remarkable advertisement of the absolute effi- 
ciency of the analgesic methods described. 

Anesthesia and Analgesia. By John Desmond Morti- 
mer, M.H. (Lond.), F.R.C.S. (Eng.) First edition, 
27b pages; 2<> illustrations. \Villi.\m Wood & Co., 
New York, 1914. Price, $2.00. 

This volume on anesthesia and analgesia has been writ- 
ten, not so nmch from the point of view of the specialist, 
as that of the general practitioner and surgeon. Much of 
the routine matter usually included in te.xt-books on anes- 
thesia has been omitted, but on tlie contrary such impor- 
tant subjects as the preparation and after treatment of the 
patient, the selection of the anesthetic, the difficulties pecu- 
liar to certain operations, and the relative advantages of 
anesthesia and analgesia have been fully considered. 

The chapter on the anesthetist's equipment, and his pre- 
paredness for such accessor)' operations as laryngotomy, 
tracheotomy, saline transfusion, lavage of the stomach, and 
measures for artificial respiration, is admirably conceived 
and replete with valuable suggestions. 

Likewise the chapters devoted to the selection of the 
anesthetic, in reference to the patient and contemplated 
operative procedure; posture during anesthesia, and team- 
work between surgeon and anesthetist are pregnant with 
practical information. 

In no other volume on the subject is there such a mas- 
terly exposition of reflexes under anesthesia, and how they 
may be controlled by a mutual understanding between the 
operator and the anesthetist. 

The tyro is told how to meet the difficulties, dangers and 
emergencies arising under anesthesia, and the expert may 
learn some useful practices from Mortimer's postanesthetic 
regimen. 

\Vhile the routine procedures of spinal and local anal- 
gesia are succinctly considered, no effort has been made 
to compete with the more extensive monographs on these 
subjects. The book closes with a very interesting and in- 
structive chapter on the medico-legal position of the 
anesthetist. 

The routine observance of Mortimer's invaluable sug- 
gestions in his practical manual will go far in enabling the 
anesthetist to establish cordial relations between his pa- 
tients, his operating surgeons and himself. 



Index and Abstracts 

A Resume of the International Current 

Literature of .Anesthesia and .-\nalgesia. 



EDITOR'S NOTE: Authors of pertinent articles, who 
desire to have them indexed and abstracted, are cordially 
invited to send copies of the journals containing their con- 
tributions, direct to the editor, immediately on publication. 
Also the receipt of reprints for filing and reference will be 
duly appreciated. 

ACETONCRIA FOLLOWING SPIN.\L AxESTHESIA. G. Gellhorn, 

St. Louis. Zentralblatt fiir Chirurgie, August 29, 1914. 

Adrexalin-Cocaix Surface Anesthesia. R. S. Cauthen, 
Charlotte, N. C. Southern Medical Journal. Octo- 
ber, 1914. 

Anesthesia, Phases of. J. A. Kirk, Louisville. Ken- 
tucky Medical Journal, August 15, 1914. 

Anesthesia. Progress in General Inhalation. D. Kul- 
enkampf. Deutsche medicinische Wochenschrift, Sep- 
tember 7, 1914. 

Anesthetic. Choice of, in Operating for .Abscess of the 
Lung. F. T. Murphy, St. Louis. Annals of Surgery, 
July, 1914. 

Aniesthetic Powder. Dusting Wounds with, Before Su- 
turing. G. Hotz. Muenchener medicinische Woch- 
enschrift, July 21, 1914. 

Anesthetic. Selection of. E. R. Horine, Louisville, Ky. 
Kentucky Medical Journal, October IS, 1914. 

Anesthetists, Non-Medical, and the Law. L. Irwell. 
Buffalo. New York Medical Times. September, 1914. 



Anoci-Association, — Evolution of Shockless Opera- 
tions. H. M. \\'. Gray, London. British Medical 
Journal, August 22, 1914. 

Anoci-Association Anesthesia. Experiences with. E. C. 
Davis, -Atlanta. Georgia Medical Association Jour- 
nal, August, 1914. 

A.noci-Operating. \\. P. Carr, W'ashington, D. C. Vir- 
ginia Medical Senii-Monthly, October 9, 1914. 

Anoci-Association in the Prevention of Shock and 
Post-Operative Discomforts. H. B. Butler and E. 
W. Sheaf, British Medical Journal, July 18, 1914. 

Basing their opinion on 143 major operations performed 
under anoci-association, Butler and Sheaf conclude that 
it is ideal in preventing shock and ameliorating post- 
operative discomforts. Ward and Home Sisters who 
started out by being sceptical, arc now quite convinced 
of its advantages, and declare that patients operated un- 
der anoci-association are no trouble after operation. 

In two amputations through the thigh in old people, in 
addition to the usual novocain inliltration, the sciatic 
nerve was injected with quinine and urea, and there was 
no shock and practically no after-pain. 

One girl of 17 years had a large one-sided goitre, which 
caused her great pain and dyspnoea. The operation for 
removal was conducted without the slightest anxiety, and 
recovery was normal and rapid. The same patient was 
subsequently operated on by another surgeon for enuclea- 
tion of the tonsils and died under the anesthetic. 

Necroscopy revealed status lymphaticus. This would 
seem to indicate that anoci-association saved her from 
disaster on the occasion of the first operation. 

So far there has been no trouble in the healing of 
the operative wounds. 

Apparatus, — Improved Ether Inhaler. A. E. Gallant, 
New York Medical Journal, October 31, l'^14. 

Arterial Hypertension and Hypotension in Medicine 
and Surgery. H. H. Roberts, M.D.. Lexington, Ky. 
Southern Medical Journal, September, 1914. 

Roberts insists that during an operation there is noth- 
ing which will give the surgeon more reliable inforrna- 
tion as to the patient's condition than the repeated taking 
of the blood pressure by means of a sphygmomanometer. 
Preliminary measurement of the normal systolic pressure 
of the patient is one of the essentials in determining the 
vital resistance for any contemplated surgical procedure. 

The effect of any anesthetic is exerted chieflv on the 
circulation, and the ability to withstand anesthesia safely 
depends in great measure on the integrity of the vasomotor 
and cardiomotor systems in maintaining blood-pressure 
at its normal level. The sphygmomanometer with an en- 
larged dial for easy reading should be used for ascertain- 
ing the circulatory tension at frequent intervals duriiig 
the course of all operations. A fall in blood-pressure will 
give warning of impending danger long before any un- 
toward symptoms of the pulse or respiration can be noted, 
in fact, the anesthetist opens himself to criticism if he ne- 
glects this precautionary method of anticipating the occur- 
rence of shock. 

The surgeon should realize that unnecessary manipula- 
tions of exposed viscera, their vessels, nerves, pedicles or 
messenteries, are productive of a determining fall in blood 
pressure, and the onset of surgical shock from trauma 
may be very precipitous. If the blood pressure falls as 
low as 100 mm. the danger line has been reached, and 
operative manipulations should cease, while saline solution 
is given, especially in the presence of hemorrhage. 

Ordinarily during the induction of anesthesia there is a 
rise of tension due to stimulation of the cardiomotor and 
vasomotor centers through excitement or the anesthetic 
agents themselves, notably nitrous oxid and ether. Hy- 
pertension under nitrous oxid may become dangerous, un- 
less asphyxia is absolutely controlled by the concomitant 
use of oxygen. Ether acts as a preliminarv- stimulant 
and raises blood-pressure slightly, and depression onry 
follows after lengthy administrations, when too deep a 
degree of surgical narcosis has been maintained and mus- 
cular relaxation has been extreme. On the contrarv, in 



62 



American Journal of Surgery 
Anesthesia Supplement 



Index and Abstracts. 



January, 1915. 



patients with hypotension, chloroform may cause sudden 
death by an abrupt drop in blood pressure, although the 
sphygmomanometer, in routine use, will do much to ob- 
viate such preventable catastrojihies. 

It is a mistake to use the sphygmomanometer only in 
the operative room or in the preliminary taking of the 
blood pressure. In hazardous risks the blood-pressure 
should be taken at intervals after the patient's return 
to bed to anticipate postoperative collapse. 

Blood Pressure During Anesthesia and Analgesia for 
De.vtistry. E. I. McKesson, Toledo. New Jersey 
State Dental Journal, September, 1914. 

Cardiac Fibrilation and its Relation to Chloroform 
Anesthesia. J. A. McWilliams. British Medical 
Journal, September 19, 1914. 

Chloroform Anesthesia. E. C. Fisher, Richmond, Va. 
Virginia Medical Semi-Monthly, October 9, 1914. 

Chloroform .\nd Ether Anesthesia, Effects of, on Pro- 
tein Contents of Blood Serum of Rabbits. L. W. 
Buck, San Francisco. Journal of Pharmacology and 
Experimental Therapeutics, July, 1914. 

Chloroform Toxicity aiid Hepatic Necrosis, Influence 
of Diet on. E. I. Opie and L. B. .Alford, St. Louis. 
Journal American Medical Association, March 21, 1914. 

By laboratory experiment and clinical results, Crile has 
pointed out the necessity for preserving the glycogenic 
functional activity of the liver, particularly in the presence 
of acidosis complicating operation and anesthesia. This 
view is supported by Opie and Alford, who, in carrying 
out their experiments upon animals, using chloroform 
as an anesthetic, and employing fats and meats, as well 
as carbohydrates as foodstuffs, found that animals which 
received a preoperative diet of carbohydrates all survived ; 
whereas all of those receiving fats and meats died from 
the effects of the anesthetic. Microscopic examination of 
the liver in starch-fed animals showed scanty areas of 
necrosis, while in those under a fat and meat diet the 
hepatic necrosis involved from two to three-fifths of the 
lobules. This pernicious action of chloroform is prob- 
ably due to its sollubility and diffusibility in fats, which 
thereby determines its activity on the liver, resulting in 
pronounced necrosis. 

Clinically it is therefore advisable to feed cardiac, renal 
and diabetic acidosis risks on gruels, supplemented by 
taka-diastase and pancreatin, up to within three hours of 
operation, and to establish this diatery as soon as pos- 
sible after the anesthetic. 

Dangers of Anesthesia, Recent Experiments Defining. 
Yandel Henderson. Surgery, Gynecology and Ob- 
stetrics, September, 1914. 

Deaths, Analysis of. Occurring in the Course of 1,573 
Operations. E. MacD. Stanton, Schenectady, N. Y. 
Albany Medical Annals, August, 1914. 

Death During Tonsillectomy from Reflex Inhibition. 
H. Dupuy. New Orleans Medical and Surgical Jour- 
nal, August, 1914. 

Dentin, Anesthesia of the, With Albargin. Dr. Licht- 

witz. Dental Cosmos, August, 1914. 

Lichtwitz finds that albargin, a combination of silver 
nitrate with gelatose, answers all possible requirements 
as an obtunding analgesic for hypersensitive dentin. It 
is conveniently applied with a double-headed ball and 
spatula burnisher. It can be satisfactorily applied in hy- 
peresthesia of the dentin at the cervical margin with in- 
cipient caries, in erosions, in hypersensitive dentin which 
is to be excavated in cavity preparation, in grinding teeth 
for crown and bridge work, in hyperesthesia due to close 
bite or attrition, and the carious deciduous teeth of chil- 
dren, in apthae and all other inflammatory conditions in 
which silver nitrate is indicated. 

A fragment of an albargin tablet is pressed upon the 
hypersensitive field of operation, where it is left adhering 
for the desired length of time. To prevent its dissolution 
the field is kept dry. It is rarely necessary to prolong 
the application beyond a period of five minutes, or to re- 
peat the application. 



A single application of albargin, in Lichtwitz's experi- 
ence, has controlled the progress of caries in deciduous 
teeth during a period of two years; and has controlled 
hyperesthesia of the dentin at the cervical margin for as 
long as one year. In excavating hypersensitive cavities or 
in grinding down teeth, the effect of albargin as an anal- 
gesic is more prolonged than that of phenol, cocain, per- 
hydrol or any other medicaments. 

Differential Atmospheric Pressure Procedures. Ber- 
liner Klinische Wochenschrift, September 7, 1914. 

Dream, an Ether Anesthesia, Partial Analysis of. 
J. E. Lind. Alienist and Neurologist, August, 1914. 

Ether Anesthesia. G. L. Closson, Seattle. Northwest 
Medicine, September, 1914. 

Ethyl Chloride, Induction of Anesthesia and. C. De- 
derer, Los Angeles. California State Journal of Medi- 
cine, October, 1914. 

Fearful Patients, Anesthesia For. H. Scholz. Beit- 
rdge zur klinischen Chirnrgie, June, 1914. 

While patients who dread an operation may attempt to 
conceal their fear, under a placid exterior, their dread is 
generally revealed by some disturbance of visceral or 
vasomotor innervation, such as tachycardia, pseudo-angina, 
polyuria, glycosuria, diarrhea, angioneurotic edema, shal- 
low and sighing respiration, pallor and dryness of the 
mouth. Scholz, in studying the condition of fearful pa- 
tients, coming to operation, concludes that abnormal fear, 
alone, will precipitate acapnia. Such subjects are also 
prone to exhibit reflex syncope, during the induction of 
anesthesia, on account of the irritation by the anesthetic 
vapors of the nasal terminals of the trigeminus, and co- 
incidentally the terminals of the vagus in the heart and 
in the respiratory centers of the medulla. Rosenberg has 
found that cocanization abolishes this reflex, and Gwath- 
mey overcomes it by the use of essence of bitter orange 
peel. 

Fearful patients suffer a constant decline in blood-pres- 
sure during the induction of anesthesia by ether or chloro- 
form, the average decrease being 45 mm. of mercury in 
IS minutes, or until the stage of surgical narcosis has 
been reached. Even then further decreases may be noted 
during visceral manipulation. 

Scholz considers the persistence of a dilated pupil, dur- 
ing the induction of chloroform anesthesia, as a sign of 
impending danger. Also it is possible to induce fainting 
from sheer fright, if fearful patients, who are struggling, 
are too forcibly controlled. 

Scholz corroborates the views of MacCardie on disasters 
occurring in the Trendelenburg posture, and illustrates his 
contention with roentgenograms of anesthetized dogs, 
showing the remarkable displacement of the diaphragm 
due to changes in posture. Collapse in the head-down 
position may be entirely due to mechanical obstruction 
to the pumping action of the heart. 

FitzGeraldism — What ts it? (Pressure Analgesia). 
Wm. Harper DeFord, Des Moines, la. New Jersey 
State Dental Journal, September, 1914. 

Impurities in Commercial Nitrous Oxid for Dental Use, 
and Their Injurious Effects by Inhalation. W. B. 

Hart and F. W. Minhall, British Dental Journal, 
June 15, 1914. 

In their carefully tabulated analyses. Hart and Minhall 
have found that, considering the short interval of time 
that nitrous oxid is inhaled in dental anesthesia, and the 
large dilution of the gas by air or oxygen for analgesia 
the minute amounts of gaseous impurities found in 
the samples examined by them, are in general too small 
to have any effect on the patient, and it would appear 
that nitric oxid is the impurity that calls for special 
attention. 

The purity of the gas can be maintained and the opera- 
tion of purification simplified by the use of the purest 
ammonium nitrate as raw material. The use of ammonium 
sulfate or sodium nitrate calls for extraordinary precau- 
tions in manufacture, in view of the varying quality of 
these materials on the commercial market. 



Vol. 1. No. 2. 



Index and Abstracts. 



American Journal of Surgery 
A'u-slhcsia Supf'lcnif nt 



63 



While Baskerville and Stevenson recommend a minimum 
of 95 per cent, of nitrous oxid in the commercial product, 
there appears to be no difticultics in the manufacture of 
a gas of 98 per cent., as the authors show in a table of 
American analyses. 

Basing their conclusions on their analytical results, Hart 
' and Minhall propose the following recommendations as 
to the quality of commercial nitrous oxid for anesthetic 
and analgesic use: 

Nitrous oxid, 98 per cent, minimum ; moisture, not to 
exceed 0.0002 gram per ICOcc. ; carbon dioxid, not to ex- 
ceed 0.05 per cent, by volume; nitric oxid not to exceed 
0.001 per cent, by volume; ammonia, not to exceed 0.001 
per cent, by volume ; hydrochloric acid, chlorin and its 
oxids. idodin, sulfur <lio"xid, sulfuric anhydrid, hydrogen 
sullid, carbon monoxid, nitrogen, tri-. tetr-, and pentoxids. 
cvanogen, hydrocyanic acid, hydrogen phosphid. arsenid 
and antimonid, ozone, dust and all other impurities to 
be absent in an examination of 20 liters of the gas. 

Gexito Urin-.-xry Tr.\ct, Gexer.\l Axesthesi.\ with Spe- 

ci.\L Reference to the Surgery of. J. T. Gwathmey. 

New York Medical Journal. November 7, 1914. 
Gexito Urin.^rv Tr.^ct, Loc.^l Anesthesi.\ in Relation 

TO THE Surgery of. J. F. Mitchell. Washington, D. C. 

New York Medical Journal, November 7. 1*^14. 
High Frequency .Analgesi.a. Milton D. Neef. Dental 

Summary, November, 1914. 
Impurities in Nitrous Oxid. H. D. Haskins. Cleveland 

Medical Journal, August, 1914. 
Intra-Oral Opfjjations, Anesthesia for. F. H. McMe- 

chan. Cincinnati Medical News, August, 1914. 
Intrapharyngeal Administration of Warmed Ether by 

the Nasal Route. H. M. Page. Lancet. July 18, 

1914. 
Tntratrache.\l Insufflation. B. M. Ricketts, Cincinnati. 

Medical Record, September 19, 1914. 
Intratracheal Insufflation of Ether. H. T. Thomp- 
son, Edinburgh Medical Journal, August, 1914. 
Intravenous Ether Anesthesia. H. Kummell, Hamburg. 

Surgerj-, Gynecology and Obstetrics, September. 1914. 
Local Anesthesia. H. A. Brady, Danville, \'a. Virginia 

Medical Semi-Monthly, September 11, 1914. 
Local .\nesthesia. T. Torland, Seattle. Northwest 

Medicine, September, 1914. 
Local Anesthesia in M..\jor Surgery'. W. A. Shelton, 

Kansas City. Missouri State Medical Association 

Journal, October. 1914. 
Local Anesthesia. Operations for Inguinal Hernia 

Under. J. A. Bodine, New York. Medical Record, 

September 26, 1914. 
Local Anesthesia in Rectal Surgery. D. R. Pickens, 

Nashville. Tennessee State Medical Journal, Septem- 
ber, 1914. 
Local Anesthesia. Conduction and Infiltration. B. R. 

East. Detroit. The Dental Summary, September, 1914. 
Local Anesthesia, Thyroid Oper.\tions Under. F. H. 

Lahev. Boston Medical and Surgical Journal, October 

8, 1914. 
Local Anesthesia. Intr.wenous. Total Peripher.\l 

An.\lgesia After. A. W. Meyer. Archives fiir 

klinische Chirurgie, CV. No. 1. 

Local Anesthesia in Over 1,000 Major Surgical Oper- 
ations. T- A. Crisler. Memphis, Tennessee State 
Medical Journal, July, 1914. 

W'hile Crisler has found nitrous oxid-oxygen anesthesia 
in conjunction with hyoscin-morphin. almost ideal in se- 
lected cases, he has found some patients who could not 
be thoroughly relaxed under it. and a few in whom sur- 
gical narcosis was impossible for a period sufficiently long 
for an average operation. Its objectionable features lie 
in the fact that an exceptionally experienced anesthetist 
is required for its administration and the necessary ap- 
paratus is only available in well-equipped hospitals. 

Three j'ears ago he began the use of hyoscin and mor- 
phin in connection with novocain to the exclusion of 
other anesthetics in operations for goitre, and he has 
gradually extended the use of these agents into abdominal 
surgery with gratifying results. 



Three preliminary doses of morphin-hyoscin arc given 
to secure amnesia and partial analgesia. The anoci-asso- 
ciation technic of Crile is followed in obtunding the ab- 
dominal wall and the operative areas, and inhalation nar- 
cosis is only resorted to in about 25 per cent, of routine 
cases, in which the analgesia is not efticient on account 
of acute inflammatory conditions. 

While the method lengthens the operative period, this 
objection is offset by the decrease in manipulative trauma, 
and peripheral shock. The technic also obviates anes- 
thephobia, postoperative nausea, and diminishes the ten- 
dency toward flatulency, irritation of the kidneys and 
bronchial mucous membranes, and billiary necrosis. 

The only complications noted in over 1,000 major opera- 
tions were three cases of epileptiform convulsions, wdiich 
occurred while operating in the neighborhood of the uterus 
and bladder. These seizures were brief and without any 
ill-effect. Artificial respir.ition has not been necessary in 
a single instance, although as much as a grain of morphin 
and 1/25 grain of hyoscin was used to secure narcosis. 
Coincidentally as much as two ounces of a 2 per cent, 
solution of novocain has been used without any toxic mani- 
festations. 

Local Anesthetics. Combination of, with Potassium 
Sulph.\te. a. Hoffmann and M. Kochmann. Beit- 
riige zur klisische Chirurgie, May. 1914. 

Local Anesthetic, Quinine and Urea Hydrochloride 
AS A. in Exploratory Operations. E. D. Twyman, 
Independence. Mo. Missouri State Medical Associa- 
tion Journal, September. 1914. 

Local Anesthetics — Some Comparative Physiological 
Reactions. O. E. Clossons, Detroit. Michigan State 
Medical Society Journal, October, 1914. 

Magnesium Salts. Ether and Chloroform. Editorial. 
Journal American Medical Association, August 15, 
1914. 

Morphin, Limit.'^tions and Uses of, as an Aid to Anes- 
thesia. J. S. Keyser, Wilmington. Delaware State 
Medical Journal. July, 1914. 

Nitrous Oxid-Oxygen Anesthesia. H. L. Geary, Seattle. 
Northwest Medicine. September, 1914. 

Nitrous Oxid, Some Considerations After 13,000 Ad- 
ministrations of. W. I. Jones. D.D.S.. Columbus O.. 
Ohio State Medical Journal, August, 1914. 

Jones reports thirteen thousand administrations of 
nitrous o.xide-oxygen with but one fatality on the table, 
in an extra-hazardous risk. While a large percentage of 
the anesthesias were for dental, quite a percentage were 
for major surgical operations in bad subjects. His young- 
est patient was four weeks, for cleft palate; his oldest 
86 years, for prostatectomy. 

His experience with nitrous oxid-oxygen in brain sur- 
gery corroborates Teter's. satisfactory anesthesia being 
maintained by 92 parts nitrous o.xid and 8 parts oxygen, 
experiments during the operations proved conclusively that 
discoloration, dilitation and protrusion of the brain oc- 
curred only in the presence of oxygen deprivation, and 
assumed dangerous proportions only when asphyxia was 
imminent. Jones has met with occasional instances of 
acapnia in anemic and asphyxia in plethoric, obese or al- 
coholic subjects; but all cases responded promptly to arti- 
ficial respiration and perflation with oxygen. 

McKesson's findings regarding blood pressure during 
4.000 nitrous oxid-oxygen anesthesia are also corroborated 
in Jones' e.xperience. and he has observed that any im- 
periling turgesence of blood vessels, even in the presence 
of arterio-sclerosis must be the result of either asphy.xia 
or pushing the anesthesia beyond the depth required for 
surgical interference. 

For safe and satisfactory results w-ith this technic of 
anesthesia Jones suggests that the anesthetist should bring 
as much skill to its administration as the surgeon does to 
the operation. He offers his records and the desperate 
character of many of the cases handled to contravert the 
efforts of some surgeons to indescriminately condemn the 
technic. 

Ether in small amounts for purposes of relaxation was 
necessitated in from 20 to 25 per cent, of the cases re- 
corded. 



64 



American Journal of Surgery 
Anesthesia Supplement 



Index and Abstracts. 



January, 1915. 



Jones concludes tliat while nitrous oxid-oxygen anes- 
thesia does not make the work of the surgeon easier, it 
is immeasurably better for the patient. 

Novocain Poisoning. R. P. Giffcn and F. F. Gundrum, 
Santa Barbara. California State Journal, October, 
1914. 

Oil-Ether Colonic .\nesthesia. J. T. Gwathmey, New 
York. Medical Record, October 3, 1914. 

Oil-Ether Colonic Anesthesia. W. W. Spargo, Albu- 
querque. New Mexico Medical Journal, July, 1914. 

Para\-ertebral Anesthesia for Gall Bladder Surgery. 
A. T. Jurasz. Zentralblatt fiir Chirurgie, August 29, 
1914. 

Posture in Relation to General Anesthesia. MacCardie, 
Birmingham, Proceedings of the Royal Society of 
Medicine. Section of Anesthetics, April, 1914. 

While the Trendelenburg posture may be advantageous 
to the surgeon during certain phases of operative pro- 
cedures, it may give rise to complications that jeopardize 
the life of the patient or that make the maintenance of 
general narcosis extremely hazardous. It is McCardie's 
opinion that frequently anesthetics have been blamed for 
these complications which are really induced by this par- 
ticular posture, especially when the angle of inclination 
has exceeded 45 degrees. The posture not only promotes 
copious venous hemorrhage, and embarrasses pulmonary 
ventilation, but also puts an additional strain on the heart. 
Likewise it seems to be an important factor in the oc- 
currence of post-operative pneumonia and bronchitis : and 
Zweifel holds it occasionally responsible for post-opera- 
tive intestinal obstruction, surgical emphesema, apoplexy 
and acute dilitation of the stomach. Zweifel reduced the 
incidence of pulmonary embolism from 18 cases in 1,800 
operations to 3 in 800. by resorting to the posture as infre- 
quently as possible, and then maintaining the extremities 
in the same horizontal plane as the body instead of allow- 
ing them to be flexed over the end of the table. 

The recent researches of Meltzer, Auer and Githens on 
the curare-like action of ether in promoting the fatigu- 
ability of musculature, explains why the Trendelenburg 
posture is more dangerous during ether narcosis than when 
chloroform is used; or when, according to Gatch, Gann 
and Mann, the patient is properly under the influence of 
morphine. These observers conclude that the ill-effects 
of the Trendelenburg posture are due primarily to failure 
of respiration, and can only be combated by the stimula- 
tion of hypercapnia. In the presence of even mild grades 
of asphyxial embarrassment, the entire mechanism with 
which the body compensates for the effects of gravity, is 
put to an e.xhaustive strain, and the heart has to pump 
against an increased arterial pressure at a time when it is 
poorly able to respond. 

McCardie concludes by advising that the posture be re- 
sorted to as infrequently as possible; and then only for 
brief periods, and that it should not be used at all on 
patients suffering from obesity, obstructed breathing, car- 
diac, renal or arterial complications. .Mso the posture 
should be sustained by support at the shoulders, and not 
by allowing the legs to hang over the edge of the table, in 
order to obviate the danger of thrombosis. 

Gatch has even found it advisable to operate sov.ie 
hazardous risks, under gas-oxygen anesthesia in a semi- 
sitting position or the reverse Trendelenburg. 

Prostatectomy Under Local Anesthesia. Emory Lanp- 
hear. St. Louis. The Urologic and Cutaneous Review, 
November, 1914. 

Psychic Factors of Surgical .^NESTHESIA. R. H. Fergu- 
son, East Orange, N. J. Illinois State Medical Jour- 
nal, August, 1914. 

Record Card for the Anesthetist. P. L. Flagg, New 
York. Journal American Medical Association, Sep- 
tember 19, 1914. 

Regional Analgesia for Abdominal Operations H. 
Hackenbruch. Deutsche Zeitschrift fiir Chirurgie, 
CXXVIII, Nos. 5-6. 

Scopolamin-Morphin, Use of, in Labor. A. Rongy and 
S. S. .-^rluck. New York Medical Journal, Septem- 
ber 19, 1914. 



Scopolamin-Morphin in Labor. Magnus Tate, Cincin- 
nati. Lancet-Clinic, October 24, 1914. 

Scopolamix-Narcophin Seminarcosis in Labor. A. Har- 
rar and R. McPherson, New York. American Journal 
of Obstetrics, October, 1914. 

Shock, Treatment of. Conservation versus Stimulation 
IN. C. S. Holt, Fort Worth, .•\rkansas Medical So- 
ciety Journal, September, 1914. 

Shock, Psychic, Following Operations. J. E. Engstad, 
Minneapolis. Journal-Lancet, October 1, 1914. 

Shock, Traumatic. S. W. Hobson. Newport News. Vir- 
ginia Medical Semi-Monthly, October 9, 1914. 

Shock, Peripheral Origin of. F. C. M^nn, Indianap- 
olis, Bulletin of Johns Hopkins Hospital, July, 1914. 

While Mann found it possible to produce the usual signs 
of shock in animals by means of e.xcessive heat or cold, 
the condition supervened far more readily by exposure 
and trauma of the abdominal viscera. With the abdominal 
wall intact and hemorrhage prevented, Mann found it im- 
possible to reduce anesthetized animals to a state of shock 
by any degree of sensory stimulation. While the respira- 
tory center is more quickly injured by shock than any 
other vital center, acapnia is not a primary factor in its 
incidence. The vasomotor is the most resistant of all 
vital centers and is not depressed nor fatigued in shock. 
That shock is due to primary failure of the heart, due to 
involvement of the cardio-inhibitory or cardio-accelerator 
mechanism, cannot be maintained, since the peripheral and 
untraumatized visceral arteries are constricted in its 
presence. 

W'hile shock produced by exposure and trauma of the 
abdominal viscera may be partly due to a paralysis of the 
vasamotor mechanism of the splanchnic area, still Mann 
considers that the more important factor is the tremendous 
loss of red cells and fluid from the blood, due to the 
reaction of the great, delicate vascular splanchnic area 
to irritation — an acute inflammation of the peritoneum due 
to operative trauma and exposure to changes of tempera- 
ture. The peritoneum offers an area of exposure equal 
to the entire cutaneous surface of the body, and the 
supervention of shock, similar to the abdominal type, only 
occurs when a great area of subcutaneous tissue has been 
exposed and traumatized. 

Muscular relaxation, decreased abdominal pressure, and 
impaired respiration are accessory factors, because they 
tend to decrease the amount of blood returned to the 
heart. A relatively slight decrease in blood-supply mark- 
edly depresses the cellular activity of the cerebral cortex, 
and degenerative changes in the cells of the central 
nervous system are the result and not the cause of shock. 
General anesthesia, just short of the loss of muscle tone, 
prevents painful impulses from affecting the cells of the 
central nervous system. Under such conditions, Mann 
considers nerve blockmg as useless in the prevention of 
shock. 

According to Mann, the term "shock" should only be 
used to apply to the patient's condition when, without 
anv grossly discernable hemorrhage having occurred, the 
amount of circulatory fluid is greatly diminished on ac- 
count of stagnation of the blood in the smaller veins and 
capillaries or by exudation of the fluid and cellular ele- 
ments of the blood from the same. 

Spinal Anesthesia. J. Overton and L. E. Burch, Nash- 
ville, Tenn. The Southern Practitioner, October, 1914. 

Spinal Anesthesia. C. G. Parsons. Denver Medical 
Times, November, 1914. 

SpiJja Anesthesia, Experiences with. _ A. Gfoerer. 
Muenchener medicinische Wochenschrift, September 
8, 1914. 

Spinal Anesthesia in Urology. G. G. Smith, Boston. 
Inter-State Medical Journal, November, 1914. 

Trigeminal Neurai.gi.\, Treatment of, by Intracranial 
Injections of Alcohol. Hartel. Deutsche Zeit- 
schrift fiir Chirurgie, Band 126, Heft 5-6, 1914. 

Trigeminal and Other Neuralgias, Some Experiences 
with Alcohol Injections in. Wilfred Harris, Lon- 
don. Journal American Medical Association, Novem- 
ber 14, 1914. 



AMERICAN 



JOURNAL OF SURGERY 



Vol, XXIX. 



I'KI'.RL'ARV, 1915. 



No. 2 



PRE-CANCEROUS LESIOXS AXD TRANSI- 
TION TYPES OF MALIGNANT DIS- 
EASE OF THE TONGUE AND THEIR 
RELATION TO SYPHILIS; WITH 
REMARKS ON EARLY DIAG- 
NOSIS AND OPERATION. 
G. Fr.\nk L\'dston, M.D., 
Formerly Professor of Genito-Urinary Surgery and Syph- 
ilology, State University of Illinois. 

Chicago, III. 



In no department of surgery are mistakes in 
diagnosis and treatment more frequently made than 
in the surgical diseases of the tongue. Nowhere 
are the results of inaccurate diagnosis and ill- 
advised treatment more deplorable. The truth of 
this has so frequently been impressed upon me dur- 
ing thirty-five years of abundant opportunities for 
observation, that I feel that the profession cannot 
be too often reminded of the sources of error and 
of its duty in this field. 

Strange to say, improvements in our diagnostic 
resources often have ill served us in the diagnosis 
and treatment of diseases of the tongue. The micro- 
scope and the Wasserman test alike are friends 
from which we frequently should be saved. These 
diagnostic handmaidens have been responsible for 
the loss of valuable lives and much discredit to the 
art of surgery. This sounds treasonable, but one 
must needs form a few definite conclusions from 
wide experience. I shall later endeavor to justify 
these conclusions. 

The various forms of diseases of the tongue 
which, by their intimate etiologic or differential 
diagnostic relations to malignant disease, are of 
especial interest to the surgeon, have been well 
outlined by Butlin:^ 

1. "Predisposing conditions, such as leukoplakia, 
ichthyosis — chronic superficial glossitis — which may 
exist for many years without the occurrence of 
cancer, but which undoubtedly render the individual 
more liable to cancer than are individuals in whom 
the tongue is healthy. 

2. "Pre-cancerous conditions, such as wart 
growths, thick plaques, sore places, which are not 



exactly cancerous, but wliich inevitably proceed to 
cancer unless they are completely removed or de- 
stroyed. 

3. "Actual cancer, in one of its various forms, 
when it is obvious to an educated surgeon, and 
ought to excite suspicion in the minds of persoiic 
who are not experts." 

The conditions enumerated by the distinguished 
English surgeon are, unfortunately, what may be 
termed (a) pre-terminal and (b) terminal condi- 
tions. Underlying all we sliould recognize (1) 
etiologic factors of which the local pathologic con- 
ditions are merely the outward expression, and (2) 
factors of local irritation which act merely by de- 
termining or localizing the conditions. 

Sutton- states that epithelioma of the tongue is 
preceded in 20 per cent, of cases by "leucoplakia 
and ichthyosis, which are frequently referred to as 
pre-cancerous conditions." He further says: 1. 
"Ichthyotic patches do not necessarily become epi- 
theliomatous. 2. Epithelioma attacking an ichthy- 
otic tongue does not always begin in the ichthyotic 
patch. 3. The stump of an epitheliomatous tongue 
may become ichthyotic after removal and yet malig- 
nant disease not recur in it." 

These obser\'ations of Sutton's do not lessen the 
importance of ichthyosis in the etiology of tongue 
cancer. The same underlying predisposition which 
leads to ichthyosis — leucoplakia — may develop 
epithelioma precociously in another part of the 
tongtie, while in the case of the ichthyotic patches 
occurring in the amputation stump of an epitholio- 
matous tongue, the patient is not likely to live long 
enough to experience a recurrence at the site of 
the leucoplakia. It must be remembered, too, that 
the su]>er\-ention of carcinoma upon leucoplakia 
mav not occur for many years, during which the 
case is likely to go through the hands of many sur- 
geons. Many cases perish from shypilitic degenera- 
tive conditions before the leucoplakia has had time 
to undergo malignant change. 

There is little doubt that syphilis, mercury, alco- 
holics, and smoking or chewing tobacco, or all these 
causes combined, are the usual exciting causes: 
first, of glossitis ; second, of leucoplakia ; third, of 



^ Henry T. Butlin. Monograph. Diseases of the Tongue, and 
British Med. Journ., Apr. 6, 1890, and Apr. 14, 1894. 



T. Bland Sutton. Tumors. Innocent and Malignant, 1893. 



34 



Journal of Sukceky. 



Lydston — Pre-Cancerous Lesions. 



Fkbbuaby, 1915. 



Primary predisposing cause 



Secondary predisposing causes 
(Irritative) 



carcinoma. Tiie fact remains, however, that it is 
only in those who are predisposed to pathologic 
changes in the mucosa who develop the more se- 
rious conditions. As Butlin-' says : "The fact that 
thousands of persons are subjected to the various 
sources of irritation mentioned is no argument 
against their potency as etiologic factors." I will 
go further and state, as my opinion, that the large 
number of exceptions really emphasize the dan- 
gers of such conditions, merely by arguing the ex- 
istence of a special predisposition. 

For practical purposes the author has formulated 
die etiology of carcinoma of the tongue as follows: 
viz. : 

CAUSES OF CANCER OF THE TONGUE. 

Heredity (?) in- 
herent tissue ten- 
dency to cancer. 
Congenital malfor- 
m a t i o n of the 
tongTie 

Uncleanliness o f 
mouth 
Syphilis 

' Tobacco 

'Alcohol 
Caustics 
Mercury 
Bad teeth 

I Gumma 
Ulcers 

'Mucus patches 
Cicatrices 
Fissures 

[Leucoplasia 
(' ' Leucoplakia, ' ' 
'Ichthyosis," "hy- 
pe r - Keratosis," 
'chronic superficial 

^glossitis") 

The role which congenital malformation plays iii 
the etiology of the conditions underlying cancer of 
the tongue is not thoroughly appreciated. The 
"raspberry" tongue and other conditions in which 
the tongue is fissured, or its border crenated, with 
exaggerated development of the papillae, are often 
responsible for the development (1) of glossitis, (2) 
of leucoplakia, and (3) of malignant disease. Fig- 
ure 1 shows a tongue of this kind which later 
developed malignancy. (Case 2.) 

The role which prolonged irritation per se plays 
in the etiology of epithelioma probably is well 



Exciting causes 
(Irritative) 



shown by the observations of Albarran,-" Annas," 
and Binaghi," on the association of psorosperosis 
with epithelioma. Bryant" reports several cases of 
epithelioma originating in presumably non-specific 
ulcers and cicatrices. Eve' also shows very clearly 
the importance of irritation per se in the etiology 
of epithelioma. 

The etiologic relation of syphilis to malignant 
diseases of the tongue has been fairly well estab- 
lished by a considerable number of observations. 
(-)ne of the earliest of these noted — indeed, the ear- 
liest relating to sarcoma that I have been able to 
find — was a case of my own,^ which will be pre- 
sented later. Some of the observations upon the 





^-~ --y-^.m.'^r^'^^'^ 


M 


w 


^^^^^^ijMK^W" ■ 


i|K 




f 





Fig. 1. Congenitally fissured tongue, with hypertrophy of the 
papillae, and later development of leucoplasia, in an old syphilitic 
K'ase 2). Malignancy finally developed in this case. (From sketch 
by the author.) 

co-relation of cancer and syphilis and the difficul- 
ties of differential diagnosis are worthy of especial 
comment because cf their distinctly illustrative 
value. 

Jonathan Hutchinson," and, following him. Von 
Langenbeck, early called attention to the etiologic 
relation of syphilis to cancer, i.e., "combined" 
syphilis and cancer. 

\^erneuil and Ozenne" some years later called 
attention to what they considered a simultaneous 
development of cancer and tertiary syphilis of the 
tongue, forming a "cancero-gummous" lesion. 

Zancerini claims that syphilis creates "a special 
predisposition to cancer, by the local irritation and 



• Diseases of the Tongue. 



* Sur des tum. epithel. contenant des sporospermies., Compt. rend. 
Soc. de bioL, Paris, 1889. 

"^ Sulla Presenze dei blastomiceti negli epitheliomi e sulla loro 
iimportanza parassitaria., Policlin., Roma, 1896. 

•^ I blastomiceti negli epitclioimi., Policlin., Roma, vol. XI, 1895. 
' Lancet. London, vol. XI, 1882, and vol. I, 1884. 

* Relation of Epithelioma to irritation and Chronic inflammation, 
Rrit. Med. Journ., vol. I, 1881. 

» Malignant Transformation of Syphiloma of the Tongue, N. Y. 
Med. Rcc, N. V., Aug. 26, 1889. 

» Med. Press and Circular, vol. XI, 1883. 

" Quoted by Fournier, without reference or date. 



Vol. XXIX, No. X 



Lydston — Pre-Cancerous Lesions. 



American 

jourxajl of surgekv. 



35 



general nutritive disturbance produced by its 
toxins." 

Lang, in 1886, reported three cases of cancer of 
the tongue which he attributed to degeneration in 
syphihtic lesions. One of his cases is especially 
interesting. 



'Case • 



-. A middle-aged woman had suffered 



from syphilis for a protracted period. Scars of 
former syphilitic process present upon the trunk 
and face, the palate being perforated and the upper 
lip having suffered considerable loss of substance. 
At the time she came under observation most of 
the ulcers were covered with a white scab, the his- 
tologic examination of which did not reveal any 
sign of diagnostic importance. About a month 
later, however, a small, white, indolent ulceration 
appeared upon the hard palate. A small portion of 
the involved tissue was excised and upon micro- 
scopic examination was found to be epithelioma." 

Lang states that he had obsen'ed three other very 
similar cases, the development of the carcinoma 
upon the syphilitic soil being demonstrated in each 
instance by microscopic examination. The first 
case that came under his observation had suffered 
from a characteristic course of syphilis, including 
numerous relapses of iritis and gfinnmatous ulcera- 
tions that had cicatrized, with the exception of one 
which became transformed into a '"cancroid" of the 
skin. The second case was that of a man, aged 46, 
who had suffered from various syphilitic ulcerations 
on different parts of the face and body. After 
anti-syphilitic treatment, one ulcer, located beneath 
the tongue, proved resistant to treatment and be- 
came transformed into cancer. In the third case, 
a syphilitic infiltration located in the lower lip un- 
derwent a relapse at the end of a year and assumed 
a carcinomatous character. 

Von Esmarck,i= in 1889, called attention to the 
association of sarcoma with syphilis, laying especial 
stress upon sarcomatous degeneration of tissues 
affected by syphiloma. He especially deplored the 
delay in accurate diagnosis in such cases until too 
late to save life by operation. The author operated 
a case of this kind in 1884. (Case I to be described 
later.) 

Dubois-Havenitti^^ reports a very interesting case 
showing the difficulty of making a differential diag- 
nosis between gummatous ulcer of the tongue and 
epithelioma. The ulcer in this case was located on 
the border of the tongue, the surface of the organ 
showing "leucoplakia." A "sub-maxillary adenitis" 
was present. Repeated microscopic examinations 
failed to show malignancy. On the other hand, spe- 
cific treatment aggravated the condition. The con- 



clusion of this case has not been recorded, but it 
would be easy to surmise what finally happened. 

Chifolian and Duroeux'* report a case of "mixed 
syphilis and cancer" of the tongue. The authors 
state that in such cases the malignant growth gen- 
erally develops in the cicatrix of an old lesion or 
in a leucoplakic plaque. 

Du Castel'^ reports a case of ulcer of the tongue 
in which the dift'erential diagnosis between epithe- 
lioma and syphiloma was the subject of varying 
opinions. To my mind this was either a definitely 
malignant or a "borderline" case, in any event de- 
manding e.xcision. 

The difficulties attending differentiation of epitlie- 
lioma and syphiloma of the tongue are well illus- 




/- 



Fig. 2. Incipient leucoplasia buccalis in advanced syphilis (Case 
3). showing superficial hyperplasia and hyaline degeneration (Kena- 
tosis) of epithelium (X 130). 

trated by the so-called "hybrid" types of tongue 
disease, the characteristics of syphilis and those of 
cancer being combined. "° 

Kenny'' reports a case of "combination of syph- 
ilis and epithelioma" in a man of 49 years. A 
nodule appeared on the left side of the base of the 
tongue several months after a typic giimmous ulcer 
on the right pillar of the fauces had healed under 
anti-syphilitic treatment. The excised nodule 
proved to be epithelioma. "Combination" in this 
case is an unhappy nomenclature. There was merely 
a co-existence of syphilis and cancer in the same 
subject, with no evident real correlation. No ob- 
servations were made on the matter of transition in 
type. Some very interesting observations on the 
microscopic study of the excised tissue were made: 



^- Ueber die Aetiologie und Diagnose der Carcinome insbesondere 
derjenigen der Zunge und Lippe, Allg. W^ien. med. Ztg., 18S9, 
XXXIV, and Cent. f. Chir.. vol. XVI. 1889. 

"Press Med. Beige., vol. LXV, 1913. 



"Ann. des Mai. Vener., Mav. 1913. 

".Ann. de Derm, et de Syph.. vol. XXV. 1894. 

^* Bellaserra. Estudio clinico e anatomo-patologico delgoma-lingual 
sifilitico y de la hibridez cancero-esclero-gommosa; tratamiento. Rev. 
de cien. Med. Barcel. vol. X. 1884. 

"Australasian Med. Gaz., Dec. 20, 1898. 



36 



American 
JoL'R.vAL OF Surgery. 



Lydston — Pre-Cancerous Lesions. 



February, 1915. 



1. "Masses of epithelium dipping down continu- 
ously from the epithelium on the dorsum of the 
tongue into a mass of connective tissue material 
in a more or less irregular manner. 

2. "Masses of epithelium from the opposite side, 
apparently much broader in outline than those of 
No. 1, but not invading the connective tissue so 
deeply or so irregularly. 

3. "At various parts, chiefly on the surface or 
just below the surface of the epithelium mentioned 
under ( 1 ) a number of concentric horny masses, 
not unlike cellnest.s. on superficial examination." 
(See Fig. 4, author's case, for similar appearance.) 

4. "Scattered through the connective tissue are 
a large number of small round cells, with one, and 
occasionally more than one, nucleus, and in parts 
can also be seen a number of islets of epithelium, 
quite separated from the prolongations of the epi- 
thelium mentioned in No. 1. Also in parts the 
coats of the small vessels seem thickened, especially 
the intima. 

A study of the processes of cpithcUiun. 

"If there are many secondary processes found 
jutting out in irregular directions, it should arouse 
some degree of suspicion, and especially if these 
processes are exciting any irritation of the con- 
nective tissue. The connective tissue grows in a 
normal manner if left to itself, but immediately any 
growth of epithelium takes places into it, it seems 
to act on it in much the same way as other aseptic 
foreign substances, producing some vascular reac- 
tion. 

A study of the ccH-ncsls and deep layers of cells 
of the processes. 

"The cell-nests should be searched for any signs 
of multiplicity of nuclei, secondary fatty degenera- 
tion, etc. In the cells composing the nests, and in 
die Malphigian layer, when actively dividing, are 
often seen evidences of division of the nuclei, 
whereas normal cells cut in a partly horizontal way 
are mono-nucleated. 

"Close obser\ation of the connective tissue for 
evidences of irritation, especially in the region 
where the processes seem to be abnormally long, 
or the Malphigian deep cells seem to be actively 
proliferating." 

The microscopist's report was "a tumor begin- 
ning to be malignant." 

Archibald Smith"* re[>orted a case of "Syphilitic 
Tongue with Commencing Malignancy" superven- 
ing upon "leucoplakia" lingualis. This presented 
the appearance of a fungating gumma on the left 



side of the dorsum, surrounded by epithelial pro- 
liferation. The pathologist's report was "papillary 
outgrowths with much subcutaneous round-celled 
infiltration. One portion shows so much activity 
that it must be pronounced a squamous-celled epi- 
thelioma. " 

The conditions improved somewhat under anti- 
syphilitic treatment. 

\V. 1. Wheeler'" reported three cases of epithe- 
lioma supervening upon gumma of the tongue. The 
author remarked that old syphilitic deposits were 
"fertile sources for cancerous development." His 
clinical experience in this regard and the obstinacy 
of such growths led him to excise them. The micro- 
scope showed early malignant development in all 







Fig. 3. Advanced stage of leucoplasia labialis, in syphilis of long 
standing (Case 2). Showing marked epithelial hyperplasia with 
advanced hyaline degeneration. (Keratosis) X 70. 

three cases. Wheeler recommends early operation 
in all persistent growths or deposits in the tongue 
because of their proneness to develop into cancer. 
The pre-cancerous stage of such growths he log- 
ically believes to be the ideal time for operation. 
His cases, apparently, were treated by circum- 
scribed resection. 

Fournier'-" reports a case of "mixed" or "syphilo- 
epitheliomatous" glossitis. This type of epithe- 
lioma of the tongue in a syphilitic, in my opinion, is 
due to a mere coincidence of the two diseases. Such 
cases are a little trying as to diagnosis, but the 
swelling and discomfort due to the superadded 
syphilitic element subside under specific therapy. 
Unfortunately, the malignant induration which is 
left behind is likely to be temporized with until it 



'» West London Med. Journ., vol. XV, 1909. 



^f Syphil. depos. in the Human Tongue followed by Epithelioma. 
Trans. Royal Acad., Ireland, vol. VII, 1889. 
=» Bull. Soc. Fr. de Derm, et de Syph., 1898. 



\0L. XXIX, No. 2. 



Lydston — Pre-Cancerous Lesions. 



American 

J0U».\AL OF SUKCEtY. 



37 



is too late. The same may be said of complicating 
mixed-infection-glossitis in cancer, which may sub- 
side under any sort of treatment, providing it be 
not irritative. Errors in diagnosis under such con- 
ditions are frequent — and sometimes excusable. 
Mercurial glossitis, complicating botli syphiloma and 
cancer, is a not infrequent source of confusion. 

In an able and well illustrated paper by Emanuel 
Friend,-' attention is called to the necessity for 
early diagnosis in suspicious ulcerative conditions 
and new growths of the tongue. He reports a num- 
ber of striking cases illustrating his point. He lays 
especial stress on the frequency with which "leuco- 
plakia" acts as the foundation of malignant new- 
growths. 



lesions occur in the form of hyperplastic mucus and 
submucus infiltrations, classed by different authori- 
ties as leucoplakia or leucoplasia — terms intended 
to convey their characteristic whitish appearance 
and tendency to the formation of distinct hyper- 
plastic plaques (Figs. 1-5-7). Post-syphilitic leu- 
coplasia is probably as comprehensive and accurate 
as any term tlius far suggested.-^ The term psoria- 
sis, ichthyosis, tylosis, leuco-keratosis, diskeratosis, 
and hyper-keratosis serve simply to add confusion 
to the subject. 

"It may be doubted whether leucoplasia should 
be classified as a distinct pathologic entity, but 
seemingly these lesions are sufficiently characteristic 
to warrant such classification. From a clinical 
standpoint there can be no question of accuracy." 





^ 



■f 



Fig. 4. Superficial hyaline degeneration (Keratosis) in epithelioma 
of the tongue succeeding leucoplasia in advanced syphilis (Case 5), 
showing "nest" of proliferation and degeneration of epithelium near 
periphery (X 235). 

My own experience has led me to the conclusion 
that malignant disease is to be apprehended in all 
cases of obstinate "leucoplakia," and of gumma of 
the tongue, and tliat the condition therefore, as a 
rule, is not to be temporized with. 

In my text-book," published in 1899, appears the 
following : 

"Certain lesions of the mucus membrane in late 
syphilis are most typically sequelar. They are the 
result, not only of syphilis per se, but of numerous 
other factors to which the mucus membranes are 
exposed during the active period of the disease or 
during the intennissions betw-een the active mani- 
festations. The post-syphilitic character of the 
lesions is so marked that anti-syphilitic treatment 
often eitlier has no effect or is injurious. These 




Fig. 5. Epithelioma of the tongue developing in congenitally mal- 
formed tongue in advanced syphilis, following glossitis and leucop- 
lasia of long standing (Case 2). Showing areas of leucoplasia and 
sclerosed nodules at site of former yummata, one of which, on the 
right side of the tongue, is breakingdown. Plaques of leucoplasia 
also are seen, and the tongue is thicked by recurrent attacks of 
glossitis. The appearance of the tongue, as seen in Fig. 1, has been 
changed by the sclerotic process and "glazing" of the surface. 
(i^rom sketch by the author.) 

Perrin believes that: 

1. The white hyperplastic plaques, presenting 
themselves as syphilitic phenomena, have for tlieir 
elementarj' characters functional and organic dis- 
turbances of the epithelium. 2. They may occur 
as a consequence of both the syphilis and anti- 
syphilitic treatment. 3. In some instances there 
exists some peculiar morbid constitutional condition 
or diasthesis as the predisposing cause of leuco- 
plasia. 4. Such conditions are peculiarly likely to 
occur in both syphilitic and non-syphilitic patients 
addicted to tobacco. 5. There is a large number of 
cases of mixed character in which the condition is 



=1 111. Med. Journ., September, 1910. 

— Genito-Urinary, Venereal and Sexual Diseases. 



=3 The etiology of leucoplasia — or leucoplakia — and its relations to 
cancer of the tongue were also discussed in my paper in the N. Y. 
Med. Rec, Aug. 26, 1889. 



38 



American 
JouBSAL OF Surgery. 



Lydston — Pre-Cancerous Lesions. 



February. 1915. 



excited by .syphilis and tobacco combined in gouty 
or rheumatic subjects. 

With reference to the relation of syphiHs to leu- 
coplasia, the occurrence of the latter independently 
of the former must be taken into consideration. 
Indeed, contrasting the small proportion of patients 
who develop leucoplasia with the larger number 
who indulge in tobacco and liquor — with or without 
overactive mercurial therapeusis — it is rational to 
infer that, even in cases in which syphilis appears 
to be primarily responsible for leucoplasia, the sub- 
ject is the victim of some peculiar predisposition 
that differentiates him from the average syphilitic. 
In several instances the author's attention has been 
directed to the question of idiosyncrasy as an ex- 
planation for the occurrence of leucoplasia by the 
occurrence of such lesions in non-syphilitic blood 
relations. 

I further say in my text-book : 

"Post-syphilitic leucoplasia is important chiclly 
from the fact that, while its dependence upon syph- 
ilis usually is recognized, the mistake is made of 
believing that the lesions should be quite as tracta- 
ble under anti-syphilitic treatment as other lesions 
of the mucus membranes occurring in this disease. 
These lesions, however, should be regarded as 
essentially non-syphilitic neoplasms occurring upon 
a syphilitic foundation. With this in mind the prac- 
titioner may readily comprehend the correct prin- 
ciples of treatment. Forgetting this, he is likely to 
do the patient incalculable injury through mis- 
guided and enthusiastic efforts to cure the lesions 
by strictly anti-syphilitic treatment. Ordinary local 
treatment simply aggravates the difficulty, as a rule, 
and only the most radical measures are likely to 
be effective. An additional reason for regarding 
these lesions as important, per se, is the indubitable 
fact that they may assume a malignant character. 

According to Hulke,-'' ichthyosis — i.e., leuco- 
plasia — of the tongue consists essentially in "hyper- 
trophy of the epithelial and papillary elements of 
the mucous membrane." The relation of this condi- 
tion of the tongue to syphilis and cancer is very 
important. All authorities unite in acknowledging 
its relations to syphilis — although it may occur in 
non-!;yphilitics. That the condition is prone to de- 
velop epithelial cancer, Weir" long ago showed 
most conclusively by the history of 68 cases, of 
which number 35 eventually developed epithelioma. 

The condition underlying leucoplasia does not 
always develop distinct white plaques of hyper- 
plastic epithelium. Some local perversion of nutri- 
tion may develop fissures of greater or less depth 



and extent, with margins of hyperplastic epithe- 
lium, or the edges of which may have become trans- 
formed by atrophy, presenting a smooth, glazed, 
and dry appearance, the characteristic papillated 
appearance of the tongue being replaced by a 
smooth quasi-mucus surface. In other instances, 
distinct ridges of greater or less extent present 
themselves, particularly along the tongue or the 
inner surface of the buccal mucus membrane at the 
point of contact of the tongue and cheek with the 
teeth. This form of epithelial hyperplasia is espe- 
cially likely to occur in patients overtreated with 
mercury. We find in other instances the classic 
type of leucoplasia formation in which more or 
or less elevated, distinct, whitish plaques of degen- 




=> riiriral Sociftv R.nn.ts, V..1 NI. I). 1. 

»N. Y. Med. Jour., Mar. 18, 1875. 



Fig. 6. Epithelial nests from epithelioma following gumma leuco- 
plasia of tongue removed in Case 6. Sliowing advanced hyaline 
degeneration and characteristic "pearls." (X 275) 

erated epithelial overgrowth are noted. These 
plaques may undergo transformation, and present 
the smooth, reddened, glazed appearance already 
described in connection with fissures. When the 
epithelium is transformed in this manner, lesions 
that are trivial in appearance are the seat of con- 
siderable irritation and pain. Excessive smokers, 
especially, are liable to such lesions. 

The more formidable variety of post-syphilitic 
neoplasm occurs in the form of distinct, circum- 
scribed -nodules of greater or less extent, that have 
a tendency to develop along the margins of the 
tongue, but are often seen upon one or the other 
side of the lingual raphe, in some instances limiting 
themselves entirely to the base of the tongue on 
one or both sides (Figs. 5-7). These lesions are 
very likely to be mistaken for simple gummata. 
Doubtless nodular gummy infiltration is the point 
of departure for the lesion in some instances, but 



Vol. XXIX. No. 2. 



LvDSTON — Pre-Cancerous Lesions. 



Americas 
Journal of Surcfrv. 



39 



instead of resolution, suppuration, or necrosis oc- 
curring, the gummy deposit apparently is removed 
or transformed — at least replaced by connective 
tissue new growth. This may subside to a certain 
extent, but is very likely to i-emain permanently and 
enlarge from time to time, each successive exacer- 
bation being followed by an increase of permanent 
enlargement. Such nodules are to be regarded as 
extremelv dangerous, as it is this form of post- 
syphilitic mucus lesion that is most likely to under- 
go malignant transformation (Figs. 3-7). 

Even a superficial study of these lesions should 
convince the practical clinician that it is but a step 
between these benign epithelial and connective tis- 
sue overgrowths and malignant neoplasm. The 
nodular variety of the atTection especially should 
be regarded as essentially pre-cancerous. In this 
view alone lies the safety of the patient. 




Fig. 7. Epitheliuii.a foiiouing chronic glossitis — with resultant 
macroglossia — and Icucopla^ia in advanced syphilis (Case III). Show- 
ing indurated malignant nodule and areas' of leucoplasia. (From 
sketch by the author.) 

In the treatment of leucoplasia and other pre- 
cancerous states of the mucus membrane, ."^everal 
factors must be taken into consideration, vi : 

1. The possible e.xistence of a certain d' 
activity of the original constitutional t.' 
syphilis. 

2. The question whether syphilis per sr 
long since been eradicated, as a consequt ce of 
which anti-syphilitic treatment will simply add fuel 
to the fire. 

3. The relation of previous anti-syphilitic treat- 
ment — particularly in the direction of overdosing 
with mercury — to lesions present. 

4. The existence of trophoneurosis-' due to syph- 
ilis, treatment, idiosyncrasy, or all combined. 



ee of 

-ble— 

is not 



5. The relation, as etiologic factors, of local irri- 
tants, such as tobacco, lic|uor, highly seasoned food, 
and the application of caustics. 

6. And, most important of all, the circumstance 
that the lesion may require attention as a neoplastic 
entity independently of its relation to any of the 
foregoing factors, with the distinct object in mind 
of preventing transformation into malignant dis- 
ease. 

Apropos of transition epithelioma, I-Viend, in 
Senn's classical work on tumors (189.3), reports 
three cases of lupus vulgaris of the face which 
finally underwent transformation into epithelioma. 
As Friend expresse it: "The lupus furnished the 
locus minoris resist rntiac for the malignant devel- 




^ Vide the author's paper on Tropho-neurosis in its relations to 
the Phenomena of Syphilis. Trans, Southern Surg, and Gynec. 
.■^ssoc. 1890. Also his text book. 1899, and report of case of 
cranial and spinal syphilis. N. Y. Med. Rec, 1914. 



F.g. S. 

opment." I would go even further and state that 
the lupus probably acted directly by vitiating the 
nutrition of the epithelial cells and stimulating them 
— or rather, perhaps, removing the normal nutritive 
inhibition — to rapid multiplication. The result of 
rapid proliferation of degraded cells is too familiar 
to require special comment. The analogy of syph- 
ilis and lupus requires no special comment. 

\'arious other authors have admitted the etiolo- 
gic relation of syphilis to cancer through the me- 
dium of "leucoplakia." Kaposi, Lang, Neumann, 
and GriJnfeld especially have directed attention to 
it. Following Barthelemy. a number of authorities, 
of whom Hutchinson is the most prominent, have 
asserted that syphilis predisposes to tubercle in 
early life and to cancer in later life. 

It is noteworthy that syphilis was at one time 
supposed to be, to a certain extent, antagonistic to 
carcinoma. This fallacy, however, with increasing 



'40 



American 
Journal of Surgery. 



LvDSTON — Pre-Cancerous Lesions. 



February, 1915. 



accuracy of clinical and pathological knowledge, has 
given way to the generally accepted belief that 
syphilis in a measure predisposes to cancer, merely 
by disturbing nutrition. Experienced observers 
have recognized a special factor in syphilis which 
tends to develop cancer and to localize it in the site 
of syphilitic lesions and syphilitic cicatrices. 

At this point 1 desire to make clear my own posi- 
tion as to the "transition" or "metamorphosis" of 
syphiloma into carcinoma. 1 regard the syphiloma- 
tous tissue as merely a nutritionally perverted 
matrix in which the carcinoma develops. To my 
classes 1 have been wont to liken the process to 
the mechanical one of so-called petrifaction of or- 
ganic matter, in which cells and fibers are grad- 
ually replaced by calcific or silicious deposit. The 
direct excitant producing, first, syphilitic; and, sec- 
ond, malignant change, is a matter of indifference. 
All that is necessary is that there shall be an ex- 
citant. 

In a masterly paper read before the Chicago 
Laryngological and Otological Society, Charles M. 
Robertson-' reported four most interesting cases, 
three of carcinoma and one of sarcoma of the 
throat, developing into syphilitic cicatrices. The au- 
thor concludes as follows : "Tumors of such charac- 
ter are probably due to some continued irritation, 
either in the fomi of physiological or chemical 
agents or gummatous areas, which are, by reason 
of their position, most exposed. There is a causa- 
tive feature also in the altered nutrition of the part 
in which embryonic cell poliferation is stimulated." 
"We all must agree that malignant growths may 
and often do succeed syphilitic lesions, especially 
in the tongue and throat, and for this reason the 
prognosis of syphilitic gumma should be guarded. 
In latent syphilis the anti-syphilitic treatment should 
be continued with the thought that its administra- 
tion is prophylactic to malignant growths. In ad- 
dition to specific treatment, it is essential to remove 
all sources of irritation in the way of stimulation, 
traumatisms, the correction of irregular teeth, ai-d 
the prohibition of the use of alcohol and tobacco. 
We should be on the lookout for these complica- 
tions of syphilis, and should they occur, our duty is 
plain in surgical intervention at as early a date as 
possible, for even at the most favorable time we 
are unable to make a favorable prognosis." 

It is especially important to remember that, in a 
measure, irritation bears the same relation to syph- 
ilitic lesions that it does to malignant processes. In 
the presence of constitutional syphilis on the one 
hand, or of cancer predisposition upon the other, a 



2' Malignant Tumors of the Throat, etc., Jour, Ophthal. and Otol., 
November, 1910, 



lesion develops. When syphilis and cancer predis- 
position are combined, local irritation is doubly 
dangerous. 

In my paper of 1889-" and in my text-book-" in 
1899, I wrote as follows in re the relation of cancer 
and syphilis : 

"In recognizing the transformation of syphilitic 
processes into cancer, the author does not claim 
that the histologic elements of syphilis ever are 
transformed into those of cancer, but that the ele- 
ments of syphilis having been removed, the tissues 
are left in such a damaged state that continued 
irritation may result in cancerous degeneration. On 
the other hand, a syphilitic process may recur so 
frequently, and be so obstinate to treatment, that 
the irritation thereby produced is capable of caus- 
ing cancer. 

"It is too soon to discuss the question of the 
existence of special bacilli in syphilis and in cancer 
to disprove the possibility of the transformation 
of the one into the other. It is conceivable that 
both cancerous and syphilitic deposits may act in 
the same manner as other irritating processes. If 
a cancer were present in the mouth of a syphilitic 
subject, syphilitic processes presumably would be 
more likely to develop in the vicinity of the malig- 
nant disease than elsewhere. A somewhat similar 
relation exists between an existing syphilitic lesion 
and the development of carcinoma. Whether or 
not actual transformation occurs, cancer may de- 
velop in tissues indubitably afifected by syphilis, and 
cancer go on to destruction of tissue and finally 
prove fatal, and without any preliminary change in 
the physical appearance of the tissues affected by 
syphilis prior to the development of cancer. 

"To put the matter of transformation of syphilis 
into cancer concisely, the author does not believe 
that syphilitic cells can possibly be transformed into 
cancer-cells, but holds that the irritation of the 
tissues produced by the former may, in the pres- 
ence of favorable constitutional and local condi- 
tions, develop a new process of tissue-building or 
neoplastic deposit resulting in the formation of 
cancer-cells, merely from the changes excited in 
the epithelium." 

Ribbert's theory is interesting. He holds that 
there is a peculiar relationship between the base- 
ment membrane and the underlying epithelial cells, 
which, if disturbed, leads to active proliferation of 
the latter, with resulting invasion of the deep struc- 
tures and the development of malignancy. 

It is probable that in some cases in which cancer 
and syphiloma are found in the mouth of the same 

=» Med. Rco., N. Y., Aug. 26, 1889. 

=" Genito-Urinary, Venereal and Sexual Diseases, 1899. 



Vol. XXIX, No. 2. 



L^i-ps rn.\ — Pre-Cancerous Lesions. 



auerican 

Journal of Surgery. 



41 



subject, the relation of the two diseases is purely 
coincidental. When, however, a carcinoma super- 
venes upon syphilitic lesion, or upon the scar of 
an antecedent lesion, it is safe to rule out coinci- 
dence. Leucoplasia predisposes to cancer irrespec- 
tive of the cause of the process. Leucoplasia, after 
all, is really a hyper-keratosis of the mucosa, anal- 
ogous to that occurring in the skin, there probably 
being in some cases merely a more definite chronic 
inflammatory character to the process than in tlie 
case of the integument. 

Butlin'" reports four cases of "leucoma" or "leu- 
coplakia" of the vulva, the first complicated with 
an ulcer which probably was cancerous, and the 
other three with undoubted cancer: "The plaques 
formed only on the mucus surface, not on the skin, 
and in app>earance, feel, and variety of form were 
precisely similar to the white plaques which form 
upon the mucus membrane of the mouth. In two 
instances the vulva and the mouth were attacked 
in the same patient. It seemed that the disease 
was identical in both situations, and if so the im- 
portance of tobacco and of the direct contact of 
alcohol as factors in the production of the disease 
have been overestimated. There was no reason in 
any of these cases to suspect syphilis, either inher- 
ited or acqitired.^^ Gout or rheumatism seemed to 
possibly be an etiological factor in these cases. The 
signs of inflammation were so little evident in sec- 
tions of the leucoma of the vulva that the condition 
seemed more like a degeneration than an inflamma- 
tion, or even the result of past inflammation. Since 
the altered surface evidently predisposes to the 
development of cancer, it would seem wise to freely 
remove all such plaques from the vulva, even if 
there are no signs of cancerous changes." 

Butlin's cases obviously are inconclusive. I pre- 
sent them merely because of their suggestiveness. 
My italics indicate tlie diagnostic fallacy. The fact 
that the conditions found in the mouth and the 
vulva were the same is no argument against the 
etiologic importance of alcohol and tobacco in the 
case of leucoma of the mouth. It shows merely 
that irritation produces serious results in both lo- 
calities. 

I wish to remark in passing that not all white 
patches of the mucosa, and especially of the geni- 
talia, are true leucoplasia. White areas occasion- 
ally are seen which are identical with leucoderma. 
In some instances this condition is teratological. I 
recall a case of a young woman the upper surface 
of whose tongue from birth suggested leucoplakia. 



This never had given rise to any discomfort and, 
under the most rigid analysis, there was no sus- 
picion of syphilis. I have observed many instances 
of patches of white or pinkish white follicles of the 
mucosa which were innocuous. 

It is not only in the mouth that a distinct etiolo- 
gic relation of syphilis to cancer is seen. In a case 
which fell under my observation — a man only 33 
years of age — epithelioma supervened upon a typic 
Hunterian chancre in the fossa glandis. The 
chancre was followed by classical syphilis. The 
penile lesion did not heal, but underwent a "fun- 
goid" transformation resembling simple papilloma. 
I finally e.xcised the lesion, but the histologic diag- 
nosis was unsatisfactor}' and as healing was prompt 
I did not suspect carcinoma. Three months later, 
however, the process recurred, and the microscope 
showed t\pic epithelioma. Operation was refused, 
the inguinal glands became involved, and the pa- 
tient died several months later of repeated hemor- 
rhages. 

Schmidt's case^- is interesting in this connection. 




Fig- 



Cross section of specimen of tongue removed in Case III. 



The early age of my patient was an instructive fea- 
ture of the case. The practitioner is too frequently 
misled by the comparative youth of some patients. 
The author recalls a lamentable case of rapidly 
fatal epithelioma of the lip in a man of 40, and 
another of the cen'i.x in a woman of 24. 

Either epithelioma or sarcoma may follow syph- 
ilitic lesions of the tongue, but in the cases in which 
sarcoma develops, it is my opinion that it most fre- 
quently will be found to have followed gumma — 
and especially where intercurrent attacks of glossitis 
have occurred — rather than leucoplasia, and that 
where leucoplasia pre-existed it was associated with 
gumma. 

According to my observation, the progress of the 
syphilitic tongue toward malignancy often is marked 
by recurrent attacks of more or less acute difTuse 
glossitis. This may involve the tongue in part 



» British Med. Jour.. July 13. 1901. 
^ Italics mine. G.F.L. 



*2 O. L. Schmidt: Case of Syphilitic Initial Lesion Followed by 
Epithelioma. Jour. Cut. Dis., N. Y., 1907. 



42 



American- 
Journal oi" Surgery. 



LvDSTOx — Pre-Cancekous Lesions. 



February, 1915. 



or in its entirety. Each attack leaves the organ in 
a more susceptible condition, to both additional 
syphilitic lesions and to future complicating glos- 
sitis. The tongue may be increasingly and perma- 
nently more or Jess englarged — macroglossia. 
Kcienig^^ also has called attention to this point, at- 
tributing to attrition by the teeth the intercurrent 
attacks of glossitis producing the macroglossia. 

Gumma of the tongue, especially, is prone to in- 
flammatory complications. The sclerosis that fol- 
lows glossitis is a condition which, in the presence 
of the special cancerous predisposition, particularly 
favors the development of malignancy. 

The exciting causes of intercurrent glossitis in 
syphilis of tlie tongue comprise irritants of all kinds. 
The ill-advised use of caustics, septic infection, and 
mercury are the chief of these. Patients under the 
full influence of mercury always are on the verge 
of inflammations of the tissues and organs of the 
mouth. 

Intercurrent glossitis in syphilis of the tongue 
may prove fatal, as shown by a case of my own.^* 
A man of di7 . suffering from chronic mucus patches 
and ulcers of. the tongue, became infected by hold- 
ing in his mouth for several hours while hunting 
some small rifle cartridges. Within 24 hours acute 
glossitis set in, the inflammation extending, 48 hours 
later, to the larynx and producing odenia of the 
glottis. I finally performed a tracheotomy, but the 
operation proved to be merely palliative. Death 
occurred from exhaustion 12 hours later. Whatever 
chance for his life this patient might have had was 
lost through a "conservative" consultant who re- 
fused to permit early free incisions to be made in 
the tongue. 

In the differential diagnosis of lesions of the 
tongue, the value of the microscope often consists 
chiefly in confirming the clinical diagnosis after it 
is too late to accomplish much by operation. \\'here 
a superficial neoplasm or ulcer matures early, the 
diagnosis may be made comparatively early by the 
microscope, but such lesions should not be allowed 
to progress to a mature condition. They would 
better be removed as soon as they are proved to 
be resistant to ordinary measures of treatment. 

The rapid course of carcinoma of the tongue is 
in itself suggestive of the danger of waiting for a 
microscopic diagnosis in cases which clinically seem 
to warrant operation. The large majority of the 
unoperated die within twelve months. Unoperated 
cases differ only as to the time of death. They all 
die. 



•••' Lehr. dfr Spec. Chir., 1878. 

** .Acute Septic Glossitis, followed by Oedema Glottidis, Western 
Med. Reporter, January, 1885. 



As to the Wassermann test, it frequently is fal- 
lacious. Syphilis of the mouth and tongue often 
leads to cancer, and in such cases a positive Was- 
sermann merely shows that the patient is still syph- 
ilitic — actively so. A positive Wassermann in 
doubtful cases warrants thorough anti-syphilitic 
treatment — indeed, a negative does not contraindi- 
cate it — but if the response is not prompt, operation 
is indicated. It indicates also the continuation of 
treatment after operation, even in indubitable 
cancer. 

In cases in which carcinoma develops in a syph- 
ilitic, with no relation of the one disease to the 
other — e.g.. in a carcinoma developing in a recent 
syphilitic — or in which syphilis is contracted by a 
carcinomatous subject, the W'assermann may be 
especially misleading. Examples of both these 
sources of confusion are met with. 

And there is another side to the story : The fact 
that the W'assermann test is unreliable in certain 
special conditions in no wise proves that the test 
should be relegated to the limbo of the forgotten. A 
few months since I heard a distinguished ])rofessor 
of surgery publicly condemn the ^^'assermaIm as 
worthless, because, forsooth, he had operated upon, 
first, a brain tumor, in which there had been three 
positive Wassermanns, and found the tumor to be a 
glioma; second, upon an ulcerated tumor of the 
tongue in which there had been several Wasser- 
manns, but which proved to be carcinoma. As to 
how he arrived at the conclusion that glioma or 
carcinoma should insure against the existence of 
syphilis, the distinguished surgeon did not state. 
His experience proved, not that the Wassermann 
was worthless, but merely that the test was an un- 
safe guide in the cases mentioned, simply because 
syphilis co-existed respectfully with glioma and 
carcinoma. He overlooked the possible etiologic 
relation of syphilis to the carcinoma of the tongue. 

If the promptness with which epithelioma of the 
tongue invades the neighboring lymphatics were 
more generally understood, operation on the aver- 
age would not be so long delayed. The time is past 
for the "simple infection and inflammation" explan- 
ation of lymphatic enlargements beneath the jaw 
in suspicious lesions of the tongue. 

In passing, it may be well to remind the general 
practitioner that adenopathy in suspicious chronic 
lesions of the tongue is in general evidence against 
syphilis and in favor of malignancy, if chancre can 
be excluded. The lesions of late syphilis are not 
attended by adenopathy, save when mixed infection 
is superadded, as is sometimes the case if the tongue 
lesion be irritated, by caustics or otherwise. 



Vol. XXIX, No. 2. 



Lydston — Pre-Cancerous Lesions. 



.^MERICAN 

Journal of Surgery. 



43 



The fallacy of attempts at tlie removal of stub- 
born syphilitic lesions by internal medication or by 
caustics should at once be obvious, but, unfortun- 
ately, the profession at large has not yet learned its 
lesson, much to the detriment of surgerj' and at 
great cost to the laity. Possibly if the profession, 
in certain conditions, regarded minor operations 
on the tongue as the best prophylaxis of malignant 
disease, many valuable lives might be saved. The 
careful early e.Kcision of leucoplasic areas and stub- 
born gummata is the keynote of tongue cancer sur- 
gery. A comparatively trivial operation ofttimcs 
will save life. 

Apropos of "prc-cancerous" lesions of the mouth. 
tongue and throat in general, the best time to oper- 
ate upon cancer is when doctors are differing as 
to the nature of the lesion. The older members of 
the profession will recall the differences of learned 
opinion in the cases of General Grant and the 
Emperor Frederick. The outcome of these cases 
was merely that which is usual in such diagnostic 
controversies. 

Extirpated doubtful lesions are the most praise- 
worthy kind, especially when, as usually is the case, 
the patient is entitled to the benefit of the doubt. 
Allowing patients to die without a rational attempt 
to save life whilst waiting for a microscopic diag- 
nosis of malignancy, which diagnosis may lie in the 
realm of impossibilities, possibly may by ultra- 
scientific, but it certainly also is ultra-foolish. 

Butlin's personal statistics,^^ especially, give evi- 
dence of the safety of o|>erations upon the tongue. 
In one of his earlier papers he recounts 46 cases 
of removal of one-half or the whole of the organ, 
with but one fatal result. As for the minor resec- 
tions, they are practically absolutely safe. 

Later, Butlin^^ further cites Whitehead-'" with 
139, Kocher^* 59, Kronlein^' 33, and himself" with 
102 cases of operation, 333 in all, showing llyi per 
cent', of mortality, which is reduced to 7 per cent, 
for the uncomplicated and raised to 25 per cent, for 
the more seriously complicated operations. 

The post-operative results in the foregoing cases 
showed that 20 per cent, were alive and well or 
•died of other diseases more than three years after 
operation, a number of others being alive and well 
from one to three years after operation, but not to 
be counted as cures until the generally accepted 
cancer "recurrence limit" of three years had been 
reached. 



== Brit. Med. Jour., Apr. 14, 1894. 

** Dis. of Tongue. 

" Lancet, vol. I. 1S91. 

"Sachs: Langenbeck's Arch., vol. .\LV. 1893. 

«»Beitrage z. Klin. Chir., vol. XVII. 1896. 

» Brit. Med. Jour., vol. I. 1898. 



Cases alive many years after operation are re- 
ported by numerous authors. Jonathan Hutchin- 
son" reports a number as living at the end of 8 or 
10 years and one 19 years. Buchanan,^- one living 
30 years; Heath,'"'' one 23 years and one 15 years; 
Spencer,*' one 12 years: Stonham," one 13 years; 
Whitehead,''" one 14 years; Wheeler," one 15 
years; Krtinlein,'"' one 12 years; and IJutlin,''" one 
13 years. 

Although the lapse of years after operation is 
increasingly suggestive of a permanent cure, recur- 
rence after a long period of time occur sufficiently 
often to warn us against too great optimism. Thus 
Pean''" reports a case of recurrence after 15 years 





Fig. 10. Epitheliorra of tongue in late syphilis. Showing super- 
ficial necrotic area with chronic inflammatory intiltration beneath it, 
of specimen removed in Case III. No evidence of malignancy. 
(X 53) 

Kocher,'"' one after 10 and another after 12 
years; and Crerar,^- one after 6 years. 

Contrasting the results of non-interference with 
the average prolongation of life by operation, even 
an occasional error in diagnosis followed by opera- 
tion would not weigh much in the balance of life 
saving. 

The fact that lymphatic invasion occurs early em- 
phasizes the advisability of cleaning out the tissues 
beneath the jaw as a systematic procedure in oper- 
ating upon the tongue for malignant disease, 
whether perceptible gland involvement exists or not. 



1 Arch. Surg., 1898, and Clin. Jour., 

= Edin. Med. Jour., 1894-5. 

'Lancet, 1899, and Trans. Path. Soc, 

' Quoted by F.utlin. 

• Trans. Clin. Soc. Lond., 1886. 

'Lancet, 1888 and 1891. 

' riub. Torr. Med. S<■^. i8'>-. 

'Bindef: Eeitr. z. Klin. Chir., 1896. 

' Dis. of the Tcnjiue. 

' Lc' • ns d» Cl-n. Chir.. 1892. 

1 Sachs, .'^rch. f. Klin. Chir.. 1893. 

■• Brit. Med. J,.ur.. 1885. 



1876. 



44 



American 
Journal of Surgerv 



Lydston — Pee-Cancerous Lesions. 



February, 1915. 



The abundant lymphatic supply of the sublingual 
and submaxillary salivary glands should at once 
suggest their routine removal because of their be- 
ing an especially dangerous source of recurrence. 

It is not my intention here to enter into the merits 
of the various standard operations for lesions of 
the tongue. My own custom is: 

1. To give the patient, by operation, the benefit 
of reasonable doubt, where a microscopically "be- 
nign" lesion grows progressively worse despite 
proper treatment. 

2. To resect with knife or scissors all "pre-can- 
cerous" or obstinate and suspicious lesions, espe- 
cially post-gummatous sclerosis and leucoplakia. 

3. To remove half the tongue when it is reason- 
ably certain that a given lesion of the organ is 
malignant and the case is seen early enough to war- 
rant a limited operation. 

4. To remove the entire tongue in more advanced 
cases. 

5. To clean out the tissue beneath the jaw, in- 
cluding the salivary glands, on one side in the 
limited, and on both sides in the advanced cases. 

The galvano-cautery loop, the ecraseur, and the 
Kocher operation all have their range of applica- 
bility. The preliminary ligation of the lingual or 
ranine arteries is not always necessary. A rapid 
and safe operation can be done from within the 
mouth by using forceps in a fashion similar to that 
employed in vaginal hysterectomy, the forceps be- 
ing allowed to remain in situ for from 24 to 48 
hours. Rapid operation sometimes is very essen- 
tial. In many cases the patient is greatly debili- 
tated from the following factors : 

1. Lack of proper alimentation. 

2. Digestive disturbance. 

3. Hemorrhage. 

4. Pain and lack of sleep. 

5. Depression incidental to a knowledge of the 
true condition. 

6. Sepsis. 

7. Most important of all, the untoward efifects 
of vigorous anti-syphilitic treatment. 

Such favorable results as have been recorded in 
early cases are not to be expected in advanced cases, 
merely because of the conditions mentioned in the 
foregoing. 

In presenting cases illustrative of the subject dis- 
cussed in this paper, I have selected merely a few 
of a typic character, illustrating: 

1. The importance of sypliilis as an etiologic fac- 
tor in malignant disease of the tongue. 

2. The difficulties of diagnosis. 



3. The fallibility of microscopic study of the 
lesions prior to complete operation. 

4. The advisability of radical treatment, by sur- 
gical measures, of all obstinate syphilitic lesions of 
the mouth and especially of the tongue. 

5. The importance of early operation in suspi- 
cious lesions. 

6. The wisdom, in many cases, of relying on the 
clincal aspect of the case, irrespective of the results 
of the Wassermann, or of the microscopic study 
of the lesions prior to complete removal. 

Case I : Sarcoma of the tongue, following syph- 
ilis."^ 

A man 29 years of age. Gambler. Good family 
history. Contracted syphilis at the age of 18. Sec- 
ondary symptoms appeared about four months after 
the initial lesion, a pronounced papulo-pustular 
eruption appearing and resulting in considerable 
scarring of the skin. Multiple mucus patches de- 
veloped and were very annoying, especially those 
upon the tongue. A thorough course of mercury 
was given for three months, after which he went to 
the Hot Springs, where for three months he was 
rubbed with an enormous amount of mercury, and 
twice badly salivated. Two months later eruptions 
again appeared upon the body, with larger mucus 
patches than before, the tongue giving considerable 
trouble, evidently from glossitis. A troublesome 
old eczema of the hands now developed. He re- 
turned to the Springs and remained there for eleven 
weeks, taking large doses of mercury internally. 
He returned home and was apparently well for 
three months, when mucus patches and eruptions 
appeared, "sores" now appearing on the penis. 

Five years after the beginning of the syphilis the 
patient fell under care of a physician who for six 
months again freely rubbed him with mercury. 
He improved for a time and then quiet treatment, 
but, later, growing worse, returned to the same 
physician and for at least eighteen months took 
mercury freely. 

A year later — eight years after contracting the 
disease — the patient consulted me for the first time. 
He then had unequivocal cerebral syphilis — pachy- 
meningitis — and tuberculo-squamous syphilides -uf)- 
on the forehead, forearms, and legs ; the tibiae 
and sternum were excessively tender, with osteoco- 
pic pains. Cephalalgia was constant and intense. 
A gummy ulcer with several fissures existed upon 
the penis just back of the corona. 

The tongue was rough and coated with a thick, 
dirty, yellowish-gray fur, with marked dryness in 
the center and anterior part of the organ. The 
tongue showed several sclero-gummous nodules, one 
in the center of the organ and the others near its 
base. The lesions resembled those shown in fig- 
ure 5. The patient admitted that the tobacco and 
alcohol habits had been persisted in for a great 
portion of the time that he had been under treat- 

" Malignant Transformation of Syphiloma of the Tongue. Am- 
putation of Tongue by Galvano-Cautery. Reported in N. Y. Med. 
Record, Oct. 26, 1889, and in the author's text book on Genito- 
urinary, Venereal and Sexual Diseases, 1899, pp. 442-5. 



Vol. XXIX, No. 2. 



Lydston — Pre-Cancerous Lesions. 



American 
Journal of Sukgery. 



45 



ment, and, strange to say, stated that his physicians 
had not restricted him in his indulgences. 

Treatment was now very vigorous. Codliver-oil 
and iron were ordered on account of marked de- 
bility. The mixed treatment and potassic iodid in 
saturated solution were given, the dose of iodid 
being rapidly increased to 300 grains per diem, and 
continued for three weeks with no results until the 
end of that time. Local applications of acid nitrate 
of mercury were made to the tongue from time to 
time, with apparent benefit. When the symptoms 
improved iodid was diminished to 60 grains per 
day, the tonics being continued. 

At the end of three months the patient was free 
from trouble, save that his tongue was more mark- 
edly psoriatic than ever, the nodules upon its sur- 
face being still perceptible. This condition never 
disappeared entirely. 

The case remained comparatively well for some 
months, the tongue creating some uneasiness from 
time to time on account of commencing ulceration 
of the nodules, which at first rapidly yielded to 
treatment. Finally, however, the nodules and fur- 
ring of the tongue became more prominent, and re- 
mained so in spite of treatment, and furring becom- 
ing a sort of membranous deposit like wet chamois- 
leather, that reformed as fast as it was reinoved. 
The patient now again went to Hot Springs. 

A short time later, while the patient was at the 
Springs, under the care of the late Dr. S. S. Vaughn, 
the tongue swelled considerably, the nodules began 
to ulcerate, and at one time a severe hemorrhage 
occurred. 

After all means of treatinent had been tried for 
two months without avail, the case was pronounced 
probably cancerous and Dr. Vaughn referred the 
case to the author for excision. 

Upon examination the tongue was found filling 
the mouth and pressing upon the teeth in such a 
manner that it had become eroded and ulcerated by 
them — subacute diffuse glossitis. Salivation was 
profuse ; a deep sloughy ulcer existed at the center 
and back part of the organ. There were no other 
lesions on any part of the body. Several micro- 
scopic examinations failed to demonstrate malig- 
nancy. 

As the patient experienced great difficulty in mas- 
ticating and swallowing, he was subsisting entirely 
upon fluid food, and not being primarily ver\' ro- 
bust, had become emaciated. The treatment insti- 
tuted was chiefly tonic and supportive, in conjunc- 
tion with sodium iodid. Local applications were 
made of a compound of carbolic acid, iodin, and 
menthol in mild strength. 

Improvement at first was rapid and within a 
week the tongue was reduced to nearly its normal 
size. In a few days, however, it again suddenly 
enlarged — acute diffuse glossitis — upon the right 
side, being at least double the thickness upon the 
right side that it was upon the left. This condi- 
tion soon subsided, but was succeeded by enlarge- 
ment of the nodules previously mentioned, several 
new nodules appearing on the upper surface of the 
tongue. 

Within a few days the left side of the tongue 



underwent a similar diffuse enlargement, which 
also subsided and was succeeded by the development 
of nodules. The whole tongue now became so 
swollen that it hung over the edges of the teeth, 
protruding through the spaces left by extracted 
teeth. There was little or no pain and such as there 
was was referred by the patient to the "holes" 
worn in the tongue by the teeth. Speech was so 
impaired that the patient resorted to sign language. 

The case went on from bad to worse — many dif- 
ferent plans of treatment being tried without avail. 
Sloughing began and continued until the tongue 
was in such a condition that even if healing had 
been possible the organ would have been practi- 
cally useless. The base of the tongue was a foul 
mass of hyperplastic ulcerating tissue, the odor and 
secretion of which were not only offensive to the 
patient and others, but also prominent factors in 
producing the constitutional disturbance. 

There seemed to be no hope of benefit from 




Fig. 11. Showing deeper area of specimen in Case III. No evi- 
dence of malignancy. (X 53) 

treatment and the malignancy of the process apK 
peared to be now clinically established, although 
microscopic evidence was wanting. As the patient 
was anxious to have something done to remove the 
foul and stinking mass from his mouth, I per- 
formed complete excision with the galvano-cautery. 

At the end of a week the eschar produced by 
the cauterization became detached, without hemor- 
rhage, and left a fairly healthy surface ; the fetor 
of the breath was gone, and the sloughing at the 
base of the tongue had ceased. The floor of the 
mouth healed nicely and remained in a tolerably 
healthy condition for several weeks. The general 
condition of the patient improved considerably and 
he could talk surprisingly well. 

The late Dr. I. N. Dan forth examined the ex- 
cised specimen and pronounced it of a "sarcoma- 
tous character," but atypic. 

About a month after the operation the submax- 
illary glands and retro-maxillary glands became en- 



46 



American 
Journal of Surgery. 



LvDSTON — Pre-Cancerous Lesions. 



February, 1915. 



larged and quite tender. There was a moderate 
degree of cephalalgia and otalgia. The ulcerative 
process on the floor of the month recurred, but did 
not progress rapidly nor ulcerate extensively. A 
small ulcer formed upon the right pillar of the 
fauces. These sypmtoms practically settled the 
question of malignancy. Two months later an ab- 
scess formed in the submaxillary lymphatic glands. 
This, when opened, gave exit to a thin, sanious 
fluid. Pain was now very severe. At the end of 
three months occasional hemorrhages from the 
mouth began. The patient finally died, four months 
after the operation and four years from the time 
he first consulted me, from a sudden hemorrhage — 
probably from the internal carotid — during the 
night. 

This unfortunate case is interesting in many re- 
spects. During its course there developed distinct- 
ive features of several forms of glossal pathology. 
During the period that the patient was under my 
observation, the tongue presented gummy nodules 
and ulceration, lingual psoriasis — leucoplasia — dif- 
fuse syphilomatous deposit, and recurrent attacks 
of glossitis. Until sloughing began it resembled 
Case II (Fig. 5). At various times before coming 
under observation, and probably once afterward, 
as shown by the history, mercurial stomatitis oc- 
curred and fonned an important feature of the 
case, particularly as regards the etiology of the 
process that finally necessitated removal of the 
tongue. Prior to extensive destruction of the organ, 
these various conditions merged into a general hy- 
perplasia, followed by sclerosis, the tongue being 
extremely indurated. What little chance this pa- 
tient may have had for recovery, or even for a 
considerable prolongation of life, obviously was lost 
through failure to recognize early and remove the 
pre-cancerous lesions. To the author, the lesions 
taught by the case proved invaluable. 

C.\SE II: A man 63 years of age. Speculator. 
One maternal uncle died of cancer. The case had 
been under my observation for more than thirty 
years. When I first saw him he was suffering from 
tertiary syphilis with varied but typic manifesta- 
tion. Obstinate mucus patches of the mouth, tongue 
and throat were most annoying. He had been a 
heavy smoker, but he did not drink. The surface 
of the tongue was congenitally malformed (Fig. 1). 
The patient was negligent and treatment spasmodic 
during my observation of the case. 

Some twenty years before the finale, leucoplakic 
areas, fissures, and gummata developed on the 
tongue. These yielded to treatment or were ex- 
cised. Seven years before the tongue lesions de- 
veloped malignancy, I removed the patient's lip for 
epithelioma, cleaning out the tissues beneath the 
jaw on the left side, corresponding to the lesion, 
and submentally across to the opjwsite side. There 
was no adenopathy. The submaxillary and sub- 
lingual salivary glands were removed. At the same 



time I removed a huge lipoma from the neck and 
interscapular region, operation upon which hitherto 
had been obstinately refused. 

The epithelioma of the lip appeared denovo; 
there had been no preceding labial lesion, syphilitic 
or other. The patient had stopped smoking some 
years before the epithelioma appeared on the lip. 
Cancer predisposition undoubtedly underlay this 
case. 

Recovery was prompt and there was no recur- 
rence of the epithelioma. The patient finally sought 
other advice for his tongue, which had grown stead- 
ily worse from lesion development and intercurrent 
glossitis. He returned to me, however, at the end 
of a year — about October 1, 1913. The appearance 
of the tongue at this time is shown in figure 5. In 
a general way, the macroscopic appearance was not 
unlike that of Case I, in its advanced stages. 

Anti-syphilitic treatment, and especially potassic 
iodid, had been carried to the maximum, with steady 
change for the worse. Anemia and debility from 
lack of proper nourishment and the effect of drugs 
was marked. Repeated microscopic examinations 
failed to show malignancy and the Wassermann 
was distinctly positive. 

I put the case upon tonics and administered sal- 
varsan three times within eight weeks, with no re- 
sult. Meanwhile several necrotic areas appeared 
upon the tongue. The glands beneath the jaw were 
not enlarged. Although the microscopic report still 
was negative, a diagnosis of malignancy now was 
made and operation proposed and consented to. I 
performed a Kocher operation December 30, 1913, 
with ? preliminary ligation of the lingual arteries 
and cleaning out of the submaxillary spaces. The 
patient did not react and died of shock 24 hours 
after operation. Should I operate another case of 
a similar nature, I should either proceed by two 
stages ; first, cleaning out the tissues beneath the 
jaw and ligating the Unguals, and removing the 
tongue later, after recovery from the effects of the 
first operation, or do a rapid excision from within 
the mouth. The shock of a complete operation is 
too severe where the general condition is as bad 
as it was in this case.^'' 

The microscopic examination of sections taken 
from the deeper portion of the removed organ 
showed typic epithelioma. Figure 6 beautifully 
shows a series of epithelial nests from one of these 
sections. 

Case III : Epithelioma of the tongue following 
leucoplasia bnccalis, labiaJis et Unrfualis. 

A man 53 years of age, merchant, no history of 
cancerous heredity, with a more or less obscure 
history of lues thirty years before, consulted me 
for leucoplastic lesions of the oral cavity. The 
tongue, lower lip, and inside of the left cheek pre- 
sented incipient but typic leucoplasic areas. 

There was a moderate diffuse chronic glossitis. 
The patient was a very excessive smoker and a so- 
called temperate drinker. Wassermann was posi- 
tive. The patient was advised of the dangers of 
the condition and specific treatment was given, with 

"* T note that Butlin favors the "two stage" plan — with a fort- 
night interim — ^in complicated cases. 



Vol. XXIX, No. 2. 



Lydston — Pre-Cancerous Lesions. 



American 
Journal of Surgery. 



47 



tlie understanding that, if the condition did not 
promptly improve, the involved areas were to be 
excised. Special emphasis was laid upon the dan- 
ger of the development of malignant disease. 

Unfortunately, as the sequence proved, improve- 
ment occurred, and the patient consecjuently mini- 
mized the importance of the warning and advice 
given him. lie also, I suspect, rebelled against 
the proscription of alcoholics and tobacco and 
finally changed medical advisers. A year and a 
half later he again consulted me for an indurated 
ulcer upon the left margin of the tongue, at about 
the junction of the anterior with the middle third 
of the organ. There also were several areas of 
leucoplakia (Fig. 7). There was no glandular in- 
volvement. 

The ulcer had begun developing several months 
after I last saw the case and had been most i>er- 
sistently and thoroughly treated with mercury and 
iodid for gumma, which it resembled sufficiently to 
account of the error usually committed in such 
cases. 

Despite the negative microscopic evidence and 
the known existence of lues, I regarded the lesion 
as either malignant, or at least "pre-cancerous," and 
advised resection of the tongue. To satisfy the 
patient, incidentally to strengthen my position re- 
garding the diagnosis, I administered two doses of 
salvarsan and a four weeks' intramuscular course 
of mercury salicylate. Conditions growing worse 
instead of better, I advised immediate operation, 
which was consented to. 

August 4, 1913, I removed the left half of the 
tongue intraorally by ecraseur and scissors and 
cleaned out the submaxillary region from the right 
of the middle line in front, back to the posterior 
maxillary space, including the corresponding sub- 
maxillary and sublingual salivary glands. A little 
more than one-half inch of the remaining portion of 
the tip of the tongue also was excised. There was 
but one bleeding point^ — the left ranine artery — 
which was troublesome. This was caught with for- 
ceps and the instrument left in situ for 36 hours. 

Healing of both wounds was prompt, as is usual 
in such cases, and at present writing, seventeen 
months after the operation, the patient is perfectly 
well. Figure 8 shows the appearance of the healed 
remaining portion of the tongue. Speech is but 
slightly impaired. 

Several leucoplastic areas on the lip and cheek 
have been excised at various intervals since the re- 
moval of the tongue, none having been apparent for 
some months. Anti-syphilitic treatment has been 
intermittently continued. 

Figure 9 shows the macroscopic appearance of a 
cross section of the removed portion of the tongue. 
At A is seen the area of destruction. 

Figures 10-11-12 show the microscopic charac- 
ters of the specimen. It will be seen that in the 
superficial section fFig. 10) there are no evidences 
of malignant change. The same is true of figure 11, 
which was taken from about the center of the 
specimen. 

Figure 12, however, which was taken from the 
deepest part of the specimen, shows typic epithe- 



lioma. It is important to note also that the younger 
nests are those farthest removed from the bottom 
of the section, the evidences of hyaline degenera- 
tion, i.e., the characteristic "pearls," being located 
below. This probably is explicable by a metastasis 
via the lymphatics, the perverted cells lodging in 
the deeper portion of the tissue and extending up- 
ward by contiguity in the direction from which they 
came. 

It w'ould be difficult to present a case which would 
more lucidly show the fallacy of relying entirely 
upon the microscope for an ante-operative diagnosis 
of a suspicious lesion of the tongue. It also will 
be noted that the Wasscrmann test in such cases 
would be likely to be misleading, rather than helpful. 

The prospect for a permanent cure is at least 










7 



Fig. 12. Section from deepest pt.t of specimen removed from 
Case III. Showing various stages of epithelial proliferation and de- 
generation, hyaline degeneration being advanced, and epithelial nests 
characteristic, in direct ratio to distance from the periphery of the 
affected portion of the tongue. (X 56) 

hopeful in this case, thanks to the clinical diagnosis 
alone. 

C.\SE IV: Seen in consulation. A man of 45, 
merchant, with good family history, had been for 
about four years under the care of a ver)- compe- 
tent surgeon for indubitable syphilis. During this 
time lesions of the tongue had been very annoying. 
For two years the patient had been under constant 
treatment for "gumma" of the tongue. During this 
time he had on several occasions been seen in con- 
sultation by a very eminent and experienced surgeon 
and teacher. Specific medication had been given 
ad max. with appropriate local measures, but the 
case grew progressively worse. There was moder- 
ate macroglossia with a number of nodules, some 
of which were sloughing, and a necrotic area of 
considerable size on the upper surface of the 
tongue. The breath had the fetor usual to such 
conditions. There was no adenopathy. The pa- 
tient w-as distinctly cachectic and suffering from 
unilateral otalgia, chiefly at night. I promptly made 



48 



American 
Journal of Surgery. 



Lydston — Pre-Cancerous Lesions. 



February, 1915. 



a diagnosis of carcinoma. "It cannot possibly be 
carcinoma," said his physician. "Why, we have 
had eleven microscopic examinations of the tissue 
and all were negative." 

"Just the same," I replied, "it is carcinoma. 
Sloughing has begun and at any moment may lead 
to serious hemorrhage and an emergency operation. 
I should advise immediate removal of the tongue." 

Later I met the consultant, who made the same 
comment on my diagnosis, including the enumera- 
tion of the microscopic examinations and their re- 
sults. I still insisted that my diagnosis was cor- 
rect. The patient declined operation and imme- 
diately went to New York and consulted the late 
Dr. William T. Bull, who, I believe, confirmed my 
diagnosis. Operation still was refused and the pa- 
tient returned to his home in Ohio. 

Within a week after I saw the case, an uncon- 
trollable hemorrhage occurred and the consultant 
to whom I have referred was compelled to perform 
an emergency operation. The patient died from 
renal complications on the eleventh day. 

The physician in charge reported that micro- 
scopic examination of deep sections of the tongue 
specimen showed typic malignancy, the case prob- 
ably being histologically similar to Case III (Figs. 
9, 10, 11, 12), which readily explains the error in 
the early diagnosis. 

Case V: A woman 48 years of age — a prostitute 
— appeared at my clinic with tertiary squamae — 
"psoriasis" — of the palms and soles, a "tubercular" 
shyphilide of the face and chronic mucus patches 
and ulcers of the tongue. Family history free from 
cancer. The patient smoked cigarettes inordinately 
and indulged in liquor to excess. Treatment having 
given relief, the case passed from under observa- 
tion. Two years later she consulted me for lingual 
leucoplasia and a small, indurated, circular, ulcerat- 
ing plaque about 15 mm. in diameter on the tip of 
the tongue. There was no adenopathy. The micro- 
scope showed typic malignancy (epithelioma) and 
an advanced superficial sclerosis and keratosis 
(Figs. 4-13). Operation was advised and con- 
sented to. A little more than an inch of the an- 
terior portion of the tongue was removed and the 
leucoplastic areas excised. The submaxillary spaces 
were not cleaned out, because of the patient's oppo- 
sition to remaining in hospital. Healing was 
prompt and, while the case remained under my ob- 
servation, a period of some ten months, there was 
no recurrence. At this time speech was but slightly 
impaired. I do not know the final outcome of the 
case, as the patient drifted away and, I believe, left 
the city. 

The advanced stage of hyaline degeneration and 
absence of adenopathy and the small size of the 
malignant lesion are noteworthy. 

Malignancy following syphilitic leucoplasia is by 
no means limited to the tongue. The author has 
had two cases of epithelioma of the cheek, one of 
which involved the floor of the mouth and gums, 
and several of epithelioma of the lip, in syphilitics, 
which were preceded by leucoplasia. The first men- 



tioned of these cases was peculiarly distressing to 
me, as the patient was an intimate friend who had 
been under observation and careful supervision for 
twenty-five years or more. Temperate in other 
things, he was an excessive smoker. Ten years be- 
fore the fatal ending, I warned him of the dangers 
incidental to a rather diffuse leucoplasic area on 
the buccal mucus membrane at the angle of the 
mouth, suggested removal of the affected tissue, 
and also endeavored without success to induce him 
to cease smoking. 

It has been my experience that in these cases, as 
well as in those in which the tongue is involved, 
with reformation of the patient's health and careful 
excision of the leucoplasic areas as fast as they 
appear, the mouth can be put in a safe condition 
and will so remain in a large proportion of cases. 

Case VI : A man 50 years of age, architect, was 
referred to me for what his physician termed an 
obstinate "syphilitic mucus ulcer" of the left bor- 
der of the tongue, posteriorly. Family history neg- 
ative as to cancer. The history of syphilis was clear 
and there were several characteristic ancient nodes 
— osteo-hyperplasia- — upon the tibiae. There was a 
marked internal strabismus of the right eye, from 
third nerve involvement, which had developed one 
year before I saw the case. The tongue presented 
several nodules which, the patient stated, had ap- 
peared and disappeared from time to time, for sev- 
eral years. There was slight macroglossia and 
numerous leucoplasic areas. The ulcer was about 
2 cm. in diameter, with indurated borders. Pain 
in the left ear had developed about four weeks pre- 
viously. Patient was a moderate drinker and a 
heavy smoker. He had not been advised of the 
dangers of either liquor or tobacco. 

The condition had grown steadily worse under 
treatment. There was no adenopathy. The Was- 
sermann was positive. Microscopic examination 
negative. I kept the jjatient under observation for 
four weeks, during which time I gave him a dose of 
salvarsan, followed by iodid and mercury, the case 
growing progressively worse. Microscopic exami- 
nation again was negative. A diagnosis of carci- 
noma was made and operation advised, whereupon 
the patient left me and went to a sanatarium to be 
"cured" by a vegetarian regimen and colonic flush- 
ings. I saw the case four months later, at which 
time considerable sloughing had occurred and there 
was extensive gland involvement and marked 
cachexia. I pronounced the case technically inop- 
erable, but suggested removing the sloughing tongue 
mass by the cautery loop for palliation. The patient 
declined the operation and returned home, dying 
of hemorrhage and exhaustion within six months. 

CONCLUSIONS. 

1. Syphilis, via the so-called "precancerous" con- 
ditions — such as leucoplasia and gumma, with as- 
sociated chronic diffuse glossitis — is the most 
potent factor in making dynamic the predisposition 



Vol. XXIX, No. 2. 



Lydston — Pre-Cancerous I 



Amehicas 

JoL'kNAl. nt SrHC.ERY. 



49 



underlying cancer of tlie mouth and tongue and 
probably also of the throat. 

2. Alcohol and tobacco — especially the latter — 
and the local irritation produced by treatment of 
syphilis or by bad teeth, or both, are most potent 
factors in the etiology of cancer in syphilitics. 

3. The local conditions furnish the exciting cause 
of cell proliferation and the syphilitic constitution 
supplies the perversion of cell nutrition through 
which the cancerous predisposition becomes dy- 
namic. 

4. Through the operation of the etiologic factors 
just mentioned, the syphilitic cell infiltration, and 
the scar ti.ssue produced by it, are replaced by ma- 
lisrnant cell growth. 




Fig. 13. Section from tongue in old syphilitic, shuwing typic 
epithelial nests with marked hyaline defeneration ("pearls") from 
area immediately beneath section shown m Fig. 4 (Case V) X 90. 

5. The best prophylaxis of pre-cancerous lesions 
is afforded by rational constitutional treatment, 
avoidance of local irritation, careful mouth surgery 
and hygiene, and total abstinence from alcohol and 
tobacco. 

6. The best prophylactic of cancer of the oral 
cavit}' — and especially of the tongue — is a concom- 
itant of syphilis, is excision of all obstinate chronic 
lesions of the mucosa and sublying tissues, whether 
regarded as characteristically syphilitic or not. 

7. The best time for operation in suspicion lesions 
of the tongue is before the diagnosis of malignancy 
is definitely established. Operation upon "pre-can- 
cerous" lesions is much more effective as a life- 
saver, on the average, than is operation upon in- 
dubitable cancer. 

8. Neither the microscope nor the Wassermann 
should rule the surgeon in doubtful cases. In ex- 
■5>erienced hands, the clinical diagnosis, even admit- 



ting that occasional errors are probable, is safer 
in the long run than reliance upon laboratory meth- 
ods, especially if the surgeon is even a fairly com- 
petent syphilologist. 

9. In lesions of lesser magnitude, operations may 
be limited, but resection of half or all of the tongue 
— according to the location and extent of the lesion 
— is indicated in those of greater magnitude, and 
invariably when the diagnosis of cancer is clearly 
established. 

10. The tissues beneath the jaw always should be 
cleansed out in the more extensive tongue excisions. 
This should include the removal of the salivary 
glands. 

11. The average of successes from tongue resec- 
tion, and the average longevity of the subjects oper- 
ated, will be higher or lower according to whether 
the profession is dominated by sound surgical judg- 
ment and experience — with its obvious corollary, 
practical common sense — or by laboratory reports. 
In brief, the oftener we operate on "suspicion," 
justified by careful clinical study of lesions of the 
tongue, the better for humanity. 

32 X. St.\te Street. 

Additional References. 
Fairlie Clarke: Diseases of the Tongue. 1873. 
Franke : Beitrag zur Entwickelung bosartiger Gesch- 

wulste aut dem Boden alter syphilitischer Narben, Wurz- 

biirg, 1894. 

Dentu : Des rapport de la leukokeratose avec I'^pi- 
thelioma, Mem. Assoc. Fran. Chir., vol. VIII. Paris. 
1895. 

King: Relation of Svphilis to Cancers of the Mucous 
Membranes. N. Y. Med. Jour., vol. LXVIII, 1898. 

Lekisch: Ueber Kombination Syphilis und Carcinose. 
Munchen, 1900. 

Sickmann : Ueber Vorkommen von Carcinom bei SvfiHti- 
schen. Kiel. 1901. 

Romer : Ueber Carcinom auf leutischem Boden. Bonn. 
1903. 

Tern.-: Luetic infection followed bv epithelioma. Occi- 
dental Med. Times, 1903. 

Etcheverri : Syphilis at Cancer. Ann. Derm, et Syph., 
1904. 

Finato : Un caso di epithelioma associato a sifiloma. 

Clin. Med. Firenze, vol. II, 190S. 
Montgomery and Sherman: A combination of syphilis 

and epithelioma of the tongue. Tour. Cut. Dis. and 

Syph., N. Y., 1906. 

Letulle : Le role de la syphilis dans le cancer. Jour, de 

med. de Paris. 1907. 
Ozenne : Du role de la syphilis dans le cancer. Clin. 

Prat. Mai. des yeux du lar}Tix, etc., Paris, 1908. 
Legrand : Syphihs et Cancer. Tour, de Med. de Paris. 

190S. 
Horand : Cancer sur Svphilis ou cancer juxtasj'philitique. 

Lyon, 1907. Paris, 1908. 
Papiantz : Du role de la syphilis dans I'^tiologie du can- 
cer. Geneve, 1908. 
Crivelli : Syphilis and Cancer. Trans. Australas. Med. 

Cong.. Australasian Med. Gaz.. 1909. 
Rohrbach : Ueber eine hochgradige atypische epithelwuch- 

erung bei Syphilis ; ein Beitrag zur Carcinomgenese. 

Berl. Klin. Wochenschr., vol. XLIX, 1912. 
M. Artelli. La degenerazione epitheliale della leucochera- 

tosi. Arch. Ital. di Otol., 1913, vol. XXIV, 183-186. 



50 



americas 

Journal of Surgery. 



Brickner — Subluxation of the Shoulder. 



February, 1915. 



TRAUMATIC FORWARD SUBLUXATION 
OF THE SHOULDER: A CLIN- 
ICAL ENTITY.* 
Walter M. Brickner, IM.D., F.A.C.S., 

Associate Surgeon, Mount Sinai Hospital, 

New York. 



In recent surgical literature there are but few 
references to traumatic incomplete dislocation of 
the head of the humerus. Indeed, the occurrence 
of primary, uncomplicated, trautnatic subluxation 
of the shoulder has never been definitely accepted. 
The older writers were far from agreeing on the 
subject, and later authorities deny the possibility 
of a subluxation of the shoulder except as a com- 
plication of an arthropathy or a paralysis, or as 
a chronic condition resulting from a complete dis- 
location. This is the view of .Stimson.' Hamilton, 
in his also classic work," declared "that the exist- 
ence of this [forward] or of any other form of 
partial dislocation of the shoulder joint as a trau- 
matic accident, has not up to this moment been 
fairly established ; and that the anatomical struc- 
ture of the joint renders its occurrence exceedingly 
improbable, if not impossible." 

In Cotton's work^ there is no section on subluxa- 
tion of the shoulder. "Rupture of the bicep ten- 
don," however, he describes as "a. condition which 
may be confused with subluxation. The condition 
is, in fact, a subluxation of minor grade." 

For most of the reported instances of subluxation 
we must go back to early writers. Cases were men- 
tioned by Petit. Duverney, Chopart, Hargrave, 
Dupuytren, South, Pinel, and others. Some of 
these, however, were probably associated with 
chronic arthritis. South's case was verified post- 
mortem ; it showed a small tear in the capsule, but 
it was complicated by fracture of the coracoid, the 
acromion, and the clavicle ; the head of the hu- 
merus rested on the anterior glenoid margin. 
Pinel's case was associated with fracture of the 
acromion, and acromio-clavicular luxation. In 
Hargrave's case the long tendon of the biceps was 
torn, and Chopart thought that in his case there 
was distortion of this tendon. In Dupuytren's case, 
the head of the humerus rested on the ribs (Ham- 
ilton). In the other cases clinically recorded in 
the pre-Roentgen ])eriod, we are not able to exclude 
such injuries as fracture of the glenoid rim, etc. 

Astley Cooper was the first to describe at length 
"partial dislocation of the os humeri," which he 
believed to be "not a very rare accident." He re- 

' Read before the ritrhopcflic .Section, N. Y. Academy of 
Medicine, January 15, 1915. 



ported two cases observed clinically, and adds the 
description of the dissection of a third case, in 
which he found the long tendon of the biceps rup- 
tured and the head of the humerus lying below the 
coracoid, occupying a new articular surface formed 
on the neck of the scapula. Hamilton says of this 
case, with much justification, I think : "We shall 
have no difiiculty in assigning it to its proper place 
as a complete subcoracoid dislocation." The de- 
scription of the deformity in Cooper's two other 
cases also leaves one in doubt as to their character. 
In the posthumous edition of Cooper's work* is in- 
cluded a fourth case, a dissection by Douglass, in 
which, again, the head of humerus lay in front 
of the neck of the scapula — clearly not a subluxa- 
tion. 

Malgaigne's'' arguments for and clear description 
of forward subluxation of the shoulder afford much 
less basis for dispute. He believes that the condi- 
tion results from stretching or slight tearing of 
the capsule ; and he points out that a groove in the 
middle of the articular surface of the head of the 
humerus, made by contact with the glenoid mar- 
gin, as described by Sedillot, must necessarily be- 
speak an incomplete dislocation. Malgaigne was 
able, on the cadaver, to produce a subluxation with- 
out rupture of the capsule, after removing the del- 
toid. Panas found himself unable to produce the 
lesion post-mortem. 

In 1890, Broca and Harlmann" recorded the dis- 
section of a case of extra-coracoid dislocation, 
which, they said, was of the character that Mal- 
gaigne would have called a subluxation. They 
found a stripping up of the periosteum on the an- 
terior surface of the neck of the scapula, where it 
was continuous with the capsule. They also found 
that all of the anterior half of the articular fibro- 
cartilage of the glenoid cavity was torn off, and that 
a fragment of bone was detached from the inferior 
margin. Such complications could, of course, be 
readily recognized to-day by radiography. Broca 
and Hartmann believe that so-called partial luxa- 
tions of the shoulder are, in fact, complete but not 
extensive dislocations. 

Miiller,' in 1894, reported one and referred to 
four other cases of subluxation of the shoulder 
seen by him : but, evidently awed by the authority 
of Hippocrates. Desault, and Stromeyer, who de- 
nied the occurrence of this subluxation as a trau- 
matic lesion, he, too, curiously concludes that the 
lesion is a secondary one due to rapidly developing 
atrophy and paralysis of the deltoid and supra- 
spinatus, often also of the infraspinatus and teres 
minor, arising reflexly from tearing of the joint 



Vol. XXIX. No. 1. 



Brickner — Subluxation of the Shoulder. 



American 
Journal of Surgerv. 



51 



fibers of the circumflex and suprascapular nerves ! 
This fantastic hypothesis need not detain us. 

Coming now to recent authors, I find but the 
two following reports: 

Xale" records a traumatic subluxation of the 
shoulder resulting from a fall on the outstretched 
arm. The head of the humerus was prominent an- 
teriorly. A radiograph showed the bones normal. 
There was, however, a subluxation of the acromial 
end of the clavicle. 

MirieP reports five cases of forward subluxation. 
He emphasizes the insignificance of the causative 
trauma (sometimes even unappreciated by the pa- 
tient), the absence of the chief symptoms of dislo- 
cation, and the variety of the functional disturb- 
ances produced. He notes that slight manipulation 
brings the arm into place, and that the patient can 
then move it freely. 

We may pause here to consider the important 
question, What is a subluxation of the shoulder/ 

Subluxation of a ginglymus or an arthrosis is 
well recognized and understood as a sliding of the 
opposing articular surfaces one on the other so that 
they continue in contact over only a part of their 
surfaces. Of the cnarthroses (shoulder, hip), 
however, some authors have maintained that a dis- 
location must necessarily be complete, that partial 
contact of the articulating surfaces is impossible. 
Hamilton says, of the humerus : 'Tt is only by hav- 
ing placed the semi-diameter of the head of the 
bone outside of the margin of the glenoid fossa 
that it can be made for one moment to retain its 
abnormal position. . . . If we admit, with 
Malgaigne, that occasionally the capsule has been 
found capable of extension without actual rupture, 
I am still unwilling to regard this as a fair sample 
of a partial dislocation, since the head of the bone 
no longer moves in its socket, being at no point 
in actual contact with the articular surface of the 
glenoid fossa." Malgaigne had to contend with 
the same arguments in his own time. He said : 
"There are those who insist that in incomplete lux- 
ation there must be partial contact between the 
articular surfaces, and they refuse to give this title 
to luxations of the enarthroses in which the head 
of the bone is displaced but a little from the cavity, 
because all contact is destroyed. By this argu- 
ment, a dislocation of the knee bringing the inner 
condyle of the tibia under the outer condyle of the 
femur is an incomplete luxation : but a subluxa- 
tion consisting in the simple separation of articular 
surfaces, however slight, must be called a complete 
luxation. Let us return," he continues, "to positive 
science and true surgical conceptions. Hippocrates 



denied the possibility of incomplete dislocation of 
the humerus and the femur, because he could not 
conceive that the rounded head of these bones could 
rest on the edge of the articular cavity without 
sliding in again or falling altogether out, but we 
thus see that such a condition, which he could not 
recognize, would constitute, in his eyes, a subluxa- 
tion, indeed. ... A luxation is incomplete 
when the articular surfaces have not passed entirely 
one beyond the other; the persistence of partial 
contact of these two surfaces or the absence of all 
contact is a matter that does not determine the de- 
gree of the luxation." 

W'e might, of course, think of a luxation of the 
shoulder as incomplete if the head of the humerus 
has not passed through the capsule ; but this is not 
always correct, for Eve'" and Broca and Hartmann' 
have recorded instances of complete dislocation in 
which the capsule was unruptured, the periosteum 
continuous with it being stripped up from the neck 
of the scapula. 

I would define as a subluxation of the shoulder 
one in which the articulating surface of the hu- 
merus has not passed beyond the edge of the glen- 
oid, but remains in contact (even in articulating 
contact) with the joint surface of the fibro-cartilage 
attached to the glenoid margin. 

With this conception in mind, I would take issue 
with the many who deny the occurrence of a pure 
traumatic subluxation of the shoulder. I base my 
acceptance of such a clinical entity on my experi- 
ence with the three following cases: 

C.-\SE I: Miss A. D., aged 25. was referred to 
me on Xovember 27, 1912, by Dr. Leo Kessel. On 
November 21, she had been riding a spirited horse, 
and her arms had been much jerked by the bridle 
reins. The next day she had severe pain in the 
left shoulder, radiating down the arm, and she was 
scarcely able to raise the arm. These symptoms 
continued. 

There was a slight but unmistakable prominence 
of the head of the humerus anteriorly, and a cor- 
responding slight depression posteriorly below the 
acromion — the deformity by no means, however, 
that of a complete dislocation. The outer (del- 
toid) contour of the shoulder was normal. There 
was tenderness over the prominent head of the bone 
anteriorly : none elsewhere. The patient could per- 
form internal rotation freely (put her hand behind 
her back"), but abduction was very limited and 
painful. The Ji"-ray picture showed nothing ab- 
normal. 

When I abducted her arm to the horizontal, the 
prominence of the humerus receded completely, the 
pain disappeared, and the patient was able to con- 
tinue full abduction herself without difficulty. 
\\'hen the arm was lowered below the horizontal, 
the deformity, the pain, and the disabilitv' reai> 



52 



American 
Journal of Surgery. 



Brickner — Subluxation of the Shoulder. 



February, 1915. 



peared. We went through this maneuver several 
times, always with the same result. 

The patient was put to bed with her arm con- 
tinuously abducted to about 135 degrees, held in 
position by a sling passed from the wrist to the 
head of the bed, in much the same manner as I 
have described for the automatic restoration of 
abduction in the treatment of stiff and painful 
shoulder of other varieties." On the fifth day the 
arm was released and the signs and symptoms 
promptly recurred. The abduction was therefore 
resumed, without intermission, for another six 
days, which effected a cure. 

Case II: Mrs. D. S., aged 38, referred by Dr. 
R. T. Frank, on July 9, 1913. This woman could 
recall no definite trauma, but she was accustomed 
to doing heavy washing and laborious housework. 

For several weeks she had had severe pain in 
the right shoulder and inability to abduct her arm. 
For three days before consulting me the pain and 
disability had become worse. 

There was moderate prominence of the head of 
the humerus anteriorly, a corresponding depression 
posteriorly, and slight flattening of the deltoid re- 
gion. Abduction was limited to 60 degrees and 
rotation was also limited in both directions. The 
.f-ray picture was normal. 

Passive abduction met with so much resistance 
that I thought narcosis would be needed to reduce 
the subluxation. With some effort, however, I suc- 
ceeded in fully abducting the arm without an anes- 
thetic. As the extremity was raised the deformity 
disappeared with an audible snap, and active mo- 
tions at once became possible. 

The patient was instructed to keep the arm ab- 
ducted alongside the head, in bed, for two weeks. 
I did not see her again, but I was told that her 
condition was thus cured. 

Case III: Mrs. A. S., aged 53, was admitted to 
Dr. Lilienthal's service in Mount Sinai Hospital on 
April 13, 1913. Three years previously she had 
had pain and stiffness in the left shoulder (dura- 
tion not ascertained). For ten months she had 
again suffered severe pain and marked limitation 
of abduction and rotation in the left shoulder, 
which was very tender just under the margin of 
the acromion somewhat anteriorly. For this con- 
dition she had been treated in the out-patient sur- 
gical and physical therapeutic departments. The 
.r-ray appearance was normal. It was believed that 
the patient was suffering from an adhesive sub- 
acromial bursitis, for which, since other measures 
had failed, open operation was indicated. In this 
judgment of the case I concurred. 

As soon as the patient was anesthetized, how- 
ever, and the muscle spasm relaxed, there was at 
once evident the deformity of an incomplete for- 
ward dislocation, viz., prominence of the humeral 
head anteriorly, depression posteriorly, and slight 
flattening in the deltoid region — none of these signs 
by any means as marked as in a complete luxation. 
As the arm was abducted, with palpable and audi- 
ble tearing of adhesions, the deformity was reduced 
with a distinct snap. 

The arm was kept in full abduction for twelve 



days, in the same manner as the other two cases., 
which effected a cure of the subluxation. Then 
massage and passive movements were instituted to 
secure full function, and the patient was discharged 
on May 30, with the usefulness of her arm restored. 

I recently saw a fourth case of forward subluxa- 
tion of the shoulder in the Third Surgical Service 
of Mount Sinai Hospital. The patient, a middle- 
aged woman, gave a history of attacks of uncon- 
sciousness, during which she would sometimes fall. 
As the result of such a fall she was unable to 
abduct her left arm and had some pain in the 
shoulder, which presented the same slight deform- 
ity described in the three preceding cases. In ad- 
dition, the head of the humerus could be moved 
forward and backward in the socket. The de- 




formity was promptly recognized as a subluxation 
by all the members of the attending and house staffs 
who saw it. (See illustration.) The radiograph 
showed a slight fracture of the lower margin of the 
glenoid rim and a chipping of the greater tuberosity 
of the humerus. Moreover, the Wassermann re- 
action was strongly positive. The case is, there- 
fore, not one of uncomplicated subluxation, not 
only because of the fractures, but also because there 
may have been a true arthropathy. I mention it 
here to indicate that the deformity of a shoulder 
subluxation can be recognized without much diffi- 
culty, and distinguished at a glance from the much 
greater deformity of a complete dislocation. In 
this case abduction did not effect reduction. This 
was accomplished by bringing the arm across the 
chest by a modified Kocher manipulation. When 
that position was relaxed the deformity reappeared. 
It will be seen that my three cases much resemble 
those of Miriel, as he describes them — in the insig- 



\oL. XXIX. No. 



Brickner — Subluxation of the Shoulder. 



amf.rican 
Journal ov Subgerv. 



53 



nificance of the producing violence, in the appear- 
ance of the comparatively slight deformity, and in 
the ease of reduction. 

What is the anatomy of traumatic forward sub- 
luxation of the shoulder? I think we may assume 
— indeed, it has been shown — that there is a stretch- 
ing or tearing of the capsule, and further that the 
largest arc of the articulating surface of the hu- 
merus, instead of lying in the center of the glenoid 
cavity, is moved forward to or upon the fibro-car- 
tilage of the anterior margin of the glenoid rim. 
Whether articulation continues over an actual sur- 
face or merely in a line, I do not know ; but it must 
be borne in mind that in these cases articulatioii 
is not by any means entirely lost — rotation can be 
performed, sometimes freely, with little or no pain 
and without crepitus. 

What maintains the position of subluxation? 
Why does not the head of the humerus slip back 
into its socket or fall entirely out of it? Is any 
lesion other than the capsular injury necessary to 
maintain the deformity? 

If, at the time of the injury, the glenoid rim 
impresses a groove in the cartilaginous surface of 
the humerus, as suggested by Malgaigne, this might 
be sufficient to maintain the malposition, if the 
arm were not rotated. But since rotation, w'hich 
is not destroyed, would at once move the groove 
away from the rim, we may, I think, deny the 
necessity for postulating such a depression. 

The long head of the biceps is believed to assist 
in maintaining the head of the humerus in its 
place; and various writers have held that disloca- 
tion or rupture of this long tendon is necessary 
to effect the deformity we have been considering. 
This has been based, partly at least,' upon the early 
case of Soden (reported by Astley Cooper) of 
upward partial dislocation of the humerus resulting 
from displacement of this tendon. Hamilton 
strongly inclined to believe that such a displacement 
is essential to the production of so-called subluxa- 
tion. However, he quoted Gerster. who, like Bar- 
deleben, Pitha, and Volkmann. denied the occur- 
rence of an uncomplicated dislocation of the long 
head of the biceps and insisted that it had never 
been satisfactorily demonstrated upon the living or 
dead subject. The tendon is retained in the groove 
between the two tuberosities by a fibrous pro- 
longation from the pectoralis major, and is not 
easily displaced. In my own cases there was noth- 
ing whatever to suggest that such a displacement 
had taken place. If dislocation of the long head 
of the biceps will cause subluxation, rupture of the 
tendon ought to do the same. But such a rupture 



may occur without any displacement of the hu- 
merus, and Hamilton confesses that in the only 
case of ruptured tendon seen by him the relations 
of the head of the humerus were not disturbed. 

Can we deny that subluxation of the shoulder 
is not the result of a complete dislocation partially 
reduced? 1 do not think we can. In some people 
the shoulder dislocates from comparatively mild 
violence and sometimes such a dislocation is at 
once spontaneously reduced, and may thus go un- 
recognized. In my second and third cases I can by 
no means exclude such an occurrence. In the first 
case, however, if tugging on the bridle reins had 
actually produced a complete dislocation that had 
spontaneously receded, it seems at least likely that 
my manipulations of the arm six days later would 
have reproduced the dislocation. 

WHiile we cannot deny that subluxations of the 
shoulder are not the result of complete disloca- 
tions, on the other hand there is no reason for as- 
suming that they are so produced. Until otherwise 
proven we may regard the condition as a primary 
one, and we may recognize that : 

Pure, uncomplicated, traumatic forzvard subluxa- 
tion of the shoulder is a real clinical entity. 

It is an occasional cause of shoulder disability 
that has heretofore been overlooked in the studies 
of "stiff and painful shoulder." 

It may be produced by very mild violence. 

It is marked by prominence of the head of the 
humeru.s in front, a corresponding depression be- 
hind, slight or no appreciable flattening of the del- 
toid — all much less than in full dislocation. 

It produces pain in the shoulder, radiating dozsni 
the arm, and inability to abdnct; but rotation may 
be but little inhibited. 

It shozi'S nothing abnormal in the radiograph. 
("Perhaps by stereoscopy or some other means the 
displacement mav be demonstrable radiographi- 
cally.) 

In the series here reported the deformity zcas 
reduced by abducting the arm, and the condition 
zvas cured by maintaining abduction for tzvelve to 
fourteen days. 

30 West Ninety-second Street. 

references. 

1. Lewis A. Stimson : A Practical Treatise on Frac- 
tures and Dislocations, Lea & Febiger, 7th edition, 1912, 
pp. 67S-8. 

2. Frank H. Hamilton : .A Practical Treatise on Frac- 
tures and Dislocations, 7th American edition, 1884. pp. 
738-743. 

3. Frederic J. Cotton : Dislocations and Joint Frac- 
tures, W. B. Saunders Co.. 1910. 

4. .^stley Cooper; A Treatise on Dislocations and 
Fractures of the Joints. (Edited by Bransbv Cooper), 
1844. pp. 349-356. _ 

5. J.-F. Malgaigne : Traite des Fractures et des Lu.xa- 
tions. 1855, vol. 2, pp. 494-S02: p. 14. 



54 



American 
Journal of Surgery. 



Buerger — Urethrovesical Diagnosis. 



February, 1915. 



6. A. Broca et H. Hartmann : Contribution a I'etude des 
luxations de I'epaule (lu.xations dites incompletes, etc.), 
Bull. Soc. Anat. de Paris, 1890, l.xv., pp. 312-336. 

7. P. Miiller: Die Sublu.xation des Humerus nach 
Trauma. Centralbl. f. Chir., li^94, xxi., p. 993. 

8. P". P. Vale: Case of Traumatic Subluxation of the 
Humerus. Washington Med. Ann., 1908, vii., p. 5. 

9. M. Miriel : Des subluxations de I'epaule. Gaz. 
d'hop., Paris, 1912, Ixxxv., p. 1307. 

10. F. S. Eve : A Case of Subcoracoid Dislocation of 
the Humerus. Medico-Chir. Trans., London, 1880, Ixiii., 
p. 317. 

11. W. M. Brickncr: A Simple, Easily Regulable Meth- 
od of Applying Abduction in the Treatment of Shoulder 
Disability, Med. Record, January 2, 1915. 



CONCERNING CERTAIN PROBLEMS IN 
URETHROVESICAL DIAGNOSIS AND 
TREATMENT (WITH DESCRIP- 
TION OF A NEW IN- 
STRUMENT). 

Leo Buerger, M.D., 

Associate .\ttending Surgeon, and Associate in Surgical 

Pathology, Mt. Sinai Hospital ; Attending Surgeon, 

Har Moriah Hospital; Instructor in Clinical 

Surgery, Columbia Uni\'er6ity, 

New York. 



In the past decade we have witnessed a complete 
revolution in our conception of the proper method 
of carrying out operative procedures in the bladder 
through the cystoscope. The introduction of a new 
endovesical armamentarium, too, has altered not 
a little the technic of observation cystoscopy and 
catheterization of the ureters, whilst the adoption of 
the cysto-urethroscope in routine work has made 
possible the visualization of the posterior urethra 
and neck of the bladder in so clear a manner that 
this region has been transformed from a veritable 
terra incognita into a thoroughly explored and 
easily approachable field. 

The development, introduction and perfection of 
new instruments have probably done more for the 
popularization of cystoscopic investigation than the 
prolific writings of the older specialists, who, it is 
true, almost monopolized this field for many years. 
This was due to the fact that they alone possessed 
the requisite skill to make a complete urologic?.] 
examination with the somewhat imperfect and cum- 
bersome appliances at their disposal. Thus, the 
operating cystoscope of Nitze, in spite of the in- 
genuity of its inventor and the enormous amount 
of work entailed in its construction, must neces- 
sarily by reason of its complexity have been rele- 
gated into the hands of only a few skilful techni- 
cians. Then, too, the optical systems of the older 
observation instruments, the darkness of the visual 
field, the inversion of the picture, the traumatism 
inflicted by the large-sized, irregularly formed 
catheterizing cystoscope — all these presented diffi- 



culties to the general surgeon, so that many re- 
frained from using the instrument at all, and, 
.strange to say, many even urged against this method 
of examination. 

Although some ten years ago intravesical diag- 
nosis and the application of therapeutic measures 
in the bladder were procedures resorted to by rela- 
tively few, what by the simplification of instru- 
ments, the invention of a new optical system, and 
the demonstration that lesions heretofore almost 
inaccessible could be brought to light with ease and 
precision, thorough investigation and thorough 
therapeutic operative methods in the bladder and 
urethra ofier to-day no greater difficulty than any 
of the general surgical manipulations. 

Thus, we have witnessed in this country, at least, 
at two different periods, the introduction and re- 
jection of methods of technic in cystoscopic work, 
each time initiated by the development and popu- 
larization of new types of instruments. For a time 
the older Nitze cystoscope introduced by .American 
students studying in Berlin and \'ienna held almost 
complete sway in this country, only to be supplanted 
in great part by what may regarded as a simpler 
method of catheterization — the method of Brenner 
perfected by Tilden Brown. The revival of the 
indirect method has been almost universal in the 
United States, however, since it was conclusively 
demonstrated some six years ago that the Nitze 
indirect prismatic system was after all the best to 
use, for the difficulties presented by the older in- 
struments had been completely abolished with the 
construction of a new mechanical assemblage (Fig. 
1), and by distinct improvements in the optical ap- 
paratus.' The principles laid down by the author at 
that time and the demonstration that the synchron- 
ous catheterization of both ureters could be made 
even easier than single catheterization with the 
older Nitze instrument, have been generally ac- 
cepted ; and even in the modifications of the au- 
thor's instrument that have found their way into 
literature since, not a single essential element of 
these principles has been altered. Furthermore, 
when in 1910- by the use of three reversals-' it was 
found possible by the author to construct a telescope 
giving many times more light than we had hereto- 
fore been able to procure in catheterizing telescopes, 
it seemed that the most intricate problem and dif- 
ficulty that confronted us in ordinary routine and 
catheterizing cystoscopy had been solved. 

But we are not content to-day merely to look 
into the bladder and catheterize the ureters, for 
vesical and renal lesions present more difficult tasks 
to the cystoscopist and genito-urinary surgeon. 



Vol. XXIX. No. 2. 



Buerger — Urethrovesical Diagnosis. 



Americas 

JOC-RNAI. Ot SfBCERV. 



55 



That keen investigator, Nitze, had already attacked 
these other problems when he developed a series 
of operating cystoscopes. With these, it is true, 
he was successful in doing operative work in 
the vesical interior. Others, however, had found 
his instruments so cumbersome, unwieldy, and com- 
plicated that relatively few genito-urinary surgeons 
possessed the skill and patience to master the dif- 
ficulties of the technic. Operative cystoscopy, 
therefore, remained for many years rather of the- 
oretical interest than a practical art. Indeed, the 
operating cystoscope seemed to be a curiosity in 
the armamentarium of a few, and not a generally 
useful instrument. 

Some four years ago, after considerable experi- 
mentation, my endeavor to construct a cystoscopic 
instrument, by means of which operative and diag- 
nostic work could be easily carried out, bore fruit 
in the production of the instrument depicted in 
figure 2. It was found possible without appreciably 
increasing flic sice of the catheterizing cystoscope, 




Fig. I. .\uthor's observation and catheterizing cystoscope. 

to construct an instrument* that would carry de- 
vices of adequate size, so that the execution of 
op>erative maneuvers in the interior of the bladder 
would be as precise and effectual as the manipula- 
tions that can be carried out by the surgeon under 
the direct guidance of the eye. 

The most useful of the devices that can be in- 
troduced through the operating cystoscope can be 
seen in figures 3 and 4, where the forceps for the 
purpose of grasping foreign bodies, punch forceps 
for the removal of pieces of tissue, and cutting for- 
ceps are depicted. Some of these (Fig. 3) are made 
to pass through a flexible wire canula that can be 
directed against any part of the bladder interior, 
others (Fig. 4) close by a scissor-like motion and 
are practically part of the canula itself. In addi- 
tion to these most generally useful instruments, 
there is the snare (Fig. 3), particularly to be rec- 
ommended for the removal of papillomata. Figure 
2 shows the operating cystoscope with one of the 



operating forceps in place, the handle for the pur- 
pose of closing the jaws being also illustrated. 

In practice I have found this instrument useful 
in the removal of foreign bodies, in the excision 
of pieces of mucus membrane for differential diag- 
nosis of intravesical lesions, in the removal 
of portions of tumor for diagnosis, in the 
excision of callous ulcers, in the removal of 
small stones, in the snaring of papillomata and 
foreign bodies, in the division of a stenosed ure- 
teral orifice, in facilitating the employment of the 
high-frequency current, in the introduction of oli- 
vary bougies for dilitation of the ureters, in the 
intravesical treatment of ureterocele by division and 
excision, in the passage of large catheters (such as 
could not usually be passed through an ordinary 
cystoscope), in the employment of more than two 
catheters for purposes of special diagnosis, in the 
excision of mucus membrane about the ureteral 
orifices, to diagnosticate renal tuberculosis, and in 
many other rare and interesting conditions. 

Thus, some of the difficulties of observation cys- 
toscopy, ureteral catheterization, and operative 









,( ' 




' ' y^ 


V 


BBQmrJtwj—— 




'~r- 










'-- 






Fit;. 2. .\ut!ior's o|)eraling cystoscoftt-. 

cystoscopy had been eliminated by the adoption 
of properly constructed devices. 

Are we able to say that no other problem in the 
field of visual diagnosis of the lower urinary tract 
remains to be solved? Indeed not. It is true that 
the demonstration of the anterior urethra had been 
adequately accomplished in principle, at least, by 
Desormaux.^ His endoscope has subsequently been 
perfected by many workers since the introduction 
of the modern electric lamp. But there still re- 
mained certain other portions of the urethrovesical 
tract that offered even greater difficulties than those 
with which the urologist had been previously con- 
fronted. I refer to the posterior urethra and to the 
region of the neck of the bladder, the latter includ- 
ing the spincteric and juxtasphinteric regions. 

It is my purpose in this paper to refer briefly to 
some of my previous work, in which the question 
of the examination of the posterior urethra had 
been investigated, and then to show that even those 



56 



American 
Journal OF Surgery. 



Buerger — Urethrovesical Diagnosis. 



February, 1915. 



regions which are so difficult of approach, namely, 
the sphincteric and juxtasphincteric portions of the 
bladder, may be thoroughly scrutinized and made 
accessible for operating purposes. 

In 1909 the shortcomings of the methods that 
had been employed up to that time for viewing the 
posterior urethra had induced me to direct my ef- 
forts towards the construction of an instrument 
by means of which the neck of the bladder and 
posterior urethra could be more satisfactorily seen. 
It is true that Goldschmidt had produced about 
this time an instrument that gave a fairly good 
view. However, even his innovation had left a 
great deal to be desired ; for, not only do the struc- 
tures brought into view by his instrument appear 
distorted by virtue of the very nature of the optical 
apparatus, but manipulation of the instrument in 




Fig. 3. Working ends of operating instruments including cutting, 
grasping, punch lorceps and snare. 

the urethra produced a certain amount of trauma- 
tism, because of its mechanical construction. All 
the drawbacks of this instrument, namely, optical 
distortion of the image, inadequate illumination and 
the probability of traumatism were overcome in the 
construction of an instrument to which I gave the 
name of cystourethroscope (Fig. 5). In this, by 
the adoption of a fenestra of small size into which 
the mucous membrane could hardly prolapse except 
at the verumontanum, by the employment of a new 
type of roof illumination and by the introduction of 
an optical system of small visual angle, it was found 
possible to establish conditions permitting of very 
good vision in practically all of the posterior 
urethra. 

The possibilities of this instrument have been 
fairly well outlined in other papers." Its value in 
demonstrating clearly every detail of the posterior 
and anterior urethra has been sufficiently estab- 
lished so as to need no comment here. It suffices 
to say that we are now able to view the verumon- 



tanum, utricle, ejaculatory ducts, prostatic ducts, 
sulci on either side of the verumontanum, the whole 
of the prostatic urethra, and a portion of the neck 
of the bladder with the same degree of distinctness 
and accuracy with which the interior of the blad- 
der can be inspected through an observation cysto- 
scope. I was able to show that operative proced- 
ures could be carried out in the posterior urethra, 
that ulcers and tumors could be cauterized by the 
fulguration method, that the ejaculatory ducts 
could be probed as well as the utricle, that the site 
of strictures of large caliber could be definitely out- 
lined, that anomalies could be beautifully demon- 
strated, and that in the diagnosis of prostatic hyper- 
trophy the employment of this instrument was abso- 
lutely essential for an exact appreciation not only 
of the extent of the hypertrophy, but of its nature 
and situation. 

The region of the internal sphincter is even less 
accessible and certainly more difficult of approach 
with endoscopic operative instruments than the pos- 
terior urethra. Its anatomical conformation makes 




Fig. 4. Scissor type of cutting and punch forceps. 

operative procedures through a cystoscope or ureth- 
roscope exceedingly difficult. Both in cystoscopy 
and in cystourethroscopy, we have to rely on a 
considerable extent for tiie clearness of the field 
upon the unfolding of the parts, that is. upon our 
ability to dilate the parts with a clear fluid, devel- 
oping a space in which the telescopic instrument 
can have free play. This we are able to do in the 
bladder with great ease, where the sphincter suc- 
cessfully bars the egrees or exit of the water after 
it is allowed to flow in. This, too, we are able to 
accomplish in the posterior urethra, but in a some- 
what difi^erent manner. As the irrigating fluid flows 
out of the instrument at the fenestra, it tends to 
dilate the posterior urethra, its easy entrance into 
the bladder being successfully barred by the grasp 
of the internal sphincter about the shaft of the in- 
strument. 

Quite different are the conditions when the tele- 
scope is at the vesical sphincter. The fenestra is 
then partly in the bladder, into which the irrigating 



Vol. X.XIX. No. 2. 



Buerger — Urethrovesical Diagnosis. 



American 
Journal of Surgery. 



57 



fluid can pass without hindrance. Then, again, the 
distensibihty of the vesical sphincter is much less 
than that of the posterior urethra or bladder, and 
the tendency of lens system and parts to be seen 
to approach each other is difficult to overcome. 
Not only this, but our attempts to gain room for 
operative work, for the protrusion of instruments 
of precision, must be rewarded with very little suc- 
cess in so small a working space, unless by reduc- 
tion of the size of the appliances or by the construc- 
tion of a special telescopic instrument, we are able 
to negative some of the obstacles above described. 

Were it not for the fact that we not infrequently 
encounter lesions of this very part of the bladder, 
the necessity for an operating instrument would 
hardly arise. With the new type of cystoscope used 
in the convex sheath, with the so-called close-vision 
cystoscope devised by the author some years ago, 
and with the cystourethroscoi>e a certain amount of 
operative work can surely be carried out in the 
sphinteric region. 

However, neither the cystoscope nor the cys- 
tourethroscope can be regarded as completely satis- 
factory in this territory. The former is not ideal 




Fig. 5. Author's cystourethroscope. 

for purposes of inspection by reason of its large 
fenestra, the great distance between the center of 
illumination and the part to be seen, and the na- 
ture of the optical system. Nor is it satisfactory in 
the accomplishment of work that must be carried 
out within a very small space. The experienced 
cystoscopist readily appreciates how impossible it 
is to illuminate the field properly with the cysto- 
scope, how trans-illumination will occur, and how 
the deflector of the instrument will be situated too 
far back in the urethra for the guidance of the 
operating devices when the sphinteric region is to 
be attacked. Much better is the cystourethroscope 
in this regard, except that it will not carry forceps 
large enough for the excision of pieces for micro- 
scopic examination. In diagnosis and for fulgura- 
tion it will, however, answer all purposes. 

About a year ago, therefore, I devised an operat- 
ing cystourethroscope which combines features of 
the operating cystoscope and cystourethroscope. 



In this instrument it was thought wise to assemble 
the features of close-vision that were so success- 
fully developed in the cystourethroscope with such 
variations in mechanical detail as would permit 
simultaneously the adequate ins])ection of the parts 
and their operative control. Figure 6 depicts this 
instrument, which, at first glance, might be regarded 
as identical with the cystourethroscope. However, 
it presents the following differences ; the light is 
changeable, resembling that first suggested in the 
author's first type cystourethroscope; two dift'erent 



■sr^ 




Fig. 6. Author's operating cystourethroscope. 

styles of lamps may be utilized, one small lamp that 
hugs the roof of the sheath and is designed for 
moderate illumination at the sphincter; another, 
shorter, more brilliant lamp that will be of greater 
use in illuminating the bladder. The former of 
these lamps is the one that answers practically all 
purposes, and will be seen to be situated very close 
to the telescope. This is an essential feature, if 
we wish to get proper illumination of parts that 
are limited to the small space presented by the in- 
ternal vesical sphincter. 

The telescope differs, in its length, in certain 
details of optical construction from that employed 




Fig. 7. Operating cystourethroscope with punch forceps. 

in the cystourethroscope ; and there is a larger de- 
flector, one that will be strong enough to guide not 
only a stiff bougie or fulguration wire, but also 
small-sized operating punch forceps. Its ocular 
end is provided with a large catheter outlet, of suf- 
ficient caliber to carry one or two catheters, so that 
synchronous catheterization of the ureters is pos- 
sible. A large bougie for dilatation of the ureter 
may be introduced, or smaller bougies or stylets 
for the exploration of the utricle and ejaculatory 
ducts. The sheath is similar to that found in the 
cystourethroscope, but its beak is shorter. This, 



58 



American 
Journal of Surgery. 



Buerger — Urethrovesical Diagnosis. 



February, 1915. 



however, can be replaced by a longer one if we so 
desire. The sheath is slightly oval rather than cir- 
cular in cross-section, first, in order to place the 
optical system as far away from the field as pos- 
sible, and, second, to give room for the introduction 
of the operating devices. 

In short, we have an instrument which differs 
only from the cystourethroscope in its capacity for 
the introduction of larger instruments and in the 
possibility of their control. The scope of the appa- 
ratus, too, is much wider, since it permits of easier 
catheterization of the ureters and of more exten- 
sive work in the bladder, in the sphincter, and in 
the urethra. By virtue of its longer deflector, the 
sphincter can often be pushed away, making access 
with operating instruments easier. 

Perhaps the most useful field for the application 
of this operating cystourethroscope is in the treat- 
ment of papillomata at the sphincteric margin and 
in the removal of pieces of tumor for histological 
examination (Fig. 7), when situated in the same 
region. The following case will clearly illustrate 
the value of this instrument for just this type of 
work: 

Multiple intravesical papillomata. multiple papil- 
lomata at the sphinteric margin. 

L. L., male, age 58, gave a typical history of 
papilloma of the bladder, there having been hema- 
turia for about two months without apparent cause 
and without pain. Cystoscopic examination Au- 
gust 5, 1914, showed a large papilloma about the 
size of a walnut situated about 2 cm. behind the 
left ureteral orifice, several smaller papillomata 
behind this in the posterior wall, and a large growth, 
the size of which could not definitely be determined, 
occupying the right half of the sphincter and juxta- 
sphincteric regions. Several smaller papillomata 
arose from the sphincteric margin at the left side, 
and a rather large growth occupied the superior 
wall or roof of the sphincter apparently passing 
into the wall of the roof of the posterior urethra 
for a short distance and also into the bladder, thus 
occupying the sphincteric margin, the urethra and 
the contiguous bladder region (juxtasphincteric 
region ) . 

Several treatments with the high-fre(|nency cur- 
rent destroyed the large tumor behind the left ureter 
and the smaller ones in the posterior wall, the 
catheterizing cystoscope having been employed. 

For the purpose of destroying the growths at the 
vesical margin, however, it was necessary to have 
recour.se to the operating cystourethroscope, by 
means of which on October 3, 1Q14, several pieces 
were removed with the punch forceps for micro- 
scopic examination. These proved to be papilloma 
and the use of the high-frequency current was per- 
sisted in, the operating cystourethroscope being em- 
ployed. With this instrument I was successful in 
destroying these papillomatous growths completely 
in a region where the ordinary cystoscope even with 



a convex sheath would have encountered great dif- 
ficulties. 

Several other cases of the same type where the 
growths were situated either at the sphinteric mar- 
gin or involved more extensively the urethra, the 
sphincteric margin and the bladder have been 
treated in this way. For precise and efifectual work 
in this region, both with the high-frequency method 
as well as for the removal of pieces of tumor, the 
operating cystourethroscope must be employed. 

In the posterior urethra, too, therapeutic manipu- 
lations can be executed with great ease and accu- 
racy. Papillomata can be removed, the hypertrophic 
and inflamed colliculus can be excised ; and the 
application of the high-frequency current is facili- 
tated by the use of the operating cystourethroscope. 

While in my own work the complete armamenta- 
rium — observation and catheterizing cystoscope, 
operating cystoscope, anterior urethroscope, cys- 
tourethroscope, and operating cystourethroscope — 
have all their proper sphere of usefulness, the gen- 
eral surgeon may dispense with the simple cys- 
tourethroscope, utilizing the operating cystoureth- 
roscope both for purposes of diagnosis and for spe- 
cial operative work. 



^Buerger: Annals ot Surgery, February, 1909. 

- Ruerger: New York Medical Journal, April, 1911: Am. Jour. 
Urol., September. 1911. 

^ Refers to reversal of image in the telescopic tube. 

* This instrument retains the essential principles followed in 
the construction of the author's cystoscope. 

^ Desnrmaux's instrument, devised in 1865, consisted of a tube 
to which the source of illumination was attached. This was a 
kerosene lamp, the rays of light being reflected into the endoscopic 
tube by a mirror. 

^Buerger: American Journal of Urology, January, February, 
March. 1911. 



The Gorgas Medal of the N. Y. Medical Re- 
serve Corps Associ.\tion. 

\ Gorgas Medal, to be awarded annually in 
honor of Surgeon-General Gorgas, U. S. A., has 
been established by the Medical Reserve Corps 
Association, New York State Division. Competi- 
tion for this medal is open to officers of the Med- 
ical Corps of the United States Army, the Medical 
Reserve Corps of the United States Army, and 
the Medical Corps of the organized militia. Of- 
ficers may submit papers on any subject of a 
medico-military nature. 

General Gorgas has appointed the following board 
of officers to act upon papers submitted : Colonel 
Charles Richard, Lieutenant Colonel Champe C. 
McCulloch, Jr., and Major Eugene R. Whitmore, 
Army Medical Corps. These officers are members 
of the faculty of the Army Medical School and will 
have sole authority to appoint the time that papers 
are to be submitted and to pass upon their merits. 
All inquiries should be addressed to one of these 
officers. 



Vol. XXIX, No. 2. 



Fort — -Iodine in Peritonitis. 



American 
JouR.sAL OF Surgery. 



59 



THE LOCAL EMPLOYMENT OF IODINE IN 

SUPPURATIVE PERITONITIS. 

F. T. Fort. ^LD.. 

Louisville, Ky. 



Clinical investigation and experimentation dur- 
ing the last few years have amply demonstrated 
the value of iodine as a local application in an in- 
finite variety of infective and suppurative lesions. 
Also for sterilizing and disinfecting the hands of 
the surgeon and the operative field in any anatom- 
ical situation, likewise in the treatment of contused 
and lacerated wounds of every character where an 
antiseptic or germicide is required, it has been found 
far superior to bichloride of mercury and carbolic 
acid hitherto so extensively employed. 

For injection in the treatment of joint inflamma- 
tion the value of iodine has long been known. For 
example, as early as 1878, Orlow successfully 
treated several cases of knee-joint inflammation, 
with serous and sero-purulent effusions, by tapping 
and injection of iodine solution. Reaction was 
never severe, although some of the solution was 
allowed to remain in the joint. Durante also rec- 
ommended that a one to five per cent, solution of 
iodine be injected into tuberculous joints, limiting 
the amount to about fifteen drops and repeating the 
treatment daily. 

Biagi claimed to have cured tuberculous periton- 
itis by injecting iodine solution into the cavity. 
While pain followed injection, the method was de- 
void of danger. Favorable results from similar 
methods were also reported by Campanini. 

In discussing the subject of peritonitis, the term 
"general" must be recognized as practically a mis- 
nomer, as the instances are exceedingly rare in 
which the entire peritoneal area is involved in an 
infectious or inflammatory process. The terms 
"diffuse" and "circumscribed" convey a more accu- 
rate idea as to the extent of the existing pathology. 
Moreover, it must be recognized that peritonitis can- 
not be correctly classified as a disease, per se, some 
other pathology being invariably responsible for its 
origin. 

Diffuse peritonitis, the result of extension of in- 
fection from the abdominal and pelvic viscera, is al- 
ways serious, whereas a circumscribed pelvic peri- 
tonitis may exist for a considerable period without 
inducing grave symptoms. The observable clinical 
manifestations of peritonitis may vary greatly in 
severity ; they may be barely perceptible in one in- 
stance, and in another may be so marked that the 
Hippocratic expression has already developed and 
the individual is practically moribund when he is 



first observed. If a favorable outcome is to be 
expected, the pathology must be early recognized 
and suitable treatment instituted without delay. 
The mortality attending ditTusc peritonitis under 
older methods of treatment has been extremely 
high. 

Notwithstanding the fact that the value of local 
applications of iodine in the treatment of tuber- 
culous peritonitis has for many years been recog- 
nized, no one seemed willing to recommend the 
extension of its employment to peritoneal involve- 
ment due to other causes until quite recently. To 
Dr. Eugene J. Johnson belongs the sole credit for 
suggesting the intraperitoneal application of iodine 
solution in all varieties of peritonitis regardless of 
the etiology-. As has been true with every other 
innovation in medicine and surgery from the be- 
ginning of history, this new method of treating 
peritonitis has not escaped criticism, many of the 
most prominent surgeons in the country being espe- 
cially severe and even vituperative in their discus- 
sion of the hypothesis presented. While the method 
was first employed by Johnson in 1906, the details 
in connection therewith were not published to the 
profession until 1911. The following excerpt is 
taken from an article by Crisler and Johnson which 
appeared in the Southern Medical Journal. March, 
1913 (p. 202). The expression "half-and-half" re- 
fers to a mixture of equal parts of alcohol and the 
official tincture of iodine, thus making a solution 
containing 2^ per cent, or 3j/S per cent, in alcohol :* 

"What we most wish to bring before you is the 
fact that, first, we are using the above-mentioned 
'half-and-half in all cases of peritoneal infection; 
whether it be localized, from an unruptured gan- 
grenous appendix or other source, or whether the 
peritoneum is wholly infected, it makes no differ- 
ence. We simply 'put out the fire' with this mixture 
and disregard infection thereafter. If we have a 
ruptured gall-bladder, for instance, as soon as this 
is discovered at the operation and before the in- 
cision is extended further, we literally pour a quart 
of this mixture into the abdomen and thoroughly 
sift it into all of the recesses. We do not fear the 
use of too much of the mixture ; our only fear is 
that some pocket or interspace between the coils 
of intestines or elsew^here might escape us. If the 
case is already one of acute, general, fulminating 
peritonitis, we are even more liberal with the flush- 
ing out and washing out process w'ith the 'half- 
and-half mixture. If in our judgment a quart 



* The present U. S. P. official tincture is 7% iodine, whereas it 
was formerly 5*5^. The e.xpression "half-and-half" is evidently in- 
tended to indicate the mixture employed when the proportion of 
iodine in the official tincture was 5%. In their later writings these 
authors refer to a 2V29c solution. 



60 



American 

Journal of Surgery. 



Fort — Iodine in Peritonitis 



February, 1915. 



will do, that is all that is used, though we have 
sometimes used as much as a gallon. This applies 
equally to any other infection, whether it be a rup- 
tured appendix with its consequent peritonitis, local 
or general, or a gunshot wound, or a ruptured blad- 
der, or a ruptured tube, or any other infection from 
the pelvic organs, or a perforated ulcer, or what 
not." 

My attention was especially called to this method 
of treatment by Dr. Johnson in a personal interview 
during March, 1911, at which time he stated he had 
used the method for several years. He was very 
enthusiastic and his arguments were convincing. 
It seemed certain from the results reported that 
iodine could do no possible harm to the patholog- 
ical peritoneum, and his method seemed worthy 
of an extended trial. He explained that he had 
at first experimented upon dogs with peritonitis 
artificially produced, which proved so successful 
that he later decided to employ iodine within the 
human abdomen, and that his mortality from peri- 
tonitis had thereby been markedly reduced. Since 
the method was originally suggested by Dr. John- 
son, he and Dr. Crisler have treated more than 
twelve hundred cases of peritoneal infection, using 
a 21/ per cent, solution of tincture of iodine in alco- 
hol. Their success has been remarkable, the mor- 
tality having been reduced to almost the vanishing 
point. 

It is manifestly imi^ossible for any observer to 
form an intelligent opinion as to the merits or 
demerits of iodine by its experimental application 
to the healthy peritoneum of animals. It is quite 
likely that such applications would produce exten- 
sive peritoneal irritation with the formation of 
adhesions, and the evidence thus secured as to the 
usefulness of iodine would be distinctly misleading. 
In the highly inflamed peritoneum, however, it 
would not appear that iodine applied to the infected 
area should cause greater adhesion or absorption of 
toxic material than would occur from the existing 
pathology. On the contrary, the theory has been 
confirmed by practical experience that iodine to a 
certain extent neutralizes the inflammatory peri- 
toneal exudate, thereby materially assisting in its 
resoqition and contributing to a cure in desperate 
cases in which the mortality has been tremendous 
imder other methods of treatment. 

Shortly after the personal interview with Dr. 
Johnson a patient suffering from diffuse peritonitis 
following rupture of a gangrenous appendix came 
under my observation, and it was decided to try 
the method of treatment he had so graphically de- 
scribed. The result was eminently satisfactory, and 



since then I have employed iodine in every case of 
peritonitis from any cause. The following list em- 
braces a few of the cases in which iodine has been 
used during the last two years:* 

N. B., female, aged 16 years; date of first obser- 
vation May 9, 1912. Diagnosis, appendicitis, prob- 
ably gangrenous, with diffuse peritonitis. The par- 
ents at first declined to permit the patient to be 
operated upon, but two days later (May 11), after 
a consultant emphasized the extreme gravity of the 
situation, they reluctantly allowed her to be taken 
to the hospital, where an immediate operation was 
performed. Upon opening the abdomen through a 
low median incision, pus appeared from every 
direction. Gentle digital exploration toward the 
right side caused the escape of a large quantity of 
purulent fluid. The hand was then gently carried 
toward the left, gradually pushing the intestines 
aside, and a still greater amount of pus was lib- 
erated from the left iliac region. The appendix 
was found gangrenous, and all the viscera were 
extensively adherent. Sixteen ounces of a two per 
cent, iodine-alcohol solution poured into the cavity 
were allowed to gravitate in every direction. Three 
rubber drainage tubes with gauze in the center were 
inserted, one each to the right and left fossa, and 
another behind the uterus. The patient was placed 
in bed in the Fowler position, and proctoclysis of 
salt solution and coffee given. During the first 
twelve to fifteen hours the indications were that the 
patient would almost certainly perish, but reaction 
occurred and she made an uneventful recovery. She 
is now working in one of the Louisville department 
stores, and so far as can be ascertained has re- 
mained perfectly well. 

A. T., female, aged 23. Diagnosis, bilateral pyo- 
salpinx, with circumscribed peritonitis. Operation 
June 27, 1912. One tube was greatly distended 
and densely adherent and rupture occurred during 
its removal, literally flooding the pelvis with pus. 
Six ounces of iodine-alcohol solution were poured 
into the pelvic cavity and a cigarette drain placed 
posterior to the uterus. This was removed in three 
days. Healing occurred without complication. Re- 
covery. 

R. H., female, aged 21. Diagnosis, bilateral pyo- 
salpinx, with circumscribed peritonitis. Operation 
July 6, 1912. In this case also one of the tubes rup- 
tnred during removal, flooding the pelvis with 
purulent material. Ten ounces of iodine-alcohol 
solution were poured into the cavity and the wound 
closed without drainage. Proctoclysis not used. 
Healing by first intention. Recovery. 

M. J., female, aged 27. Provisional diagnosis, 
bilateral tubo-ovarian disease, with diffuse periton- 
itis. Owing to the exceedingly thick abdominal 
walls, the exact nature of the existing pathology 
was undetermined prior to operation, which was 
performed July 9. 1912. Upon opening the abdo- 
men by median incision, a large quantity of puru- 
lent material escaped. All the viscera were densely 
adherent. After considerable difficulty the adhe- 

* These cases were hriefly reported before a meeting of the Jef- 
ferson County Medical Association, Louisville, Ky., November, 1914. 



Vol. XXIX. iNu. 2. 



Haas — Treatment of Burns. 



American 

Journal op Surgery. 



61 



sions were separated, and both tubes and ovaries 
being extensively involved in the pathology were 
removed. Great trouble was experienced in con- 
trolling the oozing which occurred from the sep- 
arated adhesions. Nine ounces of iodine-alcohol 
solution were poured into the pelvic cavity, a cig- 
arette drain inserted posterior to the uterus, with 
three or four stay-sutures. The patient left the 
operating table in extreme shock, but rallied in 
about twelve hours. One pint of black coiTee-saline 
solution used by proctoclysis. Recovery. 

S. D., female, aged 22. Diagnosis, appendicitis, 
probably gangrenous, with diffuse peritonitis. Oi> 
eration June 2, 1913. When the abdomen was 
opened to the right of median line, a large quantity 
of pus immediately appeared in the wound. The 
appendix was found gangrenous, and there was 
also a complicating bilateral pyosalpinx. Several 
ounces of iodine-alcohol solution w'ere poured into 
the cavity, and a large cigarette drain was placed 
in the cul-de-sac of Douglas. The patient w-as 
placed in bed in the Fowler position. Proctoclysis 
of saline-coiTee solution given. Recovery. 

J. M., female, aged 40 years, was admitted to the 
hospital the night of September 16, 1914, suffering 
from appendicitis. Refusing emergency operation, 
she was kept in bed until the following afternoon, 
when the symptoms of diffuse peritonitis became 
apparent. The serious nature of the condition and 
the imperative necessity for immediate surgical in- 
tervention being fully explained, she finally con- 
sented and was immediately taken to the operating 
room. When an abdominal incision was made 
through the outer border of the right rectus muscle, 
considerable purulent fluid escaped. Nature had 
accomplished little toward isolating the infectious 
material from the gangrenous appendix located to 
the outer side and posterior to the cecum. A de- 
cided fecal odor emanated from the ruptured ab- 
scess, and the appendix was so friable that its 
removal in the customary manner was impossible. 
The gangernous portions were therefore merely 
"pinched off" with forceps, and pure tincture of 
iodine applied to the remaining stump and the sur- 
rounding infected tissues. Two rubber drainage 
tubes with gauze in the center were inserted, one 
in the cul-de-sac of Douglas, the other in the right 
iliac fossa. In addition, gauze strips saturated with 
a three per cent, iodine solution were introduced 
to the site of the gangrenous appendix and brought 
through the abdominal wound with the drainage 
tubes. The incision was partially closed, and the 
patient was placed in bed in the Fowler position. 
Proctoclysis of saline-coffee solution given. She 
left the hospital within three weeks. A fecal fis- 
tula, which was anticipated, did not develop. 

For a most excellent resume of the literature concerning 
the anti-microbic action of iodine in comparison with other 
drugs, see dissertation by Kinnaman, Journal of the Ameri- 
can Medical Association, beginning with the issue of Au- 
gust 26, 1905, p. 600. See also the admirable paper by 
Senn. Surgery, Gynecology and Obstetrics. 1905, vol. I, p. 
1; and the articles of: Roberts: International Journal of 
Surgery. February, 1913. p. 56; Post-Nicoll : Quoted by 
Roberts, I. c. ; Crisler-Johnson : Southern Medical Journal, 
March, 1913, p. 202, Southern Medical Journal, February, 
1914, p. 147, etc. 



THE TRE.-\TMENT OF BURNS IN CHIL- 
DREN BY EXPOSURE TO AIR. 
Sidney V. Haas, M.D., 

.\ttending Pediatrist, Lebanon Hospital and Hebrew In- 
fant Asylum ; Consulting Physician, Hawthorne 
Home for Crippled Children. 

New York. 



Despite the endless methods of treating burns of 
the surface, whether produced by fluid or by flame, 
the results remain far from satisfactory. No local 
treatment will prevent the fatal result which follow 
burns of very large areas of body surface. The 
only hope of the future in these cases must rest 
upon a correct understanding of the pathologic 
process which ensues, a process that bears a strik- 
ing analogy to the phenomenon of anaphylaxis, 
many of these cases presenting a scarlatiniform 
erythema before death. Among recent contribu- 
tions to the pathology of bums, several observa- 
tions tend to involve the adrenals as important 
factors. Thus, Kalisko' states that changes are 
found in the adrenals in deaths from burns. There 
may be more or less extensive hemorrhage infarc- 
tion in acute cases and when death occurs later, 
marked hyperemia with reduction of lipoids. Pos- 
sibly these changes stand in direct relation to the 
cause of death in burns. 

Crile- has found that double adrenalectomy 
caused a steadily increasing exhaustion, and death 
in less than twenty-four hours, and marked changes 
in the brain cells. Animals exhausted by physical 
injur}', by fear, by infection, insomnia, etc., showed 
identical changes in tissues upon histological ex- 
amination. It is possible that here lies an explana- 
tion of the better results of the treatment of bums 
by the method to be described. 

For those cases, however, which are not so ex- 
tensively burned that recovery is impossible, a 
method of treatment may be applied which in a 
moderate experience has proved infinitely superior 
to any heretofore observed by me. It is an ancient 
method ; and as Dr. Jacobi would put it, quite an- 
cient enough to be new. Why it is not universally 
used is remarkable. It consists of exposing the 
burned areas to the atmospheric air. Nothing can 
be simpler, certainly nothing is more effective, un- 
less it may be heated air as suggested by Stappato.' 

During the last two years most of the burn cases 
at Lebanon Hospital have been treated in this way. 
Some of the cases have had a wet dressing applied 

■Kolisko: Vrtljahreschrift f. gerichtl. med. 1914. XLVII. 
^ Crile; Anoci Association, etc. Jour. A. M. K. LXIII. No. 
XVI, Oct. 17. 1914, p. 1335. 

•Stappato: Abstract. J. A. M. A. Vol. LXIII, p. 1797. 



62 



Amekicam 
jovrnai, of surgzky. 



Haas — Treatment of Burns. 



February, 1915. 



for twenty-four hours. Many of them had carron 
oil or some other oil dressing appHed before being 
brought to the hospital. It has been found, how- 
ever, that it is unnecessary to apply any dressing 
for eventy twenty- four hours; although it does not 
interfere with the subsequent treatment in any way, 
and has the advantage of perhaps rendering the 
wound cleaner. 

The patients arc placed in bed upon a clean sheet 
and the burned parts are left uncovered ; the other 
parts of tlie body are well covered in cool weather. 
In warm weather it is necessary to keep the entire 
bed well covered with mosquito netting to keep 
flies from the wound. Opium in some form is 
usually necessary during the first twenty-four or 
forty-eight hours, after that rarely. The bowels 
are freely moved, and as soon as the patient is 
hungry a full diet is given. The wound after a 
short time takes on a very characteristic appear- 



■Egg~ySCT| 




^i 


■ 


1 


A 


:.;P^ 





Fig. 1. Burned by flame November 26, 191-1: second and third 
degree. .Appearance December I J, 1914. 

ance. Those portions that have suffered only a 
first degree burn assume a normal appearance, ex- 
cepting for the redness. Those portions that are 
the seat of second and third degree burns crust 
over and, according to the depth, discharge puru- 
lent fluid under these crusts, which are lifted up 
and take on the appearance of rupia. When the 
exudate beneath the crust is not great, the cnust 
remains until it falls off, leaving a reddened, healthy 
surface without scar. 

Where the deeper burn produces a large eduda- 
tion the scab is lifted until it is loose in nearly all 
its parts and a granulating surface bathed in puru- 
lent fluid is seen beneath. These crusts should be 
left as long as possible, hut it frequently becomes 
necessary to remove them and clean the granu- 
lating surface thus exposed, by gently mopping with 
cotton moistened in boracic or other solution. The 
crusts form again immediately, but each time 
smaller, as healing from the edges proceeds very 



rapidly. The granulations by this method do not 
bleed as when a dressing is applied, except where 
the crust is forcibly separated, or from mechanical 
injury from some other source. The granulations 
are constantly bathed in the purulent fluid held be- 
neath the crusts. 

To be sure, this method of treatment does not 
create a pleasant view. The odor and appearance 
of the wounds are two of the objectionable fea- 
tures, as is also the tendency of the patient to pick 
off the scabs. An attempt was made in one case 
to replace the putrefactive by fermentative organ- 
isms: lactic bacilli were sprayed over the surface 





Fig. 



Appearance January 9, 1915. 



of the wounds which had been dusted with sugar. 
The results, however, were negative. Dusting the 
parts with boracic acid powder appears to aid ma- 
terially in keeping the wound sweet, without inter- 
fering with the healing process. 

The contrast betw'een a burned child treated by 
this method and one treated by some form of dress- 
ing is striking indeed. The terror of the one wait- 
ing for the next dressing, and the shrieks which 
accompany such a dressing, and the comparative 
air of comfort and well-being of the other, is one 
not quickly forgotten, These children lie quietly in 
bed, present good color, smile and play when they 
can do so without disturbing the burned parts, and 
take their food with relish. 

Nephritis would seem to be less frequent than 
in cases treated by dressings and, when present, 
to disappear sooner. The pallor and cachexia of 
these latter cases is not so noticeable as in those 
treated bv dressings. 



Vol. XX rx. Xo. 



HiiRRMAN — Burns. 



American 

Journal of Sckgerv. 



63 



The degree of scarring is greatly diminished, the 
time required for healing is apparently much 
shorter. 

These cases have all been observed in children, 
although several adults have been treated at the 
hospital in the same manner, and with the same 
■degree of success. Because of cold weather and 
the necessity of keeping the wards cool, the burned 
part in one case was protected by covering with a 
blanket which, however, did not touch the region. 
In this case the healing process was much slower 
than usual. 

Light and air are the important elements neces- 
sary to insure proper dessication and the best 
results. 

SUMM.^KY. 

1. This method is simple. 

2. It minimizes scarring and contractions. 

3. Healing proceeds more rapidly than under dressings. 

4. The shock of treatment is reduced to a minimum, 
as noted by the absence of pain, terror, and psychic dis- 
turbance. 

5. Nephritis would appear to be less frequent and less 
severe. 

6. The patient's spirits and appetite are maintained. 

7. At the termination of the treatment the appearance of 
the patient is quite different from that which one is accus- 
tomed to see. 

8. The treatment can be carried out at home, inex- 
pensively. 



A NOTE ON THE OPEN METHOD OF 

TRE.-\TING BURNS. 

Cn.\KLES Herrman, M.D., 

Attending Pediatrist, Lebanon Hospital, 
New York. 



Thyroid Enl.^rgement. 
The thyroid gland is enlarged at times in infec- 
tions in different organs of the body, noticeably 
in syphilis, scarlet fever, tonsilitis, and tuberculosis. 
This does not mean that the enlargement is due to 
a specific organisin, but may indicate that the in- 
creased activity of the gland is due to its effort 
to eliminate toxic materials. — G. T. M.vtl.ack in 
The Therapeutic Gazette. 



Tachyc.^rdi.\ and Uterine Growths. 
A large number of uterine growths are associ- 
ated with tachycardia and other circulatory anoina- 
lies. In some of these cases there is a palpable 
thyroid : in others no evident enlargement of the 
gland. In some an apparently normal thyroid may 
become tender and slightly enlarged during the 
presence of tachycardia. There may be localized 
tenderness, with slight enlargement of one lobe of 
the thyroid. In all of these cases one inust inves- 
tigate cautiously to determine the factor which has 
ungeared the circulatory system. In the presence 
of several of the symptoms of hyperthyrodia or per- 
verted functions and the absence of other causes, 
though there is no evident goiter, the author would 
favor strongly the thyrogenous origin of the tachy- 
cardia. — Henry N. Ekner, in The Monthly Cyclo- 
pedia and Medical Bulletin. 



During the past seven years, 180 cases of burns 
have been treated in the wards of Lebanon Hos- 
pital, and of these 7S per cent, were in children. 
We have been interested to follow the various 
methods of treatment and have always felt that 
their results were most unsatisfactory. In the four 
years from 1908 to 1912 the inortality from burns 
of the third degree was 54 per cent. Few if any 
of those dying during the first 48 hours could have 
been saved, but we feel that many of those who 
died after several weeks or months would have 
recovered if they had been treated by the "open 
method." 

The keynote of this treatment is "hands otT." 
It may be compared in some respects to the jiresent 
method of treating peritonitis. I'"ormerly the sur- 
geon by swabbing and washing tried to make the 
peritoneal cavity perfectly clean, and in so doing 
he removed the protective covering and broke up 
the fine adhesions which represented nature's at- 
tempt to limit the spread of the infectious material. 
Now the surgeon simply removes the free exudate 
and the source of the infection and interferes 
otherwise as little as possible, with the result that 
a far larger percentage of the patients recover. In 
the usual inethod of treatment of burns with local 
applications, the removal of the dressings, besides 
causing great pain, destroys the protective cover- 
ing and fine granulations. Nature's tendency to 
conservation is well illustrated in the healing of 
burns if they are left to themselves; there is then 
the least possible loss of tissue and there results 
a thin, smooth scar instead of dense cicatricial 
tissue. 

Those who die within 48 hours apparently suc- 
cumb to an acute anaphylactic shock. In those who 
die later the kidneys are apparently unable to ex- 
crete all the foreign protein material that is ab- 
sorbed from the disintegrated tissue at the site of 
the wound. If the wound is left alone the absorp- 
tion of such material is slight. 

The fever associated with these cases has usually 
been assuined to be of bacterial origin, but this is 
probably a mistake. The result of the absorption 
of an undue amount of foreign protein material is 
seen in the irritation of the kidneys as shown by 
the appearance of abnormal elements in the urine, 
and the often associated coma and vomiting remind 



64 



American 
Journal of Surgery. 



Breese — Gastro-Enterostomy. 



February, 1915. 



one forcibly of uremia. It would therefore seem 
rational to treat the condition in a similar manner 
to the treatment of uremia, namely, by improvising 
elimination through the skin, kidneys, and bowel. 
The treatment with hot air probably owes much of 
its value to its diaphoretic action. 

For preventing the multiplication of the organ- 
isms of putrefaction, I have suggested powdering 
the parts with boracic acid, and I have found it 
very effective. Briefly outlined, the treatment 
would be as follows: During the first twenty- four 
hours, if the pain is severe, morphine is admin- 
istered; after that the exudated serum covers the 
nerve endings and there is little pain if traumatism 
is prevented. Stimulants, especially suprarenal ex- 
tract, are given to control shock. The parts are 
exposed to the air and are well powdered with 
boracic acid. Elimination through the skin, kid- 
neys, and bowel is increased by the use of hot air, 
diaphoretics, high colonic irrigation with hot water, 
diuretics, and saline laxatives. 



GASTRO-ENTEROSTOMY UNDER LOCAL 

ANESTHESL^: CASE REPORT. 

E. S. Breese, M.D., 

Dayton, Ohio. 



The patient was a man of 67 years. He gave a 
history of "stomach trouble," extending back two 
years ; pain, nausea, and vomiting at frequent inter- 
vals during the last six months ; progressive loss 
of weight and strength. For three weeks prior to 
operation there were signs of pyloric obstruction, 
but no tumor could be palpated. The only nour- 
ishment he received was by rectal alimentation. 

Clinical diagnosis: Carcinoma of the stomach, 
with pyloric obstruction. 

Treatment: Lavage of the stomach until the 
water returned clear. Inhalation anesthesia was 
considered unsafe in this particular instance. 

Spinal analgesia with the patient lying on the 
side, shoulders and hips elevated, in order that a 
heavy anesthetic solution might run down into the 
dorsal curve and thereby anesthetize the segment 
of the body containing the stomach was considered. 
It was abandoned on account of the patient's weak- 
ened condition. 

The skin of the upper abdomen was prepared 
with benzine and iodin. Novocaine 1 :400 with 10 
drops of adrenalin solution to the ounce was care- 
fully injected into the skin and deeper tissues for 
a space of four inches in the midline between the 
ensiform cartilage and the umbilicus. After an 
interval of ten minutes the same area was injected 
with quinine-urea hydrochloride 1 :200. 



The incision, begun fifteen minutes after the first 
insertion of the needle and carried through skin, 
fascia, muscle, and peritoneum without discomfort 
to the patient. Careful exploration of the stomach 
revealed inoperable carcinoma of the pyloric region, 
and the manipulation caused no particular distress. 

The under surface of the transverse mesocolon 
was exposed and a point on the jejunum about 25 
cm. from its origin selected. The lowest point on 
the anterior wall of the stomach was also selected. 
These two points were quickly approximated by 
means of a Murphy gastro-enterostomy button. To 
preclude the possibility of the formation of a spur 
at the point of union, Lembert stitches were placed 
between the stomach and jejunum distal to the but- 
ton. The parts were returned to their normal cav- 
ity, the abdominal incision quickly sutured in layers 
and the skin approximated by Michel clips. 

Cutting and puncturing the viscera appeared to 
cause no pain. The patient assured me that the 
only time he was uncomfortable was when traction 
was made on the stomach and bowel. 

There was neither shock nor acceleration of 
pulse. He left the operating table in as good con- 
dition as he came on. 

Post-operative histor\<: Complete absence of nau- 
sea and vomiting. Rest in bed in the sitting pos- 
ture for eight days, at the end of which time the 
patient was removed from the hospital. Liquid 
diet in increasing amount and variety after the first 
24 hours. 

This operation is only palliation, of course, but it 
can be quickly accomplished under local anesthesia, 
with little discomfort to the patient. 



Duodenal Ulcer. 
The great majority of cases of gastric or duo- 
denal ulcer will give some indication of their pres- 
ence from the Roentgen ray examination, although 
at times, even a typical clinical case may yield no 
information, and a doubtful case may still remain 
doubtful. The points to be considered are, the 
clinical history, the tender spot, examination of the 
stomach contents and of the stool ; increased peri- 
stalsis, spasm ; the interval of time occupied by the 
stomach in emptying itself, retention and rarely 
antiperistalsis ; the evidences of adhesions or of 
cicatrization ; the contour of the organ, the pres- 
ence of diverticulum, penetrating ulcer or hour- 
glass. By carefully considering these points, we are 
usually able to venture a positive opinion, for or 
against ulcer. — W. A. Wilkins in The Canadian 
Medical Association Journal. 



Vol. XXIX. No. 2. 



Editorials. 



American 
joursal op surcery. 



65 



AmFnran 31ountal of ^urgprg 

SURGERY PUBLISHING CO. 

J. MacDONALD, Jr., M. P.. President and Treasurer 

92 William St., N. Y., U.S.A. 

to whom all coniniunications intended for the Editor, original 

articles, books tor review, exchanges, business letters 

and subscriptions should be addressed. 

SUBSCRIPTION PRICE, ONE DOLLAR 
FOREIGN, SIX SHILLINGS 

Original Articles and CHnical Reports are solicited for publica- 
tion with the understanding that they are contributed exclusively 
for this journal. 

It ts of adianlage to submit typewritten manuscript; it avoids 
errors. 

CHANCE OF ADDRESS. Subscribers changing their addresses 
should immediately notify us of their present and past locations. 
We cannot hold ourselves responsible for non-receipt of the Journal 
in suck cases unless we are thus notified. 

ILLUSTRATIONS. Half-tones, line etchings and other illus- 
trations will be furnished by the publishers when photographs or 
drawings are supplied by the author. 

C^ SPECIAL NOTICE TO SUBSCRIBERS ^3 
The "American Journal of Surgery" is never sent 
to any subscriber except upon a definite written order. 
Present and prospective readers please note this. 

WALTER M. BRICKNER, M.D., Editor 
New York, February, 1915. 



THE IMEDICAL PICKWICK. 

Have you listejied to the lispings, heard the whiffling, 
whistUng whisperings, 
Seen the strange mysterious trystings that are going on 
in town? 
There's to be another journal blazing forth from depths 
infernal, 
Or perhaps from realms supernal it will gaily flutter 
dow'n. 

There's a direful dearth of papers that can chronicle the 
capers 
Of the big and little apers of Hippocrates the sage. 
There are clinics, there are cases jotted down in divers 
places, 
But the medic and his graces are not found on any page. 
****** 

There's a new medical journal. This time, if you 
please, it's not "another journal you'll have to read," 
but another journal you are going to read, read 
regularly and, we venture to predict, read from 
cover to cover every month before you can be 
tempted from it to any of the regular medical pub- 
lications that come to your desk. 

For this is a new journal in the date of its birth 
not only. It is altogether new in its substance and 
in its purpose. Not a word of scientific medicine 
is in it, not a case report, not an "abstract of cur- 
rent literature." And yet in dignity, in interest, 
in yield of inspiration, this magazine will find a 
worthy and a welcome place among its many more 
familiar brothers that bear the burden of dry med- 
ical facts. 

As we look through the pages of the first num- 
ber of The Medical Pickzvick, issued a few weeks 
ago. we wonder that no one before undertook to 
publish what many medical men have long wished 
for — a magazine devoted to the purely literary and 
humanistic side of medicine ; to verse, fiction, hu- 
mor, satire, biography, anecdote, and lore of or by 



medical men; a periodical to quicken the interest 
of physicians in the history of their art, to stir and 
amuse them with genial satires of their own foibles, 
to banish the fatigue of their daily grind with 
pleasing wit and well selected verse, to tap their 
pent-up skill in fiction, biography, history — in short, 
a magazine both light and serious for the intellec- 
tual side of doctors as doctors. 

Just such is the new journal, The Medical Pick- 
wick. That in the first issue, before its existence 
was generally known, all the various qualities of 
the publication should be displayed by so much and 
such excellent material, is a creditable accomplish- 
ment by the editor. Dr. Samuel M. Brickner, of 
Saranac Lake, N. Y. Known to many as well by 
his own excellent verse and lay writings as by his 
contributions to gynecology and obstetrics, he has 
no doubt sounded his Pickwickian horn to his lit- 
erary friends, and forty-eight pages of delightfully 
interesting, clean, dignified, and well illustrated 
reading was the response. Fielding H. Garrison, of 
Washington, editor of the Index Medicus, and au- 
thor of a quite remarkable history of medicine, 
bespeaks the dignity and purpose of the magazine 
in a "foreword" of charming style. Among the 
very many other features are an excellent jingle 
by Samuel W. Kelly, of Cleveland, author of the 
volume "In the Year 1800" and numerous other 
contributions to literary medicine ; "The Singer in 
the Snows," an illustrated ston,' of Robert Louis 
Stevenson at Saranac Lake, by Stephen Chalmers; 
"Julius Pagel," the medical historian, by Major 
Seelig, of St. Louis, himself a deep student of 
medical history and a master of literary expres- 
sion ; "The Pickwick ]\Iedical Society," a laughable 
satire on medical meetings, by Ira S. Wile; "Mod- 
ern Medical Writers," by Davina W'aterson : "The 
Surgeon in the Field Hospital." from an old maga- 
zine; "Therapeutics of Two Hundred Years Ago," 
by Alice Chadwick, and many other historical con- 
tributions such as "Incubation at the Temple of 
Epidaurus." "Chaldean Incantation Against Dis- 
ease." "The First Account of Mountain Sickness," 
"William Hunter." "John RadclilTe," "An Old Eng- 
lish Sign-Board," and numerous anecdotes. There 
is an intimate sketch of Abraham Jacobi, of the 
authorship of which we suspect the editor, as we 
do the authorship of a brisk and amusing satire on 
newspaper publicity, entitled "Pronouncing Him 
Dead," and the sketch "Dr. Hulett's Sonnet." There 
is a short article on "Nut-Raising." by Robert T. 
Morris, of New York; a column devoted to "Hol- 
mesiana." and several other interesting articles, 
reminiscent, satirical, and otherwise. And with 
this bountiful literary feast are served numerous 
delicious tid-bits — editorials, poems, cartoons, anec- 
dotes, jokes, portraits, book reviews. Surely, such 
a magazine as this will be welcomed by those phy- 
sicians who have a sense of humor, those who want 
to be amused, those who are interested in the his- 
torical and humanistic sides of medicine, and those 
who possess literary- talent or even only a readiness 
to enjoy good literature — and who are there in the 
profession who lack all of these qualities and feel- 
ings? Surely, too. The Medical Pickzmck will be- 



60 



American 
Journal of Surgery. 



Editorials. 



February, 1915. 



come the natural repository for the short biograph- 
ical sketches that liave had to find a desultory place 
now in this medical journal and now in that one. 

Accustomed as we are to devote the editorial 
pages of the Journal to strictly surgical subjects, 
this rather lengthy consideration of another non- 
surgical journal probably seems a wide departure 
from our rule. But though we here usually adhere 
to the dry discussion of scientific topics, the literary 
aspects of medicine are close to the hearts of the 
Journal stafl:, and we believe that the advent of 
The Medical Pickwick, so important in the devel- 
opment of American medicine, so pregnant with 
interest to the profession, deserves to be brought 
thus prominently to attention. Itself dealing only 
with surgery the science, the Journal would urge 
and encourage all the qualities and attributes of 
surgery the art. .And so, with Kelley, we say for 
The Fickzinck: 

Surgeon, drop your scalpel gory, seize your pen and write 
a story 
That will celebrate the glory of the art that you profess. 
Doctor, rest your dulled gray matter while you generously 
scatter 
Your superfluous lore in chatter for our dictographic 
press. 

— W. M. B. 



THE QUADRICENTEXNIAL OF ANDREAS 
VESALIUS. 

Brute man, brute through all the dark and all 
the gilded centuries, fighting for his existence like 
the other brutes, buckles on the horrid habilaments 
of hell and hurries forth to slaughter and destroy. 
And insatiable War, his cunning, cherished com- 
panion through all the ages, with devastating shell 
and shrapnel shrieks derision of his boasted civili- 
zation. 

The great University of Louvain, rich in price- 
less collections and incunabula, cherished in the 
traditions of centuries, is in ruins. In those halls 
trod many of Europe's greatest scholars and scien- 
tists. There Andreas Vesalius, the great anatomist, 
taught and studied, and there, and at Brussels, the 
city of his birth, the quadricentennial of that event 
was to have been celebrated a month ago. 

Belgium has sorrows far greater than the pas- 
sage, uncelebrated there, of this occasion, far 
greater even than the loss of its famous old univer- 
sity. But among scholars and scientists, and not the 
least among medical men, the destruction of that 
great institution of learning will remain a bitter 
memory of the war long after the Belgians are, we 
hope, restored to homes and pros])erity. 

Medicine is international ; and so the quarter- 
centenary of Vesalius, perforce neglected in the 
land of his birth, has not gone unmarked elsewhere. 
For e.xamjilc, in New York and in Boston it was 
observed by interesting addresses and exhibits of 



books and engravings, and in Denver the life of 
Vesalius was made the subject of the presidential 
address by Dr. Carroll Edson before the County 
Medical Society. 

Vesalius's contribution to medicine needs no 
lengthy consideration here. It is familiar to most 
medical men, certainly to those who have interested 
themselves in medical history. That he upset many 
of the blindly followed teachings of Galen was a 
great accomplishment ; that he conducted and pub- 
lished, with engravings of artistic beauty and scien- 
tific precision, a systematic dissection of the human 
structures was a greater accomplishment, but that 
he established the study of anatomy in the path 
that it has since followed is, as Dr. Wm. H. Welch 
emphasized in New York, his greatest achievement. 
Dr. Lewis Pilcher well said at the Boston meet- 
ing: "After all, it is not so much what he did — 
other great anatomists have lived and worked since 
that time — but the spirit which he exemplified and 
perpetuated, that counts. We do well to honor his 
memory by such assemblies as this. We do best 
of all if into our own work we incorporate some- 
what of that spirit of inquiry, industry, boldness, 
zeal, energy, breadth of vision, doubt of dogma, 
insistence upon demonstration, which the world 
acknowledges to have been the peculiar characteris- 
tics of the Vesalian Spirit!" — W. M. B. 



FRACTURE NUMBER. 

It would be almost platitudinous to say that the 
treatment of fractures occupies to-day a large jala' e 
in surgical thought. The study of bone repair, the 
development of operative methods, and the appli- 
cation of stricter criteria to results brought this 
about. Old as it is in medicine, the management 
of fractures — fundamental in the surgical study of 
the physiology and pathology of the bones and 
joints — is to-day in a re-formative stage. Our 
mechanical methods, our operative procedures, nay, 
our physiological conceptions, are in the threshing 
machine of surgical activity. 

It is because of this activity, because of the con- 
fusion that may arise in the mind of the physician 
from the reading of scattered reports, some too 
conservative, some over-enthusiastic, that the 
Journal has from time to time devoted an entire 
issues to fractures, and has published therein articles 
most of them specially prepared, by men who have 
been leaders in the study of the treatment of frac- 
tures in its various aspects — mechanical, operative, 
economic. Thus, the last fracture number of the 
Journal (January, 1914), which was very warmly 
received, contained valuable articles by Magruder, 



Vol. XXIX. No. 2. 



Editorials and Surgical Suggestions. 



American- 
Journal of Surcekv. 



67 



Estes, Van Duyn, Albee, Stimson, Young, Cotton, 
Elsberg. and others; an editorial review of the sub- 
ject ; editorial suggestions concerning fractures ; a 
statistical study of "fractures and social loss" by 
Ira Wile ; and an illustrated critique and bibliog- 
raphy of recent fracture literature by J. C. A. 
Gerster. 

The next (March) number of the Jouknal will, 
again, be devoted to fractures. It is to contain 
the following contributed articles: "Classification of 
Fractures," by J. B. Walker, New York ; "Treat- 
ment of Fractures." by B. F. Zimmermann, Louis- 
ville ; "Fractures in the Neighborhood of the 
Joints." by Jas. K. Young, Philadelphia: "Inlay and 
Peg Bone Graft in the Treatment of Fresh and Un- 
united Fractures," by Fred. H. Albee, New York : 
"Fractures of the Femur," by W. L. Estes. South 
Bethlehem. Pa.; "The Treatment of Fractures of 
the Lower Extremities, with End Results." by 
J. H. Downey, Gainesville, Ga. ; "The Prevention 
and Treatment of Disabilities Following Fractures 
of the Limbs." by Asdey P. C. Ashhurst. Philadel- 
phia : "Medico-Legal Features of Fractures," by 
W'illiam H. Marcy, Buffalo: "Non-Reducing Oper- 
ations for Fractures and Dislocations," b_\- William 
Darrach, New York; "Hip Fractures." by F. J. 
Cotton. Boston ; "The Abduction Treatment of 
Fracture of the Clavicle," by John J. Moorhead. 
New York; "Fracture of the Ankle," by J. E. Pir- 
nuig, Cincinnati; "Infected Compound i'Tacture of 
tlie Femur into the Knee Joint; Conservative Treat- 
ment," by Howard Lilienthal, New York. 

We bespeak for the coming "fracture number" 
the same interest that its predecessors a'tracted. — 
W. M. B. 



HARE-LIP, CLUB-FOOT AND SYPHILIS. 
New York, January 15, 1913. 
Editor, .\meric-\x Jouexal of Surgery: 

In the editorial column of your January issue, 
under the caption. "Damaged Goods," you call at- 
tention to wdiat you consider an error on the part 
of the author of that play in assigning to certain 
fetal malformations [hare-lip, club-feet, and "con- 
genital hip disease"] a syphilitic origin. You deny 
this etiologic relationship and advise the correction 
of this statement "in the interest of the i>eace of 
mind of such mothers, even more than for the mere 
sake of accuracy." 

You said of the play "the medical data it pre- 
sents are for the most part accurate and well 
chosen." For accuracy sake permit me to cite you 
an authority for Brieux' statement. I refer you to 
the monograph, "Recherche et Diagnostic de I'ller- 



ido-Syphilis Tardive," by Edmond Fournier, Paris, 
1907. which is replete in examples from personal 
observations, supported by citations from eminent 
authorities, that these malformations are syphilitic 
in origin. 

It is probable that this classic work was the au- 
thority consulted by Brieux, and the correction you 
recommended is therefore unwarranted. The proof 
of the accuracy of the medical facts precludes any 
discussion of changes for sentimental reasons. 

Martin W. Ware, M.D. 

We thank Dr. Ware for citing an authority for 
Brieux' statement. W'e questioned, however, the 
correctness of the statement itself, not the play- 
wright's information. That hare-lip, club-foot, and 
similar fetal malformations appear in syphilitic 
children, just as it does in other children, there is 
no doubt. That they occur as a result of syphilis 
we very much doubt. Probably every practicing 
physician has seen several otherwise perfectly 
healthy children born w-ith hare-lip or club-foot, of 
healthy parents. What percentage of children w-ith 
these anomalies show stigmata of syphilis? What 
percentage of the inany recognizable hereditarily 
syphilitic infants have hare-lip, club-foot, or "con- 
genital hip disease" (whatever that may be) ? Now 
that we have a reliable serologic test w-e may deter- 
mine the correctness of Fournier's assertion. Until 
it has been thus substantiated we shall continue to 
share the general belief that these fetal malforma- 
tions are not evidences of a syphilitic taint. — 
W\ M. B. 



Surgical Suggestions 



In the acute stage of gonorrheal salpingitis opera- 
tion is contraindicated. The condition usually sub- 
sides under conservative treatment, and may even 
undergo spontaneous cure. 



Sometimes acutely inflamed pus-tubes rupture 
into the peritoneal cavity. W'hich provides an urgent 
indication for operation. These are probably in- 
stances of mixed infection 



The actual rupture of a pus-tube is apt to be 
preceded by attacks of severe local pain and weak- 
ness. Such attacks should suggest the possibility 
of an impending rupture and the desirability of 
relieving the tension in the sac by a vaginal inci- 
sion if the case is a recent one, or of salpingectomy 
if the condition is a recurrent one. 



68 



American- 
Journal OF Surgery. 



Surgical Sociology. 



February, 1915. 



Surgical Sociology 

Ira S. Wile, M. D., Department Editor. 



Some Dispensary Problems. 

The most striking advance in connection with 
hospital work is the development of out-patient 
departments. The number of dispensaries and out- 
patient departments existent at the end of 1914 
probably total nearly 900, of which 400 are gen- 
eral dispensaries and 300 for tuberculosis only. The 
rapid increase in the number of dispensaries is evi- 
dent from the fact that during fourteen years their 
number grew seven-fold. To-day, out-patient de- 
partments are distributed throughout the Union, 
and only ten states are to be found without one of 
these necessary institutions. 

Naturally, the larger the city, the greater the 
need of dispensary service, so that it is not strange 
to find that 75 per cent, of the dispensaries are in 
the cities of over 100,000 inhabitants and only 10 
per cent, in towns of less than 20,000. The in- 
crease of dispensaries in smaller communities is 
more marked at the present time than ever before 
and represents a wholesome advance from the un- 
derstanding of the importance of the service ren- 
dered. 

The rapid increase of special and general dispen- 
saries since 1900 has probably been due in part to 
the increased demand of physicians and surgeons 
for clinical material. A further factor in their 
development has been the need of a large portion 
of the public with limited means who have been 
made medically dependent, owing to the pressure of 
the rising cost of living. A more important reason, 
however, in the organization and growth of dispen- 
saries has been the increased interest in public 
health. 

The propaganda for the protection of the com- 
munity from the ravages of diseases, as tuberculo- 
sis, trachoma, cancer, hookworm, and the like, has 
employed out-patient clinics as part of their work. 
This is most strikingly ilhistrated in connection 
with the campaign for the prevention of tubercu- 
losis, which has resulted, within ten years, in the 
establishment of 300 tuberculosis clinics. Similar 
results, though not so large in numbers, have been 
attained through the campaign against infant Mor- 
tality, mental defectives, and the prevention of 
cancer. 

The wider dissemination of knowledge among 
industrial concerns relative to the importance of 
conserving the lives of employees, together with 
the pressure from potential workmen's compensa- 
tion acts, have impelled industrial organizations to 
establish dispensaries for the benefit of their em- 
ployees and even the members of their family. 

An appreciation of the importance of social ser- 
vice work and the following up of the cases dis- 
missed from hospitals has lead to an increase of 
out-patient facilities for the purpose of restoring 
discharged patients to a state of economic efficiency. 

The report of the Committee on Out-Patient 



Service of the American Hospital Association 
{Modern Hospital, January, 1915) calls attention 
to many interesting facts relating to the develop- 
ment of out-patient service. 

The question of the cost of dispensary service is 
of the utmost importance. The figures which seem 
to indicate that a cost per visit of a patient of less 
than twenty cents or even twenty-five cents is in- 
dicative of either a low standard of service or of 
an inadecjuate system of cost accounting. Unfor- 
tunately, in general dispensaries connected with 
hospitals complete data are not available to start 
the unit cost of dispensary service entirely from 
that of the hospital itself. Naturally, the cost de- 
pends upon the amount of money expended upon 
the entire plant and the number of visits paid by 
each of the patients. 

From the standpoint of efficiency, with an inade- 
quate expenditure of money, a proper standard of 
clinical work is difficult to maintain. If there be 
over-pressure by reason of numbers, the work even 
in a well organized plant must naturally fall below 
high standard. Of course, the standards of dis- 
pensary efficiency must be more or less relative to 
the form of its organization, the extent of its work, 
and the community it serves. 

It is a peculiarly striking fact that while the large 
majority of dispensaries state that they have ade- 
quate facilities for laboratory examinations, these 
facilities are not properly utilized by the staffs of 
the dispensaries. It is patent that this is a reflec- 
tion upon the character of the dispensary service 
aitorded and does not indicate the high standard 
of t!ie medical service which might be expected with 
available facilities for scientific clinical work. 

An excellent criterion of the general service of 
dispensaries may be found in the per cent, of pa- 
tients who paid only one visit to the clinic and failed 
to return, despite the fact that further treatment 
was needed. Where actual tests of this fact have 
been made, it has been found that the percentages 
of patients paying but one visit have varied in dif- 
ferent institutions and clinics from 30 to 75. This 
would indicate on the one hand a large wastage 
of efifort in medical and surgical service, and on 
the other, a lack of efficiency in remedying the con- 
ditions of the patients who fail to visit the clinic 
more than once. 

Obviously, this subject requires further investi- 
gation, in order to determine whether the greater 
responsibility rests upon the clinic or upon the 
patients. Furthermore, it would be interesting to 
ascertain what proportion of patients fail to return 
to one clinic and present themselves for treatment 
to another clinic. 

Tlie rapid growth of dispensaries in this country 
has interfered with their scientific investigation in 
terms of results and has permitted the organization 
of new dispensaries in a hasty and inefficient man- 
ner. It is necessary to improve the standards of 
out-patient service and to make thorough studies 
of the administrative, clinical, and social service 
which they are affording to their patients. To 
establish standards of service is a difficult matter. 
It is necessary, however, to examine the facts at 



\0L. XXIX. No. 2. 



Book Reviews. 



.\UeHlCAN 

Journal of Surgery. 



69 



present demonstrable in connection with existent 
clinics in order to determine any standards for 
the dispensaries of the future. In no type of clinic 
is this work more necessary than in the surgical 
dispensaries connected with general hospitals or in 
emergency dispensaries that have an independent 
existence. 

The function of an out-patient department is to 
serve not alone the hosi>ital with which it is con- 
nected, nor even the individual patient applying for 
treatment : it has a wider duty of far greater sig- 
nificance in its relation to the welfare of the com- 
munity that sponsors its development. 



Book Reviews 



Surgical Materials and their Uses. Alk.k.^nder M.\c- 
Lenn.xn. M. B., C. M. (Glas.). X'isiting Surgeon. Glas- 
gow Royal Hospital for Sick Children; .Assistant Sur- 
geon, Western Infirmary, Glasgow; Consulting Sur- 
geon in Glasgow, East Coast Railways : Honorary Con- 
sulting Surgeon, Royal Infirmary, Stirling; Consulting 
Surgeon to the County Council of Lanarkshire. Duo- 
decimo; 252 pages; 277 diagrams and illustrations. 
New York: Loxgm.jv.vs, Greex & Co.. 1915. Price, 
$1.25. net. 

This small volume deals with subjects of interest to all 
practical surgeons. Bandaging, the making of splints and 
dressings, the various antiseptics and their indications, the 
preparation and uses of sutures and ligatures, the choice 
and use of instruments — all these matters and many more 
are treated here briefly and in the light of the author's 
experience. The section on splints and the section on in- 
struments possess particular value to those who seek sug- 
gestions of proved service. 

The Cancer Problem. By Willi.am Se.\m.\x B.mx- 

BRiiKiE. A.M.. Sc.D.. M.D.. Professor of Surgery. 
New York Polyclinic Medical School and Hospital ; 
Surgeon, New York Skin and Cancer Hospital, etc., 
etc. Octavo ; 534 pages. Illustrated. New York : 
The M-acmill.\x Co., 1914. 

The perusal of this very comprehensive book affords 
a sense of melancholy, not, we hasten to add. because 
the author has not done his part well, but because the 
book tells of so much work done with so little accom- 
plished. We cannot escape the thought of how utterly 
futile this book will be, should the cause of cancer be dis- 
covered tomorrow. Although published only yesterday, 
this book would be as suddenly ancient as the Humoral 
Pathology of Galen. Bainbridge conscientiously reviews 
all the theories, both old and modern, of the cause of 
cancer; he relates the story of cancer research, especially 
that concerning animal tumors — but when it is all done, 
ignorance is still our portion. 

We come upon a little surer ground when we read of 
the distribution and statistics of cancer, but even these 
subjects, we feel, are only desperate graspings at straws. 
They remind us strongly of old text-book discussions 
upon malaria before the mosquito etiology was discov- 
ered. The chapters that give one the largest sense of 
security are those upon histopathology, the clinical course 
and diagnosis of cancer and the treatment, non-surgical 
and surgical. The discussions are on broad lines and 
leave nothing to be desired in the way of clearness, sound- 
ness of reasoning, completeness and modernity. But 
w'hat a waste of valuable space is the author's serious 
discussion of all the various cancer "cures" ! These could 
conscientiously be dismissed in one or two sentences, in- 
stead of a chapter of 40 pages. 

Of the general features of the book, little need be said. 
It certainly covers the ground and is ably written. For 



the special investigator it should prove serviceable, for 
it affords a wide and critical summary of the literature 
and includes an excellent bibliography. 

Balneo-Gymnastic Treatment of Chronic Diseases of 
the Heart. I'.y l'uiii\ riiKinHiK .Schott, M.D.. Bad- 
Xiuihi'iin. Germany. Duudeciiiu. ; 181 pages; 87 illus- 
trations Philadelphia: P. Bl.\kiston's Son & Co., 
I9I4. Price, $2.50. 

As Dr. James M. .Anders says in the foreword he has 
written to this book, physical therapy has been much neg- 
lected, both in the United States and in England, and this 
little book, dealing, as it does, with the mechanical and 
balncologic treatment of cardiac disease, should therefore 
arouse considerable interest. The author gives a detailed 
description of the Nauhcim bath treatment and what thera- 
peutic results may be expected from it. He also discusses 
the treatment of cardiac cases by means of graduated re- 
sistance-exercises, and shows by means of numerous full- 
page illustrations e.xactly how these gymnastic exercises are 
to be carried out. The book is untlcubtedly one that may 
be read with much profit by anyone interested in the treat- 
ment of chronic heart disease. 

The Question of Alcohol By Edvv.^rd Huntington 
\\iLLi.\M.i. M. D.. formerly .■\ssociate Professor of 
Pathology. State University of Iowa; .'\ssistant Physi- 
cian in the New York State Hospital Service. Duo- 
decimo; 121 pages. New York: 'The Goodhue Com- 
p.ANY. 1914. Price, 75 cents. 

Any one interested in the temperance question will find 
much valuable information in this little book which con- 
tains reprints of papers published in the Medical Record 
and in the Sitrz'ey. The subjects treated are: The Drug- 
Habit Menace; Temperance Instruction in Public Schools 
and Its Results; Liquor Legislation and Insanity; The 
Liquor Question In Medicine. 

Progressive Medicine. Edited by H. A. H.are and L. F. 
Apple.\i.\x. Dec. 1. 1914. Philadelphia and New York: 
Le.^ .\xd Febiger. 

This number contains the following reviews : Diseases 
of the Digestive Tract and Allied Organs, the Liver, 
Pancreas and Peritoneum, by E. H. Goodman; Diseases 
of the Kidneys, by J. R. Bradford; Genito-urinary Dis- 
eases, by C. W, Bonney; Surgery of the Extremities, 
Shock, Anesthesia, Infections, Fractures and Disloca- 
tions, and Tumors, by J. C. Bloodgood ; and Practical 
Therapeutic Referendum, by H. R. M. Landis. These re- 
views of the progress of medicine in their respective 
branches maintain the high order of previous numbers. 

Acute General Miliary Tuberculosis. By Prof. Dr. Cv. 
Cornet, Berlin and Reichenhall. Translated bv F. S. 
Tinker, B.A.. MB.. B.C., G.R.C.S., L.R.C.P'.; late 
Senior Resident and Ophthalmic Assistant to the 
Rojal Infirmarv, Liverpool. Octavo; 107 pages. 
New Y'ork: P.\ul B. Hoeber, 1914. 

This is a very satisfactory review of the subject, writ- 
ten in a didactic style. There is a fair bibliography at the 
end of the book, but it does not include many references 
in the text. 

A Manual of Biological Therapeutics. Duodecimo; 174 
pages; illustrated. Press of P.\rke. D.avis & CoM- 
P.\NY, 1914. 

Intended, as it is, to introduce to the reader the funda- 
mental principles of biological therapy, this little book, is- 
sued by Parke, Davis and Company, admirably fulfils its 
purpose. The method of preparation of the various sera 
and vaccines manufactured by this company, is carefully 
described, and the indications and dosage of each given. 
There is also a chapter devoted to sero-diagnosis in which 
the Widal reaction and complement fixation tests are de- 
scribed, and a detailed account of the use of tuberculin 
is given. 



70 



American 

Journal of Surgery. 



Progress in Surgery. 



February, li/lS. 



Progress in Surgery 

A Resume of Recent Literature. 



The Damage done by Pyelography. E. L. Keyes, Jr., 
and 11. Mohan, New York. American Journal of 
Medical Sciences, January, 1915. 

1. Momentary gentle distention of the normal pelvis 
of the kidney doubtless eauses no more damage than a 
congestion of the organ (Experiments 1 and 3), which 
congestion is doubtless of brief duration. 

2. But if the distention persists for a few minutes the 
injected fluid is absorbed into the blood-vessels and lymph 
spaces about the kidney pelvis. 

3. Although, like Strassmann, we have been unable to 
detect any coUargol forced into the collecting tubules; 

4. Nevertheless, we have found coliargol in the glom- 
eruli and in the convoluted tubules. 

5. But inasmuch as there was much less coliargol within 
the glomeruli and tubules than in the lymph spaces and 
vessels. 

6. We conclude that the appearance of the coliargol 
within the glomeruli and tubules is a secretory phenom- 
enon. 

7. In actual practice we have to consider a secondary 
infiltration due to renal retention following the examina- 
tion. 

8. This secondary distension is of far greater impor- 
tance than the primary retention at the time of injection. 

9. Secondary retention is the cause of most of the 
deaths that have been reported from pyelography. 

10. The cause of infiltration in these cases is ureteral 
obstruction. Hence it may occur when there has been 
no primary distention. 

11. Alarming symptoms following pyelography are to be 
relieved by immediate drainage of the kidney or nephrec- 
tomy. 

12. The presence of coliargol in the kidney parenchyma, 
as shown by radiograph or by operation, should not be 
a cause of apprehension, though it shows that the injec- 
tion has been made with too much force. 

13. The coliargol may enter the general circulation and 
be distributed to the other kidney and elsewhere, in some 
instances at least, and yet no great harm result. 

A Comparison of the Results of the Phenolsulph- 
onephthalein Test of Renal Function with the 
Anatomical Changes Observed in the Kidneys at 
Necropsy. W. L. Th.\ver and R. R. Snowden, 
American Journal of Medical Sciences, December, 
1914, 

These observations show, in severe chronic nephritis, 
a uniformly low 'phthalcin output which, as a rule, in 
those instances not interrupted by an acute terminal 
process, decreases steadily up to the onset of uremia, and 
is nearly or wholly suppressed from a day or two to a 
month before death. Acute terminal processes whicli 
may be unsuspected clinically, are common, and here a 
sudden diminution in the elimination of 'phthalein may 
come on in cases where the percentage previously ex- 
creted is not so low as to appear menacing. 

In not a single instance, and indeed not once in all the 
studies of the last five years, have we met with a case 
of severe chronic nephritis with a good 'phthalein elimi- 
nation. 

Chronic passive congestion (cardiac disease) results 
often in a considerable reduction in the two hours' elimi- 
nation of 'phthalein. The results are very variable in 
individual cases. In marked decompensation the 'phtha- 
lein output may be reduced to but a trace in two hours ; 
but the excretion is, as a rule, rapidly restored with the 
re-cstablishment of circulatory compensation. 

These observations are in agreement with the experi- 
mental studies of Rowntree and I-'itz. 

In the few instances of chronic nephritis of moderate 
extent which arc included among our cases the excretion 
of 'phthalein was uniformly considerably reduced. .Ml 



of these cases, howeyer, were associated with chronic 
passive congestion of considerable extent, but the percen- 
tage of 'phthalein was lower than might have been ex- 
pected with an uncomplicated passive congestion. 

In one instance of acute nephritis and in one instance 
of pure amyloid disease the 'phthalein excretion was 
greatly reduced. 

The cloudy swelling observed in acute infections was 
in some instances associated with considerable reduction 
in the 'phthalein output. 

These observations then tend to support our previous 
impression that the phenolsulphonephthalein test of 
Rowntree and Geraghty is a procedure of considerable 
diagnostic and prognostic value, especially in the study of 
chronic nephritis. 

Hemorrhage following Nephrotomies and its Treat- 
ment. (Die Blutung nach Nephrotomien und Hire Be- 
kdmpfunti.) A. A. Tschaika, St. Pciersburg. Deutsche 
Zeitsclirift fiir Chirurgie, November, 1914. 

From the very early days of kidney surgery nephrotomy, 
as an operative procedure, found for itself a definite place 
with rather clear cut indications to me. Irrespective of 
the direction of the incision into the kidney, whether 
longitudinal or transverse, or confined to upper or lower 
pole — nephrotomy, not infrequently, produced hemorrage 
of a serious order. To combat this possibility for hem- 
orrhage, various means were employed; of these the so- 
called deep "parenchymatous suture" and the well-placed 
mattress suture remained the best. A careful histological 
consideration of kidneys so sutured showed, however, that 
the suture proper caused greater and wider spread kidney 
damage than the injury given the renal parenchyma by 
the incision itself. Rabbits and dogs after nephrotomy 
and renal suture showed subsequently marked dilatation 
of the tubules with degenerative and atrophic changes in 
the tubular structures. The pyramids so compromised 
underwent cystic changes, while the extensive scar forma- 
tion replaced much previously functioning parenchryma. 
The mattress suture gave the greater changes. 

From this consideration Tschaika turned to ascertaining 
the value of the method advocated by his chief, FederofT, 
who tamponed the renal incision with perirenal fat. By 
animal experimentation the author learned that such a pro- 
cedure yielded distinct hemostatic value. Not only could 
hemorrhage be arrested, but the fat underwent partial 
histologic changes and did not produce the marked kidney 
destruction observed after the use of sutures. Federoff 
had only six cases to report, but even in this short series 
the value of the method was evident. 

The Treatment of Chronic Pyelitis. J. T. Geraghty, 

Baltimore. Journal of the American Medical Asso- 
ciation. December 19, 1914. 

Geraghty says it is surprising how slowly the profession 
has appreciated the advantage of lavage in the treatment 
of chronic pyelitis. The success of this is largely depend- 
ent on thorough examination and accurate diagnosis. 
Most cases are secondary to the infection of the kidney 
parenchyma or a part of a pyelonephritis. These latter 
are not discussed in the paper. The majority of non- 
tuberculous kidney infections are undoubtedly secondary 
to some predisposing factor, such as stone, tumor, stric- 
ture or other mechanical obstruction, and the amelioration 
or the cure is dependent on the removal of the cause. It 
is surprising. Geraghty says, how frequently even a severe 
infection of the kidney and pelvis will disappear when 
these factors are removed. The diagnosis of simple 
pyelitis from pyelonephritis is practically impossible ex- 
cept by the use of functional estimation. In the latter the 
function will be decreased, while in pure pyelitis no re- 
duction in function will be seen. Of course, one cannot 
always exclude a slight degree of pyelonephritis not re- 
ducing function, and occasionally a case occurs of dirn- 
inished function from previously healed pyelonephritis. 
The presence or absence of albumin has been of only occa- 
sional value in his hands. Pyelography is useful as show- 
ing changes in the pelvis from infection, and may be of 
value also in prognosis. Geraghty finds the organism 
causing the infection has little to do with the prognosis. 



\ OL. XXIX, No. 2. 



Progress in Surgery. 



American 
Journal of Surgery. 



71 



When a case is proved to be simple pyelitis, renal lavage 
is instituted, and in these selected cases brilliant results 
have been obtained. \'arious solutions have been em- 
ployed, but Geraghty has come to depend largely on nitrate 
of silver and liquor I'ormaldehyd. Vaccines have proved 
of doubtful value, also he.xamethylenamin, the value of 
which at the kidney level is slight. The cases in which 
lavage was used are grouped as follows: 1. Those in 
which the catheterized specimen showed a fairly active in- 
fection with normal function, and collargol shows very 
few changes in outline. In these cases the prognosis is 
very favorable. Adams begins with injections of from 
5 to 10 c.c. of 0.5 per cent of silver nitrate, the tip of 
the catheter being rather low down in the ureter and the 
strength of the injection gradually increased. Three cases 
showing good results are reported. 2. In long-standing 
pelvic infections, with marked changes in the pelvic wall 
and very few leukocytes and an occasional bacterium in 
the catheterized specimen, the prognosis is not so favor- 
able, and caution should be exercised in giving it as far 
as the eradication of the infection is concerned. 3. In in- 
fections of the kidney pelvis, with a certain amount of 
pelvic dilatation and varying amount of residual urine, 
lavage has been of comparatively little value, especially 
when the condition is largely of bacteriuria. Some im- 
provement may be obtained, but the condition is not hope- 
ful for complete cure. When nephrectomy is contra-indi- 
cated pelvic lavage should be tried for what benefit it can 
produce. In these infections with mild hydronephrosis 
silver nitrate seems less beneficial than solutions of liquor 
formaldehydi employed in strength of from 1 :S,000 to 
1 :2,000. Under such conditions it is advisable to intro- 
duce a catheter in the pelvis of the kidney, so as to empty 
it completely of the residual urine. 

The Role of Functional Kidney Tests and Preopera- 
tive and Postoperative Treatment in the Reduc- 
tion of Prostatectomy Mortality. B. A. Thum.\s, 
Philadelphia. Journal American Medical Associa- 
tion, November 28, 1914. 

Thomas holds that more important than the quantitative 
urine output for kidney function tests is, what he styles. 
the index of elimination. This is determined by dividing 
the quantity of indigocarmine (the dye is admmistered 
previously intramuscularly, or intravenously) eliminated 
during the first hour by the quantity excreted during the 
third hour after injection. This proportion is of prime 
significance, and upon it the author bases his judgment 
as to the advisability of prostatectomy. He councils 
again.st operating upon patients who have general sys- 
temic defects ; men with cardiac lesions and high blood 
pressures are bad risks ; for those who have already de- 
veloped vesical atony he advises a preliminary course of 
catheter treatment. 

After operation he employed cardiac and renal drugs, 
viz., digitalis, sparteine, diuretin, etc. The bladder is 
irrigated daily with weak silver solutions, fluids are urged 
per OS, and hypodermoclysis is used liberally. The pa- 
tient is made to sit up very early. 

The method of surgical approach for prostatectomy, 
perineal or suprapubic, should depend upon each indi- 
vidual case. The cystoscope is of invaluable aid in deter- 
mining the type of operation best suited for each instance. 

A Method of Diminishing Hemorrhage after Supra- 
pubic Prostatectomy. Edward L. Rentes, Jr., Nev/ 
York, Journal oj the American Medical Association, 
December 19, 1914. 
Keyes describes his technic in prostatectomy with spe- 
cial reference to hemorrhage. He exposes the bladder by 
suprapubic incision and enucleates the prostate between 
two fingers in the rectum and two fingers in the bladder. 
A curved staff is inserted into the rectum and a long 
Peaslee or Reverdin needle, threaded with a piece of cat- 
gut 18 inches long, is plunged along the groove of the 
staff into the perineum and passed along it until it can 
be felt in the bladder. The staff is then withdrawn, two 
Walker bladder retractors introduced to elevate the torn 
edges of the bladder neck and make it plain to the ex- 
ploring finger. The needle carrying the catgut is inserted 
through the edge of the bladder neck just deep enough to 



get a good hold at the lateral angle. Then the eye of the 
needle is brought up into the suprapubic wound and the 
catgut disengaged. The needle i.s then withdrawn from 
the puncture in the bladder neck and reintroduced at a 
corresponding point on the opposite side and again 
threaded with the catgut, allowing plenty of slack, and 
rapidly withilrawn through the perineum. If an indwell- 
ing catheter is to be used it must be now introduced. 
.After the needle has been withdrawn we have a suture, 
both ends passing through a single puncture in the peri- 
neum, passing through the deep urethra and to the blad- 
der neck and catching its lower segment at its two angles. 
Traction on the end of the bladder loop pulls the end 
down into the urethra; it thus controls hemorrhage main- 
ly, Keyes thinks, by tension on the bladder neck, .'\fter 
the bladder neck has been firmly pulled down, the two 
ends of the suture are tied about a short rubber tube laid 
again.-t the i)crineum. Drainage is provided for through 
the usual suprapubic tube or by a catheter in the urethra, 
or both. The suture is divided and withdrawn eighteen 
to twenty-four hours later. By tliis technic the immediate 
hemorrha.ge has been promptly checked and the ultimate 
l)leeding made much less than, it would otherwise have 
been. He has not had any fistula or infiammatory com- 
plications along the line of the suture in the perineum. 
The article is illustrated. 

A Simple, Easily Regulable Method of Applying Ab- 
duction in the Treatment of Shoulder Disability. 

W.M.Ti-R M. Ekick.ver, New York. Medical Record, 
January 2. 1915. 

.\lthough the importance has been learned of early ab- 
ductiiin after reducing fractures and dislocations of the 
head of the humerus, Brickner says that the very great 
value of abduction in the treatment of shoulder disability 
("stiff and painful shoulder") has not been sufficiently 




recognized. He refers to clumsy abduction splints that 
have been used, and points out that they not only are 
awkward, but that they provide no ready means of fre- 
quently regulating and gradually increasing the abduction. 

The simple abduction method shown in the picture 
Brickner employs very often in the treatment of shoulder 
disability — both in early cases to prevent, and in late cases 
to cure, the stiffness and loss of motion, e.g., in disability 
arisin.g from sprains, and in such cases of subacromial 
bursitis as do not require operation, and. especially, when 
not associated with injury to, and lime deposit in the su- 
praspinatus tendon. He also used it successfully in three 
successive cases of forward subluxation of the head of the 
humerus, causing extreme shoulder disability. 

The patient is put to bed in semi-recumbent position, 
supported on pillows, not too soft. He abducts the af- 
fected arm. on the pillow, as far as he comfortably can. 
A muslin bandage is then looped lightly about the wrist 
afid carried to a convenient spot on the headpiece of the 
bed. where it is fastened. The upper end of the bed is 



72 



American 
Journal of Surgery. 



Progress in Surgery. 



February, 19IS. 



then raised on "shock blocks" or chairs. As the patient's 
body little by little slides down in bed his arm travels 
(relatively) furtlier and further up; and thus a shoulder 
that obstinately resists forccable efforts at abduction yields 
steadily, painlessly, to this gradual countertraction, which 
the patient often does not even feel. It is striking to 
observe that a person whose shoulder for months has not 
been abducted, actively or passively, beyond forty-five de- 
grees, put thus to bed in the afternoon, may be found the 
nc.\t morning with his arm alongside his head ! Few 
cases respond so quickly, however. The treatment may 
require a week or more to restore full abduction. 

The procedure can be variously modified : 

Instead of fastening the bandage sling to the head of the 
bed, it may, in the daytime, be looped over the cross-bar 
(or a pulley) and carried down to the opposite hand, and 
the patient allowed to amuse himself by pulling upon it 
from time to time, which will hasten the results in suita- 
ble cases. 

In those instances in which the condition does not de- 
mand, or the patient will not consent to continuous treat- 
ment, it may be employed only at night. It may be applied 
also, but not so satisfactorily, in a large reclining chair. 

If continued abduction grows painful or irksome it 
may be intermitted from time to time, the patient merely 
slipping his wrist out of the bandage loop and resting the 
arm on a pillow or by his side. 

A back-rest may be substituted, if for any reason pref- 
erable to the e.xaggerated Fowler's position. 

Pillows may be piled up comfortably under the arm as 
auxiliary to or, from time to time, substitute for the sling. 

In many cases of shoulder disability there is limitation 
of external rotation. In such cases the forearm will not 
drop back on the pillow in the plane of the body, and it 
should be supported on a small additional pillow placed 
behind it. This device is desirable sometimes in other 
cases merely to relieve the fatigue of continued rotation. 

If, w'hen the patient slides down as far as the bed will 
allow, the arm is not fully abducted, he should prop him- 
self up again, and shorten the sling or apply it at the 
elbow. 

AH of these adjustments ean be made by the fatioit him- 
self, and no speeial attendant is' needed. 

This plan of treatment is not advised for recent frac- 
tures or complete dislocations (where moderate, fixed ab- 
duction is required), for arthritic conditions, nor for any 
shoulder disability until as definite a diagnosis as possible 
is established by all available means. In cases of adhesive 
subacromial bursitis with calcareous deposit in or on the 
injured supra- or infraspinatus tendon, Brickner says that 
open operation will yield more speedy results. At any 
rate, in such of these cases as may be submitted to this 
gradual abduction treatment, if it aggravates the pain or 
fails to promptly increase the arc of motion, it should be 
abandoned for a more radical measure. 

The Operative Treatment of Contracted and De- 
formed Hands in Multiple Arthritis. G. R. Elliot, 
New York, Xew York Medical Journal, November 
14, 1914. 
Elliot recommends that radical treatment be employed 
only when the process is quiescent. The operation co:i- 
sists in forcibly reducing under anesthesia the displace- 
nients of the fingers. If hyperextension exists the finger 
is hyperflexcd and vice versa. In some cases an open 
operation may be necessary, but this measure Elliot finds 
is only rarely necessary. After the manipulation, the hand 
is kept in splints padded in such a manner as to keep 
up a continuous correction of the deformity. Each joint 
is wrapped in gauze moistened in a solution of aconite, 
belladonna and glycerin. The pain is intense for the first 
three or four days, requiring sedatives. The splint is con- 
tinued for two weeks and the wet dressing is left off 
when the reaction has subsided. The results have been 
very satisfactory and thus far no recurrences have taken 
place. 

The Significance of the Jackson Veil. Da.mfl N. Eis- 

K.NUKATM and E. VV. .Sch.noor, Chicago. Annals of 

Surgery, November, 1914. 

The authors, in a well planned and presented study 

which included observations during operations, dissec- 



tions of the cadaver, and examination of ten fetuses, 
maintain that the parietocolic fold of Jonnesco (pericolic 
membranes or Jackson veil) is a constant fold of peri- 
toneum found during fetal and postnatal life. This mem- 
brane is finely translucent, as a rule, but may become 
greatly thickened ; its vascularity may vary so that some 
cases present but a few fine capillaries, while in other 
instances the membrane shows a marked vascular supply. 
Almost invariably the right parietocolic fold has its upper 
border at the level of the hepatic flexure, its lower border 
about one or one and a half inches above the lower end 
of the cecum — this lower border may fuse with the fold 
of Treves. Where the membrane is of the description 
just cited, it should not be stripped oH under any pretext, 
since this structure represents the persistence of a fetal 
membranous layer whose operative removal would leave 
an extensive raw surface. In contradistinction, however, 
to this innocent form of pericolic band there is also the 
type which produces the definite pathological picture of 
colonic constriction (Lane's kink) with its attending clin- 
ical symptoms. Here operative interference is indicated. 
The authors assert that in the majority of instances the 
membrane is a normal structure. They claim, too, that, 
with Gray and Anderson, they have noted in the fetal 
cadaver a constant left parietocolic fold. 

Injuries to the Bowel from Shell and Bullet Wounds. 

P. LocKH.\RT Mi:.MMERV. Loiidon. British Medical 
Journal, November 28, 1914. 

.\s the result of observations made upon many injuries 
of the intestine noted in the present war, Mummery con- 
cludes that the patient should not be immediately oper- 
ated upon, even if proper surgical facilities are available. 
The best treatment is a complete rest, absence of food 
and liberal administration of morphine. Surgical treatment 
should be reserved for the treatment of later and sec- 
ondary complications. 

The Subcutaneous Injection of Oxygen as a Therapeu- 
tic Measure. John MlCk.ve, Montreal. American 
Jouiiial of Medical Sciences, December, 1914. 

McCrae injects the oxygen from the tank directly into 
the subcutaneous tissue, usually of the upper thorax. He 
does not measure the quantity accurately, but he recom- 
mends that the injection is continued imtil a lump, half 
the size of a football, is raised. The absorption occurs 
rapidly, so that in a few minutes the mass will have dis- 
appeared. McCrae reports a case in which he believes the 
injection unquestionably saved life. This case was a man, 
aged thirty years, who had undergone resection of the 
bowel for new growth. Three hours after the operation 
he appeared to be dyinc ; he had edema of the lungs with 
rapid respiration, and McCrae did not believe he would 
live a quarter of an hour. He was given four large in- 
jections during three hours and the improvement was 
immediate. In pneumonia the results were disappointing. 
McCrae recommends the injection on the following con- 
ditions : 

1. Accidents from anesthesia. 

2. Edema of the lungs, edema of the glottis, and acci- 
dental interference with respiration by disease of the 
upper part of the respiratory tract. 

3. Marked dyspnea with defective oxygenation, as in 
cardiac and renal disease. 

4. .\sphyxia of infants at birth. 

5. Syncope. 

6. Electrocution. 

A New Method for the Control of Post-Anesthetic 
Nausea. J. E. Lumb.vrd, New York. Medical Rec- 
ord, December 19, 1914. 

Believing that nausea following anesthesia is due to the 
smell of the anesthetic, Lumbard has devised a simple 
method whereby a piece of .gauze impregnated with per- 
fume is attached to the patient's nose after the anesthetic 
has been administered. Lumbard claims that the method 
is hi.ghly efficient in preventing nausea. The selection of 
the perfume depends upon the likings of the patient. In 
the author's practice, he prefers the oil of bitter orange 
peel. 



AMERICAN 



JOURNAL OF SURGERY 



Vol. XX 1\ 



MARCH, 1915. 



Xo. 3. 



RESULTS OF SOME FRACTURE 
OPERATIONS. 
Sir Wm. Arbuthxot Laxe, B.\rt., F.R.C.S. 
London^ Exg. 



The measures that have to be adopted in the case 
of malunited and ununited fractures are important 
for two reasons : first, because malunion, and Ijy 
that I mean union of the fragments in such a rela- 
tionship to one another as to materially impair the 
functional activity of the individual, and non-union 
of the fragments with conseqvient disability repre- 




Flg. 1. 

sent the failure of their treatment by means other 
than operative; second, because the difficulties that 
these operations present are enormously in excess 
of those met in the primary treatment of these in- 
juries. 

Nothing can be more disappointing than the re- 
sults of the operative treatment of simple fractures 
by many surgeons, most of whom would appear to 
possess sufficient skill and surgical cleanliness to 
perform the ordinary operations of every-day life 
with a reasonable amount of success. 

\Mien we are told that the surgeon has to remove 
a certain proportion of steel plates after operations 
for simple fractures, we realize that this has re- 



sulted from gross carelessness of the necessary 
technic on the part of the surgeon who is solely 
responsible for the failure of his methods of treat- 
ment. It is useless for that surgeon to blame the 
plates or his assistants, presuming he has control 
of the arrangements and that he is working in his 
own theater. There are some occasions in which 
a man is required to perform operations in unfavor- 
able circumstances and with assistants who are im- 
perfectly trained, and these conditions may oflfer 
some excuse for failure, but when it is necessary 
to remove a plate after .m operatinn for simple 




Fig. 2. 

fracture performed in circumstances that ought to 
guarantee a successful result, the operator should 
see to his technic and should not be satisfied till he 
has succeeded in excluding these avoidable failures, 
absolutely from his practice. 

I have had many opportunities of seeing frac- 
tures that have been operated on unsuccessfully and 
have not been surprised at the unsatisfactory re- 
sults obtained. 

These failures were due to a want of observation 
of the simplest rules by which asepsis can always 
be ensured. They were also brought about by a 
deficient knowledge of the simplest mechanical prin- 
ciples and to a want of skill and ingenuity. They 



74 



American 

Journal of Surgery. 



Laxe — Fracture Operations. 



March, 1915. 



failed chiefly by the employment of excessive force, 
immensely powerful traction on the fragments be- 
ing a great source of danger. An immense amount 
of force was substituted for skilful manipulation 
which is easily the most effectual means by which 
accurate apposition can be ensured. Another com- 



latter the surgeon has merely to replace in accurate 
coaptation two broken surfaces and to retain them 
securely with or without a plate. The only in- 
superable obstacle to an accurate apposition of frag- 
ments in a simple fracture is excessive comminu- 
tion of fragments, but in this case a satisfactory 




Fig. 3. 



Fig. 4. 



Fts 6. 



!^S9H 


■ 


1 


i 




^1 


H 


KViB; 


h^'^^B 


^^H 


^. 




['9 


H 


1 




^^^1 


H 


L 


^ 




^^H 


^M 


^K<t' 


■X 


I 


1 


m 




H 


■ 


Hhi 




mm 


'M 


^^^^^^^H^TTt 






i 


B 




A. 


i 


H 





Fig. 7. 



Fig. 8. 



mon source of failure is to use ridiculously small 
plates. On principle one should employ the largest 
and the stoutest plates that circumstances permit. 

In the case of mal-union or non-union of frag- 
ments the difficulties are very much greater than in 
the case of simple fractures. In dealing with the 



Fig. 9. 

result may usually be obtained by skilful handling. 
When the fragments have united to one another in 
a bad position it is necessary to divide the junction 
in such a way as to secure perfect alignment of the 
bones and to avoid any reduction of the normal 
length of the limb. To secure perfect alignment at 



VeL. XXIX, No. 3. 



Lane — Fracture Operations. 



American 

journai. of surcerv. 



75 



the cost of shortening of the bone renders tlie oper- position that the limb was useless. This wa:. due 

ation much less difhailt. but this is a measure that in part to the very considerable shortening and in 

a skilled surgeon would never adopt. Again, the part to the tact that not only did the axes of the 

union of fractures of two bones, such as the radius fragments not correspond vertically, but they also 

and ulna, in had position, may accentuate the dif- formed with one another a large angle open in- 

ficulties of accurate restoration of the fragments to wards. A large piece of the shall was also dis- 





Fig. 12 



their relationship to one another, especially if a placed downward, where it was united with the 

fracture is surrounded by very important nerves, lower fragment. 

as in that portion of the radius encircled by the In order to be able to bring two considerable sec- 

supinator brevis. tional areas of the fragments into apposition, it 




Fig. 11. 




I. On February 1, 1910, a man, aged 46, fell in 
an aeroplane accident and sustained a very severe, 
comminuted fracture of the upper part of the shaft 
of his right femur. Union took place in such a 



Fig. 13. 

would have been necessary to shorten the limb by 
about four inches. Instead of this a small propor- 
tion of the circumference of the shaft of the lower 
fragment was placed in contact with a correspond- 



;6 



American 
Jot'RXAL OF Surgery. 



Lane — Fracture Operations. 



March, 1915. 



ing surface of the upper, and they were retained The condition of the fracture on May 25, 1911. is 

in apposition by means of a very stout steel plate shown in figure 2. 

and screws. II. Figure 3 represents an imperfectly united 

As soon as possible tlic jiaticnt was gotten up fracture of the tibia which came under my care ten 

on an ambulatory spHnt, devised l)y ^Ir. Hoefftche, weeks after the receipt of the injury. At the oper- 





Fig. Ifi 



with the idea of gorging the extremity with blood, ation, on February b, 1912, the tibial fragments 
which brought about abundant callus formation, re- were secured in accurate apposition. Figure 4 

shows the result of operation on May 2, 1912, when 





Pig. 16. 



suiting from the crystaUization in bone of the lines the normal function of the leg was completely re- 

of force. stored. 

The patient's present condition is most satisfac- III. Figure 5 represents a very bad compound 

tory. He walks with hardly an appreciable limp, fracture which came under my care about ten weeks 



Vol. XXIX, No. 3. 



Albee — Inlay Bone Graft. 



American 

Journal of Surgery. 



17 



after the injury. The bones were united in a very 
bad position. Extensive damage to the soft parts 
was the chief reason given for the very unsatisfac- 
tory result. Figure 6 shows the result of operation 
when the patient had regained full use of the limb. 

IV. Figure 7 shows an ununited, comminuted 
fracture of the tibia and 'fibula about ten weeks 
^fter the accident. Figure 8 is a radiogram of the 
bone seven months after the operation. Although 
the patient was 56 years old, by getting him up and 
about on a HoefTtche's ambulatory splint one was 
able to obtain nearly as much crystallization of bone 
along the line of force as in the case of quite a 
young subject. 

V. Figure 9 shows the result of an operation 
for mal-united fracture of the shaft of the femur 
ten months after it had been broken. The displace- 
ment of the fragments was very great and the union 
so insecure that it broke soon after the patient was 
allowed to walk. 

This operation restored the femur to its original 
length and the patient to vigorous activity. 

VI. Figure 10 shows the result of a fall in an 
aeroplane, and figure 11 the condition of the femur 
two rnonths later, the result being perfect. 

\TI. Figure 12 shows a badly united fracture, 
the junction of the fragments allowing fairly free 
movement. The patient had been operated upon 
and a steel plate inserted. Suppuration followed 
and the surgeon had to remove the plate. Some of 
the fragments of broken screws can be seen in the 
radiogram. 

I operated on November 25, 1913. Figure 13 
shows the condition of the bone on April 9, 1914. 

\TII. Figure 14 shows an ununited fracture of 
the neck of the femur, incapacitating the patient 
from following his normal active occupation : and 
figure 15 shows the result of operation when the 
.patient, an officer, was able to resume duty. 

IX. Figure 16 is a radiogram of a badly united 
fracture of the tibia and fibula which incapacitated 
the sufferer. Figure 17 shows the result of the 
operation, which restored the man to a life of 
activity. 

These excellent radiograms were all made bv Mr. 
W. A. Coldwell. 



Operatiox for Fe.acture of thf. L.arger Bones. 
Many surgeons have been teaching, and using, 
open operation almost as a routine practice in frac- 
tures of the larger bones. The result of this prac- 
tice and teaching has been disastrous in the hands 
of those not well equipped for the work, and even 
the most expert have contributed their quota of 
bad results. — W. F. C.\RR in The Virginia Medical 
Semi-Monthly. 



THE INLAY BONE GRAFT VERSUS LANE 

PLATES IN THE TREATMENT 

OF FRACTURES.* 

Fred H. Albee, M.D., F.A.C.S., 

Prulessor of Onliopedic Surgery, New York; New York 

Post-Graduate Medical School, and I'nivirsity 

of \'ermont. 

New York. 



I am glad to have this opportunity of present- 
ing the work I am doing with inlay-grafts as a 
substitute for the Lane plates in ununited and 
fresh fractures, and especially in comminuted 
fractures. I do not wish to be understood as 
recommending the inlay-graft for all cases of 
fracture any more than the Lane's plate is recom- 
mended. These operations are often done when 
not necessary. We should employ external 
means of reduction and fixation, and avoid an 
open operation whenever possible. 

There are, however, certain cases w'here one is 
compelled to perform an open operation in order 
to secure a satisfactory functional limb. 

I began bone transplantation work for Pott's 
disease and ununited fractures in 1911. using the 
chisel and mallet to obtain the graft. A year and 
a half ago, I began to develop an electro-motive 
equipment which is manufactured by Kny- 
Scheerer & Co., the advantages of which I shall 
outline. It is a small universal motor, and can be 
used with any electrical current, without re- 
adjustment. I have had occasion to use it with 
various electrical currents in Germany, France, 
and England ; also upon a twenty-five cycle cur- 
rent transmitted into Canada from Niagara Falls, 
and, so far as I could determine, with approxi- 
mately the same cutting force. It is most con- 
venient to be always able to connect it to any 
electric light socket, with the certainty of ob- 
taining a satisfactor\" current and without fear 
of damaging the motor. The electrical current is 
transmitted directly to the motor itself through a 
sterilizable wire cable on the end of which is a 
metal plunger which is inserted through a long 
sleeve on the shell. This is far more trustworthy 
than when the electrical wire is contacted with 
the outside of the sterilizable shell, necessitating 
a movable spring contact for transmitting the 
current through the shell to the motor (Hartley- 
Kenyon). The outfit is most reliable. The one I 
have has been employed in one hundred and 
seventy-five cases, and has not failed once. 



•Read before the Association of Xew York and New England 
Railway Surgeons, October 22, 1914. 



78 



American 

Joi.'RNAL OF SURCERV. 



Albee — Inlay Bone Graft. 



March, 1915. 



The automatic catch for holding the special 
attachments, such as the lathe, twin saw, drill, 
etc., is similar to the catch used by dentists, and 
IS very easy of adjustment, and as far as I know 
is the first automatic catch to be incorporated into 
an electro-motive surgical outfit. It permits the 
cutting motor tools to be changed with almost the 
speed of hand instruments and is almost indis- 
pensable to rapid work in all osteoplastic opera- 
tions, especially in fractures where so many dif- 
ferent cutting tools are used. The shell is steril- 
ized the same as the Hartley-Kenyon outfit. The 
shell, which entirely covers the motor, and the 
electric wire leading to it, are boiled, insuring 
perfect sterilization of every part of the outfit that 
is handled or comes near the field of operation. 
The lathe or doweling attachment — as well as all 
the cutting tools — is also boiled. The speed of 
rotation of the dowel cutters is reduced ten times 
by steel gears. Two of the most common cutters 
are always in place, for making round graft-nails 
or spikes. The smaller ones are used to hold in- 
lay-grafts in place, or for other purposes for which 
metal screws would ordinarily be used; and the 
larger ones are used in fracture of the neck of the 
femur, in place of a metal spike. 

I have, also, had constructed a very small saw 
which can be employed to advantage in deep 
cavities that are difficult to get at, sucli as 
laminectomies, etc. I'"ig. 1 is a cut of the latest 
model of my twin saw, which is far more satis- 
factory than the preceding models. Each of the 
saws is mounted on a separate shaft and can be 
used as a single saw. The shaft of one is made 
hollow, so that the shaft of the other can be in- 
serted into it, with the saws at any distance apart, 
according to the size of the bone being operated 
and the width of the graft or gutter desired. The 
adjustment of the distance between the saws is 
managed by pushing the shaft of the distal saw 
into the hollow shaft of the proximal saw. The 
shafts are then locked in that position by placing 
a strong clamp, or better, the accompanying small 
wrench, on the flat-sided end of the hollow shaft 
(to prevent it from turning), while the surgeon 
turns the saw (on this same shaft) with a gauze 
sponge held over the teeth of the saw. 

The motor outfit and these attachments are not 
absolutely necessary, but it is a great advantage 
to have them, as a large percentage of graft and 
l)one plastic work can be done more exactly and 
quickly, and with better results. This is especially 
true in fracture work. 

There is tmich discussion as to the exact role 



which an autogenous bone graft plays, but, as no 
one has (juestioned its reliability as a surgical 
agent, the discussion is really an academic one. 
The autogenous bone graft is most reliable, and 
if there is no infection and primary union of tissue 
is secured, close to 100 per cent of good results 
will be obtained. 

Fig. 4 is the skiagram of a most interesting case 
in which two grafts were inserted to restore two- 
thirds of the tibial shaft which had been removed 
■ for sarcoma. This case was operated upon, by 
the writer, at a clinic held at Grand Rapids, 
J\lich., in February, 1913. The family were very 
reluctant to give permission for operation and 
would only consent to a plastic operation, not an 
amputation. We found that the tumor had in- 
\olved the pojjliteal space, and complete removal 
was im])ossible. About two-thirds of the tibia — ■ 
at its middle and upper portions — was removed. 
.\. graft six inches long was removed from the 
crest of the tibia, and on account of the evident 
necessity of later amputation of the leg, a graft 
of small diameter was obtained, and in attempting 
to adjust it in place it was accidentally broken 
into two equal fragments. The broken ends of 
these graft fragments were inserted into the 
upper and lower tibial fragments by the inlay 
method, and were contacted one with the other in 
the centre of the leg. 

Later, the family gave permission for the am- 
putation, and the specimen was kindly obtained 
for me by Drs. Fabian and Campbell, just four 
weeks after the grafts were inserted. Strong and 
complete bony union had occurred notwithstand- 
ing the fact that the diameter of the grafts above 
and below the point of union had not changed. 
The bony union between these fragmentary grafts 
is at so great a distance from any other bone, 
which could have furnished osteogcnetic cells, 
that tiure is not a shadow of a doubt that the 
crdlous formation came from the actix'e osteo- 
genesis of the grafts themselves. 

This specimen demonstrates conclusively that 
the graft does act as a true graft in certain in- 
stances. In all bone grafts which are proix-rly 
inserted a certain varying number of the 
peripheral and central cells live and proliferate, 
and a varying part of the central portion of the 
graft acts as an osteo-conductivc scafTold. In 
favorable subjects, the entire graft may retain its 
viability, especially where the graft is inserted 
by the most ideal technic — namely, by the in- 
lay method, which brings into close apposition 
each of tile four elements or layers of the graft to 



XXIX. No. 3. 



AlBEE IXLAV r."\)- (iRAl'T. 



American 
Journal of Surgery. 



79 



their corresponding elements in the recipient bone 
(i. e., periosteum, compact bone, endostcum, and 
marrow substance). 

Now, I wish to emphasize the action of WoUT's 
law in its application to bone grafts. Even if 
fracture fragments are in contact, Wolff's law has 
its influence and causes a proliferation and en- 
largement of the diameter of the graft and a con- 
sequent tilling in between ends of the fragments 
and union of the fracture. In a comparative way, 
the graft is still more efficacious in gunshot or 
other fractures where there is comminution or 




]-"ig. l-;i is cut of author's adjustable twin saw with the 
individual saws separated, either of wdiich can be used as 
a single saw. When it is desirable to use them as a twin 
saw. the shaft of the one to the left (a) is inserted into 
the hollow portion of the shaft of the saw to the right 
at B. as represented in Fig. 2. The distance of the saws 
apart is adjusted as required by caliper measurements. 
The saws are then locked firmly together by placing the 
accompanying small wrench or a strong clamp on the flat 
end of the shaft at C, and tuniing the saw D (covered 
with sterile sponge^ with right hand. This is done 
quickly and causes the shaft of the distal saw (a) to be 
grasped by a compression ring in the hollow shaft of the 
proximal saw (see Fig. 2). The saws are released from 
each other by turning proximal saw in opposite direction. 

When these saws are in place in motor and in action 
the.y are covered with a spray-guard which not only fur- 
nishes a constant spray of salt solution on the saws to 
keep them from heating but prevents the flying of the 
solution from the centrifugal action of saw. 

loss of bone substance from infection, and conse- 
quent sequestration. In such cases the graft 
spans a hiatus and its proliferation fills in the 
space, thus restoring the length and strength of 
the fractured bone. 

A good illustration of the influence of A\'olff's 
law is where a portion of the tibia has been de- 
stroyed by osteomyelitis and removed. Without 
the support of the tibia, the use of the leg causes 
an abnormal amount of stress both from weight- 
bearing and muscular pull to be borne by the 
fibula, which hypertrophies up to a strength com- 
mensurate with this added strain. The same 
thing happens to a graft, which is not of sufficient 
diameter to withstand the stress that comes upon 
it — it proliferates to an adequate size. Again, the 
tibia or bone from which the graft has been re- 
moved proUferates until it becomes the same size 
and strength that it was before the graft was 
removed ; and this occurs in about two to four 



months, if the skiagram can be trusted. Thus it 
is seen that Wolff's law has to do with function, 
and is operable in fragments of bone as well as 
complete skeletal bones, and has an important 
bearing upon the plan of treatment and the prog- 
ress of convalescence in a very large portion of 
bone and joint work. 

This paper is based on over 350 bone graft 
operations of different kinds — in over three hun- 
dred of which the graft was removed from the 
patient's own tibia. 

Of the three hundred cases where the graft was 




Fig. 3 is author's motor, and the shells which cover it 
are sterilized by boilmg (Hartley Keayon method). A is 
author's right angled twin saw, devised to enable the sur- 
geon to perfonii inlay graft work in deep wounds and 
diflicult regions to get at. 

obtained from the tibia, in no instance has there 
been any trouble with the tibia from which the 
bone was removed. Of 44 cases of ununited frac- 
tures which I have operated upon by the inlay 
graft method, 19 had been previously plated. In 
reference to these statistics. I wish to advatice a 
further statement. A metal plate placed on a 
fracture inhibits seriously, as a rule, the callus 
formation on that side of the fragment at the 
same time that osteogenesis may be active on the 
other side of the fragments, and in a certain per- 
centage of cases the inhibition to callus formation 
is sufficient to result in non-union, even though 
there may have been no infection. There are few 
surgeons who execute Lane's technic, therefore 
infection occurs in a varying percentage of cases, 
which is a frequent cause of :ion-union. Apropos 
of this. Thomas has emphasized the imreliability 
of the Lane plate as used by a number of oper- 
ators, and cites statistics of 450 fracture cases 
gathered by him at Cook County Hospital. It 
was found that it had been necessary to remo\'e 
the Lane plates on account of suppuration or 
other causes in 48 per cent of the cases which 
had been plated. 



80 



American 

TofRNAL OF Surgery. 



Albee — Inlay Bone Graft. 



March, 1915. 



In every case of non-union which has existed 
for any length of time from any cause whatso- 
ever — whether from soft tissue between the frag- 
ments, local infection, systemic disease, idiosyn- 
crasy in lack of osteogenesis, or from the inhib- 
itory influence to bone growth from a Lane's plate 
or. other metal appliance ; there is always a dis- 
tinct pathological change in the fragment ends, 
consisting in diminution of and degeneration of 
bone cells and a coincident increase of calcium 
salts, or, in other words, a sclerosis. This 
eburnated area may extend as much as one and a 
half inches into each fragment, and osteogenesis 
is greatly impaired — so much so that bone frag- 
ments ideally contacted and perfectly immobilized 
by external splints or internal metal devices do 
not unite. In other words, it is clear that the 
surgical problem which presents itself is not the 
securing of better fixation and a more close ap- 
proximation of the fragment ends by bone re- 
moval and freshening, but the furnishing of an 
efficient internal splint and at the same time a 
bone-growing and osteo-conductive element 
which spans these sclerosed areas and is at the 
same time closely and favorably contacted with 
the healthy vascular osteogenetic bone in each 
fragment beyond the eburnated area and distal to 
the point of fracture. The inlay-bone graft fulfills 
all these requirements and even more, in that, it 
acts as a strong stimulus to osteogenesis on the 
part of the host fragments themselves. 

In fresh fractures, the graft material can prac- 
tically always be taken from the fragments them- 
selves, as the osteogenesis of this bone has not 
become impaired. In most of our latter cases of 
non-union the graft material has also been taken 
from the fragments, with uniform success. In 
such cases, however, the inlay insert should al- 
ways, when possible, be obtained from the upper 
fragment and slid downward into the distal frag- 
ment. This is important, on account of the laree 
amount of rarefaction which always appears in 
the distal fragment of a pseudo-arthrosis of long 
standing, and the relatively smaller amount of 
osteoporosis in the proximal fragment. 

The Author's inlay technic varies somewhat 
according to individual cases and requirements. 
In small bones, such as those of the forearm, the 
inlay is best held in place by kangaroo tendon 
either placed in drill holes to the side of the 
groove or wrapped completely about the bone. 
In fresh fractures of the large bones, such as the 
femur, where marrow cavity has not become filled 
with new-formed bone and there is nothing to 



prevent the inlay from slipping into the marrow 
cavity, the graft and gutter beds are made wider 
at their periphery than at the marrow side. With 
the fractured fragments held in proper alignment, 
the graft to be employed is usually removed from 
the fractured bone — generally the proximal frag- 
ment — and then slid distally into a groove one- 
half its length which has been prepared for it in 
the distal fragment. In a femur, the sliding inlay 
should be about five to six inches long. The re- 
moval of both long and short grafts is started by 
making parallel cuts 1/32 to 1/16 inch deep, with 
the twin saws adjusted at a suitable distance 
apart, depending upon the size of graft and gutter 
to be formed. The purpose is to outline a graft of 
uniform width throughout its whole extent. 
These parallel saw cuts are then continued 
through the corte.x to the medullary cavity with 




the single niulur saw, held at such an angle as to 
cause the cuts to converge in approaching the 
medullary cavity, in order to prevent the graft, 
when pressed tightly into position, from slipping 
into the medullary cavity. The ends of the grafts 
are freed with transverse cuts made with either 
a very small motor saw or a narrow chisel. The 
thickness of the saw-blade makes sufficient dif- 
ference in the size of the graft and gutter to allow 
the inlay, when slid into position, to sink slightly 
below the borders of the gutter, thus furnishing 
a margin of the guttersides above the graft into 
which holes are drilled obliquely to receive the 
autogenous dowel-pegs. 

The inlay, which has a wedge-shaped cross- 
section, is pressed tightly into position and held 
there firmly by citlier a Lowman or a Berg clamp 
while the holes are drilled and the dowel-pegs in- 
serted. It may be necessary or wise to allow the 
drill to sink a fraction of, or its whole, diameter 
into the edge of the graft. The pegs are obtained 
by splitting the short segment (removed from the 
distal fragment for the purpose of making the 
groove for the inlay) into two or three fragments, 
and pushing them through the author's motor 



Vol. XXIX, Xo. 3. 



Albke — IxLAV Bone Graft. 



American 
Journal of Surgery. 



81 



lathe or doweling instrument. Each of these 
dowels, which is long enough to make two or 
three fixation pegs, is driven lightly into the holes 
over the inlay and while an assistant holds its 
distal end with a forceps, the surgeon cuts it with 
the small motor saw at the desired place. The 
remaining portion of the dowel is then used in 
like manner for additional pegs. 

In ununited fractures of large bones, where the 
marrow cavity is filled with a bone plug which 
prevents the inlay from slipping into the medul- 
lary canal, and in all the smaller bones and all 
individual cases where the mechanics are favor- 
able, the twin motor saw alone is used in remov- 
ing the inlay graft and preparing its gutter bed. 
In fractures of long bones where the difficulty of 
fixation is great, the inlay is held in place by the 
bone graft pegs or heavy kangaroo tendon, or 
both, as seems best. The fragments are motor- 
drilled on each side of the gutter, and the tendon 
is placed as indicated by the diagram. When the 
graft and its gutter-bed are formed by the twin- 
saw, the graft is just twice the thickness of a saw 
cut narrower than its bed, which allows space for 
heavy strands of kangaroo tendon to be placed 
between the graft and gutter-wall on each side. 
(See Fig. 6D.) 

In the case of small bones, such as the radius 
or ulna, the encircling of the fragments with the 
tendon is very efficacious in holding the insert 
firmly in place. In severe comminuted fractures 
from gunshots or other causes, where there is a 
space to be spanned and the length of the limb 
maintained by the inlay, it is best to tongue and 
groove the ends of the graft and bone cortex of 
gutter ends. The groove should be in the end of 
the graft, and the tongue in the gutter-ends. Any 
tendency to shortening of the limb by muscular 
pull, etc., causes the tongue and groove joints to 
become all the more firmly locked and is thus a 
sure preventive of shortening. The graft, how- 
ever small, will in time hypertrophy, under the 
action of Wolff's law, and will become the size 
and strength of the bone whose substance it is 
supplying. The value of the graft in this type of 
cases cannot be overestimated. 

An important point in the technic of bone 
grafting in its application to all types of fractures 
is the sufficient length of the transplant. In the 
case of the intramedullary graft this may afford 
a great deal of difficulty, but with the inlay meth- 
od it is accomplished with ease. A graft six 
inches long can be inlaid as easily as one two 
inches in length. Several unsuccessful results 



have come to me in which I am sure the con- 
tributing causes of failure were the shortness of 
the graft, the intramedullary method, and the 
fact that it did not extend sufficiently beyond the 
sclerosed fragment ends to alTord adequate and 
exact contact with vascular-osteogenetic bone. In 
one of these cases, the inlay graft had been used, 
but the technic had been most defective and 
the unsuccessful result was not astonishing. The 
case was a long-standing ununited fracture, with 




Fig. 5 is a schematic drawing from an actual case, of 
an united fracture of the tibia of one year duration, with 
a marked displacement of the lower fragment backward 
in a woman weighing 250 pounds. The bone ends were 
freshened and sufficient bone removed with motor and 
hand tools to allow the reduction of the fragments. On 
account of the strong tendency to a relapse of the lower 
fragment backward, the inlay graft was slid down on the 
inner side of the tibia, so that it prevented a relapse of the 
displacement by virtue of its inherent inlay mechanics. 
If the inlay had been placed in the anterior surfaces of 
the fragments the displacement would have been prevented 
wholly by the sutures which held it in place and would 
not have been so trustworthy. The lower fragment was 
short, therefore the inlay was extended completely to the 
tip of the malleolus so as to obtain as extensive contact 
and firm fixation of this fragment as possible. In this 
instance if the lower fragment should be so short or 
pathologically changed that bony union with graft should 
not be secured there would still be malleolar joint sup- 
port from the lower end of the graft, providing the 
graft united with the upper fragment which can be as- 
sured by a very long contact. The inlay technic is es- 
pecially adapted to fractures near joints in that the graft 
can be extended completely to nearby joints. 

marked sclerosis of bone, extending into each 
fragment for about one and a quarter inches, as 
shown by the X-ray. The graft insert was only 
about two inches long and did not even extend 
through eburnated bone. The graft should have 
been not less than five inches long, thus extending 
well into the osteogenetic bone of both fragments 



82 



American 
Journal of Surgery. 



Alhee — l.vLAv Bone Grai-t. 



March. 1915. 



beyond the sclerosed area. This is an important 
technical point, and cannot be too strongly em- 
phasized. 

Four of my present series of ununited fractures 
had previously been unsuccessfully operated upon 
by the intramedullary technic, which, I believe, 
is largely explained liy the fact that this tech- 




Kig. 6. Tiifsc ilrauings illustrate the technic ut fixing 
the inlay Kraft in place where kangaroo tendon is used 
for that purpose. A represents the cross-sectinn of a 
large hone which has been guttered at (e) fur the re- 
ception of the inlay and drilled at f f iov the lend. in. 
G is the eye end of a proper sized curved needle or the 
author's special Hexihle instiunient bent for this sized 
bone, into which has been threaded a loop of strong black 
silk. 

B is a smaller bone with a smaller curved needle or 
the threading instrument l.ient more acutely for the smaller 
bone in the drill hole. Tlie drawing (c) represents the 
loop of silk pulled upward from the gutter and the end 
of the kanagroo tendon (i) placed through it. The needle 
or threading instrument, the silk thread and the kanagroo 
tendon are pulled back through the drill hole in direction 
of arrow. The same procedure is repeated at (j) for 
the purpose of pulling through the other end of kangaroo 
tendon. This technic can be readily practiced in the most 
inaccessible wounds. Many times the tendon is stiff 
enough so that it can be pushed through the drill holes 
without the aid of anything, of sometimes when the 
drill holes are in a suitalile relationship to each other a 
curved needle threaded with the tendon can be passed 
through both drill holes at the same time. D represents 
the kangaoo tendon in place over the graft and tied. If 
the marrow cavity of the fractured bone is large and not 
filled with firm bone as in the case of a fresh fracture, then 
two strands of the tendon can be placed through the 
drill holes and one left beneath the graft to prevent it dis- 
placing into the marrow cavity. It may at any time be 
deemed advisable to supplement the kangaroo tendon with 
bone graft peg for fixing the graft in place. The jiegs 
are used in all fresh fractures of large single hones where 
the problem of fixation is difficult. The graft gutter is 
made with converging walls so that the graft will wedge 
in firmly and cannot displace into marrow cavity. See 
drawing, Fig. S-E. In this instance the gutter and sliding 
graft is made by outlining them with twin saws which is 
allow-ed to cut into the surface of the bone about 1/32 
inches. This determines the uniform width of the graft 
and gutter, the cuts are then changed to converging ones 
and are completed to the marrow cavity with the single 
motor saw. 

nic docs not afford an ideal histological contact 
of graft to host fragments, even when well ex- 
ecuted. 

Two important advantages of the inlay tech- 
nic as applied to ununited fractures are : First, 
the ease with which sufficient contact with osteo- 



genetic bone beyond the sclerosed area can be 
secured ; and, second, the readiness with which 
this contact can be varied in accordance with the 
difKculties encountered. The more desperate the 
case and the more frequently it has been unsuc- 
cessfully operated upon, the longer must be the 
inlay transplant. One of my series — an ununited 
fracture of the radius and ulna — had been oper- 
ated upon unsuccessfully seven times, including 
the use of Lane's plates, silver wire, nails and in- 
tramedullary grafts, and it was then pronounced 
impossible to secure union. The inlay grafts used 
were very long, extending to the tips of the 
styloid processes, and well beyond the eburnated 
area in the upper fragments. In five weeks' time 
there was firm union. The X-ray showed that all 
through there was hrm union of graft to that 
portion of the distal fragment beyond the 
eburnated area. There was, however, no union 
between the fragments themselves or between the 
eburnated area in the ends of the fragments and 
the graft. The result would undoubtedly have 
been a failure had the graft inlays been short and 
had not extended well beyond the sclerosed areas 
of the fragment ends. Again, it would have been 
most difficult to have inserted medullary grafts 
without breaking the ulna graft while inserting 
the radial transplant, or vice versa. (A united 
fibula has been broken, to my knowledge, in at- 
tempting to insert the intramedullary graft into 
the tibia.) It would also have been most difficult 
to have reached and secured satisfactory contact 
with osteogenetic bone beyond the eburnated 
zone. This difficulty, however, is inherent in the 
intramedullary technic, and no doubt was largely 
responsible for the previous failure from this type 
of operation in this jxirticular case. 

A strong argument for the inlay technic is 
its universal applicability to all types of fractures 
of long bones, however near the joints they ma}- 
be. A good illustration is an ununited fracture of 
the tibia in good apposition near the ankle joint, 
where the fibula has become united. The accessi- 
ble portion of the fibrous union is removed. 
There is no occasion to disturb the relationship 
of the fragments. The thickened periosteum is 
sjilit and peeled sidewise (on lower fragment 
only), and with the motor twin-saws and a nar- 
row chisel a groove is made in the lower fragment 
completely to the tip of the malleolus, if the frag- 
ment is very short. Then, by means of the same 
twin saw, a cortical graft four or five inches long 
is removed froin the upper fragment, and slid 
down into the groove, in the lower fragment. 



\oL. XXIX. No. 3. 



Albee — Inlay Bone Graft. 



.American 

Joi'RNAL OF SURCERY. 



83 



\\ hen the fracture is very near a juiiu, as the 
ankle, aiul the lower fragment affords a very short 
contact, the graft can be extended to the tip of the 
malleolus, so that joint support will be largely 
supplied by the end of the graft which is in the 
malleolus as in a shell, even if by chance bony 
union should not occur between graft and lower 
fragment ; provided, of course, that union has 




c 

'1 ■ 



tig. 7-A is a skiagram of an ununited liaitun ui the 
tibia of eight months duration. Two Lane's plates were 
put on immediately after the fracture occurred and primary 
union of soft tissues and excellent apposition of the fra.ij- 
ments were obtained as j"-ray shows. Nevertheless, union 
did not occur, as has been observed in many other simi- 
larly plated cases. The metal plates were removed and an 
inlay graft (c d) S}4 inches long slid down from the 
upper fragment as shown in skiagram Fig 7-b. The arrow 
(e) indicates region between the fragmerit ends where a 
large number of small grafts were inserted. The screws 
were found disengaged from the bone and layin,g in large 
cavities in the bones. There was a large amount of bone 
destruction about the plates and screws. There was no 
callus formation whatsoever in the region of the metal. 
Bony union occurred almost immediately after the inlay 
graft. In live weeks' time the union was very firm and the 
limb is functionating normally, now nine months after 
graft operation.. It is believed that in this case as well as 
man.y others that the meta! plates contributed to non- 
union. 

taken place between the upper fraginent and the 
graft, which should be made certain by a long in- 
lay atid consequent extensive contact. 

In e.xceptional instances there is no necessity 
for using any means of holding the graft iti 
place. 

To fix the inlay in place, the question arises of 
the choice for the purpose between bone pegs or 
heavy kangaroo tendon placed in drill holes or 
wrapped entirely around the bone when it is 
small, as the bones of the forearm. 

An important mechanical feature of the inlay. 



which should not be oxerlooked, is that it it is 
inserted in proper relationship to the forces which 
are causing displacement, it becomes by its own 
inherent mechanics a most effective fixation agent, 
irres|)ecti\e of the means usetl to fi.x it m place. 
.\ii illustrative case (see drawings, l'"ig. 5 1 was 
that of a one-year ununited fracture of t!ie tibia 
(situated about one inch from the ankle joint) in 
a ver}' stout woman. There was a marked dis- 
placement of the lower fragment and foot pos- 
teriorly. The lione ends were freshened and the 
lower fragment was forced forward into place. 
-Although there was a strong tendency for this 
Jrugment to spring back into its old position, a 
long inlay placed into the inner side of the frag- 
ments held them securely, by virtue of the me- 
chanics of the inlay, without depending upon the 
kangaroo tendon and the graft pegs which held it 
in place. (Jn the other hand, if this inlay had 
been placed into the anterior ur posterior surface 
of the tibial fragments, its fixation force would 
have been wholly dependent upon the pegs or 
tendon which held it in place. 

I have repeatedly and successfully used the 
bone .graft for spanning through tuberculous foci 
in Pott's disease of the spine, and tuberculosis" of 
the ankle and knee joints. The cortical bone graft 
in m\ experience has always withstood pure 
tuberculous infection, providing it has a satisfac- 
tor\- contact with healthy bone on each side of 
the infected focus. It will also resist attenuated 
pyogenic infection under similar conditions, as 
has been proven by experiments conducted bv 
Phemister and myself in both surgical usage and 
laboratory work. ■• The importance of this for- 
tunate property of the bone graft is readily ap- 
parent, in that it doubly assures its trustworthi- 
ness as a general surgical agent (when compared 
with metal). Especially is this true in its applica- 
tion to compound fractures in which infection is 
feared, or where a mild infection has already oc- 
curred. The following is an illustrative case. 

A man forty-five years of age came to me with 
an infected ununited fracture of the tibia of six 
months' duration, and gave the following history : 
Six months previously he had sustained a fracture 
of the lower third of the tibia and fibula. The 
tibia was immediately plated with two long 
Lane's plates. Infection occurred, and the plates 
were removed in three weeks' time. The wound 
continued to discharge profusely, and an X-ray 
examination revealed a sequestration of the com- 

*lSec .Albee: Experimental Study of Rone Growth and the 
-Spiral Bone Transplant. Jour. .\. M. A., April 5, 19U, Vol. IX, 
pp. 1044-49.) 



84 



American 
Journal of Sukgery. 



Albee — Inlay Bone Graft. 



March, 1915. 



plete diameter of the upper fragment of the tibia, 
from the upper screw-holes of the Lane plates 
down to the end of the fragment. The discharg- 
ing sinus was increased in size, and the seques- 
trum — about two and a half inches long — com- 
prising the entire diameter of the tibia, was re- 
moved. The cavity thus produced was packed, 
and the leg was put up in a plaster cast, making 
use of the united fibula to prevent approximation 
of the remaining tibial fragments and consequent 
shortening of the leg. At the end of eight weeks, 
the sinus was still discharging a considerable 
amount of sero-purulent material and on account 
of the large cavity between the fragment ends, 
the prognosis as to when the sinus would heal 
was most uncertain. As the patient was very 
anxious to have something done immediately to 
get a union of his tibia, I decided to make an 
attempt, and with the use of the motor twin saw 
I dragged a strong cortical graft down from the 
upper fragment into a groove made with the same 
instrument in the lower fragment. (The cavity 
was first curetted out carefully and filled with 
tincture of iodine (3j.'2%), and the whole oper- 
ating outfit was then changed.) The inlay was 
slid into place from the upper fragment and held 
with peg grafts, which were made on the oper- 
ating table by splitting into three portions with 
the motor saw the fragment of bone removed 
from lower fragment in making the groove for 
the inlay, and then shaping these portions into 
three long pegs by means of my motor lathe. On 
account of the large size of the sinus, it was im- 
possible to cover about an inch of the centre of 
the graft, where it spanned across the sinus open- 
ing. However, much to our gratification, the 
convalescence was most satisfactory ; granula- 
tions covered the exposed portion of the graft 
very rapidly, and there was firm union between 
transplant and fragments in six weeks' time. In 
twelve weeks' time, sufficient osteogenesis had 
occurred to make the tibia apparently as strong 
as ever. 

I have also had even more striking experience 
in experimental graft work on the dog, which 
demonstrated still more conclusively the bacteria- 
resisting properties of the bone graft. Wounds 
have become virulently septic on the second and 
third days after operation, laying bare the graft 
which was bathed in pus at the bottom of the 
wound. Nevertheless, either a portion or whole 
of the grafts took and lived. 

Whatever be the means of internal fixation, 
whether the Lane plate or the inlay graft, the 



limb should be firmly immobilized in as near a 
neutral position as possible, i. e., a posture of the 
limb which causes the relaxation of those muscles 
which happen to have a displacing influence in 
that particular fracture. If this is done, inlay or 
peg grafts, Lane's plates or neck of femur spikes 
will not bend or break during the period of this 
external fixation. Weight bearing function and 
non-union or soft callus, and bone absorption are 
the causes of internal metal-fixation-splints yield- 
ing. 

Summary. 

The bone graft is a trustworthy surgical agent, 
as proved by my uniform success in its employ- 
ment in over 350 surgical cases ; also by a careful 
study — microscopically, macroscopically, and by 
'the .v-ray — of its results when used experi- 
mentally, and in the presence of primary union 
.ind with mild infections, in human cases. The 
field of usefulness of the cortical graft is distinctly 
enhanced because of its resistance to tuberculous 
and attenuated pyogenic infection. Its field is 
also enlarged by the use of motor-driven instru- 
ments, such as circular saws of different sizes, the 
adjustable twin saw, and the lathe or dowel in- 
strument with different adjustments for making, 
as conditions demand, various sizes of bone graft 
inlay, nails, or spikes. By the use of this motor 
outfit and its products, in conjunction with kan- 
garoo tendon, I have during the past two years 
been able to entirely avoid the use of all metal in 
the form of screws, nails. Lane plates, wire, etc., 
for internal bone fixation purposes. This has been 
made possible largely by making the most of well- 
known fundamental mechanical devices, hitherto 
rarely, if at all, used in surgery, such as bone in- 
lays, wedges, dowels, tongue-and-groove joints, 
mortices and dove-tail joints. 

40 East Forty-first Street. 



Disease vs. Age in Fracture. 
There will always be deaths following serious 
tractures in persons who are diseased. Age of it- 
self does not affect the prognosis in any way. Just 
as good and prompt union occurs in men over 90 as 
in young men, provided they are not victims of 
nephritis, angina, excessive arteriosclerosis, or other 
advanced disease. The prognosis is grave, even in 
young persons, with diabetes, delirium tremens, 
advanced nephritis, epilepsy, or cardiac disease; 
and in all persons nearing the end from any dis- 
ease the shock of a serious fracture may bring 
about a fatal termination. — W. P. Carr in the Vir- 
ginia Medical Semi- Monthly. 



Vol. XXIX, No. 3. 



Darrach — Non-Reducing Operations. 



American 
Journal of Surgery. 



85 



N()\-REDUCIi\G OPERATIONS FOR FRAC- 
TURES AND DISLOCATION'S. 

William Darrach, A.M., M.D., F.A.C.S., 
New York City. . 



The treatment of fractures has received much 
attention of late, and especially the operative meth- 
ods. While the large majority of fractures and 
dislocations can be best treated by the closed 
method, there is a remaining four per cent, which 
require open operation. Such operations can be 
divided into four classes : ( 1 ) The open reduction 
of recent cases. (2) The open reduction of old 
cases. (3) Non-reducing operations. (4) Opera- 
tions where some appliance is used which penetrates 
the bone and emerges through the skin. 

A great deal has been written about the use of 
Lane plates, of bone grafts, and of Steinmann 
nails, etc., and whether or not a fracture should be 
reduced by the open method, or treated by the closed 
method. There is. however, a considerable field for 
operative measures for the relief of those frac- 
tures and dislocations which are not covered by the 
above procedures, and it is to these non-reducing 
operations that I would call attention. The major- 
ity of these are late cases, eighteen days or more 
after the injury. If seen early they will frequently 
come into the first class, w-here a reduction can be 
accomplished. Among 206 operations for fractures 
and dislocations, fifty-five have come under this 
heading. 

By non-reducing operations are meant those 
where no reduction is tried, but by some other 
means the attempt is made to prevent or overcome 
the deformity, or impairment of function due to 
fracture or dislocation. 

These again can be subdivided into groups: 

First. — The removal of loose fragments. If 
these press on the skin, the vessels, or nerves, or 
by their presence interfere with proper muscular 
action, or when near joints if they limit motion, and 
for some reason cannot be put back into their nor- 
mal position, they should be removed. Of the fifty- 
five cases in this general class, twenty-two belong 
in this first group. One humeral head was removed 
in a dislocation of the shoulder associated with 
fracture of the anatomical neck. In seven cases the 
outer portion of the lower humeral articular sur- 
face was broken off and displaced outward. Three 
of these were pure capitellar breaks, while the 
others involved some of the adjacent portion of 
the bone. In three fractures of the radial head the 
loose fragments were interfering with motion and 
were removed. In one Colles' fracture there was 



a loose fragment lying among the flexor tendons 
and interfering with their proper motion. In four 
cases of fracture of the scaphoid, with dislocation 
forward of the ulnar fragments with the semi-lunar, 
the bones could not be reduced and were excised. 
In one fracture of the scaphoid there was a dorsal 
dislocation of the ulnar fragment which could not 
be reduced. In one transverse fracture of the 
semi-lunar the persistence of pain for two months 
warranted its removal. In three fractures of the 
astragulus with complete dislocation of one frag- 
ment, the latter was removed and the rest of the 
bone left in place. 

Second. — Removal of fragments of bone that 
have become firmly united in improper positions, 
or of e.rccssive callus. In two malunited clavicles, 
tlie outer end of the inner fragment threatened the 
skin. Union was firm and there was no functional 
disability. The deformity did not bother either 
man, so the projecting fragment was cut away in- 
stead of breaking up the union and attempting to 
re-establish the normal relationship. In one case 
of separation of the upper humeral epiphy.sis the 
deformity partially recurred after an open reduc- 
tion, and it was not recognized until after union 
had taken place. The projection of the lower frag- 
ment came against the outer margin of the acro- 
mion in abduction. This was cut away, restoring 
the full amount of abduction. In five fractures of 
the lower extremity of the humerus excessive callus 
was removed in four, increasing the amount of 
flexion : and in one supracondyloid with a dorsally 
displaced lower fraginent, the projecting portion of 
the shaft in front was cut away, making a new 
fossa for the coronoid. In four Colles' fractures 
with dorsally displaced lower fragments, the pro- 
jecting lip of the upper fragment caused marked 
interference with the movements of the flexor ten- 
dons, and it was cut away subperiosteally. This 
was followed in all cases by marked improvement 
in the finger motions and grip. In three cases of 
old Pott's fracture, with imperfect reduction of the 
astragalus, there was limitation of flexion due to 
the impinging of the neck of the astragalus against 
the anterior lip of the tibia. When the latter was 
cut away the added 10°-15° of flexion gave marked 
improvement, making outward rotation of the leg 
unnecessary, and stopping the strain on the inner 
arch. 

Third. — Retnoval of a portion of bone 'vhich is 
displaced, but othensnse healthy. In two cases the 
radial head was excised because of irreducible an- 
terior dislocation. In two others it was removed 
because of fracture extensive enough to interfere 
with pronation and supination. In one of these 



86 



American 
Journal of Surgery. 



Walker — Classification of Fractures. 



March, 1915. 



cases a second operation had to be performed to 
remove a fragment of the radial head which had 
been displaced into the substance of the brachialis 
anticus, and had proliferated there sufificiently to 
interfere with flexion. This last operation belongs 
to the second group. In two cases of old dislocation 
of the head of the ulna, the latter with the adjacent 
portion of the shaft, was removed subperiosteally, 
leaving the styloid process intact. The latter pro- 
cedure is important to preserve the attachment of 
the internal lateral ligament of the wrist. In both 
cases there was a regeneration of bone with com- 
plete return of pronation and supination. In four 
other cases the same procedure was carried out for 
a derangement of the lower radio-ulnar articula- 
tion following a Colles' fracture with impaction, or 
radial shifting of the lower fragment. In one case 
a portion of the lower ulnar shaft was excised for 
the same purpose. The result was not as satisfac- 
tory here, as union between the two ends was de- 
layed for eighteen months. 

Fourth. — A cuneiform ostectomy was performed 
in two cases. One was on a femur with marked 
outward bowing, and one on a tibia with inward 
and forward bowing. The former case failed as 
the fragments overrode and a later plating operation 
became necessary. The second was quite successful. 
Fifth. — An arthrectomy was done in two cases 
of dislocation of the outer end of the clavicle. The 
cartilage was removed from both articular surfaces 
of the joint and a fibrous union was obtained. This 
seemed preferable to the recurring luxation. In the 
second instance the main lesion was recognized and 
repaired, viz., the conoid and trapezoid ligaments 
had been torn and were sutured. 

Sixth. — Two cases of blood injection for delayed 
union are included for the sake of completeness. 
Both were successful. 

Most of the cases enumerated above were late 
cases which had not received successful treatment 
at the time of their injury. If all fractures could 
receive proper, immediate treatment, such opera- 
tions as have been enumerated would rarely be 
necessary. 



CLASSIFICATION OF FRACTURES. 

John B. Walker, M.D., 

Professor of Clinical Surgery, College of Physicians antl 

Surgeons, Columbia University; Surgeon 

to Bellevue Hospital. 

New York City. 



The Lane Plate. 
I have never put on a Lane plate, but I have had 
to remove many. Of 54 that were applied by half 
a dozen of our best surgeons at the Emergency 
Hospital, .30 had to be removed for non-union, sup- 
puration, irritation, breaking or bending of the 
plate. The other 24 may have trouble later. — W. P. 
Carr in the Virginia Medical Semi-Monthly. 



In a previous paper^ it has been shown that the 
present methods of treating fractures usually give 
very unsatisfactory results. It therefore becomes 
necessary to establish authoritative standards by 
which subsequent fracture work can be measured 
and compared. Only by knowing the exact nature 
of the injury can we judge of the excellence of the 
final end-results. And these results are becoming of 
increasing importance not only to the surgeon but to 
the layman, as they effect the amount of compen- 
sation received by the workman. 

The fact tliat it is of primary importance to know 
the exact location of a fracture is almost universally 
disregarded in the reports of both laymen and physi- 
cians, and very seldom has the classification been 
adopted which is employed and recommended by 
the British Fracture Committee.- For instance, in 
studying the very exhaustive report of the Commis- 
sioner of Labor for 1909,^ we find that in Great 
Britain the fracture cases are grouped under the 
title "Fractures of Limbs and Bones of Trunk." 
Of these injuries there are 3,682 during the five 
years covered in this report. This, of course, gives 
no idea of the number of fractures of the extremi- 
ties, nor does it aid us in gathering data as to dura- 
tion and final results of such injuries. 

Denmark has a very complete table of accidents 
by trades, and one on the total loss of a member; 
but unless the victim of an accident has lost a limb 
we find no statistics of the location of the injury in 
the Commissioner's report. 

In France, accidents are classified by cause and 
by industry, but there is no information on the sub- 
ject of the seat or extent of injury. 

Germany has such a complete list for sickness in- 
surance that it leads us to hope for more detailed 
classification of accidents, but we find nothing but 
the large division of "arms" and "legs," and the 
only subdivision is of the right or left arm or leg. 
Even these fractures are found scattered in with 
"wounds" and "contusions," as is also the case in 
the tables of Italy (in 1902-03), where there were 
10,382 accidents reported as "wounds, contusions 
and fractures." This grouping is purely arbitrary 
and it is absolutely impossible to tell how many of 
these accidents were fractures, since "wounds and 
fractures" may be quite exclusive of each other. 
In Russia, all injuries are grouped as "wounds 



Vol.. XXIX. Xo. 3. 



Walker — Classification of Fractures. 



loURN 



American 



87 



and fractures of the lower extremities" in 8,429 
cases out of 43,536 total injuries, or 20/t. 

Norway speaks only of the "breaking of limbs." 
It has been said that the laiety and the profes- 
sion both err in presenting inaccurate and neglect- 
ful reports. I should like to present some statistics 
to bear out this point. To take the layman first : 
In this class we must consider not only the com- 
pensation reports mentioned, but the reports of the 
great corporations. 

Among the best of the compensation reports are 
the excellent records under the title "Workmen's 
Insurance in Austria," Vol. I, p. 1, but even where 
the division of accidents is given in a quite com- 
plete and definite summary, the division of accidents 
is given with only the subdivision, "Fractures of 
the upper (or lower) leg." Eight hundred and 
fifty-seven cases are given with only such subdivi- 
sion, without going into detail as to whether it was 
the neck of the femur, upper, middle or lower third. 
This is not detailed enough to be of value in de- 
termining a comparison with the British Fracture 
Committee statistics. The lumping of these statis- 
tics will result in a wrong average, and thus an 
erroneous idea of the duration of disability will he 
given. This point is brought out in the report of 
the British Fracture Committee, which shows that 
of 87 fractures of the neck of the femur, only 23% 
recovered good function ; of 49 fractures of the 
upper third, 47% recovered good function ; of 108 
fractures of the middle third, 49% recovered good 
function; of 54 fractures of the lower third, 55% 
recovered good function. This will easily show the 
error of the averaging method. 

In our country the report of accidents reported 
by "Nature of Injury" in bulletin No. 155, issued 
by the United States Bureau of Labor Statistics, 
covering compensation for accidents to employees 
of the United States,* has the classification of in- 
juries designated only by the columns headed 
"upper" or "lower" extremities, "including frac- 
tures." And in the tables which give "Fractures of 
Lower Extremities," it refers only to "either leg" 
or "fracture of both legs," neglecting to give the 
site of injury. It must be noted that this report 
is supposed to be exceedingly comprehensive, and 
covers some 25,055 cases of "Injuries of upper and 
lower extremities," divided as follows: For upper 
extremities, 5,076 compensated cases, 7,098 non- 
compensated ; for lower extremities, 4,608 compen- 
sated, and 8.273 non-compensated cases. But since 
this table includes loss of an arm or leg, etc., we 
cannot estimate the proportion of fractures. 

Mr. Harris, in "Industrial Accidents and 



Loss of Earning Power,"" states that the group of 
injuries designated as "Wounds, Contusions, Frac- 
tures, etc.," forms "nearly 95% of the total num- 
ber of injuries for which compensation was paid, 
both in 1907 and 1897. . . . Injuries to the arms 
and legs formed the most numerous class of acci- 
dents, the two comprising 58.43'"( of all injuries 
compensated in 1907. . . . Wounds, fractures, 
etc., of the arms comprised 32.41% of the 1907 in- 
juries as compared with 25.21% in 1897." Again 
we see the inaccuracy resulting from lumping 
"Wounds and Fractures," and this also emphasizes, 
since such a large proportion of injuries are in this 
class, the necessity of a better classification, that 
our knowledge may be more exact. 

In the "First Annual Report of the Industrial 
Accident Board" of the Commonwealth of Massa- 
chusetts,*^ we have tables giving in great detail the 
industry, sex, etc., of the injured persons, the cause 
of the accidents by industries, etc., but absolutely 
no information in regard to results, unless the re- 
sult has been the loss of a limb, in which case it is 
recorded. 

The Minnesota Bureau of Labor" in its 13th 
Biennial Report for 1911-12 gives statistics of 
"Breaks and Fractures," and further gives a table 
of "Fractures — serious, lesser and slight," by in- 
dustry; but again, this does not indicate their site. 
And out of the 1,230 cases thus reported, the end- 
results are given in only 516 cases — less than 50%. 
In the most recent 14th Biennial Report (1914) 
of this State, a table is given of the "part of body 
injured," but this names only the members in a gen- 
eral way, leg, hand, etc. Its fractures are included 
in the column "Breaks and Fractures," of which 
there are 2,585 cases reported; but of these, only 
jo6 or 2j% are classified. It is also perhaps a note- 
worthy fact (in emphasizing the importance of this 
subject of fractures) that there are nearly three 
times as many "breaks and fractures" in 1913-14 
as in 1911-12; and over twice as many in 1913-14 
as in 1912-13. 

Harris, who has before been referred to as nearer 
accurate than any of the other reporters, back-slides 
when he comes to his little pamphlet on "The Oc- 
cupation Hazard of Locomotive Firemen,""* and de- 
scribes injuries to the extremities as nierely 
"broken." 

The greatest care is taken to minimize fhe risk 
in the iron and steel industry, but the United 
States Government report on conditions of employ- 
ment in the iron and steel industry* specifies the re- 
sult of accident only in so far as indicating whether 
the accident befell an arm or a leg. It does not 



88 



American 
loL-RXAi, OF Surgery. 



\\ ALKER — Classification of 1''kactures. 



March, 1915. 



analyze accidents with the exactness one would ex- 
pect. 

In looking over the reports from various large 
industrial corporations, manufacturing concerns, 
railroads, etc., the same lack of classification of ac- 
cidents is noteworthy. This is the more surpris- 
ing because the manager of every great business 
enterprise today is provided with records in elabo- 
rate detail. Our railroad engineers, for instance, 
know the quality, character, and prices of steel 
rails and the total yearly cost of purchase in this 
department or any other, because their construction 
departments are continually keeping records of 
these things with elaborate detail. But they ap- 
parently do not know what they are paying for a 
fracture among their employees ; how much they 
must allow for treatment of fracture cases in time 
and money, or even whether that fracture is be- 
ing treated by the most efficient methods. 

One of the largest of the great steel corporations 
reports 4 fractures of the femur in 3 years ; stat- 
ing that their men were able to work in from 4 to 5 
months' time, though only one, they state, did return 
to work. 

.Another corporation reports the average as 5 
months; still another reports 251 cases of leg frac- 
tures in 2 years, without further designating the 
seat of the fracture. One of the great railroads 
reports 24 femur fractures. At the end of the year 
only 13 patients were working, and their average 
disability was 246 days, i. e., 8 months, as com- 
pared with 4 to 5 months in the report of the steel 
corporation. One asks which records are correct, 
and if such wide variation does not argue for the 
crying need of standardization in classifying cases? 

We are, however, encouraged to expect better re- 
ports from such companies from a notice that at 
least one of the big railroads has established a most 
complete card-index system in order that it may 
learn most accurately the end-results following the 
injuries to men in its employ. 

But we cannot blame the laymen for vagueness 
or negligence in reports when those of the profes- 
sion itself are far from unanimous in their meth- 
ods of classification. A careful perusal of the files 
of the current technical papers will readily disclose 
the fact that there is little attention paid to this 
phase of the subject of fractures. And when it is 
mentioned at all, the material is often so hidden in 
a mass of unnecessary and unscientific detail that 
it is next to impossible to get it out. Even tech- 
nical articles are most unsatisfactory, on accotuit of 
the difference of classification. In consulting the 
records of various h()S]>itals (for fracture data), 



which were dictated at various times by different 
surgeons, a considerable variation of nomenclature 
was found. Some adhered to the old terms of intra- 
capsular and extra-capsular, others included both. 
varieties of fractures under the single term of 
"fracture of neck"; still others used Kocher's 
classification of fracture subcapitalis and fractura 
iutertrochanterica. The terms of intracapsular are 
unscientific, inaccurate and misleading because the 
majority of cases do not fall distinctly into either 
group since they are "mixed." Intracapsular 
cases were supposed to include all those in which 
the lines of fracture were entirely within the cap- 
sule ; extracapsular, all those which were entirely 
without the capsule. The majority of fracture lines 
are oblique or diagonal and not strictly transverse, 
consequently a fracture may be intracapsular in 
front and extracapsular behind, inasmuch as the 
capsule is so placed that it includes more of the 
joint in front and below than above and behind. 
Kocher's terms, while more strictly anatomical, 
have not gained popular usage. Stimson's classifica- 
tion has been followed, i. e., fracture through the 
neck or subcapital, and fractures at the base of 
the neck. 

.Some of the titles of articles in the various mag- 
azines lead us to hope to find good statistics, but 
often when looked up, these articles are found to 
deal only with the indications for operation, meth- 
ods, and technic. etc. Even in the most excellent 
report of the British Fracture Committee the dura- 
tion of disability was unstated in 263 out of 638 
cases of fractures, or 41%. 

In a recent article by Pringle,^" who has analyzed 
230 cases of '"open fractures of the long bones, 
treated by operative methods," the material, al- 
though admirably arranged, contains no mention of 
subdivision. It merely says, "Cases — Femur — 21," 
and again the important question of "where frac- 
tured" is neglected. 

Foreign surgeons seem to construct very good 
articles on this subject, to judge from some articles 
in recent magazines, but one is not sure even with 
them that any constructive scheme of classification 
has been agreed upon." 

All surgeons must admit the necessity of collect- 
ing data for future guidance in giving the best 
prognosis and trcatnictit. Rut it is possible to make 
this material of value only by carefully classifying 
and correctly collecting large numbers of cases, so 
that vvc can find the normal average duration of 
disability, which is our best guide for treatment 
in a given type of case. In our previous attempts 
to do this we have become more and more dissatis- 



Vol.. XXIX, No. 



Walker — Classification of Fractures. 



American- 

JofRNAL OF SURGtRV. 



89 



serve to awaken a realization of tlie present situa- 
tion, which will result in a reform of the system 
of classif_\ing and reporting injuries as indicated, 
so tliat we shall ultimately be able to find useful 
data on which to base recommendations for the 
most satisfactory treatment of fractures. 

BTBLTOGRAI'HN- 

1. Walker. Femur Fractures; Statistics of 
End-Ke.sults. American Journal of Surgery. 
Dei-emlicr, 1914. 

2. Report of Fractures Committee, British 
Medical Journal. Nov. 1912. 

3. Workmen's Insurance and Compen.sation 
System in Europe. 24th Annual Report of the 
Commissioner of Labor. 190*'. 

4. Bulletin 1.S5 of the U. S. Bureau of Labor 
. Statistics, p. 182fT. 

5. Industrial Accidents and Loss of Earnint; 
Power. Henry J. Harris, p. 184. 

6. First .Xninial Report of the Industrial Ac- 
cident Board of the Commonwealth of Massa- 
chusetts. 

7. Thirteenth Biennial Report of the Minne- 
sota Bureau of Labor, p. 80, and Fourteenth 
Biennial Report of the Minnesota Department 
of Labor and Industries, p. 62. 

8. Henry J. Harris. The Occupation Haz- 
ard of Locomotive Firemen, p. 196. 

'). Conditions of Employment in the Iron and 
Steel Industry in the U. S., p. 62-63. 

10. J. H. Pringle. An Analysis of 230 cases 
of open fracture of the long "bones treated by 
operative methods. British J<.urnal of Surgery. 
Julv. 1914. 

11 Beitr. 2 klin. Chirur,. 1913. \ o\. 
LXXXVin. 

12. W. L. Estes. End Results of Fracture 
of the Shaft of the Femur, .\nnals of Sur- 
gery, July. 1912. 
N-nviRv Form for Fr.^ctvres. 

(d.) " " shaft, 

(e.) Supra of condylic fracture. 

(f.) Separated lower epiphysis (with or without frac- 
ture), 
(g.) Internal condyle: external condyle, capitellum. 
Radius : 

(a.) Fracture of shaft. 

(b.) Separated lower epiphysis (with or without frac- 
ture). 
Ulna : 

(a.) Fracture of olecranon, 
(b.) " " shaft 

(c.) Separated lower epiphysis (with or without frac- 
ture). 
Radius and Ulna : 

(a.) Fracture of shafts of both bones, 
(b.) Colles' fracture. 
.-\ge Groups : 
13-10: 11-15: 10-20: 
and over. 



fied with present statistics, for our judgment tells 
us that the majority of statistics are incorrect. An 
example of the failure to secure satisfactory data 
is shown in the attempt of Estes,'- reported in the 
Annals of Surgery for July. 1912. to collect sulificicnt 
statistics for the Pennsylvania State Medical So- 
ciety to establish definitely reliable standards of effi- 
ciency. After much labor he decided that the cases 
collected were unavailable for such use, owing to 
the indefinite nature of many of the reports. In a 
total of 760 reported cases, the seat of fracture is 
not stated in 482 cases ; the amount of shortening 
was not stated in 200 cases : the age of the patient 
was not given in 394 cases; the question of anes- 
thesia was not stated in 409 cases; and the method 
of treatment was not stated in 360 cases ; the length 
of time in bed was not stated in 466 cases ; the dura- 
tion of disability was not stated in 576 cases; while 
the reports of the use of the .r-ray were that it was 
used in 130 cases only and showed good apposition 
without angulation in only 5"? cases. 

It has been shown that it is most necessary for 
primary records to be classified by a universal sys- 
tem in order to be of any value; and therefore the 
form of inquir\- used by the British Fracture Com- 
mittee is here suggested as the most satisfactory 
form. 

It is earnestly hoped that the above statistics will 

Femur : 

(a.) Fracture of neck. 

(b.) ". " upper third of shaft. 

(c.) " " middle of shaft. 

(d.) " ." lower third of shaft. 

(e.) " " lower extremity involving knee joint 

Tibia: 

(a.) Fracture of shaft. 

(b.) Internal malleolus. 
Fibula: 

(a.) Fracture of shaft. 

(b.) Separated lower epiphysis (with or without frac- 
ture). 
Tibia and Fibula : 

(a.) Fracture of shafts of both bones. 

(b.) Pott's fracture. 
Humerus : 

(a.) Anatomical neck. 

(b.) Fracture of tuberosity 

(c.) " " surgical neck. 

American SuRGIC.^L .\ssocr.\TioN'. 
General Results : Good Moderate Bad 
Anatomical 
Functional 

1. Bone 2. Site, Neck Upper Middle Lower 3d 

3. Name 4. Sex S. Age 6. Occupation 

7. Case of Dr 8. Hosp. where treated 9. Date of entering Hosp 

10. Cause of fracture direct viohnce indirect violence. 

11. Kind of fracture oblique spiral transverse simple . .compound commmuted 

12. Reduction How many hours elapsed after accident before reduction? 

13. Anaesthetic used yes no 

14. Fixation — Closed Method : ' Ohcii Method : 

How long after injury was operation performed?.. 



21-25: 26-45: 45-CO : 61 years 



. Con d vie. 



Splints 

Plaster of Paris 

Traction: Bucks Bardenheuer 



A\'as open reduction alone performed?.... 
What form of internal fixation was used?. 

Steel plates 

Bone grafts 



90 



American 
Journal of Surcery. 



ZlMMERMANN TREATMENT OF FRACTURES. 



March, 1915. 



Jones Steinmann Wire Nails 

Hodgen Vertical Was it later necessary to remove fixation mate- 

Amt. weight used ? rials ? 

\5. Shortening At first dressing? When all apparatus was removed? 

When discharged from Hosp? At latest observation? 

16. X-ray first finding on the day? At latest observation? 

17. How long was patient confined in bed? How long in Hospital? 

18. How long did patient use crutches or canes? ■ 

19. Results I'inal examination made weeks months after injury 

20. Disability partial complete estmiated by : 

swelling of soft parts pain deformity shortening angulation 

interference with joint function endurance 

21. i\Iortality age of patient cause of death 

Location and kind of fracture 

22. Duration of absence from work weeks months 

23. Is patient fully able to take his former job? 

24. Present wage earning capacity compared with former? 



TREATMENT OF FRACTURES. 

B. F. ZiM.MERMANN, M.D., 

Louisville, Ky. 



The majority of those who were in the medical 
school clinics ten or fifteen years ago probably re- 
member that the general surgeon who successfully 
reduced a fracture received scant consideration, 
whereas the abdominal surgeon "crowned himself 
with glory" by removing healthy ovaries to cure 
hysteria! The writer recalls an eminent surgeon 
who had devoted especial attention to the treatment 
of fractures and other bone lesions, and at the same 
time had achieved brilliant results in abdominal and 
general surgery. Certain of his competitors applied 
the undesirable epithet to him of "bone surgeon" 
with the view fas he thought) of detracting from 
the value of his work in other directions. He re- 
marked at the time, "They will live to see the day 
when they will be glad to have the title 'bone sur- 
geons' " ! His prediction has come true, for the 
treatment of bone lesions is today the most diffi- 
cult of all surgery, requiring a technical finesse 
scarcely known to the abdominal surgeon of twenty 
years ago, and possessed by comparatively few of 
the present. 

The two recently developed greatest factors that 
have contributed to the more successful manage- 
ment of fractures are the .r-ray and open operation. 
Whatever may be the final decision of surgeons as 
to the advisability of the open method, the fact 
remains that it has undoubtedly stimulated more 
careful study of fractures, resulting in decided im- 
provement in treatment by the closed method. That 
where possible the x-vslj should be employed in 
every case of fracture, or suspected fracture, can- 
not be gainsaid. That excellent results may be 
obtained without its use is not a valid argument 
against it, as it afifords information as to adjust- 
ment of fragments which is obtainable by no other 
means. 



The primary object in the treatment of fractures 
is to secure a good functional result. The major- 
ity of these injuries occurs in people who earn their 
livelihood by manual labor, and in proportion to 
their disability is the curtailment of their useful- 
ness, as seldom are such individuals fitted for any 
other vocation. Where perfect anatomical align- 
ment can be secured, the best results may be ex- 
]>ected ; but it is unwise to risk the functional integ- 
rity of a limb for the sake of anatomical reduction. 

Jones considers every fracture a potential de- 
formity, and the first consideration in the treatment 
is to maintain a true anatomical alignment of the 
shaft in the case of long bones. "A joint which is 
tender to palpation is not ready for movement" 
(Thomas). Experience shows that, excepting in 
actual conditions of disease, nearly all cases of 
"non-union" are cases of "delayed union." Phys- 
iological use is the best agent to assist in making 
union solid, but it is wise to protect a fracture 
with artificial support even after it appears to be 
firmly united. 

While Lane may successfully plate all his simple 
fractures, and Murphy may secure union in un- 
imited fractures by bone transplants, such radical 
procedures will always represent a small portion of 
the fracture work required of physicians and sur- 
geons. 

What are the principal factors to be considered 
in the treatinent of a given fracture? First, is the 
general condition of the patient : the method of 
treatment must be adapted to the patient and the 
fracture, and not the patient and the fracture to the 
method of treatment. Careful physical examina- 
tion is therefore a prerequisite to the production of 
best results in the treatment. The management of 
a fracture in an individual of extreme age would 
necessarily be difi^erent from that in a young healthy 
adult. Organic disease, particularly cardiac and 
renal, would militate against prolonged confinement 
to bed. The temperament of the individual inust 
also be considered, the highlv nervous not submit- 



Vol. XXIX, No. 3. 



ZiMMERMANN — TREATMENT OF FRACTURES. 



Americas 

Journal ov SuKt-tHv. 



91 



ting to enforced confinement with such readiness 
and ease as does one of phlegmatic temperament. 
The presence or absence of syphilis and other dis- 
eases must be ascertained, also the personal habits 
of the individual, particularly as to indulgence in 
alcohol. 

Second, the surroundings and environment : pa- 
tients do not select the time and place to sustain a 
fracture! For example, in railroad surgery, they 
are found in the yards, shops, on the road, etc., 
where surroundings are not such as would be se- 
lected had the surgeon his choice as to the time and 
place for treatment. Under such circumstances it 
is always best to immediately apply a temporary 
dressing, the patient being then removed to a place 
where permanent dressings can be properly applied. 
Reduction and fixation apparatus should never be 
employed until the patient has been placed in the 
most favorable surroundings. 

Third, the fracture itself and wliat will be pro- 
ductive of the best result in that particular frac- 
ture: this will be determined by the nature and 
location of the fracture, whether simple or com- 
pound, and whether in the shaft of one of the long 
bones, or near a joint. 

Study of individual fractures naturally leads one 
to the consideration of the open and closed methods 
of treatment. In the majority of cases the closed 
method will secure good functional results, and for 
the average surgeon and practitioner is by far the 
safest procedure. There are certain fractures, how- 
ever, in which better results can be secured by the 
open method of treatment : but in such cases it is 
necessary that the patient be under the care of a 
competent surgeon in a thoroughly equipped hos- 
pital with trained assistants. The one fact above 
all others which has contributed to disastrous re- 
sults following the open method of treatment is 
that surgeons have not strictly adhered to these 
requirements. 

The operative technic in the open method is most 
difficult, and the acme of asepsis should be the 
w-atchword. To attempt short-cuts by ignoring the 
technic so laboriously perfected by the pioneer 
laborers in this field invites disaster, and here as 
elsewhere he who does things by halves will secure 
faulty results. I have seen plates applied to bones 
and the patient returned to bed without the applica- 
tion of a cast, splint, or other means of protection. 
Quite recently I amputated a leg because of infec- 
tion resulting from the plating of a compound frac- 
ture which had not perfectly healed, and the open 
method was condemned by the surgeon who under- 
took the original work. Xot long- aeo while doins 



a transplantation a surgeon of reputation who was 
present remarked that refusal to permit anything 
that had touched the gloved hand to enter the wound 
was an acknowledgment of failure in proper sterili- 
zation and handling of the gloves, entirely over- 
looking the facts that gloves are more likely to be 
contaminated during the operation than instru- 
ments, that a glove admitted to the wound is likely 
to be punctured, that even a small unrecognized 
puncture constitutes a condition which would de- 
stroy the chance of success. The open method 
unciuestionably has it place, and while numerically 
considered the fractures treated by the open will 
be far less than by the closed method, there are 
rather clear and distinct indications for employment 
of the former procedure. 

Briefly stated, the indications for the open treat- 
ment are as follows: (1) In fractures of the shaft 
of long bones where reduction cannot be secured 
by the closed method, or if secured cannot be main- 
tained ; (2) where there is interposition of the soft 
parts; (3) in spiral fractures of the humerus and 
femur; (4) in cases of multiple fracture; (5) in 
fracture with marked rotation of the fragment; (6) 
fracture of both bones of the leg or the forearm — 
in these fractures unsatisfactory results are often- 
times secured by the closed treatment, and the open 
method is to be advocated with plating of either 
one or both bones; (7) fractures in or near joints 
where the fragments or joint surfaces cannot be 
brought into proper position to secure anatomical 
alignment and physiological results. Malposition or 
detachment of fragments in the region of joints 
usually indicates an excessive amount of callus, and 
the method which will secure the best apposition of 
the fragments should be adopted. In many cases 
this can be better secured by the open than the 
closed treatment. 

Let it be again emphasized that the general con- 
dition of the patient must be carefully studied be- 
fore attempting such radical methods of treatment. 
The aged and the very young manifestly do not 
make good subjects for the open treatment. 

As to the time for operation : in this particular 
there seems to be a wide divergence of opinion. 
Some surgeons advocate immediate operation ; 
whereas others advise delay until a week or ten 
days have elapsed following the injury. Inasmuch 
as good results have been secured by the advocates 
of both immediate and delayed operation, and since 
it is unproven that the results of one plan are supe- 
rior to the other, it must be concluded that any time 
within the first ten days is suitable for operative 
procedures. 



92 



American 
TovsxAL OF Surgery. 



ZiMMERMANN TREATMENT OF FRACTURES. 



March, 1915. 



In fractures of the leg, Dujarier believes that 
between the fifth and tenth day following the in- 
jury is the most favorable time for operation. 
Asepsis is vigorously exacted, and neither gloved 
finger nor any instrument which has touched the 
gloved hand is allowed to enter the wound. To 
maintain the fragments in position he advocates 
a double pronged hook or red copper wire 2 mm. 
in diameter. In some instances both may be neces- 
sary. The following indications for the open treat- 
ment arc noted : ( 1 ) In transverse fractures, before 
or after reduction, where the fragments are not 
partially in contact; (2) in oblique fractures opera- 
tion is indicated in nearly every case, the exceptions 
being those with very little displacement and with 
overriding of less than one centimeter; (3) the 
choice between hooks and wires is made according 
to the nature of the fracture as shown by antero- 
posterior and lateral radiographs; hooks are used 
in tran.<;verse and slightly oblique fractures. The 
only contraindications are the general condition of 
the patient, or such local condition of the skin as 
render an aseptic operation impossible. 

Fredet follows the technic of Lambotte, but re- 
stricts the indications for open treatment to those 
cases that are incapable of healing by the conserva- 
tive methods, and concludes : (I) That operation 
should not be undertaken without perfect equip- 
ment; (2) that it should be restricted to grave frac- 
tures, which cannot heal by bloodless methods ; to 
those in which there is a chance that they will not 
heal by bloodless methods ; and those which appar- 
ently will be greatly delayed in union; (3) that the 
operation is too difficult to be undertaken by any 
but experienced surgeons. The primary consider- 
ations in the operation as devised by Lambotte are : 
The perfect reduction of the fracture, and the solid 
and lasting maintenance of that reduction ; large in- 
cisions and rigid asepsis, the gloved hand never be- 
ing permitted to enter the wound. In maintaining 
the fragment in position he suggests : ( 1 ) In oblique 
fractures a circle of bronze-aluminum wire; (2) 
screws may be advantageously used where frag- 
ments arc to be fixed to shaft, or in T-fractures, 
but cannot be expected to be permanent when head 
rests subcutaneously ; (3) plates. 

It has been shown that from the first to the fourth 
day following fracture is the period of infiltration, 
when there is a great deal of extravasation of blood ; 
by the tenth day connective tissue and callus have 
commenced to form ; the extravasation of blood has 
then been largely absorbed, and there is probably 
less trauma to the tissues in operating at that time. 

ITitzrot has rccentlv reviewed the theorv of bone 



regeneration advanced by Dupuytren and Wieder, 
and based upon his experience concludes : ( 1 ) First 
to fourth day, period of infiltration; (2) fourth to 
twelfth day period, gradual absorption of the ex- 
udate from the soft parts and its replacement by 
connective tissues ; the endosteum undergoes forma- 
tion of osteoid trabeculae at a distance from the line 
of fracture; (3) twelfth to eighty-fifth day, stage 
of reorganization ; augmentation of callus where it 
is most needed, and absorption where it is not re- 
quired ; (4) permanent callus formation, eighty- 
fifth to two hundred and eightieth day; absorption 
of callus with re-deposition of dense bone in the 
dilated spaces, and the appearance of distinct 
lamellae in the new bone. He states that while 
Wieder did not continue his work to the fifth stage 
as did Dupuytren, in fractures which had perfectly 
united there is until the third month nothing but 
cartilage or connective tissue across the line of frac- 
ture. Cartilage was always found on tlie concave 
side of the fracture with its apex at the line of 
fracture and its base on the periosteum. The most 
important factor in the stage of exudation is the 
formation of fibrin. 

While it may be the consensus of opinion that 
the open treatment somewhat delays union, this is 
not a valid argument against the method when used 
in fractures where better results can be secured 
than by the closed treatment. The objection that 
the open treatment contributes to non-union is 
probably an admission of faulty technic, and it is 
not alone the presence of the foreign body which 
prevents union, but some low type of infection ex- 
isting at the time of operation. The fact that some 
plates have to be removed after union is apparent 
is insufficient to condemn the method. The plate 
has performed its function if it has held the frag- 
ments in perfect anatomical alignment, and its re- 
moval — while in many cases can be accomplished 
under local anesthesia or general anesthesia may be 
administered if necessary — requires but a short time 
and is attended by little danger to the patient, leav- 
ing a wound which speedily heals. 

In this connection, however, Roberts cautions 
against the too enthusiastic adoption of the open 
method, with the application of plates, etc., as a 
routine means of dealing with fractures. The pro- 
fession and the public should know that while the 
method is a necessity in some cases, and its adop- 
tion a question of judgment in others, there are 
many instances of subcutaneous fracture in which 
it is conlraindicated. Good results can oftentimes 
be obtained, both as to anatomic restoration of the 
parts, good function and rapid cures, bv external 



Vol. XXIX, No. 3. 



ZiMMERMANN — TREATMENT OF FRACTURES, 



American 
Journal of Surgery. 



93 



dressings guided by a thoughtful, careful surgeon 
who has a mechanical mind and anatomical knowl- 
edge. The operative treatment is particularly dan- 
gerous when adopted by novices in aseptic surgery, 
or in places where complete aseptic surroundings 
caimot be obtained. 

Fracture of the bones of the arm. In fractures 
of the tuberosities or neck of the humerus, better 
results are obtained by the open treatment, nailing 
the fragments in proper position. The fragments 
are of such nature and so situated that it is difficult 
and oftentimes impossible to secure proper anatom- 
ical alignment by the closed method. If, however, 
the closed method nuist be employed, the arm should 
be dressed in abduction and external rotation. 

Believing that anatomic data are oftentimes over- 
looked, Cohn reviews the insertion of muscles at- 
tached to the tuberosities, and based upon informa- 
tion thus obtained advocates abduction and external 
rotation of the arm to favor apposition of the frag- 
ments, and to overcome the action of the subscapu- 
laris which has a tendency to lacerate the capsule 
and thereby favors dislocation. Further external 
rotation favors apposition of the shaft with the 
tuberosity, and abduction also relieves the pressure 
upon the tuberosity by relaxing the deltoid. 

In transverse fractures of the shaft good results 
can he secured by the closed treatment, dressing the 
arm in such position, and maintaining it by splints 
and extension, as will meet the requirements of the 
individual fracture. 

In oblique and spiral fractures of the humerus, 
the best results can be secured by encircling the 
fragments with wire, and thus retaining them in 
that position. 

In any fracture of the humerus where the skia- 
gram shows that the integrity of the musculo-spiral 
ner\'e may be jeopardized by the fragment or sub- 
sequent callus formation, the open treatment is in- 
dicated at the time of the fracture. 

In fractures at the elbow, involving the condyles, 
the arm should be dressed in acute flexion if treated 
by the closed method. The better plan is the open 
treatment, nailing the condyles to the shaft, thus 
securing proper anatomical alignment of fragments 
and joint surfaces. This treatment reduces callus 
formation to the ininimum, and is par excellence the 
method to be employed in fractures in or near the 
joints. 

Murphy suggests that after dressing in full 
flexion fractures of the condyles should not be dis- 
turbed for passive motion in less than two and a 
half weeks for children, and three weeks for adults. 



Passive motion too early causes pain, produces 
laceration, and results in extensive cicatricial for- 
mation with consequent ankylosis or limitation of 
motion. The best method of securing good posi- 
tion after condylar fracture is by the open operation 
and nailing on the fourth or fifth day. This pre- 
vents friction which produces callus. The less the 
amomit of callus, the less the likelihood of ankylo- 
sis. _\ftcr nailing the fragments, the arm may be 
placed i;i a sling with no other dressing. In frac- 
ture of the olecranon, nailing at proper angle is 
better than plating (jr wiring. In old fractures, 
\arious operations have been suggested to approxi- 
mate nonnal anatomical position. In fracture of 
the humerus near its head, fragments should be 
adjusted by operation and nailed. Impacted frac- 
tures of the upper tibia are usually diagnosed sprain 
and overlooked. Fractures near hip joint usually 
require nailing. Fractures of the neck, twenty-five 
to thirty pounds e.xtension, with superlative abduc- 
tion of both legs. 

Skinner concludes that (1) in ankle fractures the 
functional result depends upon the proper reduc- 
tion of the astragalus, so that the line of weight- 
bearing force which passes through center of tibia 
also passes through the astragalus at its center. 
This line is shown on the antero-posterior roent- 
genogram of the ankle; (2) in wrist fractures the 
entire styloid process of the lower end of radius is 
constantly distal to a line which touches the tip of 
the ulnar styloid, which line is at a right angle to 
the longitudinal axis of the radius. The functional 
result depends upon the reduction of the radial 
stvloid to this position, which is shown on postero- 
anterior roentgenogram of the wrist. 

In fractures of the olecranon jjrocess, the short 
fragments should be nailed to the long fragment, 
and the arm then dressed in extension. In frac- 
tures of one bone of the forearm, in nearly all in- 
stances, the closed method should be eiuployed. 
Tile other bone acting as a splint, it is not ditTicult 
to secure a fair alignment of the fragments with 
good functional results. In fracture of both Ijones 
of the forearm, it is difficult to secure and maintain 
good apposition of the fragments by the closed 
niethod of treatment, and the open operation with 
plating or wiring of one or both bones is to be 
preferred. The excessive amount of callus forma- 
tion sometimes markedly interferes with rotation of 
the arm. especially under the older methods of treat- 
ment. In nearly all cases of Colles' fracture, which 
is the most frequent fracture of the region of the 
wrist joint, the closed method will be successful. 

In the lower extremitv, fractures of the neck of 



94 



American 
TocRNAi. OF Surgery. 



ZiMMER.MANX — TREATMENT OF FkaCTUEES. 



March, 1915. 



the femur involving the trochanters can usually be 
successfully treated with the leg in abduction, re- 
taining it in position by either a plaster cast encir- 
cling the leg and trunk to the costal region, or ab- 
duction of both legs retained by the Rainey splint. 
In fractures of the neck of the bone, in addition to 
these measures a weight and extension of twenty- 
five to thirty pounds as suggested by Murphy is of 
service. These fractures may also be successfully 
treated by the open method, the trochanters or neck 
being nailed in proper position. In treating frac- 
tures of the hip, Moore advocates the so-called ana- 
tomical method of Maxwell. He states it has been 
demonstrated by Maxwell, Ruth, Whitman, and 
others that fractures of the neck of the femur can 
be treated about as successfully as those of the 
shaft, and that the practically hopeless prognosis as 
to function given in most text books is based upon 
the results of the older methods of treatment. The 
reason for failure of the older methods lies in the 
fact that the fragments are not brought into apposi- 
tion. Maxwell's method in brief consists in add- 
ing a "side pull" to Buck's extension, the result of 
the "two pulls" being a "pull outward" in the long 
axis of the neck of the femur, thereby rendering 
the capsule tense and bringing the fragments into 
proper relation. 

In fractures of the shaft of the femur, short- 
ening and consequent deformity may be expected 
when treated by the closed method. The muscles 
are so strong that it requires a great deal of force 
to overcome the displacement and secure proper re- 
duction. By operative treatment good apposition 
of the fragments can be secured, and by careful 
manipulation of the limb after application of the 
plate this apposition can be maintained. The exten- 
sion methods by use of the caliper splint, or by a 
nail driven through the lower end of the femur with 
extension applied from this point, are said to be 
more effective than the time-honored Buck's exten- 
sion apparatus, but the writer has had no experience 
with these measures, and desires to candidly state 
that they do not appeal to him. 

In fractures of the condyles at the lower end of 
the femur, where extension cannot be applied, and 
where malposition of the fragments is likely to 
result in stiffness or limitation of movement of the 
knee joint, the open method of treatment and nail- 
ing the fragments in proper position is the method 
of choice. 

The same general rules apply to fracture of the 
leg as to the forearm, viz., if one bone only be 
broken the other acts as a splint, and such cases can 
be successfully treated by the closed method. If 



both bones are broken, proper anatomical alignment 
is difficult to secure, and the open operation with 
plating of the tibia will give the best results. In 
fractures of the lower end of the tibia and fibula, 
which are of great importance because of their fre- 
quency and the deformity which so often follows, 
-X'-ray examination is almost indispensable. The 
classical Pott's fracture is rare when compared 
with the number of fractures which occur in this 
locality. These fractures are usually accompanied 
by more or less displacement of the astragalus, the 
result of widening of the mortise, either by rupture 
of the interosseous ligament or fractures of one or 
both of the malleoli. In order to secure a good 
weight-bearing leg, proper reduction is necessary, 
and without skiagrams it is difficult to determine the 
degree and direction of the dislocation of the astra- 
galus, and what measures may best be employed to 
accomplish reduction. Colvin concludes that (1) 
the lesions occurring at the lower end of the tibia 
and fibula are very varied in character, usually re- 
quiring the radiograph for differentiation, and as a 
guide to treatment; (2) Pott's fracture (as he de- 
scribes it) is very rare; (3) the most frequent lesion 
is a bimalleolar fracture, and the commonest de- 
formity is that of the everted foot; (4) the various 
lesions are produced by a predominating everting 
or inverting force; (5) these forces used as cor- 
rective measures in either direction may result in 
the production of a deformity, the opposite to the 
one caused by the original injury : (6) adduction or 
inversion of the foot is not necessary as a retention 
dressing, excepting in Pott's fracture, and if used 
in bimalleolar fractures is very liable to result in 
deformity; (7) the original inverting or everting 
force which fractured one or both malleoli may have 
spent itself before displacement of the malleoli has 
occurred, and any subsequent force applied in either 
direction will cause an eversion or inversion de- 
formity. 

In typical Pott's fracture the foot dressed in ad- 
djction with a long internal splint, is usually all that 
is required. In fracture of both malleoli, this is 
not a suitable dressing, and the better plan is to 
nail the fragments in position, dressing the foot in 
line with the long axis and at right angles to the 
leg. Lipping fractures, as mentioned by Speed, are 
rather common in this situation and can only be rec- 
ognized by the ;i:-ray. Unrecognized and untreated 
they lead to serious subsequent disability. 

Speed emphasizes the importance of correct axis 
of weight-bearing force and relation of joint sur- 
faces, i.e., from the anterior superior iliac spine 
through patella and middle of astragalus. If joint 



Vol. XXIX. No. 3. 



ZiM.MlCK.MAXN TREATMENT OF FkacTLKES. 



American 
JouK KAL OF Surgery. 



95 



surface of tibia and astragalus bear correct relation 
to each other, prognosis for a useful weight-bearing 
function of foot and ankle is excellent. It is said 
that one may disregard position of fragments in 
the diagnosis. Powerful weight-bearing function 
can only be accomplished by replacing the malleoli 
in proper position. Of great importance are lip- 
ping fractures with anterior or posterior displace- 
ment of the astragalus. If lower end of fibula alone 
has been split or twisted, hold astragalus well 
against the internal malleolus and then hope to 
drag the cracked or broken external malleolus over 
to its position by forced inversion, depending upon 
such fibres of the external lateral ligaments as are 
still intact. Where both malleoli are broken, treat- 
ment is more difficult. Simple inversion is not suffi- 
cient. There is usually displacements of the astra- 
galus which must be returned to the proper position 
and fragmenis so adjusted that the normal mortise 
will be retained. In some cases manipulation and 
plaster cast will be sufficient, in others nailing may 
be required. Where bimalleolar fracture is com- 
plicated by rupture of the interosseous ligament 
with separation of lower ends of bones and possible 
forcing upward of astragalus, the open operation is 
advised nailing the malleoli and also fastening the 
tibia and fibula together. After the open operation 
the foot should rest at right angle and not in ad- 
duction. After dressing is removed, practice gentle 
massage, but not sufficient to cause pain; weights 
may be cautiously applied. If painful, this is ample 
evidence that callus is not yet matured. If external 
malleolus the greatest sufferer at the beginning of 
weight application, the foot should be turned slightly 
inward to prevent yielding of callus. "Lipping 
fractures" should be carefully looked for, i.e., where 
a wedge of bone is "knocked off" the tibia. Dis- 
placement of fragment and excessive callus com- 
monly obserA'ed. If foot is fixed in extreme dorsi- 
flexion for a few days, the deformity will not re- 
turn. However, the open operation may become 
necessary in some cases. "Among the laboring 
class nothing so interferes with wage earning as 
weakened leg support and the whole train of life 
that follows the ability to get about on two good 
feet is very different from that which follows the 
permanent and partial disability of a bad ankle." 
These fractures occasionally have some permanency 
treated by the very best m.ethods devised, and each 
man so afflicted should be given the very best treat- 
ment, and should not be allowed to use the ankle 
until callus is hard enough and ligaments sufficiently 
strong to bear his weight. This may be anywhere 
from three to twelve months. Speed closes his 



paper with the following summary: (1) .Ankle frac- 
tures are relatively numerous and have much intlu- 
ence on the wage-earning power of laboring people ; 
(2) Pott's fracture as classically understood is very 
rare; (3) each ankle fractrre should be treated in 
accordance with the most searching diagnosis, aided 
if possible by skiagrams, and not by routine meth- 
ods; (4) both antero-posterior and lateral skiagrams 
should be most carefully studied; (5) more empha- 
sis should be laid on the treatment of fracture of 
the external malleolus with or without ligamentous 
damage on the inner side of the ankle by over-cor- 
rection in extreme inversion on a splint or in a cast ; 
(6) special attention should be paid to cases with 
posterior or anterior displacement of the foot, as 
these indicate lipping fractures of the tibia or com- 
plete separation of the external malleolus with loss 
of either anterior or posterior tibio-fibular liga- 
ments ; operation should be considered in these 
cases; (7) operative measures — simple replacement, 
nailing, or other procedures — give perfect anatom- 
ical results in selected cases; (8) use of the foot 
should not be permitted until pain is not caused. 

Magruder concludes an instructive article on the 
treatment of fractures as follows: (1) The ideal 
treatment is the closed method where reduction can 
be maintained; (2) open method without introduc- 
tion of foreign body when reduction can be main- 
tained; (3) open method with use of least possible 
amount of foreign material. Indications for opera- 
tion: (1) Where complete reduction is impossible 
otherwise; (2) interposition of soft parts: (3) 
spiral fracture with separation: (4) where apposi- 
tion cannot be maintained; (5) multiple fractures; 
(6) rotation of fragments; (7) injury to blood- 
vessels; (8) marked deformity. Advantages of 
open treatment: (1) Better union: (2) relief from 
pressure upon nerves; (3) anatomical reduction; 
(4) removal of interposed soft parts; (5) less dan- 
ger of ankylosis in joint fractures. Treatment of 
compound fractures : ( 1 ) Extensive comminution 
of bone and inoperable damage to blood-vessels and 
nerves, immediate amputation is advised ; (2) where 
amputation is not indicated, treat as closed fracture. 

The importance of physiological use and passive 
motion at the proper time in the treatment of frac- 
tures cannot be overestimated, and gentle massage 
is also entitled to greater importance than has hith- 
erto been accorded the practice. The period in the 
treatment of fractures when movement and massage 
may be most advantageously applied must neces- 
sarily vary in different cases for obvious reasons. 

It is a trite saying that a joint that is tender to 
palpation is not ready for movement, and that pas- 



90 



American 
Journal uf Surgery. 



Cotton — Hip Fractures. 



March, 1915. 



sive motion should be practiced with caution for 
fear of stimulating callus fornialion. rerhaps the 
best agent to assist in making union solid is physio- 
logical use, but the fracture should be protected by 
artificial support even after it appears that the frag- 
ments have firmly united. 

Kkikkeni-ks. 
Jcjuos: .American Journal of Orthopedic Surgery, 1913, 

xi, 314. 
Dujarier: Journal dcChirurgie, 1913, xi, 269. 
i-'redet: Journal de t hirurgic, xi, 289. 
Ilitzrot: \\'isconsin Medical Journal, 1913, xii, 211. 
Roberts: Annals of .Surgery, 1913, Ivii, 545. 
Colin; New Orleans Med. & Surg. Journal, 1914, Ixvi, 670. 
Skinner : Surgery. Gynecology & Obstet., 1914, xviii, 238. 
Murphy: Journal Lancet. 1914, xxxiv, 261. 
Moore : Old Dominion Medical Journal, 1914, xvii, 133. 
Colvin : Surgery, Gynecology & Obstet., 1914, xviii. 99. 
Speed : Surgery. Gynecology & Obstet., 1914. xix. 73. 
Magruder: American Journal of Surgery, 1914. xxviii. 1. 



HIP FRACTURES. 

F. J. Cotton, A.M., M.D., 

Boston. 



A half dozen years ago I was seized with an idea 
concerning hip fractures. I knew even less about 
hips then than I do now, but experience and inves- 
tigation since then have convinced me that the idea 
is sound for the class of cases to which it is appli- 
cable. 

The idea, as then formulated, is delightfully 
simple. // unimpacted hip fractures do badly, 
while impacted hip fractures unite tuell, then zvliy 
not impact the loose fractures artificially? Why not? 
1 have found no reason why not, and have found 
reason to believe the procedure one of real value, 
not only in the hope it gives in the handling of un- 
impacted cases, but also in the freedom it gives us 
in handling cases impacted, but with serious de- 
formity, that we have in the past been afraid (and 
rightly afraid) to correct, for fear of prejudicing 
union. Of this pet method of mine, you are doomed 
to hear more presently. Init first must come a broad 
review of the situation. 

When I came to look up the current knowledge 
of hip fracture, I found a curious chaos. Many 
worthy gentlemen cured all their cases, but cu- 
riously enough, by wholly diverse methods, and 
,-iny thing like precise data seemed hard to come at. 
Presently I found out why, and in my own attempt 
to track down old cases, I grew tolerant of other 
people's failures. 

These cases are mainly in the aged — the depend- 
ent aged who go from son to daughter, to cousin, 
and only too often to the county farm, or its equiv- 
alent, and cannot be really studied. 

I have no data that suit me, and find others sim- 



ilarly fixed : let me only ask the reader if he knows 
the present state of the three cases he treated for 
fractured hip last winter? The whole trouble with 
our knowledge of these cases is that we have not 
had the facts, and we have allowed ourselves to 
generalize from our impressions. Our lack of pre- 
cise knowledge comes down to three items : 

1. We have not classified our cases. 

2. We have not studied untreated cases, or cases 
under "routine" treatment. 

3. Our knowledge of end-results is imperfect in 
toto, and the results have not been studied in accu- 
rate relation, either to the primary lesion or to the 
treatment followed. 

In this paper I have only a few points to make ; 
many details are to be omitted, ruthlessly. 

As to Item 1 : Three generations ago, Astley 
Cooper gave us the classification ; we had just sim- 
ply forgotten it. 

Hip fractures arc either extracapsular or intra- 
capsular. If intracapsular, they are either impacted 
or they are not. 

That's all. 

The extracapsular fractures show no tendency to 
failure of union; they are like any other fracture — 
subject to deformity if not well handled. Yet they 
have been lumped with the others, and have been 
responsible for the vogue of apjiarently successful 
methods of treatment, as we shall see. 

As to Item 2, .we have not studied routine cases. 
Not only do we get union regularly and uniformly 
in the extracapsular breaks, crippled though they 
may be from deformity, contractures, and secondary 
arthritis, but even in the intracapsular cases we 
have led ourselves astray. It is not true that all 
impacted fractures get bony union. Not rarely, the 
trifling degree of impaction present breaks up in 
bed — in splints — owing to the force of gravity, act- 
ing with the loosening tendency of that primary 
rarefaction that attends all bone repair. Nor is it 
true that ability to walk proves bony union. Good 
funciion may be present without a trace of bony 
union. 

Item 3 : End-results have not been studied as to 
their relation to original lesions; that has been said 
already. They have not been studied in relation to 
special methods of treatment. Especially they have 
not been studied as to the resttlts of dififerent meth- 
ods, in dififerent classes of lesions. These fractures 
are treated in but five ways (for I shall not go into 
the operative treatment, interesting as it is, at this 
time) : 

1. Expectant treatment, or treatment with sand- 
bags, with the long side splint, etc., is merely a 



Vol. XXIX, No. 3. 



Cotton — II i p Fr.actu res. 



.Americas 

JOUR.NAL OF SLKGERY. 



97 



form of rest. In the cases of both types, it gives 
the result of original forces, and lesions unin- 
fluenced for good or bad by the surgeon — some- 
times they are good. In impacted fractures of the 
neck proper, well impacted without great eversion, 
in old people, this is the treatment. If impaction 
is absent, or gives way in the first few weeks, this 
treatment gives wretched results. In the extra- 
capsular cases, rarely firmly impacted, it does not 
insure against muscle-pull and progressive deform- 
ity, and is not a desirable method. 

2. Direct traction. Some years ago, with J. B. 
Blake, I had a chance to watch results of this treat- 
ment systematically applied on all cases in a four 
months' service. I think Blake will agree with me 
that in fractures of the neck proper, the results, 
so far as traced, were distinctly poor. We did not 
try it on the extracapsular cases. Here it should 
be somewhat better than the simple expectant 
plan. 

3. Longitudinal, combined with lateral traction. 
This is the Phillips-Maxwell-Ruth method — the 
"anatomic" method, largely used to the west of us. 
I am not clever enough to see why it is even 
"anatomic" to pull apart fracture-surfaces, in ill- 
vascularized bone, for that is what the method must 
do, if it works at all. There are many blanket rec- 
ommendations of this method, but no serious 
critique of results that I have seen. There is a tri- 
umphant series of dry specimens of end-results, ob- 
tained post-mortem in cases long healed. I have 
seen these specimens : there were seven in all. Of 
these, six were indubitably extracapsular fractures, 
and in the seventh, arthritic and periarthritic 
changes made diagnosis difficult, but the original le- 
sion seemed to have been extraarticular. Xot a 
specimen, nor a plate, nor an end-result report have 
I seen to show the value or the sanity of this meth- 
od in relation to the intracapsular neck-fractures 
that represent the only cases of real difficulty. From 
what we have lately learned as to bone repair, the 
chance of repair in bone of low vitality and poor 
circulation, like that of grafts and intra-articular 
fragments, depends entirely on close coaptation and 
fixation : exactly what this method works against. 
I am ven,' ready to accept this method as adequate 
— perhaps the best scheme, in extra-articular frac- 
tures — but if we so use it, let us not forget what 
cases we are getting our show results in. 

, 4. Whitman's method. Like all his work, it is 
clever and logical. Undoubtedly the method is 
good, and as we shall presently see, I use it freely, 
but it is open to several objections. 

In the first place (not really an importaiit mat- 



ter), many men are inclined to doubt the locking 
of the upper fragment at the limit of abduction, 
believing rather that tension on the abductor 
muscles gives the linnt of abduction. 

Secondly, there is real danger that in less ex- 
I)ert hands than Whitman's, the fragments may 
be forced by one anotlur, not jammed together. 
This I shall illustrate later. 

Thirdly, plaster spicas in stout patients do not 
hold abduction firmly. 

Fourthly, and most important. Whitman seems 
to have made no discrimination as to the lesion 
present, in cases treated or cases reported. .Ml 
fractures of the hip look alike to him. seem- 
ingly. 
Until we have some real .r-ray demonstration of 
the results, and of the percentage of good results 
obtained by this method, in unimpacted intracap- 
sular fractures, it will continue to be obvious that 
this treatment rests on argument rather than on 
tests. One thing is certain, however: the position 
of abduction is worth while, when we can use it. 
One of the graver factors in disability from hip 
fracture, is the common contracture of the muscles 
in abduction. This is definitely prevented by the 
maintenance of abduction during repair, and Whit- 
man deserves full credit for introducing practical 
abduction, whether we agree with him wholly or 
only in part. 

So far as the extracapsular cases go — those that 
unite anyhow, but tend to be twisted — I do not 
know whether Ruth's scheme or Whitman's or my 
own is best. 

5. My method. .Artificial impaction with the mal- 
let. Frankly a method open to the saine objection 
as Whitman's ; not sufficiently proved as yet by the 
sheer test of results, but at least logical and defi- 
nitely useful so far as we have gone. What I have 
done is to anesthetize lightly, then pull the loose 
fracture into position ; then, padding the trochanter 
heavily with felt, drive the trochanter in with care- 
ful, slow blows, with a heavy wooden mallet. As 
this is done, one feels that the bone impacts and 
the free outward rolling motion disappears 
promptly. Just how much force is needed it is hard 
to define. It is not great, and the large mallet 
used is chosen, not to hit a hard blow, but to get 
sufficient iinpact from a slow, controlled sunng. In 
the dozen and a half or two dozen cases, in which 
I have used this method, no harin has been done. 
In only one case did even any ecchymosis appear 
over the trochanter, where the blow was delivered. 
In the cases originally iinpacted, but with serious 
deformity, I have not hesitated to remodel them, 



98 



American 

Journal Of Surgery. 



Downey — Fractures of Lower Extremity. 



March, 1915. 



and tlien to re-impact. In so doing, one need use 
but little force, either in manipulating or in impact- 
ing. Contrary to the usual idea, these impactions 
are not very solid, and what one does is to remodel 
and then consolidate the impaction, so to speak; it 
is never broken up bodily. I have also impacted 
a number of cases of extracapsular fractures with 
uniformly good results. Most of these fractures 
are loose, and we can pull them down and then im- 
pact them. In this class, the same thing practically 
can be accomplished by continued traction. In the 
neck fractures, however, unimpacted or loosened, 
nothing can take the place of this method ; in no 
other way can we give, in these almost hopeless 
cases, the practical security of a firm impaction. 

No one method is going to give results in all hip 
fractures. The selection of cases should be on 
about the following plan : 

In a percentage of very old or infirm people, we 
can do nothing but wait the event, and take chances 
on the hip. In many cases of true neck fracture, 
the position is tolerable ; the impaction seems solid ; 
active interference is unnecessary ; abduction dur- 
ing treatment is advisable to avoid adduction con- 
tractures; it can be secured by sand bags or in a 
plaster spica, according to the patient. If impac- 
tion seems not very firm, then sharp abduction in 
a spica plaster is wise. If there is no impaction, 
or if the position needs remodeling, and the patient 
can take ether, then we should use the mallet. 



FRACTURES OF THE LOWER EXTREMITY 

AND THEIR TREATMENT. 

J. H. Downey, M.D., 

Gainesville, Ga. 



Bone Transplantation in Pott's Disease. 

Surgical measures for tuberculous spine disease 
are a great advance over conservative treatment, 
but should be restricted to selected cases. Un- 
doubtedly they shorten the period of disability. 

Not only may existing deformity be prevented 
from becoming exaggerated, but also deformity it- 
self may be prevented by surgical measures. 

Too early reliance cannot be placed on the 
strength of the bone graft. It takes time for the 
splint to become securely fixed by permanent callus. 

External support must not be disregarded for 
many months following the operation ; otherwise 
deformity may ultimately occur. 

Even with post-operative protective treatment for 
a period of six or more months, the duration of 
treatment is much shorter than the average dura- 
tion under non-operative methods. 

Success of bone transplantation for the cure of 
tuberculous spine disease depends on the proper 
implantation of the bone splint into the diseased 
and normal contiguous vertebrne. Essential to the 
success is the careful protective after-treatment for 
a period of months. — Charles M. Jacobs in The 
J. A. M. A. 



Tlie awakening of our profession to the defects 
in our method of treating fractures of the lower 
extremity could be portrayed in no more forceful 
argument than that presented by Dr. J. B. Walker 
in the December, 1914, number of the American 
Journal of Surgery. The facts and figures 
brought out in his article coincide with my experi- 
ence and observation for a number of years past. 

Early in 1894 I recognized that our methods were 
very imperfect ; that anything like a universally 
good result was the exception rather than the rule 
with even our best men ; and that the results with 
the less careful were simply appalling. At this time 
I began a careful study of my fracture cases to see 
where these defects were. 

First was the uncertainty of the methods we were 
taught. We were impressed, from both the lecture- 
room and the text-books, to bring the fractured 
ends of the bone in apposition and hold them there, 
but the methods described for this purpose were 
incapable of doing so. Human strength is abso- 
lutely incapable of a pull strong and long enough 
to overcome the action of the powerful muscles 
of the thigh under the painful irritation of frac- 
tured bones for a sufficient length of time to ap- 
ply a permanent dressing. 

Then, the dressings we were advised to use were 
mechanically faulty and incapable of holding the 
bone ends in apposition ; consequently, with defec- 
tive reduction in the first place, and imperfect re- 
tention in the second, bad results were all we could 
expect ; hence, the old idea that one to one and one- 
halt inches of shortening was justifiable. 

I believe every physician who has pulled on a 
fractured femur to reduce it and hold it reduced 
for twenty to thirty minutes will agree with me, 
that his strength was inadequate and too unsteady 
for that purpose. Therefore, some mechanical 
device that will pull slow and steadily to insure 
perfect reduction with minimum amount of pain, 
and hold as long as may be necessary in a fixed 
position to apply a pennanent dressing, is the first 
pre-requisite we must adopt in the improvement of 
our treatment. 

The methods usually taught and described most 
frequently in our text-books are Buck's extension, 
with some modification, the Hodgen apparatus, and 
a straight plaster-of-Paris cast, none of which meets 
the rational requirements for which they were in- 



Vol. XXIX, No. 3. 



Downey — Fractures of Lower Extremity. 



American 
Journal ok Surgery. 



99 



tended, and 1 believe that every man who will think 
carefully and unbiased, with due reference to po- 
sition and muscular action, will see that Buck's ex- 
tension is unsuited for fractures near the condyles 
or the trochanters. See figure 1 from Wyeth's 
Surgery, pages 173 and 174. And again, muscular 
action is not a mathematical problem, and I do not 
believe the man has yet lived or will live who can 
calculate accurately the amount of weight neces- 
sary to exactly overcome the action of tlie muscle 
in different limbs, or in the same limb at different 
times. And as these fractured ends of bones are 
hidden deep under the muscles, they cannot be ob- 
seiA'ed. The weights, if too light, are ineffective 
and allow overriding. If too heavy, they pull the 
bones apart and are conducive to non-union. 

Our Hodgen splint, being cheap and easy to ap- 
ply, and feeling reasonably comfortable to the pa- 
tient, often meets the reauirement of the doctor or 




surgeon who contents himself with doing some- 
thing just to relieve the suffering of his patient. 
This man has done the same thing that a surgeon 
would do if he administered morphine to a case 
of acute appendicitis — eased his pain and masked 
his symptoms. Let us see if this statement is true : 

As I said in the beginning, we have been taught 
that the proper method of treating fractures is to 
bring the fractured fragments in apposition and hold 
them there. Suppose a fracture is in the upper 
third of the femur, our Hodgen apparatus supports 
only the lower fragment, and the upper one is left 
without any retention device whatever, and is held 
still or in place merely by the patient's holding 
still, otherwise the movement of the fragments is 
as certain as are the movements of the body. It 
appears to me from our teaching and my experi- 
ence that both of these fragments should be fixed. 

Now as to the extension and counter-extension. 
With one point of fixation in the ceiling of a room 
and the leg swinging in a trough by a rope at an 
angle of forty-five degrees, with the patient simply 
lying in bed, how can we maintain the exact dis- 
tance between the ends of the fractured bone ? For, 
certainly, he will "give" to the continual pull or 
traction, which must be considerable, if at all ef- 



fectual ; consequently, as he slips down in bed, over- 
riding or angulation may be expected. 

Our straight plaster cast is equally as unsatis- 
factory, because this method is open to the same 
objections in fractures of the upper and lower ends 
of femur as the Buck's extension, since muscular 
rigidity and action tend to produce deformity. 
(Sec cut, figure 1.) Our two points of fixation 
are too w idely separated to get the best results, and 




as time passes, the plaster crumbles against the 
perineum, and the cast, being straight and tapering, 
the muscles taut and rigid, the limb naturally tele- 
scopes into the cast with disastrous results. 

After some ten or twelve years, with varying 
degrees of success by these methods, I tried to im- 
prove them, and in the Journal of the American 




Fig. 3. 

Medical Association, August 25, 1906, I described 
a method which I had devised after a thorough 
dissection of the varying ways we had been taught. 
I changed our reduction from human pulling and 
uncertain weights to careful, slow, steady, mechan- 
ical traction, until, by measurement and comparison 



100 



American 

TorRNAL OF Surgery. 



DowNEV — Fractures of Lower Extremity. 



March, 1915. 



with the well limb on the opposite .<ide. 1 was sure 
of perfect reduction. Then, second, 1 selected that 
position which placed the limb and muscles in the 
nearest approach to a restful position, promoting 
muscular relaxation, and in which we could force 
the long fragment of bone, over which we have 
control, to conform with the natural axis of the 
short one. which is often too short to be forced in 
line, and by so doing to produce angles in the limb 
that would serve as points of fi.xation between the 
ends of the bone that is fractured, instead of the 
whole limb. That is, in a case of fracture of the 
femur, by the angle at the hip and knee, we fix the 
distance between these points. The cast being 
angular, there can be no telescoping from above 




downward, or from below upward. The same is 
true in a case of fracture of the tibia and fibula. 
The angle at the knee and the swell at the heel 
and instep produce fixed poitits that make shorten- 
ing impossible, if it has been perfectly reduced 
and the cast properly applied. See figures III and 
IV. 

In this way, if reduction is assured and the ends 
of the bones maintained exactly the same distance 
apart, as on the uninjured side, by the angle at the 
knee and hip. and coaptation is good, keeping the 
shaft in perfect line, subsequent traction or exten- 
sion by any means whatsoever would be wholly un- 
necessary. To this methtid I gave the name of the 
Double Angular Plaster of Paris Splint. 

The advantages offered by this method are many. 
As stated above, the position gives restful position 
and muscular relaxation, lessening the tendency to 
spasms of muscle, both of which are of great ad- 
vantage, as muscular rigidity is a very important 
factor in producing overriding and deformity. In 
this position, with steady traction, the fragments 
will usually come into apposition if portions of s(jft 



tissue do not intervene. This position prevents 
any telescoping of the limb into a cast when the 
swelling subsides or the limb shrinks, for neither 
upper or lower fragment can possibly move in these 
angles. It further controls any possibility of rota- 
tion, thus avoiding an inward or outward displace- 
ment of the foot. 

This splint has the further advantage that, in- 
asmuch as the patient is placed in a natural sitting 
position and the attitude assumed in the use of 




FlK. 5. 

crutches, it renders him much more comfortable, 
and gives him that freedom which, by any other 
method, is absolutely unheard of. This freedom 
of movement can be assumed as soon as the cast 
dries and the soreness from the primary injury sub- 
sides, which usually takes from three to six days. 
Also, it is especially a boon to the aged or other- 
wise enfeebled, among whom bed-ridden cases often 
terminate with such high -mortality. 

Also, if we are careful in the reduction and in 
the application of the cast, we may expect a fairly 
perfect anatomical and an absolutely functional 
result. 

In my article in lyQb, I described at some length 
a table with the top dropping or telescoping out of 
the way, so as to give access to the patient, mean- 
while liolding the hips fixed, and a device to main- 
tain an ecjuable mechanical traction. This was to 



Vol. XXIX. No. 3- 



DowxEV — Fractures of Lower Extremity. 



Journal of Surgery. 



101 



facilitate the application of a plaster of paris cast 
under traction in any position, without any move- 
ment of the patient whatsoever. I may add in this 
connection that 1 think the profession thought I was 
describing a table or a piece of apparatus for com- 
mercial ptirposes, whereas what I was actually do- 
ing was proposing a method of treatment which of- 
fered much to sutifering humanity. 

The Application. To get the best results, a dou- 
ble angular plaster splint must be applied in sec- 






tions ; two in fractures of the femur (see figure 
III, first section) and three in cases of fracture of 
the tibia and fibula (see figure II). The reason 
for sectional application, is that traction must be 
made over the plaster, and the section over which 
the traction is made must be put on and allowed 
to partially set or it will dent in and harden with 
depressions. These are likely to cause pressure 
sores, pain, and possibly deformity. Here is the 
stumbling block. Plaster casts have always been 
applied to the limb straight, and from below up 
without interruption, and it is hard for most of 
those to whom I have explained this method to see 
why the sectional application of the plaster is nec- 
essary, but the above explanation, I hope, will suf- 
fice. Again, it has been our custom to keep the 
patient with fracture of the femur in bed from four 
to six weeks, at the least, and when we reduce 



these weeks to days, we put another stump in the 
road which is hard to get around. .Also surpris- 
ing, perhaps, is the statement that rarely is there 
pain sufficient to require an opiate after the first 
twenty-four to forty-eigiit hours. 

For a long lime I did not have access to a good 
.r-ray machine and I could not show the end-re- 
sult, but now that I have this machine, I can show- 
results of which t atn not ashamed. \'el 1 know 
tliat claims of such radical improvement over the 
old methods, from a man practically unknown to 
tlie profession and in such a small place as CJaines- 
ville must naturally be taken with a good deal of 
doubt, but I hope time will clear away these fears 
;iiid give to this class of unfortunate humanity 
\\ liat is justly theirs — a ven,' much diminished pain ; 




Fig. 7. 

freedom of almost any movement without fear of 
pain or displacement of the fragment ; almost per- 
fect anatomical and an absolutely perfect func- 
tional result in the end, and this in from sixteen 
to twenty instead of thirty-two to forty weeks. 

Technic. In case of fracture of the tibia and 
fibula, apply first, a plaster slipper to just above the 
ankle and then a stovepipe-elbow-shaped plaster 
cast, with the knee flexed, from two or three in- 
ches below the knee to midway of the thigh (see 
figure II). Allow these to partially set and apply 
extension and counter-extension by some mechan- 
ical device that will pull and hold the fragments 
in place until the interspace can be filled (see figure 
11). At the points of union at the upper and lower 
end of the middle section, I use wire gauze inter- 
woven between the layers of plaster to make the 
unions finn. Then, after the plaster has sufficiently 



102 



American 

Journal of Surgery. 



Downey — Fractures of Lower Extremity. 



March, 1915. 



set to prevent displacement, go over the whole cast 
with a couple of layers of fresh plaster, thus com- 
pleting the cast. 

In the case of a fracture of the femur, only two 
sections are necessary. The limb is flexed to al- 
most right angles at the knee, and the cast is applied 
in the usual way from the base of the toes to just 
above the knee (see figure III). After partially 
setting, the thigh is flexed on the abdomen and 
mechanical extension and counter-extension are 
made (see figure III) until by measurement and 
comparison with the uninjured limb of the opposite 
side, one is sure of the reduction. Then begin at 
the upper end ofthe first section and carry the other 
section up to the transverse nipple line (see figure 
IV), reinforcing at the hip with gauze wire and 
numerous turns back and forth with layers of plas- 
ter. At this point we must make the outer portion 
of the cast doubly strong, as we only have two- 
ihirds of a circle which otherwise makes the cast 




Fig. 8. 

weak at this point, and the getting in and out of 
bed and the early use of crutches puts undue strain 
on it. If these precautions are carried out, we 
need have little fear of a break or reapplication of 
the cast under four or five weeks. 

Figure I shows deformity produced by rigid 
muscular action, and Figure VIII shows the relaxed 
state of muscles and how readily the long fragment 
will conform to the natural axis of the short one. 

Figure IV gives the complete permanent dressing 
for any fracture of the femur, regardless of loca- 
tion ; and in compound fractures a window can 
easily be cut in the cast for dressing wounds, while 
the perfect fixation afforded by the angles at the 
hip and knee makes it almost ideal for these cases. 

I append a few case histories and skiagrams 
showing results one year or more after accidents. 

L. B., aged 18. Fracture of the middle of the 
femur, resulting from being thrown from a buggy 
by a frightened horse, on August 23, 1912. Frac- 
ture reduced and permanent dressing applied two 
hours later. On the 26th the patient got up, and. 



with the assistance of a couple of nurses, walked 
to the front veranda, where she spent the re- 
mainder of the day ; and she did not stay in bed any 
more during the whole process of repair except at 
night. She had but one injection of morphia after 
the permanent cast was applied. The cast was re- 
moved October 15th. Crutches were used for a 
couple of weeks longer, after which time she at- 
tended to her usual household duties with little dis- 
comfort of a slight stiffness in the knee from a con- 
tractured condition of the muscles, which soon dis- 
appeared under daily exercise. By December 1st 
she had no physical reminder of having had a frac- 
ture at all (see figure V). 

R. P., age T>7 , farmer. Fell from a scaft'old 
February 2.Sth, suffering an oblique fracture of the 
upper third of the femur. Was put in a Hodgen's 
splint until March 1st when, under mechanical trac- 
tion, the limb was pulled out some two inches from 
the shortening which had occurred up to that time, 
and the double angular plaster splint was applied 
from the base of the toes to the transverse nipple 
line. The patient was put to bed, had a good night's 
rest, got up, ate breakfast in a Morris chair the 
next morning, and sat up eleven hours. He went to 
the toilet to move his bowels as usual, and did not 
stay in bed except at night during the process of 
repair. The cast was removed permanently on 
April 15th, and on May 19th crutches were laid 
aside for good. This patient drove his automobile 
baclc~and forth to town during the fourth week, 
and rode around over his plantation in a buggy 
from this time until after May 19th, when he was 
able to resume his horse-back riding. The results 
of this case are shown by the skiagram (figure VI). 
The point that gave him the most discomfort was 
a splinter of bone which slightly penetrated the 
soft structure. Had it not been for this, the pa- 
tient would have been perfectly comfortable by 
August 1st; but the end-results are almost anatom- 
ical and absolute functional. 

V. G., aged 16, March 18, 1913, was run over 
by a wagon containing two thousand pounds of 
fertilizer. Both tibia and fibula were broken, the 
limb being bent almost at right angles. The patient 
was put in the usual angular splint six hours later. 
The fourth day he was allowed to walk about the 
house on crutches. On May 10th, the cast was re- 
moved, and on the 25th the crutches were laid 
aside. The accompanying skiagram (figure VII) 
shows the end-result, eighteen months afterwards. 



R.\DIOGRAPHY IN FRACTURES. 

Too often the attending surgeon, who is usually 
the "family physician," with a most laudable desire 
to spare the patient expense, does not suggest, or at 
least does not urge a Roentgen examination, and 
finds too late that the "bones have slipped" in the 
dressing, as he supposes, and a permanent impair- 
ment or deformity is the result. Has he not sub- 
jected this patient to a far greater expense than 
the cost of the examination? — A. L. Gray in the 
Virginia Medical Semi-Monthly. 



Vol. XXIX, No. 3. 



ESTES 



k FitrVCTURES. 



American 
Journal or Surgery. 



103 



FRACTURES OF THE FEMUR. 
W. L. EsTES, A.M., M.D., 

Director and Pliy.>ician and Surgeon-in-Chief, St. Luke': 
Hospital. 
So. Bethlehem, Pa. 



General CotisideraHons. A fracture of any bone 
of a living human being is not simply "a solution of 
the continuity of the bone," but an injury which, in 
the large majority of instances, is a complex trau- 
matic condition, consisting of the break in the bone 
and injury to the soft tissues of the part involved, 
of greater or less severity. In some cases the in- 
jury to the soft tissues is of more importance than 
the fracture of the bone itself, in the majority of 
cases the injury to the soft tissues is of great im- 
portance ; and in no instance, except perhaps in the 
rare cases of so-called "green stick fracture," may 
they be neglected or forgotten in treating the case. 

The cause of fractures is usually stated as (a) 
direct and (b) indirect violence. A great deal of 
rubbish has been written and taught about "causes 
of fractures." Unquestionably a fracture may be 
produced by force sufficient to overcome the static 
resistance of the bone, applied directly to a region 
supported by the bone. About this there can be no 
controversy. In civil life fracture by direct violence 
is comparatively rare. Fractures by indirect violence 
are the ones about which anatomists, mechanics, and 
all sorts of doctors have talked, taught and contro- 
verted. 

I have analyzed the conditions, and histories of a 
large number of indirect violence fractures and I 
feel sure in nearly every instance the fracture of the 
bone, if it were a long bone, was produced by in- 
coordinate leverage. 

When a human being uses his extremities volun- 
tarily for motion and locomotion he accomplishes 
these acts by coordinate leverage, the motion to 
the levers (the bones), being applied by the co- 
ordinate use of the proper muscles. If taken un- 
awares, the position of the extremity, part of the 
extremity, or the trunk, may be such that even slight 
momentum results in violent incoordinate leverage 
and a fracture may result. 

Diagnosis. Distortion, "false mobility," great 
pain and local tenderness, ecchymosis, swelling and 
crepitus, if all are present in any case one may easily 
conclude a fracture has occurred. Sometimes dis- 
tortion is difficult to appreciate, no crepitus is felt, 
and there is fixity of the extremity or part of the 
extremity, only great pain and local tenderness is 
present, perhaps considerable swelling and some 
ecchynosis. Such cases may be extremely difficult 
to determine especially if the lesion be near a joint. 



To resolve the difficulty by manipulation and make 
a positive diagnosis immediately in such cases, some- 
times is absolutely unnecessary, it is harmful in 
many cases, it is barbarous in others. 

Careful ocular examination and comparison w-ith 
the uninjured limb, if the uninjured one is a normal 
member, careful measurements and the greatest pos- 
sible manipulation, continued for only a very short 
time, may be employed. If this does not suffice to 
establish the diagnosis, fixation in the position as- 
sumed by the extremity should be secured and a 
radiographic investigation by a competent operator 
should be made as soon as practicable. 

Prolonged manipulation and careless handling or 
forceful attempts to elicit crepitus should always be 
avoided. The dreadful pain from these methods of 
diagnosing causes spasm of the muscles and on 
account of the incongruous positions which follow 
may make the determination doubly difficult. 

In obscure cases difficult to diagnose, if manipula- 
tion is necessary to establish the diagnosis, it should 
be postponed until the physician is prepared and 
ready to make his permanent dressing, then a gen- 
eral anesthetic should be given, if the patient's gen- 
eral condition will admit of it, and setting should 
immediately follow the manipulation, or better still 
the manipulations should accomplish the setting, 
and the permanent splint or dressing be applied at 
once. 3iluch better however is it to reach the cor- 
rect diagnosis by a skiagram or by fluoroscopic ex- 
amination. I very much doubt that a physician who 
cannot give his patient the benefit of a well taken 
skiagram or himself be able to make a fluoroscopic 
examination should, in these modern days, attempt 
to treat major fracture cases. 

What was said in the opening paragraph in re- 
gard to fractures generally is particularly true of 
fractures of the femur. These cases are serious, 
complex injuries and one in treating them must not 
lose sight of this fact. 

The first thing to do is to find out the condition of 
the individual as regards his strength, condition of 
shock, manifestations and result of his pain, etc., 
etc. The general requirements should first be done, 
then the special ones be attended to. 

Shock in many cases is marked and requires care 
and discrimination in managing it. The early shock, 
that which comes on immediately after the injury, 
is a psychical one or due to "anoci associations." 
This is best treated by morphia given in full doses. 
Persistent or late shock means hemorrhage as a rule. 
This may require exploration by incision, and pack- 
ing of the lacerated cavity, or ligation of bleeding 
vessels. 



104 



A M UhlCAN 
IfilR.NAL Ul- SUKC'.ERY. 



I{sTES — Femur Fractures. 



March, 1915. 



Pain and muscular spasm are the special ever- 
present and overpowering- immediate sequel of frac- 
tures of the femur. The pain is so severe and try- 
ing in many cases it rapidly e.xhausts the patient. 
The position of the fragments sometimes aggra- 
vates the pain. One should try rapidly and gently 
to ascertain in a general way whether the fragments 
are pressing against the skin or the nerves and place 
tlie limb in such a position that this pressure shall 
he relieved. Then give a full dose of morphia, and 
immobilize and fix the extremity, unless one is pre- 
pared at once to reduce and splint the fracture. In 
this latter case a general anesthetic should be given 
and all manipulations be done in anesthesia. 

In complete fractures of the shaft of the femur 
there is always more or less hemorrhage. I have 
seen tremendous extravastion of blood subcutane- 
ously and between the muscles in some cases. One 
should estimate the severity of the hemorrhage by 
the tension and general quality of the pulse, and by 
the size of the hematoma about the fracture, and 
should direct his measures accordingly. 

Active stimulation, hypodermo- or proctoclysis, 
and in a few instances intravenous saline solutions, 
must be used. Unless the physician has the benefit 
of a well-equipped operation room and thoroughly 
aseptic technic he should open the soft tissues by 
incision to control hemorrhage only in instances of 
direct necessity; these instances will be very rare. 
A tourniquet or elastic bandage should be used only 
when nothing else avails. 

The first aid or preliminary treatment should be 
only gentle extension, and fixation of the limb in 
extension until the patient may be taken to, or tided 
over for, his permanent dressing. 

Prolonged attempts at reduction or manipulations 
for the establishment of the accurate relative posi- 
tions of the fragments when the examiner is not 
prepared immediately to put on his permanent or 
final dressing is reprehensible because it is unneces- 
sary and brutal. 

When the patient must be transported the limb 
should be fixed in the position in whicli it is found, 
unless the fragments are evidently pressing on the 
skin or on some nerve trunk. In the latter case 
sufficient variation of the position must be made to 
relieve this pressure, then the limb should be fixed. 

Except in cases of fracture of the neck, within the 
capsular ligament, a general anesthetic should be 
emj)Ioyed in inanipulating and reducing the fracture. 
This is best even in cases where Buck's extension 
or some variation of. the Buck's extension is to be 
used. 

It must always be borne in mind thai no two cases 



of fracture are exactly alike. For this reason the 
.same apparatus cannot without modification be 
used with ditYerent individuals, even though the 
fracture nf the bone seems exactly alike. The ap- 
paratus must be adapted to each indk'idual cose and 
not the case to the apparatus. 

Treatment of fractures of the femur. It should 
always be borne in mind that text book statements 
are at best average statements — more clearly as re- 
gards fractures, they, as a rule, try to note what 
the ordinary displacements, signs and indications of 
a particular fracture should be. Usually these 
statements are based on anatomic and mechanical 
considerations entirely. The physiologic and patho- 
logic forces are not usually recognized or regarded. 
For instance, fractures of the upper third of the 
shaft of the femur are followed by upward and out- 
ward displacements of the upper fragment, and 
upward and inward displacement of the lower frag- 
ment, according to the books, and anatomically it 
should be so. As a matter of fact, in one case at 
least, I have seen almost the reverse condition. 

Displacements and distortion in every case will 
depend upon the extent and severity of the injury 
to the contiguous soft tissues. A muscle which or- 
dinarily should produce a certain special deviation 
of the fragments may be almost or completely para- 
lyzed by the severity of the injury, and another 
muscle which ordinarily cannot successfully oppose 
it may be stimulated to tetanic spasm and by its 
super violence produce an entirely different or 
widely varying distortion and displacement from 
that the books and ordinary experience have taught 
us to expect. 

Again, most of the innerx'ating nerves may be 
severed, or the main nervous trunk be almost 
crushed by the leverage and weight of a fractured 
long bone. Paresis of the muscles may follow ; 
gravity and leverage alone will then determine the 
displacement. Congenital or acquired previous dis- 
tortions also influence displacements. Therefore a 
safe postulate for handling and treating any case 
of fracture of the femur is, never take anything for 
granted. Determine each individual case accurately 
and carefully and treat it according to its indiz-idnal 
requirements. 

Some years ago I was called in consultation and 
asked to reduce a fracture of the lower third of the 
femur in the case of an old man. The physician in 
charge told me he had tried repeatedly, always un- 
successfully, to reduce the fracture. It was a frac- 
ture almost transverse and the old gentleman was 
rather thin. I thought by etherizing him I should 
certainly be able to reduce and retain the fracture 



\oi.. XXIX. No. 3. 



EsTES — Femur Fractures. 



-American 

JotR.SAl. OF StKCERY. 



105 



in place. I was astonished and greatly chagrined 
to find that my assistant and I by any of the or- 
dinary means and methods could not reduce the 
fracture. Finally it occurred to me to examine the 
uninjured lower extremity. I found the most ex- 
aggerated case of bow legs I had ever seen. This 
gave me the necessary indication. By changing the 
direction of the traction and using a fulcrum just 
above the kneejoint. the adjustment was quickly and 
easily done. 

Treatment of the fractures of the several parts of 
the femur. . 

1st. Fracture of the neck: This fracture usually 
occurs in old people or in middle-aged women, un- 
less it is produced by direct violence. 

In the senile cases it is commonly intracapsular. 
When it occurs in healthy adults, the fracture is apt 
to be near the junction of the neck with the shaft 
and it is partially extracapsular, especially pos- 
teriorly. 

This last form may be impacted, the former 
never. 

The age of the patient, the history of the case, 
viz., a sudden trip and fall followed by inability 
to stand, great pain in and about the hip, sometimes 
running down to and also felt in the knee; extremity. 
easily moved at the hip by manipulation, eversion 
of the foot, shortening of the extremity, elevation 
of the trochanter major shown by Nelaton's line or 
Bryant's triangle, local tenderness, great pain when 
the extremity is moved, especially when rotation is 
attempted, will serve to make the diagnosis, pro- 
vided one may exclude fracture of the pelvis about 
and including the acetabulum. It is not necessary 
to attempt to obtain crepitus, to do this is very 
painful. 

The fracture at the junction with the shaft usu- 
ally shows crepitus by even gentle passive move- 
ment. This, in addition to the signs indicated above, 
will make a diagnosis of fracture easy, but it is 
not ahvays easy to differentiate between the tw^o, 
even though one remembers that crepitus is much 
more easily elicited in the latter than in the former 
case. A good skiagram may be necessary to clear 
up the diagnosis. 

Treatment. Senile cases demand attention to 
their general condition at once. They are usually 
in shock on account of the great pain produced, and 
will require full doses of morphia the first twenty- 
four hours. While it is true that some old people 
do not stand confinement in bed well, it is not true 
of all cases by any means. One must early judge 
this feature and be guided in his treatment by this 
determination. As a rule, a dressing and apparatus 



should be employed which will enable the patient 
to move about a little in bed and to change position 
from time to time. It is rigid fixation in one posi- 
tion in bed and pain which proves so exhausting to 
old people. Strong traction and the necessity of re- 
maining fixed on the back is very irksome, and is 
apt to be i)ainful, hence the ordinary traction de- 
vices should not be used for any length of time in 
cases of old people. 

I have found the old Hodgen splint or the Nathan 
Smith wire frame splint most useful in cases of 
fracture of the neck of the femur. 

When the fracture is at the junction of the head 
and neck, I use more than 45 degrees of abduction 
in some cases, as suggested by Royal Whitman, with 
the injured limb swung free of the bed and sup- 
ported in the Hodgen apparatus, and this in turn 
held by an overhead bar. Traction may be had by 
so arranging the cords which attach the splint to 
the overhead bar that they are continually draw- 
ing dow-nwards. That is, towards the foot of the 
bed. This is necessary in most cases to overcome 
the spasm of the muscles and to relieve the grind 
on the head of the bone. 

I have recently treated a very unpromising case 
in this way with great comfort to the patient, and 
with a very successful and happy result of the treat- 
ment. 

For the fractures of the neck at the junction with 
the shaft, the overhead bar should be only a little 
obliquely placed as regards the bed, so as to obtain 
very little abduction. Swinging entirely free of the 
surface of the bed, suspended, and continually in 
traction, the limb is comfortable, and the apparatus 
permits great freedom of movement of the bod\- of 
the patient and many changes of position. The pa- 
tient may sit up in bed and use the bed pan without 
difficulty. In a sunshiney, well-ventilated room, 
near a window, an old person can stand this ap- 
paratus in most instances six weeks without seri- 
ous detriment. 

Cases which will not endure this method of treat- 
ment should have adapted an extension apparatus 
like the Hutchinson hip-joint brace, or the Thomas 
brace, and be taken out of bed, placed in a com- 
fortable wheel chair and wheeled into the fresh air. 
Massage and alcohol rubs are very grateful and use- 
ful adjuncts to the treatment. 

Some preparation of nux vomica internally, care- 
ful feeding and diversion are also very useful in 
these cases. 

Fractures of the upper third of the femur. These 
fractures are quite common, especially in children, 
and are the most difficult of all fractures of the 



106 



American 
joursal of subcery. 



EsTES — Femur Fractures. 



March, 1915. 



femur successfully to treat without an open opera- 
tion. 

The signs and symptoms are usually quite class- 
ical in these fractures ; no difficulty is found in 
diagnosing a fracture, but it is difficult, especially in 
a stout, fat or full-muscled person, to determine 
whether the fracture is oblique or spiral. It is 
nearly always one or the other. 

The tilting upwards and outward rotation of the 
upper fragment may be overcome by general anes- 
thesia, w-hich relaxes the spasm of the muscles, and 
one may accomplish a fair restitution of the frag- 
ments, but it is very difficult to hold them in proper 
place afterwards. In children this may be done by 
a well applied plaster cast put on in anesthesia and 
reinforced by flexible wood strips laid in on the an- 
terior and outer surface, and carefully fitted and 
snugly applied from the knee to the umbilical region. 
Occasionally one may succeed with a similar dress- 
ing in cases of thin, weak adults, but for strong, ro- 
bust individuals, in order to preserve the position 
of the fragments, it will be necessary to employ a 
system of downward and outward cross traction, 
with powerful extension of the extremity by 
weights, like the Bardenheuer method. I think a 
better method is to use the Nathan Smith anterior 
w-ire frame curved at the knee so as to obtain flexion 
at the knee. Bandage it carefully in place and then 
suspend the extremity in a sufficiently rotated po- 
sition to meet the displaced upper fragment. 

In a recent case in which there had been exten- 
sive superficial lacerations and serious infection, we 
tried all manner of dressings and positions, with- 
out being able to retain good apposition. On ac- 
count of the infection, no open operation could be 
employed. The child (nine years old) nevertheless 
obtained good union (though the fragments over- 
lapped) and had a perfectly useful limb afterwards. 
I shall return to this point later on. 

As was said before, this is the region of the 
femur which, when a fracture occurs, an open oper- 
ation for replacing and directly plating the frag- 
ments themselves is indicated. 

Fracture of the middle third of the femur. These 
are the most frequent of femoral fractures. Easily 
diagnosed as a rule. I have no record nor can I re- 
member ever to have seen but one incomplete or 
green stick fracture of the femur; this was at this 
region. U.sually they are oblique or spiral ; they are 
sometimes transverse, however. The lower frag- 
ment is usually drawn upwards above the end of 
the upper fragment, but it may lie in any position 
as regards the horizontal directions. I have seen 
anterior, posterior, internal and external positions 



of the lower fragment as regards the upper frag- 
ment. It all depends upon the nature and extent 
of the injury. 

Middle third fractures are usually considered the 
ones especially requiring some form of traction 
method for their treatment. Except in a few se- 
lected cases I have quite lost my preference for trac- 
tion methods of treating these fractures, since skia- 
grams so persistently showed me overlapped frag- 
ments, inaccurate apposition and nearly always a 
little angulation, as a part of my result. Besides a 
stiff, painful knee joint is apt to persist for many 
weeks. 

For transverse fractures, I have had better re- 
sults with a plaster of paris fixed dressing after re- 
duction in general anesthesia. This should be re- 
moved in three weeks, the limb carefully washed 
with alcohol, massaged, the joints very carefully 
moved, and another plaster dressing applied. 

Also for oblique or spiral fractures in most in- 
stances the plaster splint applied in complete gen- 
eral anesthesia is best and most comfortable. These 
splints should be applied while the limb is power- 
fully extended by means of a Lemon or a Lam- 
botte apparatus. Manual extension cannot be kept 
up unvaryingly for a sufficient length of time. If 
one has the benefit of a first-class modern fluoro- 
scope to see just what he is doing, he will be very 
fortunate indeed. 

For the traction method I have been accustomed 
to use for many years a modification of the Volk- 
man leg and foot piece to prevent rotation of the 
foot, and to lessen friction. My apparatus consists 
of a leg and foot piece, which is bandaged to the 
leg and foot after the adhesive plaster strips have 
been laid on. Cross pieces go out on either side 
from under the leg piece and ride on two pieces of 
hard wood planed to a narrow edge. These are 
made like an ordinary railroad into flat sections, of 
varying sizes and lengths. This apparatus raises 
the leg and foot a little, keeps them off the bed and 
slides easily in the running grooves on the track of 
hard w'ood. When properly applied the apparatus 
keeps the foot constantly in proper position and 
prevents any deviation of the leg. 

In some instances Steinmann's nails may be used' 
for extension. I must confess to a prejudice against 
this method. I prefer plating the fragments when 
any operation is necessary. 

While the little operation of thrusting an aseptic 
nail through the extremity, including the bone, may 
itself be attended by little danger, it is quite a dif- 
ferent matter during the weeks of traction on this 
nail, for the tissues must be irritated by the pull 



Vol. XXIX. No. 3. 



EsTES — Femur Fr.\ctures. 



American 
Journal of Surgery. 



107 



and movements produced by the varying position 
of the patient, and infection is very apt to follow 
the irritation. 

After any method of reduction and dressing, 
especially after a fixed dressing, such as plaster of 
paris, has been put on, a skiagram should be taken 
or a fluoroscopic examination be made to find out 
clearly whether the fragments are held in good po- 
sition. Overlapping to a slight extent in cases of 
oblique and spiral fractures will not very much hin- 
der good union and satisfactorj' function afterward, 
provided there is no angulation or rotation of the 
fragments on the proper axis of the bone. 

Overlapping in cases of transverse or short, ir- 
regular oblique fractures will make a great differ- 
ence, however, much deformity, doubtful union, 
and usually long delayed and never complete func- 
tion will result. Finding this after attempting to 
reduce and fix a fracture, another attempt should 
be made, and if again unsuccessful in resorting the 
fragments to proper position, my rule is to operate. 

Whatever apparatus is used, in about three weeks 
at least, the limb should be carefully inspected, care- 
fully washed off with alcohol and massaged. The 
ankle joint should be slightly moved and the knee 
joint should also be flexed as much as practicable 
without provoking spasm of the muscles and dis- 
placement of the fragments. 

In many instances a surgeon waits too long be- 
fore he begins massage and passive movements. I 
would not go so far as Championniere in regard 
to massage in fractures, but it seems to me it should 
be employed as early as practicable. 

Fractures of the lower third of the femur. The 
diagnosis of these fractures is usually easy. The 
displacement of the ends of the fragments follows 
the general rule of fractures of the femur below 
the upper third. The lower fragment is usually 
drawn upwards as regards the upper fragment (ex- 
cept in cases of the specific fracture to be men- 
tioned presently) ; unless they are badly lacerated, 
the abductors are very apt to draw the upper frag- 
ment inward. In which case the lower fragment 
will be found displaced upwards, a little backwards 
and to the outside. 

There is a fracture, however, usually transverse, 
the displacement of which is, lower fragment dis- 
placed baclcwards and tilted so that the end presses 
backwards into the upper part of the popliteal 
space. This fracture is produced by the whirling 
motion caused by a rotating wheel. Children who 
jump on wagons and whose lower extremity is 
caught in the wheel, and workmen caught in slowly- 



revolving large machine wheels, have this special 
kind of fracture. 

The condition is a very characteristic one. It 
is an extremely painful one because the end of the 
lower fragment presses firmly against the blood ves- 
sels and nerves which pass through the popliteal 
space. Also grave injury to the vessels may result 
from tliis pressure. It is therefore necessary to 
reduce this fracture very soon to prevent thrombosis 
in, or laceration of, the vessels. If it is not prac- 
ticable to reduce the fracture at once, the leg should 
be flexed at the knee and immobilized in this posi- 
tion until an anesthetic may be given and reduction 
accomplislied. 

One must have in mind that this fracture is the 
analogue of fracture of the lower third of the hu- 



€~ 




merus just above the condyles. Jones of Liverpool 
has taught us that to reduce and hold the fragments 
of the humerus in place it is necessary to actually 
flex the forearm on the arm and fix it in this posi- 
tion. A similar method of reduction should be used 
in the supra condyloid femoral fracture, namely, 
extreme flexion of the knee joint and manipulation 
of tlie lower fragment into place. Ordinarily this 
may be accomplished, and when reduced, as it is a 
transverse fracture, one has only to jam the frag- 
ments end to end and have them held in this position 
while the leg is slowly and carefully brought to its 
proper position. A fixed dressing of plaster of 
paris may then be applied. 

When the violence has been great, however, the 
displaced lower fragment may be caught between 
the heads of the gastrocnemius and the hamstring 
tendons, and lacerated shreds from these fibrous 
structures may be so wrapped about the ragged 
ends of the fragments that they will be firmly held 
and no manipulation or position will suffice to re- 
lease them. In this case an open operation will be 
necessary in order to obtain good restitution of the 
fragments. 

Ordinary fracture of the lower third may be 
treated by traction methods, with Hamilton's co- 
aptation splints to prevent deviation. For children 
and for some not verj' strong and thin adults a fixed 
dressing of moulded splints, preferably plaster of 



108 



American 
Journal of Surgery. 



EsTES — Femur Fractures. 



Makch, 1915. 



paris, ai)plied in general anesthesia may be used 
to advantage. W'hen the plaster has hardened, the 
extremity may be swung clear of the bed by attach- 
ing bandage supports and cords carried to a bar 
above the bed. \Mien the reduction has been good, 
the method of treatment is a very grateful one. 
Skiagrams should be taken soon after the dressing 
is applied in order to be sure of the reduction. 

End-results of fracture of the femur. Tp to this 
time there has not been established any authorita- 
tive standard by which surgeons might compare 
their results after fracture of the femur. 

In 1890 the American Surgical Association ap- 
pointed a commission to determine and report what 
should be the conditions which should be considered 
as indicating good end results after fractures of 
the femur. 

The summary of the report of this commission 
is as follows : 

1. There must be firm boii}- union. 

2. There must be correct axial relations of the 
fragments. 

3. Correct relations of the anterior planes of the 
upper and lower fragments must be maintained. 

4. Shortening nuist not exceed from one-eighth 
to one inch. 

.^. Lameness must not result as a consequence 
of shortening over one inch. 

6. The conditions attending the treatment, how- 
ever, may prevent these satisfactory results. 

This is a standardization from an authoritative 
source, certainly, but it was made before the era of 
.r-ray and the surgeons of that time did not practice 
open methods for the treatment of fractures. 

This year the .\merican Surgical Association has 
a comnu'ttee working on this matter of standardiza- 
tion. It is to be hoped that this committee will be 
able to formulate a summary which will bring the 
conditions u]> to date. 

Taking, however, the above standardization as 
existing at present, what is the average result ob- 
tained by surgeons wlm treat fractures of the 
femur? 

In 1912 1 made a study of 760 cases of fractures 
of the femur, collected from many surgeons. Un- 
fortunately, the records of these cases were so in- 
complete in most instances, it was impossible to de- 
duce accurate data from them. .Seven hundred of 
these cases were reported to have made satisfac- 
tory recoveries. T presume this may mean that 700 
out of 760 cases had bony union. 

In regard to the second condition, tiainely, cor- 
rect axial relation of the fragments. 620 cases had 



this point noted, 114 of these cases (or 18.1%) had 
serious axial displacements. 

The third condition was not noted. 

The fourth, tlie average shortening of the re- 
ported cases, did not exceed one inch. 

This matter of shortening, however, is a very 
uncertain one. It is well established that a man's 
femora ;ire rarely the same length. Sometimes they 
vary, in what seems normal conditions, as much 
as one inch. I have a child, a thirteen-year-old girl, 
under treatment now, one of whose femora is one 
and three-eighths inches longer than the other. This 
is a case of unequal development, apparently, how- 
ever, with the same conditions of the legs on both 
sides, and like conditions of development, etc. 

Then, too, measurements are fre(|uently very 
carelessly and inaccurately taken and may not be 
trusted. Therefore, unless the fifth condition, 
namely, laineness results as a consequence of the 
shortening, or serious tilting of the pelvis and 
spinal curvature develops as a consequence, I think 
not more than one inch may be taken as a good 
fmictional result. If there is this much shortening 
as a result of the fracture, it is surely due to over- 
lapping of the fragments. This will require a large 
callus to assure firm union, and this in turn will 
produce sotne deformity and usually cause a good 
deal of pain for some time. 

One must now bear in mind that the almost uni- 
versal use of .r-ray and the demand of a patient to 
have a print of the plate, require of the surgeon not 
only a good functional result, but a good mechanical 
and cosmetic result also. 

In the report on the 760 cases of fracture of the 
femur, only 130 were reported as skiagraphed, 83 
of these, or 63%, showed good apposition. These 
.I'-ray cases came from the best and most systematic 
surgeons and cannot be considered the average re- 
sult obtained by all surgeons by any means. .A.lso, 
if I may judge by my own experience, this does not 
express the result of the old conservative treatment, 
but it is the average result of both methods, viz., 
conservative and open methods. 

Of 299 of my own cases of fracture of the shaft 
of the femur, 100 of which were compound, com- 
minuted or complicated fractures, the average short- 
ening when they left the hospital was three-fourths 
of an inch. 

All but one of these cases had Arm bony union. 
Only about 2'^', of these treated by the conservative 
method showed accurate reposition of the frag- 
ments, when .r-rayed after the permanent dressings 
were applied. 

In one case of compound comminuted fracture. 



Vol., XXIX. No. 3. 



EsTES — Femur Fractures. 



American 

Toi'RNAL OF SURGERy. 



109 



when the fragments were cleared away, I found 
there was a loss of two and one-half inches of the 
shaft, yet this patient made a good functional re- 
covery, and by the use of a high shoe was able to 
work again. 

Axial displacement is a very serious matter in a 
final result. This not only is apt to lead to distor- 
tion of the pelvis and spinal column, but results 
in persistent pain in tlie ankle and knee joints and 
it usually incapacitates a man for further laborious 
work. 

The cases I have been able to trace and follow up 
have only been about 30% of my fractures, these 
have been able to return to their former jobs. These 
cases had no serious axial displacements. When 
some time ago I found by the old method of exten- 
sion, external splints, etc., etc., as I said, only about 
2% of my cases showed accurate apposition, and 
in many instances cases which seemed in perfect 
alignment, and showed ven.' little shortening by the 
usual methods of measuring, when skiagraphed 
exhibited overlapping and poor apposition, I became 
so disgusted that I began seriously to consider and 
to practice far more generally the operative method 
and direct splinting of the bone. 

Of the last 48 fractures of the femur we have 
treated at St. Luke's Hospital, I find 21 of them 
were plated, nearly 50%, whereas four years ago 
only 7% were plated. So far we have had no 
fatality from these operations, and but one case has 
been seriously infected out of 41 cases operated. 

From other surgeons I have collected 60 oper- 
ated cases without a death, making 101 cases of 
fracture of the femur operated on without a fatality. 
It is evident, therefore, that the operation may be 
done without serious danger. 

What are the advantages of the open method, and 
when or in which cases ought it to be used? 

It will be better to take the last question first. 
In my clinic at St. Luke's Hospital it is the rule 
in simple fractures of the femur to attempt reduc- 
tion in general anesthesia and while the patient is 
relaxed and unconscious to apply a permanent 
dressing. Then the fracture is .r-rayed. If the 
reposition is not good, especially if the fragments 
are not in alignment, another effort at reduction 
is made and again an .r-ray is taken. If again the 
position is bad, the state of aft'airs is explained to 
the patient and he is offered the operation. We 
find patients ver>' rarely refuse to have the opera- 
tion. Within ten days after the fracture the opera- 
tion is performed. 

If a physician must treat a case of fracture of 
the femur in a private house or in any institution 



not equipped and ready for the most careful aseptic 
technic, and if he has not qualified himself to do 
thorough aseptic work, he should not for a moment 
consider any but one of the so-called conservative 
methods of treating the fracture. The open or 
operative methods in such condition, it seems to me, 
are never permissible. 

Having had proper training and in a well-regu- 
lated, clean, modern hospital, a surgeon should de- 
cide in any given case whether the open or the 
closed method will be best for his patient. He must 
decide this matter promptly, that is to say, within 
ten days, for primary operations are much less se- 
vere as a rule, and are followed by better results 
than secondary or late operations are. 

To treat the question dogmatically, I should say, 
fractures of the neck within the capsule should al- 
ways be treated conservatively. The open method 
may be used on such cases only when the head has 
been dislocated from the acetabulum. 

Fractures of the upper third oft'er especial and 
cogent indications for the open method. 

Fractures of the middle third may best be treated 
by the open method if they are transverse, and can- 
not be reduced by general anesthesia, traction and 
manipulation. Oblique fractures which have short, 
irregular bevels or shoulders, and those which have 
markedly been displaced and have gathered on the 
ends and between the fragments a quantity of fascia, 
muscles, etc., are indications for the open method. 

A fracture of the lower third, if it be one which 
has the lower fragment tilted backward in such a 
way that it has been entangled in the lacerated fibres 
and fascia of the heads of the gastrocnemius 
muscle and hamstring tendons and cannot be re- 
placed under ether by manipulation and flexion, 
should as a rule be treated by the open method. 

In general, a fracture of any part of the femur 
except its neck, which cannot be reduced in anes- 
thesia, and retained in position by some proper ap- 
paratus by the middle of the second week, should 
have the benefit of an open operation unless there 
is a contraindication in the condition of the patient 
or some strong social or medico-legal consideration 
against it. 

In determining the question of open or closed 
method, the surgeon should never forget that a finite 
operator doing an open operation on a human be- 
ing can never be sure he is not introducing some 
sort of sepsis. There is. therefore, always a pos- 
sible added danger in open operations. 

Furthermore, open operation for fractures of the 
femur require large wounds and are not easy opera- 
tions to perform. They ma}- prove a serious tax on 



no 



American 
Journal of Surgery. 



PiRRUNG — Ankle Fractures. 



March, 1915. 



the strength of a patient and must never be Hghtly 
undertaken. 

The surgeon should not forget all this and he 
should make the patient appreciate the main fac- 
tors of the probable result without the operations 
and its added danger if undertaken. 

The advantages of the operation are (1) direct 
ocular examination of the condition of the frag- 
ments; (2) reposition and fixation by direct splint- 
ing of the bone while under one's eyes ; (3) evacua- 
tion of the blood and detritus from about the frag- 
ments; (4) a condition almost painless during after 
treatment and convalescence; (5) much more free- 
dom of movement in bed while convalescing; (6) 
earlier employment of passive movements and mas- 
sage. 

As regards results, our experience has been that 
the operated cases require a little longer period of 
disability, probably three weeks longer. The align- 
ment is always good and very rarely does any bow- 
ing occur afterwards unless the patient is allowed 
to bear weight too early. In every instance, so 
far as we have been able to follow our cases, the 
patient has been able to return to his former job, 
except in one case, who refractured his bone while 
still in the hospital (a recent case), and he has not 
been able yet to return to his work. He has consid- 
erable overlapping and callus and shortening as the 
result of his last fracture, which was treated with- 
out operation. 

The average period of disability for fracture of 
the femur worked out in our cases is thirteen 
months. This means the time a laborer may count 
as necessary before he may with confidence return 
to his hard work. Most cases leave the hospital in 
ten weeks, walking with the aid of a cane or 
crutches, but it requires a much longer period for 
them to be able to do a full day's work. Our fol- 
low-up system shows, as said above, the average 
time for full ability is thirteen months. 



"FRACTURES ABOUT THE ANKLE." 

J. Edward Pirrung, M.D., F.A.C.S., 

Visiting Surgeon to the Good Samaritan Hospital, Clin- 
ician in Surgery, University of Cincinnati. 
Cincinnati, Ohio. 



Alignment of Bones by Foreign Bodies. 
I am certain that the application of any large for- 
eign body to a fractured bone or the insertion of 
nails, screws or wire through and through the 
medullary canal, with the idea of fixing the bone in 
alignment, is wrong in principle and productive of 
much harm. The alignment can always be main- 
tained by splints, or plaster casts, and the only 
legitimate use for any foreign body in the bone is 
to prevent shortening or to hold down the end of 
some short fragment that is tilted out of place by 
muscular action. — W. P. Carr in the Virginia Med- 
ical Semi-Monthly. 



In the past physicians, surgeons, and even au- 
thors of some text-books of surgery have been con- 
tent to regard all fractures about the ankle joint 
as "Pott's fractures." Percival Pott described his 
fracture in 1769. He described it as that of a frac- 
ture of the fibula, three or four inches above the 
external malleolus with a tearing of the internal 
lateral ligament. 

The occurrence of such a fracture as described 
by Pott is infrequent, and the usage by authors and 
physicians of the term "Pott's fracture"' to describe 
all fractures about the ankle joint is to be de- 
plored. Ankle fractures are of many varieties. 
Wherever it has been possible in private or hos- 
pital practice, I have carefully checked up all re- 
cent cases of fractured ankles. In a considerable 
number of such cases I have not had to treat a 
single case of fracture of the fibula above the ex- 
ternal malleolus that was not complicated by some 
other injury than a torn internal ligament. The 
usual complication of fractured fibula was a frac- 
tured internal malleolus. The force of eversion 
breaking the external bone, continuation of the 
forces or the dislocation inwards or backwards (in- 
version-adduction) of the astragalus, breaking off 
the internal malleolus with its attached internal 
ligaments. Dislocations of the astragalus or of the 
tibia alone do not occur without accompanying tears 
of ligaments or fractured malleoli. Fracture by 
inversion usually breaks the fibula about the ankle 
joint: if the force continues, the internal malleolus 
with its attached ligaments may be torn off. In- 
ternal dislocation of the astragalus may occur when 
both malleoli are broken or when the external 
lateral ligament is torn. Posterior dislocations are 
frequent in bimalleolar fractures. The external 
malleolar fracture, or fractures of the fibula above 
the joint, occurs frequently without appreciable tear 
in the external lateral ligament or fracture of the 
bony internal malleolus. In such cases there is 
slight dislocation (inversion inwards) of the as- 
tragalus, the strong external lateral and tibio-fibular 
ligaments being unruptured, and the fibula frac- 
tures above the articulation. A much rarer injury 
is that which occurs when the astragalus is driven 
between the tibia and fibula, tearing (he tibio-fibular 
ligament, and many times breaking the fibula high 
above the joint. This, the so-called "Dupuytren's 
fracture," is due to direct violence caused by falls 



Vol. XXIX, No. 3. 



PiRRUNG — Ankle Fractures. 



Ill 



from a height, high jumps, and alhed injuries. 
These fractures may be complicated by a fracture 
of the astragalus or of the oscalcis. Splitting of 
the anterior articular surface of the tibia often 
-occurs with these fractures. Fractures of both the 
tibia and fibula occur very frequently, and many 
of these fractures are compounded. Some occur 
from direct violence, as from kicks, blows, and run- 
over injuries; frequently comminution occurs as the 
results of indirect violence. 

In transverse fracture of both bones, the 
fracture in the tibia usually occurs just above the 
internal malleolus, that of the fibula slightly higher 
up. The lines of fracture in other injuries where 
both bones are broken may be oblique, from below 
upwards or backwards; they may be V-shaped, 
spiral, or T-shaped ; rarely a longitudinal split frac- 
ture of the tibia occurs. The commoner forms of 
tibial fractures are the spirals and the obliques ; 
these are indirect injuries, and they are very often 
compounded. Other varieties than the above- 
mentioned fractures may occur, but these are the 
commoner ones. 

Fractures of the astragalus are not very com- 
mon. They occur in falls from an extreme height 
or direct crushing injuries. The fragments in as- 
tragalus fractures are greatly displaced. Recently 
I have had to treat two cases of fractured astraga- 
lus, one occurring from the crushing of the foot 
under an automobile wheel, the other from a fall 
from a height. In one case I removed the entire 
astragalus, in the other nothing was done except 
to keep the foot in such a position that motion at 
the ankle was allowed. 

The frequency and kinds of the various fractures 
may be noted in the following tables. Speed {Surg. 
Gyn. & Obst., July, 1914) gives the following tables 
•of fractures at the ankle, based on an ^-ray study. 

External malleolus alone 60 

External malleolus with fractured internal lat- 
eral ligament as evidenced in skiagram .... 31 

Internal malleolus alone 10 

Both malleoli 47 

Appreciable separation of interosseous liga- 
ments 10 

Both bones fractured above the epiphysis 12 

Fracture external malleolus and epiphyseal 

separation 1 

Lipping fracture (tearing of edge of the ar- 
ticular surface of tibia) 16 

187 
Displacements of Astragalus: 

Inward 5 



Outward 25 

Backward 6 

Results after setting, using tibio-astragalar axis 
as basis: 

Good 38 

Bad 27 

Colvin, of St. Paul {Surg., Gyn. and Obst., Jan- 
uary 14, 1914), analyzing sixty cases of ankle frac- 
ture in the services of all attending surgeons, gives 
the following table : 

1. Fracture of the external malleolus of the 

fibula above the joint 16 

2. Fracture of the internal malleolus alone ... 4 

3. Fracture of both malleoli 27 

4. Fracture of internal malleolus, and of fibula 

above the joint combined with backward 
displacement of the foot 3 

5. Fracture of the internal malleolus, and split- 

ting off of a considerable triangle of bones 
from the tibio, at the tibio-fibular junc- 
tion 1 

6. Split fractures of the tibia at the tibio-fibular 

junction of minor degree with no other 
fracture 1 

7. Comminution of the articular surface of the 

tibia , 1 

8. Supramalleolar fracture 5 

9. Fracture of the fibula and rupture of the 

internal lateral ligament (Pott's frac- 
ture) 1 

60 
Results of examination of 36 skiagrams of cases 
of ankle fractures— Pirrung : 
Anterior splitting of the tibial articular sur- 
face 2 

Fracture of external malleolus 2 

Fracture of both malleoli 8 

Fracture of the internal malleolus and of the 

fibula above the joint 4 

Comminution of the articular surface of tibia 3 

Supramalleolar fracture of both bones 7 

Fracture of fibula above the joint, with dislo- 
cation outwards of the astragalus and rup- 
ture of the internal lateral ligaments (Pott's 

fracture) 2 

Spirals of the tibia (near the joint) 6 

Spiral of tibia and fracture of fibula 2 

36 

An analysis of these tables shows conclusively 
the unreasonableness of classifying and treating all 
cases of fractures of the ankle as Pott's fractures. 
The use of the Dupuytren's splint, the "Pott's frac- 
ture" classical splint is absolutely harmful in many 



112 



American 

JovRNAL OF Surgery. 



PiRRUNG — Ankle Fractures. 



March. 1915. 



of these injuries. I submit, however, that it is the 
ideal splint for treating true Pott's fracture. It 
is also very useful in fractures of the fibula or 
internal malleolar fractures. I do not allow "Du- 
puytren's" splint to be used in other fractures 
about the ankle joint. ]\ly preference in these cases 
is for examination and manipulation under anes- 
thesia, an x-ray picture having been taken. This 
examination should be made as soon after the in- 
jury as possible, and splints or plasters are to be 
applied while the patient is still under the influence 
of the anesthetic. 

Ether, unless contraindicated, is the anesthetic of 
choice. Plaster that is applied on house fiannel 
as a "Crofts" splint, seems to me to be nearer the 
ideal splint for these cases. This splint "Crofts" 
allows for the swelling. It can be tightened or loos- 
ened at will and permits of full inspection of the 
injured limb. 

In considering a classification of injuries at the 
ankle joint the one made by Walton in a general 
classification of joint fractures seemed to me the 
best for methods of description as well as for treat- 
ment. He divides them as follows : 

First : Those involving the articular surfaces of 
the tibia or astragalus. 

Second : Those near to but not invading the 
joint surface. 

Third : Those fractures associated with dislo- 
cations and tears in the ligaments. 

The integrity of the ankle joint depends upon 
its ligamentous attachments, together with the mor- 
tise-like joint of the astragalus inserted between the 
external and internal malleoli. The articulation is 
between the lower end of the tibia and the astraga- 
lus. The strong inferior tibio-fibular and the in- 
terosseus ligament adds strength to the joint, 
through their action in holding the two bones to- 
gether. Other ligaments pass from the posterior 
and anterior surfaces of the joint. 

The problems requiring consideration under this 
classification of Walton would be in the first 
group. They concern the damage done to the ar- 
ticular surfaces and synovia, tears of the ligaments, 
tendons, or muscles ; displacements or comminution 
of fragments; and, lastly, hemorrhage in the joint. 
Some of these cases of ankle joint fractures will 
be compounded, providing another serious problem 
to combat, that of infection. 

In the second group we will liave to consider 
all transverse fractures above the articulation, supra 
malleolar fractures as well as injuries along the 
epiphyseal line. This group will also include the 
V-shaped fractures, the oblique and the s[iirals of 
tile tibia and fibula. 



In the third group are all fractures of the mal- 
leoli with ligamentous tears ("Pott's fractures"), 
dislocations of the astragalus frequently occurs with 
fractures or when the ligaments are torn, they 
can conveniently be considered in this group. The 
dislocations of the astragalus may be internal or 
external, posterior or anterior. Wide dislocations 
of the astragalus usually mean bad tears in the 
ligaments or a fractured bone. 

I have previously stated that I preferred "Crofts" 
splint or a simple plaster splint for treating those 
fractures of the ankle other than the Pott's frac- 
ture. "Crofts" splint can be utilized in holding the 
foot in any position desired. If inversion-adduction 
of the foot is wanted, it need only be allowed to 
harden in that position. If it is dorsi-fiexion of 
the foot that is wished for, it can be fixed in that 
position. This splint allows of full inspection of 
the ankle and that is one of the great advantages. 

Treat Pott's fractures by adduction-inversion. 
Treat bi-malleolar fractures first by reduction of 
the fragments and replacements of the astragalus, 
if it be dislocated, care being taken to have the 
center of the articular surface of the astragalus on 
the center of a line dropped from the tubercle of 
the tibia ; now place the foot in plaster at right 
angles to the leg, having the foot slightly dorsi- 
flexed in order that the bones will be firmly held 
together ; be sure the astragalus is brought forward, 
because posterior dislocation is frequent in bimal- 
leolar fractures. Fractures of the external mal- 
leolus without damage to the internal or external 
ligaments will require only that the foot be put 
in plaster at right angles to the leg. A slight 
amount of adduction-inversion is of course desired 
in order that through the external ligamentous pull 
the ends of the fibula will more readily come into 
apposition. The amount of adduction and inversion 
used is only about one-third of the adduction-inver- 
sion used in the treatment of a Pott's fracture. 

What class of cases will require an operation for 
good results? 

1. The spirals that cause great tearing of tis- 
sues and displacements of the fragments. 

2. Impacted fracture of the tibia into or near 
the joint. 

3. Posterior or anterior splitting fractures of the 
articular surfaces of the tibia, with dislocation of 
the astragalus. These are always complicated by 
torn ligaments. 

4. Transverse fracture of both bones near the 
ankle-joint where it is impossible to immobilize or 
retain the ends in apposition. These cases may 
often recpiire division of the tendo Achilles for a 
perfect result. 



Vol. XXIX. No. 3- 



PiRRUNG — Ankle Fractures. 



American 

lotBNAL OF StRGERV. 



113 



The operations done in some of these cases is 
simple incision and replacements of fragments. 
This is to be preferred. In other cases autogenous 
grafts from the patient's opposite shin, wire screws, 
plates, or nails nia)' also be used. The astragalus 
is always put in alignment with the tibia. The 
fibula can be ignored in many of the cases, or it 
can otlierwise be reduced by external manipula- 
tions. A retentive dressing is always required in 
the cases operated upon. It should be continued 
from three to five weeks. No weight-bearing should 
be allowed in ankle fractures for from seven to 
ten weeks. When the patient does begin to walk 
the heel of the shoe should be raised on the inner 
side so that all of the body weight is deflected from 
the inner to the outer side of the tarsus. 

One other class of cases is still to be consid- 
ered, viz : the compound fractures. 

I treat these expectantly, at least for a time, until 
I can determine just what degree of infection is 
going to occur. Under an anesthetic I gently 
cleanse the leg with wet gauze. I do not irrigate. 
I then replace the bony fragments with instruments 
(fingers should not touch the bone). Then I cover 
the bones with skin and soft tissue. The leg is 
dressed with gauze saturated in alcohol 65 per cent., 
camphor .^ per cent. A cage splint of wire or a box 
splint is applied. Repeatedly during the days fol- 
lowing, this solution of camphor and alcohol is 
poured over the dressings to keep them soft and 
moist. Later a radiograph is again taken. If the 
apposition is good and no infection occurs I apply 
the Crofts splint, cutting out a window or splitting 
it to allow dressing of the wound. If infection 
occurs but the apposition of fragments is good I 
am inclined to continue immobilization as best I 
can. Many of these cases will eventually overcome 
the infection, and union will then occur. A foreign 
body placed on a fracture already infected can do 
no good; it will do harm in prolonging infection 
and delaying union. 

What are some of the end-results of the present- 
day treatment in ankle fracture? 

Traumatic flat-foot is very common, a weakened 
arch, a weak everted foot, toeing out of the foot, 
broadening and stiffening of the ankle joint, and 
sometimes dropped ankle. Contractions and stif- 
fening of the muscles and tendons and imperfect 
dorsi-flexion are some of the poor end-results. I 
attribute many of these poor results to a faulty 
diagnosis and faulty methods of treatment, to- 
gether with the too early return to weight-bearing 
before the tendons have had time to unite properly 
and before the new callus has had sufficient time 



to liarden. The time of bony union cannot be 
arbitrarily stated. In my experience the average 
case re(|uires from seven to twelve weeks, excep- 
tional cases longer. A much longer period may 
be ref|uired for firm union of tendons. .An ankle 
thai shows pain on finger pressure along the frac- 
tured bones, or when attempts at weight-bearing 
cause much pain, is not ready to be used. It is not 
ready to bear even the slightest weight through the 
aid of crutches. Gentle massage, hot dry packs, 
hot oven bakings, together with active and passive 
motion will hasten repair of the tissues and relieve 
the pain and congestion. Dorsi-flexion is to be 
practiced by the patient. Lateral motion should be 
performed by the nurse or pliysician in charge. 

Robt. Jones (Amer. Jour., Orthopedic Surgery, 
\'ol. XI, page 334, October, 1913) says of fractures 
of the leg that there is little to be said until the 
low-er fourth of the leg is reached. Fractures above 
this are comparativel}- easy to handle, even if both 
bones are broken, but fractures of the lower fourth 
of the tibia or of both bones in this region are 
extremely difficult to control even if the tendo 
Achilles be divided. The slightest error of align- 
ment may mean constant pain and weakness in the 
ankle for months afterwards. Although I approach 
most other fractures with confidence that I can 
treat them successfully by manipulation, I feel that 
in fractures of the lower fourth of the tibia and 
fibula operation is usually the wisest course for me. 

In conclusion, I would therefore essay to help 
reconstruct some of the views now held concern- 
ing the seriousness of fractures about the ankle. 
The novice feels able to treat these buf runs away 
from the easier thigh cases. 

In all cases of ankle fracture carefully investigate 
them by the use of the X-ray. Examine and reduce 
all cases under an anesthetic. There is no routine 
appliance or splint to be used recommended, nor is 
there a method of operation advocated to the ex- 
clusion of all others. What is absolutely required 
is that a careful study of each case should be made 
under the guidance of the X-ray, and that reduction 
must be under anesthesia. W'hen this is done, each 
of us must then decide for himself whether by an 
open operation or by manipulation he can best re- 
duce and retain the parts in their former relations. 
In the past physician and patient have been resigned 
to some deformity in fractures and certain func- 
tional losses. In the future, yes even now, the 
public and the law courts are demanding of sur- 
geons the conservation of anatomy as well as of 
function. The surgeon is not so much interested 
in a slight deformitv if function is good. He 



114 



American 
Journal of Surgery. 



Ash HURST — Disabilities Following Fractures. 



March, 1915. 



should, however, be greatly interested in the dis- 
abilities arising from these injuries. The nearer 
the end-results of our treatment approach to the 
anatomical, the more certain are we to retain func- 
tion. 



THE PREVENTION AND TREATMENT OF 

THE DISABILITIES FOLLOWING 

FRACTURES OF THE LIMBS.* 

Astley p. C. Ash hurst, M.D., F.A.C.S., 

Philadelphia. 



During the last few years I have had under my 
care a great many patients sufifering from disabili- 
ties due to fractures of the limbs. This has im- 
pressed me with the frequency and seriousness of 
such disabilities ; and as the first step toward their 
prevention is a knowledge of their origin, I ven- 
ture to bring before you this subject, which I 
believe is of prime importance. In fact, I can- 
not but believe that, taking fractures of the 
limbs in general, the results of treatment are 
less satisfactory than they used to be. And I 
think this is so not alone because we have advanced 
our standards of what shall be considered good re- 
sults, but also because our treatment is less efficient 
than in former years. This state of affairs, per- 
haps, may be attributed to the comparative lack of 
interest in, and neglect of proper instruction of 
students concerning the treatment of fractures dur- 
ing the decade, let us say, from 1900 to 1910. This 
was a period during which the interest of the sur- 
gical side of the profession was concentrated largely 
upon abdominal surgery ; it was a vast and fascinat- 
ing subject, which had just begun to reach its stage 
of mature development, and in society meetings, 
clinics, and the class room swept everything before 
it. 

During this wave of enthusiasm interest in dry 
bones lagged, and it was not until within the last 
four or five years that bone surgery, and especially 
the subject of fractures, began to be restored to 
its former state of importance. The consequence 
is that most students of medicine who began their 
practical work during the abdominal decade knew 
little or nothing, and cared less, about the pathology 
or treatment of fractures. 

It is unfortunately true that in the present state 
of civilization in this country, as indeed everywhere 
else in the world, it is still necessary for the gen- 
eral practitioner to have under his care every year 
a number of cases of fracture ; he simply cannot 
avoid it. No doubt it would be much better for 



•Read by invitation at a meeting of the Brooklyn Surgical Soci- 
ety. February 4, I9I5. 



the patients if all cases of fracture could be referred 
to surgeons taking special interest in such work ; 
and I think it is not to be disputed that whenever 
possible it is the duty of the family physician to- 
send such cases to such a surgeon, and not to 
attempt to treat them himself. This course of ac- 
tion, however, is possible only in populous communi- 
ties ; and the grave responsibilities which must be 
assumed by the country practitioner, who must in- 
deed be not a "jack" but a "master" of all trades in 
the profession, render his lot most unenviable. 

But as it is impossible to know in advance which 
students of medicine will be able in after life to 
avoid having fractures under their care, it is neces- 
sary to insist that all shall receive adequate instruc- 
tion in this, as in all other fundamental branches 
of medical science and art. I believe the tendency 
toward specialization is to be condemned at least 
until after the hospital years ; and during these hos- 
pital years it is the duty both of those in charge of 
out-patients and of those in charge of the wards 
to train the Resident Physicians most carefully in 
the diagnosis, prognosis and treatment of fractures. 
Too much reliance, in particular, should not be 
placed on the X-ray, in diagnosis and prognosis. 
That young doctor whom you see depending en- 
tirely upon a skiagraph in a doubtful case, may be 
a few months hence hundreds of miles from the 
nearest X-ray outfit and may have to depend upon 
his X-ray fingers in treating his patients. It is 
mere folly for anyone to state, as Lane has done, 
that it is a pure waste of time to teach students the 
classical signs for the diagnosis of fracture, since 
the only thing needed is a good skiagraph. 

So, too, in regard to the operative treatment of 
recent fractures. It is generally recognized that 
this method cannot be applied successfully even by 
the average general surgeon ; much less by the oc- 
casional operator or country practitioner. Indeed, 
the operative treatment of fractures deserves almost 
to be considered a specialty; it is difiicult manual 
labor, requires extraordinary care in the preserva- 
tion of asepsis, and necessitates a special armamen- 
tarium possessed by few general hospitals and by 
no general practitioners. No one who does much 
work in fractures fails to see every year one or 
more lamentable results due to operative treatment 
of recent fractures by the inexpert. 

It is on all these accounts doubly incumbent on 
those who are responsible for the theoretical and 
practical instruction of medical students to so train 
them in what may be truly called conservative 
methods of treatment, that they will be able without 
resort to operation to cure their patients with the 



Vol. XXIX, No. 3. 



Young — Fractures Near Joints. 



American 
Journal of Surgery. 



115 



minimum of disability. For a number of years I 
have been urging this very thing upon the profes- 
sion : that non-operative treatment not only pos- 
sesses the inestimable advantages of carrying out 
the sound surgical maxim "pruniim own nocere" 
but also may be employed by any sensible practi- 
tioner with a reasonable degree of success; and 
when employed with intelligence, thoroughness, and 
enthusiasm, in fractures almost of any type, and 
in long series of consecutive cases, will give as good 
as if not better results than will be secured by op- 
eration, done by the average surgeon, and without 
unnecessary risk to the patient. 

Before discussing in detail the prevention and 
treatment of disabilities following fractures of the 
limbs, I may lay down certain theses, which will 
be developed in the sequel: 

1. Lesions of the soft parts always a'company 
fractures of bone, but too often are ignored in 
treatment, and are a very frequent cause of dis- 
ability. 

2. In compound fractures lesions of the soft parts 
always should take precedence over those of the 
bones. 

3. Active movements and functional use of the 
limb are the most important factors in overcoming 
disabilities due to lesions of the soft parts. Mas- 
sage, especially efflenrage and petrissage, is of 
much value in relieving edema, overcoming stiffness 
in neighboring joints, etc. ; but passive movements 
usually are useless and often are harmful. 

4. When the fracture occurs in the shaft of a 
long bone, it is not always possible (without open 
operation) to secure anatomical reduction of the 
fragments, and in most cases such reduction is un- 
necessary. 

5. When the fracture occurs near a joint, it is in- 
dispensable to secure anatomical reduction and this 
should be obtained by open operation if necessary. 

6. If operation is necessary this fact should be 
determined within a week or ten days of the ac- 
cident, and operation should be performed before 
vicious union occurs or bone atrophy develops. 

7. If operative treatment is required for old 
diaphyseal fractures, it is because of nonunion or 
because of concurrent lesions of the soft parts, and 
scarcely ever because of malunion of the bones. 

8. Malunion rarely requires operative relief ex- 
cept when occurring in the immediate neighborhood 
of joints. 

9. Nonunion is not always an indication for op- 
eration, and operation should be delayed until it 
is certain that cure will not take place without it. 

(To be continued.) 



FRACTURES IN THE NEIGHBORHOOD OF 

JOINTS. 

James K. Young, M.D., 

Associate Professor of Orthopedic Surgery in the Uni- 
versity of Pennsylvania; Professor of Orthopedic 
Surgery in the Philadelphia Polyclinic; Clinical 
Professor of Orthopedic Surgery in the 
Women's Medical College. 
Phij..'\delphia. 



The practice of orthopedic surgery is limited to 
the consideration of chronic and progressive de- 
formities. The orthopedic surgeon has no desire 
to treat the acute type of fractures, although he is 
eminently fitted by his mechanical training for the 
most successful treatment of these conditions; and 
his skill is further enhanced in this special field by 
the large experience gained in the treatment of 
vicious union, ununited fractures, and traumatic 
arthritis; therefore, fractures in the vicinity of the 
joints are usually referred to the orthopedic sur- 
geon after froin four to six weeks of unsuccessful 
treatment. 

As demonstrated in the past, .r-ray studies are 
especially useful in the recognition of injuries about 
the joints, but since the introduction of roentgen- 
ology, too much reliance has been placed upon it, at 
the expense of tlie clinical signs. These should, in 
everj' case, be studied most carefully and corrobo- 
rated by the x-rays. The most important clinical 
symptoms are the existence of signs of mobility, the 
distribution of the discoloration, and the time of 
its appearance. 

At times it is impossible to secure the .r-ray ex- 
amination immediately. In those instances, how- 
ever, the clinical findings should always be con- 
firmed as soon as possible. Thus, in mountainous 
or remote districts, for example, the practitioner, or 
consulting surgeon, may be compelled to arrive at 
the diagnosis of the condition solely on the clinical 
symptoms, and under such circumstances a thor- 
ough knowledge of the clinical signs is invaluable. 
This is also true even in some obscure cases, as 
upon one occasion, when I made a correct diagnosis 
of fracture of the lesser tuberosity of the humerus, 
from the position of the arm at the time of the acci- 
dent, and the discoloration of the arm along the 
course of the biceps muscle. 

The consideration of fractures in the vicinity of 
joints can be most intelligently studied under the 
following four appropriate headings : 

1. Simple fractures. 

2. Compound fractures. 

3. Comminuted fractures. 

4. Fractures complicated with dislocation. 

1. Simple fracture in the vicinity of joints should 



116 



American 
Toi'RN'AL OF Surgery. 



Young — Fractures Near Joints. 



March, 1915. 



not be difficult of recognition, if due attention be 
given to the physical signs and if these be confirmed 
by the .r-rays. The greatest difficulty is in the treat- 
ment of these cases, particularly in holding the 
fragments in apposition. In the larger joints, as 
in the shoulder or hip, if the fracture occur below 
the insertion of the deltoid or psoas, the limb may 
often be placed in a position favorable for the main- 
tenance of complete aj^jxisition ; but where this is 
impossible of accomplishment, resort must be had 
to plaiting the bones, the employment of screws, 
ivory pegs, or the use of some kind of mechanical 
appliance. In fracture about the elbow joint, treat- 
ment has been greatly simplified by the employment 
of extreme flexion, first introduced to the profes- 
sion by Jones, of Liverpool. In simple fracture 
about the knee joint, unless the fracture extend into 
the cavity of the joint, the maintenance of fixation 
is not ver>' difficult if fixation and extension be 
combined. The fundamental rule is, that the joint 
should be kept in the best possible position for use, 
if ankylosis occurs; this fact should always be 
borne in mind. The elbow should be maintained in 
flexion and the knee in full extension, so that if 
ankylosis occurs, the member will remain a useful 
one. The principal exception to this rule is in frac- 
ture of the olecranon, which, for a time at least, 
must be treated in full extension. In simple frac- 
tures in the vicinity of joints, and especially where 
separation of continuity occurs, the early institution 
of massage and passive movements is invaluable. 

It should be borne in mind that ankylosis of 
joints, as enunciated by Phelps, does not depend 
upon either motion or fixation, but upon the amount 
of disease or injury of the constituent parts of the 
articulation itself. In simple fracture involving the 
joint, sometimes a large fragment, as the anatomical 
head of the humerus, may be loose in the shoulder 
joint, or the head of the astragulus may lie loose 
in the ankle joint; these must be removed under 
the strictest aceptic conditions. 

2. Compound fractures in the vicinity of joints 
are so fJ-equently followed by infection that these 
are the most difticult cases to treat, but even in 
these, by patient care, the infection can sometimes 
be prevented by pro])er fixation of the joint, and 
the correct arrangement made for the dressings may 
ofttimes prevent the disastrous results. Where the 
compound fracture is also comminuted (3) the 
smaller fragments should be removed and the larger 
ones approximated with wire or plates and the limb 
placed in the best possible position for the occur- 
rence of ankylosis. Suitable appliances and frac- 
ture splints are here invaluable, as the bracketed 



wire splint of Packard, used formerly in excision 
of the knee joint, and the bracketed wire splint used 
by Esinarch in excision of the elbow joint, and 
which found extensive employment during the 
Franco-Prussian \\'ar. The last is forcibly illus- 
trated in the case of a lad brought to me from the 
coal regions of Pennsylvania, who had sustained 
a compound comminuted infected elbow joint which 
surgeons wished to amputate. I performed a par- 
tial excision and then dressed the injury upon an 
Esmarch bracketed-elbow splint, resulting in a per- 
fectly useful arm. In compound comminuted 
fractures of the shoulder hip. or ankle joint, a typ- 




Fig, 1. Compound comminuted fracture of the elbow joiBt, 
treated by e.xcision and Volkmann splint. 



ical or atypical excision is usually the best possible 
surgical procedure. In compound fractures of the 
astragulus, the results are very often gratifying 
after excision of this bone — partial or complete — 
the malleoli completely adapting themselves to the 
new surface and giving a very satisfactory articu- 
lation ; although recovery is accomplished with a 
very slight shortening of the limb. 

4. Fractures complicated mith dislocation in the 
z'icinity of joints. These are the cases that most 
often seek relief from the orthopedic surgeon and 
each of these is a study in itself. The most com- 
mon of these are so well known that they do not 
need detailed description, but special attention 
should be called to the shoulder, hip, and ankle 
joints, and, perhaps, to the elbow joint. Where the 
simple fracture is complicated with dislocation, the 
reduction should bo made under an anesthetic as 



Vol. XXIX, Xo. 3. 



Young — Fractures Near Joints. 



American 
JnrRSAL OK Surgery. 



117 



promptly as possible, and the fracture should be 
held in apposition by means of plates, screws, or a 
mechanical device: then the greater part of the sur- 
gical treatment should be directed to the dislocation, 
especially to its maintenance and the prevention of 
ankylosis. In many of these cases there will be a 
rupture of the capsule, and this should engage the 
surgeon's attention if an operation is performed, 
since a recurrence of the dislocation is very prone 
to occur, if this important precaution be omitted. 
In some joints, as the ankle, an excision of the 
astragulus and a reduction of the dislocation give 
the best possible results. The time for this opera- 




Fig. 2. Compound comminuted fracture of the elbow joint, show. 
ing splint completed. 

tion will depend upon a number of factors, but if 
the patient's condition be good, it can be undertaken 
at once; but if it is not perfomied at that time, a 
certain period should elapse for the plugging of the 
vessels, the reduction of the swelling, etc., just the 
same as in operations for fracture of the patella, 
where a period of a week to ten days is allowed to 
elapse. Resection of the head of the radius gives 
excellent results, where there is limitation of flexion 
following fracture of the neck of the radius, with 
obstruction of supination or flexion. 

Aseptic technic. In considering fractures in the 
vicinity of joints, one cannot too strongly emphasize 
the fact that there must be an absolutely aseptic 
technic. Surgeons have learned that the peritoneal 
cavity will tolerate errors of technic and will abso- 
lutely destroy infection, but no such beneficent pro- 
vision exists in the articular cavities ; and an error 
of technic in these regions too often means the de- 
velopment of septicemia and the death of the pa- 



tient. If, therefore, the surgeon is un[)repared to 
perform an absolutely aseptic operation he is un- 
worthy of the task and should dismiss the matter 
from his mind ; on the other hand, given an abso- 
lutely aseptic technic, there is no more danger in 
the opening of a joint than in the opening of the 
peritoneal cavity by the skilled surgeon. 

The operating room and everything in connec- 
tion with it must be as sterile as possible and every- 
one in the operating room must have the entire 




Fig. 
joint. 



Fracture of the astragalus with dislocation oi the ankle 



head and face covered except the eyes. The patient 
should be separated from the anesthetist by a gauze 
screen. The hands of the surgeon, assistants, 
nurses, etc.. should be thoroughly prepared by wash- 
ing with soft soap for five minutes, then alcohol, 
tlien a solution of bichloride and finally sterile 
water; after which sterile gauze must be worn. No 
one connected with the case should have dressed a 
septic case for twenty-four hours previously, and 
if they have they need take special precautions. 
Joints should be washed with soft soap for three to 
five days before the oi>eration, and be specially pre- 
pared three times within the twenty-four hours pre- 
ceding the operation. This special preparation of 
the joint should be with soft soap, alcohol, bichlo- 
ride, and sterile water, and then a dry dressing 
applied each time. If I have confidence in the pre- 
vious preparation, I do not prepare the part at time 
of operation ; but if there is the slightest doubt 
about its thoroughness, a final preparation is made 



118 



American 

Joi-RNAL OF Surgery. 



LiLlENTHAL — FeMUR FraCTL'RE. 



March, 1913. 



at the time of operation. The incision should be 
made through a piece of wet gauze and this can 
then be attached to the skin by clips. Long inci- 
sions should be avoided as much as possible on 
accouht of infection, and where possible, as in the 
knee joint, the tourniquet should be used to secure 
a bloodless field of operation. 

I practically agree with Jones, of Liverpool, that 
the employment of passive movement as is so gen- 
erally practiced is positively harmful as it disturbs 
the fragments of bones and leads to fresh plastic 
ettusioiis, excess of calltis formation, and increase 
of connective tissue about the articulation, all of 
which favor the development of increased stiffness. 
The oft-repeated to-and-fro movements only do so 
much damage, and no time is given for recovery 
before a fresh injury has been done. It is the part 
of wisdom never to move a joint, as long as union 
is likely to be disturbed. A joint should be put 
through each of its movements but once, and then 
left to recover from the damage. In one, two, or 
three days, each movement is again repeated, but 
oitlv once. Passive movements thus applied are 
comparatively painless, and are not followed by 
any untoward reaction, which is always an indica- 
tion for continued rest. 

At the end of two weeks the part may be moved 
two or three inches and fixed in that position. Ten 
days later the position may again be changed to 
that of the first position; and not till the end of 
three weeks should passive movements be begun, 
and then but one movement in each direction — in 
the knee, flexion, and extension ; in the elbow, supi- 
nation, and pronation, partial extension and flexion. 
.\otliing but good may be said for early and gentle 
massage, if skilfully applied and not combined with 
passive movements. 



A Method of pLUOROScoric Loc.vlization. 

Say, for example, that the foreign body is in the 
arm. If possible the arm is moved till the foreign 
body presents itself at the highest point — that is, 
nearest to tlie surface. If the i:iart cannot be moved 
the tube is moved to obtain this information. When 
this highest point is determined, a metal pointer is 
pressed gently over the part, and presently an area 
is discovered when on pressure the foreign body 
will move. This s])ot indicates the nearest route 
to the foreign substance, and the depth can be easily 
estimated, a pencil mark made on the skin, and the 
necessary data given to the surgeon. — IIekschel 
Harris in the British Medical Journal. 



INFECTED COMPOUND FRACTURE OF 
THE FEMUR INTO THE KXEE JOINT. 
TREATMENT BY CONSERVA- 
TIVE SURGERY. 
Howard Liliexthal, M.D., F.A.C.S., 

Attending Surgeon to Mt. Sinai Hospital; X'isitin^ Sur- 
geon to Bellcvue Hospital. 
Xew York. 



The following remarkable case illustrates the im- 
portance of conservative operative methods. It 
also shows what astonishing powers of recuperation 
are possessed by children. The feeble resistance 
of the child to shock and the quick recovery from 
the most extensive traumatism, once the initial 
shock is past, are phenomena which have often been 
brought to my notice. 

On April 9, 1913, Annie B., a child of six, was 
admitted to Bellevue Flospital. Six weeks before 
she had sustained an open fracture of the femur 
into the left knee and for a time she had been 
treated in a hospital. The parents, however, in- 
advisedly took her home and the case was fright- 
fully neglected. 

The condition of this patient on admission to the 
hospital was so wretched that it seemed that re- 
covery were hardly possible. In addition to profuse 
suppuration in and about the left knee, complicating 
a fracture of the internal condyle of the femur, 
there was extensive pocketing down the leg and up 
the thigh. There were deep ulcerations upon both 
feet, especially on the dorsal surfaces, and a large 
bed-sore over the sacrum. The child was emaciated 
to the last degree and the eyes had the peculiar 
glazed appearance of a moribund person. The con- 
dition of the left knee in particular was so dreadful 
that the question of immediate amputation as a life- 
saving measure was seriously considered. How- 
ever, I decided to make one attempt to save the 
limb, and at my request Dr. Edwin Beer performed 
the operation devised a number of years ago at the 
Mayo clinic. 

This operation consists in severing, through an 
anterior transverse incision, all the soft tissues ex- 
cept a posterior flap in which run the main vessels 
and the ner\'e supply of the leg. The procedure 
afi^ords in fact much the same advantage that might 
be derived from amputation and yet the member is 
left dangling by this important though narrow 
jiiece of tissue until the wide drainage thus obtained 
shall have relieved tlie se])sis. After this incision 
has been made the limb is put up at a right angle, 
the huge gaping wound into the knee joint present- 
ing anteriorly and being treated by packing. All 
the recesses of the joint are thus fully exposed. 

.At this operation the loose internal condyle of 
the femur was removed. The photograph (Fig. 1) 
not only illustrates the appearance of the parts at 
the site of operation, but gives an impression of the 
general condition of the patient. Although it is 
hard to believe, yet the little girl had been in even 
a more deplorable state before the operation, the 



Vol. X.MX. No. i. 



LiLiENTiiAL — Femur FRAcrrRE. 



American 
Journal ov Surgery. 



119 




fig. 1. 



picture having been taken about four weeks after- 
ward. Note the ulceration of the leg and foot and 
also of the thigh — and the right foot was almost 
as bad as the left. (See Fig. 2 showing cicatrices.) 

Very gradually the patient rallied, but it was not 
until May 22 that we felt justified in attempting to 
straighten the knee. 

In general anesthesia I operated, removing more 
than an inch of the lower end of the femur in order 
to arrive at viable bone, and scraping away the 
granulations from the upper end of the tibia. Posi- 
tion was maintained with the aid of a molded plas- 
ter of Paris posterior splint. The discharge was pro- 
fuse, necessitating many dressings ; and six weeks 
later the prognosis as to the limb and even as to 
life itself was most doubtful. An annoying diarrhea 
set in to further complicate this terrible case. 

With careful nursing through the summer and 
largely perhaps owing to the out-door treatment on 
the fire escape balcony, the patient gradually gained 
until by the middle of September she could hardly 
be recognized as the same shown in Fig. 1. There 
was naturally great shortening, but all the wounds 
except a small granulating spot had healed. There 
was some motion between the tibia and femur, but 
it was impossible to bring the bones into alignment, 
a flexion at about 160° having resulted. 

The patient was sent home at the parents' re- 
quest and remained there until winter, when she 
entered Mt. Sinai Hospital 

On December 1.5, 1913. in ether anesthesia, I 
made an incision through the anterior cicatrix be- 
tween the bones and by forcible flexion exposed 
their ends. With the chisel about one-half inch 
was removed from the lower part of the femur, 
when it was found easy to place the parts in good 
position. Fixation was secured with plaster of 
Paris bandage. Perfect healing and good ankylo- 
,sis then occurred and the child was discharged well 
on March 27, 1914, about a year after her original 



injury. She walks with the aid of a steel extension 
piece. 

In putting this case on record I feel it is but fair 




F.g. .\ 

to give full credit for the happy result to the gener- 
osity of Bellevue Hospital. For months this little 
girl was cared for b}' a special nurse and anything 
w'hich it w'as in the power of the authorities to 



120 



American 

Jol-RNAL OF SUBGERV, 



MooRHEAD — Fracture of Clavicle. 



March, 1915. 



grant was forthcoming. The members of the 
House Staff, too, deserve appreciation for the in- 
terest which they displayed and for the careful at- 
tention the case received at their hands. 
4S East Seventy-fourth Street. 



THE ABDUCTION TREATMENT OF FRAC- 
TURE OF THE CLAVICLE. 

John J. Moorhead, M.D., F.A.C.S., 
Adjunct Professor and .Adjunct Visiting Surgeon N. Y. 
Post-Graduate Medical School and Hospital ; Attend- 
ing Surgeon N. Y. Red Cross Hospital ; Assistant 
Visiting Surgeon Harlem Hospital. 

New York. 



The vast majority of fractures of the clavicle 
make an excellent functional but a very poor ana- 
tomical recovery. This outcome is so uniform that 
surgeons at the first visit are quite ready to promise 
the patient a normally acting shoulder-joint, but a 
knobbed fracture site, and this last in some cases is 
marked enough to be called a deformity and in cer- 
tain occupations may even lead to disability. 

It is quite axiomatic that poor reduction of a 
fracture means large and often excessive callus, and 
in no instance is this precept more applicable than 
in the clavicle. The clavicle also exemplifies an- 
other fracture precept, namely, that bony deformity 
or imperfect union does not necessarily mean dis- 
ability, as we know that the shoulder may act per- 
fectly despite marked overlapping, excessive callus, 
shortening or fibrous union of the clavicle. 

The essential reasons for poor alignment and the 
consequent deformity following this fracture may 
be said to depend upon (1) anatomical and (2) 
surgical grounds. 

(1) Anatomical grounds. This "S" shaped bone 
supports no weights and lends no particular contour 
to the upper chest or outer shoulder, and indeed its 
only function is to act as a spinnaker boom support 
for muscles and ligaments. Of these muscles the 
action of those at the inner end (the sterno-mastoid 
and pectorals) is balanced by others at the outer 
end (the trapezius and deltoid), and when the bone 
is broken at the usual site near the middle, these 
muscles are no longer held opposingly taut and the 
outer end of the bone fails and with it the shoulder, 
and thus the characteristic deformity occurs with 
the inner two-thirds of the clavicle overlapping the 
outer one-third, which is also pulled forward and 
inward. This then produces a very marked ana- 
tomical deformity and unless the reconstruction is 
architecturally accurate, the site of trouble will for 
a long time and perhaps forever remain noticeable. 

(2) Surgical grounds. These relate to our in- 



ability to firmly hold the parts in place during the 
process of repair, even assuming that we have been 
wholly successful in our primary adjustment of 
them. The deformity due to the fracture (having 
always in mind the typical oblique cleavage about 
two and one-half inches from the acromial end) is 
a doi'.'nward, inzvard, and fonvard tilting of the 
smaller fragment, and hence the indication for 
treatment is to lift this fragment upzvard, outward, 
and backivard; or in short, when the bone is donn 
and in, we must lift it up and out. To do this suc- 
cessfully we are often compelled to exert a great 
deal of force in elevating and pushing back the 
shoulder; and even assuming that we have been 
able to reduce the deformity and align the bone, it 
is often quite impossible to retain it by a safe and 
comfortable dressing. Stimson, nestor and author- 
ity of authorities, says that since the time of Hip- 
pocrates many sorts of retaining devices have been 
employed, but in the end all have been practically 
discarded except some sling arrangement like 
Mayor's, a Velpeau dressing, or the favorite of all, 
Sayre's adhesive plaster two-piece dressing. Stim- 
son further says: "Displacement and shortening, 
however, are the rule; only those cases apparently 
are exempt in which the line of fracture is trans- 
verse and there is no displacement at first. The 
amount of the shortening may vary from a frac- 
tion of an inch to or even over two inches, and it 
may be produced by angular displacement or by 
overriding or by both" (6th edition, p. 207). 

As stated, deformity over the fracture site, mal- 
union, or even non-union, may still coexist with a 
functionally active shoulder, and because of this, 
in the ordinary case, we make the reduction as per- 
fect as possible and apply a comfortable dressing, 
knowing in advance that we will have some deform- 
ity but little or no disability if we do not keep the 
shoulder immobilized too long. 

There are, however, some cases in which we 
strive to limit deformity either because our patient 
is a woman given to wearing a low-necked gown, or 
perhaps is a laborer who carries weights on his 
shoulder, and to whom a knob on the clavicle might 
prove disabling. In another group of comminuted, 
badly displaced fractures, or those associated with 
other injuries, it may be inadvisable to use the clas- 
sical and accepted dressings, and it is for these 
somewhat exceptional cases that I wish to present 
what I have chosen to call the "Abduction Method" 
of treatment. 

My attention was quite accidentally directed last 
.•\pril to the merits of this procedure during the 
treatment of a fracture of the upper third of the 
humerus in a chauffeur whose automobile collided 



Vol. XXIX, Xo. 3- 



Marcv — Medico-Legal Features. 



American 
Journal of Surgery. 



121 



with a tree. The arm was placed in a position of 
right angled abduction and held thus by a plaster 
of Paris spica passing over the injured shoulder. 
Later I learned from the .r-ray plates that the clav- 
icle of the same side had been also broken, and that 
the position of abduction had almost completely 
aligned the collar bone even as it had the humerus. 

Reflecting on this case, it at once became apparent 
that the essentials of treatment of fractured clavicle 
(namely, pushing the shoulder up and out) would 
be accomplished by abducting the arm to or be- 
yond a right angle, and that further pulling back 
of the abducted arm would allow easy correction 
of overlapping. Since then I have tried this method 
in some few selected cases and apparently it acts 
very well in that group in which there is comminu- 
tion or marked overlapping; or when deformity is 
likely to prove important from a social or occupa- 
tional standpoint. 

Application of the abduction dressing. The 
clothing is removed to the waist line and the patient 
is seated on a stool or low chair. An assistant 
stands behind the patient and elevates both arms to 
a right angle or beyond by grasping the elbows pre- 
viously bent to a right angle. The elbows are then 
pulled further backward until overlapping or mal- 
alignment is corrected, the shoulder being still fur- 
ther elevated if required. This position gives easy 
control of the deformity because of the leverage 
on the shoulder obtained by grasping tlie bent 
elbows, and the abduction and retraction of the 
shoulder should be sufficiently active to over-correct 
the original deformity when possible. While the 
parts are thus held, a sheet-lint or flannel bandage 
is applied from tlie wrist to the affected shoulder 
and the latter is then bandaged spica-fashion, leav- 
ing the opposite arm entirely unbandaged. The 
prominences of the elbow are suitably protected 
by cotton and a pad of the same material is placed 
in the axilla, and then plaster of Paris bandages are 
used to retain the arm in this position of abduction. 

Instead of having the patient seated during the 
abduction and retracticn, the same manipulation 
may be practiced by allowing him to rest the head 
on one table and the remainder of the body from 
the waist down on another table, thus leaving free 
the shoulders and upper chest. I have found it use- 
ful to reinforce the plaster with strips of basswood 
to maintain the bend of the elbow and the elevated 
arm ; sheet aluminum or other metallic strips would 
act equally well. 

The part of the plaster spica over the fracture 
can be cut away, when desired, to permit inspec- 
tion, and in some cases to prevent the penetration 



of a bony spicule. The spica cast remains in posi- 
tion about three weeks, and if union is not then 
firm, the same cast or another is to be used as neces- 
sary. .•\fter removal of the cast, a sling is used for 
a week and thereafter no further support is usually 
required. If joint stiffness occurs, it is to be 
treated according to the standard methods. 

In offering this procedure I recognize that it 
may seem needlessly irksome and painful to the 
patient ; but as a matter of practice we know that 
an almost identical spica is uncomplainingly worn 
in many cases of fracture of the shaft or neck of 
the humerus. It may also appear over-elaborate 
and scarcely worth the trouble, but it certainly has 
a place in a selected type of case presenting the 
peculiar features already mentioned, and in general 
it is applicable in that group of cases in which plat- 
ing; or suturing might be advisable. 



.SOME MEDICO-LEG.AL FE.ATURES OF 
FRACTURES. 

WiLLI.AM H. ]\I.\RCY, M.D., 
BUFF.^LO, N. Y. 



There are several angles from which to look at 
this question: First, fron'i the standpoint of the 
physician as applying to himself ; second, from the 
standpoint of the susceptibility of the patient : and 
third, from the standpoint of the litigant. 

First. As to the physician, the law holds that 
in taking care of a fracture he must exercise rea- 
sonable care and prudence, and it requires only that 
care and prudence measured by the average skill of 
the physicians or surgeons in the community where 
he practices. 

It is indeed prudent to have a radiograph of the 
fracture, even though it is of no aid in taking care 
of the case, for it provides a record and speaks 
for itself as to what the physician found and was 
treating. 

F)Ut radiographs are so misleading, and make 
such a false impression on those inexperienced in 
radiography that, in my opinion, they should not 
be permitted to be viewed by a jury in any trial. 
To illustrate, a perfect recoverj- after a fracture 
as far as function and usefulness of the limb or 
joint is concerned may show in a radiograph the 
bones more or less out of alignment with large 
callus formation. On the other hand, one may 
have a comminuted fracture about a joint of such 
a nature that if set with all the bones in perfect 
alignment it would make a pretty .f-ray exhibit, but 
would leave a stiff joint : whereas, sacrificing align- 
ment for the sake of function, a man would get 



122 



Joi- 



American 

SNAL OF Sl'RGERY. 



Makcv — Medico-Legal Features. 



March, 1915. 



a good recovery as far a.s function is concerned, 
and yet a radiogram of the joint would show such 
a deformity that if exhibited it would constitute 
sufficient grounds in a jury's mind to find a doctor 
guilty of malpractice, or to believe the defendant 
is suffering a permanent disability. 

Second. Susceptibility of the individual to frac- 
ture. The fracture is often important from a med- 
ico-legal point of view. l'"ractures may result spon- 
taneously, or they may be caused by falls or blows. 

Illustrating the spontaneous fracture: I was 
called to see Miss R. a year or so ago. She had 
been riding a tandem motor-cycle when Dr. S. ap- 
proached in an automobile with the lamps on his 
car unlighted and, according to the doctor's story, 
the girl jumped oft' without being hit and without 
falling, but she sustained a fracture of the left 
tibia. When I saw the case the leg was swollen, 
there was distinct crepitation, no ecchymosis, and 
no pain. I diagnosed a Charcot's fracture. I in- 
sisted upon her removing her clothing and found 
her other leg covered with syphilitic ulcers. This 
cleared up what might have been a very unpleasant 
■case for the doctor. 

The bones of the aged are more brittle than at 
any other time of life, hence it is not uncommon for 
old people to fractures from violence that would 
not cause severe injury in adult life. The bones of 
the very young are not as fragile as those of the 
aged, but they are more fragile than those of the 
adult, for it is in middle life that the bones reach 
their maximum solidity and firmness. Certain dis- 
eases, rickets, syphilis, and others, render the bones 
more fragile, and there is a peculiar condition which 
is characterized by excessive brittleness of the 
"bones and which appears to be more or less hered- 
itary. This brittleness may lead to fracture from 
a violence that would not affect a normal bone. In 
these cases it is almost impossible to determine the 
actual amount of violence used and one can demon- 
strate the brittleness only by post-mortem. 

A medical witness may be asked to determine 
whether a fracture was produced before or after 
•death. If the fracture occurred some time before 
■death, there will be effusion of blood into the tis- 
sues and other evidence of laceration of the muscles, 
and there may be signs of inflammation. Fractures 
occurring shortly before death and those occurring 
immediately after death, while the body is still 
warm, present similar cii;iracteristics. 

Fractures occurring a consideral)le time after 
death are unattended by any large amount of blood 
•effusion and are, as a rule, of no difficulty to the 
medical witness. If a person received a fracture 
•only a short time before death there may be no 
appreciable evidence that he lived after the frac- 
ture was sustained, or that the fracture ini"ht not 



have been caused after death. If there is evidence 
of some eff'ort of nature to repair the injured bone 
in the way of pouring out of blood or the beginning 
of callus formation, the injury was clearly not post- 
mortem. 

In childhood, bones unite rapidly, and late in 
life, very slowly; occasionally when a person is not 
in good physical condition repair may be very much 
delayed ; and, rarely, one meets a fracture that will 
not mend at all. 

Fractures may occur as the result of moderate 
muscular exercise and the parts most apt to suff'er 
are the tips of the elbow, patella, heel, and occa- 
sionally the upper arm, as in throwing a ball. Some- 
times a rib fractures in violent coughing. Many 
fractures of the femur have occurred from simple 
muscular work where no particular violence was 
exerted. In fractures of this nature there is no 
bruise of the skin, nor any appearance that violence 
had been inflicted. The presence of ecchymosis re- 
moves any question as to the spontaneous fracture 
of bones. 

TiiiRn. The litigant. Occasionally a cjuestion 
arises as to whether a person has ever had a frac- 
ture. Such questions arise when persons sue for 
damages long after an accident, and the same ques- 
tion arises in recent accidents where the .r-ray 
readings are falsely interpreted. 

x'\s a rule, in the old cases, the place of fracture 
can be determined by a slight projection or thick- 
ening of the bone where union has taken place, and 
often the alignment of the bones of the limb is not 
normal. It is impossible to say in these cases how 
long previously the fracture took place where there 
is nothing but the ossified callus at our disposal. 

What I want to lay especial stress upon is frac- 
ture and deformity as interpreted by the .r-rav in 
cases in litigation by physicians who have not had 
a wide experience in .I'-ray work. In such cases 
there may be pointed out to a jury, or gotten into 
the records that a certain fracture or deformity 
exists when in reality no fracture or deformity is 
present. Consider, for example, an individual with 
a saddle back. Take an antero-posterior radio- 
graph and there will be on the plate what appears 
to be the bodies of some of the vertebrae separated 
more than the others, the s])inous processes being 
brought closer together than anteriorly — which 
could be interpreted, oft'-hand, by some phvsicians, 
as a compressed fracture of the si)inc witli no cord 
sym])toms. 

Flex the legs of the same indiviilual, bringing 
his knees up, raise his shoulders and take the arch 
out of his back, ;md bring the curve of his back 



Vol. XXIX. No. 3. 



Marcv — Medico-Legal Features. 



American 
Journal o¥ Surgery. 



123 



down on the plate and the .v-ray picture then will 
show that the spaces are equal, and the bodies are 
equal, and that what was interpreted in the other 
plate as a compression fracture, did not exist. 

In a radiograph of a normal spine with gas in 
the bowel in front of the vertebne, one notes a hazy 
effect on the plate about the vertebra; that might 
be interpreted as a spondylitis; in a radiograph of 
the same spine under different conditions and at 
different times this hazy effect is all cleared up and 
the picture is a normal one. 

Occupational effects on the spine are at times mis- 
leading, e. g., in a blacksmith the bodies on one 
side are narrower, with increased density. 

Where the deep psoas muscle crosses the trans- 
verse process of the vertebrae it often leaves a line 
that is interpreted as a fracture of the transverse 
process. Likewise, in a large individual the crease 
or fold at the groin may throw a line on the plate 
across the vertebrje that will be read as a fracture. 
But when a transverse process is fractured it is al- 
ways out of alignment on account of muscle pull. 

Where the intercostal groove in the rib runs up 
to the facet it makes a line that looks like a frac- 
ture, but in almost all rib fractures there is callus, 
and the distal end is out of alignment. Again, one 
often finds that ossification in the costal cartilages 
that produces an irregularity in the picture that is 
sometimes mistaken for a fracture. 

In the skull the minengeal blood vessel grooves 
are all too often interpreted as fractures. 

In an antero-posterior radiograph of the hip there 
is often foreshortening of the neck of the femur 
and some might interpret this as an impacted frac- 
ture of the neck, judging by the radiograph ; a radio- 
graph made with the rays striking at right angles 
will show there is no shortening of the neck of the 
femur. 

Quite similarly a radiograph of the foot, taken 
antero-posteriorly, can produce a picture showing 
the tarsal bones separated on the big-toe side, and 
crowded together toward the little toe. I have 
often seen this described as a deformity due to in- 
jury. 

.■\bout two years ago Dr. Goldthwaite read a 
paper in Buffalo touching particularly upon injury 
to the sacro-iliac joint. Following his visit to Buf- 
falo it was my privilege to be called into no less 
than twelve consecutive cases that were in litigation, 
the plaintiff" claiming to be suffering from a separa- 
tion of the sacro-iliac joint due to trauma. 

The first case was that of Miss M., who had been 
in a head-on collision of cars. It was claimed she 
suffered a large hematoma and discoloration over 
the sacrum, a separation of the sacro-iliac joint. 



and hemorrhage into the cord, and that she had 
been bed-ridden for two years. The case was pre- 
sented to me by the defense, who claimed they had 
sixty witnesses who would swear that the girl was 
not iut or injured in the back; but the defense was 
confronted by the fact that the girl had a large 
discoloration over the sacrum and a radiograph 
showed a sacro-iliac joint separation. With the 
history of the defense that the girl received no in- 
jury over the sacrum, I suggested that the discolora- 
tion miglit be the blue edema of hysteria, called 
by some the angio-neurotic edema of hysteria ; and 
that the separation of the sacro-iliac joint might be 
an "illusion picture" taken of the joint at an angle. 

As the plaintiff would settle only for a very large 
sum out of all reason, a jury was procured and tlie 
case proceeded to trial. 

The trial was a very spectacular one. The pa- 
tient was brought into court on a stretcher, and 
besides the regular hospital attendants, she was 
escorted by a fan brigade, an ammonia brigade and 
a hypodermic brigade. She was taken to the wit- 
ness stand on a wheeled cot. But one question 
was asked her, viz., "XMiat is your name?" She 
immediately went into a faint and all the brigades 
"got busy" with their specialty, and after a demon- 
stration of from ten to fifteen minutes before the 
jun,-. without arousing the patient, they all filed out 
of court as they had come in with the patient. It 
was arranged that the plaintiff's deposition should 
be taken at her home and I was appointed by the 
Court to be present. 

At home she answered questions freelv, and dur- 
ing her cross-examination the most typical black 
and blue mark appeared upon her face and remained 
there about one-half hour before it disappeared. 

The plaintift"s physicians evidently did not know 
the theory upon which the defendant proceeded, 
and their six or eight doctors varied in their de- 
scription of the black and blue area ; but the plain- 
tiff's attorney, from the testimony of the last wit- 
ness, who was a sister, suspected our theory, as she 
seemed to be able to describe tlie black and blue 
area as most typical of that found after trauma ; 
she evidently wished to make a good witness for the 
plaintiff', and upon being asked by the defense how 
long the black and blue area had remained after 
the accident, she replied "one year." 

We also procured half a dozen normal cases of 
about the same build as the plaintiff' and took radio- 
graphs of the sacro-iliac joint by tipping the pelvis 
and taking it at an angle, and we had plates that 
appeared almost identical with that of the plaintiff. 
These plates were presented to the jury, also the 
theory of blue edema of hysteria as explaining the 
discoloration over the sacnnn, and I might sav these 
exhibits had something to do with the plaintiff re- 
ceiving nothing at the hands of the jury. 

.Another case I might relate of so-called separa- 
tion of the sacro-iliac joint with rarefaction of the 
bone or softening close to the joint ; this was a nor- 
mal joint, but a cathartic had not cleared out an ac- 
cumulation in the bowel that reflected on the plate, 
and the joint was radiographed at an angle. 



124 



Amkrilan 
Journal m- Surgery. 



Editorials. 



March, 1915. 



Amprtran diuurnal nf ^urgrrg 

SURGERY PUBLISHING CO. 

J. MacDONALD, Jr.. M. P., President and Treasurer 
92 William St., N. Y., U. S. A. 

to whom all conirmmications intended for the Editor, original 

articles, bouks for review, exchanges, business letters 

and subscriptions should be addressed. 

SUBSCRIPTION PRICE, ONE DOLLAR 
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Original Articles and Clinical Reports are solicited for publica- 
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CHANCE OF ADDRESS. Subscribers changing their addresses 
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tCT- SPECIAL NOTICE TO SUBSCRIBERS "a 
The "American Journal of Surgery" is never sent 
to any subscriber except upon a definite written order. 
Present and prospective readers please note this. 

WALTER M. BRICKNER, M.D., Editor 

New York, M.^RCH, 1915. 

OUR DECENNIAL. 

With this issue the Americ.\n Journal of Sur- 
gery conipleles ten years of publication under its 
present editorial direction, literary and managerial. 
In this decade The Journal has steadily developed 
in circulation, in influence, in the value of its con- 
tril)uted articles. 

The plan of The Jour.n'al, formulated in 1905, 
has. been modified only by the addition, several 
years ago, of the unique Department of Surgical 
Sociology, which has been conducted by Dr. Ira S. 
Wile, whose accomplishments in social medicine are 
well known. We believe that this original and 
stimulating de])artment has been enjoyed by our 
readers. i\t any rate, like Surgical Suggestions, u 
has been widely cjuoted. A feature, but lately add- 
ed, is the Quarterly Supplement of .Anesthesia and 
Analgesia, edited by Dr. V. Moeffer McMechan, in 
which our readers will find all that is best and most 
modern in this l)ranili of surgery. 

The other associate editors and the assistant ed- 
itor. Dr. Erwin Reissman, have also been connected 
with The Journal for a long time, and all have 
served it faithfully. Of these. Dr. Eli Moschcowitz 
has been on The Journal staff throughout the ten 
years. A trained pathologist and .a thoughtful clini- 
cian, broad-visioned in medicine and broad in all 
the interests that make for culture, he has brought 
his intellectual qualities, his medical foresight and 
criti(|ue to the loyal and enthusiastic su[)port of 
The Journal in various editorial departments. 



In addition to the many shorter contributions, 
FiiE Journal has published 'several serial articles 
Dii practical surgical subjects that have subsequently 
been printed in book form. In addition to One 
Thousand Surgical Suggestions, reprinted from an 
editorial column, these books have been : Paraffin 
in Surgery, by Wm. H. Luckett and Franz Horn; 
Plaster of Paris and How to Use It, by Martin W. 
Ware ; Blood Examinations in Surgical Diagnosis, 
by Ira S. Wile ; Practical Poii.cs in Anesthesia, and 
Guiding Principles in Surgical Practice, by Freder- 
ick-Emil Neef ; Surgical Operations with Local 
Anesthesia, by .\rthur E. Hertzler ; and Diseases 
of the Bones and Joints, by Leonard W. Ely. Rich- 
ard Hall Johnston's interesting articles on Straight 
Direct Laryngo-, Broncho- and Esophagoscopy 
have recently been completed. 

In our "Salutatory" in 1905, we said: "It is the 
intention of the editor to conduct a high class jotir- 
nal of practical surgery. . . . Beyond that aim 
he has no 'editorial policy' to announce — no foibles 
to foist, no quarrels to pursue.'' On this, our tenth 
birthday, we repeat these peaceful declarations. — 
W. M. B. 



FRACTURES. 



Until the birth of asepsis made possible the de- 
velopment of abdominal (and, later, thoracic and 
intracranial) operations, surgery concerned itself 
chiefly with the extremities. Now th.it the path- 
ology of most surgical visceral lesions has been 
learned and their treatment fairly standardized, 
surgical thought, seeking new realms to conquer, 
reverts to the still undeveloped field that concerns 
the bones and joints — whose pathology and repair 
still present so many problems of whii'h we have 
but scratched the surface. Touching on almost 
every aspect of these problems is the treatment of 
fractures in its various phases — reduction, restora- 
tion of functioiL non-union, repair. So thoroug'^.ly 
are these considerations based on the physiology 
and pathology of the skeletal structin-es, that the 
study of fractures must, of necessity, be a funda- 
mental part of the surgical investigation into the 
management of the aiifections of these tissues in 
general. 

The economic aspect of fractures has been de- 
manding increasing attention. It has, indeed, com- 
[iclled a study of our fracture results from a new 
viewpoint — their measurement in broad terms of 
restored economic efficiency. Wile's statistical 
])rescntation in our last "fracture number," and the 
data published by Walker in The Journal, De- 



Vol. XXIX, No. 3. 



Editorials and Surgical Suggestions 



American 

Journal of Surgery. 



125 



ceniber, 1914, frayiiientary thougli they arc, aft'ord 
some inkling of the heavy burden upon the com- 
munity at hirge, upon industrial workers in partic- 
ular, that is imposed by loss of function after frac- 
tures; while Cotton's article in this issue of The 
JouRXAL reminds us that we have not gathered 
sufficient data concerning ultimate results in that 
particularly crippling and hard-to-manage injury, 
fracture of the neck of the femur. 

In recent years the etTorts to secure adequate re- 
duction and fixation have evolved traction apparatus 
such as those of Lemon and Downey, semi-operative 
traction methods (Steinmann, Codivilla), and va- 
rious operative procedures — by the employment of 
external clamps and screws (Lambret, Lambotte 
Hachenbruch, Lilienthal), and by concealed plates 
and bone splints (Lane, Albee, Murphy). 

Of the operative methods of fixation. Lane's has 
had the widest trial. It is still having "its day in 
court," and there are indications that the final ver- 
dict will not be altogether favorable. The number 
of cases, operated upon by good surgeons, in which 
the metal plate has caused trouble and had to be 
removed, is altogether too large. In his latest ar- 
ticle, published in this issue of The Journal, Lane 
repeats that this is always the fault of the operator. 
Perhaps this is true, but we incline to the belief 
that the blame must also be borne in part by the 
physiolog}' of the tissues. 

In what percentage of cases operated upon by 
men who have competently followed Lane's technic 
throughout have the plates maintained fixation, se- 
cured union, and remained unirritatingly in situ? 
Moreover, if experienced surgeons generally have 
failed to master Lane's technical details, is his 
method an acceptable one for so common and wide- 
spread a condition as fractures? 

Various men have observed that the use of Lane's 
plates delays union. We pointed out last year that 
metal plates and screws thus applied to the bone 
can, independent of other factors, prei'erit union. 
The non-employment of a plaster cast and the early 
assumption of active and passive movements and 
massage no doubt help bone formation, but the fail- 
ure to follow this post-operative plan will not lift 
from the Lane plate the great objection that it is 
an inhibitant of osteogenesis. Its employment is 
therefore unphysiological and should, we believe, 
be limited to those cases in which less rigid splint- 
ing cannot be relied upon. In all other cases we 
would prefer the inlaid bone-graft-splint, or the 
simple non-splinting bone graft, both of which op- 
erate on, and not in defiance of, physiological prin- 
ciples— W. M. B. 



LETTER TO EDITOR. 

London, Eng., January 15, 1915. 
Editor, .ViMKRicAN Journal of Surgery : 

In your editorial on Association in October is- 
sue you are sceptical concerning Professor Crile's 
explanation of post-operative pneumonia. May 1 
point out that it was shown by Dr. William Pasteur, 
physician to the Middlesex Ilospital, in an oration 
published in the (London) Lancet, May 20, 1911, 
that post-operative pulmonary complications are to 
a great extent due to inhibition of the diapliragm 
following operations in its region — this leading to 
massive pulmonary collapse, a condition that may 
go on to broncho-pneumonia if infective material 
be present. Hence the site of operation is a very 
important factor. Of course, one must not forget 
other predisposing and exciting causes, such as pre- 
vious disease, overtight bandages, etc., but these are 
probably far less important than was formerly sup- 
posed. 

In The Lancet, October 25, 1913, I suggested 
that reflex inhibition of the diaphragm may also 
partly account for the nausea, flatulence and vomit- 
ing which are so much more common after opera- 
tions on the kidney than after those on some other 
abdominal organs, especially the uterus. 
Yours faithfully, 
J. D. AIortimer, M.B., F.R.C.S. 



Surgical Suggestions 



W'ire sutures are unnecessary and undesirable in 
operating upon the fractured patella or olecranon. 
Kangaroo tendon, which is slowdv absorbed, is 



strong enough. 



After injur}- to an extremity localized tenderness 
or extensive ecchymosis is each sufficiently sug- 
gestive of a fracture to make an .r-ray examination 
desirable, even though all other signs are absent. 



In cases of fracture of the base of the skull, oper- 
ation is not indicated unless the cerebral symptoms 
are persistent or progressive. 



A "pathological fracture" is usually due to a bone 
tumor (sarcoma, carcinoma, myeloma), cyst or 
gumma. An expert interpretation of a radiograph 
will best sen-e to distinguish these. The Wasser- 
mann reaction,- it must be remembered, is some- 
times negative in tertiary syphilis. 



It is worth remembering that abduction is of 
great value in the prevention and in the treatment 
of stiffness of the shoulder after trauma. 



126 



American 

Journal of Surgery. 



Surgical Sociology. 



March, 1915v. 



Surgical Sociology 

Ira S. Wile, M. D., Department Editor. 



SOME SOCIAL PHASES OF FRACTURES. 

Within the domain of surgery, few conditions in- 
volve greater responsibilities for the surgeon than 
fractures. Prognosis is involved with greater diffi- 
culty than in most conditions requiring surgical 
treatment. From the standpoint of social results, 
fractures involve greater hazards than amputations. 
As a result of fracture the various tissues of the 
limb are so injured as to render the problem of earn- 
ing a living by muscular labor a serious one. 

The e.x[)ansion of systems of workmen's compen- 
sation makes an understanding of the hazards of 
fractures a pertinent subject for investigation. The 
question of the liability of fracture in occupation is 
heightened among workers sufifering from some spe- 
cific disease or among those who, because of under- 
feeding, are much below par. The predisposing 
causes influencing fracture may not be of immense 
importance in connection with compensation itself, 
but it is certainly true that insofar as employers" 
liability is concerned, previous disease of the bones 
should be considered in connection with the after- 
eflfects of a fracture. The association of sarcoma, 
previous osteomyelitis, and osteomalacia afford ex- 
cellent examples wherein technical difficulties may 
arise in connection with the determination of com- 
pensation for fractures among industrial workers. 

With all varieties of fractures, the particular dif- 
ficulty lies in foretelling the state of union which 
may be secured. The processes of healing in bones 
are slow in action ; and permanent and sound union 
of fragments may not occur until several months 
after the injury. Tlie more severe the labor of the 
worker, the greater the delay before he is physically 
fit to return to his occupation. What represents 
sound union for one individual is not necessarily 
adequate for another. It is not possible to lay down 
a rule as to when a victim of a fracture of the arm, 
for example, should be able to return to his occupa- 
tion. Each fracture case must be judged on it.:i 
merits. Even though artificial means, such as 
wiring and plating, are employed, it is a serious mat- 
ter to determine when it is absolutely safe for the 
resumption of strenuous employment. Non-union 
fractures, delayed union, mal-union, complicate the 
social difficulties resulting from fractures. 

The economic losses incident to fractures are not 
merely the wage loss because of inability to be at 
work. The thrifty and financially able voluntarily 
assume the burden of accident insurance in order to 
protect themselves from economic losses due to in- 
jury. The pur|)0se of this insnnmce, however, is to 
prevent the occurrence of the social losses that 
might accrue where there is no money available. 

It is unfortunate to state that fractures among 
the poor increase their poverty. It is incontroverti- 
ble that the individual temporarily disabled by a 
fracture is an economic burden upon the household, 
a food consumer, a virtual source of increased eco- 



nomic distress because of the care which must be 
lavished upon him. The expenditures for hospital 
service, radiographs, and dressings form a severe 
ta.x upon the slender savings, if any exist, and tend 
to lower (he vitality of members of the household 
because of their deprivation from the ordinary food 
and clothing which they otherwise would be able to 
secure. In fact, for the time being the injured vic- 
tim is a greater drain upon the family than he would 
be if suddenly killed. 

The difficulties of estimating the degree of dis- 
ability have long been recognized. In Denmark,, 
however, the principle of grading degrees of 
impainnent in accident cases obtains, and 
total disability is paid for in terms of the 
degree of impairment that resulted from the 
accident. From the report of 1906, in all 
their accident cases only 15.6 per cent, presented 
more than 25 per cent, of total disability. Inas- 
much as this return covered industrial accidents of 
all types, it is fair to assume for the moment that 
similar figures may apply with reference to the de- 
grees of impairment in fracture cases. To grant 
that 25 per cent, of total disability may result from 
a fracture may mean that the patient is obliged tO' 
change his occupation, accept a lower wage or ac- 
tually be thrown among the unemployed or unem- 
ployable. 

There is another phase of fractures which is also 
of serious importance. Regardless of the fact that 
the social responsibility upon a surgeon is more 
weighty in the case of fractures than among many 
other conditions, the rate of compensation for sur- 
geons for attendance upon patients suffering with 
fractures has not been carefully defined in many of 
the workmen's compensation acts. For example, 
in the fee bill of the New York State Workmen's 
Compensation Commission, which has been ap- 
proved by the Medical Society of the State of New 
York, we find that the rate for the treatment of a 
fracture of the femur is twenty dollars, while ampu- 
tation of a finger or toe is compensated at the rate 
of fifteen dollars. The treatment of a fracture of 
the spine, with all its responsibilities, is compen- 
sated at the rate of thirty dollars, while tracheotomy 
is to be compensated at the rate of forty dollars. 
The principal distinction made in the compensation 
rate is that compound fractures shall receive 25 per 
cent, extra, while operatings for wiring and plating 
of bones shall be compensated with 50 per cent, 
extra. 

As a whole, the fee bill is excellent, though the 
fees do not indicate any particular relation to the 
responsibilities of the surgeon nor indeed to the 
social significance of the injuries for which com- 
pensation is made. Fractures of the forearm or 
upper arm extending into the elbow, even though 
not compound, are more serious than many other 
types of fractures and special rate of compensation 
for a fracture of this type would be entirely within 
the bounds of logic and reason. 

It is not fair, however, to criticize at this time 
the compensation rates as laid down by the New 
York law. They have been approved by the Med- 
ical Society of the state, which it is fair to presume 



Vol. XXIX, No. 3. 



Progress in Surgery. 



American 
Journal of Surgery. 



127 



carefully considered the economic aspects of the 
problem insofar as it relates to the surgeons. The 
workmen's compensation law itself gives careful 
consideration to the social needs of the workers and 
it is fair to assume that imder the workings of the 
new enactment, fracture cases will be properly cared 
for from the standpoint of the surgeon, the patient, 
the family, and the community. It is to be hoped, 
however, that in future reports, the arrangements 
of statistics will be such as to give us a wider knowl- 
edge regarding the relation of fractures to social 
efficiencv as well as to its economic cost to the state. 



Progress in Surgery 

A Resume of Recent Literature. 



Modem Bone and Joint Surgery. Astley P. C. Ash- 
hurst, Philadelphia. -Vt-;i- York Medical Journal, 
January 30, 1915. 

The perfection of asepsis has changed greatly the pres- 
ent treatment of fractures and of ankylosis and made 
possible modern methods of bone transplantation. 

The interest in the treatment of fractures has been 
quickened largely by the wide usefulness of the .r-rays. 
With their aid better anatomical diagnosis is possible and 
better and more accurate reduction, though accurate ana- 
tomical reduction of a fracture in the shaft of a long 
bone, for instance, is not always necessary to secure per- 
fect functional recovery. Such a result is, however, de- 
sirable in fractures of the lower extremity where dis- 
placement and shortening are not so readily compensated 
for as in the arm or forearm; in fractures near joints 
accurate reduction is imperative. Reduction frequently 
is accomplished by manipulation ; when required, open 
operation should be performed. In old fractures resec- 
tion of the fractured bones with plating may be called for. 

For the treatment of ankylosis the old classic procedure 
of excision is often replaced by arthroplasty, i. e., inter- 
position of fat or fascia flaps. This allows much greater 
stability at the elbow and shoulder and even a fair amount 
of mobility at the hip and knee. The function of the 

Sknee after arthroplasty is of striking value, especially 
when compared with the rigidity following excision. 
Arthroplasty is, however, a difficult operation and not 
always a successful one. 

Bone transplantation finds its greatest indication in un- 
united fractures. It is used to fix the spine in vertebral 
tuberculosis, and after excision of a bone tumor, inserting 
a transplant may be the only method to maintain the form 
and function of a limb. 

In addition, modern surgery offers arthrotomy and reef- 
ing of the capsule for irreducible dislocations, e.xcision of 
the diaphysis for osteomyelitis and orthrodesis — ankylosis 
for paralytic flail joints. 

The Use of Indirect or External Fixation in the Open 
Treatment of Fractures. E. P. Qu.mx, Bismarck, 
S. D. The Journal-Lancet, January 1, 1915. 

The author contrasts the use of bone-plates with that 
of external fixation in the open treatment of fractures 
and believes that the latter is the method usually to be 
preferred. He says : "The purpose of this paper is not 
to condemn bone-plating when sufficiently indicated and 
properly performed, but. rather, to dignify it, and to extol 
it to the highest plane in surgery, where it should be ap- 
proached only by the cleanest of hands, conscience and 
specialization." He quotes the work of Groves, Lambotte 
and Freeman, all of whom advise various types of appa- 
ratus which indirectly hold the fractured bones in apposi- 
tion. After reduction the author advises small incisions 
about two inches from the fracture, blunt dissection down 
to the bone, insertion of a screw into each fragment, and 



the maintenance of apposition by external clamps. The 
screws are left in place from two to live weeks. 

The method is comparatively easy aiid rapidly applied, 
permitting a surgeon of good operative judgment and 
technic, but lacking extensive experience in bone surgery, 
to operate with reasonable safety and success and with a 
minimum destruction of bone elements. The fixation is 
firm and permits early movement of neighboring joints. 
There is no metal in contact with the fracture line. The 
screws arc entirely removable, leaving no foreign body 
behind. In compound fractures it holds the fragments in 
lilace, aids drainage, and makes dressings convenient and 
painless. 

Transplantation of Bone in Ununited Fractures, M. S. 

Henderso.v, Rochester, Minn. The Journal-Lancet, 
December 1, 1914. 

A consideration of 32 cases of delayed union in the long 
bones, treated by means of bone transplantation, shows 
that the method is an excellent one. In only five cases 
were the results unsuccessful, the remaining twenty-seven 
doing extremely well. Transplantation of bone is prefer- 
able to the metal plate in treatment of cases of non-union, 
with the probable exception of the femur. Clinical and 
radiographic studies tend to show that the hard cortical 
bone used as an intramedullary plug is slowly absorbed, 
and does not persist as a permanent splint. In its absorp- 
tion it promotes osteogenesis. Absolute fixation is to be 
maintained, particularly in the humerus, where a trans- 
plant is used. The inlay method is the method of choice 
where possible, for by it an anatomical approximation of 
tissues is allowed — periosteum to periosteum, cortex to 
cortex, medulla to medulla. Hard bone placed in the 
spongy bones in the epiphyses is gradually absorbed to 
be replaced by bone normal to that area. 

Fractures of the Neck of the Femur: Its Treatment 

John- B. Walker, New York. The \e-w York State 
Medical Journal. December, 1914. 

A careful study of 112 cases of fracture of the neck of 
the femur leads Walker to the following conclusions : 

1. Fracture of the neck of the femur occurs under fifty 
years of age more frequently than was formerly believed. 

2. Any injury to the hip followed by disability should 
suggest the possibility of a fracture of the neck, and 
requires an expert examination aided by an r-ray photo- 
graph. 

3. Reduction of the deformity with complete immobili- 
zation of the fracture during the period of repair by 
means of a plaster spica bandage is advised in all suitable 
cases. 

4. This is to be followed by early gymnastic movements, 
active rather than passive. 

5. .A.11 weight-bearing upon the fracture is to be avoided 
for from four to six months ; in some cases even longer. 

Fracture of the Elbow in Childhood. Willi.am Fran- 
cis Campbell, Brooklyn. The Medical Times, Febru- 
ary, 1915. 

In the fracture of a long bone a slight discrepancy of 
the fragments is compatible with perfect functional result. 
But in fracture of the elbow even slight abnormal promi- 
nence in the interior of the joint will be an obstacle to 
normal joint movements, and may be the cause of perma- 
nent disability. 

It is obvious that reduction here is something more than 
the reposition of fragments; it implies a coaptation so 
accurate and a retention so complete that the resulting 
joint surfaces will permit of normal joint movements. 

If the fragments be accurately reduced and held in this 
position the question of duration of immobilization and 
the special position in which the limb should be placed 
are secondary considerations. 

The fundamental fact must be appreciated that it is not 
the duration of the immobilization that produces anky- 
losis, it is the faulty reduction causing periosteal prolifer- 
ation that locks the joint; and further, no special position 
of the arm will obviate the disastrous results of an incom- 



128 



American 
joubnal of subcery. 



Progress in Surgery. 



March, 1915. 



plete reduction. The general rule to be followed in all 
cases of fractured elbozv is — accurate reduction maintained 
by that splint and that position of the arm ivhich is best 
suited to the special indications of the indizndual case. 

Each fracture is a special problem, with its individual 
needs and its peculiar indications; and while no precise 
rules can be formulated, certain precepts may be followed 
which will be a sale guide in all cases. 

Find out exactly just what is fractured and be satisfied 
with nothing hut anatomical accuracy. 

A clinical e.xamination under anesthesia is the first 
requisite; but it is never sufficient; it rnust be supple- 
mented by an .I'-ray examination. Two radiographs should 
be made,' one profile, and one surface view. The x-ray 
picture without proper interpretation is futile. 

Reduce the fracture by such maneuvers as are efficient 
in accurately coapting the fragments (flexion, extension, 
traction, direct pressure, etc.). Care should be taken to 
avoid any rough manipulations. 

Immobilize permanently only ivhen assured that reduc- 
tion has been obtained, and that the position of the arm 
and the splint selected are adequate to maintain reduction. 

This will be evidenced by (a) normal conformation of 
the parts; (b) a normal range of flexion and extension. 
But best of all is confirmation furnished by a second 
radiograph. 

Osteitis Fibrosa with Report of a Case. James \'.\n 
ZwALUWENBURG, Ann Arbor, Mich. The Journal of 
the Michigan State Medical Society, January, 1915. 

The author describes a boy, 14 years old, complaining of 
deep-seated pain in the hips. With this there developed 
a peculiar waddling gait and a deformity causing a for- 
ward and outward bending of the femora and an apparent 
shortening. The boy met with an accident, supposed to 
be a fracture, and the .;'-rays thereupon taken were inter- 
preted as those of a case of osteitis fibrosa. 

The radiograms revealed sharply circumscribed areas of 
diminished opacity usually longitudinally striated, but 
without involvement of the periosteum or the formation 
of distinct bony shells about them. The diaphyses of the 
long bones of the lower extremity are the sites of election. 

From inflammatory diseases of bone, viz. : osteomyelitis, 
tuberculosis and syphilis, it is distinguished by the ab- 
sence of any evidence of secondary reaction in the neigh- 
boring tissue. From rickets it is distinguished by the 
absence of the characteristic changes in the epiphyses. 
Multiple metastatic sarcoma may give very similar pic- 
tures, but the striations are aljsent. Sarcomata rarely 
occur as multiple lesions, show an early tendency toward 
rupture through the bony corte.x, and frequently show 
bony spicules as slender striations radially arranged from 
the point of primary growth. 

To the uninitiated the condition presents many difficul- 
ties, and many cases have been subjected to cur.'ttago 
under the suspicion of an osteomyelitis or have undergone 
amputation for sarcoma. 

Mechanical Treatment of Compound and Suppurating 
Fractures Occurring at the Seat of War. R. Jones, 
Liverpool. British .Uri/iru/ .Imirnal, January 16, 
1915. 

Jones believes that operative methfids are out of the 
question in gunshot fractures. He also decries the use 
of plaster of Paris. It mops up discharges like blotting 
paper, becomes very offensive and adds to the already 
existing infection. The author describes in detail his 
methods for the most connnon forms of fractures. He is 
very partial to mechanical splints of various kinds. For 
the femur he advocates a modification of the old Thomas 
splint. Fractures of the humerus, however, require no 
splints. The elbow is merely slung at right angles and 
fixed by a broad bandage to the side. Where ankylosis 
is expected after a bad smash and suppuration of the 
shoulder, the arm should be kept abducted slightly for- 
ward and slightly rotated inwards. Jones warns against 
the removal of loose pieces of bone through the wound. 
If quite loose they can be taken out, cleaned, and re- 
placed. Even in the presence of jnis they may unite. 



Complete Fracture of the Lower Third of the Radius, 
in Childhood, with Greenstick Fracture of the 
Ulna. Pe.n'n G. Skillern, Jr., Philadelphia. Annals 
of Surgery, February, 1915. 
Skillern states that in childhood a comiplete fracture of 
the radius with incomplete greenstick fracture of the ulna 
in the lower thirds of their shaft represejits as distinct a 
variety of fracture involving both bones as is present in 
the mechanism and characteristics of the better known 
and differentiated entity, Colles' fracture. The cause of 
this newly described type of fracture is quite constantly 
a fall while in motion, off of skates or a bicycle. In the 
resulting deformity the lower fragment of the radius is 
displaced to the dorsum and laterally, the ulna is bent 
with its concavity toward the radius, the radial portion 
of the fibers of the ulna at the site of fracture are com- 
pressed, not torn asunder, while the inner fibers are only 
separated. 

From a study of cases the author demonstrates that it 
is the intact outer fibers of the ulna, which serve to main- 
tain the position of both bones after the trauma has al- 
ready broken the inner ulnar fibers. These outer fibers, 
therefore, maintain the deformity of vicious bowing of 
the ulna. Accordingly, the ulna greenstick fracture is 
converted into a complete fracture, the inner border of the 
ulna thereupon permits of alignment, while the radial 
fragments reduce themselves spontaneously with a little 
pressure. 

The Prognosis and Conservative Treatment of Frac- 
tures, Notably End-Results. W. P C.\rr, Wash- 
ington, D. C. Tlie Virginia Medical Scmi-Monthly, 
January 22. 1915. 
Carr believes that practically all fractures of the femur 
may be successfully treated by extension with weight and 
pulley. The weight must be sufficient to overcome all 
shortening, and must be applied within eight hours after 
the fracture, thus sparing the patient much needless pain 
from the muscular contraction; furthermore, it must pull 
in the right direction to keep the bone in alignment. He 
advises the use of good quality adhesive plaster neatly ap- 
plied from the point of fracture down to the ankle and 
joined to a board to which the cord of the weight is at- 
tached. Two cautions must be observed : the heel must 
not be pressed downward to the mattress, and the board 
must not be allowed to become embedded in the folds of 
the bedclothes. To prevent the patient from slipping 
down in bed, a number of devices are available : passing 
bandages under the arms and fastening them to the head 
of the bed; having an inclined plane of boards under the 
mattress so as to get it to an angle of 30° ; the same result 
can be accomplished by having a bed with a hinge in the 
middle. A small pillow under the knee will prevent pain- 
ful sagging. The pain attendant on the application of the 
pulley should be relieved by a full dose of morphia. 

Although it is difficult to overcome shortening if the 
patient is not seen until thirty-six hours after the fracture, 
it can sometimes be done on a fracture extension table, 
under an anesthetic. 

In a transverse fracture, the rough ends of the frag- 
ments may be brought end to end, and made to interlock 
without open operation. Then the plaster cast may be 
applied from the toes to above the waist. Carr advocates 
the use of the weight and pulley for two or three weeks, 
and then uses a plaster cast, from the toes to the nipple. 

Most fractures of the humerus may be treated without 
open operation by first putting a plaster jacket around the 
chest an<l both shoulders, then around the forearm and 
elbow with the elbow at right angles and the thumb point- 
ing upward. After the hardening, reduce the fracture 
by extension and manual manipulation with the arm at 
right angles to the body. Still holding the arm at a wide 
angle to the body, fill in the gap between the plaster cast 
on the forearm and that around the shoulders. When 
this latter hardens, extension against the flexed forearm 
and counter-extension against the thoracic jacket will 
prevent all shortening and displacement. 

The only cases of fracture in which he considers opera- 
tion advisable are those of the patella, olecranon, some 
comminuted fractures about elbow and knee, fractures at 
the anatomical neck of the humerus, and in cases where 
fragments have been caught under the muscles. 



AMERICAN 

JOURNAL OF SURGERY 



Vol. XXIX. 



APRIL, 1915. 



Xo. 4. 



A REVIEW OF 114 COXSECUTRE OPERA- 

TIOXS FOR ACUTE APPEXDICITIS, 

WITHOUT MORTALITY.* 

Thew Wright, M.D., F.A.C.S., 

Surgeon to the Buffalo General Hospital. 

Buffalo, N. Y. 



The following report is based upon 114 consecu- 
tive cases operated upon by me at the Buffalo Gen- 
eral, Children's and Erie County Hospitals and in 
private homes (13 cases). The cases were all 
acute ; no interval or chronic cases being included 
in this report, as, of course, such cases should have 
no mortality. This series embraces all types of the 
acute disease and includes several of considerable 
interest. 

I have grouped them under the headings of "ca- 
tarrhal," suppurative, gangrenous, and perforative 
appendicitis, the latter consisting of those cases in 
which the gangrenous or suppurative type had rup- 
tured. Of the catarrhal type there were 57, of the 
suppurative 48, of the gangrenous 9, of the perfo- 
rative 35. 

It has been of interest to note how few of the 
cases have shown the position of the appendix to 
be that usually displayed in text-books as normal. 
Nearly all showed either a posterior position with 
regard to the caput ceci, varying from implanation 
in the retro-cecal fossa to the true retro-cecal type 
lying both retro-cecal and extraperitoneal ; or a 
short and distorted meso-appendix causing kinking 
or constriction of the appendix. This leads me to 
believe that anatomical peculiarities causing an in- 
terference with the lumen of the appendix must be 
an etiological factor of considerable importance in 
the disease. Lane's kink and the various pericolic 
membranes which we have noticed occasionally 
causing symptoms in chronic cases have been noted 
but a few times in this series, for the acute inflam- 
mation present has in the majority of cases for- 
bidden manipulations more extensive than .those 
necessary to meet the immediate indication. 

There were in this series three cases in which the 
first symptom, pain, was evidently coincident with 
perforation of the appendix and the beginning of 



•Read before the Buffalo Academy of Medicine, January 6, 1915. 



peritonitis. One was a man whose first symptom 
was sudden and severe pain in llie right lower (juad- 
rant which seized him about 10.30 A.M. I saw him 
at 3 P.M., operated at once, and found a perforation 
in the tip of the appendix and free pus. The other 
two were operated upon eight and ten hours, re- 
spectively, after the sudden pain. In both these 
cases there was a large amount of pus and in nei- 
ther case were there any adhesions. 

Pain was the initial symptom in all these cases, 
but two, both of which were children, one 5, the 
other 9, in which the attack was ushered in by vom- 
iting, which persisted for several liours before the 
onset of pain. 

In three of the suppurative but non-perforative 
type, with the disease still confined to the appendix, 
the rigidity was so marked on both sides of the 
abdomen, not even relaxing under anesthesia, that 
a perforation was suspected. 

Two of this series were in pregnant women, one 
five, the other seven months pregnant. Both 
aborted. The one pregnant five months had been 
sick four days and had an appendix with a short 
mesentery imbedded in the retro-cecal fossa. The 
other had a perforated purulent appendix adherent 
to the fundus of the uterus near the umbilicus, and 
had been sick three days. 

One case was a woman weighing 270 pounds, 
with a ruptured empyema of the appendix in the 
third day of the disease. Two weeks following 
operation she developed an acute cholecystitis which 
was diagnosed but treated expectantly because of 
the proximity of the discharging well in her abdom- 
inal wall. After 24 hours the gall-bladder ruptured 
and an operation was done, evacuating a pint of 
bile and pus containing forty-odd stones. She made 
an uneventful recovery. 

I appreciate my good fortune in having so many 
cases recover, but I feel that with the increasing 
knowledge of both the profession and the laity, 
tliese statistics should, as a rule, be improved rather 
than otherwise. Even to-day we are getting too 
many cases in the advanced stages of the disease. 
As Murphy says, the mortality of appendicitis is 
that of delay, and every case of appendicitis lost 
means someone to blame. 



130 



American 

JoTRNAL OK Surgery. 



Wright — Appendicitis. 



April, 1915. 



In diagnosis 1 have come to rely upon the his- 
tory, and the fingers, /. c, palliation. JJlood counts 
were made in a numlier of this scries, but 1 am 
coming to place less value upon them, both as an 
aid in diagnosis and in determining the type of dis- 
ease: for I find tlial tliey arc unnecessary in diag- 
nosis and of little value in telling the condition pres- 
ent, several of the pus cases having normal counts 
and some of the catarrJial cases showing the high- 
est leucocytosis. 1 have usually found leucocytosis 
]iresent in my cases, but 1 have not delayed opera- 
tion on account of its alisence. 

My rule has licen to operate at the earliest pos- 
sible moment after the diagnosis was made, never 
allowing a case to wait for a more convenient time, 
for 1 have felt both unable to tell what was going 
to take ])Iace in the abdomen and often what had 
already transpired. 

1 believe that our knowledge of how to operjite 
has increased since the time when (Jchsner advised 
delay in cases over 48 hours old, and 1 hold that all 
cases should be operated upon when seen if proper 
operative and post-operative facilities are at hand. 
I ijclieve that gentleness in handling the tissues, 
avoidance of more numipulatiou th;in is absolutely 
necessary, ample drainage, plus starvation, procto- 
clysis. Fowler's positiun. and if necessarv gastric 
lavage will give a lower mortality and morbidity 
than non-interference. 

1 believe with ( )chsner that intestinal peristalsis 
is a great factnr in the sjireading of a |)eritonitis, 
and 1 allow nothing by mouth so long as a periton- 
itis e.xists. 1 drain all jjcrforated cases and all gan- 
grenous cases where there is pus. 1 do not con- 
sider the mere presence of fluid, no matter how 
much nor how turl)id, an indication for drainage. 
I ni;ike no etftirt to evacu.ite pus other than to 
sponge out that wliicji jiresents at the wound : be- 
lieving that the indication is to relieve tension ;in(l 
establisli ;i point of le.ast resistance toward the 
wound. 1 use the I'Owler, or pelvis-low position in 
all drainage cases, but I prefer to obtain it by ele- 
vating tile he;i(l of tlie l)ed rather th;ui l)y means 
of .a head-rest or ])atcut mattress, for one can thus 
be sure tii;it it is .ahviiys maintained, and 1 find it 
more comfortalijc for the patients. 

l'"or drainage 1 use the split soft rubber tube of 
one-half inch lumen, placing one tube at the ajjpen- 
di.x stum]) and, if there is ])us in the jjclvis, placing 
another tube to the bottom of the |)elvic cavit\'. I 
never irrigate. 

In dealing with a localized absces.s, I endeavor to 
wall it off, with gauze, from the general peritoneal 
cavity 1)efore evacuating, not because of the fear of 



overflow, but because of the danger of poking the 
finger among the agglutinated loops of bowel dur- 
ing the delivery of the appendix and thus allowing 
pus to leak into the general peritoneal cavity witii- 
out knowing it. 

There was but one case in this series in which it 
seemed wise merely to drain an abscess, leaving the 
removal of the appendix for a later date. Recurrent 
discomfort in the ajipendi.x region led me to operate 
upon the case ten months later when an obliterated 
stump was found, the discomfort being caused by 
an adhesion rumiing from the cecum to the right 
ovary. 

The principles of treatment have been the same 
throughout this series. The preparation consists 
of a dry shave, a coat of tincture of iodine, and a 
hypodermatic injection of morphine and sco])ola- 
minc. Operation is performed under combined local 
and general anesthesia. 1 greatly prefer nitrous 
oxide-oxygen narcosis, though a third of this series 
received ether by the drop method. The use of gas 
;md oxygen unquestionably reduces operative shock 
and materialh' aids in lessening post-operative dis- 
comfort. 

In the majority of these cases the right rectus in- 
cision was used, though the low McBurnev was 
employed in about a fourth of the cases seen early. 
I prefer the rectus incision when a large exposure is 
needed. The apjiendix is located as quickly as pos- 
sible, its mesentery is crushed and ligated in the for- 
ceps mark, the appendix is likewise crushed and 
ligated at its base and cut between the ligature and 
a forceps. In the non-perforative cases removal 
of the appendix is preceded by the passing of a 
linen purse-string suture, and tlie appendix stump 
is touched with iodine and depressed into the cecal 
wall. In the perforative cases a catgut suture is 
used. If the cecum is edematous and appears friable 
no burying of the stump is attempted. No endeavor 
to suture fat or mesentery over the stump is made 
in cases where the cecum will not hold a purse- 
string sutiue. The wound is closed in layers 
throughout or to the tubes in dniiuage cases. 

Post-operative treatment consists of l^iwlcr's po- 
sition in drainage cases: contimious proctoclysis in 
all cases, using sterile tap water in jireference to 
salt solution and adding to it tincture of ojiium in 
ten to fifteen minim doses ever\ two to four hours 
to keep the patient conifortaiile, supplementing this 
with morphine hyi)odernialicaily in the se\'ere peri- 
tonitis cases. Nothing is allowed by mouth so long 
as there is evidence of peritoneal irritation, and the 
stomach is washed out if there is .my suggestion of 
regm-gitation or gastric dilataticin or if vomiting 



Vol. XXIX, No. 4. 



Wright — Appendicitis. 



American 
Journal op Surgery. 



131 



persists. Xo cathartics are given aiul no attempt 
to move tlie bowels is made in any case for 48 hours, 
when a small enema is administered. In the severe 
cases of peritonitis 1 endeavor to keep the bowels 
absolutely at rest and I believe in the use of mor- 
phine to the amount required to keep the patient 
quiet. 

This series of successful operations was stopped 
by a case operated u{X)n within 36 hours from the 
first symptoms of the disease, a time when we 
should expect very few fatalities. He had, how- 
ever, received osteopathic treatment with a view, 
as the osteopath told me, of massaging his "pylorus" 
which he located between the umbilicus and the 
iliac rest. On operation I found a ruptured appen- 
dix and about the most extensive peritonitis that 
it has been my misfortune to see. The patient was 
overwhelmed by the toxemia and died within 18 
hours from the time of operation. 

AB.STR.\CT OF C.\SE HISTORIES. 

J. M., 20, second attack, suppurative, sick 48 
hours. 

A. H., 25, first attack, perforated, gangrenous, 
free pus, drained, sick 72 hours. 

R. S., 9, first attack, sick four days, gangrenous, 
pus, drained. 

C. B., 10, first attack, suppurative, sick 36 hours. 
T. J. G., 25, first attack catarrhal, sick 12 hours. 
J. F., 27, first attack suppurative and perforated, 

drained, sick 48 hours. 

E. \V., 18, first attack, suppurative and perfo- 
rated, drained, sick 48 hours. 

H. -A. F., 20, second attack, suppurative and per- 
forated, drained, sick 36 hours. 

-A. K., 17, second attack, catarrhal, sick 12 hours. 

J. E., 27, first attack, catarrhal, sick 12 hours. 

R. G. F., 50, first attack, gangrenous, no drain, 
sick 18 hours. 

J. N., 30, second attack, catarrhal, sick 12 hours. 

F. R., 36, first attack, suppurative, sick 18 hours. 
\\" F.. 30, first attack, gangrenous and perforated, 

drained, sick 72 hours. 

D. T., 16, third attack, catarrhal, sick 12 hours. 
M. M., 22, first attack, catarrhal, sick 18 hours. 
\\". S., 9. first attack, catarrhal, sick 12 hours. 
2vl. S., 14, suppurative, sick 18 hours. 

W. E., 40, first attack, gangrenous, no drain, sick 
36 hours. 

A. H. W., 30. first attack, gangrenous, free pus, 
2 drains, sick 3 days. 

J. C.. 10, first attack, suppurative, perforated, 
drained, sick 50 hours. 

L. F., 20. first attack, catarrhal, sick 18 hours. 

D. B., 40, second attack, gangrenous, perforated, 
drained, sick 48 hours. 

G. T., 18, first attack, suppurative, ^ick 24 hours. 

E. K., 40, first attack, catarrhal, sick 18 hours. 
M. K., 18, second attack, catarrhal, sick 12 hours. 
M. E., 18, first attack, catarrhal, sick 18 hours. 
W. H. L., 25, second attack, suppurative, perfo- 
rated, drained, sick 36 hours. 



.M. .*>., 17, first attack, catarrhal, sick 6 hours. 

R. S., 10, second attack, catarrhal, sick 6 hours. 

F. E., 25, second attack, catarrhal, sick 10 hours. 

L. P., 30, first attack, catarrhal, sick 18 hours. 

S. T., 28, first attack, suppurative, sick 36 hours. 

S. P., 30, first attack, suppurative, perforated, 
drained, sick 48 hours. 

J. R., 20, third attack, suppurative, sick 12 hours. 

M. M., 24, first attack, catarrlial. sick 48 hours. 

M. S., 30, first attack, su])i)urative, perforated, 
drained, sick 72 hours. This patient was seven 
months pregnant. 

.A. R., 27, first attack, su]>purative, perforated, 
drained, sick 36 hours. 

F. N., 33, first attack, suppurative, perforated, 
drained, sick 48 hours. This patient developed a 
suppurative cholecystitis two weeks after operation. 
Gall-bladder ruptured in 24 hours and second oper- 
ation was made. 

E. F., 31, second attack, catarrhal, sick 36 hours. 
W. \., 27, first attack, catarrhal, sick 12 hours. 
1-. G.. 18, second attack, suppurative, perforated, 

drained. This patient had first symptom of pain 
at 10.30, was operated on at 3, and appendi.x was 
found ruptured, and free pus present. 

M. D., 12, first attack, catarrhal, sick 12 hours. 

P. L., 28. first attack, catarrhal, sick 24 hours. 

F. C. G., 20, first attack, catarrhal, sick 18 hours. 
M. B., 28, first attack, catarrhal, sick 12 hours. 
H. W., 23, first attack, catarrhal, sick 12 hours. 
W. J., 30, first attack, gangrenous, perforated, 

drained, sick 48 hours. 

J. M., 30, first attack, catarrhal, sick 18 hours. 

J. T., 9, first attack, catarrhal, sick 24 hours. 

C. T., 30, second attack, catarrhal, sick 18 hours. 

W. C, 31, second attack, catarrhal, sick 18 hours. 

C. H., 11, first attack, suppurative, perforated, 
drained, sick 3 days. 

T. B., 7, first attack, suppurative, sick 36 hours. 

E. G.. 20, first attack, catarrhal, sick 24 hours. 
L. S., 20, first attack, catarrhal, sick 24 hours. 
M. P.., 20, first attack, catarrhal, sick 36 hours. 
M. R., 18. first attack, suppurative, sick 24 hours. 
C. R., 25, first attack, catarrhal, sick 18 hours. 

T. R., 9, first attack, catarrhal, sick 24 hours. 

M. M., 29, first attack, suppurative, perforated, 
drained, sick 36 hours. 

W. P., 30, first attack, suppurative, perforated, 
drained, sick 48 hours. 

J. F., 27. first attack, catarrhal, sick 36 hours. 

J. S., 20. second attack, suppurative, sick 40 
hours. 

M. \'., 27, numerous attacks, suppurative, sick 
24 hours. 

F. W'.. 35. suppurative, perforated, drained, sick 
48 hours. 

T. G., 33. second attack, suppurative perforated, 
drained, sick 48 hours. 

G. .\., 11, first attack, catarrhal, sick 18 hours. 
J. D., 22, first attack, catarrhal, sick 24 hours. 
E. W., 16, first attack, catarrhal, sick 12 hours. 
A. F. B., 23, first attack, suppurative, sick 18 

hours. 

H. R. \V., 30, several attacks, suppurative, sick 18 
hours. 



?32 



American 
Journal of Surgery. 



Ash HURST — ^Fractures of Limbs. 



April, 1915. 



M. K., 22, first attack, suppurative, perforated, 
drained, sick 48 hours. Appendix left in and re- 
moved at operation ten months later. 

P. B., 19, third attack, catarrhal, sick 18 hours. 

F. C, 9, first attack, suppurative, perforated, 
large amount of free pus, drained, sick 72 hours. 

K. B., 26. first attack, catarrhal, sick 24 hours. 

E. M., 30, second attack, catarrhal, sick 18 hours. 
W. B., 19, several attacks, catarrhal, sick 18 

hours. 

M. G., 20, suppurative, perforated, free pus, 
drained, sick 8 hours. 

\\'. S., 2)2), several attacks, catarrhal, sick 24 hours. 

R. S., 14, second attack, catarrhal, sick 48 hours. 

M. L., 7, second attack, catarrhal, sick 24 hours. 

.\. H., 70, first attack, catarrhal, sick 12 hours. 

M. H., 9, first attack, catarrhal, sick 18 hours. 

J. M., 20, second attack, catarrhal, sick 36 hours. 

.\. S., 17, first attack, suppurative, perforated, 
drained, sick 72 hours. 

R. v., 32, several attacks, catarrhal, sick 24 
hours. 

F. B., 35. first attack, catarrhal, sick 18 hours. 
.\. W., 40, first attack, catarrhal, sick 24 hours. 
F. K., 27, first attack, suppurative, sick 90 hours, 

5 months pregnant. 

A. F., 28, first attack, suppurative, perforated, 
drained, sick 48 hours. 

B. C, 40, several attacks, suppurative, perfo- 
rated, drained, sick 72 hours. 

J. McM., 27, first attack, catarrhal, sick 18 hours. 

j. S.. 30, first attack, catarrhal, sick 18 hours. 

J. H. W., 30, first attack, suppurative, perforated, 
drained, sick 36 hours. 

J. D. M., 22, first attack, suppurative, perforated, 
drained, sick four days. 

H. F., 11, first attack, suppurative, perforated, 
drained, sick 3 days. 

H. P., 17, second attack, catarrhal, sick 24 hours. 

J. H. K., suppurative, perforated, drained, sick 
5 days. 

M. G., 5, first attack, suppurative, perforated, 
much free pus, drained, sick 48 hours. 

H. P., 18, first attack, catarrhal, sick 24 hours. 

P. E., 24, second attack, catarrhal, sick 24 hours. 

R. F., 20. first attack, suppurative, perforated, 
drained. 

E. P., 11. first attack, suppurative, perforated, 
extensive peritonitis, drained, sick 4 days. 

R. C., 12, first attack, suppurative, sick 3 days. 

F. H., 18, first attack, suppurative, perforated, 
drained. 

I. R., 22, first attack, catarrhal, sick 24 hours. 

L. R., 26, first attack, catarrhal, sick IS hours. 

M. K., 29, first attack, suppurative, perforated, 
drained, sick 10 hours. 

J. P.., 7, first attack, suppurative, perforated, 
much free pus, drained, sick 72 hours. 

.■\. K., 8. catarrhal, sick 24 hours. 

W. H., 10. first attack, suppurative, sick 18 hours. 

\. S., 28, second attack, gangrenous, perforated, 
drained, sick 48 hours. 

R. W., 19, first attack, suppurative, sick 24 hours. 

479 Delaware .'\vknue. 



THE PREVENTION AND TREATMENT OF 

THE DISABILITIES FOLLOWING 

FRACTURES OF THE LIMBS. 

AsTLEY P. C. Ash HURST, M.D., F.A.C.S., 

Philadelphia. 



(Conlinucd from the March issue.) 

1. Disability from Lesions of the Soft Parts. 

In every fracture there is contusion, ecchymosis, 
extravasation, and often muscular laceration, ac- 
companying the osseous injury; and the disability 
which follows the fracture, in a large proportion 
of cases, is due to neglect of the soft parts, while 
attention has been concentrated upon the bony de- 
formity. 

Yet the surgeon must not neglect the osseous 
lesion in his devotion to the care of the soft parts. 
There is a happy medium between the school of 
Lucas-Championnierc, which ignores the bones and 
devotes all its attention to the soft parts by mas- 
sage and by mobilization of the neighboring joints, 
and the modern operative school which teaches that 
so long as the ends of the broken bone are brought 
into absolute anatomical reposition the soft parts 
may be safely left to take care of themselves. The 
former school has the merit of recognizing that 
the bones are not sticks or stones or bars of iron, 
but that they are living tissue, and if given even a 
slight chance will rectify their own deformities in 
many instances and so produce no lasting disabil- 
ity ; while the operative school is too prone to ignore 
primary lesions of the soft parts, and to blame all 
subsequent disability not on these (the real cause) 
but on insignificant osseous distortions appreciable 
only on skiagraphic examination. 

It is not my purpose now to describe in detail 
the methods to be employed in proper care of the 
soft parts, but I may state as a general rule that 
for the first week or ten days the condition of the 
soft parts should receive paramount consideration, 
especially when the fracture is not close to a joint. 
When the fracture is close to a joint there is no 
doubt that the easiest means of relieving the swell- 
ing of the soft parts is to secure anatomical re- 
duction of the fragments as soon as possible ; and 
this no doubt is true also though in less degree in 
the case of fractures in the shafts of long bones. 
But in the latter instances it is very much more 
difficult to secure accurate reduction without open 
operation than when the fracture is close to a joint, 
and malunion of a diaiihyscal fracture per se 
is very rarely a cause of disability. Hence I be- 
lieve that in diaphyseal fractures attempts at re- 
duction sometimes may be postponed for a few 
days until the swelling begins to subside. Up until 



Vol. XXIX, No. 4. 



AsiIHt'RST^-FRACTURES OF LiMBS. 



American 
Journal OF Sur gery. 



■133 



the end of the first week no insuperable obstacle to 
reduction will develop, unless it was present also 
from the very moment of the accident, as for exam- 
ple, entanglement of the fragments in the soft 
parts. 

Proper care of the soft parts requires that the 
dressing be removed two or three times weekly 
(less often as the case advances) to permit cleansing 
of the skin ; and as union progresses to allow of 
ver)' gentle passive movement of the neighboring 
joints. Such passive movements should never cause 
pain, and as already indicated should be substituted 
by active movements so soon as union of the bones 
permits. 





Fig. 1. 



Fig. 2. 



One of the most frequent causes of disability due 
to neglect of the soft parts is edema of the limb 
below the seat of injury. Of course such edema is 
not always avoidable in the lower extremity, but in 
the upper limb it is nearly invariably an evidence 
of neglect. A common and perfectly unjustifiable 
error is neglect to bandage the hand and forearm in 
cases of fracture of the humerus, or even neglect 
to bandage below the wrist in cases of fracture in 
this situation. In treating a Colles's fracture of 
the radius, for instance; it is no unusual fault for 
the dresser to leave the hand and fingers totally 
unsupported by the bandage, no turns of which 
pass below the thumb ; the result is that the hand 
and fingers become very edematous, and stiffness, 
pain and marked disability persist in the fingers long 
after the bone has united. Similarly, in fractures 
of the humerus, the dresser will make all secure 
from the shoulder to the elbow, but will leave the 
hand and forearm bare ; thev then become edema- 



tous, and long after the sh.ouldcr is healed, the pa- 
tient must be treated for stiffness in the wrist and 
fingers. Only last summer I had to keep such a 
patient under treatment for more than three months 
after the shoulder fracture ceased to trouble her, 
because she was totally incapacitated by the condi- 
tion of her hand ; even more incapacitated, indeed, 
than if her hand had been amputated for those 
three months, since she suffered much discomfort 
from its presence. 

In the lower extremity, as 1 have said, swelling 
of the foot cannot always be prevented during con- 
valescence, owing to its constantly dependent posi- 
tion ; but I am sure much less disability would re- 




F.g. 3. 

suit on this score if the soft parts of the lower ex- 
tremity received, as is their due, two or three times 
weekly, proper "dressing"' as in the case of frac- 
tures in the upper extremity, instead of being im- 
prisoned for weeks at a time, as is usually the case, 
in circular gypsum cases. 

Perhaps the most conspicuous example of lesions 
of the soft parts overshadowing those of the bones, 
is to be found in cases of Volkman's contracture. 
Though this seriously disabling condition occasion- 
ally has developed in cases where no dressings at 
all have been employed, it is the result, in the vast 
majority of instances of constriction from too 
tightly applied splints or bandages, particularly when 
these are not removed for some days or weeks at 
a time. It should be an invariable rule for the 
surgeon to see the patient the next day after the 
fracture, and personally to examine the condition 
of the finger tips and make certain that there is 
no interference with the circulation, and that the 



134 



American 

tol-rnal of surgery. 



AsHHURST — Fractures of Limbs. 



April, 1915. 



dressing is comfortable. .An unconifortable dress- 
ing always is inefficient even if not positively harm- 
ful. 

2. Compound Fractures. 
There is no class of fractnres in which care of the 
soft parts assumes such importance as in compound 
fractures. Here the bones are quite a secondary 
consideration ; and even in cases where immediate 
formal operation is required it is usually inadvis- 
able to apply plate or other form of internal fixa- 
tion until asepsis can be assured by definitive heal- 
ing of the soft parts. 




Fig. 4. 

I cite below several illustrative cases, in all of 
which the state of the soft parts made it proper for 
the first dressing to assume tlie character of a 
major ojieration. 

Case 1 : Compound conuiiiiiutcd fracture of 
radius and ulna, rupture of ulnar artery and ner;'e. 
etc. 

Fred B., aged 28 years, was admitted to Dr. 
Frazier's service in the Episcopal Hosiiital. Dec. 
12, 1909. His left forearm had been crushed be- 
tween two freight cars while he was engaged in 
coupling them. All four ends of the broken radius 
and ulna projected through a jagged wound of the 
soft parts, the skin being torn loose all around the 
circumference of the limb except for 4 cm. over 
the extensor surface of the radius, and the flexor 
muscles being extensively ruptured. There was 
loss of sensation in the distribution of the ulnar 
nerve below the injury. I operated about eight 
hours after injury. The ulnar artery was crushed 
and its ends widely separated ; both ends were 
ligated. The ulnar nerve was crushed for a dis- 
tance of 4 cm., only the fibrous sheath remaining 
intact. P>y dissecting the proximal end even to 
the elbow, and the distal end to the wrist, and by 
flexing the wrist, it was impossilile to make the 



ends of the ulnar nerve meet by 1.25 cm. There- 
fore a flap was turned up from the distal segment 
of the nerve, about 3 cm. in length, and sutured 
to the central end, without tension. The ends of 
the radius were drilled, and united by a suture of 
chromic gut No. 3. The ulna was found to be 
broken in two places, the intervening fragment 
being composed of three splinters. Silver wire 
was wrapped around these splinters, and they were 
sutured to the lower fragment of the ulna by 
chromic gut. passed through drill holes. .\ rub- 
ber drainage tube was passed across the flexor sur- 
face of the bones, and the ruptured muscles were 
carefully repaired. The limb was kept vertical, 
and alcohol douches were given as often as the 
dressings became dry. 

The attempts to secure fixation of the bones 
were not very successful, as is evident from skia- 
graphs made soon after operation ; this gives 
one the impression that the bones might have 
been struck by liglitning. There was prolonged but 
never very active suppuration and sloughing, and 
the three splinters composing the middle fragment 
of the ulna were soon discharged as sequestra. 
Bony union occurred in the radius, but only fibrous 
union in the ulna, .\bout a year after the accident, 
and when the soft parts had been healed for more 
than eight months, a sequestrum worked loose from 
the radius. Though an excellent result was ob- 
tained eventually, I believe even the little that was 
done to the bones at the time of operation tended 
to delay repair. 

Compare, for instance, the much more rapid re- 
covery in the following even severer case. 

Case II: Crush of forearm, double compound 
fracture of the humerus. 

bred H., aged 33 years, was admitted to my 
service in the Episcopal Hospital May 27, 1913. 
His right arm had been caught in machinery, and 
he had been knocked up against the ceiling and 
then flung across the room. Here also all four 
ends of the broken radius and ulna projected from 
a gaping wound .in the flexor surface of the fore- 
arm ; there was also a double fracture of the 
liumerus of the same side, and one of the fragments 
of the humerus was projecting through the skin, 
on the inner side of the arm, below the axilla. 

Operation was immediate. Fortunately no ar- 
teries or nerves were injured : only the basilic 
vein, transfixed by the humeral fragmert, required 
double ligation. The upper fragment of the ulna 
was resected, as it could not be satisfactorih 
cleansed. Partial reduction of the various bony 
displacements was made, but no form of internal 
tixation was emijloyed. Skiagraphs, made as soon 
as the patient could be moved from his room, 
showed that fairly good position of the bones 
iiad been secured. The soft parts healed with very 
little sloughing, no sequestration of the bones oc- 
curred, and firm union developed in the humerus 
within si.x weeks ( I-'igs. 1 and 2). Though only 
fibrous union occurred in the forearm, and neces- 
sitated a subse(|uent operation, it is manifest that 
no attempt at i>rimary fixation of the fragments 
would have obviated tliis result : while the absence 



Vou XXIX. No. 4. 



AsiiuLRST — Fractures of Limbs. 



American 
Journal of Subceky. 



135 



of foreign bodies from the wounds pemiitted rapid 
healing of the soft parts, a contrast to the cases 
where metal splints are employed. 

I may add that in spite of the extensive lesions 
of the soft parts in Cases 3 and 4. there w'as never 
anv disability from stiffness of the neighboring 
joints; the fingers are perfectly sujiple. 

Case III ; Compound coinminiitcd fracture of 
radius, and compound dislocation of ulna at ^crist. 

\\'illiam E.. aged 52 years, had his left forearm 
caught in machinery. Oct. 13, 1914. and was brought 
to the Episcoi^al Hospital. The carpal extremity 
of the ulna was sticking out through the soft parts 
for three or four inches, and there was a compound 




Fig. 



Fig. 6. 



comminuted fracture of the radius, with great 
laceration of the soft parts. After having his 
wounds dressed in the receiving ward, the patient 
absolutely refused to remain in the hospital, main- 
taining that the injury was trivial. Four days 
later, October 17, he presented himself at the dis- 
pensary, and was again urged to remain in the 
ward, but again went home. On his return home, 
however, he found himself so weak that he sent 
for the ambulance, wliich brought him to Dr. 
Frazier's service at 5.30 p. m. 

Operation. At 7.30 p. m., I operated. The hand, 
forearm, and hand were greatly swollen ; there were 
lymphageitic streaks extending toward the axilla, 
and the man was very septic, with a temperature 
of 101° F, All the sutures were removed, and the 
original wounds were enlarged, giving vent to large 
amounts of pus. The lower end of the ulna was 
again luxated, and was left protruding for about 
7 cm. (nearly 3 inches), in order to provide for 
drainage ; and a tube was passed through the wrist 
joint, which was full of pus, and another tube 
across the forearm at the site of fracture, through 
the interosseous space. Culture of the pus gave a 
pure growth of staphylococcus aureus. All opened 
surfaces were swabbed with hot carbolic solution 
( 1 :20 ). alcohol dressings were applied, and the fore- 



arm was suspended vertically for a week. The pa- 
tient's temperature fell at once, the swelling sub- 
sided within a couple of days, and by dint of abso- 
lutely disregarding the position of the bones, it be- 
came possible to save the patient's arm, which was 
in a condition almost justifying am[)utation when 
first seen. F"ig. 3 is from a skiagraph made 17 days 
after the operation : it shows the ulna still project- 
ing far beyond the soft parts, and the radial frag- 
ments overlapping until the joint surface is at the 
level of the upper fragment. The ulna gradually was 
covered in by the soft parts, and two months after 
operation projected less than an inch. Fig. 4, from 
a skiagraph made nearly three months after opera- 





Fi>;, r, F,g. ,- 

tion, shows to what a surprising degree the radial 
defomiity has been spontaneously corrected. On 
January 15, 1915, three months after injury, I re- 
sected the end of the ulna, and removed a few small 
sequestra from the radius, in which fibrous union 
was present. There was at this time scarcely any 
suppuration from the few sinuses still present, and 
active movements in the fingers were beginning to 
be possible. 

This case shows the great danger of inefficient 
care of the soft parts from the first. Had the 
patient been willing to remain in the hospital when 
first injured, with his forearm in vertical suspen- 
sion, and with irrigation, it is quite possible that no 
serious infection would have occurred : and that the 
soft parts would have been in a condition to warrant 
one in correcting the bony deformit}- before mal- 
union had occurred. As it is, the man put his life 
in jeopardy, very nearly lost his arm, has been totally 
incapacitated for months, and will never possess a 
very useful hand. 

3. Treatment of Disability from Lesions of the Soft 
Parts. 

Active movements and functional use of the limb 



136 



American 
Joi'BNAL OF Surgery. 



Ash HURST — Fractures of Limbs. 



AniL, 1915. 



are the most important factors in overcoming dis- 
abilities due to lesions of the soft parts; massage 
is a valuable adjuvant; but passive movements, es- 
pecially if forced, usually are useless and often are 
harmful. These facts should be, and indeed actu- 
ally are well known, but I see them ignored with 
lamentable frequency. To cite a case in point : 

Case IV. Stiff elbow follozmng forced passive 
movements after fractiire. 

A surgeon brought his nephew to see me August 
9, 1911. The boy, aged 7 years, had injured his 
left elbow eight weeks previously. His uncle had 
dressed the elbow in the Velpeau position, and had 




Hg. 9. 

a skiagraph taken, which showed a fracture of the 
external condyle of the humerus, not fully reduced. 
Three weeks after the injury the boy was taken 
to a consultant, who made further attempts, under 
ether, to reduce the deformity. The elbow was 
then dressed on an anterior right angled splint for 
two days; then all dressings were discontinued, and 
four days after the attempted reduction passive 
movements were prescribed. This prescription was 
carried out most energetically by the masseur, who 
forced the elbow into full flexion and full exten- 
sion every day for three weeks continuously. By 
this time the boy had suffered so much pain, and 
the elbow had become so manifestly worse, that a 
halt was called. 

When I was asked to see the boy, eight weeks 
after the injury, and one week after passive motion 
had been stopped, T found the joint hot, tender, and 
painful on motion. The range of motion was only 
50 degrees (85 to 135 degrees). The lower end of 
the humerus was half again as thick as normal in 
its antcro-posterior diameter and there was tender- 
ness on pressure over both biceps and triceps. Skia- 
graphs made the previous day showed the joint 
fairly normal, but there was new formed suliperi- 
osteal bone on the front and back of the humerus, 
where the forced i)assive motion had exerted its 



greatest influence; while the only new-formed bone 
visible in antero-posterior view was above the frac- 
tured external condyle ; but there was very little 
exuberant callus here. 

My advice was to do absolutely nothing to the 
boy's elbow for a month, and to let him use it as 
he wanted. His uncle afterwards reported to me 
that at the end of two months the range of motion 
in the elbow was very nearly normal in both flexion 
and extension, and that the joint gave no further 
trouble. 

This lesson I learned early in my professional 
life. As a resident physician in the hospitals some 
of my chiefs "believed in the use of early passive 
motion" for fractures around the elbow ; and many 
is the elbow on which at their instigation I en- 
forced violent passive movement with the idea of 
preventing or of breaking up adhesions, destroying 
or wearing away exuberant callus, etc. The chil- 
dred kicked, screamed, and yelled; their parents, 
the orderly, and the nurse held them still, while I 
gave them excruciating pain, and unwittingly 
aroused more osteogenetic and inflammatory pro- 
cesses around the elbow than were present before; 
and 1 never saw an elbow which failed to stififen 
up under this treatment. Fractures around the 
elbow I regarded as hopeless; I anticipated a stiff 
joint, deformity, or at least considerable limitation 
of motion almost in every case, and I rarely failed 
to find it. But as years have gone by I have become 
more and more convinced of the truth of Stimson's 
epigrammatic statement: "If you leave the arm 
alone, you save your time, and the patient's time, 
and he gets well quite as promptly." 

Now what is true of the elbow joint is true of 
all joints; and even iii the case of fractures of the 
diaphyses of long bones, forced, painful, passive 
movements always are to be avoided. If the neigh- 
boring joints are stifY, encourage the patient to use 
the parts as much as he can ; aid the absorption 
of exudate by hot-air baking and massage ; but 
beware of passive motion. 

It must be admitted, however, that occasionally 
in adults it is possible to improve the range of 
motion in a joint by forcible passive movements 
under an anesthetic ; but it is possible only when 
the joint is no longer hot and painful, only when 
the inflammatory reaction initiated by the fracture 
has long since subsided. 
4. Fractures in the Diaphyses of the Long Bones. 

I come next to speak of the supposed necessity, 
or at least of the propriety of securing anatomical 
replacement of the fragments in a diaphyseal frac- 
ture. Not only is such replacement often impos- 
sible, but T do not hesitate to state that in most 
cases I regard it as totally unnecessary. Reasonably 



Vol. XXIX, No. -». 



Asii HURST — Fractures of Limbs. 



Americas 
Journal of Surgery. 



137 



accurate reduction is desirable, and usually possi- 
ble; but it is a very rare thing for disability to re- 
sult solely from failure to secure anatomically ac- 
curate reduction of such a fracture. It is suffi- 
cient, in such fractures, as I have pointed out on 
former occasions, to secure firm bony union, with 
no appreciable shortening, and with preservation of 
the axis of the limb. The power of nature in round- 
ing off bony prominences and in bridging gaps by 
callus is especially manifest in childhood ; and it 
is in them that the most satisfactory results are 
obtained from unpromising beginnings. But this 
power, though less manifest in adults still is active 
in them. Let me cite several cases in illustration. 





Fig. 10. 



Fig. 11. 



Case V : Comminuted fracture of left femurs- 
irreducible: recovery zvithout disability. 

Milton G., aged 7 years, was admitted to Dr. 
Frazier's service in the Episcopal Hospital Nov. 1, 
1914. A wagon had run over the boy's thigh, and 
on account of the condition of the soft parts, at- 
tempts at reduction wei-e delayed. There was 1.5 
cm. shortening. Meantime the limb was placed 
in a Hamilton splint, and sufficient weights were 
applied to overcome shortening almost entirely. 
Skiagraphs, however, showed very marked dis- 
placement of the fragments (Figs. 5 and 6). On 
November 20 the child was etherized and I made 
attempts to secure reduction. Subsequent skia- 
graphs showed that the position was scarcely 
at all improved, and on account of the very 
wide separation of the fragments, I feared non- 
union, in spite of the patient's youth. Therefore 
I thought that operative reduction was indicated. 
But two days later, November 22, before operation 
could be done, the children's ward was placed under 
quarantine for an outbreak of scarlet fever. The 
limb was therefore re-dressed on a Hamilton splint, 
and conservative measures continued. On Decem- 



ber 20, some union was apparent, and early in 
January union became very firm. There was now 
only 0.5 cm. shortening. The ifis medicatrix natures 
had done its work well (Figs. 7 and 8). Toward 
the end of January, the boy was able to walk, and 
there is every prospect of his ultimate recovery of 
perfect function. 

This case of course is an extreme example, but 
serves well to demonstrate the slight importance in 
children of accurate anatomical reduction of dia- 
physeal fractures. Let me now cite some cases 
in adults : one such is the fracture of the humerus 
(a double compound fracture) which occurred in 
the patient already recorded herewith as Case 2. 
Other examples are the following: 

C.^SE VI : Fracture of shaft of femur, unre- 
duced for thirty years. Shortening 6.§ cm.; very 
little disability. 

A man, aged 50 years, came under my care in Dr. 
Frazier's service at the Episcopal Hospital in 
-August, 1911. Thirty years previously he had sus- 
tained a fracture of his femur; he had just fallen 
again, and feared he had re- fractured the same 
bone. There appeared, however, to be only a con- 
tusion. For thirty years this patient had pursued 
his usual occupation, entailing hard physical labor, 
earning from three to four dollars daily, with short- 
ening of 6.5 cm. He w-ore a lift in his heel, and 
walked without a disabling limp. He had some pain 
in his thigh in damp weather. I asked him how 
much he could have made if his thigh never had 
been broken, and he replied, perhaps five or six dol- 
lars daily. 

C.\SE VII : Fracture of left femur, unreduced; 
no disability. 

Louis M., aged 55 years, was admitted to Dr. 
Frazier's service in the Episcopal Hospital Oct. 
31, 1914, with compound fractures of both femurs. 
In the preceding May he had fractured his right 
femur, but the second fracture, in November, 1914, 
occurred a little below the previous injury. The 
skiagraph made after the second fracture (Fig. 9) 
shows that the first fracture had united with con- 
siderable deformity. In spite of this deformity, 
this patient had only 2 cm. shortening on leaving 
the hospital after his first accident. He had used 
crutches for five weeks after his discharge, being 
out of work thirteen weeks in all ; and had worked 
as teamster until his second accident, without any 
disability whatever. His knee, he said, flexed to a 
right angle ; he wore no raise on his heel to com- 
pensate for the shortening, and he considered him- 
self an entirely able-bodied man until his second 
accident. No better proof of the solidity of the 
union could be required than is furnished by the 
fact that the second accident produced not a re-frac- 
ture at the site of the old injury, but an entirely dis- 
tinct fracture below. 

Of course the results in these patients do not 
form an argument against attempting to secure bet- 
ter reduction, but they certainly prove that very 



138 



American 
Journal of Svbgery. 



Ash HURST — Fractures of Limbs. 



April. 1915. 



marked deformity (so long as the axis is pre- 
served ) in a diaphyseal fracture may cause very 
little disability. These cases are examples of ex- 
treme deformity; and if satisfactory function can 
be secured in such cases, much more certainly will 
it be secured in cases where the primary deformitv 
is slii:;ht or in those in which reduction is easily 
obtained. Certainly I admit, and no one will dis- 
pute, that it is desirai)le to secure as accurate reduc- 
tion as is ]wssible ; but 1 contend that sufficient re- 
duction usually can be secured (almost always in 
children) without open operative intervention.* 
5. Fractures Near Joints. 
\'ery different are fractures near joints. Quite 
apart from the <|uestions of axial deviation, of ro- 



tiires near joints. So convinced am 1 of the neces- 
sity of securing accurate reduction in joint frac- 
tures, that I believe open operative reduction should 
be undertaken in the vast majority of cases where 
bloodless attempts fail to secure anatomical reposi- 
tion. Of course open treatment in these as in other 
fractures must not be adopted except where suitable 
facilities exist, both as regards the operator and 
the operating room. 

Fortunately the bloodless reduction of joint frac- 
tures is relatively easy compared to that of dia- 
physeal fractures, since the position of the shorter 
fragment usually can be controlled through the 
neighboring joint. Thus, abduction at the shoulder 
and hip, fle.vion at the elbow and knee, and adduc- 




I'ig. 12. 

tatory deformity, of shortening, and of lesions of 
the soft parts (all of which factors must be con- 
sidered here as well as in fractures of the diaphy- 
ses), there is the additional and all-important fac- 
tor of impairment of joint motion. Tnless accu- 
rate reduction is secured there will be permanent 
disability of some degree, varying with the extent 
of persistent deformity. 

Fractures at the elbow and the ankle probably 
furnish the largest proportion of cases of disability 
and from the slightest grades of deformity; but 
fractures at the wrist are a frequent cause ; while 
those of the shoulder and hip, though relatively less 
frequent, nevertheless present a rather high per- 
centage of disability. P'ractures at the knee (ex- 
cept those of the patella, which may be disregarded 
in this connection ) are so rare that few such pa- 
tients are seen complaining of disability. 

It will be noted subse(|uently that nearly all 
fractures which require operation for the relief of 
disability due to malunion of the bones are frac- 

"1 may here emphasize the impoii.nicc of ihc position in which 
the inTiIi_ IS dresscfi. .is one of tlic most valuable aitls to rerlilc- 
tion. Weight extension, moreover, is .ipplicable to fractures of 
the upper limb as well as to those of the thiKh and let;. thonRh 
this fact often is forgotten. I merely mention in passing the value 
of Steinmann nail extension in fractures of the leg, where the seat 
of fracture is too low for the ordinary Buck's extension apparatus 
to be efficient. 



tioii at the wrist and ankle may be employed when 
necessary to maintain the fragments in ajjposition. 

1 believe it is much more important, also, in 
joint fractures than in diaphyseal fractures for re- 
duction to be secured as soon as possible after the 
accident. Delay of three or four days may not 
only render reduction extremely difficult or even 
impossible, but may allow such swelling of the soft 
parts to occur as to ensure disability on this score 
esen if reduction of the bones is subsequentlv ob- 
tained. 

It is important also in joint fr;ictures, when 
once accurate reduction has been obtained, to leave 
the joint at rest until bony union has occurred. 
Attempts at early passive motion arc particularly 
harmful in these fractures. When once bony union 
has occurred, the patient will be able to execute 
active movements without p;iin. and in this manner 
will regain the normal range of motion in a short 
time. If stiffness i)ersists. it is due to the condi- 
tion of the soft parts; and this condition is due 
in its turn either to failure to reduce earl\- enough 
and accurately enough, or to neglect of the soft 
parts while the fracture was mending. If the soft 
parts are in good condition and joint motion is 
persistently limited, it will be found that whatever 



Vou X.XIX. No. ■). 



Ash HURST — Fractures of Limbs. 



American 
Journal of Surgery. 



139 



range of motion exists is painless, and that arrest 
of motion at each end of the arc is produced by 
bony contact. Under such circumstances no in- 
crease in the range of motion can be secured ex- 
cept by op)eration (excision of callus, arthroplasty, 
etc.). If motion is painful, and it is not arrested 
by bony contact, improvement may be looked for 
as the condition of the soft parts returns to normal, 
under conservative treatment (active movements, 
light massage, hot-air baking, etc.). 

6. The Propitious Time for Operation. 

It is inifKjrtant to determine as soon as possible 

after the injury whether or not operation will be 

required; and the operation, if required, should be 

undertaken neither too early nor too late. Except 





Fig. 14. 

in the case of severe compound fractures, when the 
first dressing should assume the character of a 
formal operation, it is not desirable to operate be- 
fore the fifth day. But it is possible, almost al- 
ways, by the tenth day after the accident, to know 
whether or not o{>eration will be required. This 
allows time for thorough examination and diagnosis, 
including the making of the necessary skiagraphs 
(always in two planes), as well as for attempts at 
reduction (under an anesthetic if necessary), and 
for the making of more skiagraphs to learn what has 
been accomplished. 

Operations before the fifth day are more dan- 
gerous than those done between the fifth and tenth 
day. because the condition of the soft parts predis- 
poses them to infection. It is best not to operate 
until sufficient time has elapsed for subsidence of 
swelling and commencement of organization of the 
effused blood. In the case of the femur this may 



require postponement of the operation for two 
weeks or even longer. And in any case where the 
skin is broken (as is frequently the case in frac- 
tures of the leg, even when there is not a true 
compound fracture), it should be the invariable 
rule not to oj)erate until the skin is soundly healed. 
(_)n the other hand, an oiieralion once being de- 
termined on. it should not be unduly fxjstponed. 
It is both luore difficult and more dangerous to 
correct malunion or nonunion by operation than it 
is to jirevent them by the same means. If malunion 
occurs it is often impossible to overcome the short- 
ening, and the most that can be done is to restore the 
axis of the limb, or to relieve the soft parts of inju- 
rious pressure bv exci>ion of exuberant callus, etc. 





Fig. 16. 

Nonunion, except in compound fractures, almost 
always is due to imperfect reduction of fragments 
when the fracture was recent. When operation 
is delayed beyond the second week, there is almost 
always found more or less osteoporosis of the distal 
fragment ; this renders it difficult to make screws 
hold in it, and it is often necessary to reinforce the 
application of a plate by encircling wires. 

Hence it is the duty of the modern surgeon to 
learn and to teach others which classes of injury 
require primary operation, and which do not. He 
should not start out with preconceived notions, that 
all fractures require primary' operation, or on the 
other hand that primary operation is never neces- 
sary. Xor should he base his judgment on purely 
theoretical grounds. I believe the best and safest 
way to accjuire knowledge on this subject is to study 
the end-results of fractures, and to work backward 
from them until we learn which fractures, and with 



140 



Amebkan 

Journal of Surgery. 



AsHHURST — Fractures o& Limbs. 



/. AnuLi 1915. 



what grades of primary and unreduced deformity, 
give us lasting disability, and which do not. 
7. Treatment of Disability follozinng Diaphyseal 
fractures. 

If operative treatment is required for old dia- 
physeal fractures it is because of nonunion or be- 
cause of concurrent lesions of the soft parts, and 
scarcely ever because of malunion of the bones. 
This statement embodies the conclusion I have 
reached by a study of end-results. In the patients 
who have come under my care for disability fol- 
lowing diaphyseal fractures, the disability was 
clearly due to one of two factors: either nonunion 
or lesions of the soft parts. 

Malunion in a diaphyseal fracture, regarded as 
affecting the bone itself, may cause (1) shortening, 
(2) axial or rotatory deformity, or (3) nonunion 
may be present. Neither malunion nor nonunion 
of them^lves will interfere with the free move- 
ments of the neighboring joints. Such limitation of 
motion, as well as persistent swelling, aches and 
pains, stiffness in wet weather, etc., almost without 
exception are due to concurrent lesions of the soft 
parts. I have cited already several examples to 
demonstrate the very slight disability which fol- 
lows even considerable bony deformity, so long as 
the soft parts are in good condition. Shortening 
alone, even in the lower extremity, causes surpris- 
ingly little disability, so long as union is firm and 
the axis of the limb is preserved. Now, though 
shortening of 1 to 3 cm. is sufficiently common after 
non-operative treatment, axial and rotatory deform- 
ity are very rare, and scarcely need be considered as 
causes of disability. 

Nonunion is the chief factor which causes dis- 
ability in cases of diaphyseal fracture ; but it also 
is comparatively very rare. In all the recent frac- 
tures treated by myself, probably approaching a 
thousand in number, I have never yet had a case ol 
nonunion, except in a few cases of severe compound 
fracture in which immediate operation was required 
on account of the condition of the soft parts (Cases 
1 and 2 are examples), and in some cases of frac- 
ture of the neck of the femur in the aged. 

On the other hand, I have seen numerous cases in 
which lesions of the soft parts were the cause for 
which the patients sought relief. 

Case VIII : Malunion of fracture of radius and 
ulna; paralysis of ulnar nerve. 

Dolores D., aged 13 years, was referred to my 
service at the Episcopal Hospital Nov. 16, 1914, by 
Dr. E. E. W. Given. On August 6, 1914, this girl 
had .sustained a fracture of both bones of the left 
forearm ; four weeks after the splints had been re- 
moved, and eight weeks after the first accident, she 



fell again, but did not completely re- fracture the 
bones. Splints were re-applied for a further period 
of about four weeks, but after their removal pain 
and disability persisted, and considerable bony de- 
formity was present. When the child first came 
under Dr. Given's notice, in November, more than 
a month after the second injury, there was readily 
visible bony deformity, and the hand was not only 
useless, but the seat of constant pain. There was 
anesthesia and hyperesthesia in the distribution of 
the ulnar nerve, with wasting of the thenar and 
hyi>otlienar eminences and of the interosseous 
muscles. 

At operation, November 25, 1914, the ulnar nerve 
was found caught in scar tissue over the lower end 




Fig. 17. 

of the upper ulnar fragment (Fig. 10). Union in 
both radial and ulnar fractures was only fibrous, 
and resection and plating of both bones was done. 
Within three days there was evidence of some re- 
turn of sensation in the ulnar distriljution, and by 
the end of a week sensation was normal. Progress 
thereafter was uneventful. At the end of four 
weeks firm union was j^resent, the soft parts had 
returned to normal, and a fair range of rotation was 
present. 

It appears to me that if proper care had been 
taken of the soft parts, bony union would have oc- 
curred, even after the second injury, in spite of 
the deformity present; and that this deformity 
alone would not have been a cause of much dis- 
ability. Opportunity being afforded for operation, 
because of the nerve lesion, I believe I was jus- 
tified in securing better reduction of the fragments. 

Case IX. Malunion of fracture of radius and 
ulna; disability from adhesions of the soft parts. 

Joseph P., aged 43 years, was referred to my 
service at the Episcopal Hospital in h'cbruary, 1914. 
Two months previously his hand and forearm had 
been caught in a cable, fracturing the radius and 



Vou XXIX, No. 4. 



Asm HURST — Fractures of Lkmus. 



American 

JoiRNAL Ol SVKGEfcY. 



141 



ulna above the wrist, and greatly contusing the soft 
parts. The fractures had united with scarcely any 
axial displacement, though the lower fragments were 
displaced toward the extensor surface (Fig. 11). 
Wrist motion was greatly limited, and though rota- 
tion of the forearm was possible through more than 
half the normal range, the hand was perfectly use- 
less, owing to inability to make a fist (Fig. 13). 
For more than six months this man was treated 
by massage and passive motion, with negligible im- 
provement. He then consented to an operation, 
which was done August 8, 1914, and consisted sim- 
ply in chipping off the bony angles, and thoroughly 
freeing the adherent muscles, back and front (Fig. 
12). The result was restoration of normal rota- 




Fig. 18. 

tion, and very nearly normal movements in the 
wrist. But it was still impossible for him to make 
a fist, owing to i>ersisting adhesions in the hand 
and fingers. Finally, on November 11, 1914, he was 
again etherized, and these adhesions forcibly rup- 
tured, and the fingers dressed in full flexion. This 
could not be maintained, however, and when last 
seen, early in December, 1914, he was still unable 
to make a tight fist, and therefore to hold a trowel 
and resume his former work as plasterer, though 
the condition was probably 7h per cent, better than 
before operation, and he could still make a living 
at other work (Fig. 13). 

In this patient the deformity was by no means 
so great as to produce disability by itself; and if 
it had not been for adhesions of the soft parts, I 
have no doubt that an excellent functional result 
would have been secured without operation. 

8. Treatment of Disability from Fractures 
Joints. 
When a fracture occurs close to a joint, 
slight deformity may entail great disability, 
the first place it is more important here than in the 
shaft of a long bone to maintain the axis of the f rag- 



near 

very 
In 



ments, since less com|)cnsatory bone changes can 
occur when one fragmeiU is very short than when 
both are of nearly equal length. A slight tilt of 
the short joint fragment will cause marked de- 
viation of the articular surface. 1 liave already em- 
phasized, perhaps sufficiently, the importance of ac- 
curate reduction in these lesions, and have cited 
cases indicating that in most instances such re- 
duction can be obtained without resort to opera- 
tion ; but I cannot refrain from quoting some fur- 
ther examples which illustrate the very serious dis- 
ability which follows neglect of accurate reduc- 
tion. 




Fig. 19. 

C.\SE X. Malnnioii of a Colics' fracture of the 
radius: median neuritis; resection and screiv fixa- 
tion. 

Anna K., aged 28 years, sustained a Colies' frac- 
ture of the right radius June 1, 1914. She was 
treated by her family physician, who placed the 
forearm on a straight palmar splint, but made no 
attempt to "set" the fracture. Over fourteen 
months after injury this young woman came under 
my care, complaining not only of the conspicuous 
deformity (Fig. 16), but of complete disability, 
from weakness, loss of flexion at the wrist, and 
sweating and paresthesia in the distribution of the 
median nerve. She was admitted to my service at 
the Episcopal Hospital, and I operated October 10, 
1914. The carpal fragment was found united by 
bone to the extensor surface of the diaphysis, while 
the fractured surface of the diaphysis, free of all 
bony contact, jutted up against the median nerve 
and flexor tendons (Fig. 14). Resection and screw 
fixation restored the parts to normal (Fig. 15), 
and on December 12, one week after her return to 
her usual work in a mill, the grateful patient re- 
turned to report that she found her hand in every 



142 



AUEHICAN 

JOVKNAL OF SuRGERr. 



AsHHURST — Fractures of Limbs. 



April, 1915. 



way as good as it had ever been before the accident 
(Fig. 16). 

Case XI : Malunion of fracture at ankle. Re- 
section and scrcM fixation. 

James C, 31 years old, fractured his left ankle 
in July. 1914. In .September, 1914, he came under 
my care in the orthoj^edic service at the Episcopal 
Hospital, because of persistent disability. He was 
unable to dorsiHe.x the foot beyond 90 degrees, and 
as a consequence had to walk with his whole limb 
in external rotation, carrying the foot in the coronal 
plane of the body. Even thus he sutTered constant 
pains along the fibula from the external malleolus 
upward. .\ skiagraph (Figs. 17 and 18) showed 
an unreduced oblicjue fracture of the lower fifth of 
the fibula, entering the ankle joint and detaching 
also the adjacent surface of the tibia. The astrag- 
alus was dislocated slightly backward, with the foot, 
and there was distinct diastasis at the tibio-fibular 
joint, the fibula being abnormally movable on the 
tibia in the antero-posterior plane. A fracture of 
the internal malleolus was not visible in the skia- 
grai)h. 

I kept this man under observation for two months, 
hi)])ing that improvement might occur; but he per- 
sistently urged operative treatment, on the ground 
of absolute disability for his former work. Finally, 
on December 9, 1914, five months after the fracture, 
I operated, resecting the line of fracture in the fib- 
ula, cutting a new groove for it in the tibia, detach- 
ing the misplaced internal malleolus ( which was now- 
seen to have been fractured) and restoring it to 
its normal position. The fragments were fixed by 
three large Lambotte screws. Figs. 19 and 20 
show that the posterior displacement of the fibula 
and astragalus has been overcome, and that the 
fibula is fixed firmly against the tibia. 

Not until eight weeks after operation was this 
man allowed to bear any weight on his limb. He 
was then able to walk painlessly and without further 
disability. 

In these and similar cases the proper time for 
operative reduction of the deformity (if bloodless 
reduction was impossible) was while the lesions 
still were recent, and not after malunion had oc- 
curred, and the j)atients had lieen dis;ibled for 
months. 

'). 'freiitinent of Xoii-iniion. 

As I have already indicated, comparatively few 
cases of real nonunion have come under my care. 
The distinction between delayed union and non- 
union mav be said to l)e that, in the former, union 
will occur eventu.ally without operative interfer- 
ence : while in cases of true nonunion the bones re- 
main ununited in spite of all methods of conserva- 
tive treatment. I think this distinction is important 
to bear in mind, and believe that the surgeon should 
not be inclined to rush his patient with delayed 
union into a possibly very brilliant but by no means 
necessary operation. T am sure that in a good many 
of the cases of operative treatment of so-called non- 



union now being reported in medical literature, 
non-operative measures might very well have been 
effectual in securing bony union, and in as short 
a time as by opierative treatment. I have esi>ecially 
in mind just now delayed union in fracture of the 
leg; I know of a case of this kind where bony union 
had not developed at the end of six weeks, and the 
surgeon at once resorted to bone transplantation. 
The operation was perfectly successful, and firm 
bony union developed. But then I recall numerous 
similar cases of delayed union where the patients 
developed bony union within a few weeks after 
being allowed to walk around in their gypsum cases. 
Of course if there is marked deformity in a case 
of dclaved union, a better end result usuallv will 




Fig. JO. 

be secured by operative means, since reduction of 
the deformity can be obtained at the same time 
that bony union is encouraged. 

ihit the surgeon must nevertheless stop to con- 
sider whether the patient's condition is not good 
enough as it is, even though firm union is not pres- 
ent. He should remember that bony union does 
not nccessarilv follow operation, and that opera- 
tion may even make the patient's condition worse. 

There appears to be little doubt that the most 
efficient way to secure l.xmy union is to insert a 
bone transplant. I have recorded elsewhere (An- 
nals of Surgery, 1914, ii, 779) the very satisfactory 
result obtained by this means in a case of nonunion 
of the neck of the femur, in a young adult who 
had been unable to walk without crutches for eight 
months ; and I have also employed it in the fore- 
arm. In young children, where the osteogenic 
powers arc so much better than in adults, T prefer, 



Vou XXIX, Xo. 4. 



NEfiioF — Hand Injuries. 



Americas 

Journal of St" rgerv. 



143 



when nonunion occurs in a joint-fracture (I have 
operated on three of the external condyle of the 
humerus), to fix the fragments with sutures or 
screws, after freshening their surfaces. 
Conclusions. 

The conclusion uf the whole matter seems to mc 
to be a recognition of the fact that it is necessary 
and always will be necessary, for a large pro- 
portion of the profession, who are not trained sur- 
geons, to have cases of fracture under their care, 
lliey cannot avoid it. They cannot adopt operative 
treatment even when it is requisite to prevent dis- 
abilitv. The only remedy is to have them so well 
trained in measures that they can apply, as to 
enable them to secure the least possible degree of 
disability. 

Then I believe the average surgeon should rec- 
ognize that the operative treatment of fractures 
is not as indispensable as some writers would have 
us believe ; and that he should continue in the fu- 
ture, as he has in the past, to give preference to 
non-operative methods ; that he should feel prouder 
of curing ten patients without disability and with- 
out resort to operation, than of recording fifty or 
one hundred brilliant operations, most of which 
were really quite unnecessary had he only known 
enough surgery to make efficient use of non-opera- 
tive means. 

It is important also for the trained surgeon in 
charge of a case of fracture to be capable of rec- 
ognizing while the lesion is still recent, whether or 
not open reduction is requisite. That cases re- 
quiring open treatment e.xist, even the utmost con- 
servatism cannot deny ; cases in which it is man- 
ifestly im]x>ssible to secure any sort of respectable 
result without operation. 

Finally, may I venture to suggest that the pa- 
tient's interests might perhaps be promoted, if not 
only the general practitioner but the average gen- 
eral surgeon as well should feel a little more 
Hallerian diffidence than he does at present about 
undertaking operations which may have (and fre- 
quently have had) such disastrous results as those 
for fractures of the limbs. Whether a patient 
will recover, or whether he will die. after such 
an operation, cannot always be foretold. A very 
slight lapse in aseptic technic may prove fatal. At 
all events, there is often a question whether as 
good a result might not have been obtained with- 
out operation. I often recall in this connection 
that wise maxim of Heister; it may be interpreted 
either of good or of bad results : /;; prcrdicendis 
fracturarum n-entibus multa utique chirurc/is opus 
est circunispcctionc. 



SEQL'Er.AE OF MINOR L\JUR1I-:S IXCO.M- 

PLETELY SEVERING NERVES OF THE 

HAND. THEIR SURGICAL 

TREATMENT. 

ll.xROLi) Xeuhof, M.D., 

New York City. 



.Miluiugh the immediate and final results of com- 
plete division of the nerves to the hand are .so well 
known that any recapitulation is unnecessary, rela- 
tively little attention has been devoted to sequelae 
of partial severance, anatomical or physiological, of 
these nerves. That insignificant injuries may pro- 
duce lesions of the nerves to the hand sufficiently 
]iainful and incapacitating to require serious atten- 
tion does not appear to be generally known. There- 
fore a number of cases that have come under my 
observation will be described in some detail. Be- 
fore doing so, the results of incomplete division of 
nerves should he described briefly.* 

The symptoms and signs of incomplete division 
of a mixed nerve are similar in essential charac- 
teristics, whether the injury is sudden ( from a 
wound), or develops gradually ( from cicatrix, cal- 
lus, etc.). whether the incomplete severance is ana- 
tomical or ph\siological. It was formerlv believed 
that such symptoms were chiefly motor. Sherren 
and others have shown, however, that sensory 
changes always occur and that motor manifestations, 
though generally present, need not neces>arilv fol- 
low. 

An area of tactile anesthesia is present almost 
invariably. Within that zone sensibility to pin (trick 
and temperature is generally deficient : it may be 
intact, however, in some of the slighter injuries, 
and 1 wish to place especial emphasis upon this in 
view of some of the cases I have encountered. Loss 
of sensibility to touch may therefore be the only 
sign of injury to a nerve. However, with pro- 
nounced sensory changes there are usually motor 
alterations. .Some or all of the muscles supplied 
by the affected nerve may be paralyzed more or 
less completely. It may be impossible to distinguish 
between complete and partial division of a nerve 
until <ine or two weeks have elapsed. At the end 
of that period, however, muscles supplied by the 
partially severed nerve do not present the typical 
reaction of degeneration, in contradistinction to that 
of total division. The mode of recovery after incom- 
plete division is also in striking contrast to that fol- 
lowing total division. In the latter, sensibilitv to 



*A fuller and more accurate description is to be found in 
Lewandowsky's Handbuch der Xeurologie. Vols. I and 11. and in 
tbe monograph upon Injuries of the Nerves and Their Treatment. 
t>v Tames Sherren. Many of my remarks are based upon these 
works: it should be stated that my own experience has been the 
guide in what I have chosen to say upon certain disputed points. 



144 



American 

Journal of Suruery. 



Neuhof — Hand Injuries. 



April, 1915. 



pain returns long before that to touch ; in the for- 
mer, they return about the same time. Generally 
the return is far more prompt and complete when 
a nerve is incompletely severed, for evident reasons. 

The sequelae of untreated cases of partial nerve 
division are of interest in connection with those to 
be described. Pain is more common tlian after 
complete severance and is often more severe. It 
may be so intense that patients are entirely inca- 
pacitated from any work. Pain is frequently asso- 
ciated with skin tenderness in the field of distribu- 
tion of the injured nerve. It rarely appears directly 
after the trauma, the quiescent period varying from 
days to weeks ; diagnosis of "hysteria" are not in- 
frequently made because this fact is not recognized. 
Sensibility to pin prick and temperature generally 
returns more or less completely, even when treat- 
ment has not been instituted, but tactile anesthesia 
remains, in direct proportion to the extent of the 
injury. No description is necessary of the trophic 
changes in the skin and nails that may develop. 

Concerning the results of operation for incom- 
plete division of the nerves to the hand it may be 
said that they are generally good, as far as com- 
pression of the musculo-spiral nerve is concerned. 
No general statement concerning partial severance 
of other nerves of the hand can be made because 
the reports in the literature are too scanty. This 
is particularly true of the group of cases of minor 
injury, the subject of this paper. The results I 
have obtained by simple operative treatment have 
been very satisfactory ; they will be described in the 
individual case reports. Before the latter are pre- 
.sented I wish to repeat that incomplete severance 
of nerves may result not alone from major injuries 
leaving well-defined traces, but also from traumata 
so insignificant that patients recall them with diffi- 
culty and attach no importance to them. This is 
the important point to be gained from the perusal 
of the case reports. 

Case I : Mary S., 18 years old, servant. For 
six months has had severe pain in the left thumb 
almost constantly. It began gradually, is steadily 
growing worse, and is sometimes violent enough to 
prevent sleep. Objects held in the left hand are 
occasionally dropped ; the patient has accustomed 
herself to do all carrying with the right hand. Pro- 
fuse sweating of the skin of the affected thumb. 

Examination: Tactile anesthesia over the entire 
palmar and lateral aspects of the thumb, less exten- 
sive on the extensor surface. (See diagram.) It 
extends over the thenar eminence and is lost shortly 
above the radial aspect of the wrist. Small area 
of thermal and pin prick anesthesia on finger pulp. 
During examination beads of perspiration appeared 
over the thenar eminence. 

Two inches above the wrist, on llie radial side 



of the flexor surface of the forearm, there is an 
insignilicant, slightly tender short transverse scar. 
Sensory changes begin shortly below this point. 
Upon inquiry it was learned that the cicatrix was 
the result of incision of a small abscess, done about 
one month before the onset of pain in the thumb. 

Diagnosis: Incomplete severance of the radial 
cutaneous nerve, from an incised wound or from 
the cicatrix following the abscess. 

Operation: Local anesthesia. Vertical incision 
surrounding scar. This was carefully dissected 
from the subcutaneous tissues, and found adherent 
to the radial cutaneous nerve. At the point of at- 
tachment the nerve is thickened and firm, .'\bout 
three-eighths of an inch nerve was resected with 
the cicatrix, and its ends approximated by a single 
suture; this was covered witli a small flap of fat. 
Suture of wound. 

Post-operative course: Prompt relief of pain. 
Distinct shrinkage of area of tactile anesthesia, 
after four weeks. Normal sensibility to touch, pain, 
and temperature, six weeks later, and has so re- 
mained to the present time (three years after oper- 
ation). 

Case II: Jacob S., tailor, 36 years old. Slipped 
going downstairs and fell upon hypothenar emi- 
nence of right hand. For a few days some swelling 
and tenderness on ulnar side of the wrist and tin- 
gling sensations in the little finger. These disap- 
peared and the patient felt well except for some 
stiffness of the fingers and hand. Pain in the fourth 
and fifth fingers began about three weeks after the 
fall. Soon after, weakness in the grasp of the hand 
was noticed. Pain became progressively more se- 
vere and lancinating. The hand gradually became 
unfit for work, and wasting of thenar and hypothe- 
nar eminences were noted. Over this latter pro- 
nounced sensitiveness of the skin developed. The 
man's general condition became seriously under- 
mined. He had been treated for central nervous 
disease. Wassermann reaction negative. 

Examination: Nine months after injury (March 
26, 1913). Lesion evidently one involving the ulnar 
nerve. The skin over the hypothenar eminence and 
palmar aspect of the little finger is thin and glossy. 
Both eminences are atrophied moderately ; inter- 
osseous spaces hollow. Hand grip weakened. Ad- 
ductor power of thumb markedly diminished. 
Ability to spread fingers limited. Very pronounced 
weakness and diminished motion in all the move- 
ments of the little finger; to a lesser degree, of the 
ring finger. No absolute loss of any motion. Tac- 
tile anesthesia is a well defined zone over the last 
two fingers; smaller, ill defined areas of thermal 
and pain insensibility. (See diagram.) Exquisite 
tenderness of skin in anesthetic zone. Immediately 
external to and below the pisiform bone a small area 
markedly sensitive to pressure; a pea-sized nodule 
is indistinctly felt here, some distance under the 
skin. Electrical tests of the affected muscles; ne 
response to intermitted current. Rather sluggish 
contractions with galvanic current ; no "reaction of 
degeneration." 

Diagnosis: Incomplete severance of the ulnar 
nerve at the pisiform bone, due to pressure. Sec- 



\oi_ XXIX, No. 4. 



Neuhof — Hand Injukies. 



American 

Journal of Surgery. 



145 



ondarv inflammatory changes in nerve about the 
blocked area. 

Operation: March, 1913. Curved incision across 
the wrist. Rather dense scar tissue encountered. 
Ulnar artery isolated and retracted. Ulnar nerve 
found free down to a point a little above level of 
the pisiform. From here to (and slightly including) 
the division of the nerve into its two branches (the 
deep and superticial palmar) a ciuarter inch below 
the pisiform, the nerve was embedded in inflam- 
matory tissue so dense that its recognition and iso- 
lation involved minutest care. When freed the 
nerve was found compressed : otherwise appeared 
to be intact. The case seemed one of anatomically 
disturbed but physiologically blocked conduction. 
The nerve was covered with sterile vaseline, the 
scar tissue excised, the wound sutured. 

Post-operative course: Prompt disappearance of 
pain : slight return about three weeks after opera- 
tion, recurrence lasting several weeks ; permanent 
freedom from pain thereafter. Patient employed 
electricity and massage very conscientiously, but 
motor and sensory improvement very slow in first 
six months after operation. Since then, however, 
it has been more rapid. Examination, June, 1914: 
Excellent general condition. No pain. Hand use- 
ful for a little work. Tone of skin over thenar and 
hypothenar eminences much improved. Both are 
much fuller, less flabby ; similar improvement of 
the interossei. Eair power in spreading fingers, 
functions of little finger considerably improved, 
pronounced w-eakness of adductor pow-er of thumb 
remains. Area of thermal and pin prick anesthesia 
gone : that of actile anesthesia much smaller and 
ill-defined. 

In a recent letter (November, 1914) the patient, 
who lives out of town, writes that there has been 
steady improvement in range and power of motions, 
including those of thumb. 

Case HI :* Harry J., 12 years old, came under 
observation in July, 1911. complaining of pain along 
the radial side of lower left forearm, of one month's 
duration. It had become steadily worse, sometimes 
accompanied by pain along the outer side of the 
upper forearm and arm. At first no history of 
trauma was given ; only after the examination sug- 
gested a nerve lesion and the patient and his mother 
were carefully questioned was it learned that, some 
time in the early part of May the boy's left fore- 
arm was struck by a baseball (in the region now- 
most painful), a black-and-blue spot remaining for 
several days. 

Examination: Area of exquisite skin sensitive- 
ness beginning about three inches above w-rist and 
extending in a one-inch strip along radial side of 
anterior surface of forearm to base of thumb. This 
zone is somewhat hypersensitive to pin prick ; nev- 
ertheless there are several small patches of tactile 
anesthesia within it. Possibly slight alteration in 
themial sensibility (examination of this small pa- 
tient rather difficult). No motor changes. 

Diagnosis: Contusion of anterior branch of ex- 
ternal cutaneous nerve. Operation advised, not ac- 

•From the Surgical Department of the Mount Sinai Hospital 
Dispensary. 



ccptcd at first. Patient returned after three weeks 
comi)laining of increased jiain despite a variety of 
therajn-. No additional findings. 

Operation: Vertical incision al upper level of sen- 
sitive skin area. No scar tissue encountered. After 
considerable search the nerve was found. Slightly 
thicker and firmer than the remainder of the ex- 
posed part for a length of one-half inch almost 
opposite up]K'r level of the sensitive zone. This 
portion of the nerve resected. No attempt al sutur- 
ing the divided nerve, because little or no sensory 
changes result from' division of this branch. Wound 
sutured. 

Post-operative course: Pain as severe as that be- 
fore operation for about one week, and then gradu- 
ally disappeared. At examination, one month after 




Oblique lines indicate areas of tactile anesthesia. 

Cross lines indicate areas of thermal and pain anesthesia. 

operation, patient entirely free from pain, skin sen- 
sitiveness gone. Small area of tactile anesthesia 
immediately below the incision. Patient disappeared 
from observation soon after, quite well when last 
seen. 

Case IV: Charles S.. 30 years old. chaufifeur. 
Dull, aching, continuous pain in second and third 
fingers of right hand for two months. These fingers 
feel numb and there is the same sensation to a 
lesser degree in the thumb. Motion of the latter 
have become "clumsy," although there is no great 
difliculty in gripping and holding the driving wheel. 
Pain not improved by varied treatment employed, 
and, although not progressive, is "getting on his 
nerves." Upon inquiring into the possibility of 
trauma, it was learned that, about two weeks before 
the onset of pain, the anterior surface of the right 
wrist received a sharp blow from the crank-handle 
when the engine back-fired. The patient placed no 
significance upon this, but he could not recall any 
previous injury in that region. 

Examination: Very slight atrophy of thenar emi- 
nence. Some weakness in power of moving thumb 
towards and away from the palm. Tactile anes- 
thesia over the palmar surfaces of the index and 



146 



AwERltAX 

Journal of Surgery. 



Neuhof — Hand Injlkies. 



Aprii., 1915. 



middle fingers, to a slight extent on the ulnar aspect 
of the thumb. The zone extends up the radial side 
of the palm to a short distance below the wrist. 
(See diagram. ) On the dorsal aspect of the fingers, 
this zone is limited to the two distal phalanges. 
Area of insensibility to pain and temperature much 
smaller. A point of moderate tenderness to pres- 
sure on the anterior aspect of the wrist, directly 
internal to the tendon of the palmaris longus. Deep 
palpation here results in tingling sensations in the 
radial half of the hand. 

Diagnosis: Contusion, incomplete severance of 
median nerve at the wrist. 

Operation: October, 1914. Local anesthesia. 
Short vertical incision at tender point (the course 
of the median nerve at the wrist). Thin fibrous 
tissue over and rather intimately adherent to nerve. 
When dissected free, median nerve found congested 
and enlarged in a fusiform manner at the wrist for 
a distance of about three-eighths of an inch. In 
order to relieve the evident edematous condition of 
the nerve, a small incision was made into the 
sheath and the nerve fibers gently separated by 
blunt dissection. This resulted in the escape of 
some clear fluid and distinct reduction in the size 
of the fusiform swelling. Small strip of subcuta- 
neous fat placed over the nerve, wound sutured. 

Post-operative course: Very rapid improvement, 
beginning soon after operation. Pain disappeared 
within two weeks, area of tactile anesthesia began 
to shrink about one week later. At the present time, 
two iponths after operation, patient feels he is com- 
pletely cured : however, some tactile insensibility 
over index and middle fingers still remains, and 
full power has not as yet returned to the thunib. 
At the present rate of improvement the patient 
should be quite well in a short time. 

Case V: Abraham K., 51 years old, violinist. 
A small incised wound of palm of left hand, due to 
broken glass, was treated and healed promptly about 
two months before he came under my observation. 
At the time of injury, tingling in the middle and 
ring fingers for several days, disappeared for about 
three weeks, then returned. Return accompanied 
by burning sensations in these fingers which h'ive 
become progressively more painful. A certain stiflf- 
ness of the third and fourth fingers and, to a lesser 
degree, of the adjoining fingers, has developed, so 
that the patient has experienced "some loss of deli- 
cacy of touch in playing the violin." 

Examination: Slightly tender, short, transverse 
scar between heads of third and fourth metacarpal 
bones, on the left palm. Shooting pains in middle 
and ring fingers upon pressure over cicatrix. Skin 
over tlie adjoining surfaces of these fingers and 
their palmar surfaces tender to pressure, hypersen- 
sitive to pin prick: there appears to be small spots 
of tactile anesthesia in this hyperalgesic zone. No 
motor changes. 

Diagnosis: Either com])lete or incomplete divi- 
sion of the palmar digital branch of the median 
nerve, severe pain .suggesting the latter lesion. 

Operation: January, 1914. Local anesthesia. 
Small vertical incision surrounding scar. Latter 
deeper in subcutaneous tissues than expected. Cica- 



trix excised. Search for ner\e fruitless. All ves- 
tiges of scar tissue removed. Wound sutured. 

Post-operatiz'e course: Very satisfactory. Pain 
and paraesthesiae began to clear up soon after oper- 
ation ; stiffness of fingers improved to such an extent 
in three weeks that patient was able to pursue his 
professional work with very little discomfort. Ex- 
amination, two months after operation: Hyperalge- 
sic zone almost gone, a few scattered points remain- 
ing : replaced by a zone distinctly hyposensitive to 
touch and pin prick. About six weeks later, patient 
reported himself entirely well, but an opportunity 
for a detailed examination was not obtained. 

A number of other instances of injury of the dig- 
ital nerves has been observed ; these were not oper- 
ated upon, the end-results are unknown, and they 
will therefore not be reported. Llowcver, unoper- 
ated cases, observed in the Surgical Department of 
the Mount Sinai Hospital Dispensary, will be pre- 
sented because it is of interest in connection with 
the group of ca.ses under consideration. 

Case VI: Moses C, four years old. Weakness 
of right hand first observed at age of three. Has 
been progressive and accompanied by progressive 
wasting of hand and, to a lesser degree, of fore- 
arm. In the beginning frequent complaint of pain 
in hand and forearm ; much less after the first few 
months. Case appears to have been treated as one 
of anterior poliomvelitis. 

When examination of the ami disclosed a pro- 
tiounced valgus deformity of the elbow, the mother 
was questioned about its etiology. She had not 
noticed it and does not recall any injury. How- 
ever, when the patient was about two years old, he 
was treated for "rheumatism" of that joint, the 
symptoms — pain and swelling — having licen of 
some two weeks' duration. 

Examination: Valgus deformity of right elbow 
not present on left side. A small, firm, slightly 
tender, subcutaneous mass palpable at inner aspect 
of right elbow, in the approximate situation of the 
ulnar nerve. .Y-ray shows that there had been a 
supracondylar fracture that healed with consider- 
able deformity of the lower end of the humerus. 

Since the outcome of this case is unknown (oper- 
ation refused and patient disappeared from observa- 
tion), the detailed neurological examination will not 
be described. The findings were typically those of 
incomplete severance of the ulnar nerve at the elbow 
— impaired power of ulnar flexion and adduction, 
weakness of the interossei and of adduction of 
thumb, tactile anesthesia and diminished sensibility 
to pain in ulnar third of hand. 

Those cases have been presented in which my 
notes are complete and in which the end-results of 
operation could be determined, .'\lthough not nu- 
merous, they suffice to demonstrate that the nerves 
of the hand can be incompletely severed by insignifi- 
cant traumata: that the evidence of such severance 
is readily found in a routine examination for a 
nerve lesion: that the sequelae of such injuries may 
be serious, and that the results of simple operations 
are often satisfactory. 
1275 Madtson Avenue, 



Vol. XXIX, No. 4. 



Berens — Ambulant Meningitis. 



.\MKHICAN 

Joi-KNAi. or Sl-rgeky. 



147 



A.MBULANT OTITIC MENINGTITS.* 

T. Passmore Berens, M.D., F.A.C.S., 

New York. 



There seems to have been Dut little written on tliis 
subject. This statement must serve as my excuse 
for presenting the following cases, one in the service 
of Dr. Wendell C. Phillips, at the Manhattan Eye, 
Ear and Tliroat Hospital, operated upon and de- 
scribed by Dr. S. J. Kopetzky, and one operated 
upon by me in the same institution. To these I have 
added a few unpublished remarks on seventeen sim- 
ilar cases, including three of my own, by Dr. James 
G. Dwyer. 

R. F. .Admitted to the service of Dr. Wendell C. 
Phillips at the Manhattan Eye. Ear and Throat Hos- 
pital and operated upon by Dr. Samuel J. Kopetzky. 

Patient underwent a simple mastoid operation in 
the early spring for acute mastoiditis. The wound 
healed. leaving a persistent post-auricular fistula, 
for which the patient was readmitted to the hospital 
on September 4. 1914, for a plastic operation. 

The operation consisted in freshening the wound 
edges and approximating the skin surfaces and hold- 
ing them in place with metal sutures. 

From September 5 to September 9 nothing out 
of the ordinary was noted. On the tenth some 
headache was complained of and the temperature 
rose during the night to 104.6°. 

On September 11a blood culture found negative. 
Lumbar puncture gave the following: 

Physical : Heavy fioculi in clear fluid. 

Chemical : Copper reduction present and marked ; 
lactic acid very faint reaction. 

Cytology : An occasional lymphocyte present. 

Bacterial : Direct smear negative. Culture nega- 
tive at end of 24 hours. 

The temperature ranged between 103° and 105°, 
with remissions downward. No chills were noted. 
The pulse remained between 96 and 100, mostly 
around 80-96. The respirations remained at 24-28. 

The only complaint was headache at this time. 

On September 1? the abdomen became rigid and 
there was some stiffness of the back. Widal test 
negative. 

Two hours before the subsequent operations the 
patient became unconscious. 

On September 15 an exploratory operation was 
undertaken, preceded by lumbar puncture. 

The lumbar puncture gave the following results : 

Physical: Cloudy fluid. 

Chemical : Copper reduction absent : lactic acid 
present, marked. 

Bacterial : Smear revealed streptococci. 

The diagnosis of meningitis was thus substan- 
tiated. 

The exploratory operation showed the following: 

Cerebellum explored for abscess and found neg- 
ative. 

•"Report of Two Cases of Cerebrospinal Menin^'tis Presenting 
No Central Nervous Phenomena Until Shortly Before Death." 
Transactions American Otological Society, 1913. 



Lateral sinus opened aiui a thromljus found near 
knee, of small size. 

Bleeding obtained from botli ends. Jugular there- 
fore" not ligatcd. 

Decompression over teginen and cerebellum. 

The patient died September 18. No autopsy. 

The case is noteworthy for the following: 

1. The failure of the original wound to heal in 
the normal way after the simple mastoid operation. 

2. The patictu admitted for a plastic operation 
and in apparently good health recovers from the 
effects of this procedure and remains without inci- 
dent for almost a week. 

3. Complains of headache and gives temperature 
changes which prompt: (a) Blood examination; 
(b) cerebrospinal fluid examination: and these ex- 
aminations fail to show anything out of the normal. 

4. Two and a half days later lumbar puncture re- 
veals all the evidence of a fully developed strep- 
tococcus infection of the meninges; and the ex- 
ploratory operation reveals a thrombus. 

Comment : The meningitis probalily bad its origin 
in the infection of tlie sinus. 

July 24, 1914, Mr. X., a well-nourished, large 
man. 55, consulted me because of difficulty of 
hearing and a sense of fullness in his left ear. He 
claimed to have had almost no illness until the slight 
attack of grippe that put him to bed for several 
days about five or si.x weeks previous to his visit to 
my office. While convalescing from this attack 
he had been taken with pain in the left ear. which 
persisted for four days. As it grew better he no- 
ticed a slight discharge. 

Examination: There was an inconsiderable 
aiTiount of secretion in the canal and a slight droop- 
ing of the posterior superior wall of the left ear. 
Pressure by probe revealed that this drooping was 
evidently caused by an exostosis in the canal wall. 
There was almost no redness of the drum-mem- 
brane, which, however, appeared thickened and 
slightly bulging with a small nipple-like perforation 
in the posterior superior segment. No pain on 
pressure over the mastoid. Temperature 99°. No 
discharge from the nose, which appeared fairly 
normal. Hearing distance : Akoumeter, 3 inches. 
Weber to left. CH fork 25/25. 

Under local anesthesia a free paracentesis was 
performed and hot bichloride of mercury irriga- 
tions were ordered. .A culture was sent to the lab- 
oratory of the Alanhattan Eye, Ear and Throat 
Hospital. On July 27 the report on the culture 
v\as "Bacillus mucosus capsulatus of Friedlander." 
My notes at this visit read : "Patient is feeling con- 
siderably better ; there is only a slight discharge 
through the drum-membranes. Temperature nor- 
mal." 

Mr. X. was seen daily until .August 4. Each day 
the temperature was normal. At this time the hear- 
ing distance had increased to about 9 inches. The 
patient claimed that he felt decidedly better and 



148 



Ameruan 
Journal of Surgery. 



Derexs — Ambulant Meningitis. 



April, 1915. 



rather objected when I requested him to call the 
ne.xt day. 

On August 5 the patient complained of severe 
pains in the head especially in the vertex. He 
claimed that he had not slept since two o'clock that 
morning. Temperature 101.6°. There was abso- 
lutely no tenderness about the mastoid and no 
edema. There was slightly more discharge in the 
canal. The patient presented an expression of ex- 
treme anxiety and looked rather pasty. He was 
sent to the Manhattan Eye, Ear and Throat Hos- 
pital for mastoid operation. 

Upon my arrival at the hospital, about two hours 
later. I found that the pain in the vertex was de- 
cidedly worse. The patient complained very bitterly 
about it. His temperature had risen to 102.5° ; and 
because of experience in two similar cases I decided 
to examine the cerebrospinal fluid by means of a 
Uinibar puncture. In spite of the fact that no phys- 
ical sign or symptom pointed to involvement of the 
cerebrospinal system, the lumbar puncture (which 
was performed by Dr. J. G. Dwyer) brought forth 
a milky-colored fluid under pressure. About 10 c.c. 
were obtained. A hasty microscopical examination 
revealed pus. 

While this examination was being made by Dr. 
Dwyer I proceeded to perform tlie mastoid opera- 
tion. The mastoid process was small and exten- 
sively eburnated, excepting in the region of the 
sinus where the bone was slightly softened. The 
sinus was freely uncovered and found to be per- 
fectly normal in appearance. There was also slight 
softening of the bone in the region of the tegmen, 
where the dura was freely exposed and found to be 
of perfectly normal appearance. The antrum was 
extremely small. It contained pus, but no granula- 
tions. The posterior canal wall was removed and 
an exostosis found on it. The internal ear was not 
disturbed. The patient's condition was bad ; his 
pulse was very rapid and weak, and it was consid- 
ered inadvisable to open the dura. Dr. Dwyer 
injected 45 grains of urotropin into the spinal canal, 
whereupon the pulse regained considerable of its 
fullness and regularity. 

The following morning the patient complained 
much of pain in the vertex. Cerebration was some- 
what delayed, but his answers were clear, and Ker- 
nig and P.abinsky tests were negative. His tempera- 
ture rose to 104°, and that night he gradually went 
into a state of coma, in which he died on August 7. 
A post-mortem examination was not allowed. Ex- 
amination through the wound failed to reveal any 
abscess in the brain. 

Dr. Dwyer's report on the cerebrospinal fluid was 
as follows : 

Physical: A turbid fluid: heavy precijMtate upon 
centrifuging. 

Chemical : Copper reduction absent ; lactic acid 
present. 

P.acterial: Bacillus mucosus capsulatus of Fried- 
lander. 

Culture: The same organism. 

Cytological: Mainly polynuclcar; some large 
mononuclear. 



The case is remarkable because of : 

1. The normal temperature for 11 days, i. e., until 
two days before death. 

2. No visible point of entrance of the infection 
from the middle ear or mastoid. 

3. Complete lack of clinical symptoms until the 
headache and elevation of temperature appeared, 
only a few hours before the cerebrospinal fluid was 
found to be milky, indicating either an extremely 
rapid infection, or that the infection of the men- 
inges had been present a considerable length of 
time, perhaps days. 

Dr. James G. Dwyer allows me to quote from an 
unpublished paper the following: 

"During the past two years there have come un- 
der the notice of the writer seventeen cases of men- 
ingitis, in which the only method of diagnosis was 
by lumbar puncture, as none of these cases pre- 
sented the clinical picture of meningitis so that the 
diagnosis could not be made by the usual means, 
that is, the usual clinical means. In many of the 
cases it was only in the routine bacteriological and 
cytological examinations that the condition was 
diagnosed. In most of these cases, as far as could 
be gleaned from their histories, and as far as could 
be judgfed from the cerebrospinal fluid, the menin- 
gitis had lasted for as long as two weeks, the patient 
going about his ordinary business as usual : and it 
was only when coma or delirium supervened that 
attention was directed to the meninges. In none 
of these cases were any of the ordinary symptoms 
present; the leucocyte and differential count were 
above the normal, but not like that found in the ful- 
minating or classical type. There were no symp- 
toms of pressure ; in short, were it not for the 
cerebrospinal fluid findings, the patient would seem 
to be on the road to recovery. It was noted that in 
some few of the cases operative interference seemed 
to cliange the character to a more active form, but 
this was not always noted, and several of the pa- 
tients died in full consciousness. 

"All of these cases showed capsuled organisms ; 
the majority showed streptococcus mucosus capsu- 
latus, and two showed the bacillus mucosus capsu- 
latus or Friedlander bacillus. In all, the fluid was 
very turbid just before death, and in most from 
the beginning. All of the usual tests — chemical, 
bacteriological and cytological — were done on these 
fluids, so that the whole presents a very interesting 
and instructure picture. 

"These cases are reported because is shows the 
necessity of routine laboratory aids and draws our 
attention to a particular form of meningitis which, 
while answering to the general characteristics of 
meningitis as we know it from the laboratory stand- 
point, gives us no clue as to the actual condition 



Vol. XXIX. No. 4. 



Johnston — Rhinoplasty. 



American 
Journal op Surgery. 



149 



present from the clinical standpoint ; and the early 
recognition of this will at least help us in our prog- 
nosis if in no other way. It also shows the neces- 
sity of cultures being taken in all of our operative 
cases ; and if any of these capsuled organisms are 
found, our attention will be directed more quickly 
to any possible complication. 

"The question arises, Why do we have this pic- 
ture with this group of organisms? The answer is 
hard to find, but we must remember that an organ- 
ism with a capsule is very highly protected against 
the action of the anti-bodies, that the capsule acts 
as a protective wall to the organism and thus hin- 
ders to a certain extent the ordinary protective 
factors." 

As I said before the Otological Society two years 
ago.t the only reference I could find in literature 
to this class of cases is that by Brieger, quoted by 
Preysing in the Transaction of the German Otolog- 
ical Association, 1912 ; and I take the liberty of 
again using the same quotation : 

"In many cases of suppurative meningitis we see 
all the symptoms disappear after opening the laby- 
rinth and after repeated lumbar puncture. I have 
seen such cases, which appeared almost in the last 
stages, seemingly completely recover. They got up 
out of bed, walked about, felt perfectly well ; and 
we were astounded to see that within a few hours 
after a condition of apparent complete well-being, 
death should supervene. Autopsy revealed that in 
some cases there occurred in parts of the subarach- 
noid space, inaccessible to lumbar puncture or to 
other exploratory methods, a widespread plastic in- 
filtration, while in other cases there existed, in addi- 
tion to these localized infiltrations, diffuse inflam- 
mation of the meninges. ■■ 

It seems, then, that there is a type of meningitis 
purnlenta, w'hich from its complete lack of symp- 
toms is quite distinct from the picture we usually 
find in the text-books and rarely in the general lit- 
erature on the subject. If we can accept the term 
"ambulant typhoid." why not call this "ambulant 
meningitis" ? 

These cases teach the necessity for bacterial ex- 
amination, and accent the fact of the gravity of 
infections due to capsuled organisms. Headache, 
though not severe, in the presence of a discharging 
ear. should excite our gravest fears. Lumbar punc- 
ture, though perhaps an admission of weakness of 
our diagnostic skill, must be resorted to in order to 
establish a diagnosis ; and will prove invaluable in 
forming a correct prognosis. 

35 Park Avexue. 



TOTAL RHINOPLASTY: A CASE REPORT. 
RiCH.'MiD H. Johnston, M.D., 

B.\LTIMORE, Md. 



In November, 1913, I was consulted by R. A., 
25 years old, native of Canada, who gave the fol- 
lowing history: Up to the time of his accident he 
had been generally healthy. He had had no venereal 
disease. Three years before I saw him, while 
working in a saw-mill, he was drawn against the 
saw in a manner which he could not explain. He 
thought he was sucked down by the force of the 
saw-. In falling he threw his head to the right, 
which probably saved his life. The left biceps 
muscle was removed to the humerus ; the nose was 




tRead before the Eastern Si'ction of the Amcrtcan Larytigolog- 
ical, Rhinological and Otological Society, 



Fig. 1. 

cut entirely off, the lower lip was cut ofif to the 
lower border of the inferior maxilla, while the upper 
lip was cut through to the right of the middle line 
and hung down on the right side. The left upper 
lip was cut away from the bone, the forehead had 
several cuts on the left, and the left cheek was cut 
into ribbons. Unfortunately, the physician who 
saw him afterwards did not re-attach the nose, al- 
though it was found and preserved for some time. 
He sutured the cheek, forehead, and upper lip. 
.Xothing was done to the lower lip, which was com- 
pletely cut away, as described. The patient was 
removed to a hospital, where for a time his condi- 
tion was critical. After five months he was able 
to go to his liome, where for a year he was practi- 
cally an invalid. During this time he had no con- 
trol over his lower lip. so that saliva constantly 
dribbled from his mouth. After his recovery his 
appearance prevented his getting a position. 



150 



American 
Journal of Surgery. 



loHXSTON — Rhinoplasty. 



April, 1915. 



When I saw the patient his condition was as 
follows: The nose was shaved off on the left side 
even with his cheek, while on the right a slight 
projection of bone and cartilage could be seen. The 
mucus membrane of the interior of the nose was 
exposed, revealing what was left of the bony sep- 
tum and the inferior and middle turbinated bodies. 
The mucous membrane still performed its func- 
tion and preserved its glistening appearance after 
an exposure to the atmosphere of three years. To 
hide the deformity the patient wore a gauze shield. 
The scars in the forehead and cheek were distinct. 
The left eye could not be entirely closed because 
of the scar on the upper lid. The lower lip was 
made up entirely of scar tissue, which was tightly 




Fig. 2. XX — Cartilage iindt-T tlie skin. aaa — Line of on which 
skin was later dissected up and turned into opening, bbb — Flap 
for making new nnse, 

adherent to the bone from the teeth, which were 
exposed to the mental process. The upper lip 
showed a hare-lip to the right of the center, expos- 
ing the teeth ; the scar tissue was not so extensive 
as in the lower lip. .\11 these lesions are shown in 
photograph 1. 

Because of the numerous scars on the face I pro- 
posed to plant a ])iece of cartilage under the skin 
of the left forearm and two months later to trans- 
plant the flap to the remains of the nose. When I 
explained to the patient that the arm would have 
to be held in a cramped position for two or three 
weeks before cutting the flap away, he refused to 
submit to it. He insisted that the flap be taken 
from the forehead, though it would add another 
scar. 

On December 29, 1913, I exposed the left eighth 
rib and removed a ])iece .of cartilage, 1.3 inches 



long, which was pared down to a thickness of 5mm. 
and notched slightly % of an inch from one end. 
An incision was then made through skin and perios- 
teum a little above the center of the left forehead, 
1.2 inches from the middle line. With a sharp ele- 
vator the periosteum was raised from the bone and 
the cartilage slipped underneath it. The skin was 
then sutured. The transplantation of the cartilage 
is shown in photograph 2. 

In order to allow plenty of time for the cartilage 
to attach itself to periosteum, the final operation 
for the restoration of the nose was delayed until 
March 12, 1914. The first step in the second oper- 
ation was dissecting up the skin on the two sides 
of the remains of the nose (Fig. 2). The flaps 




were turned into tlie facial opening, skin surface 
down and sutured in the middle line so that the 
raw surfaces would quickly unite with the raw sur- 
faces to be brought down from the forehead. The 
skin flaps helped also to form a foundation upon 
which the new nose was to be built. The flap for 
the formation of the nose began at the inner end 
of the right eyebrow and continued up to the hair 
line and then across the forehead to the end of the 
transplanted cartilage ; from this point it passed 
downward and inward above the left eyebrow to 
the root of the nose. The skin was dissected away 
from the periosteum up to the cartilage, which was 
removed from the bone with its strip of attached 
periosteum. The flap was then turned down with 
raw surface below. The upper end of the cartilage 
was stitched above to hold it stationary, while below 
it was bent at the notch referred to above so that 
the lower end was sutured into an incision of the 



Vol. XXIX, No. 4. 



MiERS — PiEMATOiMA OF THE FaLLOPIAN TuBE. 



American 
Journal of SuROERy. 



151 



upper lip, the nose would project from the face. 
The flap was split in the middle line up to the car- 
tilage. After this was done the two edges of the 
flap were sutured to the raw surfaces on the sides. 
The two lower flaps, formed by splitting the skin 
to the cartilage, were turned up into the nostrils 
and held in place by pieces of rubber tubing in- 
serted on each side of the cartilage. The flap from 
the forehead was made large to allow for shrink- 
age and because the patient wanted a large nose, 
which was a family characteristic. The flap was 
nourished by the bridge of skin left between the 
eyebrow. The nose w-as covered with iodoformized 
gauze held in place with adhesive strips. 

The first dressing was made five days later and 



HEM.-VTOAIA IX THE i-ALLOPlAxX TUBE 
WITH PROLONGED UTERINE HEM- 
ORRHAGE: A CASE REPORT. 
E. M. AIiERs, AI.D., 
Harper, Kans.as. 




the nose was found in good condition with sensa- 
tion highly developed. The stitches were removed 
on the twelfth day. On April 28 the wound of the 
forehead was scraped and covered with Thiersch 
skin grafts from the inner thigh ; two of them took 
well, but the third sloughed. To build up the lips 
and to give the patient a mouth with which to eat 
and to talk properly, many operations were re- 
quired because of the excessive amount of scar 
tissue. 

The final result of the operations is shown in 
photographs 3 and 4. While the new nose is by 
no means perfect, the foundation is such that suc- 
cessful operations to shape it and to reduce its size 
can be done at any time. After having had no 
nose for three years, the patient was well satisfied 
with the result. 

807 Xdrth Charles Street. 



Mrs. K., housewife, age 27, entered the Walker 
Hospital at .Anthony, Kansas, December 22, 1914. 
Slie had always been well except that she had long 
had leucorrhca. .Soon after her marriage dysuria 
developed and the leucorrhea increased, staining her 
clothes. She was married at 19, has two living 
children. Her father died of apoplexy; the remain- 
ing family histor\- is of no interest. 

Three years ago she had a miscarriage at seven 
months : and nine months later another miscarriage 
at six months. Two years ago she was suddenly 
seized with pain in the back and lower right iliac 
region ; she began flowing at once, not severely but 
with small clots and watery blood. She had chills 
and fever. A physician diagnosed appendicitis. 
With this attack she was confined to her bed for 
two days, after which she felt well, but had recur- 
ring pains, which she said were like colic, sometimes 
lasting a minute and at other times an hour. She 
flowed constantly from this attack to the time of 
admittance to the hospital, a period of two years, 
the flow consisting of small black clots, the size of 
a pea, and watery blood, necessitating her wearing 
a napkin constantly. .A.t her menstrual periods, 
which were regular, there was a profuse flow last- 
ing six to nine days, with much pain, witli bearing- 
down sensations. 

What was the cause of the hemorrhage? Could 
this woman have had an extra-uterine pregnancy 
witli hemorrhage from the uterus? The history of 
the case would indicate this, but the duration of 
the existing conditions, the constant hemorrhage, 
and the absence of shock would not support this 
conclusion. Can we connect the early marital 
symptoms — increased discharge, dysuria, and dull 
bearing-down pain — with secondary salpingitis due 
to gonorrheal infection, which the husband admits 
having? This would account for the dysmenorrhea 
and peculiar colicky pain, but what of the hemor- 
rhage? Could the pus cause an erosion of the mu- 
cous membrane with oozing hemorrhage in tube 
and uterus ? 

Physical examination: A frail, weak, emaciated 
patient. Two years ago she w'eighed 118 pounds, 
now she weighs 83 pounds ; pupils widely dilated, 
reacting to light normally; pulse 132; temperature 
normal ; anxious expression ; chest negative ; abdo- 
men flat; pain on deep pressure over right iliac low 



152 



American 

Jot'BNAL OF Surgery. 



MiERS — Hematoma of the Fallopian Tube. 



April, 1915. 



down ; no rigidity ; vagiiuil examination showed 
small clots of blood and watery blood ; also purulent 
mucous exudate ; no external tears or abnormality ; 
cervix slightly lacerated, soft and admitting little 
finger; uterus somewhat enlarged, movable, normal 
position : left tube and ovary apparently normal. 
There was a mass in the right side, ciuite large, mov- 
able and not very tender. Abdomen otherwise neg- 
ative. Urine negative. 

In all cases of extra-uterine gestation are found 
symptoms that simulate normal pregnancy, of which 
she had none. In ectopic gestation there is usually 
a history of long standing sterility with manifesta- 
tions of endometritis, suppressed menses, increase 
in size of the abdomen and breasts, and digestive 
disturbances, such as nausea and vomiting, occur- 
ring at an early date. There are two signs sug- 
gestive of ectopic gestation : "First, bloody di.=- 
charge: second, peritonitic phenomena." The latter 
present themselves with pain, more or less sharp, 
in the lower abdomen, radiating to the loins and 
back and recurring at every menstrual period, sim- 
ulating in a degree labor pains, accompanied by 
enlargement of the abdomen, very sensitive to pres- 
sure and requiring the patient to go to bed. The 
bloody discharge is often accompanied by expulsion 
of the decidua in part or complete. This condition 
is often diagnosed miscarriage. A tumor situated 
on either side of the uterus, or posteriorly, is only 
pathognomic of tubal gestation when accompanied 
by sharp, colicky, localized, recurrent pain, history 
of sterility, signs of pregnancy, and — if ruptured — 
by the usual signs of hemorrhage, with faintness 
and rapid pulse. This simulates our case if we dis- 
regard the long duration of the symptoms, although 
I cannot tell the length of time this mass had ex- 
isted. The history would lead one to suspect ectopic 
gestation from the start. 

I operated December 26. Ojiening the abdomen 
revealed considerable free fluid — bloody serum with 
clots in Douglas' cul-de-sac. The left ovary and 
tube were normal : the right tulie was sausage- 
shaped, five inches long, and of a diameter about 
that of a silver dollar. The tube w'as ruptured on 
tlie upper surface near the fimbriated extremity, 
and contained a large black clot of blood. The 
right ovary was cystic and contained a hematoma. 
Tube and ovary were removed. Tlic patient made 
a good recovery, and all symptoms disappeared. 

Probably this was a case of ectopic gestation with 
expulsion of the decidua and fetus cither through 
the uterus or into the peritoneal cavity with ab- 
sorption; at any rate, no trace of them was found. 
1 think, however, that we cannot exclude the possi- 



bility that salpingitis might have caused an erosion 
of the mucous membrane, producing an oozing hem- 
orrha£;e and formation of clots. 



The Misuse of the Catheter in Correcting 
Ossicular Rigidity. 
An experience of years with catheter-inflation 
has convinced me that the frequent routine use of 
the catheter as a nwaiis of correcting ossicular 
rigidity is based on a false conception of the mech- 
anism involved. The theory on which it is used is, 
of course, obvious, viz., that the act of inflation 
moves the drum membrane and with it the ossicles, 
thereby tending to restore their normal mobility. 
The beginner in otology is often enthusiastic over 
the distinct functional gain following a first or sec- 
ond inflation, and is at a loss to explain his failure 
by the same means to obtain continued and pro- 
gressive improvement of hearing. The explana- 
tion of this phenomenon is that the first few infla- 
tions in the case of an individual whose ears have 
not been under recent treatment often do result in 
the breaking or at least modifying of small intra- 
tympanic adhesions, with consequent improvement 
of sound transmission. If continued as a routine 
measure the force of the inflations are exerted more 
and more in the direction of stretching the drum 
membrane while exerting progressively less influ- 
ence on the ossicular chain. Used too frequently 
or too forcibly, and continued over a considerable 
period of time, the net result is a disturbance of the 
tone or balance of the conducting mechanism far 
outweighing the influence of the comparatively 
small movements of the ossicular chain. — Philip 
Kerrison in The J. A. M. A. 



Renal Infection. 
In tile hyperacute and even in many of the acute 
and chronic cases of renal infection, the local signs 
are often completely masked by the general symp- 
toms of septic intoxication or by the even more 
common fact of the patient's referring all the symp- 
toms to the bladder ; and thus those who do not 
know some of the multicolored garments under 
which renal infection disguises itself are apt to 
overlook the golden period at which the kidney 
itself, the real seat of the trouble, might receive aid 
and thus avert either complete destruction of the 
organ of one side, or prevent the spread of the 
infection to the other. — D. N. Eisendratii in the 
Interstate Medical Journal. 



Vol. XXIX. No. 4. 



Editorials. 



American 
Journal of Surgerv. 



153 



Amprtran 3lountal nf ^urgr rg 



1 [ P H\ I It I-. 



SURGERY PUBLISHING CO. 

J. MacDONALD. Jr.. M. P.. President and Treasurer 

92 William St., N. Y., U. S. A. 

to whom all communications intended for the Editor, original 

articles, books for review, exchanges, business letters 

and subscriptions should be addressed. 

SUBSCRIPTION PRICE, ONE DOLLAR 
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We cannot hold ourselves responsible for non-receipt of the Journal 
in such cases unless ue are thus notified. 

ILLUSTRATION'S. Half-tones, line etchings and other illus- 
trations will be furnished by the publishers zvhen photographs or 
drawings are supplied by the author. 



C? SPECIAL NOTICE TO SUBSCRIBERS ^3 
The "American Journal of Surgery" is never sent 
to any subscriber except upon a definite written order. 
Present and prospective readers please note this. 

WALTER M. BRICKNER, M.D., Editor 
Xew York, April, 1915. 

SIMPLE METHODS OF BLOOD TR.W'S- 
FUSION. 

The transfusion of blood has been amply estab- 
lished in therapeutic value in a variety of condi- 
tions; and yet, because of the technical difficulties 
in the operation that have heretofore obtained, the 
procedure has not come into that general employ- 
ment which its often life-saving service deserv^es. 
Technically, the easiest method of transferring the 
blood was, until recently, the syringe method ol 
Lindeman. But that, too, is very far from simple ; 
it requires a very nice technic, trained assistants, 
and numerous expensive, easily-broken syringes. 
Without very great care the cannulae, frequently 
handled and pushed and pulled upon by the syringes, 
are apt to become dislodged ; and clotting in syringe 
or cannula is often the experience of the inexpert. 

Recently Lester J. Unger, an interne in Mt. 
Sinai Hospital, Xew York, has greatly simplified 
the syringe transfusion method, reducing the num- 
ber of syringes to two, obviating the handling of 
the cannulae, and so accelerating the procedure 
that a thousand cubic centimeters of blood can read- 
ily be transferred in five minutes. To accomplish 
this he uses a double two-way stop-cock. 

As described by him in the Journal of the Amer- 
ican Medical Association, February 13, 1915, "it is 
a stop-cock, which alternately connects a syringe 
for blood to the donor and at the same time a 
syringe with saline to the recipient; then by turning 
the cock the syringe with blood is immediately con- 



nected to the recipient an<l the syringe with saline 
to tile donor." 

The 20 c.c. syringe for as])irating and injecting 
the blood fits directly into an opening in the small 
current-directing mechanism ; the recipient's and 
donor's cannulae and the syringe for saline solu- 
tion (a single barrelful is sufficient for the trans- 
fusion) are connected with this switching mechan- 
ism by paraffined rubber tubes. It will l)e readily 
seen that the employment of this apparatus, which 
requires no special skill, is vastly simpler than trans- 
fusion lay the method of Lindeman or by the anasto- 
mosing of blood-vessels with sutures (Carrel), or 
special cannulae (Crile, Elsberg, Soresi). 

But in order that the transfusion of blood may 
be employed whenever and wherever emergencies 
may require it, it must be possible not only without 
any special skill, but also without any special appa- 
ratus. In other words, it must be as readily per- 
formable as an intravenous saline infusion, the few 
paraphernalia for which are everywhere easily pro- 
curable. That transfusion inay be reduced to the 
same simple procedure as infusion, it is only neces- 
sary to keep the blood fluid. To accomplish this 
defribination has been employed, which, however, 
deprives the blood of important constituents. The 
search for a safe anticoagulant therefore suggested 
itself. Leech extract (hirudin) is too toxic if mixed 
in sufficient amount to prevent clotting of the whole 
blood used (Satterlee and Hooker used it in small 
amounts to prevent clotting in syringes). Sodium 
citrate, much used in laboratory tests as an anti- 
coagulant, was found safe in the necessary amount 
(0.02%) by Hustin of Brussels, who reported 
(Annates ct Bulletin de la Socictc Royale des Sci- 
ences Medicales, May, 1914) the successful injec- 
tion into a patient of blood mixed with a solution 
of sodium citrate and glucose. 

\\^ithout knowledge of Hustin's work or of each 
other's, two New York investigators, Richard Weil 
and Richard Lewisohn, also, and simultaneously, 
arrived at the employment of sodium citrate as the 
means of simplifying transfusion by maintaining 
the fluidity of the blood. They both found, too, 
that, curiously enough, the sodium citrate intro- 
duced with the donor's into the recipient's blood 
does not reduce the coagulability of the latter 
(which would be a serious objection in many cases) 
but actually increases it. 

Weil reported {Journal of the American Medi- 
cal Association, January 30, 1915) the syringe in- 
jection into human patients of small amounts of 
blood (10 to 350 c.c.) kept fluid, in an ice-box, by 
a 1% admixture of sodium citrate. 



154 



American 

ToURNAL OF Surgery. 



Surgical Suggestions. 



.\PRIL, 1915. 



Lewisohn went further. He transfused larger 
amounts (1,000 to 1,200 c.c.) of fresh blood mixed 
with a solution of sodium citrate to form a 0.2% 
dilution of the latter, which, like Hustin, he found 
by experiment sufficient to keep the blood fluid 48 
hours or more. Lewisohn's method is exceedingly 
simple, obviating even the use of syringes. x'\s de- 
scribed in the Medical Record. January 23, 1915, 
he allows the blood to run from the donor's vein 
through an ordinary cannula or large needle into 
a glass jar, containing five c.c. of 10% sodium 
citrate solution. While the blood is running into 
the jar it is stirred with a glass rod to effect a good 
mixture of blood and citrate solution. The blood 
is then poured into an ordinary glass funnel or sal- 
varsan jar which is connected by a piece of rubber 
tubing with the cannula or needle in the recipient's 
vein. Surely a simple method of transfusion — 
quite as simple as, if not more simjjlc than, the in- 
travenous injection of salvarsan. 

Accumulating e.xperience has thus far shown no 
danger in the use of citrate blood and it appears 
to be quite as effectual as unmixed blood. In ad- 
dition to its great sim|)licity, the transfusion of 
citrated blood has the advantage over Crile's 
method that, like Lindeman's and Unger's, the 
amount of blood introduced can be accurately meas- 
ured, and it has the further advantage over all 
these methods that it can be conducted leisurely 
and without the simultaneous presence of donor 
and donee — indeed, the blood can be carried from 
the donor's home to the patient's. 

It is interesting to note that there has appeared 
another claimant for honors in the transfusion of 
citrated blood. In the Medical Record, February 
27, 191.=^. G. A. Rueck of New York says that he 
conceived the idea in January, 1914, and carried it 
out experimentally on rabbits in that month, ani 
in May, 1914. injected a patient with 250 c.c. of a 
blood-saline solution — sodium citrate mixture. On 
these accounts he "claims to be the originator of this 
method of blood transfusion" — which quite ignores 
Hustin (another indignity to Belgium!) 

Blood transfusion has at last been transformed 
from a tedious, delicate, and often difficult surgical 
operation to a simple procedure that can be con- 
ducted almost anywhere and by any physician. 

With Unger's apparatus unmixed blood can be 
readily and quickly transferred from one person 
to another. Without tliat, or any special apparatus, 
citrated blood, which appears to be equally service- 
able, can be transferred by the method of Lewisohn 
— to date the simplest of all transfusion procedures. 
— W. M. B. 



Surgical Suggestions 



Do not be hasty in urging operation for exoph- 
thalmic goiter. Even bad cases sometimes recover 
completely under conservative treatment. 



When cough, emaciation, fever, and hemoptysis 
are not associated with tubercle bacilli in the spu- 
tum, consider neoplasm of the lung. Metastastic 
sarcoma of the lung may give the same physical 
signs of localized tuberculosis. 



In all varieties of acute tubal and adnexal infec- 
tion radical operation is often unnecessary and un- 
desirable. Many so-called "pus-tubes" get well 
without operation or subside into a chronic state. 



Pure forward subluxation of the head of the 
humerus can occur from mild violence and it is 
one of tlie occasional causes of shoulder disability. 
It is reduced by abduction, and continuous abduc- 
tion for two weeks will cure it. 



Keeping tally of the ]>ads and sponges used and 
discarded during a la[)arotomy puts a serious re- 
sponsibility and a great strain upon the nurses and 
always carries the chance of an error in calculation. 
Moreover, if a sponge or pad is unaccounted for it 
entails a manual search among the patient's viscera 
and in the pile of discards. It is simpler and safer 
to leave no untaped sponge entirely within the cav- 
ity, even for a brief period, and to use as pads and 
packings only those that are long enough to so far 
protrude from the wound that they cannot be lost. 



The following is a very simple and often sur- 
prisingly effective method of securing abduction in 
the treatment of shoulder disability: In a semi- 
recumbent position in bed the patient abducts his 
arm on the pillow as much as he comfortably can. 
A bandage sling is looped lightly about the wrist or 
the elbow at one end and tied to the head of the bed 
at the other. The head of the bed is then raised on 
chairs. .As the patient gradually slides down, the 
arm travels (relatively) up alongside his head. By 
this means persistent and marked abduction dis- 
ability is sometimes cured in twenty-four hours. 



Vol. X.XIX, No. 4. 



Surgical Sociology. 



America.s 
Journal of Surgery. 



155 



Surgical Sociology 

Ira S. Wile, M. D., Department Editor. 



Cancer and the Simple Life. 

The ravages of cancer continue to excite interest 
•and research while the death rate apparently con- 
tinues to advance. During 1913, cancer and other 
malignant tumors caused 49,928 deaths in the reg- 
istration area, corresponding to the death rate of 
78.9 per liundred thousand population. The rapid- 
ity with which the mortality rate from this disease 
has increased is well evidenced by the fact that the 
death rate per hundred thousand population in 1900 
was only 63. It is undoubtedly true that a con- 
siderable proportion of this increase is due to im- 
provement in diagnostic methods and more frequent 
operations with the definite diagnosis established 
on the operating table. 

When it is appreciated that since 1900 the death 
rate from tuberculosis of all forms has decreased 
from 201.9 to 147.6 in 1913. while the typhoid mor- 
tality has fallen during the same period of time from 
35.9 to 17.9. it is patent that some unusual process 
is developing in the community making for a higher 
mortality from malignant diseases, while infectious 
diseases are apparently coming under the control of 
modern sanitary science. 

The general attitude towards carcinoma has been 
to recognize it as a surgical condition demanding 
prompt attention, and stress has been placed upon 
the importance and necessity of early diagnosis. 
Bulkley. in his recent book on Cancer, registers his 
objections to considering malignant tumors as sur- 
gical conditions and indicates that inadequate atten- 
tion has been given to the medical considerations 
involved before and after operation. It is timely 
to draw attention to the fact that operations merely 
remove the results of the disease and that the appli- 
cation of the .r-ray, radium, caustics, and various 
other procedures fails to reach the root of the diffi- 
cuhy. 

It is true that traumatism is not the whole cause 
of cancer, and that its parasitic origin has not been 
demonstrated. The definite place of heredity and 
occupation in the etiology of cancer has not been 
ascertained. Similarly, it is true that carcinoma is 
not limited to the aged nor does it spend its effects 
upon any particular sex. race, or class of persons, 
nor in any particular section of the world. 

In view of the negative results which thus far 
have attended our researches. Bulkley arrives at 
the conclusion that deranged metabolism is "the only 
possible etiological element.'' 

It may be true that the incidence of cancer appear 
to increase along the line of modern civilization, but 
it does not necessarily follow that there is anv dis- 
tinct relation between our civilization and cancer 
growth. The facts that living conditions are more 
complex, that the consumption of coffee, meat, and 
alcoholic beverages appears to be increasing, and 
that living is more of a nerve strain than in pre- 



vious decades, hardly suffice to indicate a casual 
relation. It might be equally true that the inci- 
dence of cancer has increased in direct proportion 
with the increase of the wheat crop or the produc- 
tion of gold. 

The dangers of argument by post hoes are every- 
where recognized. It is possible that as great errors 
may be committed in judging modern living condi- 
tions to be the cause of cancer as in the ancient view 
that malaria was merely a form of paludism or 
yellow fever was caused by vitiated air. 

In the I'nited States economic conditions vary 
considerably and standards of living must naturally 
be altered by the degree of prosperity. The stress 
and strains of living will vary in different States of 
the Union according to the industries employing the 
bulk of the population. Similarly, the relative dif- 
ferences between living in cities and rural sections 
ought to evidence some relation to the cancer mor- 
tality providing the incidence of cancer is largely 
dependent upon the conditions under which people 
live. 

In considering the cancer mortality rate of the 
United States the only really significant fact evi- 
denced is that it appears to be lower among the 
colored people than among the white. For example, 
the death rate from cancer in 1913 for the regis- 
tration area was 78.9. but for the whites it was 80 
and for the colored 57.3 Contrasting the cities in 
the registration areas, the total mortality rate was 
87.8. for the whites 88.4 and colored 72.9. In the 
rural parts of the registration States the total mor- 
tality 69.4, for the whites 70.7 and for the colored 
42.2. Here is an opportunity for bio-chemistry to 
investigate the differences between the white and 
the colored which induces a possibly greater immu- 
nity on the part of the colored people. 

From these same figures, it is also significant 
that the mortality rate from cancer appears to be 
higher both for the white and colored population in 
cities than in rural parts of registration States. This 
need not necessarily indicate, however, that the com- 
plex living of the city is responsible for the higher 
mortality rate from cancer or that it possesses any 
specific casual relation to it. The relative mortality 
in urban districts as compared to rural districts 
holds true for all causes of mortality and is par- 
ticularlv noticeable in such diseases as measles, scar- 
let fever, diphtheria, tuberculosis, rheumatism, men- 
ingitis, bronchitis, diarrhea, appendicitis, hernia, cir- 
rhosis of the liver. Bright's disease, puerperal fever, 
congenital debility, and even suicide. It is. there- 
fore, suggestive that, while the rural sections of the 
community apparently possess a lower mortality 
rate for many diseases, the underlying conditions 
incident to this fact are general in their nature and 
in no wise specifically related to any single disease. 

Bulkley makes the following statement : "The 
simple life, with the avoidance of the dietetic and 
other causes which have been found to induce can- 
cer in nations and individuals, promises the best 
hope for the arrest of the rapidly increasing devel- 
opment of cancer throughout the world." While it 
is undoubtedly true that the return to the simple 



156 



American 

Journal of Subgerv. 



Book Reviews. 



April, 1915. 



life might cause a decrea.se in many of the diseases 
due to dietetic irregularities and metabolic inactivi- 
ties, it still remains to be shown that this simplicity 
of living will decrease the cancer morbidity more 
than that of any other cause of death. 

Until the cause of tuberculosis was demonstrated, 
heredity was held to be as important a factor in its 
etiology as unsanitary living conditions. When 
modern science eventually discovers the causative 
factor of cancer, it will be possible to decrease the 
morbidity which will lead to a fall in the mortality 
rate. Until such an epoch-making discovery is 
achieved, early diagnosis and prompt surgical atten- 
tion is the most satisfactory procedure for attacking 
the huge problem. It may be true that fully ninety 
per cent, of those who have once been affected with 
cancer die of it. It is also indubitable that the gen- 
eral mortality rate from this disease is increasing 
despite of our surgery, but longer periods of life 
are granted to those who submit to tlie earlv opera- 
tions than would be possible without such operative 
procedures. 

It is most reasonable to believe that various forms 
of medical and dietetic treatment, now empirical in 
nature, may have a distinct influence upon carci- 
noma. If abstinence from meat or a full vegetarian 
diet is productive of a greater resistance to carci- 
noma, a most interesting field of investigation is 
open in order to ascertain the reason for the in- 
creased resistance to the disease. Until, however, 
some direct causal relation is demonstrated between 
diet and cancer, communities are safer in clinging 
to the belief that immediate surgery is of greater 
value than experimentation with variable systems 
of dietetics. Modern surgery is a palliative of can- 
cer, occasionally a cure for cancer, and may be in a 
few selected instances a preventive of cancer, al- 
though the last is never .susceptible of proof. 



Book R 



eviews 



Obstetric Nursing. A Manual for Nurses and Stu- 
dents and Practitioners of Medicine. By Ch.^rles 
-Si.-MMKK ISacon. Ph.B., M.U., Professor of Obstetrics, 
University of Illinois and the Chicago Polyclinic. Duo- 
decimo : 3S5 pages ; 123 illustrations. Philadelphia and 
New York:LE.i & Febicer, 1915. 

It is a pleasure to have read this book. The reviewer 
knows no book in the Englisli language dealing with this 
subject that has so much received the personal touch of 
the author. The title of the book is very modest. While 
pnmardy written for nurses, it is safe to sav that all phy- 
sicians may read it with a great deal of profit to them- 
selves and not a little lienefit to the patient. The three 
opening chapters deal with the <Iutics of the nurse to her- 
self, to the physician, and to the patient. The advice given 
cannot fail to improve the eflicicncy of the average nurse, 
The entire domain of obstetrics is covered from the view- 
point of caring for the obstetric patient and her infant. 
While an exhaustive description is not given of the phys- 
iology, the pathology, and operative tcchnic, the book is 
nevertheless complete in important practical detail. The 
little work breathes cleanliness; it savors of the spirit of 
Oliver Wendell Holmes and clean obstetric nursing. 



A Student's Manual of Gynecology. By John Osborn 
PoLAK, M.Sc, M.D., F.A.C.S., Professor "of Obstetrics 
and Gynecology, Long Island Medical College. Duo- 
decimo ; 414 pages ; 100 engravings and 9 colored plates. 
Philadelphia and New York: Lea & Febiger, 1915. 
Cloth, $3.00 net. 

For students who desire to get the outlines of gynecol- 
ogy briefly and tersely stated and at the same time to be- 
come conversant with most of the items of gynecologic 
disease, the little volume of Polak's is capital. The au- 
thor's large experience is boiled down into exceedingly 
compact chapters; diagnostic hints and surgical indications 
are stated in the clearest and most practical terms. Illus- 
trations are particularly descriptive of operative proced- 
ures. The book's chief virtue is clearness; students are 
not apt to be puzzled about the conditions described; its 
fault lies in the rather false impression it may give stu- 
dents that pathology is a tinishetl subject of which all the 
facts arc cut and dried and finally established. 

Selected Addresses on Subjects Relating to Educa- 
tion, Biography, Travel, etc. By J-\mes Tyson. M.D., 
LL.D., Professor of Medicine, Emeritus. University 
of Penns.ylvania. Duodecimo ; 358 pages. Philadel- 
phia: P. Blakiston's Son & Co.. 1914. 

The essays reprinted in this volume cover a wide range. 
Without carrying any large message or distinguished b.y 
unusual depth of thought, they afford pleasant and whole- 
some reading. The style is simple and unpretentious. 
We noted one or two mistakes. On page 335. the date of 
the discovery of the spirocheta pallida is given as 1SS4 
instead of 1904. Also on page 326 Ross — and not Reed — 
is mentioned as one of the discoverers of the mosquito 
etiology of yellow fever. 

The Heart in Early Life. By G. A. Sutherland. M.D.. 
F.R.C.P. ; Senior Physician to the Hampstead and 
North West London Hospital ; Physician to Padding- 
ton Green Children's Hospital. Duodecimo; 207 
pages. London : Henry Frowde, Oxford University 
Press ; Hodder and Stoughton, 1914. 

Sutherland divides his work into three main parts : 
1. Functional cardiac disturbances. 2. Paroxysmal tachy- 
cardia. 3. Organic heart disease. It is in the first part 
that we must seek whatever justification the special title 
of the book holds, for the reason that most of the func- 
tional disturbances that aflfect hearts occur in the young. 
The author discusses the various forms of arrhythmia, 
tachycardia and bradycardia. We had expected an ex- 
tended discussion of congenital heart disease, but this 
subject, except in relation to certain murmurs, is strangely 
missing. In the chapter upon the uses of digitalis, the 
indications are not given with sufficient precision. There 
is also no mention of the now comparatively common 
form of heart disease, the subacute infectious variety or 
endocarditis lenta; nor is there any mention of the com- 
mon cardiac disturbances in the young associated with 
orthostatic albuminuria. The discussion of the subject is 
on broad lines and is tempered with sound judgment. 
The exposition is thoroughly modern and is based largely 
upon the work of Mackenzie and his pupils. 

The Difficulties and Emergencies of Obstetric Practice. 

By CoMYNs Berkeley and Victor Bonney. 2iui Edi- 
tion. Octavo; 807 pages; 302 illustrations. Phila- 
delphia: P. Blakiston's Son & Co., 1915. Price $7.50. 

This book was reviewed in these columns about a year 
ago. We were then glad to recommend it. The second 
revised edition is heartily welcome. Apart from its lucid 
style and comiileteness, it is invaluable as an expression of 
a very large personal experience of the two authors. 

The Philosophy of Radio-Activity or Selective In- 
volution. I!y Fit.enm; Coleman Savii«;k. M.D., New 
^'ork. Octavo; 151 pages. New York: Tin: William 
R. Jenkins Company, 1914. Price $1.50. 

The book treats radio-activity not in the sense commonly 
understood by medical men, but rather in a broad, com- 



Voi_ XXIX. No. 4. 



Books Received. — Progress in Surgery. 



American 
Journal of Surgery. 



157 



parative, philosophic way. For the student of philosophy 
the book should prove of interest. For the average med- 
ical practitioner and even j'-ray specialist it will be of 
sli.eht. if any. practical value. 



Books Received 



The Cancer Problem. By William Seam.\n Bain- 
BKiDGE, .V.M.. Scl)., M.D. ; Professor of Surgery, New 
York Polyclinic Medical School and Hospital ; Sur- 
geon, New York Skin and Cancer Hospital, etc., etc. 
Octavo; 534 pages; illustrated. New York; The 
Macmillan Co., 1914. Price, $4.«), net. 

Abdominal Operations. By Sir Berkeley Moynihan, 
M.S. c London), F.R.C.S., Leeds, Englaiid. Third 
Editton. In two large octavo volumes, illustrated. 
Philadelphia and London : W. B. Saunders Co., 1914. 

A Medical Dictionary for Nurses. Giving the Defi- 
nition, Pronunciation, and Derivation of Terms used 
in Medicine, together with Supplementary Tables of 
Weights, Measures, and Chemical Symbols, etc.. Ar- 
ranged with Special Reference to Use by Nurses. By 
Amy Elizabeth Pope, Graduate of School of Nurs- 
ing of the Presbjlerian Hospital, New York; Special 
Diploma, Teachers College, Columbia University; 
formerly Instructor in the School of Nursing, Pres- 
byterian Hospital; Instructor in the School of Nurs- 
ing, St. Luke's Hospital, San Francisco, etc. Duo- 
decimo ; 288 pages. New Y'ork and London ; G. P. 
Putnam's Sons, 1914. Price, $1.00, net. 

International Clinic Week at the N. Y. Polyclinic 
Medical School and Hospital, during the Inter- 
national Surgical Congress, April, 1914. Pamphlet, 
103 pages. 

A Nursing Manual for Nurses and Nursing Orderlies. 

By DCNCAN C. L. FiTZWILLIAMS, M.D., Ch.M., 
F.R.C.S., Surgeon in Charge of Out-Patients and Lec- 
turer in Clinical Surgery, St. Mary's Hospital, Lon- 
don, etc. Duodecimo; 466 pages; illustrated. Lon- 
don : Oxford Uni\-ersitv Press, 1914. Price $2.50. 



Progress in Surgery 

A Resume of Recent Literature. 



Report of a Case of Ununited Fracture of the Tibia 
Repaired by Bone Grafting. Prescott Le Breton, 
Buffalo. Buffalo Medical Journal, January, 1915. 

Le Breton reports an interesting case in which a frac- 
ture of the right tibia, a little below the knee joint, was 
sustained by a child three weeks old, the parts remaining 
ununited until, at the age of seven years, perfect union 
was secured by bone grafting. When the child began to 
walk, the lower leg was bowed, and on weight bearing 
there was so marked a give ."as to remind one of con- 
genital hip dislocation." There was also shortening and 
atrophy. 

An indsion was made over the fracture; the ends were 
cleared of the dense fibrous tissue, and the long end of 
the upper fragment was cut off and removed. Two canals 
w-ere chiselled out above and below for a bone transplant. 
Then, with an electric saw, graft of suitable size was re- 
moved from the opposite tibia, fitted into the right tibia, 
and retained by kangaroo tendon and chromic catgut. A 
plaster cast with the knee in considerable flexion kept the 
fragments in line. In eight weeks, union was firm and 
walking allowed, .-^n osteotomy done to the lower part 
of the same bone corrected the lower bow leg. The child 
has now a perfectly straight leg. The sole of the shoe is 
increased to make up for the shortening. 



Prevalent Fallacies Concerning Subacromial Bursitis. 
Its Pathogenesis and Rational Operative Treat- 
ment Walter M. Bricknkk, New ^ ork. •Amcncun 
Journal of the Medical Sciences, March, 1915. 

Brickner refutes the current misconceptions concerning 
subacromial bursitis, and sets forth his conclusions, based 
on the careful study and treatment of a large number of 
cases, that: there is no diagnostic point of tenderness; 
usually little or no swelling; the shadow seen radiographi- 
cally is due, not to thickening of the bursal wall, but to a 
calcareous deposit found in or on the supraspinatus or 
infraspinatus tendon, and therefore beneath, never zi'ithin 
the bursa; not only is the removal of the bursa unnecessary, 
but its complete excision, as some books recommend, is 
impossible without mutilating dissection; subacromial bur- 
sitis is traumatic, resulting from the bruising of the bursa 
and the underlying tendon, by external violence or, more 
often, by an unduly vigorous active or passive abduction 
of the arm ; it does not arise from bacterial or toxic irri- 
tation. 

The calcareous deposit appears early, even in a few days 
after trauma. W'hether seen early or late, within or upon 
the tendon, it may be semi-fluid or solid, small or large, 
single or multiple. It does not come from the bone. 

He then describes the technic of the operation he em- 
ploys, which experience has shown him to be the "surest 
means of early cure." The patient has been placed partly 
on his side with a cushion under the affected shoulder. 
From the outer border of the acromion downward over 
the greater tuberosity, a two and one-half or three-inch 
vertical incision is made, exposing the deltoid muscle, 
which, having been split, is retracted. This discloses the 
roof of t