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1: 



ANNALS 



OF 



SURGERY 

A MONTHLY REVIEW OF SURGICAL SCIENCE AND PRACTICE 

EDITED BY 

LEWIS STEPHEN PILCHER, M.D., LL.D., 

OF NEW YORK. 



WITH THE COLLABORATION OF 



WILLIAM WHITE. M.D., LL.D., 

OF PHILADELPHIA, 

Professor of Surgery in the University of 
Pennsylvania. 



Sir WILLIAM MACEWEN, M.D., LL.D., 

OF GLASGOW, 

Professor of Surgery in the University of 
Glasgow. 



SIR W. WATSON CHEYNE, C.B., F.R.S., 

OF LONDON, 

Professor of Surgery in King's College. 



^T.f 



1.0 



VOLUME XLIX ; / / "^ 

JANUARY— JUNE, 1909 



jn.1 



LONDON 

CASSELL & COMPANY, LIMITED 

PHILADELPHIA 

J. B. LIPPINCOTT COMPANY 



%l 



i^ 



fi- 



COPYRIGHT BY 

J. B. LIPPINCOTT COMPANY 
1909 



CONTRIBUTORS TO VOLUME XLIX. 



Alexander, E. G., M.D., of Philadelphia, Visiting Surgeon to the Out- 

Patient Department of the Episcopal Hospital. 
Alexander, Samuel, M.D., of New York, Professor of Clinical Surgery, 

Cornell University Medical College (Department of Genito-Urinary 

Diseases) ; Surgeon to Bellevue Hospital. 

Bainbridge, William Seaman, M.D., of New York City, Clinical Profes- 
sor of Surgery, New York PolycHnic Medical School and Hospital; 
Consulting Surgeon, Manhattan State Hospital ; Surgeon, New York 
Skin and Cancer Hospital ; Associate Surgeon, Woman's Hospital. 

Barney, J. D., M.D., Assistant in Anatomy in the Harvard Medical School. 

Bloodgood, Joseph C, M.D., of Baltimore, Md., Associate Professor of 
Surgery in the Johns Hopkins University. 

Buerger, Leo, M.D., of New York, Assistant Adjunct Surgeon and Asso- 
ciate in Surgical Pathology, Mt. Sinai Hospital; Associate Surgeon, 
Mt. Moriah Hospital; Cystoscopist, West Side German Dispensary. 

Cabot, Hugh, M.D., of Boston, Mass. 

Carnett, John Berton, M.D., of Philadelphia, Associate in' Surgery, 

University of Pennsylvania; Assistant Surgeon to the University and 

the Philadelphia General Hospitals; Consulting Surgeon to the 

Phcenixville Hospital. 
CoDMAN, Ernest A., M.D., of Boston, Mass., Assistant Visiting Surgeon, 

Massachusetts General Hospital. 
Cunningham, John H., Jr., M.D., of Boston, Mass., Visiting Surgeon 

to the Long Island Hospital ; Third Assistant Visiting Surgeon, Boston 

City Hospital. 
Cumston, Charles Greene, M.D., of Boston, Mass. 
Cushway, Bertram Charles, M.D., of Chicago. 

Davis, John Staige, M.D., of Baltimore, Md., Assistant Surgeon in the 
Out-Patient Department of Johns Hopkins Hospital. 

Deaver, Harry C, M.D., of Philadelphia, Professor of Surgery, Woman's 
Medical College; Surgeon to the Episcopal and Stetson's Hospitals 
and to the Children's Hospital of the Mary J. Drexel Home. 

iii 



iv CONTRIBUTORS TO VOLUME XLIX. 

Deaver, John B., M.D., of Philadelphia, Surgeon-in-Chief. 
Denslow, Legrand N., M.D., of New York. 
Despard, Duncan L., M.D., of Philadelphia. 

Eastman, Joseph Rmus, M.D., of Indianapolis, Clinical Professor of 
Surgery in the Indiana University School of Medicine. 

Echols, Chester M., M.D., of Milwaukee, Wis. 

Eliot, Ellsworth, Jr., M.D., of New York, Surgeon, to the Presbyterian 
and Gouverneur Hospitals. 

Erdmann, John F., M.D., of New York, Professor of Surgery, New York 
Post-Graduate Medical School and Hospital. 

Ferguson, Alexander Hugh, M.D., CM., of Chicago, Professor of 

Clinical Surgery, University of Illinois. 
FiSK, Arthur Lyman, M.D., of New York. 
Fowler, Russell S., M.D., of Brooklyn, New York, Chief Surgeon, 

German Hospital; Surgeon, Methodist Episcopal (Seney) Hospital. 

Gatch, Willis D.^ M.D., of Baltimore, Md., Assistant Resident Surgeon 
in the Johns Hopkins Hospital. 

Gibson, Chas. Langdon, M.D., of New York, Surgeon to St. Luke's 
Hospital. 

Goodman, Edward H., M.D., of Philadelphia, Assistant Instructor in 
Medicine, University of Pennsylvania; Dispensary Physician, Presby- 
terian Hospital. 

Hammond, Levi J., M.D., of Philadelphia, Surgeon to the Methodist 
Episcopal and Maternity Hospitals. 

Hawkes, Forbes, M.D., of New York, Surgeon to Trinity Hospital; 
Associate Surgeon, Presbyterian Hospital ; Consulting Surgeon, 
Nassau and St. Joseph's Hospitals, Long Island; Instructor in 
Surgery, Columbia University. 

Hepburn, Thomas M., M.D., of Hartford, Conn. 

Hewson, Addinell, M.D., of Philadelphia, Professor of Anatomy in Phila- 
delphia Polyclinic Hospital; Surgeon to St. Timothy's and American 
Oncologic Hospitals. 

Janeway, Henry H., M.D., of New York. 

Kelly, James A., M.D., of Philadelphia, Visiting Surgeon, St. Mary's 
Hospital; Pathologist and Instructor in Surgery, Philadelphia Poly- 
clinic Hospital and College. 



-Vi^ 



Annals of S 



NNALS OF OURGERY 



Vol. XLIX JANUARY, 1909 No. i 



ORIGINAL MEMOIRS. 



STUDIES IN CANCER— HISTORICAL AND 
CRITICAL.* 

BY JAMES G. MUMFORD, M.D., 

OF BOSTON, MASS. 

" Medicine is of all the Arts the most noble ; but owing 
to the ignorance of those who practice it, and of those who, 
inconsiderate^, form a judgment of them, it is at present far 
behind all the other Arts." ^ So wrote Hippocrates twenty- 
three centuries ago. Meantime we have developed beyond 
that calamitous condition. The more we know, the more 
keenly are we aware that the end is not yet ; yet with the devel- 
opment of knowledge, we have been wont through all time 
to proclaim present superiority. The medical orator who 
thunders of modern wisdom is but the parrot. Medical orators 
have so thundered since the days of Celsus and of Galen ; and 
we do well to recall the first Aphorism of the Father of Medi- 
cine : " Life is short and the Art is long; the occasion fleeting; 
experience fallacious, and judgment difficult." 

We are but the fore-wave, the skirmish line of the army 
of science. We see what is now doing; we may overwhelm 
the outworks of the enemy ; we may obtain a lodgment within 
his posts ; but the calm on-looker, of broad view and philosophic 
judgment, knows that babble and shouting and close push of 

♦Read before the St. Louis Medical Society, October 29, 1908. 
* Hippocrates : " The Law." 



2 JAMES G. MUMFORD. 

pike do not represent all the struggle, nor all the force, nor 
all strategy. The sea lies behind the breaker ; the army behind 
the rifleman, and accumulated science behind the clever 
hypothesis and striking achievement of yesterday. 

We are wont to proclaim that two of the great problems 
of medicine to-day are the tuberculosis problem and the cancer 
problem; that the one we are by way of solving; that upon 
the other light is beginning to dawn. 

Doubtless we are correct, for we have advanced beyond 
the age of Hippocrates ; but for myself I confess that not until 
I had begun to look upon these problems as a whole, especially 
upon the campaign against cancer, did I come to grasp in 
proper perspective the wide significance of that disease, and 
its omnipresence — the antiquit)'', force and earnestness of the 
struggle against it ; the yeoman service of our ancestors in the 
battle, and the very present pass at which we are arrived. 

We say that this is a neurasthenic age; many men and 
most women chatter of pathology and psychiatry. Yet mark 
how our ancestors lived in constant dread of disease. Their 
literature abounds in therapeutic maxims, and their liturgies 
with prayer that they be delivered from sickness. Until recent 
years the earth was unpeopled; famine, plague and countless 
ailments mowed down the populations; and their daily speech 
began with an enquiry as to health, which we still perpetuate 
in the familiar greeting, — " how do you do," in every language 
of Christendom. 

Cancer holds a front place among the diseases which have 
afflicted mankind since record began. Recent writers err when 
they tell us that cancer went unrecognized in old times ; never- 
theless it is rapidly increasing now, though it has always been 
a disease of urgency. For more than two thousand years the 
frequency and the frightful nature of cancer have been known ; 
but the disease often was confused with other ailments. It 
is increasing now, but so is population and the average life- 
span. 

As we look back, however, over the history of this scourge, 
we observe two parallel and striking lines of belief regarding 



STUDIES IN CANCER. 3 

it, — lines which have run down without approach or diverg- 
ence from the earHest times to our own, — the belief of the 
laity in the hopelessness of cancer, and the belief of the best 
physicians in the possibility of its cure. This scepticism of 
the ignorant is the most serious obstacle which meets us in 
our strugfgle to-day. It has always been most serious. 

Another age-old conception, familiar especially to phy- 
sicians, is the immunity conception. Cropping up through all 
the writings, frequently one finds the conviction expressed that 
certain persons cannot have cancer; that certain states of the 
blood prohibit its growth; that even if implanted in some, it 
fails to flourish, and dies. 

No disease more than cancer, probably, has been the sub- 
ject of discussion more bitter, scornful, intolerant, personal 
and unscientific. Until this day something of that spirit main- 
tains. We see how this must have been, for until recent years 
the spirit of science had not affected deeply the average physi- 
cian. Writers treated medicine as they treated religion, in 
the spirit of dogma — if we except a few great souls appear- 
ing here and there. That is the tendency of poor human 
nature, perhaps. Not even yet have we learned to exorcise 
the man from the thesis. Men have fumbled about terms 
and definitions. Hypothesis and assumption have been substi- 
tuted for theory; and theory for unquestioned fact. 

Furthermore, the cancer problem has always presented 
two questions for solution ; and still presents them, — the cause 
and the cure. The cause, we debate to-day; while, for the 
cure, we have arrived at certain hopeful, if limited, conclusions. 

In a single brief essay we may not review the great 
literature of cancer ; but let us cite a few names ; let us glance 
at the trend of the debate as it unfolds itself; and let us see 
how the struggles and accomplishments of the past lead up to, 
and develop, the achievements of the present. 

The name Galen sums the ancient literature of cancer, as 
it sums so much else in ancient science. That hard-fighting 
debater, keen observer, and acrid, egotistical physiologist of 
the second century, played his part with the rest of us in the 



4 JAMES G. MUMFORD. 

great discussion. With little effort of the imagination one 
projects oneself back for eighteen hundred years, and visual- 
izes the gifted, highly educated, ready-witted Greek; living 
in Rome; cultivating the great, lashing his rascally fellow- 
practitioners, and adding daily to that great store of accu- 
mulated learning, which was to hold bound the medical world 
for sixty generations. 

Galen gathered up and elaborated former knowledge 
regarding cancer; and that former knowledge was consider- 
able. His great master and predecessor by five hundred years, 
Hippocrates, had realized keenly the obvious distinction be- 
tween superficial and concealed cancer, — as regards ease of 
diagnosis ; and while he advised removing the former by oper- 
ation, he said also : " Do not treat occult cancer, lest the patient 
die." 

A hundred years before Galen, Cornelius Celsus also 
wrote about cancer, and established the diagnosis by " explo- 
ration " as we should now say. He cauterized away suspicious 
tumors. If the growth recurred he called it carcinoma; if 
it did not reappear it was not carcinoma. This happy method 
reminds Roswell Park of a facetious saying of Duparque: 
" Cancer is incurable because it cannot be cured ; the reason 
we cannot cure it is because it is incurable; therefore, if one 
by chance should happen to cure it, it must be that there was 
no cancer." 

Such were the traditions in which Galen was educated; 
and they have a singularly modern flavor. That great man 
was not discouraged, however. Systematically he studied 
cancer. Indeed he gave to it its name, from the fancied 
resemblance of breast cancer, with its surrounding dilated 
veins, to a great crab v/ith its embracing tentacles. Here 
was a writer who investigated all things for himself. Shall 
we not acknowledge the acumen of a man who recognized 
internal metastases and their significance ; and said that cancer 
is due to a disordered function of the parts — even though he 
thought that the primary cause is an excess of black bile; 
and that metastasis occurs through the veins? He did not 



STUDIES IN CANCER. 5 

despair of curing early cancer. Rationally, and according to 
his belief, he cleared the individual organism by purgatives 
and bleeding; and thoroughly removed the growth by a wide 
excision. He deserved the flattering applause of his suc- 
cessors, who failed to improve on his treatment for nearly 
seventeen centuries. 

In some details, however, knowledge of the subject grew 
during tliose centuries, and reasoning became established upon 
sounder premises. We are wont to exclaim that with the 
passing of Galen and such of his ancient followers as Leoni- 
das, Alexander of Tralles, Paulus, and their like, science died 
for a thousand years. Now truly that is an unwarranted esti- 
mate, inherited from European writers of the Renaissance, 
after the veil had been lifted from the Dark Ages of Europe. 
To the spirited and prosperous races of western Asia those 
ages were not dark ; and we must not forget the debt we still 
owe to the accomplished Asiatic scientists, brethren of those 
Saracens who spread themselves over half of Asia and Africa ; 
conquered Spain; built up a mighty empire which flourished 
for a thousand years; and maintained a great civilization, 
the ruins of which still challenge our wonder and respect. 

The oriental scientists may not have advanced our knowl- 
edge of cancer, but they maintained and fortified the old 
argument, that early and thorough excision is the only radical 
cure for malignant disease; while one of them, Avenzoar, in 
the twelfth century, was the writer to show us that the breast 
is not, after all, the commonest seat of cancer, but that the 
stomach and the uterus share its malignant honors. 

The vStudent of our history turns always, and with sat- 
isfaction to Ambroise Pare, the great French clinician of the 
time of our English Elizabeth. Now Pare was a mighty 
power in the surgical world — a man versed in many things — 
an operator of vast experience; nor do we turn to him in 
vain for light on the cancer problem. He was no reader, 
but he had heard good surgical talk; and was able in some 
fashion to formulate ideas on malignant disease. He classi- 
fied tumors as, — ^the hard scirrhus; the rough scirrhus; the 



6 JAMES G. MUMFORD. 

cancerous scirrhus; and the phlegmonous scirrhus. Perhaps 
we might translate these terms into, — fibroid; scirrhus; med- 
ullary cancer; and ulcerating cancer. 

Mark that word scirrhus. It had been in use since 
Galen's time. Until the daj's of our grandfathers almost, 
surgeons failed to recognize tumors as composed of distinct 
histological elements. A scirrhous tumor was a hard tumor, 
whether innocent or malignant; but surgeons did know that 
some scirrhi remain harmless for years, while others run a 
short and fatal course. And so, when a scirrhus showed 
evident signs of malignancy, the old writers said that it had 
changed to cancer. At the same time they perceived that 
the " cancerous scirrhus " (medullary) is often malignant 
from the start. 

Pare had his inherited conceptions of cancer's etiology 
also : " It is the product of melancholic," he said, " and women 
more than men are its victims." He and his contemporary, 
Fabricius ab Aquapendente, operated with the knife, and 
seared the wound with the hot irons; while Fabricius Hil- 
danus, a few years later (1600), proved himself a bold, suc- 
cessful and skilful operator; for he dissected thoroughly with 
his fingers, cleaned out the axilla, and tied all bleeding points, 
to procure hsemostasis and promote prompt and sound wound- 
healing. 

We think of this picturesque Pare as the first of our 
great modern clinical surgeons; but he had a proper successor 
in the next century, Richard Wiseman, whose shrewd and 
delightful writings should stand side by side with those of 
John Evelyn and Samuel Pepys. Wiseman was Charles IPs 
surgeon, and was greatly beloved by that cheerful monarch. 
Here is the account of one of Wiseman's most illuminating 
cases : 

" A Captain of a Company in one of His MAJESTY'S Regiments of 
Foot, quartering in the North of England, was troubled with a small 
Excrescence under his Tongue. He consulted the Physicians and Chir- 
urgeons in his Neighborhood: but it increasing with Pain, he was per- 
suaded by his Friends to come to London to me. But after he came 
to Town, he met with some who told him that such a small thing was 



STUDIES IN CANCER. 7 

not worth the troubling me. Upon which he went to some other, and hav- 
ing got somewhat to dress it, he returned to his Command in some of 
the Neighboring Counties, and there fell into the Chirurgeon's hands, 
where it increasing and spreading, much infected the internal salivary 
Glandules- on both sides the Tongue, all the lower left Maxilla, and part 
of all the right. 'Twas fixing upon the lower Lip, the Teeth all loose, 
and some of them fallen out : There were also some Glands without under 
the Jaws. In this condition he came to me. I acquainted his Friends 
that it was a Cancer and incurable. If an attempt was to be made in 
hopes of a Cure, it was to be by burning it out. They consulted their 
Friends : and afterwards Dr. Tho. Cox, Dr. Walter Needham, and myself 
met. It was concluded by them, that there was no other way or hopes 
to cure him; how that might succeed, we doubted. If he would have it 
attempted, it should be at his desire, and not upon any Assurance from 
us to cure him thereby; for indeed it was doubtful. The next Day he 
sent for us to meet at his Chamber in order to do the extirpation. Ac- 
cordingly we met, and having Mr. Gosling with us, and our actual Cau- 
teries and all things ready, we placed the Patient in a clear Light, then 
pulled out the Teeth that lay loose, and as it were buried in the Fungus. 
Then having his Head held firm, and his lower Lip defended, I passed in 
a plain Chisel-Cautery under the Fungus, as low as I could, to avoid 
scorching of the Lip, and thrust it forwards to the Tongue, by which 
I brought off that Fungus and the rotten Alveoli at twice or thrice repeat- 
ing the Cautery; then with the Bolt-Cautery dried the basis to a crust. 
After with a Scoop-Cautery I made a thrust at the Fungus over-spreading 
the left Jaw, and made separation of that, and what was rotten of the 
Alveoli; then with Olive and Bolt-Cauteries I dried that as well as he 
would permit." " In this Patient the Escars separated, and the Ulcers 
digested, and that part of the Tongue near the Tonsil cicatrized ; but the 
while a hard Swelling arose in his right Thigh, and became so painful, 
that he was forced to keep his Bed; the Matter fermented also in the 
salival Glands, and made Apostemations on the outside under the Jaws ; 
of which together he languished and died."* 

No student conld read that without gaining a clear idea 
of the appearance and course of cancer. The little touch on 
metastasis is a master-stroke. 

With the eighteenth century, studies in the science of 
medicine not only revived actively, but spread w^idely. The 
labors of anatomists and physiologists were bearing fruit. 
Vesalius, Malpighi, Leeuwenhoek, Descartes, Borelli, Pare, 
Harvey, and Sydenham had left their mark ; and their earnest 
inquiries were continued in the laboratories and hospitals by 

"Wiseman's " Surgery," vol. i, pp. 191, 192, 194. (Sixth edition, I734-) 



8 JAMES G. MUMFORD. 

Boerhaave, Von Haller, Morgagni, Petit, Le Dran, Lancisi, 
Cheselden, and the Hunters. That was a notable century for 
surgeons. The apothecaries were separated from the physi- 
cians, and the old-time distinction between barber-surgeons 
and surgeons-of-the-long-robe was being erased. 

Henri Frangois Le Dran — who published in 1749 — was 
one of the great teachers of the time, — Surgeon to La Charite; 
Consulting Surgeon to the Army; Member of the Academy 
of Surgery of Paris; and Fellow of the Royal Society of 
London — titles with the familiar ring to modern ears. 

Le Dran loved his profession and his pupils. His charm- 
ing lectures are still full of vital and absorbing interest; and 
boldly he attacks the cancer problem with no uncertain hand. 
At once he rebukes the sceptics, for he proclaims that cancer 
is curable — not late cancer, but cancer that is perceived early, 
and is cut out betimes. All cancers are but forms of scirrhus, 
he says. Cancer is a malignant disease with corroding juices ; 
and he tells of dissecting a cancer after its removal, and how 
the juice spurting forth, bleached his clothes and burned his 
face. He draws a sharp distinction between gland-cancer 
and surface- (or squamous) cancer; he reasserts the tale of 
the scirrhus, i. e., how it may always remain harmless, or may 
develop malignancy; while he preaches unceasingly the prev- 
alence qi cancer, and that it must be conquered. Le Dran, too, 
perceived that cancer frequently occurs in the uterus, where 
it makes known its presence by dribbling hemorrhage; and 
he exclaims regarding the dissemination of any cancer : " I 
have known fresh cancers to arise in different parts even 
after the extirpation of that which appeared at first." And 
note this : " In this case also the bones may break by being 
affected by some cancerous tumor." 

There creeps into his writings a curious observation, often 
confirmed later by other writers, to the effect that while many 
a cancer results from an injury, for such a cancer excision 
often promises a cure. The reasonableness of this assertion 
arises from the fact that cancer from an injury — if that cause 
be admitted — is likely to appear near the body's surface; that 



STUDIES IN CANCER. 9 

it is obvious from the beginning of its course, and that it offers 
an excellent opportunity for early and thorough excision. 

Le Dran perceived that surgery rather than medicine 
was like to solve the problem of the cure of cancer, but he 
was as far as the ancients from recognizing the cause of the 
disease. He seems to have believed that cancer appears in the 
most vigorous persons in the prime of life; that there may 
be an inherent tendency to cancer, as John Hunter also 
thought ; and that with " vitiated humors and diathesis " in 
the remote background, a local irritant may be the cancer's 
immediate cause. You will find that such conceptions have 
been common to many thoughtful men for more than two 
centuries. 

With the end of the eighteenth century there began a 
great outpouring of cancer writings (which we misname " lit- 
erature "), and names crowd the text; note, — Hunter, Fearon, 
Pearson, and Adams at the end of the eighteenth century; 
Home and Abemethy at the beginning of the nineteenth ; but 
it is to Bichat especially, at the beginning of the last century, 
that we owe our first conception of proper studies in cancer, 
as in other tissue developments. 

Let us glance at some of the teachings of the least of 
these writers, and then see how with the nineteenth century, 
the problem passed through rapid and kaleidoscopic changes. 
Henry Fearon, who published in 1790,^ gives us one of the 
best essays on cancer under the old conception. This writer 
was a London surgeon who operated at the Surrey Dispensar}\ 
His paper, embodied in a book, obtained the prize medal of 
the Medical Society of London. 

He begins with the statement, so familiar still : " There 
is no disease to which human nature is subject, confessedly 
more beyond the reach of internal medicine, than cancer." 
So far all was plain sailing, but Fearon promptly promulgated 
a theory, which was revised by Broussais in the next century ; 
which was regarded by Virchow as worthy of consideration; 



s « 



A Treatise on Cancers," by Henry Fearon, London, 1790. (The 
quotations are from the Third Edition.) 



lO JAMES G. MUMFORD. 

which still enters prominently into the theses of those who 
regard cancer as of microbic origin. Fearon maintained " that 
inflammation is the proximate cause of the disease, and inva- 
riably and universally connected with it." He devotes one 
hundred pages of close reasoning to the support of this 
proposition. 

Moreover he appreciated and insisted upon the increas- 
ing prevalence of cancer. He recognized that the ancient 
conception of tumors as due to a condition of humors had 
been overturned more than one hundred years earlier through 
studies of the blood by Harvey, Malpighi, and Leeuwenhoek, 
who regarded blood changes as the cause of tumor disease; 
and he paid due deference to the beliefs of Boerhaave and the 
Cartesians who ascribed tumors to the then newly discovered 
lymph ; but his o\vn careful inspection of the disease, especially 
of its manifestations on the surface of the body, convinced 
him that malignant new growths are allied to, if not identical 
with those phenomena which we have come to know as 
granulomata. 

Fearon maintained many other propositions still familiar 
to us in the cancer debate, viz., that metastases partake of 
the same general character as the primary tumor; that the 
spread of cancer is by contact dissemination, as well as through 
the lymphatics and blood-vessels, and that the rapidity of its 
development into a general constitutional ailment is depend- 
ent largely on the lymph supply of the parts. 

Fearon's most important contribution to cancer writings, 
however, was on his new method of operating. Former sur- 
geons had taught that the wound resulting from cancer excis- 
ion should be left open, for that thus recurrence of the disease 
is best retarded through slow healing, inflammatory reaction, 
and the formation of granulation tissue. This notion of in- 
flammatory reaction was the point on which Fearon seized 
most eagerly. He asserted that inflammatory reaction is the 
process most to be dreaded, for that through inflammatory 
reaction cancer development is encouraged. Close the wound 
promptly, he proclaimed ; that through a primary union, health 



STUDIES IN CANCER. II 

quickly may be restored and the patient put in a condition to 
withstand a recurrent attack of the disease. It is interesting 
and amusing to read in detail Fearon's. laudation of his own 
ingenuity, and his account of others' failures. 

In those old days, scientific arguments were often based 
upon individual experiences of special cases, and writers de- 
fended their points as a barrister defends his brief. In no 
one particular, however, are the conclusions of those old 
writers more disappointing than in the failure of the authors 
to give us their end-results. Their descriptions are far more 
picturesque and entertaining, however, than are the writings 
of us moderns. We look to the bare statistical facts; they 
sought to arouse the interest, sympathy and approval of the 
reader. 

Here is one of Fearon's little stories: 



" Mrs. Elizabeth Ellis, of Camberwell, sent for me in the spring of 
1783, to examine her right breast." (Now-a-days we would say: E. E., 
female, widow, age 60, housewife; family history negative; previous his- 
tory negative; present illness, one year; lesion, right breast.) "Mrs. 
Ellis said all the medical gentlemen that had seen it, agreed in the opinion 
of it's being a confirmed cancer. The operation had been recommended, 
but she never could make up her mind to submit to so horrid and painful 
an operation, which in the end might not prove successful ; and to use her 
own words, this opinion was riveted more firmly in her mind, from the 
sufferings of a neighbor of hers, who had undergone the operation, under 
the care of one of the first surgeons in town, and gave her a dreadful 

account of the pain of the operation These considerations had 

determined her to suflfer the disease to carry her to the grave, until she 
heard of Mrs. Smith's case ; on this account, she had retracted her former 
opinion, and sent for me to perform the operation as soon as I thought 
proper; she thought excessive grief was the cause of her complaint; for 
soon after the death of her husband she perceived a small lump in her 

breast At the time I saw her it was large and firmly attached 

to the pectoral muscles and ribs, and had a large cancerous sore round 
the nipple, attended with lancinating pains through the tumor, which was 
hard, craggy and uneven. She was corpulent and near sixty years of age. 
I told her I feared she had too long deferred the operation. Her answer 
was that she was determined to have it oflF. From her pressing and 
anxious solicitations, I suffered her to send for the family surgeon, Mr. 
Green of Peckham, who accordingly met Mr. Haynes and me next morn- 
ing. I performed the operation, including the cancerous sore in a double 
incision, and was obliged to cut away a considerable portion of the pectoral 



12 JAMES G. MUMFORD. 

muscle and lay two of her ribs bare. The edges of the wound were 
brought into contact, they united, and the cicatrix was formed in the 
usual time."* 

Upon the advent of careful statistical writing, and the rise 
of the German School with its clumsy, wordy, and involved 
method of reporting, such picturesque stories as that of Mrs. 
Elizabeth Ellis disappeared from our literature. 

For fifty years we have seen nothing so delightful as the 
next: "A young farmer of 35 came up out of Lincolnshire 
to me in London, to tell me about a disease in his testicle 
and a fistula in the corner of each eye." So wrote John 
Pearson in 1793, a friend and collaborator of Henry Fearon, 

Joseph Adams wrote about the same time. He was a 
diligent student of the ancients, but without avail, for he 
says, — " It is a frequent remark that many facts passed cur- 
rent for ages without having their validity inquired into. It 
would be to little purpose to dwell on the strange opinions of 
ancient writers, the inaccuracy with which they confounded 

the symptoms, and even the seat of the disease 

By the kindness of Dr. Sims in allowing me the full scope 
of his library, and directing me through it, I have had access 
to all the early writers, till I was wearied with fruitless re- 
searches and unsatisfactory inquiries. . . . It is hardly 
credible how little information is to be gained." 

John Abernethy, also a contemporary of Fearon, some- 
what younger than the latter, was a man of far more distinc- 
tion, whose sayings, endeavors, and productions made a great 
impression upon the surgery of one hundred years ago. Aber- 
nethy was John Hunter's favorite pupil probably, and was 
nearer to that great prophet than was any other of his disciples. 
Abernethy seems always to have been overshadowed by his 
brilliant and famous contemporary, Astley Cooper, but I be- 
lieve a study of the writings of Abernethy will show him to 
be the sounder scientist, and the more modest great man.^ 

* Fearon : " Treatise on Cancers," p. 161. 

'Every faithful student of medicine should read George Macllwain's 
delightful Memoirs of John Abernethy. 



STUDIES IN CANCER. 



13 



Now John Abemethy turned his attention to cancer, 
among his other pursuits, and he has favored us with a curious 
classification. He seems to have determined to revive the old 
term " sarcoma," long in disuse. Galen had said, " We call 
sarcoma, — fleshy excrescences, praeter naturam." Abernethy 
felt that sarcoma, rather than carcinoma, was a term properly 
to be applied to all malignant tumors. Obviously, distinctions 
between epithelial structures and connective tissue structures 
were not clear to him. 

So we find him writing of (i) the common vascular or 
organized sarcoma (this is probably the familiar round-cell 
sarcoma) ; (2) adipose sarcoma (which may be nothing more 
than a lipoma) ; (3) pancreatic sarcoma (probably encepha- 
loid cancer) ; (4) cystic sarcoma (possibly the modern cyst- 
adenoma) ; (5) mammary sarcoma (perhaps a mixed sarcoma 
in the modern sense) ; (6) tuberculated sarcoma (probably 
diffuse sarcomatosis) ; (7) pulpy sarcoma (the nature of this 
growth is not at all obvious) ; (8) carcino-sarcoma (by this 
term the author obviously means malignant scirrhus in the 
then accepted sense) . 

Abernethy's influence would have gone far towards estab- 
lishing this nomenclature had it not been for the rise of the 
new French School, which under the influence of Bichat and 
the stimulus of almost unrestricted opportunities for research 
was carrying science forward at a rate hitherto unknown even 
to the gigantic capacity of John Hunter. 

Some clear light, however, dawned upon Abemethy. 
Here is a new point in cancer history: The structure of a 
tumor is something like that of the part in which it grows; 
and, to quote Baillie : " Knowledge of morbid structure does 
not lead with certainty to the knowledge of morbid actions, 
although the one is the effect of the other." 

We must not suppose that those old operators made slight 
and ineffective dissections — Abemethy tells us that in some 
cases of tumors the newly formed part alone requires removal, 
whilst in others the surrounding substance must be taken away, 



14 JAMES G. MUMFORD. 

or a radical cure cannot be effected ; and he reports cases which 
survived operation for four, six and ten years before the 
recurrence of the disease. Joseph Adams, Christopher T. 
Johnson,® Everard Home, Astley Cooper, John Howard, and 
James Wardrop had similar experiences, and enrolled them- 
selves vigorously among those effective obsei'vers, clinicians, 
and writers, who helped to open the way for the expanding 
science of the nineteenth century. 

Writers are wont to tell us that Bichat's is the figure 
which separates the old from the new pathology. No student 
of medical history questions this assertion. At the same time, 
1 have written to little purpose, if I have failed to show that 
writers before Bichat, or still uninfluenced by Bichat's work, 
were beginning to appreciate in some fashion the structure of 
cancer. Bichat worked without the microscope. He did not 
reduce to their lowest terms all the structures of the human 
body, but he did perceive and he taught that organs are made 
up of diverse and complex structures, and that in many cases 
the disease of an organ is evidenced by changes within the 
structure of that organ. " Every tissue has its own diseases," 
said Bichat. As Williams''^ reminds us, this was a great 
advance on previous ideas, for on the basis of Bichat's teach- 
ing, the modern study of tumors rests ; and this work of Bichat 
was carried further by Laennec, Andral, Louis, Bayle, and 
Cruveilhier. Thus in a large sense Bichat anticipated the 
cell-theory of modern pathologists. 

We do not at once see the English, French, and German 
writers of one hundred years ago accepting and profiting by 
Bichat's teaching. Doubtless his work was little known to 
many of them; and so, only gradually and fitfully did his 
ideas become incorporated into the writings on cancer. For 
example, John Rodman and William Farr, who published in 
1818 and in 1822, had little conception of the new pathology, 

* Christopher T. Johnson is a little known, or forgotten, writer. His 
prize essay, presented to the Royal College of Surgeons in 1808, is a 
remarkably spirited and illuminating discourse on cancer. 

' " The Natural History of Cancer," by W. Roger Williams, 1908. 



STUDIES IN CANCER. 



15 



though their own conception of cancer's pathology is not 
uninteresting, since it leads up to such hypotheses as culmi- 
nated in those teachings of Broussais to which I have referred. 

Rodman maintained that cancer is contagious, that it is 
in the nature of an inflammation due to catching cold; while 
Farr was convinced that cancer is a constitutional disease 
somewhat of the nature of syphilis, and is hereditary. He 
also stated that it is due to catching cold. 

Farr is a most interesting writer. He thought he had 
discovered a drug which should deal with cancer as mercury 
deals with syphilis. His drug was Fucus Helminthocorton, 
which he chose because of his " knowledge of its powerful 
effects as a vermifuge " ; and incidentially Farr assures us 
that fucus helminthocorton is a Corsican sea-moss, and was 
highly commended by Napoleon. Farr devotes a large part 
of his book to attacks upon his contemporaries and upon their 
methods of treating cancer. Especially he belittles Car- 
michael, whose iron tonics had had a great vogue in cancer 
therapy. One notes with interest that iron has been a favor- 
ite drug for centuries in the cure of cancer, while only the 
other day Skene Keith and George E. Keith produced an 
original little book, in which they advocate strongly certain 
uses of iron to alleviate the distressing symptoms of advanced 
cancer.^ 

Farr was not always successful with his treatment, how- 
ever, but he has a pleasant way of explaining disaster, some- 
what as follows : " The death of this lady was materially 
hastened if not entirely caused by her being obliged to change 
her lodgings in one of the coldest days of the winter. I have 
strong reasons for believing that the wound would never have 
taken on so violent and malignant an action as almost imme- 
diately followed, but for this circumstance." 

Furthermore this author calls our attention to the fre- 
qtient concealment of cancer by its victims, who succeed in 
keeping themselves comfortable, in avoiding observation and 



• " Cancer : Relief of Pain and Possible Cure." 1908. 



1 6 JAMES G. MUMFORD. 

in checking the disease " by keeping the part warmly covered, 
the bowels open, and avoiding cold." 

With the passing of the generation represented by Farr 
and Rodman, there passes away the old i8th century school 
of surgeons, and our interest in their quaint, spirited and pic- 
turesque methods of doing business and reporting thereon. 
With Bichat, Laennec, Louis, Miiller, and Virchow we come 
suddenly into a modern atmosphere — an atmosphere frigfid, 
exact, scientific, searching, but not so interesting historically. 
An extremely notable, eccentric and surprising person in 
the midst of such a group of scientists was Broussais, a pupil 
of Bichat, and a forceful, pugnacious figure in the first quarter 
of the last century. In spite of his distinguished training, he 
was caught by such ingenious hypotheses as those of Rod- 
man and Fearon, who believed in the inflammatory nature 
of cancer. Broussais occupied an important position in Paris. 
His teaching was persuasive and infectious, and he won a 
great following; for he taught that all tumors, including can- 
cers, are but forms of chronic inflammation consequent on 
organic irritation. As Williams observes sadly, " the extreme 
simplicity, comprehensiveness and positiveness of this crude 
generalization, suddenly sprung on a scientific world, hesitat- 
ing between the old humoral doctrines and the nascent 
anatomico-pathological tentatives, captivated every one, and 
the Broussaisian system in an incredibly short time became 
supreme." 

Soon, however, the opponents of Broussais were able tri- 
umphantly to proclaim that the supremacy of his conception 
was short-lived, for the microscope was finally and properly 
developed in the second quarter of the last century, so that 
promptly the cellular structure of organized beings was dis- 
covered. We accord to Schleiden and to Schwann the demon- 
stration of the famous cell theory, and the application by 
Schwann of this theory to the animal world, in 1838. 

In that very year Johannes Miiller, the great anatomist 
of Berlin, published his work on the origin of tumors — a work 
upon which are founded our modern conceptions of the cellu- 



STUDIES IN CANCER. 1 7 

lar nature and pathogenesis of cancer, and of all other neo- 
plasms. Miiller's descriptions satisfy the histological picture, 
but he falls short of meeting our conceptions of cancer's etiol- 
ogy. He believed that the tumor cells are derived from a 
fluid which is exuded from the blood, — the so-called coagula- 
ble lymph of John Hunter, but under a new name, — blas- 
tema. He ascribed the origin of cancer to aberrations of 
the force inherent in this coagulable lymph, causing the re- 
sulting cells to deviate from their usual evolution; and he 
insisted on the correspondence between normal tissue devel- 
opment from the embryo, and the pathological development 
of new growths. Said he : " It is one and the same power, 
which being maintained continually from the germ to the 
latest period of life, determines all organic formation." 
Within little more than twenty years, Virchow in his Cellu- 
lar Pathology (1859), championed the cell-theory as explained 
by Miiller, but with this exception, that he eliminated the 
coagulable lymph or blastema origin of cells. It is in that 
elimination that the greatness of his conception rests ; for Vir- 
chow exclaimed " omnis cellula e cellula " ; or, as Williams 
paraphrases it, — " Where a cell rises, there a cell must have 
previously existed, just as an animal can spring only from an 
animal, and a plant from a plant." 

We begin now to see, in the stage of cancer discussion 
which was reached by the middle of the last century, how two 
distinct hypotheses regarding the causation of cancer were 
beginning to work themselves out : the intrinsic and the extrin- 
sic hypotheses — the assertion that forces of malignant growth 
originate within the organism itself, and the assertion that 
such forces are implanted from without upon the organism. 

May we not, somewhat fancifully perhaps, name the 
generations of this discussion thus: The intrinsic conception 
starts with the humoral hypothesis, and is followed by the 
blood hypothesis, the lymph hypothesis, the blastema hypothe- 
sis, down to Cohnheim's embryonal hypothesis of to-day. 

We may trace the extrinsic hypothesis thus: From the 
earliest times, such conceptions as are recorded above have 



l8 JAMES G. MUMFORD. 

not held sway undisputed. Many of the ancients seem to 
have believed that cancer itself was a parasite — not a para- 
site in the modern sense, a disease due to the invasion of 
organisms — but actually itself a parasite, a monster imbedding 
itself in human tissues, and there gnawing and destroying 
life. Some such hideous conception of cancer long existed, 
in spite of the humoral and other doctrines. For many years, 
however, the extrinsic hypothesis lay in abeyance, until in 
the seventeenth and eighteenth centuries it was revived by 
those writers who began to teach that cancer is something 
in the nature of an infection ; that it may be likened to tuber- 
culosis and to syphilis; that possibly it is hereditary; that 
there is strong reason to believe in its contagiousness; that it 
is due to catching cold; that its phenomena are of the nature 
of inflammation; and so we come down to the hypothesis 
of Broussais, and finally to the propositions of that array of 
modem pathologists, Rappin, Pfeififer, Plimmer, Gaylord, 
vSanfelice, Park, and those others who, basing their studies on 
the teachings of bacteriology, believe that cancer is truly a 
parasitic disease. 

Among the writers of English books, perhaps Roger 
Williams is the most inspiring example of those who hold to 
the intrinsic hypothesis regarding cancer; and Roswell Park, 
among us, of those who hold to the extrinsic hypothesis. 

Throughout the gradual development of this debate on 
the causation of cancer, there has persisted at the same time 
an interesting and progressive discussion upon the treatment 
of cancer ; for, as I have said, these two discussions, on causa- 
tion and on treatment, progressively run through all the 
writings on the subject. While men have wandered far asun- 
der in their conceptions of the cause of cancer, they have 
gradually approached nearer and nearer in their views of its 
treatment. Most surgeons are now in complete accord regard- 
ing the removal of cancer by operation, though ingenious 
writers, appearing here and there, are still proposing and 
advocating other measures. 

Let us now glance in brief detail at the development of 



STUDIES IN CANCER. 19 

cancer therapy during the last half century. It is not yet three 
years since Beard proposed his trypsin treatment of cancer, 
a treatment founded upon the conception that one important 
function of the pancreas is to control the irresponsible growth 
of certain trophoblastic germ-cells, which develop into cancer. 
It is asserted that trypsin supplies to the organism an element 
which will control or eliminate even the abnormal development 
of these cells. 

Fifty years ago J. Weldon Fell, an American practicing 
in London, brought forth a somewhat similar panacea. Fell 
lacked our present knowledge of chemistry, but he was 
convinced that there exists somewhere in the organism 
a controlling force which normally limits cancer development ; 
and that with the withdrawal of this force, cancer will appear. 
Perhaps in some sense this was a crude and irrational notion 
of phagocytosis. At any rate he produced the following inter- 
esting observation, — " It occurred to me that it would be nec- 
essary to find some active agent exerting a specific effect upon 
cancerous matter, and which would exert the same influence 
by absorption, destroying the tendency existing in many cases 
in the constitution for the reproduction of cancerous cells, 
and which, taken at the same time internally, would destroy 
the cancerous diathesis." Here is what he found, — " A root, 
used by the North American Indians on the shore of Lake 
Superior .... known commonly among these Indians 
by the name of puccoon, but from the blood-like juice that 
exudes it is called by botanists the Sanguinaria Canadensis. 
. . . . No doubt some poor squaw, suffering from this 
dreadful disease, was the first who applied it, after having 
tried in despair all the simple herbarium of the uneducated 
savage." 

Fell's remedy had a great vogue, and was investigated 
extensively by a commission in the Middlesex Hospital. The 
commission admitted in a report that the remedy apparently 
removed tumors, but wound up with this Delphic statement, — 
" The undersigned have not as yet had time to ascertain the 
average duration of the benefit conferred by the treatment. 



20 JAMES G. MUMFORD. 

nor have they any means of knowing whether, in the event 
of a return of the disease, tliere be any difference observable 
from what is known to take place after excision." 

Fell's treatment was employed for some twenty years, 
but gradually fell into disuse, and was forgotten. 

About the time of Fell there arose a method of surgical 
writing which simplifies immensely our studies in the history 
of disease — a method of " Surgical System " writing. In 
i860 Holmes's " System of Surgery " was published in Lon- 
don — a great collection of monographs written much after 
the manner of present-day Systems of Surgery. Charles H. 
Moore and Sir James Paget supplied the articles on cancer 
and on tumors. They sum up admirably the beliefs and prac- 
tices of the time, but our space does not permit a complete 
review of the voluminous subsequent contributions which 
these articles inaugurated. 

Moore had extremely definite views on the treatment of 
cancer. He had tried and turned away from all sorts of 
remedies, and he sums up the situation with the remark that 
throughout the literature of cancer, all sound authors, with- 
out exception, have approved and have insisted upon the 
operative removal of early cancer, as the only possible method 
of permanent cure. Those men who have opposed the knife 
have generally been men either inexperienced or insignificant, 
with some favorite cancer-cure of their own to exploit. Few 
of these cancer cures are now known. 

This article of Moore's is the most satisfactory essay 
on cancer which was published up to i860. He assures us 
that the nature and character of cancer are now understood, 
but that the disease generally is as incurable as ever. He 
describes five varieties of cancer: the scirrhus, medullary, 
melanotic, epithelial, and osteoid; but he does not recognize 
as cancer the colloid and villous tumors of some of his prede- 
cessors. 

It is interesting in this connection to read Paget's essay 
on tumors, which accompanies Moore's essay on cancer. Paget 
contributed the first authoritative statement which distin- 



STUDIES IN CANCER. 



21 



guished sarcoma from cancer, without calling " sarcoma " by 
that now familiar name. He described this form of malig- 
nant connective-tissue tumor as " recurrent tumor." Paget 
says recurrent tumors do not involve the lymphatic system; 
metastases are late only, and occur through the blood-vessels; 
recurrent tumors cannot be distinguished histologically from 
benign tumors ; in some cases they may be removed many times 
with a final cure, or they may recur until they kill the patient. 

Twenty-one years after that writing of i860 Long- 
streth edited Paget's article, in a later edition of Holmes's 
Surgery; and Longstreth reminds us that the term, recurrent 
tumor, was first used by Paget to describe a group of neo- 
plasms previously little known, but confused with cancer; 
while Virchow revived the name sarcoma for this group. 

With the discovery of anaesthesia and the introduction 
of Listerism, sound, radical and successful progress in cancer 
surgery followed the development of operative surgery in 
fields other than the cancer field — progress slow and timid at 
first, but more forceful and effective, as satisfactory results 
came to be shown through accumulating statistics. We in 
this country owe to Halsted the recognition of having con- 
ceived first, developed earliest, and pushed farthest the modern 
operation for malignant disease. His great work was in deal- 
ing with breast cancer — the classic type of cancer — but grad- 
ually only have we come to see the value and the proper sig- 
nificance of his painstaking dissections, his wide excisions, his 
thorough hsemostasis, and his exhaustive study of end-results. 
These results encouraged men operating for malignant dis- 
ease in many other fields; and their results in turn showed 
that early cancer, lacking glandular involvements or with slight 
involvements and contact disseminations only, may be eradi- 
cated permanently. I need but remind my readers of recent 
successes in removing cancer of the uterus, the intestine, the 
stomach, and that most disastrous of all malignant growths, 
cancer of the tongue and jaws, in dealing with which Crile 
has been a pioneer. 

In connection with the subject of wide-reaching dissec- 



22 JAMES G. MUMFORD. 

tions for cancer, I have been interested to see how many 
thoughtful surgeons are coming to accept the teaching of 
Handley regarding the dissemination of cancer, Handley's 
views are the most recent as well as the most interesting per- 
haps, on the nature of the spread of cancer. He believes that 
the accepted notion of metastases arising from the lodgement 
of particles swept along in the lymph or blood channels gives 
a very inadequate and incomplete explanation of what actually 
occurs. He tells us that cancer dissemination is accomplished 
in a more slow and subtle fashion, — the cancer cells actually 
growing along the finer vessels of the lymphatic plexuses in 
all directions from the parent tumor, both with the lymphatic 
current and against it, while embolic invasion of the lymph- 
nodes occurs relatively late and leads to involvement of the 
blood stream after a long delay only, 

Handley reminds us of the work of Schmidt, who has 
shown that such cancer cells as reach the blood usually disap- 
pear without causing metastases. Cancer spreads through 
the tissues by permeating the lymphatic system like an invis- 
ible annular ring worm; the growing edge extending like a 
ripple, in an ever wider circle, within whose circumference 
healing processes take place, so that the area of permeation 
at any one time is not a disc but a ring. Within the circle 
of this ring small groups of cancer cells may be left here and 
there; later those groups, or rests, give rise to the malig- 
nant skin nodules, with which we are familiar. 

Those surgeons who have accepted Handley's explana- 
tion of the local spreading of cancer, see in it a logical rea- 
son for our wide-reaching dissections — dissections which must 
involve great areas of apparently sound skin — and Halsted, 
carrying this reasoning to its logical conclusion, in discussing 
the operative treatment of breast cancer, advocates the removal 
of wide skin surfaces, without regard to subsequent closure 
of the wound; while he would, if necessary, amputate the 
corresponding arm, and clean out the structures in the cor- 
responding side of the neck. These are elaborate procedures, 
but these procedures even are hopeless in the face of advanced 
malignant disease. 



STUDIES IN CANCER. 



23 



Says Childe ® in his valuable and popular book, — " Only 
one quarter of a century ago cancer was considered alike by 
the medical profession and the public to be incurable (sic). 
All the signs by which students were taught to recognize it 
were those of the disease in its advanced and therefore in- 
curable stage. The operations in its behalf were performed, 
recognizing the impossibility of its cure, and were only under- 
taken with the view of prolonging life and temporarily alle- 
viating suffering. To-day we recognize that cancer itself 
is not incurable. It is only incurable if you make it so by 
delay " ; and Crile says in a recent address, — " I have often 
thought that pending a more general enlightenment it would 
be a great boon to mankind if the words * glandular enlarge- 
ment and cachexia ' as denoting symptoms of cancer, were 
stricken from every text-book of medicine. These are ter- 
minal symptoms, and indicate that the surgical opportunity 
is forever lost." 

We have now traced the story of cancer as it has been 
developed in the writings of nearly two thousand years; and 
we have seen how the two aspects of the problem constantly 
have exercised investigators throughout this long period. It 
is not strictly true, as a recent critic has asserted, that, " the 
whole situation has so altered that the perusal of a medical 
book written before i860 is like reading a work of Hippocrates 
or Galen." Since i860 we have advanced, but with the excep- 
tion of studies founded on the bacteriological teachings of 
Pasteur, we have opened no new chapter in the discussion. 
We still turn the pages of our Chapter One; they are the 
pages of a discourse which began to be written hundreds of 
years ago, and are on lines not yet archaic. 

I have said little of methods of diagnosis. In the old 
days diagnosis depended on the results of treatment. If the 
tumor returned it was cancer; if it returned not, it was inno- 
cent " scirrhus " ; while the refinements of exact diagnosis 
were unknown. We are all familiar with modern diagnos- 

•"The Control of a Scourge," by Charles P. Childe, F.R.C.S. 



24 JAMES G. MUMFORD. 

tic methods, which for more than a generation have depended 
on the evidence furnished by the microscope. With this very 
year another test — a remarkably suggestive test, and .most 
important if it stand the proof — ^has been proposed by Crile, — 
the haemolysis test, to determine the presence of early occult 
cancer, not suitable for the ordinary methods of examina- 
tion. If we find this haemolysis test reliable — though its author 
promises nothing as yet — we shall be able by its aid to make 
a further great stride towards the cure of cancer by mechani- 
cal means. Visible cancers, if seen early, are now almost 
cured in the finding. By the haemolysis test, invisible can- 
cers will be lifted into the plane of the visible. 

Purposely I omit a discussion on present-day hypotheses 
of cancer etiology. The camps of the disputants bristle with 
weapons and activities. In each of these camps I myself cas- 
ually have dwelt. Each hypothesis has its fascinations, and 
its persuasive prophets, who demolish the outworks of their 
opponents with untiring zeal ; while they themselves are untir- 
ing in works of partisan reconstruction. If one may judge 
by analogy, and by historic precedent, one of these parties is 
destined to prove its faith. 

Such are some of the reflections which a consideration 
of this great theme — cancer — arouses in the student. No 
problem in surgery has been longer debated ; none is of wider 
interest; none has bred keener disputants and none furnishes 
a more absorbing, or a more promising subject for the investi- 
gator trained in modern methods of research. 

BIBLIOGRAPHY. 

Abernethy, John, Surgical Observations on Tumors and on Lumbar Ab- 
scesses, London, 1816. 

Adams, Francis, The Genuine Works of Hippocrates, New York, 1886. 

Adams, Joseph, Observations on Morbid Poisons, Phagedsena and Cancer, 
London, 1795. 

American Practice of Surgery, Edited by Bryant and Buck. 

Bland-Sutton, Tumours; Innocent and Malignant, 1907. 

Buchan, William, Domestic Medicine or a Treatise on the Prevention and 
Cure of Diseases, Philadelphia, 1809. 



STUDIES IN CANCER. 



25 



Carmichael, Richard, An Essay on the Effects of Carbonate and Other 

Preparations of Iron upon Cancer, Dublin, 1809. 
Childe, Charles P., The Control of a Scourge, or How Cancer is Curable, 

1907. 
Cooper, Sir Astley, Surgical Lectures. 

Crile, George W., Oration in Surgery before the American Medical Asso- 
ciation, Journal A.M.A., June 6, 1908. 
De Morgan, Campbell, The Origin of Cancer, London, 1872. 
Dennis's System of Surgery, 1896. 
Farr, William, An Essay on the Effects of the Fucus Helminthocorton 

upon Cancer, London, 1822. 
Fearon, Henry, A Treatise on Cancer, London, 1790. 
Fell, J. Weldon, A Treatise on Cancer and Its Treatment, London, 1857. 
Handley, W. S., Cancerous Dissemination, Glasgow Medical Journal, Dec, 

1905. 
Holmes's System of Surgery, i860. 
Holmes's System of Surgery, 1881. 

Home, Everard, Observations on Cancer, London, 1805. 
Howard, John, Practical Observations on Cancer, London, 181 1. 
Hunter, John, Surgical Lectures. 
Johnson, Christopher Turner, A Practical Essay on Cancer, Philadelphia, 

1811. 
Keen's Surgery. 
Keith, Skene, and Keith, George E. : Cancer ; Relief of Pain and Possible 

Cure, 1908. 
Laennec, R. T. H., Miscellaneous Papers. 

Latham, R, G., The Works of Thomas Sydenham, M.D., London, 1848. 
Laurence, John Zachariah, The Diagnosis of Surgical Cancer, London, 

1858. 
Le Dran, Henri Frangois, The Operations in Surgery, London, 1768. 
Macllvain, George, Memoirs of John Abernethy, New York, 1853. 
Mitchell, Robert, A General and Historical Treatise on Cancer Life; Its 

Causes, Progress and Treatment, London, 1879. 
Miiller, J., On the Nature and Structural Characteristics of Cancer, Lon- 
don, 1840. 
Park, Roswell, An Epitome of the History of Medicine, 1899. 
Park, Roswell, Modern Surgery. 
Park, Roswell, Some of the Modern Aspects of the Cancer Problem, 

Address before the Hartford Academy of Medicine, March, 1908. 
Park, Roswell, An Epitome of the History of Carcinoma, In Report of 

Cancer Laboratory of the New York State Board of Health, 1902-3. 
Purcell, F. Albert, On Cancer ; Its Allies and Other Tumors, Philadelphia, 

1881. 
Rodman, John, The Practical Explanation of Cancer in the Female Breast, 

London, i8i8. 
Rush, Benjamin, Medical Inquiries and Observations, Philadelphia, 1809. 
Saleeby, C. W., The Conquest of Cancer; A Plan of Campaign, 1907. 



26 JAMES G. MUMFORD. 

Velpeau, A., A Treatise on Cancer of the Breast and of the Mammar^ 
Region, London, 1856. 

Virchow, Rudolph, Miscellaneous Papers. 

Von Bergmann's System of Surgery, 1904. 

Wardrop, James, Observations on Fungus Hsematodes of Soft Cancer, 
Edinburgh, 1809. 

Walshe, Walter Hayle, The Anatomy, Physiology, Pathology and Treat- 
ment of Cancer, with Additions by J. Mason Warren, Boston, 1844. 

Walshe, Walter Hayle, The Nature and Treatment of Cancer, London, 
1846. 

Williams, W. Roger, The Natural History of Cancer, 1908. 

Wiseman, Richard, Eight Chirurgical Treatises, London, 1734. 

Wolff, Jacob, Die Lehre von der Krebskrankenheit von den AUtesten 
Zeiten bis zum Gegenwart, 1907. 



THE SERUM REACTION IN CANCER.* 

REPORT FROM THE PATHOLOGICAL LABORATORY OF THE SKIN AND CANCER 
HOSPITAL OF NEW YORK CITY. 

BY HENRY H. JANEWAY, M.D. 

OF NEW YORK. 

It is the object of this paper to record a series of observa- 
tions upon the lytic action of the serum taken from cancer 
patients upon nomial red blood-cells. Although the haemo- 
lytic properties of serum were discovered as long ago as 
1875, by Landois, it is only within the last decade that any 
attempt has been made to apply the method of serum path- 
ology to human disease! During recent years, however, the 
literature upon this subject has grown to very goodly dimen- 
sions. Of especial importance in the elucidation of the 
anaemias of certain diseases has been the discovery of " isohse- 
molysins " in certain human sera — in other words, the demon- 
stration of the fact that such serra were capable of destroying 
the red corpuscles of other individuals. It has been shown by 
Ascoli, Eisenberg, and others, that the serum in cases of 
cancer, tuberculosis, syphilis, and certain other conditions fre- 
quently contain such isohaemolysins. This discovery, although 
of great theoretical interest, has not been capable of diagnostic 
application. In 1907 Weil showed that the serum of dogs 
afflicted with lymphosarcoma in an advanced stage was capable 
of destroying the corpuscles of normal dogs, but was markedly 
resisted by the corpuscles of other dogs afflicted with the same 
malady. This capacity for resistance by the red cells of other 
animals affected with the same disease appeared to offer a 
distinctive criterion, and was also made the basis of a study 
in human disease. An analysis of Weil's paper on the latter 
subject reveals the fact that in early malignant tumors the 
serum is hsemolytic in 46.5 per cent, of the cases, in 71 per 
cent, of which the corpuscles manifested a specific resistance; 

* Read before the American Society for Cancer Research. 

27 



28 HENRY H. JANEWAY. 

in late malignant tumors that it is hsemolytic in 71.5 per cent., 
and is resisted in 80 per cent, of these. In other diseases, 
the serum is hsemolytic in only 21.5 per cent., and such hsemo- 
lytic serum is less strongly resisted by the red blood-cells of 
the same disease producing such a hsemolytic serum, than is 
the case in cancer. If, however, easily identified conditions, 
such as pneumonia and advanced tuberculosis are excluded, the 
figure (21.5 per cent.) falls to 12.5 per cent. In normal 
individuals it is never hsemolytic. A comparison of these 
figures demonstrates that the factor of resistance on the part 
of the corpuscles adds materially to the accuracy and delicacy 
of the reaction. It appears to offer a fairly characteristic, 
though not pathognomonic feature, of cancerous disease. 

The technic was as follows: About ten cubic centimetres 
of blood are withdrawn from the median vein of the patient 
whose blood is to be tested. One half to one cubic centi- 
metre of this blood is immediately mixed with about fifteen 
cubic centimetres of a solution of 0.9 per cent, of sodium 
chloride to which 1.5 per cent, sodium citrate had been added. 
The remainder of the blood is then discharged into a test- 
tube, and allowed to clot. The corpuscles are now washed 
four times by centrifuging and resuspending in salt solution. 
After the last centrifugation they are suspended in sufficient 
normal salt solution to make up a ten per cent, emulsion. 
When the serum has separated from the portion of the blood, 
which is allowed to clot within the test-tube, it is pipetted, or 
poured off. Frequently it is mixed with some of the red 
blood-cells, which may be removed by centrifugation. The 
same procedure is then repeated upon the blood taken from 
a normal individual. The essentials for making the reaction, 
therefore, are: the clear serum from the cancer patient, and 
the clear serum from the normal individual; also a ten per 
cent, emulsion of red blood-cells from a cancer patient, and 
a ten per cent, emulsion of the red cells of a normal individual. 
From these ingredients are prepared the following six 
mixtures : 

I. — 0.5 c.c. of emulsion of normal cells ; i c.c. of cancer serum. 
2. — 0.5 c.c. of emulsion of normal cells; i c.c. of serum from normal 
individual. 



SERUM REACTION IN CANCER. 



29 



3. — 0.5 c.c. of normal cells; i c.c. of normal salt solution. 

4. — 0.5 c.c. of emulsion of blood-cells from cancer patient; i c.c. of serum 

of normal individual. 
5. — 0.5 c.c. of emulsion blood-cells from cancer patient; i c.c. of serum 

from cancer patient. 
6. — 0.5 c.c. of emulsion of blood-cells from cancer patient; i c.c. of normal 

salt solution. 

The series of test-tubes is now placed in the incubator 
for two hours, and then in an ice-chest over night. In every 
case the results were read within 24 hours from the time of 
taking the blood. Haemolysis is at once evident by the 
" laked " or reddish color of the tubes in which it occurs as 
compared with the controls in salt solution. Those cases in 
which it occurred in tube i, or in tubes i and 5, but not in the 
other tubes, have been recorded as positive. 

The method as originally described by Weil involved the 
use of a number of cancer cases, and of a number of con- 
trols, the corpuscles of all of which were to be tested against 
the serum in question. It is evident that such a procedure, 
although practical with dogs, would add to the difficulties 
and complications of a clinical method. When available, it 
would enhance considerably the certainty of the reaction. Tlie 
dilution of the serum with a fractional portion of the emul- 
sion of red cells tends, of course, to intensify the hsemolytic 
power of the former, and may be reduced as low as one 
tenth, simply by using a twenty per cent, emulsion of red 
cells. In this way small amounts of blood could be made 
use of, and sufficient could be obtained from a number of 
normal individuals by merely pricking the ear. 

These are variations of technic, which each investigator 
may make for himself. 

Following out, however, the technic described by the 
author the details of the case are as follows: 

EARLY CASES OR CASES OF CANCER, WITH SMALL AMOUNT OF MALIGNANT 
TISSUE PRESENT GIVING A POSITIVE REACTION. 

Case i.— Lower lip; recurrent of epithelioma of lower lip about i 
inch in diameter, ulcerated; strength of reaction, +. 

Case 2.— Breast; recurrent carcinoma of breast; 2 operations; at the 



30 HENRY H. JANEWAY. 

first, one and a half years ago, breast was amputated. The second, one 
month ago, was for recurrence in supraclavicular glands ; at present re- 
currence again in glands of neck, no ulceration, and although of long 
duration, there was no evidence that there was more than a small amount 
of cancer tissue present ; strength of reaction, +. 

Case 3. — Breast; recurrent carcinoma in scar after removal of breast 
one year ago, not ulcerated ; strength of reaction, +. 

Case 4. — Scalp ; recurrent epithelioma in a gland of the neck follow- 
ing operation for removal of epithelioma of scalp, two years ago, affected 
gland was only the size of a walnut, and undoubtedly there was only a 
small amount of epithelioma tissue present; strength of reaction, +. 

EARLY CASES, OR CASES OF CANCER, WITH SMALL AMOUNT OF MALIGNANT 
TISSUE PRESENT GIVING A NEGATIVE REACTION. 

Case 5. — Mouth ; recurrent after operation for epithelioma of tongue. 
Case 6. — Cheek; Epithelioma of alveolar process i inch in diameter. 
Case 7. — Cheek; Epithelioma of inside of cheek and alveolar process 
of two months' duration. 

LATE CASES OF CANCER, GIVING A POSITIVE REACTION. 

Case 8. — Tongue ; large ulcerated epithelioma of tongue involving 
pillars of fauces, and tonsil ; strength of reaction, H — h. 

Case 9. — Lower lip ; very large inoperable epithelioma of lower lip 
of long duration ; strength of reaction, +. 

Case 10. — Inside cheek; large inoperable epithelioma of inside cheek, 
and alveolar process ; strength of reaction, +. 

Case ii. — Cheek; large ulceration epithelioma of cheek 3 inches in 
diameter; strength of reaction, +. 

Case 12. — Breast; very large inoperable carcinoma of breast, ulcer- 
ated ; strength of reaction, + +. 

Case 13. — Breast; recurrent carcinoma after amputation of breast in 
scar, ulcerated and advanced case ; strength of reaction, +. 

Case 14. — Rectum; large carcinoma of rectum, ulcerated; strength of 
reaction, + + -f-. 

LATE cases of CANCER, GIVING A NEGATIVE REACTION. 

Case 15. — Tongue; recurrent inoperable epithelioma of tongue. 

Case 16. — Cheek; large epithelioma presenting cauliflower growth 
I inch in diameter upon inside of cheek. 

Case 17. — Breast; inoperable cirrhotic carcinoma of breast. 

Case 18. — Breast; inoperable carcinoma of breast with axillary and 
clavicular glands. 

Case 19. — Breast; recurrent epithelioma from carcinoma of breast in 
glands above clavicle. 

Case 20. — Uterus; inoperable carcinoma of uterus. 

Case 21. — Uterus; inoperable carcinoma of uterus. 



SERUM REACTION IN CANCER. 



31 



Case 22. — Uterus ; inoperable carcinoma of uterus. 
Case 23. — Uterus; large recurrent and inoperable epithelioma of 
cervix uteri involving vaginal wall, ulcerated. 

Case 24. — (Esophagus ; inoperable carcinoma of oesophagus. 
Case 25. — CEsophagus; inoperable carcinoma of oesophagus. 

EARLY cases OF CANCER OF THE FACE OF RODENT ULCER TYPE, GIVING A 
POSITIVE REACTION, — notie. 

EARLY CASES OF CANCER OF THE FACE OF RODENT ULCER TYPE, GIVING A 
NEGATIVE REACTION. 

Case 26. — Face ; small epithelioma of face ; has received X-ray 
treatment. 

Case 27. — Nose ; small epithelioma at side of nose undergoing cure 
by X-ray treatment. 

Case 28. — Ear; small epithelioma at back of ear, of rodent ulcer type. 

Case 29. — Upper lip; epithelioma of upper lip, of rodent ulcer type 
i}4 inches in diameter, ulcerated. 

Case 30. — Cheek; epithelioma of cheek i inch in diameter, of rodent 
ulcer type. 

Case 31. — Forehead; recurrent epithelioma of forehead, recurrent after 
X-ray treatment; is not ulcerated, and covers ij^ inches in diameter. 

Case 32. — Face; small epithelioma J4 inch in diameter, now under- 
going cure by X-ray treatment. 

Case 23- — Scalp; epithelioma of scalp i inch in diameter; also small 
gland in neck. 

LATE cases of CANCER OF RODENT ULCER TYPE, GIVING A POSITIVE REACTION. 

Case 34. — Temple; epithelioma on temple 2 inches in diameter, slow 
growing of rodent ulcer type, ulcerated; strength of reaction, +. 

LATE CASE OF CANCER OF RODENT ULCER TYPE, GIVING A NEGATIVE REACTION. 

Case 35. — Face; inoperable ulcerated epithelioma of rodent ulcer type 
involving antrum and orbit ; a late case. 

It has seemed wise to the author to place cancer of the 
face in a separate class by itself, because, both pathologically 
and clinically it is at least for such a long time in its history 
so entirely different from the usual forms of cancer. 

To summarize. There were 20 late cases of malignant 
tumors (it is proper to include the late cases of cancer of 
skin in this list), of which eight yielded a positive reaction. 
or 40 per cent. 

There were seven early cases of malignant tumors, of 
which four were positive, or 57 per cent. There were ten 



32 HENRY H. JANEWAY. 

cases of a relatively benign type of tumor (rodent ulcer), all 
of which, except one, were negative. This one, however, 
was an advanced case. Of the normal sera none showed any 
haemolysis, but one case of chronic mastitis used as a control 
did show marked haemolysis. As compared with normal sera, 
it is evident that the possession of isohaemolysins is a striking 
feature of the sera of patients with malignant disease. 

This fact is certainly of great theoretical importance in 
explaining the cachexia and anaemia so characteristic of can- 
cer. It is very striking, in this connection, that the tumors 
of a relatively benign type have absolutely failed to show 
the reaction, as they are marked clinically, by an absence of 
the anaemia so characteristic of the other forms of malignant 
disease. Moreover, the resistance of the red cells seems to 
be a fairly striking and constant feature, the significance 
of which is at once apparent, while its mechanism still remains, 
for further investigation. 

The diagnostic value of the reaction may be considered 
from two standpoints^ If negative, it is quite clear that the 
case cannot be regarded with certainty as free from cancer. 
If positive it is to be regarded with likelihood, as a case of 
malignant disease more especially if certain complicating in- 
fections giving the same reaction, such as advanced tubercu- 
losis can be excluded. Although the writer has not examined 
other conditions of disease, it is evident from the results of 
others (Weil, Ascoli, etc.), that the typical reaction occurs 
in a very small proportion as compared with the cases of 
cancer ; and in practically a negligible number of normal cases. 

The statistics as obtained in the present series of cases 
compare quite closely with those published by Weil, the dif- 
ference being such as would naturally be expected, within the 
margin of error, in a rather limited number of observations. 

Averaging the percentages of positives obtained in the 
early and late cases, Weil obtained 59 per cent., and the 
writer 48.5 per cent. Finally, it is quite certain, as previously 
stated, that if the serum were tested upon a large variety of 
corpuscles, both from ascertained cases of cancer, and from 



SERUM REACTION IN CANCER. 



33 



normal individuals, the percentage of positives could be very 
considerably increased.^ It is to the obviation of such diffi- 
culties of technic that future investigation must be directed. 

Tentatively, it might be suggested that suspected cases 
of cancer should have their serum tested, as herein described, 
against the nonnal corpuscle emulsion. If negative it would 
be advisable to make a second and more comprehensive test 
in the manner suggested.' 

BIBLIOGRAPHY. 
Ascoli, Munch. Med. Woch., 1901, p. 1239. 
Crile, J. A. M. A., June, 1908, p. 1883. 
Eisenberg, Wien. kl. Woch., 1901, p. 1021. 

Lo Monaco and Panichi, Sitzungsber. d. Accad. d. Lincci, Dec. 16, 1900. 
Maragliano, Elfte Cong, fur Med., 1892, p. 152. 
Weil, Arch. Int. Med., I, 1908, p. 23. 
Weil, J. A. M. A., 1908, pp. 51, IS8. 
Weil, J. Med. R., 1907, p. 287. 
Weil, Proceedings See. Exp. Biol, and Med., 1907, p. 25. 

* Such a course is justified, because of the practical unanimity among 
all observers as to the rarity of isohaemolysins in normal sera. It is to 
the facilitating of the technic by the use of small quantities of blood from 
a number of normal individuals, that future investigation must be directed. 
Such may demonstrate that we have in this test a material aid in diagno- 
sis, but at the present writing with the evidence at hand, we cannot con- 
clude that such is the case. 

*The writer desires to express his thanks to Dr. Bainbridge and 
Dr. Torek, who have placed the material upon their service in the New 
York Skin and Cancer Hospital, at his disposal. 



Note. — Since the above has been sent to press, the writer has read 
with interest the last publication by Dr. Crile, of his results of haemolysis 
in cancer (Journal of American Medical Association, Dec. 12, 1908). 

It hardly seems possible that the different technic, which Dr. Crile 
has made use of, can alone account for his results differing so widely 
from the observations here recorded. In this connection a reasonable 
doubt might be raised as to the accuracy of a method which permits 
the defibrinization of the blood, and the sedimentation of its cells twenty- 
four hours in the cold before they are utilized in the test. 

Can the shaping of the whole blood with beads, and the subsequent 
exposure for twenty-four hours to the cold be less of a physical injury to 
the cells than the immediate centrifugation and utilization of the 
corpuscles ? 

Certainly, further investigation is needed to determine the real value 
of this reaction. 



NEWER CONCEPTIONS OF OPERATIVE TECHNIC 
IN CLEFT PALATE AND HARELIP. 

BY JOSEPH RILUS EASTMAN, M.D., 

OF INDIANAPOLIS, 
Clinical Professor of Surgery in the Indiana University School of Medicine. 

" The treatment of cleft palate," said Lane, " like surgi- 
cal treatment generally, has long been a matter of creed and 
tradition." It is remarkable with what indifference old con- 
ceptions and practices, crudities of operative technic and errors 
of surgical judgment are passed from one text-book to another. 
There is much unserviceable and confusing matter which with 
profit may be eliminated from this chapter. 

It is an old and quite generally accepted view that to 
operate for cleft palate on a child under three months of age 
is unwise. This is a matter of tradition. It is now, with 
reason, contended that under ordinary conditions cleft palate 
should be operated upon within the first week after birth. 
There is little substantial support for the statement that infants 
do not bear operations well. It is borne out by experience that 
the reverse is true. 

Lane, who declared the best time for cleft palate opera- 
tions to be the day after birth or as soon thereafter as possible, 
and whose position at first seemed open to criticism, has many 
followers. 

Many operators have expressed an assured conviction that 
the new-born child bears surgery much better than has been 
imagined, the reasons for which circumstance, all previously 
stated elsewhere by Garretson, Brophy, Lane and others, are 
as follows: 

1. The baby weighs more just after birth. 

2. Resisting power has not been reduced by the breathing 
in of cold air through a roofless mouth. 

3. Digestion has not been impaired by unsatisfactory 
feeding. 

34 



CLEFT PALATE AND HARELIP. 3c 

4. The bones are softer. 

5. The impression of pain is not so acute. 

6. The child has not developed the habit of articulating 
through the cavern of the nose. 

7. By immediate operation, the muscles of the palate are 
given an opportunity to develop instead of atrophy, and there 
is afforded the greatest possibility of development of the 
nasopharynx as the result of the pressure exerted by the air 
as it passes through. 

8. After early operations the nose is gradually pushed 
forward by the growth of the septum. 

Brown (Journal A. M. A., March 2, 1907) and Ferguson 
(Journal A. M. A., May 9, 1908) counsel in favor of a reason- 
able delay to the end that the operation can be done with the 
proper assurance of safety. They do not deny the advantage 
of early operation if conditions are favorable. 

Lane has observed that " after operations during the first 
week, the infant rarely cries or shows evidence of being in pain. 
It is almost never sick after the anaesthetic and takes its food 
within an hour or two with evident enjoyment." 

The very fact that the infant has just passed through the 
birth canal, with all the brutal mechanical insults which may 
be incident to this excursion, suggests the presence of a 
tolerance to traumatism which becomes less in evidence as the 
infant grows older. 

In ordinary cleft palate operations during the first week, 
the loss of blood should be trivial, but however this may be, 
the danger from loss of blood is not greater than at a later 
period. Experience has not suggested the slightest founda- 
tion for the truth of the statement that young infants do not 
bear the loss of blood well. If there is any reliable evidence 
to the effect that a very young infant does not bear the loss 
of a given proportion of its blood as bravely as an older 
individual, we have no knowledge of it. 

The vital resistance against trauma and hemorrhage of 
guinea-pigs and rabbits has a higher index upon the day after 
birth than upon succeeding days. B. D. Meyers, of Indiana 



36 JOSEPH RILUS EASTMAN. 

University, states that " a baby rabbit can be operated upon 
np to twelve hours after birth without an anaesthetic and with 
no apparent perception of pain, there being no outcry during 
such a procedure as the enucleation of an eyeball. Eighteen 
hours after birth such operations cause the animal to cry out." 

Meyers calls attention to a probable relationship between 
these phenomena and the circumstance that at the time of birth 
the sensory nerves are in an imperfect state of medullation 
and are, therefore, not good conductors. 

It is not known at what time medullation becomes com- 
plete in the human. Osmic acid is known to blacken medul- 
lated ner\^es but the nerves do not blacken with this agent up 
to fourteen hours after birth. 

Another phenotnenon of interest in this connection referred 
to by Meyers may be noted by removing first the heart of a 
rabbit twelve hours old and then that of another rabbit twenty- 
four hours old. The heart of the twelve-hour rabbit will 
continue to beat for an hour and a half, whereas the heart 
of the twenty-four hours' old animal will cease almost 
immediately. 

This single phenomenon, if it may be taken to indicate 
anything, suggests a marked difference in vitality (even if it 
be of an automatic sort), or a great difference in sensitiveness 
to external influences. 

Lane (" Cleft Palate and Harelip," Med. Pub. Co., Lon- 
don, 1908) lays the utmost stress upon the importance of early 
nasopharyngeal breathing as a factor in the development of 
this passage. He regards the continuous ballooning of this 
tract by air as the greatest developmental factor, concerning 
not only the walls of the space but also the adjacent bones. 

The conclusion that closure of the cleft in no wise reme- 
dies defective speech has been formulated by the observation 
of cases operated upon too late. Precise closure of the cleft 
does remedy defective articulation if the operation be done 
early enough in the period of growth. 

Surgeons who believe in the immediate operation of 
Lane proceed from the postulate that, if the cleft be closed 



CLEFT PALATE AND HARELIP. 37 

during the first week, the nasopharynx is systematically and 
forcibly dilated and ventilated and is increased in calibre as the 
constantly increasing volume of air passes through it. There 
is very little good in trying to develop a stunted nasopharynx 
after a late operation. In addition to the narrowing of the 
nasal passages, the lungs steadily become weaker and the 
adenoids more abundant from the day of birth. 

It is unfortunate that there is not better understanding 
upon the question of whether in cases of coexisting harelip and 
cleft palate, the two conditions should be corrected at the 
same time or whether the two deformities should be corrected 
at two distinct operations. It is clear that when both condi- 
tions are operated upon at the same time, the palate should be 
treated first for the reason that the presence of the defect in 
the lip provides readier access to the palate. 

Brophy waits until the palate has completely closed and 
the patient has recovered before devoting any attention to the 
lip. Lane treats the lip and the palate at the same time. In 
this controversy, most operators prefer to follow the teachings 
of Lane and operate upon the lip and palate at the same time 
or operate upon the palate after the lip has healed. 

In complete cleft of the palate, Lane's plan of correcting 
both deformities at one operation may be considered seriously 
for the following reasons, enumerated by himself (Ibid.) : 

The first and most important reason is that the soft parts 
whicli are removed necessarily from the margins of the lip 
may be of the greatest service in completing the closure of the 
anterior part of the cleft of the palate. " Indeed, to one un- 
familiar with the employment of these portions of the lip in 
this manner, the large area of cleft which the pieces of lip can 
be made to close is most striking. They have a remarkable 
vitality and bear an extraordinary amount of handling and 
suturing with safety." 

The second reason is that postponing the harelip opera- 
tion for a time reduces the chances of union. 

The third reason is that the sooner the pressure of the 
complete lip is brought to bear upon the segments of the upper 



38 JOSEPH RILUS EASTMAN. 

jaw as well as upon a displaced premaxilla, should it exist, 
the more rapid is the approximation of the bones forming the 
front of the cleft and the restoration of the premaxilla to its 
normal relationship. The mucoperitoneum covering the pre- 
maxilla is also useful in helping to close the cleft. 

The pressure which is exerted upon a protruding pre- 
maxilla by the lip after its continuity has been effected is, in the 
opinion of some surgeons, sufficient to bring about its back- 
ward displacement into the interval between the two maxillae. 

Sherman (Surgery, GyncFcology and Obstetrics, June, 
1908) remarks that " the pull of the repaired lip is quite rightly 
credited with narrowing the cleft of the palate, and this is 
a thing definitely to be desired in many instances. Therefore, 
for the sake of getting a palate on which an adequate palate 
operation can be done, the malposition of the intermaxillary 
bone must be corrected and the operation upon the harelip 
must be done. In comparison with this consideration, the fact 
that the palate operation has to be done through the smaller 
opening of the repaired mouth is a mere matter of manipulative 
dexterity." 

If the harelip be closed very early, the backward displace- 
ment of a protruding premaxilla takes place with rapidity, 
but if the harelip and cleft palate are ignored for months or 
years, it will be necessary to free the premaxilla with a chisel 
before it can be pushed back into the interval between the two 
maxillae in front. No part of the prolabium or premaxilla 
should ever be cut away, but it should always be used to assist 
in closing the gap between the maxillae where the cleft of the lip 
is bilateral or that of the palate is complete. 

Occasionally the rolled up piece of tissue hanging from 
the tip of the nose is promptly and confidently cut away, the 
family physician either being ignorant of the value of the 
prolabium in closing the defect of the lip or perhaps being 
unable to understand at all the meaning of the presence of this 
centrally developing portion of the lip. 

Although both Lane and Brophy are not averse to operat- 
ing with the patient in the dorsal recumbent position, it will be. 



CLEFT PALATE AND HARELIP. 



39 



in most cases, desirable to so drop the head of the operating 
table that there is inclination of about twenty degrees, the 
baby's head hanging over a pillow (Fig. i). In very small 
infants the same result may, of course, be accomplished by 
simply elevating the shoulders upon a small, hard pillow. 

To obviate the collection of blood in the pharynx is an 
important matter and can be accomplished best with the patient 
in Rose's head-hanging position, the height of the operator's 
stool being so adjusted that the top of the child's head comes 
to rest upon his knee. 

In cases of complete cleft of the palate, Lane's gags with 
sharp teeth which bite into the gum are useful. In complete 
cleft the jaw clutch of the Whitehead gag is in the way of the 
operator at the anterior end of the cleft. Lane's lateral gags, 
one for each side, placed at the corners of the mouth, allow 
free access to any part of the cleft. In incomplete cases, the 
Whitehead gag meets every requirement. Brophy's tubular 
speculum gag limits access to the field of operation and adds 
to its difficulties. 

In denuding the margins of the cleft, the strip of mucous 
membrane should be removed, if possible, from the entire edge 
in one piece in order that the denudation may be complete all 
around. If the two sides of the cleft are denuded separately, 
there is considerable likelihood that a small piece of mucosa 
may be left at the apex. In the presence of blood and mucus, 
obscuring the field of operation, such a small piece of mucosa 
may be allowed to remain, interfering with union at a critical 
spot. Denudation should begin at the tip of the uvular half 
upon one side and continued all around the edge of the cleft, 
finishing at the tip of the opposite half of the uvula. 

In cutting off the strip, the knife should be so held that 
more membrane is cut from the nasal than from the oral side 
of the palate. Binnie advises that this strip be cut in the 
reverse manner. It is difficult, however, to understand his 
reason for so doing. 

It is perhaps easier to bring the raw surfaces together 
with a simple suture if cut so that the oral side is bevelled. 



40 JOSEPH RILUS EASTMAN. 

If, however, mattress sutures, as used by Sherman, are to be 
employed, the desirabihty of cutting with the bevel upon the 
nasal side is quite apparent. 

A cataract knife or slender tenotome is suitable for the 
denudation. In any case, the knife should be slender enough 
that the turn can be made at the apex without breaking the 
continuity of the strip (Fig. 2). 

It is obvious that in cases of complete cleft of the palate 
it will not be possible to remove the strip of mucosa in one 
piece. 

In many cases of narrow cleft combined with a high 
palatal arch, it is not difficult to coapt the edges precisely and 
without tension after separation of the mucoperiosteum from 
the hard palate (Figs. 3 and 4). For the separation of the 
mucoperiosteum, Brophy's periosteum elevators, curved at 
right angles on the flat, are in every way efficient. 

In cases of high palatal arch, therefore, if the cleft be 
not too wide, it is useless to make paralyzing incisions for the 
relief of tension, for the two halves of the loosened mucoperi- 
osteal palate will fall together like the two halves of a canti- 
lever drawbridge, and may be sutured without tension. It 
should be remembered that the soft palate must be quite 
completely separated from the hard palate at the posterior 
border of the latter. 

The simple uniting of such loosened flaps with mattress 
sutures, as suggested by Sherman, is an ideal procedure in 
theory and a very satisfactory one in practice. The use of 
any mechanical contrivance, like Brophy's lead plates and silver 
wire, or cleats of any kind, is to no purpose in such a case, if 
indeed they are ever desirable. When the lead plates are 
used, the strain comes upon the cutting edge of the silver wire. 
The most careful study of the mechanics of this proposition 
cannot convince one that the pressure is to any considerable 
degree distributed over the under surfaces of the lead plates. 

The simpler the technic, the better. Even many of the 
special instruments may be dispensed with. Small French 
needles serve admirably and there is no better needle holder 



Fig. 1. 




Position of patient in operation for cleft palate. 



Fig. 2. 




Denudation of margin of cleft. Removal of strip in one piece. 



Fig. 



Fig. 





Fig. s. 



Fig. 6. 





Fig. 3. Separation of mucoperiosteal flap with Brophy's periosteotome. High palatal arch. 
Fig. 4. Mattress suturing without relaxation incisions after loosening of mucoperiosteal 

covering from a high arched palate. 
Fig. s- Palate with low arch and wide cleft. 

Fig. 6. Wide cleft closed with mattress sutures after dissecting of flaps and making relaxation 
incisions. Incisions packed with sterile gauze. 



Fig. 7. 



Fig. 8. 




Sherman's technic, relaxation incisions, 
mattress sutures, tape impregnated with 
wax and iodine encircling the flaps to pre- 
vent tension upon sutures. Relaxation in- 
cisions packed with s per cent, iodoform 
gauze. 



Charles Mayo's method. Unwaxed tape passed 
under flap. 



Fig. 9. 




Fig. 10. 



Tape tied with single turn and 
secured by silk ligature, ends hanging 
into the mouth. 




The ends of the tape and silk 
ligature cut short and turned around 
to nasal surface out of reach of pa- 
tient's tongue tip. 



CLEFT PALATE AND HARELIP. ' 41 

than a good Halsted artery clamp, the serrations upon whose 
jaws have been filed down a bit. 

The less machinery there is in a child's mouth for it to 
poke at with the tongue tip, the less the likelihood of failure. 
It is submitted, therefore, that in cases of reasonably narrow 
cleft and high palatal arch, it is wise simply to loosen muco- 
periosteal flaps on each side and unite the margins with mat- 
tress sutures, the same having been properly denuded. If the 
arch be low or the cleft be wide, or both, then Sherman's and 
Mayo's technic of making lateral incisions for the relief of 
tension and uniting by mattress sutures will, in most cases, 
suffice (Figs. 5 and 6). In such cases, a gauze packing in the 
lateral incisions, as introduced by Charles Mayo and employed 
by Sherman and many others, will splint or support the flaps 
better than any mechanical contrivance, and better, in the ex- 
perience of the writer, than the tape encircling the flaps used 
by Charles Mayo. 

Mayo and Sherman use 5 per cent, iodoform gauze for the 
packing of the lateral incisions. The iodoform in the gauze, 
however, serves no very important purpose and may do harm, 
as I have found, by inducing disagreeable if not alarming 
gastro-intestinal disturbances or actual intoxication. Sher- 
man remarks that the iodoform controls saprophytic action. 
This, however, is by no means as important as the prevention 
of too prompt healing with coincident increase of tension. 
Plain, sterile gauze splints the flaps as well and is, of course, 
more pleasant to bear in the mouth. 

Sherman's practice (Fig. 7) of using tape filled with 
wax and impregnated with iodine to prevent absorption of 
bacteria and consequent infection of the mouth, represents an 
advance, perhaps, over the use of simple, unwaxed tape as 
introduced by Charles Mayo (Figs. 8, 9 and 10), but there 
still remains in the use of the tape, waxed or unwaxed, some 
danger of strangulation of the flaps. 

The results of the operation of denudation, loosening of 
the flaps from the hard palate, making of lateral incisions for 
relief of tension, mattress suturing and packing of the lateral 



42 JOSEPH RILUS EASTMAN. 

clefts with sterile gauze, will not be greatly improved by the 
addition of the encircling tape, waxed or unwaxed. In other 
words, the simple operation combining the suggestions of 
Sherman and Mayo seems most efficient if the tape be discarded 
(Figs. 5 and 6). 

For the suturing of cleft palate, about every known ma- 
terial has been tried, and there still obtains great diversity 
of opinion as to what constitutes the best suture material for 
this purpose. Lane uses fine Chinese twist. Silk, linen, hemp 
and horse hair are all used, as is silver wire by Brophy. Silk- 
worm gut is the material chosen by most American operators 
for the uniting of the margins in cleft palate. 

Bunge, of Konigsberg, coapts the margins by means of a 
continuous wire Halstead suture and over this places the usual 
mucous sutures of silk. The wii-e suture is removed by draw- 
ing upon the anterior end. 

In clefts of the soft palate, Ochsner splits the edge of 
the cleft throughout its entire extent, beginning at the tip of 
the uvula on one side and extending the incision around the 
entire cleft to the tip of the uvula on the opposite side. This 
produces a broad surface for coaptation. He uses two rows 
of horse hair sutures — one row with the knotted ends turned 
toward the nasal side, the other row with the knots upon the 
oral side. 

The writer certainly does not wish to dogmatize upon so 
important a subject, but wishes respectfully to call attention 
to the usefulness of chromic catgut of small size for this pur- 
pose. It remains undissolved in the palate as long as there 
can be any possible use for it, resists infection heroically, and 
within ten days or, at most, two weeks, has quite disappeared, 
doing away, therefore, with the procedure of removing the 
stitches, a laborious performance, not unattended by annoyance 
and danger of breaking the union in the palate of a crying, 
twisting infant. 

Chromic catgut is more easily introduced than silkworm 
gut. It is softer and more pliable. The disposition of silk- 
worm gut to shape itself, owing to its springiness, into a ring 



CLEFT PALATE AND HARELIP. 43 

is not infrequently responsible for the first laceration of the 
tissues which results in complete cutting out of the suture. 
There is no hope for any cleft palate operation in which there 
is tension of any kind on the sutures. 

To recapitulate, it is proposed that simple mattressing 
of the bevelled edges of the freely loosened flaps in high palatal 
arches and in lower arches and the addition of relaxing incis- 
ions packed with sterile gauze to splint the flaps, the sutures 
being of chromic catgut, will meet every requirement for the 
restoration of the defect in the majority of cases of cleft palate. 

In Lane's technic for narrow cleft (Ibid. ) , "if the soft 
parts overlying the edges of the cleft are thick and vascular, 
a flap is cut from the mucous membrane, submucous tissue 
and periosteum of one side, having its attachment or base 
along the free margin of the cleft. The palatine vascular 
supply is divided while the flap is being reflected inwards, and 
it depends for its blood supply on vessels entering its attached 
margin. 

'■ The mucous membrane, submucous tissue and perios- 
teum are raised from the opposing margin of the cleft by an 
elevator, an incision being made along the length of the edge 
of the cleft. 

" The reflected flap with its scanty supply of blood de- 
rived from small vessels in its attached margin is then placed 
beneath the elevated flap whose blood supply is ample, and it 
is fixed in position by a double row of sutures. In this man- 
ner two extensive raw surfaces, well supplied with blood and 
uninfluenced by any tension whatever, are retained in accurate 
apposition" (Figs. 11, 12, 13, 14 and 15). 

If a wide gap is found to exist in the soft palate, Lane dis- 
sects up a flap consisting partly of mucoperiosteum from over 
the hard palate and partly of the oral layers of the soft palate. 
He turns this flap over door-like, it having been dissected free 
down to the edge of the cleft, and sutures it to the freshened 
edge upon the opposite side of the defect. 

In cases of very wide defect, after dissecting up a flap 
on one side from the oral surface of the soft palate, a similar 



44 JOSEPH RILUS EASTMAN. 

flap is dissected free from the upper or nasopharyngeal surface 
of the soft palate. It is then possible to fill in the defect by 
applying these flaps to each other, raw surface to raw surface, 
so that the tissue bridging the defect is covered more or less 
completely both above and below by mucous membrane (Figs. 
i8 and 19). 

Ferguson, of Chicago, also imbricates in a similar manner 
large mucoperiosteal flaps taken from the oral surface upon 
one side and from the nasal surface upon the other. 

The older Davies-Colley operation sought to accomplish 
the same end — that of filling in the gap by a bridge of tissue 
covered both above and below by mucosa. However, until it 
is more clearly established that a really useful purpose is con- 
served in primarily providing a mucous floor for the nasal 
space (it being very certain that finally in all cases a very 
complete mucosa covering for the nasal space is formed), it 
is useless to take the risk of sloughing incident to turning over 
the long flap attached at one end only in the Davies-Colley 
procedure. 

In wide clefts in young infants, Lane includes in the oral 
flap, mucosa from the cheek. That is, the area from which the 
flap is taken extends over and beyond the alveolus and around 
on the cheek (Figs. 16 and 17). 

It is clear that after separation of the mucoperiosteum 
from the hard palate, it will be necessary, no matter what the 
shape of the palate vault may be, to separate the soft palatal 
portion of the flaps from the posterior margin of the hard 
palate to the end that the margins of the cleft may be coapted 
without tension. J. Barry makes an important point of the 
separation of the soft from the hard palate in mobilizing the 
flaps. Of course, this means upon the nasal side alone. The 
continuity of the soft palate with the mucoperiosteum split up 
from the oral surface of the hard palate is in no sense impaired, 
but with knife or scissors introduced through a lateral incision 
and under the mucoperiosteum of the hard palate, cutting up- 
ward toward the nasal space, the soft tissues are freed from 
the sharp, posterior edge of the hard palate and, if necessary, 



Fig. II. 




Lane s method of removing mucoperiosteal flap from hard and soft 
palate upon one side of tiie cleft, and tucking the edge of this flap under 
the mucosa through a slit upon the opposite side of the cleft. 



Fig. 12 




Edge of flap tucked under slip upon opposite side of cleft and sutured. 



Fig. 13. 







Fig. 14- 



Fig. is. 





Diagrammatic sketches of technic shown in Figs. 1 1 and 12 




Fig. 16. 




Fig. 17. 




Figs. 16 and 17. Very wide flap, including mucosa covering alveolus and extending around 
upon the cheek; used by I^ane in very broad clefts. 



Fig. i8. 




Lane's or Ferguson's method : A, incision upon nasal side 
of palate for turning down flap ; B, incision upon oral side for 
loosening of mucoperiosteal flap. (After Ferguson .) 



Fig. 19. 




The nasal and oral mucoperiosteal flaps with raw surfaces 
apfxasing, leaving a mucous covering upon the nasal and upon 
the oral side of the new palate. (After Ferguson.) 



Fig. 20. 




Operation after J. Barry: Classical slits upon each side for relaxing 
Of tension and separation of flaps. 



Fig. 21. 



If 


=^ 




) 




^^M 




\ 


u^ 


f^ 




\ 



Severing of the soft from the hard palate with knife passed through 
lateral slit to edge of cleft on each side. Barry regards this as an 
important factor in securing relaxation. 



Fig. 22. 




Soft palate separated from hard palate at sharp anterior edge of latter, 
completely liberating the flap. 



Fig. 23. 




Brophy's lead plates securing silver wire relaxation sutures. 
Fig. 24. 




Diagramatic drawing showing loosened mucoperiosteal flap taken from 
a high palatal arch. 



Fig. 23. 




Flaps from the two sides of a high palatal arch falling together like the two 
halves of a cantilever drawbridge. 



CLEFT PALATE AND HARELIP. 



45 



the mucosa upon the nasal side is cut through (Figs. 20, 21 
and 22). 

No doubt every surgeon in dissecting up the mucoperios- 
teum and pushing the flaps toward the median line, breaks 
up this attachment more or less completely. However, if it be 
done as a definite step, it will save unnecessary scraping and 
trauma to the flaps. 

Barry's observations upon the use of lateral incisions 
correspond with those of Charles Mayo and are eminently prac- 
tical. It is folly to attempt to close any gap with sutures which 
are under tension, and it is a matter of record and experience 
that this tension cannot be taken off the suture by the compli- 
cated devices presented for the purpose. The lateral incisions, 
unless they are quite ruthlessly made, need not permanently 
paralyze any part of the soft palate. 

Those who have observed these cases for a few years 
after operation have become convinced that the paralysis, even 
if the posterior palatine artery and the levator and tensor 
palati muscles be divided, is only partial and temporary. Such 
incisions need never include division of the hamular process 
as in Billroth's procedure. 

There is no need of making them in cases of high palatal 
arch, as Brophy has clearly proven, but if they are needed to 
relieve tension, such incisions should be made not ruthlessly 
but to meet the demands of the specific case. The edges of 
the cleft should be drawn together and incisions made exactly 
where they are needed, a gradual cut-and-fit plan being 
followed. 

Compression in the treatment of cleft palate, according 
to extracts in Dental Cosmos, the Australian Medical Record 
and the Dublin Medical Press, and cited by Garretson ("A 
System of Oral Surgery "), was conceived some time prior to 
1851. 

The operative procedure for immediate cure of congenital 
fissure of the palate is described by Garretson as follows : 

" An instrument, a modification of the Hoey clamp, 
ordinary arterial compressor, or a Hainsby compress, is to be 



46 JOSEPH RILUS EASTMAN. 

made by so arranging the pads that they shall apply to the 
sides of the jaw and allow of the force being so directed that 
the pads can be approximated without undue facial pressure. 
The clamp of Hoey, it will be seen, needs alteration only so far 
as the pads are concerned and is quite easy of adjustment to 
this purpose. 

" The instrument ready (the infant being in proper con- 
dition), the operator commences by paring the soft parts and 
bone on both sides of the fissure, beginning on the approximal 
faces of the palate bones and cutting forward to the alveolar 
face of the chasm. This part of the operation completed, the 
little patient is to be allowed to rest until the bleeding ceases. 
A succeeding step is to re-etherize and apply the compressor; 
the curved pads to embrace the buccal faces of the alveolar 
arch. By now gradually turning the screw of the instru- 
ment, the yielding bones are brought together. The next and 
last step in the operation is to retain the parts in position by 
the use of compresses placed upon and below the malar bones 
and secured by adhesive strips applied as in the occipitolabial 
cravat of Mayo. 

"It may be urged against these manipulations that they are 
formidable and entirely too heroic; that fractures may result, 
etc. On these points the surgeon must decide for himself. 
If carefully performed, the operation is not dangerous; frac- 
ture of the bone, even if it occur, is of little consequence, the 
parts having to be kept, as it were, in splints, consequently the 
treatment of the one would be the treatment of the other. The 
marked risk is from inflammation that may be provoked ; but a 
surgeon not infrequently has to go to far greater lengths for 
even a smaller result." 

The manner of holding together the two superior maxillae, 
as practised by Brophy, of Chicago, differs from the older 
methods in that the two upper alveoli are forced and held 
together by means of stout silver wire. Brophy occasionally 
divides the malar process to the end that the edges of the 
cleft may be forced together. 

If the operation be done in a very young infant, subse- 



CLEFT PALATE AND HARELIP. 47 

quent growth and development may overcome the narrowing 
of the channels consequent upon this compression, but perhaps 
not. 

In the Brophy operation, with a stout needle threaded 
with silk or celloidin hemp, strong silver wire is passed through 
the superior maxillae just back of the malar process and high 
enough to be above the palate. In other words, the wire passes 
from the outer surface of one alveolar process through both 
sides of the upper jaw to the outer surface of the other. One 
or two additional wires are passed through both superior 
maxillae and in front of the first. The ends upon each side 
are twisted together over lead plates after the edges of the 
cleft have been forced together by powerful compression of 
the two superior maxillary bones between the operator's 
thumbs. 

It is Brophy's observation that the difference in the dis- 
tance between the two upper alveoli and the distance between 
the two lower is equal to the width of the cleft. 

In cases of complete cleft palate in the new-bom, the 
operation of Brophy is certainly the most rational one to which 
we can have recourse. The dangers from shock and sepsis 
have been, it seems, somewhat exaggerated, but even if there 
be some additional risk in the Brophy operation, is it not better 
to assume such risk in the hope of securing the best results, 
particularly as to the obviation of the speech defect? If 
Brophy's contention as to the greater width of the upper jaw 
be true, and there seems to be little doubt of it, articulation and 
occlusion of the teeth should be improved and not impaired 
by the compression of the upper alveoli. 

It is unfortunate that physicians generally are indifferent 
concerning the important matter of operating cleft palate early. 
The operation of Brophy, with the present appreciation of this 
matter, is applicable in a comparatively small number of cases 
only. 

In cases seen somewhat too late for the Brophy operation 
and with large defect of the hard palate, Ochsner's operation 
of chiseling upward between the alveolar processes and the 



48 JOSEPH RILUS EASTMAN. 

bony palate and forcing each half of the bony palate inward 
toward the median line, offers the best substitute for compres- 
sion of the upper jaws which might have been practicable had 
the case been seen when the bony parts were pliable. 

It is true of the western section of the United States at 
any rate that only a small proportion of cleft palate cases is 
seen by the surgeon during the first few weeks, and of these 
only a part are suitable cases for Brophy's technic. The field 
of its application is, therefore, at present limited. Its use 
involves forcibly pressing together the two sides of the upper 
maxillary arch with consequent narrowing of the nasopharynx 
and vault of the mouth. If good judgment is not used in the 
selection of cases for the Brophy technic, this very beneficent 
operation will, of course, disappoint. 

G. V. I. Brown (Journal A. M. A., February i, 1908), 
has found that " where forcible means have been employed 
in early infancy to bring the sides of the fissure into direct 
or too close approximation, the arrested development of the 
maxillary bones makes the anterior portion of the mouth too 
small for accommodation of the tongue in the utterance of word 
sounds. This disadvantage is increased by the fact that on 
account of early derangement of the developing teeth through 
forcible compression of the parts, not only are the incisors, 
cuspids and bicuspids erupted in such position as to reduce the 
size of the dental arch, but frequently one or more teeth erupt 
almost in the central portion of the palate." 

There is little doubt but that the failure to choose the 
proper operation for the specific case is more often culpable 
for failure than hemorrhage, vomiting or any of the other 
recognized causes of failure. There are so many varieties of 
cleft palate that there can never be a single operation which 
will apply in all cases. There always will be many operations. 
The development of the art cannot eliminate them. 

It is of fundamental importance that a suitable method 
be chosen for the case in point. ' Elaborate staphylorrhaphies 
are, no doubt, frequently made when small pivot-flap opera- 
tions are best suited to the condition and many palate defects 



CLEFT PALATE AND HARELIP. 



49 



considered hopeless, so far as Brophy's plan is concerned, can 
be corrected, for example, by Lane's method of pushing over 
flaps which embrace all the mucosa from the edge of the cleft 
to an arc on each side over and beyond the alveolus, it being 
assumed, of course, that the teeth have not yet erupted. 

Bad remote results may be expected to follow operations 
in which the soft palate is stiffened too much by traction due 
to scar formation, just as tension upon the sutures is the most 
common cause of immediate failure. 

A fruitful source of trouble after operation is the swallow- 
ing of blood which in the sensitive stomach and intestine of a 
young infant, particularly in hot weather, may set up a con- 
dition very like that produced by the active fermentation of 
indigestible food with annoying if not alarming symptoms 
of autointoxication. After cleft palate operations, the patient 
should be nourished by the administration of nourishing food 
in the form of rectal enemata during the first two days. If 
the loss of blood has been considerable, normal salt solution 
should be given by the bowel, but feeding by the mouth may 
be dispensed with during the first two days, after which sterile 
milk should be given to the exclusion of everything excepting 
sterile water. If the infant is so weak that it cannot get on 
with rectal feeding for two or three days, it should not be 
operated upon until it has sufficient vitality, unless the opera- 
tion be one of emergency. 

In almost every case of harelip, the nose is flattened. In 
unilateral cleft, it is usually seen that the ala of the nose is 
broader upon the side corresponding to the cleft (Fig. 26). 
In double harelip, both alae and both nostrils are widened. To 
the end that there may be no tension upon the lip sutures and 
that the nostril or nostrils may not be too broad, it is important 
that before suturing the freshened lip margins, the nose be 
separated from its deep connections upon the side concerned if 
the harelip be single or upon both sides if the case be one of 
double harelip. This is readily done through a transverse in- 
cision at the junction of the upper lip mucosa and gum with a 
pair of scissors passed through this incision upward between 



50 



JOSEPH RILUS EASTMAN. 



the lip and the superior maxilla (Fig. 27). The soft tissues 
are completely separated from the bone over an area large 
enough to render the alae freely movable. 

With the upper lip everted and pulled upward, the mucosa 
may be easily split at its attachment to the gum. In answer 
to the question as to the extent of the separation of the soft 
parts from the bone which suffices, Binnie answers that " keep- 
ing close to the bone the soft parts should be freed until the 
edges of the cleft when placed together show a tendency to lie 
in apposition so that the sutures when introduced may be tied 
without giving rise to tension," Some care should be taken 
that the separation be made with dull instruments in the 
neighborhood of the infra-orbital foramen in order to avoid 
injury to the infra-orbital nerve and vessels. 

The importance of relieving tension by separation of the 
nose from its deep connections has been emphasized by Charles 
H. Mayo. As necessary, however, as this step may be, it is 
not more useful in practice than the measure of passing a fine 
chromic catgut suture through the base of the septum and the 
base of the ala on the involved side, which when tied will draw 
and hold these attachments in the proper relationship for the 
establishment of a nonnal, narrow nostril. This suture is 
passed up through the transverse incision in the mucosa at its 
reflection from gum to lip. Even if the soft parts be quite 
freely separated from the bone, the unfastened ala tends to 
creep back into its abnormal position, maintaining a broad 
and unsightly nostril. The measure of keeping the nostril 
narrow with the buried chromic catgut suture should always 
follow the loosening of the nose from the bone. 

In most cases of harelip, horse-hair sutures meet the indi- 
cations. Both the deep sutures and those for precise coap- 
tation of skin and mucosa may, as is well known, be of horse 
hair. Neither silk nor silkworm-gut sutures have any demon- 
strable superiority over horse hair. Horse-hair suturing with- 
out dressing represents at once the simplest and most satis- 
factory practice. 

In a certain very small percentage of cases, retention 



Fig. 26. 




Method of narrowing the flaring nostril. Shaded area is that over 
which the lip and nose are separated from all attachments to the 
supenor maxilla. 



Pig. 27. 




_ Incision made at attachment of lip mucosa to gum. A suture is 
m place for drawing the base of the ala toward the base of the septum. 



Fig. 28. 




Author's method of preventing notching. The horse-hair sutures at 
the top and bottom of the united cleft margins are left long and tied over 
a small roll of gauze. This small roller of gauze is efficient in removing 
strain upon the horse-hair sutures. Leaving the ends of the top and 
bottom sutures long, greatly facilitates the introduction of the horse-hair 
sutures upon both skin and mucous surfaces. 



Fig. 29. 




Showing manner of introducing retention suture, according to Lane. 
Needle carrying silk suture is passed clear through the lip from inside to 
outside, about one-third of an inch from the prepared edge of the cleft 



Fig. 30. 




After having been drawn through, the needle is reintroduced at the 
aperture of exit in the skin and is passed across to a point at a corre- 
sponding distance from the edge of the cleft upon the opposite side, the 
course of the needle being just under the skin. The needle is again 
passed, starting at the second aperture of exit in the skin, through the 
lip to the mucous surface where the ends are tied. 



Fig. 31. 




Diagram showing the course of Lane's retention suture. 



Fig. 33. 



Fig. 32. 





Relaxation by means of adhesive plaster cut 
dumb-bell shape, securing small pad of gauze. 



Dr. H. R. Allen's clock-spring relaxation ab- 
sorber. 



Fig. 34. 




Relaxation by Ferguson's or Taylor's circular strap of adhesive, 
which effectually controls the risorius and orbicularis oris to a consider- 
able extent without making pressure upon the wound area. 



CLEFT PALATE AND HARELIP. ei 

sutures may become necessary. For these silver wire is useful. 
When silver wire is used for suturing, it is usually attached 
in a clumsy manner to a straight or curved needle by simply 
bending back one end of the wire after it is passed through the 
eye. It may, of course, be introduced somewhat more easily 
by using a needle anned with a loop of silk thread with which 
the wire suture is drawn into position. The free ends of the 
sutures are then twisted or shotted or secured by glass beads, 
according to the degree of tension and the character and 
location of the wound. 

If wire be threaded indirectly through the eye of a needle 
and doubled backward upon itself, there will be formed at the 
necessarily broad butt end of the needle an awkward lump. 
To jerkily draw this through delicate tissues, like those of the 
soft palate or the lip of a young infant, must, in the nature of 
things, cause tearing and contusion which detract from the 
usefulness of the suture. The jerking of the lump of wire 
through the tissues is especially disagreeable after one or more 
sutures have been introduced and secured, the likelihood of 
loosening or displacing such already adjusted sutures being 
considerable. The entrance and erratic excursions of the loop 
of wire produce an unnecessarily large skin opening and stitch 
canal and predispose to infection and consequent " cutting 
out "of the suture. 

To obviate these difficulties, I have used in harelip opera- 
tions a fine silver wire suture eighteen inches in length, to one 
end of which is attached with silver solder, after annealing of 
both metals, a full or half-curved steel needle. This gives a 
perfectly smooth joint which may be drawn through delicate 
tissues without adding unnecessary laceration to that produced 
by the needle point and which does not catch abruptly at the 
skin. In most cases, eighteen inches of wire will suffice for a 
half-dozen sutures, a piece of the desired length being cut from 
the distal end of the wire after each introduction of the needle. 
The needle, after the sutures have been thus cut away, may 
be rearmed with wire or discarded. 

Some years ago there was introduced to the profession a 



52 JOSEPH RILUS EASTMAN. 

silver wire needle with a hollow threaded butt into which a 
wire suture might be screwed and fastened. This needle has 
not come into general use for the reasons that its butt, though 
bevelled in both directions, is much larger in diameter than the 
wire it admits and its attachment to the wire is insecure. 

Silver wire is generally recognized as a useful suture 
material. It is easily sterilizable. Moreover, it has been re- 
peatedly demonstrated that metallic silver has an inhibitory 
effect upon the growth of bacteria. A properly prepared silver 
wire suture is, therefore, not simply aseptic but more or less 
" antiseptic." 

Silver wire is unirritating and strong. If it is sterilized 
by heat, as by boiling in soda solution — with instruments — the 
metal becomes annealed and is thus rendered soft and pliable 
and less liable to break when twisted. 

A beaded wire suture is easily removable since the bead is 
not apt to be obscured by the swollen tissues and is easily seized 
with forceps and cut from the wire. After the suture has been 
introduced and cut off to the desired length, the ends are passed 
each through a perforated bead. 

The malleability of silver enables the surgeon to give to 
the wire suture any desired bend. This is impossible with a 
silkworm-gut suture which, wherever possible, assumes the 
form of a ring. This disposition of silkworm gut to shape 
itself, owing to its springiness, into a ring, is, as has been pre- 
viously noted, often responsible for the first laceration of the 
tissues, which results in " cutting out." 

It will, however, rarely be necessary to use a suture of the 
character of wire. In almost every case of harelip, strong 
horse hair is in every way satisfactory. The elasticity of horse 
hair and its possibility of almost complete sterilization, together 
with its relatively small diameter, militate against scar forma- 
tion. It is the only suture material in use which grows natur- 
ally in the skin. It is constructed of epithelium, is non- 
irritating, and, if properly prepared, is the best possible suture 
material for use in the skin anywhere. It cannot be tied too 
tightly, for it will break if drawn too forcibly. 



CLEFT PALATE AND HARELIP. 53 

The writer's method of arranging the horse-hair sutures 
is as follows : 

After freshening the edges of the cleft according to the 
method suitable in the particular case, the first horse-hair 
suture is introduced at the top of the cleft, penetrating the 
skin about one-eighth of an inch from the edge of the cleft 
on one side and emerging at the mucous border. It is then 
passed through the flap on the opposite side in the same way 
except in the opposite direction. This top suture is tied and 
the ends left long. Then at the junction of the skin and the 
vermilion mucous border a similar horse-hair suture is passed, 
precisely coapting the mucosa. It is tied and the ends left 
long. Traction upon the ends of these two sutures coapts the 
freshened edges of the cleft so that intervening sutures may be 
put in easily. Especially is this true of the horse-hair sutures 
upon the mucous surface, the upper lip being everted and pulled 
upwards by traction upon the lower of the two guy sutures, the 
entire length of the freshened edges of the mucosa is exposed. 

In order to avoid the occurrence of a notch on the lip 
after the wound has shrunken, after freshening is done accord- 
ing to one of the well known methods suitable in the case and 
after introducing the horse hair sutures as described above, a 
little roll of gauze about the size of the distal phalanx of one's 
little finger is fixed with its long axis transversely to the plane 
of suture and the long ends of the uppermost and lowest horse 
hair sutures are tied over the little gauze roll so that the line 
of suture is wrapped, so to speak, around the gauze for about 
two-thirds of its circumference (Fig. 28). This simple plan 
will effectively prevent notching after healing is complete and, 
moreover, it keeps the dressing in place, a matter of no slight 
importance. 

Lane almost invariably introduces two relaxation sutures 
as follows : 

He starts the needle upon the mucous side about a third 
of an inch from the edge of the cleft, passes straight through 
the lip and out upon the skin side. He then introduces the 
needle at its minute aperture of exit and passes across the 



54 JOSEPH RILUS EASTMAN. 

plane of suture to the opposite side, keeping the needle just 
under the skin and emerging again about one-third of an inch 
from the wound margin. He then passes the needle back 
through this second opening in the skin, penetrating all of the 
tissues of the lip, including the mucosa. 

The suture is tied upon the mucous surface, an objection 
being that the knot is left upon the mucous surface where the 
infant will instinctively poke at it with the tongue (Figs. 29, 
30 and 31). 

Such sutures should be omitted if possible. If found 
necessary and silver wire be used for this purpose, the child 
will not poke with the tongue tip at the sharp ends. Lane 
uses Chinese twist. 

Devices for relieving tension after harelip operations 
should not come into contact with the wound. It is a common 
practice to use a strip of adhesive plaster passing from cheek 
to cheek. Such a strip of plaster is likely to produce unde- 
sirable pressure upon the wound. The strip of plaster is 
usually cut dumb-bell shape with the narrow part across the 
upper lip, covering just as little of the lip as possible (Fig. 32). 

It is much better to use the plaster after the fashion sug- 
gested by A. S. Taylor or A. H. Ferguson. Taylor's dressing 
consists of two narrow strips of adhesive plaster (about ^ 
inch or i cm. wide), starting well down on the cheeks, crossing 
each other over the bridge of the nose and passing well out on 
the forehead. Originally, a little square of gauze was used 
to protect the bridge of the nose and the inner ends of the 
eyebrows from the plaster, but the later dressing is a great 
improvement. The plaster which would lie over the nose and 
eyebrow is cut out on each side and folded under so that the 
adhesive surface is eliminated. 

Ferguson's suggestion is as follows : Take a strip of plas- 
ter one inch wide and about twelve inches long, place the centre 
of the strip beneath the chin, pull firmly on both ends, allow 
the plaster to adhere to both cheeks well back and then cross 
the plaster over the nose on to the forehead. Where the plas- 
ter passes over each eye, roll the strip on itself into a cord. 



CLEFT PALATE AND HARELIP. 



55 



This effectually prevents tension on the sutures, even when the 
child is crying. The line of incision should never be sealed 
either with colloidin or plaster (Fig. 34). 

H. R. Allen has recently presented a spring " tension ab- 
sorber " (Fig. 33) which is in principle somewhat similar to 
the older Hainsby compressor which consists simply of a spring 
which passes around the head, having a small pad at each ex- 
tremity. The spring was of such circle and character as to 
bring the pad to the labial commissures. 

The application of the adhesive plaster, according to Tay- 
lor and Ferguson is especially useful, for if the tension-remov- 
ing device cover the wound and is removed for a dressing, its 
support is lost just at the time when the child is sure to cry 
and struggle harder. Straps crossing the wound are unneces- 
sary for as Binnie says, " if the soft parts of the lip and cheeks 
have been sufficiently separated from the bones at the begin- 
ning of the operation, then such a measure is unnecessary and 
undesirable, as it simply irritates the already irritable patient. 
It is not necessary to apply any dressing to the wound as nature 
soon seals it with dried blood-clot. Until the sutures are re- 
moved, there should be as little interference with the wound 
as possible. If it is going to heal, it will heal under the scab 
and the best intentioned endeavors to clean the wound will 
merely interfere with nature's work and do no good, as cleanli- 
ness can never be attained in such cases. Care must be taken 
so to fix the little patient's arms that scratching of the wound 
is rendered impossible." 



ABERRANT THYROID. 

REPORT OF A CASE ; FROM THE CLINIC OF PROFESSOR KANAVEL AT THE CHICAGO 
POST-GRADUATE HOSPITAL. 

BY BERTRAM CHARLES CUSHWAY, M.D. 

OF CHICAGO. 

A REVIEW of the literature shows that but sixteen cases 
of lateral aberrant thyroids have been reported since 1857. 
Owing- to the apparent small number of such cases and the 
fact that they may play an important role in compensating 
for loss of thyroid tissue proper, it has seemed worth while 
to report this case of lateral aberrant thyroid, which, while 
similar in many respects to those previously reported, differs 
in many important characteristics. 

That so few cases have been recognized, may not mean 
that they are so rare, since the real identity of these little 
masses may be easily overlooked, as in this case, where the 
gross appearance was very unlike thyroid tissue, and the 
diagnosis can seldom be made without the aid of a microscope. 

Aberrant thyroid has been defined as a tissue mass located 
at a definite distance from the thyroid proper not connected 
with the thyroid and having the structure of a normal or 
pathological thyroid gland. 

Aberrant thyroids may be classified from the stand- 
point of embryology as, (a) median, formed from remnants 
of the thyroglossal duct; (b) lateral, from remnants of 
lateral analges of the thyroid. As to topography the hyoid 
bone may be taken as the dividing line for the median and 
lateral, into superior above and inferior below the hyoid. 
The greater number are found in the anterior triangle of the 
neck, and occasionally they may be found in the lateral. 

Case History. — Mrs. E. N., age 26, German housewife, 
entered the hospital December 13, 1906; discharged December 
14, 1906. 
56 



Fig. I. 




Photograph of the tumor dissected (same size as tumor) ; at 
lower pole three or four smaller accessory thyroids are seen 



Fig. a. 




Photomicrograph of cut section showing embryonic acini, with here and there fully 
developed acini filled with colloid material. 



ABERRANT THYROID. 



57 



Personal History: Married; no children; habits good. 

Family History: Negative; no others in the family had 
masses in the neck. 

Previous Illness : Always enjoyed fairly good health. 

Menstrual History: Negative; no enlargement of tumor 
mass during menstruation. 

Present Trouble: The patient states that two and a half 
years ago she noticed a small tumor on the left side of her neck, 
which has gradually increased in size until the present time. It 
has not been associated with any other symptoms or signs, gen- 
eral health and strength unimpaired. It has given her no pain 
nor has it been tender, and the only complaint is that it has been 
somewhat unsightly. 

Examination. — On the left side of the neck opposite the hyoid 
bone, apparently covered by the platysma and the sternomastoid 
muscle, is found a tumor, approximately the size and shape of a 
goose egg, with the smaller end directed downward in the direc- 
tion of the sternum. It is not tender and there is no fluctuation. 
The skin is apparently not connected with the tumor, since it can 
be moved over the surface without difficulty. No other enlarge- 
ment can be noted on either side of the neck. The thyroid gland 
can be demonstrated in its proper location, there are no glandular 
enlargements in other parts of the body, the examination of the 
lungs, heart and other viscera shows nothing abnormal. The 
patient states she has had the ordinary diseases of childhood and 
denies venereal infection. 

Operation. — Ether anaesthetic by Dr. Barrett. Operator, 
Dr. Kanavel; assisted by Dr. Matthews. Incision was made on 
a line drawn from the tip of the mastoid to the cornu of the 
hyoid bone. Skin, subcutaneous tissue, and platysma were 
incised. The mass was found to be a solid tumor, lying opposite 
the hyoid bone, projecting under the anterior border of the sterno- 
mastoid muscle and on separating it from the adjacent tissues it 
was found to be in juxtaposition to the carotid artery and jugular 
vein. It was separated without difficulty, except at its lower end 
where it seemed to be continuous with three or four small glands 
or tumor bodies decreasing in size, the largest at the upper end, 
the size of a small walnut, and the smallest, at the lower end not 
larger than a grain of wheat. These were all united by firm 
fibrous tissue and the lowest lay close to the capsule of the thyroid 
gland, which was demonstrated to be present. 



58 



BERTRAM CHARLES CUSHWAY. 



In removing this lower prolongation, a second incision was 
necessary, passing downward from the first along the anterior 
border of the sternomastoid muscle. The platysma was drawn 
together with two or three catgut sutures, the skin wound closed 
with interrupted silkwortn-gut sutures with silkworm-gut drain 
inserted at the lowest point. 

Subsequent History. — Silkworm-gut drain removed in eight 
hours. Silkworm-gut sutures removed in five days. The patient 
made an uninterrupted recovery and has had no subsequent 
symptoms of any kind. 

Examination of the Tumor. — The specimen consists of five 
tumor masses ; the upper and largest, size of a walnut ; the lower 
and smallest, a grain of wheat. Each mass has a separate cap- 
sule, of a yellow color, firm and very slightly vascular, the entire 
mass being connected and held together by fibrous tissue. On cut 
section the large tumor mass measured on its cut surface 5 cm. 
and to gross appearance presented a mottled grayish surface 
suggestive of sarcoma tissue. It is not so white as carcinomatous 
masses would appear. It did not present the characteristic color 
of the thyroid gland. The tissue was of firm consistency showing 
no tendency to cystic degeneration. The cut section of the smaller 
masses showed the characteristic color and consistency of thyroid 
tissue; the tissue of neither, however, was friable, but was firm 
and did not bulge above the flat surface on cut section. The 
microscopic examination shows the structure in large and small 
masses to be practically the same, presenting in general the 
picture of a thyroid except that numerous embryonic follicles are 
to be found with some epithelial proliferation in the acini and here 
and there accumulations of colloid. 

Schrager has discussed this subject fully in Surgery, 
Gynsecology and Obstetrics of October, 1906. This case is 
similar to his in general findings and microscopical appear- 
ance, but differs from his cases in gross appearance and cut 
section, the tumor described by Schrager having the appear- 
ance of the normal thyroid both in the uncut and cut sections, 
and showed a tendency to cystic degeneration, while ours 
was a strictly solid tumor, which, except for the lower pro- 
longations, did not resemble thyroid tissue in any way and 



ABERRANT THYROID. 59 

the grayish color of this tumor being especially worthy of 
note. The probability that these aberrant thyroids are fre- 
quently overlooked and mistaken for lymph-nodes or other 
tumors in this location, should cause us to look more care- 
fully for them and to think of their possible presence in 
diagnosis of tumors of the neck. Diagnosis may be impos- 
sible without the microscope, but the following points may 
suggest the presence of aberrant thyroid: 

1. A tumor located most frequently in the anterior or 
lateral triangles of the neck. 

2. Tumor mass may increase in size during period of 
menstruation. 

3. May be first noticed and increase in size at puberty. 

4. Most frequent in women. 

5. Growth usually slow and without attendant symp- 
toms unless cyst formation takes place. 

It is well to bear in mind the possibility of a compensa- 
tory hypertrophy of these masses when the thyroid gland 
may be destroyed by disease. As a majority of the cases 
reported by Schrager were cystic and nearly all of them 
presented the appearance of normal thyroid upon gross exam- 
ination the grayish color and its lack of resemblance to thyroid 
tissue in the gross specimen, and on cut section in this case, 
is worthy of note. 

I wish to express my best thanks to Professor Kanavel, 
who allowed me to study and report this case from his clinic. 



SUPPURATIVE PERICARDITIS.* 
BY ELLSWORTH ELIOT, JR., M.D., 

OF NEW YORK, 
Surgeon to the Presbyterian and Gouverneur Hospitals. 

The literature of purulent pericarditis has been admir- 
ably collated by Roberts and C. B. Porter. By the former 
surgeon 37 instances of operation for that condition were 
tabulated from different sources in 1897 and to that number 
10 additional cases, reported in the literature between 1897 
and April, 1900, were added by Porter. In the present 
instance, the rarity of this condition fully warrants the publi- 
cation of a case of this kind recently under the writer's obser- 
vation, while, at the same time, an opportunity is afforded 
for brief mention of those cases that have been published 
since Porter's contribution in 1900. 

An analysis of cases of suppurative pericarditis hitherto 
published shows that in the great majority of instances this 
condition is secondary to some distant focus of infection, 
while only exceptionally is the infection either introduced 
directly into the pericardium or of unknown origin. Thus in 
19 of Roberts' series of 39 cases there is a history of a focus 
of infection in either the lung or pleura or both, in 6 others 
the primary focus consisted of an acute osteomyelitis ; in four 
others (as in the writer's case) the original infection could 
not be traced, while in only three instances the pyopericarditis 
was the direct result of a penetrating wound. In many of 
the secondary cases, the pyopericarditis was only one of a num- 
ber of metastatic purulent foci such as are commonly asso- 
ciated in a condition of general sepsis. Closely associated 
with the etiology is prognosis and it is needless to say that the 
prospect of a cure after operation is much more favorable 
where the infection is limited to the pericardiac sac than where 

♦ Read before the New York Surgical Society, Oct. 28, 1908. 
60 



SUPPURATIVE PERICARDITIS. 6l 

the pyopericarditis is a part of a general sepsis. That occa- 
sional recoveries are secured however in this latter group of 
cases certainly warrants surgical interference under all cir- 
cumstances where the patient is not moribund as the only 
chance of averting a fatal issue. 

The pathological changes in pyopericarditis are interest- 
ing and important. Usually the entire pericardium is con- 
verted into an abscess cavity, the heart, according to Brentano, 
being displaced downward and forward against the chest 
wall, a position, in which exploratory puncture may readily 
penetrate one of its chambers. Occasionally, as in the 
writer's case, the heart is more deeply seated and not likely 
to be damaged by the exploratory needle. Exceptionally, the 
pericardium may be subdivided into several distinct abscess 
cavities as in the cases of Delorme (mentioned by Roberts) 
and of Coutts and Rowlands. Such a condition is favored by 
adhesion of the heart to the anterior pericardium, the abscess 
cavities being situated laterally and posteriorly. The char- 
acter of the purulent exudate varies. In the early stages, 
especially after infectious penetrating wounds and as a com- 
plication of pneumonia, it may be first serous and subsequently 
become purulent. It varies also in color and consistency as 
well as in the variety and number of germs which it contains. 
A thick consistency naturally increases the difficulty of diag- 
nosis by exploratory puncture. Purulent foci are also occa- 
sionally observed in the heart muscle. Thus, in the autopsy 
of Sibley's case several small abscesses were found in the wall 
of the heart and in another similar case reported by Brentano, 
the direct cause of death was said to have been a rupture of 
such an abscess into the cavity of the left ventricle. In Sib- 
ley's case (Case XV) the pus had been detected by exploratory 
puncture and although the heart proved to be deeply seated 
in the pericardium, a puncture of its wall by the exploratory 
needle is not inconceivable. 

The lesions of pyopericarditis of unknown origin or of 
those due to penetrating wounds — the so-called primary cases 
— are not always confined to the pericardium and heart. The 



62 ELLSWORTH ELIOT, Jr. 

infection frequently spreads to the anterior mediastinum and 
contiguous pleura. In Coutts and Rowlands's case (Case VII) 
an autopsy, i6 weeks after the drainage of a pyopericarditis 
complicating pneumonia and empyema, in a child two and 
one half years old, showed that the entire anterior mediastinum 
was occupied by a thick fibro-gelatinous deposit. In the 
writer's case, the anterior mediastinum was evidently infil- 
trated with a large serous exudate, the anterior wall of the 
pericardium lying at least an inch beneath the sternum. Such 
a condition may readily prevent the approximation of the 
divided edges of the pericardium to the skin, as recommended 
by Bretano, Porter, and others, and necessitates the drainage of 
the abscess cavity from a considerable depth through the 
intervening mediastinum. 

The changes in the pleura may either precede or follow 
those of the pericardium. In the former instance a localized 
empyema associated with an infectious pneumonia or merely 
the result of the lodgement of an infectious embolus may 
invade either pleural cavity at a point remote from the peri- 
cardium. In the latter instance, the opposed surfaces of the 
pleura may at first be glued together by fibrinous exudate for 
the purpose of self -protection against the extension of the 
pericardial abscess. Such a barrier may subsequently prove 
inefficient and a localized empyema close to the pericardium 
may appear, without, however, any demonstrable connection 
between the two abscess cavities. The importance of recog- 
nizing an associated empyema, whether primary or secondary, 
cannot be unduly emphasized, for in the event of such a 
complication it is only by proper incision and drainage of the 
purulent foci in both the pleura and pericardium that the 
recovery of the patient may be hoped for. The apposition 
of the opposed pleural surfaces by plastic exudate in the early 
stages of the extension of the pericarditic abscess may obliter- 
ate the corresponding part of the pleural cavity and may 
prevent a successful separation of the inner angle of the 
pleura from the anterior surface of the pericardium. Such 
artificial separation of the normal pleura is usually possible 



SUPPURATIVE PERICARDITIS. 



63 



and, in pyopericarditis, is always to be attempted by the 
surgeon in order that the underlying pericardium may be 
divided and the abscess material be evacuated without risk of 
pleural contamination. 

Lesions in more remote parts of the body are those of 
the primary focus of infection or of the resulting metastatic 
abscesses and require no special description. 

The clinical features of pyopericarditis form a distinct 
and typical picture only in the primary group of cases. Here 
the constitutional symptoms are those of a variable degree of 
sepsis while the local symptoms are those of a pericarditis 
with effusion. On the other hand, in secondary pyoperi- 
carditis the symptoms are frequently masked by those of the 
primary lesion and particularly in children the abscess in the 
pericardium may be entirely overlooked. In this group the 
diagnosis must be made chiefly on the character of the 
physical signs although the chance of error is well shown by 
the testimony of several observers who call attention to the 
similarity of the physical signs of fluid in the pericardium to 
those of a dilated heart. Although an exhaustive discussion 
of the differential diagnosis of these two conditions is beyond 
the scope of this paper yet, as an important preliminary to 
exploratory puncture as a means of diagnosis, the writer 
wishes to emphasize the value of a differential leucocyte count. 
Coutts and Rowlands mention a " high " leucocyte count in a 
child one and two-thirds years old and in the case reported by 
Scott the leucocytes, which during a previous pneumonia were 
normal, increased in number as soon as the complicating peri- 
carditis developed. In the writer's case a number of examina- 
tions of the blood gave an average leucocyte count of over 
20,000. 

In the presence of a high leucocyte count exploratory 
puncture is justifiable. The risks of this procedure have 
probably been overestimated. That the needle may enter the 
heart and that this accident is favored by the intervention of 
the heart between the fluid and the chest wall cannot be 
denied ; that laceration of the heart may also be caused by 



64 ELLSWORTH ELIOT, Jr. 

contact with the pointed needle is also quite possible; and 
finally, equally true is it, that the needle may penetrate the left 
pleural cavity with or without the lung and so, in its with- 
drawal, form a new channel for the spread of the infection 
beyond the pericardium. In fact, such accidents are on record 
in medical literature. Thus Burtenshaw reports a case of 
paracentesis in which the trocar was first introduced into the 
right ventricle and lo ounces of blood were withdrawn before 
the mistake was discovered. This accident, however, did not 
prevent the patient's recovery. A. Meldon collected in 1897 
100 cases of paracentesis of the pericardium with only one 
fatality from laceration of the right ventricle. Case XII, re- 
ported by Peters, seems to have been an instance in which a 
subsequent empyema may have been the result of infection 
spreading along the course of the needle from the punctured 
pericardium. On account of the rarity of these accidents, 
however, one should not be deterred from making the neces- 
sary exploration, especially when every preparation has been 
made for immediate operation in case pus is discovered, for 
with such a precaution the resultant damage to the heart or 
the possibility of laying open new paths of infection along 
the course of the needle would be greatly minimized. 

The possibility of such accidents, however, has led to a 
wide variability in the choice of a site for puncture. The risk, 
theoretically, of penetrating the left pleural cavity is shown 
by a study of the relation of its reflections to the chest wall. 
Investigations by Silk, Dwight and others have shown that 
the median reflection of the left pleura lies under cover of the 
sternum at the fifth costal cartilage and usually also beneath 
the sixth, while generally at the seventh there is an interval 
between it and the edge of the sternum. It is only therefore 
at or below this level that the pericardium can be entered in 
exploratory puncture without first passing through the over- 
lapping pleura. This is probably the reason why Roberts and 
others favor a point of puncture close to the ensiform cartilage 
opposite the seventh costal cartilage. That a similar condition 
would obtain in the presence of a pyopericarditis, might be 



SUPPURATIVE PERICARDITIS. 65 

inferred from the investigation of Delorme and Mignon, who 
have demonstrated the fact that distention of the pericardium 
with fluid has Httle or no effect in displacing the median 
pleural reflection outward. But artificial serous distention 
is not purulent distention and according to the observations of 
Gliick, the left lung at least is displaced so far outward, if 
not the pleura as well, that, in puncture made just within the 
outermost limit of the precordial dulness, the needle readily 
penetrates the distended pericardium without damage to the 
lung or its investing pleura. This view has the support of 
Curschmann and others who unite in maintaining that ck- 
ploratory puncture at the designated point is preferable, in 
that it incurs much less risk of tearing the heart, which is 
usually pressed forward, than a puncture close to the sternal 
edge. 

In the writer's single experience, the left lung did not 
appear in the operative field and the pleura was not opened 
in the exposure of the pericardium at a point one and one-half 
inches from the sternal edge at the level of the fifth costal 
cartilage. Two preliminary exploratory punctures at a point 
slightly external had also proved harmless. That, on the 
other hand, the left pleural cavity has been opened in a number 
of operations for pyopericarditis, is a matter of record and 
the occurrence of such an accident seems to depend upon the 
degree of plastic exudate with consequent obliteration of the 
median pleural angle which has taken place, prior to the 
operation, and to which reference has already been made 
when speaking of the pathological changes of this condition. 
In general, it may be stated, that usually sufficient obliteration 
has already taken place prior to the operation to minimize the 
danger of damage to, or contamination of the left pleural 
cavity during the necessary exposure of the distended 
pericardium. 

It is also important to emphasize that here, as in purulent 
collections of all kinds, exploratory puncture sometimes fails 
to withdraw: pus. Thus Lyonnet reports a case in which two 
explorations proved unsuccessful where on subsequent autopsy 

3 



66 ELLSWORTH ELIOT, Jr. 

between 50 and 60 ounces of pus were found in the peri- 
cardium. In this case the heart, although adherent anteriorly, 
showed no trace of needle puncture. In every case of sus- 
pected pyopericarditis, where puncture is unsuccessful, the 
question of operative interference must be determined by the 
character of the physical signs, the degree of dyspnoea, the 
other symptoms of impeded and insufficient heart action and 
the degree of leucocytosis. 

In the consideration of the clinical features of pyo- 
pericarditis, mention has been made of a group of cases 
occurring especially in children in which the lesion is over- 
looked. In this connection, it is well to call attention to the 
possibility of the local symptoms of this condition simulating 
those of a peritonitis. As in pneumonia, so in a pericarditis, 
and again especially in children, such an atypical clinical pic- 
ture is apt to occur and even lead to the needless exploration 
of the abdominal cavity before the actual condition is 
recognized. 

. TREATMENT. 

Except where the patient is already in extremis or mori- 
bund, operative treatment is indicated and should take place 
without delay in all cases of suppurative pericarditis as soon 
as the diagnosis is confirmed by the needle. Moreover in 
those cases in which exploratory puncture fails to withdraw 
pus, operation is justified by evidence of continued insufficient 
cardiac or respiratory action. Operative relief should also 
be extended to patients with advanced serous pericarditis in 
which aspiration either fails or is followed by rapid reac- 
cumulation of the fluid with a return of cyanosis, dyspnoea, 
syncope or other serious symptoms. 

Puncture, alone, in pyopericarditis, with the exception 
of a few scattered instances in which a cure has resulted from 
the gradual enlargement of the puncture channel into a 
permanent fistula, affords at the best but temporary relief. 
As a rule the removal of pus in this way is but partial and 
its reaccumulation is rapid. Repeated punctures, in the hope 



SUPPURATIVE PERICARDITIS. 67 

of effecting a permanent cure, prolong the length of septic 
absorption and diminish the chance of success by subsequent 
operation. Its use, therefore, should be strictly restricted to 
diagnostic purposes. 

Operation proper consists merely in the opening of the 
pericardium and in the provision for satisfactory drainage. 
For this purpose different routes have been either suggested 
or practised by their authors with the common object of 
minimizing the risk of opening the left pleural cavity. Thus 
Bacon advocates trephining the low;er end of the sternum, but 
although, according to Curschmann, Riolan, Skelderop and 
Velpeau advocated a similar measure, no cases operated on by 
this route have as yet been reported. The writer suggests 
that the necessarily restricted space might unduly hamper the 
exposure of the pericardium especially in the presence of an 
anterior mediastinitis, and would greatly increase the difficulty 
of suturing the divided edges of the pericardium to the skin. 
Furthermore the constant passage of purulent material over 
freshly denuded bone might result in protracted if not a 
serious ostitis. 

In cases, hitherto published, including those of the 
Roberts and Porter series, the pericardium has been opened 
after the resection of an overlying costal cartilage. Roberts 
suggests that a musculocartilaginous flap consisting of the 
median portions of the 4th, 5th, and 6th costal cartilages 
and of the tissues of the intervening spaces, be raised from 
the anterior surfaces of the pericardium and pleura. This 
affords sufficient space for possible ligation of the internal 
mammary vessels as well as for the outward reflection by the 
surgeon of the left pleural angle, thus avoiding the risk of 
opening that cavity in the subsequent division of the peri- 
cardium. After the evacuation of the pus, the flap is replaced, 
leaving a sufficient orifice for drainage. Roberts had no case 
to report and no instance of his operation has thus far been 
published. Although it gives admirable exposure and amply 
fulfils the objects for which it was devised, yet the very 
serious condition of many of these patients, especially in 



68 ELLSWORTH ELIOT, Jr. 

secondary cases, seems to demand an operation that combines 
the elements of speed and simplicity, such as may be obtained 
by the rapid removal of a single costal cartilage, rather than 
one which would necessarily severely tax both the resistance 
and the reparative power of the patient. Allingham has sug- 
gested a different route, the " epigastric," and has had several 
opportunities of testing its efficiency. In this operation, an 
incision, made to the left of the median line just below the 
costal insertion of the rectus muscle, is gradually deepened 
upward through the costoxiphoid space in the diaphragm to 
the base of the pericardium, the peritoneum being pushed 
downward. It is thus seen to be a modification of Larrey's 
suggestion. In a discussion with Coutts and Rowland, Alling- 
ham refers to three successful cases operated on by this 
method the details of which, he declared, were to be pub- 
lished shortly. The operation certainly combines the advan- 
tages of opening the abscess in a dependent point and of 
probably avoiding the left pleural cavity. Its chief disadvan- 
tage is its length, the duration of the average operation being 
at least 20 minutes. The dangers of opening the peritoneal 
cavity and of hemorrhage from the terminal branches of the 
internal mammary artery are largely theoretical. 

The simplest and most rapid exposure of the pericardium 
is accomplished by the removal of the inner part of either the 
5th or 6th costal cartilage through an oblique incision parallel 
to its long axis. This opening is deepened into the anterior 
mediastinum by the divison of the perichondrium and the 
underlying plane of the triangularis sterni. The condition of 
the contiguous pleural reflection is then, if possible, determined. 
In the absence of adhesions the pleural angle is pushed out- 
ward without, if possible, any extension of the external in- 
cision. If obliteration of the pleural cavity has taken place, 
the underlying pericardium may readily be opened without 
danger of pleural penetration. The presenting pericardium is 
best divided by scissors between two pairs of forceps and the 
opening sufficiently enlarged to permit the passage of a 
finger. The pus is allowed to escape slowly in order that the 



SUPPURATIVE PERICARDITIS. 69 

heart action may not be unfavorably influenced. As the flow 
of pus ceases, the finger may be cautiously introduced through 
the opening and passed backward to either side of the heart 
with the object of separating adhesions as well as of detecting 
any hidden accumulation of pus that may have become shut 
off from the main cavity. 

Usually subsequent irrigation with either a saline or weak 
antiseptic solution is desirable, if adequate provision is made 
for the free exit of the fluid from the interior of the peri- 
cardium. Failure to observe this precaution probably 
determined a fatal issue in Parker's case (cited by Roberts). 
The irrigation may be omitted if the patient's condition de- 
mands a speedy termination of the operation. No irrigation 
was used in the writer's case. 

The divided edges of the pericardium should now be 
sewn to the skin wherever that is possible. This not only 
facilitates drainage but diminishes the risk of contamination 
of the anterior mediastinum. Such approximation may be 
prevented by a deep seated pericardium or, as in the writer's 
case, by a pre-existing mediastinitis. 

Drainage is undoubtedly favored by the movement of 
the heart which, in the absence of adhesions, tends to force out 
any accumulated pus, even though the opening is not at th^e 
lowest point of the pericardiac sac. It is still further assisted 
by the insertion of either a rubber drain or a capillary drain 
of gauze into the abscess cavity, care being taken that they 
are so introduced as not to interfere with the action of the 
heart. Riedel (ZentraL fiir Chir., 1897, p. 56) states that, 
in one of his cases, the use of a rubber drain caused stormy 
and irregular heart action and had to be discontinued. In 
the writer's case a rubber drain and, after several weeks, a 
drain of gauze, were used without any indication of cardiac 
interference. As the discharge decreases the drain should be 
shortened and its use discontinued at the earliest possible 
moment. The persistence of a sinus rarely occurs. 

After healing is complete, insufficient or irregular heart 
action is the marked exception, neither is there any indication 



70 ELLSWORTH ELIOT, Jr. 

of cardiac displacement. The patient, whose case is here 
reported, was in excellent condition after more than two 
years had elapsed since the operation, the precordial scar being 
the sole evidence of the former trouble. In the interval she 
has passed through one uneventful pregnancy. 

That such a satisfactory result cannot always be expected, 
however, is shown in the report of a case by J. A. Scott in 
which, 4 months after an operation by LeConte for a pyo- 
pericarditis complicating pneumonia in an adult of 36, palpi- 
tation sufficient to interfere with the patient's work was 
present, although there was no physical sign that would 
indicate an adhesive pericarditis. 

In conclusion the belief cannot be too strongly empha- 
sized that every case of pyopericarditis in which the patient 
is not moribund, should be treated by an operation which, in 
those cases in which a general anaesthetic cannot be tolerated, 
may yet be successfully carried out under cocaine or some 
other suitable local anaesthetic. 

Brief abstracts of cases published since 1900 follow: 

CASES GATHERED FROM LITERATURE. 

Case I. — Reichard {Zentral. fur Chir., 1900, p. 1109). Sex and age 
of patient not given. Pericarditis the result of penetrating stab wound 
with a knife. 

Operation by Lindner, because of the almost moribund condition of 
the patient, the almost imperceptible pulse and great dyspnoea, was done 
largely without an anaesthetic (anaesthetic not mentioned). The peri- 
cardium was exposed by resection of the third costal cartilage and the 
ligation of the internal mammary artery, the abscess cavity being incised 
without damage to the pleura. There was a large amount of foul pus. 
Two thick drains with tamponade of wound. The operation which lasted 
ten minutes was followed by a gradual improvement of both pulse and 
respiration. Complete recovery at the end of 6 weeks. 

Case IL — {Ibid.). Etiology; influenza and rheumatism. The diag- 
nosis was confirmed by puncture in the 5th left intercostal space outside 
the nipple line, a quantity of serohemorrhagic exudate being withdrawn 
with abundant pus cells. The condition of the patient was such as to 
forbid the extended use of a general anaesthetic. 

Operation consisted in the resection of the fourth costal cartilage, 
the pleura being pushed to one side. On opening the pericardium a large 
amount of clear fluid forcibly projected. On account of the stormy action 



SUPPURATIVE PERICARDITIS. 



71 



of the heart no drain could be inserted into the abscess cavity. A drain, 
however, was placed down to the pericardium after the suture of its 
edges to the muscle wall. The recovery was gradual and was marked by 
a somewhat irritable heart action. 

During the ensuing discussion Lindner stated that the selection of a 
different costal cartilage in these two cases was due to the difference in 
the extent and degree of the precordial dulness. 

Case III. — W. Mintz (Zentral. fur Chir., 1904, 31, 59f-6i). History, 
cause, etc., not given. 

Operation under cocaine anaesthesia; the 5th costal cartilage was 
exposed and resected through an incision over its long axis. On account 
of the fact that the opening did not correspond to the most dependent 
part of the pericardium a second incision was made along the lower 
border of the 7th costal cartilage and the pericardium exposed by blunt 
dissection. During convalescence almost the entire discharge passed 
through the lower opening. The statement is also made that this route 
was followed on one occasion by Larrey and that there is no danger of 
wounding the peritoneum if the exposed diaphragm is pushed down- 
ward and the pericardium entered at the inner angle of the incision. 

Cases IV, V, and VI. — Mentioned briefly by Allingham as three 
successful cases of which the details were to be published shortly, in 
the discussion with Coutts-Rowlands. 

Case VII. — Coutts and Rowlands {Brit. Med. Journal, 1904, i, 9^13). 
Child, two and one-half years old. One month prior to admission to the 
hospital the patient had had a pneumonia with an incomplete recovery 
and with some loss of flesh. 

Physical examination revealed a condition of rickets. There was 
an increase in the area of cardiac dulness and an almost imperceptible 
apex beat. The heart sounds were weak but pure. There was no friction 
sound. The pulse was 136, regular and of fair tension. On the right 
side posteriorly there was dulness from the 6th rib downward, passing 
around the axilla toward the front of the chest. Over this area there 
was faint bronchial breathing. The left lung was normal. The respira- 
tion was 58, and the temperature varied between from 99 to 104 in the 
afternoon. Exploratory puncture yielded nothing but a little blood. 
During the next 5 days the precordial dulness gradually extended upward. 
The apex beat disappeared and the pulse, still regular, became more rapid 
and feeble. 

Operation by Rowlands under chloroform. The pericardium was 
exposed by resection of the 5th left costal cartilage, the adjacent pleura 
being displaced outward. A half pint of pus rising to the height of three 
feet issued from the interior of the pericardium. Insertion of the finger 
into the abscess cavity. Large rubber drain. No irrigation. The imme- 
diate effect of the operation on both heart and respiration was beneficial. 
On the following day, exploration of the right pleura yielded pus 
and, under chloroform, resection of a rib in the posterior axillary line 
with incision of the underlying pleura. For 3 days thereafter the con- 
dition of the patient was variable although on the whole improved. On 



72 ELLSWORTH ELIOT, Jr. 

the 4th day after the original operation, the patient developed measles 
with subsequent pneumonia, death taking place at the 6th week from 
inanition, there having been a free discharge from the pericardium to 
the end. 

Autopsy. — This showed the entire anterior mediastinum occupied by 
a thick gelatinous deposit. In attempting to separate the pericardium 
from the left pleura an abscess cavity was opened, being a part of the 
pericardium behind and to the left of the heart. 

In the discussion Rowlands stated that it was impossible to open 
the pericardium behind without damage to the adjacent pleura, the 
larger azygos vein and the thoracic duct. 

Case VIII. — Coutts and Rowlands (Brit. Med. Journal, 1904, Jan- 
uary 22). Male. One and two-thirds years. Family history of phthisis. 
Measles 8 weeks before admission. Ever since a cough, increasing in 
intensity, has persisted. There has been much sweating. Patient com- 
plains of pain in the abdomen and loss of appetite. 

Physical Examination. — The general condition is rachitic, and wasted. 
There are signs of consolidation over the right chest posteriorly, extend- 
ing around into the axilla as far as the mammary line. The apex beat of 
the heart lies in the fourth space just within the nipple. The sounds 
are clear and distinct. Left lung is normal. At no time is the tempera- 
ture higher than 100 and exploration of the chest fails to detect pus. 

On the 9th day after admission, a patch of dulness appeared over 
the left base posteriorly and a needle inserted withdrew clear serum. 
The temperature became irregular. 

On the 2 1st day precordial dulness was first noticed. At the end of 
a week it had extended upward to the ist rib and over to the right of 
the sternum. Heart sounds were inaudible below the third space and very 
feeble above that line. The pulse was very rapid and almost imper- 
ceptible. Leucocytosis 32,000. 

Operation. — Chloroform. Although puncture at the point indicated 
by Roberts as well as in the sth left intercostal space failed to withdraw 
pus, the pericardium was exposed through the resection of the 7th costal 
cartilage and the adjacent part of the gladiolus. On opening the pericar- 
dium, between one and two ounces of pus escaped. The finger was passed 
to the base of the heart and into the oblique sinus below the heart. 
Drainage with two soft rubber tubes. 

Patient gradually sank and died on the second day. 

Autopsy. — The lesions pointed to a long existence of a pericarditis. 
Culture from the pus yielded pneumococcus. A thick layer of gelat- 
inous pus covered the opposed parietal and visceral layers of the 
pericardium. 

Case IX. — Kiliani (Annals of Surgery, 1907, 45, p. 130). Man 
22. Admitted to the German Hospital in 1901 for an attack of acute 
articular rheumatism, complicated by endocarditis and pericarditis. The 
pericardial effusion rapidly increased and became so threatening as to 
require immediate incision. Drainage of the pericardium was continued 
for seven days, after which time all oozing ceased. Immediately after 



SUPPURATIVE PERICARDITIS. 



73 



incision, the patient, who had been moribund, showed signs of improve- 
ment and his further recovery was uneventful. Five years after the 
operation the patient was in excellent health. 

Case X. — Gengenbach (Colo. Med., Denver, igo6, 3, 187-190). Male, 
8. Mumps 3 years ago. Measles twice 2 years ago with an interval of 6 
months between attacks. Scarlet fever complicated by mastoid suppura- 
tion 10 months ago. For the past 6 weeks has suffered from whooping 
cough and while the cough still persisted the present illness began 3 
weeks before admission to the hospital with headache, vomiting, abdom- 
inal pain, and some fever. Pulse of 120 and respiration of 40. Although 
there was no local tenderness or rigidity a diagnosis of appendicitis was 
made. The chest showed the physical signs of either a bronchopneumonia 
or of a pericardial effusion. 

Two days after admission patient became deeply cyanosed with symp- 
toms of syncope. At that time the apex beat was not visible but was faintly 
palpable about one inch within and at the level of the nipple. The heart 
sounds were audible but indistinct. Cardiac dulness extended from the 
and to the 6th rib and from one inch to the right of the sternum to the 
left mammary line. Paracentesis. 

Two days after paracentesis, operation under chloroform by Dr. 
Craig. The 5th rib, one and one-half inches to the left of the sternum, 
was resected, the pericardium opened and one and one-half pints of pus 
evacuated. Rubber drain. Free discharge. " Double " coccus found in 
pus. The patient, collapsed by operation, rallied. Although the discharge 
gradually lessened and the tube could be withdrawn 3 days before the 
patient died, a fatal issue could not be averted. 

Autopsy. — There was a large abscess occupying the entire left pleural 
cavity. There was no communication between this cavity and that of 
the pericardium. 

Case XL — J. A. Scott (iV. Y. Med. Journal, 1904, i, 198-200). Male 
laborer, 26. Patient gave a history of pneumonia of the right base of 
6 days' standing which, on the 3rd day, spread to the left base with 
pleurisy. 

On the 13th day the apex beat was neither visible or palpable. There 
was no pericardial friction. On the i8th day the patient developed a 
pulsus paradoxus and exploration in the 4th right space withdrew serum 
which contained the pneumococcus. On the following day, exploration in 
the same place withdrew 14 ounces of sero-turbid fluid. Seven days after 
the needle withdrew thick yellow pus. With the advent of the peri- 
carditis the leucocytosis, which during the pneumonia had been normal, 
materially increased. 

Operation under chloroform by LeConte. On account of cardiac 
weakness the chloroform was superseded by cocaine. Through an incision 
in the 5th space the pericardium was opened and between a pint and a 
quart of pus evacuated. Rubber drain, which was removed on the 26th 
day after operation. Four months after operation palpitation still persisted 
and prevented the patient's working. 

Case XII.— G. A. Peters (Edinb. Med. Jour., 1903, n. s. 13, 209^-216). 



74 ELLSWORTH ELIOT, Jr. 

Boy, 7. Patient had both measles and scarlet fever some years ago. 
One month ago preceded by malaise of 3 days' duration, patient developed 
severe pain and tenderness about the umbilicus. The pulse increased to 
100, the temperature to ioa-102 and the respiration was short, frequent 
and grunting. The abdomen gradually became prominent and purgatives 
and enemata failed to act properly. In the second v^^eek of his illness the 
tenderness became limited to the upper part of the abdomen and dulness 
was elicited above the level of the umbilicus. Soon after dulness appeared 
over the left side of the chest with diminished respiratory murmur. 
Dyspnoea appeared and increased in severity. It was urgent at the time 
of admission. 

Physical Examination. — The respiration was thoracic. There was 
dulness over the left side, especially anteriorly. The cardiac impulse could 
not be detected. Anteriorly the dulness extended up to the clavicle; 
posteriorly to the spine of the scapula, extending beyond the sternum to 
the right nipple and merging with the liver dulness below (a marked 
example of Rotch's sign of fluid in the pericardium). On auscultation 
the heart sounds were fairly audible about the left nipple with a slight 
systolic murmur. There was tubular breathing over the left chest. The 
fluid which was withdrawn from the pericardium by three widely separated 
punctures was opaque and rich in cellular elements. 

Operation. — An incomplete operation was done through the 4th space 
three-quarters of an inch to the left of the sternum and 10 ounces of 
fluid withdrawn. The rubber drain was soon blocked with lymph and 
became ineffective. The urgency of the symptoms was much relieved. 
During the 2 days following, however, the patient became steadily worse 
with cyanosis and subnormal temperature, at the end of which time a 
complete operation was done under local anaesthesia as follows : 

An incision was first made in the fifth space one-half inch to the 
right of the sternum and abandoned on account of the exposure of the 
pleura. An incision was then made in the 5th space on the left side and 
the pleura opened and packed without reaching the abscess cavity. The 
pericardium was then successfully exposed through an incision in the 
lett 4th space three-quarters of an inch from the sternum and 29 ounces 
of pus containing the staphylococcus aureus was evacuated. Drainage 
with a long rubber tube. The discharge of the pus was followed by a 
return of the liver to its normal position. 

Two weeks after this operation the dyspnoea increased and the gen- 
eral condition became weaker. Exploratory puncture at the angle of the 
left scapula withdrew pus and under ether 30 ounces of that fluid was 
evacuated from the left pleural cavity without the resection of a rib. 

The patient eventually recovered and 11 months after the operation 
could play around as well as ever. 

Case XIII. — Arthur Latham and H. S. Pendlebury (Lancet, 1903, 
I, p. 798). Male, 53. Six months before admission became short of 
breath which 5 months later compelled him to give up work. At this 
time the left pleural cavity was tapped and 10 ounces of serum withdrawn. 
The tapping was repeated on four different occasions afterward. Two 



SUPPURATIVE PERICARDITIS. 75 

months ago oedema of the legs with some distention of the abdomen 
appeared. There was jaundice. 

On admission the patient complained of sleeplessness and of cold 
extremities. The patient also complained of a cough with expectoration 
and of considerable shortness of breath with cyanosis. The pulse was 
74, respiration 24, and the temperature was normal. 

Physical Examination. — The cardiac apex could neither be seen, felt 
nor heard. The precordial dulness was much increased. There was 
dulness, diminished voice sounds and tubular breathing over the left 
axillary base. Over the left base posteriorly, the percussion note was 
impaired, the breathing distant and tubular and there were a few moist 
sounds. There was oedema of both lower extremities and the physical 
signs of ascites. Tapping 2 days after admission in the 4th space one 
and one-quarter inches to the left of the sternum withdrew 95 ounces of 
serous fluid of a brown color from the methaemoglobin which it con- 
tained. This was followed by a decrease in the oedema and in the 
abdominal distention. The cardiac sounds although faint were never- 
theless distinctly audible. Owing to a recurrence of the fluid and its 
associated symptoms, operation under chloroform by Pendlebury, one 
week after the aspiration. 

An Allingham operation was done and additional exposure gained 
by resection of the sternal end of the 6th costal cartilage. The finger 
inserted into the pericardium. There were no adhesions and the surface 
of the heart was smooth. One edge of the pericardium was stitched to 
the lower corner of the wound, a tube having been inserted into its cavity. 
The tube was removed on the fourth day and healing was complete at 
the end of the fourth week. At that time the patient was entirely free 
from dyspnoea, ascites and oedema. He also slept well at night. Four 
months after the operation patient returned to work. 

Case XIV. — A. Hall (Lancet, 1908, 2, p. 951). Female, 38. One 
month prior to admission patient was confined. One week later advent 
of puerperal sepsis with double pneumonia. The abdominal symptoms 
disappeared but the fever and weakness continued and on admission 
patient complained of extreme dyspnoea and had the appearance of being 
very sick. 

Physical Examination. — The left side of the chest was almost motion- 
less. No cardiac impulse palpable. Area of cardiac dulness extended 
from the upper border of the 2nd left rib above, one-half inch to the right 
of the sternum. On the right side laterally it extended down as far as 
the 5th rib and on the left side it corresponded to the mid-axillary line. 
The heart sounds were almost inaudible over the entire area. There was 
a slight pleuritic friction sound in the 5th left space near the nipple. 
There was dulness at the right base, and moist sounds over both bases 
posteriorly. The abdomen was full and distended but without sign of 
fluid. Urine scanty but normal. The pulse was 132, respiration 60, and 
the temperature between 100 and loi. There was a slight but frequent 
cough. A needle passed into the sth space, passed through the dia- 
phragm both near the edge of the sternum and at the level of the nipple. 
In the 4th space it passed into the pericardium and withdrew pure pus. 



76 ELLSWORTH ELIOT, Jr. 

Operation by Wilkinson. Chloroform. Excision of the 4th left costal 
cartilage; 20 ounces of gray-yellow pus were evacuated without damage 
to the pleura. The pericardium was sutured to the skin and a large 
soft, collapsible tube inserted. A profuse discharge continued to the 
death of the patient one week after the operation. 

Autopsy. — There was a small purulent pleuritic effusion over the 
right base. The death of the patient seemed to have been the result of a 
general suppurative peritonitis with dilatation of the stomach, which 
accounted for the unusually high position of the diaphragm. Examination 
of the pus in the peritoneal cavity showed both staphylococcus and 
streptococcus. 

Case XV. — W. K. Sibley (Brit. Med. Journal, 1903, i, 1192). Male, 
16. Prior history negative. Sudden onset of tonsillitis followed in 3 
days by pneumonia. This ran a severe course, the pulse rising to 150, 
the respiration to 50-60, the temperature to 103 on the 6th day. At that 
time there were pleuritic rales outside the left nipple and impaired per- 
cussion over the left base. One week after the invasion of the tonsillitis 
there was pain with fulness and tenderness in the epigastric region. The 
heart sounds were indistinct, but there was no bruit. On the 9th day 
resolution by crisis occurred with rapid disappearance of all pulmonary 
symptoms. On the other hand, the area of cardiac dulness increased and 
the apex beat could not be felt and the heart sounds became very faint. 
In this condition the patient remained until the 21st day of the illness. On 
that day he became cyanosed with much dyspnoea, especially while supine. 
The cardiac dulness increased both in an upward and outward direction. 
There was pulsus paradoxus, and on the following day the patient became 
pulseless. The heart sounds were scarcely audible. Pus was withdrawn 
by exploratory puncture in the area of precordial dulness and was found 
to contain the pneumococcus. 

A. C. E. Mixture, afterward replaced by ether. 

Operation by Lane. Under a general anaesthetic a local empyemic 
abscess was exposed after the resection of a portion of the 6th rib outside 
the nipple line. The pericardium could not be felt. Although somewhat 
relieved, symptoms indicating pent-up pus continued, and 10 days later 
a search of the empyemic cavity disclosed the pericardium bulging into 
it in such a way that it could easily be reached and opened with the 
finger, 10 ounces of pus, similar to that originally found in the pleural 
cavity, being evacuated. The heart was felt in the back part of the 
pericardium. A rubber drain at first inserted had to be discontinued on 
account of irritating the heart action. After a temporary improvement the 
patient continued to lose ground and died 10 days after the last opera- 
tion. The necessary withdrawal of the drainage tube seemed to interfere 
with the proper drainage of the abscess cavity. 

Autopsy. — There were a number of small abscesses in the wall of 
the heart from which some bleeding had occurred into both the pleural 
and pericardiac cavities. Pneumococci were found in great numbers in 
the blood. The writer states that probably a small amount of pus was 
present in the pericardium at the time of the first operation. 



SUPPURATIVE PERICARDITIS. 



77 



Case XVI.— Gluck (Verhandlung. d. deut. Gesell. f. Chir., 1907, 36, 
378-385). Male, 9. Extensive physical signs of fluid. Green-yellow pus 
withdrawn by needle in the 4th left space i cm. external to the mammary 
line. Subperiosteal resection of the 5th rib from a point opposite the 
mammary line 4 cm. externally. The pericardium was opened without 
damage to the pleura. At first the progress was satisfactory, but ulti- 
mately the patient died from general streptococcus infection. (See fol- 
lowing case for a more detailed account of the operation and additional 
symptoms.) 

Case XVII. — Gluck {Ibid.). Male, 56. "Patient operated on in 
the above m.anner and three months after was completely well." 

In Cases XVI and XVII the patient had a pericardial reflex cough, 
difficulty in swallowing and a congested enlarged liver (marked by pecu- 
liar intense pain and swelling in the left lobe of the liver). In Case XVI 
this condition led to a primary laparotomy. In spite of an extensive 
exudate a pericardial friction sound was present in both cases. 

The pericardium was exposed by a skin muscle flap with its base in 
the mammary line opposite the 4th, 5th and 6th ribs, and the 5th rib for 
a distance of 3 cm. external to the mammary line resected without 
damage to the pleura. In opening the pericardium the left border of the 
heart protruded, filling the opening so completely that only by the inser- 
tion of the finger between the heart and the inner surface of the peri- 
cardium could the fluid be evacuated. Drainage was continued for 
6 weeks. 

Before the operation the pulse was very irregular and over 150. 
Digitalis and morphine given both before and after operation. Drainage 
somewhat interfered with by the forward protrusion of the heart. 

Case XVIII. — Steward and A. E. Garrod (Proc. Roy. Soc. Med., 
London, 1907, i, I5~i7)- Female, 5. Two days prior to admission to hos- 
pital a tonsillectomy was followed on the same evening by pain in the 
abdomen and left chest. On admission the temperature was 103 and the 
pulse 120. 

Physical examination showed the presence of fluid in the left chest 
below the angle of the scapula. One week later pus was withdrawn and 
a localized empyema opened and drained by the resection of a rib. The 
pus contained pneumococcus. The operation was followed by improve- 
ment, but the temperature remained between normal and 102. 

Three weeks after operation. — " During the past few days the tem- 
perature has increased to 104, the pulse to 140-150; the leucocytosis from 
31,000 to 41,000 in an interval of two days. There have been two attacks 
of vomiting. Exploration of the old abscess cavity showed a bulging 
mass in the position of the pericardium." The child continued to grow 
worse and three days later the cardiac dulness was found to extend two 
inches to the right of the sternum and a skiagram showed a distinct 
shadow of a distended pericardium. 

Operation. — " Under light anaesthesia the pericardium was opened 
through the empyemic cavity and several ounces of thick yellow pus 
evacuated. Drainage with a rubber tube." 



78 ELLSWORTH ELIOT, Jr. 

After the operation the child's temperature gradually fell and reached 
normal in 3 weeks. Very little pus was discharged after the first day. 
Five weeks after the operation the wound had completely closed. Four 
months afterward the child had recovered its normal weight and appeared 
to be in robust health. The pulse was 100 and regular. The lung had 
fully expanded. 

Case XIX. — Godlee (discussion of above). "The pyopericarditis 
was a complication of an acute infectious osteomyelitis and was operated 
on by Raymond Johnson through an anterior incision. Although the case 
was further complicated by abscess of the elbow and later of the brain, 
the boy ultimately recovered. One year later the patient died of a recur- 
rence of the brain abscess." 

Although because of the absence of details, no tabulation of the cases 
to which he refers can be made, it is interesting to note the statement of 
Samuel West in the same discussion, viz. : " Dr. Samuel West had seen 
several similar cases in which the pericardium was opened from the back 
and the drainage secured was satisfactory. The majority of the patients 
had died because the pericarditis was of pyemic origin. In his experience 
the prognosis of pericarditis the result of pneumococcus infection was 
more favorable than in those due to streptococcus. One case was opened 
anteriorly with perfect drainage and the patient was practically well in 
a week. Another case similar to the one under discussion terminated in 
the death of the patient. The speaker thought that ordinarily simple 
incision anteriorly without the resection of a rib would provide satis- 
factory drainage." 

Case XX. — H. S. Pendlebury (Lancet, 1904, 2, 1145). Male, 31. 
Pneumonia in the left lung. Three weeks after invasion of pneumonia, 
the temperature remaining high, considerable cyanosis and dyspnoea 
developed and examination showed that the cardiac dulness extended four 
inches to the right of the sternum. The heart sounds were muffled. The 
pericardium was exposed by resection of the 6th and 7th costal cartilages 
and between 3 and 4 ounces of serum evacuated. Adhesions between 
the heart and pericardium were broken down with the finger and a tube 
inserted. Rapid recovery, the tube being removed on the 6th day. 

Case XXI. — (Ibid.). Male, 12. On admission the patient was 
cyanotic and dyspnoeic and presented the physical signs of serous peri- 
carditis and of endocarditis complicating an attack of acute articular 
rheumatism. Operation on the 6th day. The pericardium was exposed by 
resection of the 7th costal cartilage only. In pushing aside the left pleura, 
the right pleura was accidentally opened but without appreciable harm to 
the patient. On opening the pericardium the fluid which was under con- 
siderable pressure rapidly escaped. Death occurred five days later with 
little apparent benefit from the operation. 

Autopsy. — The right pleura projected beyond the left side of the 
sternum down to the level of the 7th costal cartilage. The opening in 
the pericardium was not recognized, both its visceral and parietal layers 
being in contact and adherent. There was much endocarditis with val- 
vular varicosities. 



SUPPURATIVE PERICARDITIS. 



AUTHOR S CASE. 



79 



Presbyterian Hospital, April, 1906. N. N., female, age 19. 
Admitted to the service of Dr. J. S. Thacher and Dr. Bovaird. 
Patient has always been well. She was married eleven months 
ago and has been pregnant for the past two months. There is no 
discoverable cause of a primary focus of infection. 

About six weeks before admission to the hospital, patient 
suffered from malaise. One week later pain in the left chest with 
cough appeared, the pain being intensified by a deep respiration 
as well as by the effort of coughing. At the end of another week 
dyspnoea developed, the symptoms already mentioned having in- 
creased in intensity. The bowels were loose, the patient having 
between fifteen and twenty loose watery movements each day. 
These, together with the other symptoms, caused general pros- 
tration. On admission to the medical ward of the hospital a 
physical examination showed a diffuse apex beat where the sounds 
of the heart were very indistinct. The area of cardiac dulness was 
enlarged to the right. There was a to-and-fro friction sound at 
the base. There was dulness with diminished voice and breathing 
from the angle of the scapula downward. 

The patient ran an irregularly low temperature for several 
days. The left pleural cavity was punctured and three ounces of 
serous fluid withdrawn. About a week after admission, prema- 
ture labor occurred, with a normal breech presentation. Since 
then there has been an increase in the dyspnoea with intermittent 
fever. On the day before the patient was transferred to the sur- 
gical ward, puncture of the pericardium by Dr. H. H. Mason gave 
pus, containing streptococci. At this time, the chief complaints 
were the dyspnoea, the precordial distress and the intermittent 
temperature. Physical examination of the chest showed the left 
border of the precordial dulness to be eight and one-half inches 
to the left of the midsternal line, while the right border extended 
two inches to the right of the same line. The action of the heart 
was regular, and varied between no and 120. The respiration 
was short, labored, between 40 and 50. 

Two aspirations of the pericardium were made, the first of 
which, in the fifth space one and three-quarters inches to the left 
of the sternum, was unsuccessful, although a little serum and a 
few flakes of fibrin escaped from the puncture orifice as the 



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84 ELLSWORTH ELIOT, Jr. 

needle was withdrawn. The second aspiration in the left same 
space two inches to the left of the midline withdrew three ounces 
of thick yellow pus. Leucocytosis : March 15, 23,000; March 20, 
31,200; March 24 (day after delivery), 24,600; March 26, 34,200; 
March 29, 18,800; April i, 23,200. 

Operation. — Gas and ether. Dorsal position. Horizontal in- 
cision with resection of the fifth costal cartilage one inch to the 
left of the sternum. The tissue of the anterior mediastinum was 
infiltrated, and at least one inch in thickness and spongy. Along 
a needle previously inserted into the pericardium that cavity was 
opened with a bistoury and about one pint of pus allowed to escape 
slowly. The opening was then still further dilated with the finger, 
which could feel the heart beating distinctly. The pulse became 
quite rapid during the operation and for a short time after the 
pericardium was opened was irregular. There was considerable 
respiratory embarrassment. A rubber drainage tube was inserted 
and the angles of the incision sutured. 

The patient responded well to stimulation with strychnine 
and whiskey, and on the morning after the operation was in fair 
condition. The wound was dressed daily, both rubber and gauze 
drains being used. With the patient on a back rest, the dyspnoea 
was alleviated. In this condition the patient continued for a week, 
the abscess cavity draining freely and satisfactorily. One week 
after the operation, the temperature suddenly rose to 104, the 
pulse to 140, and the respiration to 52. There was marked 
cyanosis, and the patient complained of dyspnoea and of precor- 
dial distress. Physical examination failed to disclose any explana- 
tion of these symptoms and on the following day they had sub- 
sided, the pulse decreasing to 120, the respiration between 40 and 
50 and the temperature to between normal and loi. From this 
time further progress of convalescence was uneventful, the patient 
suffering from occasional slight dyspnoea only. The pulse con- 
tinued to vary between no and 120 throughout. On May 3 the 
patient was allowed in a chair, and on May 20 was allowed to 
walk. On May 11 the rubber drain previously shortened was 
removed and replaced by a small gauze drain, which in turn was 
discontinued after May 25. Two weeks later the sinus had 
entirely closed. 



SUPPURATIVE PERICARDITIS. 

ADDITIONAL BIBLIOGRAPHY. 

Allingham, H. W., Brit. Med. Jour., 1904, i, 106. 

Bacon, Am. J. Med. Sc, Phila. and N. Y., 1905, n. s. 130, 652-656. 

Brentano, Deut. Med. Woch., 1898, 24, 506-508. 

Burtenshaw, Med. News, 1899, 74, 289-294. 

Curschmann, Ther. d. Gegenw., Berlin, 1905, 46, 385-395. 

Delorme and Mignon, Rev. de Chirurg., 1895. 

Ljunggren, C. A., Zentral. fiir Chir., 1899, 678. 

Lyonnet, Province Med. Lyon., 1897, 11, 458. 

Meldon, A., Tr. Roy. Acad. Med., Ireland, Dublin, 1897, 15, 194-205. 

Porter, C B., Annals of Surgery, 1900. 

Roberts, J. B., Am. Jour. Med. Sc, 1897, 114, 642-664. 

Smith, W. G., Practi., London., 1897, 58, 386-389. 



85 



RESTORATION OF THE PERINEAL PORTION OF 

THE URETHRA AFTER DESTRUCTION BY 

FRACTURE OF THE PELVIS. 

BY HUGH CABOT, M.D., 

OF BOSTON, MASS. 

To restore considerable gaps in the urethra resulting 
from stricture either of traumatic or inflammatory origin has 
long been a difficult problem in genito-urinary surgery. Its 
solution has been attempted by a great variety of methods, 
including grafting by the method of Thiersch, interposition 
of portions of the urethra taken from animals, plastic opera- 
tions of various kinds and approximation of the remaining 
portions of the urethra by mobilization. 

The following case with comments is submitted as a con- 
tribution in the possibility of extensive mobilizaton of the 
urethra : 

P. E. R., age 20, was admitted to the Massachusetts General 
Hospital in the service of Dr. Mixter, April 9, 1907, one and a 
half hours after having been struck by a railroad train. At the 
time of admission he was in marked shock. The only serious 
injury found was a fracture of the pelvis, confined to the pubic 
portion (Fig. i) and causing rupture of the urethra. A gum elas- 
tic catheter was inserted with some difficulty and drew 18 ounces 
of clear urine. On the following day there was complete reten- 
tion of urine, the bladder was distended up to the umbilicus 
and several attempts at catheterization with various instruments 
failed. Operation was promptly done by Dr. G. W. W. Brew- 
ster. This consisted of a free perineal section, which disclosed 
a complete transverse rupture of the urethra in the bulbar portion, 
with a large extravasation of blood and urine. The finger in 
the wound could detect a sharp fragment of the pubic bone dis- 
placed downward for about an inch. After a tedious search the 
proximal end of the urethra could not be found, but the distended 
bladder was readily felt as a bulging mass behind the bone. This 
was punctured with a knife and a large rubber drainage tube 
inserted. 
86 



Fig. 1. 




Diagram showing the fracture with resulting deformity 



Fig. 2. 




Note the position ot the retracted ends of the urethra and the relations of 
the false passage. 



Fig. 3. 




Showing the amount of mobilization of the anterior urethra. 



Fig. 4. 




Showing method of suture. 



RESTORATION OF URETHRA. 



87 



He made a satisfactory convalescence. Drained freely 
through perineal wound until May i, when the urine began to 
come freely through anterior urethra. 

Discharged from hospital May 22, 1907, at which time No. 
27 F. bougie would go readily to the bladder. Sound could not 
be passed, apparently on account of some irregularity in the 
urethra. 

He was lost sight of until October 7, 1907, when he was 
admitted on account of acute retention. The bladder was dis- 
tended to one inch below the umbilicus, and the urethra bore 
visible evidence of fruitless attempts to enter the bladder, made 
before admission. In view of failure at the time of previous 
operation to find the proximal end of the urethra, and of the 
present damaged condition of the tissues by recent instrumenta- 
tion, it seemed best to open the bladder above the pubes and 
drain, before attempting to repair the continuity of the urethra. 

Operation. — October 7 (Hugh Cabot). — Bladder opened by 
a suprapubic incision and drained. Just behind the vesical orifice 
of the urethra there was a small granulating area, evidently the 
site of the previous incision into the bladder. The finger 
passed into the vesical opening of the urethra brought up solidly 
against the back of the pubes, where it was displaced downward, 
the neck of the bladder being drawn upward behind the bone. 
The bladder was drained with a large rubber tube, about which 
it was tightly closed with inversion sutures. 

After the acute swelling of the urethra had quieted down, it 
was explored with a full sized sound. This went freely to the 
penoscrotal angle, where it turned sharply backward and ended 
blindly against the front of the pubic arch. It thus appeared 
that the pubic arch, occupying a new position; lay between the 
severed ends of the urethra which had retracted upward and that 
the previous operation had substituted a false passage between 
these two points. The condition existing at this time is shown 
in Fig. 2. 

On October 16, 9 days after the drainage operation, he was 
again etherized for the purpose of restoring the urethra if pos- 
sible. The patient was placed in extreme lithotomy position 
with sand-bag under the pelvis. Curved incision from one tuber- 
osity of the ischium to the other, passing about one and a half 
inches in front of the anus. Rectum freed from scar with con- 



88 HUGH CABOT. 

siderable difficulty, as it is in part adherent to the lower border 
of the displaced fragment of the pubes and thus lay between 
the severed ends of the urethra. After the rectum had been 
freed and pushed backward, the prostate could be made out lying 
behind the bone and was freed by blunt dissection, aided by 
downward pressure made by an assistant from within the blad- 
der. The prostate was sufficiently mobilized so that it could be 
brought down below the bone and held there without tension. A 
vertical incision was then made over the bulbar portion of the 
urethra, and the anterior urethra freed from scar tissue and 
exposed for a distance of two and a half inches. The urethra 
was entirely freed from the surrounding tissues to the above 
penoscrotal angle. This mobilized portion was about two inches 
long (Fig. 3). It was then possible to approximate the divided 
ends of the urethra without tension. The prostatic end was 
steadied by two stay sutures and the divided ends of the urethra 
were then united on the roof with interrupted catgut sutures 
passed from without and not including the mucous membrane. 
No. 14 soft-rubber catheter was then passed from the meatus to 
the bladder, and the suture completed around this as a splint, the 
divided ends coming together without tension (Fig. 4). 

The catheter was left in place until November 14, when 
both perineal and suprapubic wounds were tightly closed. On 
December 18 he was discharged from the hospital. At this time 
the urethra took a No. 27 F. webbing bougie without difficulty. 
Sounds could not be passed as the urethra made a sharp turn 
around the bony fragment of the pubes and the curve of the 
instrument would not follow it. 

The patient was seen on April 14 at which time he was 
having very little difficulty in urination and the urethra took a 
No. 20 F. bougie without difficulty, though he has had no care 
since leaving hospital. 

Comments. — This case is interesting chiefly as showing 
the extent to which the perineal and scrotal portions of the 
urethra can be mobilized without damage to their blood sup- 
ply, and the size of the defects which may thus be bridged. 
The distance between the ends of the urethra at the time of 
operation was fully two inches. Mobilization of the prostate 
probably diminished this space at least one-half inch, so that 



RESTORATION OF URETHRA. 



89 



the gap ultimately filled was about one and a half inches. It 
might be expected that the complete isolation of the anterior 
urethra from behind forward would interfere with its blood 
supply far more than when it is mobilized from before back- 
wards, as in Beck's operation for hypospadia. 

Theoretically at least the destruction of the blood supply, 
when mobilized from behind, is much greater, but this case 
would suggest that the damage is neither serious nor 
permanent. 

Success in thus bridging defects will depend largely upon 
the approximation of the divided ends without tension. If 
this cannot be done retraction will certainly follow, and a 
long fibrous stricture will result. The possibility of avoiding 
tension depends entirely upon free mobilization of the anterior 
segment, and in my own cases at least, difficulties in the past 
have depended upon failure to observe this precaution, because 
I feared to cut off the blood supply. If union takes place 
without stretching of the scar an annular stricture, which can 
be readily handled by dilatation, will result. 

This method of restoring defects seems to me much 
superior to the use of animal tissue, or to Thiersch grafting. 
Where the former method is used it is not likely that all of 
them will " take," and the amount of scar tissue is therefore 
greater than that following direct suture. 



CATHETER FEVER.* 

REPORT OF A CASE WITH A RAPIDLY FATAL TERMINATION. 

BY LEVI J, HAMMOND, M.D., 

OF PHILADELPHIA, 
Surgeon to the Methodist Episcopal and Maternity Hospitals. 

By the term " True Catheter Fever " should be impHed 
a sudden elevation of temperature varying from loi to 109 ° 
F. following instrumentation of the urethra, and in cases 
where obstruction to the flow is not from stricture, foreign 
body nor in the presence of infection, the fever is out of 
proportion to the amount of trauma inflicted. There are a 
few cases, following the introduction of a catheter through 
the urethra into the bladder, that will be followed by a sudden 
rise of temperature, carrying from 106 to 109 ° F. with cor- 
responding increase in pulse rate and respirations which, in 
spite of every known precaution, will go to a rapidly fatal 
termination. It is of these exceptional instances that the case 
herein recorded furnishes a typical example, occurring as it 
did, entirely unassociated with stricture of any calibre as well 
as in the absence of infection. When one or more of these 
complications exist, there are obvious reasons why pyrexia 
may be expected to occur from either shock or pyaemia. 

It is in those cases unassociated with either stricture or 
septic conditions of the genito-urinary tract that will be con- 
sidered in the discussion of this case, because of the greater 
obscurity in origin and also because of the more fatal termi- 
nation, these two facts leading to the belief that the obstruc- 
tion is secondary to diseases of the cerebrospinal tract. Cer- 
tain it is, that the theory of their infective origin cannot 
be satisfactorily explained by either traumatic shock, as none 
exists, or by dissemination of infection. 

It is by no means a satisfactory explanation to say that 

* Read before South Branch Philadelphia County Medical Society. 
90 



CATHETER FEVER. 



91 



the subject of this report died from reflex shock transmitted 
through infection to the nerve centres solely by way of instru- 
mentation of the urethra. To do so, would leave unaccounted 
for the etiology of the conditions which in this instance led 
to the necessity of supplanting the normal act of micturition 
by instrumentation. The following history seems to empha- 
size this conclusion. 

G. P., aged 50 years, was admitted to the Methodist Epis- 
copal Hospital, July 2, 1907, because of inability to void urine. 
Two weeks ago began to complain of pain on urination and at 
times the urethra seemed choked up. Urination was more fre- 
quent than usual, compelling him to get up at night. On Sunday, 
June 30, he was unable, for the first time, to void urine at all. 
A physician was called in but did not use catheter; gave him 
medicine with no beneficial results. On the following day 
(Monday) he passed a little water up until 4 p.m. From this 
time until the following day (Tuesday) there was no urine voided. 
He was admitted to the hospital at noon and at once taken to 
the operating room. This was 2 p.m. 

Personal Examination. — A gaunt man of good musculature, 
does not look to be older than his age given, eyes somewhat 
sunken, left pupil somewhat larger than right, both react to light 
and distance. Teeth consist of a few large snags only. Lungs 
normal, heart sounds weak, but no murmur detectable. Abdom- 
inal inspection shows marked tumor over the bladder region. 
The temperature, per rectum, was 99.4° F., pulse 100, respira- 
tions 24. 

The history pointed so clearly toward obstruction to the 
flow of urine by stricture, that the patient was at once etherized, 
and after a careful toilet of the parts had been made, a sterilized 
metal catheter was introduced, and to our surprise met with no 
resistance, three pints of light colored urine was withdrawn. 
After the catheter, which was a number 20 F., was removed, grad- 
uated sounds up to number 30 F. were passed, and were intro- 
duced without any resistance. After operation the patient's tem- 
perature, per rectum, was 103° F., respirations 30. This eleva- 
tion of temperature, which came on almost immediately after the 
use of the sounds, quickly subsided to about 100° F. and during 
the afternoon the patient voided eight ounces voluntarily. This 



92 LEVI J. HAMMOND. 

evacuation was apparently in no way under the patient's control 
as he seemed to be insensible of its occurrence, and there was also 
no voluntary power exercised. At 12 o'clock (midnight) it was 
again necessary to catheterize. This catheterization did not 
affect the temperature. The urine collected this time was dark 
red, and this was shown under the microscope to be due to the 
presence of a small amount of blood and a trace of albumin, the 
latter probably due to the presence of the trace of blood. 

The third catheterization was done during the morning of 
the following day (Wednesday) when 12 ounces were withdrawn. 
During the afternoon and evening of the same day, 11 ounces 
were voluntarily passed, the temperature varying throughout the 
day from 100.2" to 102.4° F. and the pulse ranged from 100 to 
no, respiration 28 to 36. From midnight of the third day to 
6 A.M. of the fourth he voluntarily voided 5 ounces. At 10 a.m. 
of the fourth day he was again catheterized, using a No. 20 F., 
and 10 ounces of urine were obtained. Sounds were then passed 
in sizes from No. 30 to No. 34 F. As force was unnecessary, 
their use was without pain. At 10.30 a.m., one-half hour after 
the passage of the sounds, the temperature was 99.6° F., pulse 
112, and respiration 32. At 11.30 a.m. the nurse noticed the 
patient was in a chill; the temperature at this time being, per 
rectum, 108° F. The resident physician was immediately sent 
for, and on his arrival, one-half hour later, it had arisen to 109° 
per rectum and 108.8° in axilla, pulse 120, and respirations 34. 

The patient was at once given an ice-water tub-bath, the 
water being kept at a temperature between 60 and 70° F. He 
was rubbed with ice, and ice cap kept to his head. Whiskey was 
given by the mouth, and strychnia ^/go gr. was given hypoder- 
mically. After remaining in the bath for fifteen minutes it was 
deemed advisable, on account of the pulse, to remove the patient, 
the temperature having dropped to 106° F. Alcohol rubbing, 
which was substituted for the bath, was continued fifteen minutes 
longer. At the end of this time the temperature was 103.2° F., 
making a drop of 5.2° F. in one-half hour. 

The patient was now permitted to rest, and at the end of 
another half hour the temperature was 102.4°, pulse 144. The 
patient, while in the chill, was delirious for about ten minutes ; he 
then lapsed into profound coma, remaining so for another half 
hour. The possibilities of apoplexy or uraemia were given con- 



CATHETER FEVER. 



93 



sideration. They, however, could be excluded because of the 
absence of the bounding pulse and the stertorous breathing of 
apoplexy, and the dilatation of the pupils with the urine odor to 
the breath as found in uraemia. 

At 2 P.M. the temperature was 104.4°, pulse 115, respiration 
26. At 7 P.M. the temperature was 102", pulse 104, respira- 
tions 26. Again the catheter was used and was followed by a 
chill and a rise of temperature to 105.4°. Alcohol sponging 
brought it down to 102° F. At midnight the temperature was 
100.4°, pulse 96, and respirations 24. Catheterization at 7 o'clock 
the morning of the fifth day withdrew 16 ounces of urine. From 
this time until midnight of the fifth day he voluntarily voided 
three times, amounts varying from 2 to 4 ounces at a time. From 
midnight of the fifth until 7.15 a.m. of the sixth day he voided 
6 ounces of urine. It was again necessary to resort to catheteri- 
zation at 2 P.M., when 16 ounces were obtained. Following the 
use of the catheter, which was a 32 F., sounds were again passed. 
The temperature at once went up to 104° F., pulse 112, respira- 
tions 32, and the third chill came on with delirium which 
again went into coma lasting about one hour. The temperature 
went up again to 109° F., pulse 144. A bath was given for 25 
minutes, the temperature of the water being kept between 60 
and 70° F. Whiskey, strychnine and digitalin were administered, 
the temperature dropped to 105°, and by continuing the alcohol 
rub, after a 25 minute bath, the temperature was further reduced 
to 102.8°. Again delirium and coma cleared up during the tub- 
bath. He remained rational for about four hours, again becom- 
ing delirious. The temperature at this time was 104.8°. The 
pulse dropped to 104, and respirations to 36, though at 6 o'clock, 
less than an hour later, the temperature had arisen to 106°. Ice- 
bath, stimulants and alcohol rub were given and succeeded in 
reducing it to 99.6°. At 9.15 a.m. (6th inst.) the temperature 
was 106°, and in spite of vigorous alcohol rubbing it reached 
106.4°. A fourth tubbing in water between 60 and 70° F. for 
20 minutes reduced it only to 104.6°. After a rest of 20 minutes 
in bed it had fallen to 101°, then the patient began to sink rap- 
idly, the heart becoming feeble, and he died at 3.15 p.m. the 6th 
instant, less than 72 hours after admission, from cardiac failure, 
in spite of the use of every known agent as a preventive. 
Autopsy was refused, which is especially regrettable, because if a 



94 



LEVI J. HAMMOND. 



definite lesion could be microscopically demonstrated to exist in 
the cerebrospinal tract, causing the retention in this class of cases, 
it would greatly influence the line of treatment, and probably 
delay a fatal termination. 

This remarkable phenomenon seldom, if ever, occurs in 
nervous hysterical men or women whose condition is purely 
functional, nor in children before the age of puberty even 
where so much trauma is occasioned, as in the manipulations 
necessary in the operation of litholapaxy. 

Statistics show that catheter fever in none of the recorded 
cases was chronic. The longest recorded case (A. Clark) 
lasted about three weeks, but most of the cases were of much 
shorter duration. 

T. F. Raven described a case of a man 37 years of age, where, after 
the introduction of a catheter, the temperature, which previously had been 
102°, quickly went to 105° and the pulse to 140. The temperature never 
subsided below 100° and the patient died, from what was regarded as an 
obscure affection of the nerve centre. The high temperature and increased 
pulse rate existing in this case before the catheter was used seems strongly 
to suggest the existence of systemic infection prior to the instrumentation. 

In another recorded case by A. F. Weir, death followed five days 
after the passage of a sound, from what he regarded as pyaemia. A number 
of other cases are recorded where the temperature reached 106 and 107° F., 
eventually terminating in recovery. 

W. M. Baker considers that a striking analogy exists 
between ague and the shock propagated by the sympathetic 
nervous system through the urethra. 

It is. therefore, obvious that a careful distinction must 
be made between true urethral fever, and infection resulting 
from operative interference within the urinary passage in those 
cases where before urethral instrumentation, no evidence of 
systemic infection as shown in the pulse and temperature 
existed. 

Surgeons for the most part seem to hold to the opinion 
that these high temperatures and deaths that follow are due 
to septicaemia. This may explain the large group of cases 
where catheterization has been made necessarv because of 



CATHETER FEVER. 



95 



urethral infection, but it cannot hold good in those cases 
where neither obstruction exists, nor infection is present to be 
disseminated. It is, therefore, important that we look further 
for the etiology of the pyrexia in this class of cases, and to 
do so, they should be considered from an etiologic standpoint 
under two heads: 

First, and by far the largest group, are those where 
pyrexia follows instrumentation in the presence of urethral 
obstruction. 

Second, are those cases where retention exists in the ab- 
sence of any urethral obstruction. From a clinical standpoint, 
they should be further subdivided into two groups : 

a. Those where the symptoms indicate pyaemia, and hence 
due to altered and poisoned conditions of the blood which 
acts secondarily on the nervous system. 

b. That group where the symptoms which exist from 
the onset are of central nerve disease, and therefore the nerv- 
ous system must be regarded as primarily affected through 
reflex disturbances which further react upon the vascular 
system, producing the outward sign of pyrexia. 

In the true urethral fever cases, therefore, the most 
important question, which is by no means as yet satisfactorily 
explained, is, — " To what is the sudden high temperature 
that rises in a few minutes, or at the longest a few hours, 
after the introduction of a catheter into the bladder, due ? " 

It is not a sufficient explanation to content one's self 
with the accepted theory of reflex inhibitory nerve action, since 
to do so would leave unaccounted for the condition which 
makes retention of urine without obstruction possible. It seems 
quite within the scope of logical reasoning, therefore, to give 
much thought to the condition causing the impaired bladder- 
function, as it must surely share a large responsibility in 
disturbing the heat centres and giving rise to the resulting 
symptom complex. 

It is a clinical fact that the particular point within the 
urethral canal that causes the systemic shock when the catheter 
is passed is at the vesical neck. 



96 LEVI J. HAMMOND. 

It is also a physiologic fact that the vesical constrictor 
muscle in this region of the bladder is controlled by a reflex 
nerve centre situated partly within the sympathetic and partly 
within the lumbar portion of the cord, both of which sets of 
nerves are united in the hypogastric plexus, and in the case 
that furnishes this report, there was evidently some stimula- 
tion of the centre controlling the vesical neck which acted so 
powerfully as to prevent the occurrence of dribbling or incon- 
tinence of retention, as the bladder was distended to its utmost 
capacity for two days. Another striking symptom in this 
case was that, notwithstanding the power of the constriction 
at the neck still existed, there was both loss of sensibility of 
the bladder walls, as well as of voluntary power. This fact 
is plainly shown in the history, as the patient at no time 
complained of discomfort from the immensely distended blad- 
der, which would, had sensation been acute, caused suffering 
from one-third the amount retained. 

This loss of both sensation and voluntary power justifies 
the belief that there was also defect in the dorsal region of 
the cord, as the longitudinal fibres of the posterior columns 
have been shown to be centres that have to do with reflex mus- 
cular co-ordination, hence the impairment in the function of 
the bladder walls can be, with reasonable clearness, shown to 
have, in this case at least, been due to central lesion. Thus it 
is possible to trace the nervous tract from the deep urethra 
and bladder to the nerve centres in the sympathetic, lumbar 
and dorsal portions of the spinal cord, the path by which its 
reflex inhibitory nerve influences pass. 

One of the most plausible explanations of the remark- 
able phenomenon demonstrable in this case is that the nerv- 
ous system in its entirety may be regarded as the most potent 
factor in maintaining the body in a normal condition of 
health, and that a disturbance in any part of it, directly con- 
nected with the nerve centres, will disturb the centre for the 
regulation of temperature. It seems, therefore, probable that 
the chief factor in true urethral fever is a disturbance of the 
thermogenic centres through the vesical centres. That fact 



CATHETER FEVER. 97 

is further illustrated in the extensive reflex nerve disturbance, 
especially shown in the bladder, and in cases operated for 
hemorrhoids, and also in many cases which directly affect the 
central nervous organism, as illustrated in injuries of the 
spine, and also in general systemic infections as found in the 
exanthemata, rheumatism of the joints, etc., which proves, 
therefore, beyond doubt that within the deep urethra is located 
a prominent part of the nervous system that controls the 
balance of power for the regulation of heat distribution and 
elimination. 

REFERENCES. 

Banks, W. M., Edinb. Med. Jour., 1871, xvi, pp. 1074-1083, " Urethral 

Fever." 
Barling, G., Bermingham Med. Rev., 1886, xix, pp. i-io. 
Bryant, J. H., " Catheterism and Stricture of the Urethra," Guys Hospital 

Report, 1 893-1 894, pp. 385-572. 
Cameron, H. C, Glasgow Med. Jour., 1884, xxi, pp. 174-189. 
Chapin, H. D., F. Rev. Psediat. Soc, N. Y., 1895, vii, pp. 146^150. 
Clark, A., " Catheter Fever or Urinary Fever," London Lancet, 1884, p. 137. 
Clark, A., " Discussion on Catheter or Urinary Fever," London Lancet, 

1884, p. 137 (same as above). 
Ford, W. H., St. Louis Med. Cour., 1886, xv, pp. 481-498. 
Gonley, J. W. L., Med. Rev., N. Y., 1872, vii, pp. 409-411. 
Haddon, John, M. D., Edinburgh, " A Case of Catheter Fever." 
Nixon, James, " Catheter Fever," Brit. Med. Jour., Lond., 1884, p. 265. 
Raven, T. F., " Catheter Fever," Brit. Med. Jour., Lond., 1888, ii, p. 1045. 
Thorn, Alexander, Edin. Clin, and Path. Jour., 1879-1884, " So-called 

Catheter Fever," i, 541-547. 
Weir, A. F., " Catheter Fever," N. Y. Med. Jour., 1884, xxxix, p. 15. 



CRUROSCROTAL HERNIA. 

AN ENTERO-EPIPLOCELE, WITH THE SPERMATIC CORD IN THE FEMORAL CANAL, 

THE TESTICLE IN THE SCROTUM AND AN ABSENCE OF 

THE INGUINAL CANAL. 

BY ALEXANDER HUGH FERGUSON, M.D., CM., 

OF CHICAGO, 
Professor of Clinical Surgery, University of Illinois. 

On the 23CI of August, 1908, Dr. Mateer of Wooster, 

Ohio, accompanied Mr. H to the Chicago Hospital to 

consult me regarding an hernia. Mr. H complained that 

he sufifered from an hernia in his right groin for 27 years, 
which he had never been able to control by a truss. The 
hernial region was painful and the truss hurt him. It was 
impossible to wear the truss constantly. He was conscious 
of a constant lameness and a tired feeling in his back, espe- 
cially on the right side. When the hernia troubled him most 
he became incapacitated to perform his mental work, — as a 
teacher and manager of a large institution. 

The mental depression was accompanied by a physical 
weakness which compelled him to lie down and rest. 

If not careful of his diet he was inclined to be constipated. 
He dated his rupture to a time when he was 18 years of age, 
and was pitching hay on a farm. An extra effort was made 
with the pitchfork to heave the hay, when suddenly he felt 
something give way in his right groin and at once a tumor- 
like mass appeared in the scrotum. It has increased but slightly 
since its occurrence. The contents of the hernia could be 
reduced at any time, but in spite of appliances they would 
descend again into the scrotum. 

With the exception of a severe burn he received during 
his last year in college, his general history was excellent. For 
several months after the burn he suffered from nervousness. 
There was nothing in the family history that bore upon his 
hernia. 

98 



Fig. I. 



I 




Cruroscrotal hernia. A, femoral ring; B, sac; C, omentum; D, cord; £, bed of 
the sac: F, falciform ligament; G, Poupart's ligament; H, aponeurosis external oblique 
muscle; /, Gimbemat's ligament; ] , pectineus muscle. 



CRUROSCROTAL HERNIA. gg 

A physical examination revealed a man looking- younger 
than his years, of a cheerful and buoyant disposition, com- 
plexion fair, eyes blue, squarely and stoutly built, in height 
fully 5 feet 8 inches, and weighing 185 pounds. 

Upon examining the hernia it was found to recede into 
the abdomen with gentle manipulations while in the horizontal 
position, but just as soon as he stood on his feet the contents 
of the hernia protruded into the scrotum. The sac was irre- 
ducible. The cord could be traced to the femoral opening, and 
it was placed external to the pubic spine. The neck of the 
sac lay external and anterior to the cord and its fundus could 
be felt in the scrotum. 

It was also perplexing to notice that no external ring 
could be made out. The diagnosis made was some strange 
variety of femoral hernia. In every other respect he was nor- 
mal, even the left inguinal region. 

Operative Findings. — Through a straight oblique incision 
over the mass, severing the skin, two layers of the superfascial 
fat between them and the root of the scrotum, the following 
structures were exposed : the aponeurosis of the external 
oblique, Poupart's ligaments, and the sac of the hernia. 

The sac was found in the femoral canal and scrotum. Its 
enucleation was an easy matter. The cord was also in the 
crural canal and the testicle in the scrotum as represented in 
the accompanying drawing (Fig. i). The sac was opened 
and found to contain a loop of small bowel easily reducible, 
and a mass of omentum extensively adherent to the posterior 
aspect of the sac and upwards as far as I could reach. It 
being impossible to deal with the omentum through the 
femoral opening I enlarged both it and the canal by cutting 
through all the fibrous structures parallel with and beneath 
Poupart's ligament, but in front of the great vessels, thus mak- 
ing a space large enough to allow the introduction of the sac, 
omentum, cord and testicle into the abdominal cavity. This 
being accomplished I made a new inguinal canal and placed the 
cord and testicle in their normal localities. It was, of course, 
necessary to split the fibres of the aponeurosis of the external 



lOO ALEXANDER HUGH FERGUSON. 

oblique muscle, sever the attachment of the internal oblique at 
the internal aspect of Poupart's ligament, then push the tes- 
ticle into the scrotum, and leaving the cord between the inter- 
nal oblique and transversalis fascia overriding the deep epi- 
gastric vessels as in a normal inguinal region. 

The red muscle (internal oblique) was attached the full 
length of Poupart's ligament. 

The cremasteric muscle was absent and the oblique 
inguinal canal and its openings were not in existence. The 
patient being placed in the Trendelenburg position the omen- 
tum was detached and a portion of it amputated on account 
of the extent of its raw surface. 

The sac was then ligated high up and removed. The 
operation was completed by suturing the transversalis fascia 
and the internal oblique muscle to Poupart's ligament in front 
of the cord, with interrupted sutures, repairing the wound in 
the aponeurosis of the external oblique with a continuous 
suture of fine chromic catgut and then closing the enlarged 
femoral opening by suturing the lower borders of Poupart's 
ligament to the pectineus muscle, internal to the vessels, and 
then closing the slit made in front of the vessels with a few 
interrupted sutures of catgut. The external wound was closed 
in the usual manner. 



GIANT-CELL SARCOMA OF FOREARM; PRO- 
FOUND ANEMIA FROM HEMORRHAGE; DIS- 
ARTICULATION AT THE ELBOW BY MILLER'S 
MODIFICATION OF THE CIRCULAR METHOD 
UNDER LOCAL ANESTHESIA. 

BY ALFRED C. WOOD, M.D., 

OF PHILADELPHIA, 

Assistant Professor of Surgery, University of Pennsylvania ; Surgeon to the University, 
the Philadelphia, St. Timothy's and the Howard Hospitals. 

Mrs. T., colored, married, aged 26 years, was admitted to 
the service of J. William White in the University Hospital on 
account of a large tumor of the forearm March 26, 1908, when 
the following notes were made : 

The patient's maternal grandmother and some of her aunts 
died of tuberculosis. Otherwise the family history is negative. 
There is no history of tumors in the family. 

She had the usual diseases of childhood, since which time 
she has never been ill. Although of frail build, she has always 
been able to attend to her duties about the house. 

She is the mother of three children ; one is living and in good 
health, one died in infancy, and one, born at seven months, died 
at birth. There is no history of venereal infection, and there have 
been no miscarriages. Her husband has always been healthy. 

The present trouble began in the winter of 1905 with pain in 
the left wrist, which was thought to be due to rheumatism. The 
pain continued for some time. By the following May the symp- 
toms had largely disappeared, but at this time she fell and struck 
the left forearm. Two weeks later, while sweeping, the handle 
of the broom caught on a nail, and the left wrist was severely 
sprained. After this the wrist began to swell, and became very 
painful. Her physician told her she had a fracture, for which 
a plaster-of-Paris cast was applied. When the cast was removed 
the wrist was worse and soon became more swollen than at any 
previous time. In August, as the pain and swelling persisted, an 
operation was performed, and two and one-half inches of the 
radius were removed on account of necrosis (?). The wound 
healed very slowly and by February, 1906, seemed about well. 

lOI 



I02 ALFRED C WOOD. 

Very soon, however, a small swelling developed at the site of the 
former operation. This was opened ; the wound apparently heal- 
ing satisfactorily, and again she thought she had about recovered. 
In August (1906) the present swelling began as a small lump in 
the seat of the previous operation, and has steadily enlarged until 
it reached the present size. The cicatrix broke down, leaving a 
raw surface and the skin became ulcerated from pressure. From 
both of these a varying amount of discharge appeared, and from 
time to time hemorrhages occurred. The one next to the last 
was very free, and the last one was so profuse that the patient 
fainted from loss of blood. The pain has been only moderate, but 
the tumor is tender to pressure. Daily dressings have been 
required for some time. 

The patient is a thin, anaemic, light, colored woman, looking 
quite ill. Pulse, 100 to 130; temperature, 99° to 103°. The lungs 
and heart are normal. The urine contains albumin and a few 
hyaline casts. Haemoglobin 20 per cent. ( ?), red blood corpuscles, 
2,600,000; white blood corpuscles, 18,000. 

The surface veins of the left forearm are very much dis- 
tended. The tumor consists of four distinct lobes, one internal, 
two external and a very large and sloughing mass posteriorly. 
The odor is very foul. The tumor is soft, at points almost fluc- 
tuating and somewhat tender. No bruit is heard over the tumor, 
but a distinct thrill is felt along the axillary and brachial arteries, 
most pronounced at the level of the neck of the humerus. There 
is no glandular involvement. 

A diagnosis of sarcoma was speedily reached. An early 
amputation seemed imperative on account of the recent copious 
bleeding and the danger of a fatal hemorrhage at any time. On 
the other hand, the profound anaemia (haemoglobin 20 per cent.) 
and the marked degree of exhaustion, in a person naturally deli- 
cate and frail led to a fear that any operation might result fatally. 
After careful consideration of all of the factors, a disarticulation 
at the elbow joint under local anaesthesia was decided upon. This 
was done by the writer at Dr. White's clinic on April i, 1908. 
In order to save time the simplest possible technic was required, 
and with this point in mind Dr. White suggested Miller's modifi- 
cation of the circular method. This is described in Jacobson and 
Rowland's " Operations of Surgery," 5th edition, 1908, with the 
following comments : 



Fig. 3. 




X-ray of sarcoma of forearm. 



Fig. 5. 




Showing stump two weeks after operation. 







"y-V^ 



iC/f ^-» -• , • 





Microscopic section of giant-cell sarcoma. Low power. 



/ 



GIANT-CELL SARCOMA OF FOREARM. 103 

" Mr. A. G. Miller, of Edinburgh, relying on Desault's dictum, — that, 
the simplicity of an operation is the measure of its perfection, — recom- 
mends disarticulation at the elbow and knee by a method which secures a 
long single flap by a circular cut. The whole point and simplicity of the 
procedure depends on the well-known tendency to contraction of the 
structures on the flexor aspect of a limb, as compared with those on the 
extensor, after the tissues are divided. At the elbow and knee this ten- 
dency is increased by extending the joint, and thus putting the skin on 
the flexor aspect on the stretch, while the skin on the extensor surface is 
completely relaxed. The method of procedure is as follows: The limb 
being held out quite straight, a circular incision is made 1J/2 inches below 
the condyles down to the deep fascia. The skin on the anterior or flexor 
aspect at once retracts considerably, making the line of incision oblique. 

" The extensor flap is now dissected up as far as abo've the olecranon, 
care being taken to cut on the deep fascia, and so to reflect the subcu- 
taneous deep fascia, and its contained blood-vessels along with the skin. 
The flap is loose and ample, being taken from a part where the skin is 
naturally redundant in order to accommodate itself to the normal action 
of flexion. After reflection of this flap — practically the only one — dis- 
articulation should be performed from the front. It will then be found 
that there is a long flap on the extensor and posterior aspect, with prac- 
tically no flap upon the flexor aspect. After the blood-vessels are secured 
and the nerves cut short, this single flap falls nicely over the condyles, 
and is easily secured by sutures. 

" Mr. Miller has proved by special dissections made by Mr. Whitaker 
that, the vascular supply to the extensor surface of the arm is remarkably 
good. Two large vessels are supplied to the skin here; one, on the inner 
aspect, from the inferior profunda and anastomotica ; the other, on the 
outer, from the superior profunda, both running in the subcutaneous 
cellular tissue. 

" With regard to the objection that the cicatrix in a circular amputa- 
tion is usually central and apt to adhere to the end of the bone, Mr. Miller 
replies that in his modification the cicatrix cannot be central. It is well 
up on the flexor aspect, and there is no chance of its becoming adherent 
to the bone. 

"He claims the following advantages for his method: (i) The pro- 
cedure is simple, is easily and quickly performed, and there are no elab- 
orate details to remember. (2) The skin-flap from the extensor surface 
is well accustomed to pressure and to the situation in which it is ulti- 
mately placed over the condyles. (3) The scar is in a most favorable 
position. (4) Much tissue is not required. The operation is, therefore, 
made suitable for both primary and secondary amputations." 

In the case here described the skin was infiltrated circularly 
with a one-half per cent, cocaine solution three inches below the 
joint (it was felt that an inch and a half below the joint as 
recommended would not give sufficient flap), the incision made 



I04 



ALFRED C. WOOD. 



and the skin turned up in the manner prescribed. The nerves 
were then rapidly infiltrated with a 4 per cent, cocaine solution 
and the disarticulation performed. Slight pain was felt when the 
median nerve and deep muscles were divided, otherwise the opera- 
tion was painless and was very well borne. No blood was lost, 
and throughout the pulse was not affected in the slightest degree. 
The operation required but twenty minutes from start to finish, a 
most satisfactory stump resulted, and all the claims made by 
Mr. Miller for this method seemed justified by the result in this 
case. 

The patient made a rapid recovery. The day following the 
operation the temperature was normal for the first time since 
admission, and only once did it reach 99° after operation. The 
bruit and thrill disappeared permanently. 

The stitches were removed and the patient was permitted 
to leave her bed on the fourth day. She was discharged on the 
sixteenth day, very much improved in appearance and strength. 

The following pathological report was very kindly furnished 
by Dr. George P. Muller: 

" Specimen consists of a forearm and hand ; in the region of the 
wrist is a large tumor growing at an angle of about 45 degrees with the 
plane of the forearm. The tumor mass in its greatest diameter measures 
17 cm. X 9 cm. The superior surface is ulcerated and presents a black, 
roughened surface which in many places is markedly indurated. The con- 
sistency is variable; that of the upper two-thirds of the growth being 
considerably less than the lower one-third, and indeed on the ulnar side 
fluctuation is apparent. In certain areas, particularly that portion imme- 
diately surrounding the joint, the density is very hard and resembles bony 
growth. Longitudinal section through the dorsal tumor displays a 
mottled, dirty grayish and reddish colored surface which, as the knife is 
drawn through it, is cut in certain areas with a grating sensation as though 
bone were present. In other areas necrosis is probably present, judging 
from the soft friable character of the tumor mass. 

" Microscopical examination reveals a mass of cells, atypical in appear- 
ance, irregularly arranged, and in shape, round, spindle and giant. There 
are about 15 giant cells to every field, many of them large sized and con- 
taining eight or ten nuclei. The stroma is abundant, and such blood- 
vessels as are present seem to be formed directly by the tumor tissue. 
Some free hemorrhage is present." 

Pathological Diagnosis. — Giant-cell sarcoma. 



A MODIFICATION OF THE BRADFORD FRAME FOR 

THE TREATMENT BY SUSPENSION OF 

FRACTURE OF THE FEMUR IN 

YOUNG CHILDREN. 

BY DAVID SILVER, M.D., 

OF PITTSBURGH, PA. 

The treatment of fracture of the femoral shaft in infants 
and young children by suspension of the affected leg, or of 
both legs, is a favorite method with a large number of the 
profession. For carrying out the suspension, apparatus has 
been attached to the bed (Stimson, Scudder) and to the ceiling 
(Stern), and the baby carriage has been utiHzed. The use of 
the bed confines the child to the house, while with the carriage 
nursing becomes more difficult and inconvenience is experi- 
enced in moving the child through the house. 

Several years ago, acting on a suggestion made by my 
friend, Dr. H. T. Price, I devised a simple attachment to 
the Bradford frame for use in an uncomplicated fracture in 
a nursing infant. It proved so successful in this and subse- 
quent cases that it can be recommended as a means for carry- 
ing out this method of treatment in an ideal manner. 

The gas-pipe frame is made in the usual way (about four 
inches longer than the patient and a little less in width than the 
distance between the shoulders). Opposite the hip- joint of 
the fractured leg a T connection is placed ; this must be screwed 
tightly, or riveted, to prevent turning. Into the T is screwed 
an upright piece of pipe, long enough to reach about four 
inches above the suspended foot. An L connection and a 
short (two to three inch) transverse piece of pipe, ending in 
a cap, completes the attachment. A single piece of canvas is 
used for the covering, a hole being made in the side for the 
upright to pass through. When it is desired to suspend both 
legs, the portion of the frame on which the legs ordinarily rest 
may be made much shorter, merely long enough to prevent the 
frame from tipping, and the transverse pipe must be longer. 

105 



Io6 DAVID SILVER. 

The patient is fixed on the frame in the customary man- 
ner and the adhesive straps, used for extension, are simply 
fastened to the transverse pipe at such a height that the 
buttock of the affected side swings clear, or both legs may be 
so suspended, if preferred. Carrying the napkin around the 
upright fixes the hips more firmly; if greater security is 
desired, a piece of adhesive plaster may be passed around the 
groin and fastened to the base of the upright. With coapta- 
tion splints, this gives a very secure dressing, the upright acting 
as a protection against injury. 

The case represented in the illustration is that of a six 
months old baby, in whom an untreated fracture at birth had 
resulted in marked bowing and shortening. Osteotomy and 
subcutaneous division of the adductors at the groin were 
performed and the child placed at once upon the frame. A 
straight leg with no shortening was secured. 



i 



Fig. I. 




Fracture of femur, treated on a modified Bradford frame. [7, upright, which is 
screwed into T-connection on right side of frame. L, elbow with short transverse piece 
of pipe (not showing). R, rubber tissue, covering coaptation splints and dressing, to 
prevent contamination. 



PORTABLE TRACTION APPARATUS FOR TREATING 

FRACTURES OF THE FEMUR AND 

FOR VARIOUS ORTHOP-ffiDIC 

OPERATIONS. 

BY CHESTER M. ECHOLS, M.D. 

OF MILWAUKEE, WIS. 

For several years I have treated most simple fractures 
of the femur in the youn^^ and middle-aged by the ambula- 
tory method, using for this purpose a snugly fitting spica 
plaster-of-Paris cast, reaching from the waist to the ankle and 
having incorporated in it a special traction device extending 
an inch and a half below the sole of the foot. With a high- 
soled shoe on the opposite foot the patient is permitted to 
walk about on crutches after the first two or three days, and 
every day thereafter during convalescence. Most surgeons 
would probably condemn this practice on theoretical grounds 
as dangerous. My experience with this method, however, has 
convinced me not only that it is free from danger when 
properly used, but that it is superior to any of the traction 
methods that require the patient to lie for weeks on his back. 
The patient passes his convalescence in comfort, and there 
is no fear of shortening or displacement of the fragments. 
The fault lies not in the plaster-cast method, but in its unskill- 
ful and faulty application. 

One of the greatest difficulties in the use of the spica 
plaster cast for fractures of the thigli arises from the crude 
and inadequate methods often used for holding the patient in 
position with sufficient traction and fixation of the broken 
limb while the cast is being applied. Several forms of ortho- 
paedic apparatus now in use serve this purpose admirably, but 
their expense and weight in the case of most of them are 
obstacles to their extensive adoption and use. 

The portable traction apparatus which I devised the 
past year serves such a great variety of purposes, orthopaedic 

I07 



I08 CHESTER M. ECHOLS. 

and surgical, that a detailed description of it may be of some 
interest. 

As the photographs indicate, the apparatus merely rests 
on a table, but does not have to be clamped on or attached to 
it in any way — an obvious advantage under many conditions. 

Traction is made on the patient's feet and counter trac- 
tion at the perineum with the lower limbs in any desired 
position. 

The two horizontal leg-bars (i) forty-two inches in 
length, the vertical perineal post (2) twelve inches in height, 
and the two vertical foot-posts (3) are all made of ten-gauge 
drav/n seamless steel tubing one and one-eighth inches in 
diameter, — comparatively light and practically unbreakable. 
The castings are of tough malleable iron, and the whole appa- 
ratus is nickel-plated. 

The thin metal sacral plate (5) is adjustable at any 
height. 

A leather-covered hollow wood cylinder (9) can be 
slipped over the perineal post to give a broader surface for 
pressure in cases where very powerful traction is needed. 

The horizontal leg-bars can be opened, compass-like, to 
any degree of abduction up to 180 degrees and securely 
locked at any point by a set-screw clamp (7). 

Two sliding and telescoping crutches (4) are attached tcr 
the leg-bars by means of split clamps, and are adjustable in a 
great variety of positions. 

Two specially designed sole-plates (8), each bearing a 
double pulley, are attached to the feet by means of an ordi- 
nary muslin bandage. They fit a foot of any size and can be 
used equally well with or without a shoe. The traction, how- 
ever great, can produce no trauma to the foot. 

On each of the foot-posts is a combination tackle-block 
and clamping device (6), adjustable at any height. It is so 
constructed that when the operator (Fig. 2) stops pulling, the 
clamp pinches the cord automatically and prevents any release 
of traction. 

The pull made by the operator is multiplied by four. 



PORTABLE TRACTION APPARATUS. 



109 



Thus, a pull of 100 pounds on the cord produces a traction 
of approximately 400 pounds on the leg. 

Moderate flexion, or hyperextension of the thigh, may 
be produced by (a) raising or lowering the sacral support 
(5)) (b) raising or lowering the feet (6), or (c) varying 
the thickness of the improvised head and shoulder rest. 

The apparatus may be used for breaking up an ankylosis 
of the hip- joint in cases of flexion and adduction of the 
thigh with lordosis, traction and abduction being made on 
the affected limb, while an assistant depresses the opposite 
side of the pelvis. 

The apparatus may be inverted and traction made on 
the legs without removing the patient from the bed — a useful 
manoeuvre in some cases of fracture of the shaft of the femur. 

The apparatus has also been found convenient in the 
treatment of a contracted knee-joint, which, after being 
straightened by brisement force, is held in full extension by 
a bandage tied tightly about the horizontal leg-bar. After a 
plaster cast is applied with the limb in this position the band- 
age is cut away behind the knee. A padded papier mache 
or fibre splint may be used as a support for the thigh and 
enclosed in the cast if desirable. 

By opening the horizontal leg-bars to 180 degrees, and 
applying the traction at the knees instead of the feet, the ap- 
paratus may be used like the " Extensionstische " of Heusner 
to hold the patient in position for applying a cast for double 
congenital dislocation of the hip-joints. 

The cord-and-pulley traction device used in this appara- 
tus has been found fully as eflicient as the conventional jack- 
screw or windlass affair, and is lighter and less complicated. 
The traction can be applied or released instantly. 

By using a suitably improvised back and shoulder rest 
the apparatus lends itself admirably to the application of body 
casts for Potts' disease of the dorsal or lumbar vertebrae. 

In such procedures as osteotomie suhtrochant erica and 
all open operations for old or recent fractures of the femur, 
some good traction apparatus is almost indispensable. This 



no CHESTER M. ECHOLS. 

apparatus not only furnishes the traction and fixation during 
operation, but maintains it without interruption, while the 
cast or splint is applied at the conclusion of the operation. 

The entire apparatus can be quickly taken apart and 
carried like a shot-gun in a canvas bag. 



INTESTINAL INTUSSUSCEPTION COMPLICATING 
TYPHOID FEVER. 

REPORT OF A CASE OF INTESTINAL INTUSSUSCEPTION WITH MESENTERIC 
THROMBI OCCURRING DURING FIRST WEEK OF TYPHOID FEVER. 

BY OLIVER C. SMITH, M.D., 

OF HARTFORD, CONN., 
Surgeon to the Hartford Hospital. 

The following case, from its comparative rarity, its 
serious import, and its difficulties in diagnosis has seemed 
to the writer worthy of being placed on record with the few 
others of similar character which have been reported in the 
literature. 

The patient was a female, age 20, of fairly good family history 
and previous good health, with the exception of a slight tendency 
to diarrhoea during previous three months. On August 17, she 
complained of abdominal pain followed by vomiting. Cathartic 
pills were administered by one of the family and on the following 
day castor oil. Diarrhoea promptly ensued and continued. An 
excellent general practitioner was called on the third day of the 
illness and found the patient with a temperature of 102°, pulse 
100; patient vomiting, vomitus being of a biliary character, 
bowels moving at intervals of two or three hours, slightly dis- 
tended abdomen with tenderness in the right lower quadrant. 
These symptoms increased in severity, temperature reaching 
105° F. (mouth) on the afternoon of the fourth and fifth days. 

The writer saw patient with visiting physicians on the morn- 
ing of the sixth day. The patient presented at that time the 
facies of typhoid fever. The tongue was protruded with slight 
tremor, and was coated white, pupils dilated, reacted to light, 
cheeks were flushed, there was marked restlessness and general 
discomfort. Physical examination of heart and lungs negative 
except a few rales at the base of the right lung. The abdomen 
was moderately distended, spleen not palpably enlarged, no roseola 
spots discovered, marked tenderness one inch to the mesial side 
of McBumey's point. Rigfidity of right rectus muscle fairly pro- 

III 



112 OLIVER C. SMITH. 

nounced. Digital examination of rectum revealed tender but 
movable mass in right pelvic fossa. Mass lacked doughy feel of 
an abscess. Pulse no, temperature 103.6° F. (mouth), 104° 
(rectal). Examination of urine negative. No blood examination 
made. 

A tentative diagnosis of probable enteric fever of sudden 
onset, accompanied by a peritoneal lesion in the ileocaecal region, 
probably appendicitis. 

As the nearest hospital was twenty miles distant, removal 
of the patient was considered unwise, and the operation was per- 
formed at her lodgings. Under ether anaesthesia a three-inch 
incision was made at the outer edge of the right rectus. The 
peritoneum was found injected, the pelvis containing a considerable 
amount of straw-colored peritonitic fluid. The examining finger 
at once encountered a cylindrical mass in the right pelvic fossa 
suggestive of an enoromusly swollen appendix. This proved to 
be a mesenteric thrombus. The ileum was found invaginated in 
the caecum a distance of 4 to 6 cm. The ileum as it approached 
the caecum was markedly oedematous and thickened, the appendix 
was thickened, the serosa much injected. Two large thrombi 
were removed from the mesentery, the intussusception was par- 
tially reduced by manipulation, the appendix removed, the ileum, 
close to the caecal junction, was sutured to the peritoneal wound. 

This procedure was adopted for the following reasons : first, 
there was neither gangrene of the intestine nor complete obstruc- 
tion to demand resection; second, by immobilizing the ileum we 
prevented further intussusception ; and third, by leaving it in the 
peritoneal wound it could be inspected and opened if obstruction 
should occur. 

A split tubular drain carrying gauze was introduced to the 
pelvis and a cigarette drain to the seat of operation. The balance 
of the wound was closed by tier sutures. 

The operation was followed by but slight shock. The vomit- 
ing and acute abdominal symptoms subsided at the end of twenty- 
four hours, the patient then going on through well marked typhoid 
with characteristic diarrhoea persisting for several days, roseola 
spots appearing during second week, mild delirium at night. 
During the third week the urine contained albumin and gave a 
positive Diazo reaction. The Widal blood test showed a positive 
reaction. 



INTUSSUSCEPTION IN TYPHOID. 113 

There was a moderate amount of seropurulent drainage from 
the wounds during the first two weeks. At the end of four weeks 
the wound was practically healed. The patient's temperature 
reached normal between the third and fourth weeks, and now, at 
the seventh week, convalescence is entirely established. 

Bibliography. — George G. Ross and Henry F. Page, of 
the German Hospital of Philadelphia, in an article on " Acute 
Intussusception in the Adult," published in the American Jour- 
nal of Medical Sciences, December, 1907, report two cases 
of intussusception occurring during the course of enteric 
fever, — one, a male of seventeen, the intussusception occurring 
on the twenty-sixth day; the other a female, aged nineteen, 
intussusception occurring on the nineteenth day. Both cases 
were operated upon without resection, and both recovered. 
The article further refers to reports of seven other cases which 
they have found in literature, two reported by Lieutenant 
Colonel Jennings in the British Medical Journal, 1902, in 
which the true condition was not discovered until autopsy. 
Ash reports two cases in the British Medical Journal, May 3, 
1902, the first being a male of twenty-six, intussusception 
occurring on the ninth day. Was operated upon and recov- 
ered. His second case was discovered at autopsy. Hart 
and Ashhurst, in the Annals of Surgery^ January, 1904, 
reported that they had seen intussusception occur during an 
attack of ambulatory typhoid fever. The result is not stated. 
B. L. Bryant and J. S. Bragg, in the Medical Record for 
November 18, 1905, report a case. The patient was a male, 
aged twenty-three. Diagnosis of typhoid positive. Intussus- 
ception occurred seven days after the patient entered hospital 
and seventeen days following the onset of prodromal symp- 
toms. Severe abdominal pain and vomiting marked the oc- 
currence of intussusception. Diagnosis of intestinal perfora- 
tion was made but at operation two hours later intussuscep- 
tion at the ileocaecal junction was found. This and two other 
intussusceptions in the ileum were reduced. The patient died 
five hours later from shock. 



114 



OLIVER C. SMITH. 



Of the above nine cases, including that reported by the 
writer, three were discovered at autopsy, five were operated 
upon, with four recoveries and one death. Of one the result 
is not stated. 

As laparotomies during typhoid become more common, 
intussusception will be found undoubtedly more frequently 
than in the past. At the present time it is a complication to 
be thought of, and dealt with promptly when encountered. 



A MODIFIED CRILE TUBE FOR THE DIRECT 
TRANSFUSION OF BLOOD. 

BY THOMAS N. HEPBURN, M.D. 

OF HARTFORD, CONN. 

The direct transfusion of blood, as described by Dr. 
Crile/ may be at .times an operation of emergency, when it 
is impossible to get an assistant familiar with its technic. 
Under such conditions a surgeon may find it very difficult to 
slip the vessels over the anastomosis tube. The awkwardness 
experienced by unaccustomed assistants in maintaining a 

Fig. 2. 



Fig. I. 



I 




I 




Drawiogs three times actual size. 

steady and equal traction on the blood-vessel while drawing 
it over the tube, and in holding it in place for ligation in the 
grooves, has led me to devise a tube which a single operator 
can use if the occasion demands it. 

It is the same as Dr. Crile's, with the addition of a 
wide flange at the base. This flange is pierced by four holes, 
dividing its circumference ecjually (see Fig. i). 



* Annals of Surgery for September, 1907. 



115 



ii6 



THOMAS N. HEPBURN. 



The technic of the operation may be divided as follows, 
after having dissected out the vessels to be used : 

I. Clamp gently the vein with one of the " Crile " clamps. Sever it 
cleanly as far as possible from the clamp. Flush open the lumen with 
warm saline, and, if necessary, dilate it further with mosquito hsemostats. 

Fig. 3. 



Fig. 4. 




Drawings three times actual size. 
Fig. s- Fig. 6. 




"v*^"— '*•»"'"•' 




Drawings three times actual size. 

Take four intestinal needles threaded with fine linen, knotted at the end. 
Going from within the lumen out, divide its circumference equally with 
the four threads. Then bunch the needles, and pass them through the 
tube (as in Fig. 2). Using the needles as a tractor, draw the vein 
through the tube (see Fig. 3). 

2. Separate the needles and run them through their corresponding 



TRANSFUSION TUBE. 



117 



openings in the large flange at the base. Take up the slack, and clamp all 
together at (A) with an ordinary haemostat (see Fig. 4). 

3. Using the haemostat as a tractor, you get equal traction on each of 
the threads. The passage of the threads through the holes in the flange, 
makes this traction in the direction desired. In this manner, the vein is 
reverted over the tube, and drawn up above the second groove (see 
Fig. s). When in place it is held there by taking a second haemostat and 
clamping all four threads close up behind the wide flange. Then the liga- 
ture is placed around the vein securing it in the second groove, and the 
traction threads are removed by cutting the knots (see Fig. 6). 

Fig. 7. Fig. 8. 




Drawings three times actual size. 

5. Clamp and sever the artery. Flush open its lumen, and gently 
dilate it with mosquito haemostats if necessary. Take four needles threaded 
as before [I use the same ones]. This time you pierce the walls of the 
vessel from without in to the lumen, leaving the knots on the outside. 
Pass the needles through their corresponding openings in the flange, and, 
after taking up the slack, clamp together at (A) as before (see Fig. 7). 
Using the clamp as a tractor, draw the artery on over the reverted vein 
above the first groove. Hold it in place by means of a second clamp 
behind the flange, as with the vein, and place the ligature around the 
artery in the first groove (see Fig. 8). 

6. The anastomosis being now completed, the Crile clamps on the 
vein and the artery are removed, and, if a plentiful supply of warm saline 
has been used throughout the entire operation, the transfusion is accom- 
plished. 



SURGICAL progress; 



GENITO-URINARY APPARATUS. 
Cancer of the Kidney and Bladder. 

Professor Thorkild Rovsing, of Copenhagen, reports 50 
nephrectomies for mahgnant disease. Of these 50 patients, 6 
died from the operation, 6 died from local recidive, 20 from 
metastases, 18 survived without return. Of these 18 survivors 
without return, the time that has elapsed since operation is, 
in 8 cases, more than 5 years ; in i is 16 years, in 2 is 12 years^ 
in I is 7 years, in i is 6% years, and in 3 is 5 years. These 
results are noteworthy for the small number of local returns and 
for the large number (16 per cent.) of patients who have sur- 
vived from 5 to 16 years after the operation. If these results are 
much better than those of other operators, it is due to the method 
of operation, of which the principle is to take away the kidney 
absolutely intact and closed. The first step of the operation is a 
double ligature of the ureter which is cut slowly by means of 
the thermocautery between the two ligatures; then the kidney 
and its pelvis are freed, using the greatest precaution to avoid 
any lesion of the organ ; having thus delivered the tumor outside 
of the wound, the artery and renal vein are isolated and are 
cut after ligature or forcipressure. The end of the ureter is 
then fixed upon the outside of the skin by a silk suture ; never is 
the ureter suffered to sink into the retroperitoneal connective 
tissue for fear of recidive arising from the infectious contents of 
the canal. If one does not begin by closing the ureter with the 
double ligature, the urine containing cancerous matter will escape 
at the moment of cutting the ureter infecting the retroperitoneal 
tissue, and many local returns are possibly due to this circum- 
stance. The size of the tumor of the kidney is not decisive as to 

* Reports made to the Second Congress of the International Society 
of Surgery, Brussels, September 21 to 25, 1908, from abstracts furnished 
by the authors. 
118 



CANCER OF THE KIDNEY AND BLADDER. 



119 



operative indication ; 4 of the 8 patients that remained cured more 
than 5 years, and even the 2 remaining cured more than 12 years, 
had enormous tumors. That which is of the highest importance 
is that the kidney with its tumor should be enucleated without 
being torn, and should be extirpated as a closed mass. 

RovsiNG also reported the results in 80 operations for 
cancer of the bladder, which he classified as follows : 

a. Fifty-four ablations of the tumor alone and of its base 
of implantation with a zone of i centimetre of healthy mucous 
membrane; twice this operation was done through a dilated 
urethra; in the other 52 by suprapubic section; 2 deaths, only, 
followed the operation (pneumonia) ; 7 have remained cured 
without return more than 5 years, of whom were 3 after 10 
years, 2 after 8 years, and 2 after 6 years. 

b. Five resections of the bladder wall; i of these patients 
died 8 days after operation of uraemia; i died, without return, 
from haemiplegia (cerebral tumor) after i year; i died from 
recidive after 1I/2 years; and 2 have remained cured after 11 
and 6 months, respectively. 

c. Three total extirpations of the bladder with double 
ureterostomy; of these, 3 have died from metastases with local 
recidive, i after i year; 2 after 2i/^ months. 

d. Twenty simple suprapubic cystostomies, with the sound 
de Pezzer a demeure. In all these cases an excellent palliative 
effect was obtained. 

Dr. Felix Legueu, of Paris, analyzes 15 observations of 
cancer of the kidney; these comprised 7 complete lumbar 
nephrectomies of which 6 recurred in from 4 to 25 months ; i was 
living, without recurrence, after 24 months. There were 2 in- 
complete lumbar nephrectomies, i of whom survived 18 months, 
and the other 3 years and i month. In the latter case the 
operator had to do with a voluminous tumor of the kidney, which 
was operated on in 1904; in the course of the operation it became 
apparent that the greater mass of the tumor was constituted of 
an irremovable mass of glands ; the kidney only was taken away, 
and found to contain a cancerous focus. In this case the general 
condition remained excellent for 30 months, and it was only at 
the end of that time that her health began to decline and her 
strength wasted till death. As to the other patients, all except i 
have been subjects of recidive and as a rule the return has been 



I20 SURGICAL PROGRESS. 

local. In some of these patients, the fatty capsule was not com- 
pletely taken away and in its remains the foci of recidive de- 
veloped; in I of the patients the fatty capsule was taken away 
widely, also 2 voluminous glands attached to the hilum were 
taken away, but notwithstanding this, local recidive occurred at 
the end of 2 years. In another, notwithstanding the fatty capsule 
was carefully removed, recidive intervened at the end of 4 months 
in the spinal colum. 

Six transperitoneal nephrectomies have given the following 
results: 4 recidives at periods of from 8 to 24 months; 2 sur- 
vivals without recidive to 11 and 15 months, respectively; in 
neither case has the period that has elapsed been long enough to 
warrant the consideration of the case as one of cure. 

Taken all together, these results present little encouragement 
and, indeed, are somewhat paradoxical, the incomplete operatiohs 
having given the longest periods of survival, and the operations 
complete, or supposedly so, having given rapid or early recidive. 

With a view of favoring a more thorough removal for 
malignant disease of the kidney, the author quotes with approba- 
tion a method of transperitoneal nephrectomy which has been 
proposed by Gregoire {These de Paris, 1905). The subject is 
placed in the dorsolateral position ; a long incision reaching from 
the midst of the crural arch passes upward toward the anterior 
superior spine of the ilium, thence vertically to the costal border 
which it follows inward to the extent of from 5 to 6 cm.; the 
muscular wall is incised down to the peritoneum, then the peri- 
toneum is pushed back from the posterior wall of the abdomen. 
This stripping up is effected throughout the whole length of the 
wound from the iliac to the lumbar fossa, and is accomplished 
very easily. Over the external border of the kidney is then 
made an incision which involves only the perirenal fibrous layer 
(fascia of Zuckerkandl) ; one can then continue the stripping-up 
with the hand, but it is necessary to keep close to the deep surface 
of the peritoneum in order to preserve the entire adipose capsule 
as well as the kidney; thus the kidney is isolated surrounded by 
its adipose capsule intact ; it is held to the spine only by its meso, 
in which is found the vascular pedicle. If the tumor be large, the 
lumbar pedicle is then tied, after which the removal of glands is 
proceeded with. If the kidney be not too much enlarged, one 
takes away (as in the operation upon the breast) the cancer, the 



CANCER OF THE KIDNEY AND BLADDER. 121 

lymphatic paths, and the glands, at the same time; and also the 
suprarenal capsule. If a search for glands has to be done in a 
second step, it should be done in a special manner; one should 
look for them on the right side, around or behind the vena cava ; 
and on the left side, in contact with the aorta between the cceliac 
axis and the inferior mesentery artery. No procedure gives an 
access as favorable for these extensive ablations as this incision 
of Gregoire. In Paris, a few operations only have been done 
by this procedure: One by Gregoire, had to do with a hyper- 
nephroma with glandular involvements; the patient, 3 months 
after the operation, still remains well. The other, by Michon, in 
the case of a cancer ; 2 large glands were removed ; 9 months 
later the patient was still well. 

Cancer of the Bladder. — Of 22 cases of sarcoma which have 
been followed, 15 died of recidive: 11 within 6 months, 2 within 
a year, and 2 within a period not ascertained ; 5 were surviving 
without recidive at periods, respectively, of 6 months, 9 months, 
II months, 12 months and 2 years; 2 remaining cured after 
periods of 7 and 11 years, respectively. 

Cases of carcinoma should be classified according to the 
manner in which they are dealt with. Legueu has practiced 
ablation of the tumor only and of its base of implantation in 10 
instances in which the vesical tumor was epithelial in its nature, 
pedunculated tumors, and with the pedicles hard or sessile. Of 
these 10 cases, all were the subjects of recidive: after 6 months, 
2; 7 months, i; 8 months, 2; 10 months, 2; 12 months, i; 13 
months, i. In every case, the recidive occurred in loco, and pro- 
duced a tumor of the same nature as the primary growth; i 
patient only is still in health after 2^ years; he was the subject 
of cancerous papilloma, as verified by histological examination. 

Partial resection of the bladder wall was done in 2 cases. 
These have given better results although recidive occurred all the 
same. An alveolar cancer of the bladder, operated on in 1894, 
presented a recidive only in 1899, 5 years after; it was a tumor 
which developed at the top of the bladder, widely implanted, and 
infiltrating the bladder wall, but its situation made possible a 
complete removal with a secondary collar of healthy tissue: 
the whole thickness of the bladder wall was removed to an extent 
corresponding to the size of a 5-franc piece. In 1889, the tumor 
recurred in the abdominal wall, extending to the peritoneum, and 



122 SURGICAL PROGRESS. 

the patient died of cancerous peritonitis. In another case, a 
woman, an alveolar cancer situated on the right side, involving 
the larger part of the lateral wall, was subjected to resection of 
the entire half of the bladder; she remained 8 months without 
recurrence. At the end of 14 months, the cancer had reappeared 
on the right side, resulting in death 2 years after the primary 
operation. 

Palliative operations only, involving cauterization and 
curettage, were done in 11 instances. These have given only 
bad results in the end. The pain and the hemorrhages were 
arrested for only a very short time ; at the end of a few months, 
at most, all these patients were the subjects of rapid redevelop- 
ment of the disease, provoking the same series of pain and 
suffering that the operation had been instituted to ameliorate or 
suppress. 

As to total cystectomy in cases of cancer of the bladder, 
Legueu does not favor it. It is an operation of great gravity 
attended with an immediate mortality of 55 per cent., and remains, 
even after operative recovery, attended by a certain amount of 
later danger by reason of the implantation of the ureter. But 
if total cystectomy is an operation only to be resorted to in 
exceptional instances, all experience unites in establishing the 
superiority of partial cystectomy over every other method of 
attack. It is in taking away the whole thickness of the bladder 
wall that the best results in the future are to be obtained; this 
operation is quite possible for all tumors that are not seated at 
the base of the bladder. It is possible, without too great risk, 
not only for tumors of the summit and of the lateral wall of the 
bladder, but even for all those that are seated near the base. If 
it were practiced early, as soon as the tumor is diagnosticated 
by the cystoscope, we should see statistics comparable to the cures 
obtained in other regions. In cases that have extended so far 
as to render the disease inoperable, palliative operations are not 
of any value (operations that give to the survivor no appreciable 
benefit) ; the operative risks are often considerable, and the benefit 
obtained is not sufficient to warrant exposing the patient to them, 

Henri Hartmann, of Paris, said : To the 1 1 observations 
of malignant disease of the kidney reported by my assistant. Dr. 
Lecene {Travaux Anatomaux Clinique, deuxieme serie), I can 
add 3 other cases, 14 in all, in which nephrectomies were done; 



CANCER OF THE KIDNEY AND BLADDER. 



123 



of these there were 2 operative deaths, the remaining 12 either 
having been lost sight of or they have perished since the opera- 
tion, the longest survival having been 3 years and 4 months ; 
that is to say, our results have not been very brilliant, although 
we have taken care to remove the adipose capsule. 

Bladder. — a. Sessile tumors, 8 cases: of these, i died of 
strangulated hernia ; 2 were lost sight of ; i recurred ; 4 were seen 
again without recurrence at periods, respectively, of i year, 2 
months ; i year, 7 months ; 2 years and 3 years. We always 
seize the base of the tumor and draw it out so as to produce a 
kind of mucous pedicle, which we divide, afterwards closing the 
bladder wound with a continuous suture of fine catgut which 
secures at the same time hsemostasis. 

b. Partial resection, 9 cases: of these, 3 died; i, 21 days 
after operation, from pyelonephritis; i, 6 months after operation, 
from pyelonephritis, without recurrence; i, 5 months after opera- 
tion from pyelonephritis, with local recurrence. In 3 others, we 
do not know when death supervened, but we had determined 
local recurrence at periods of 6 months, 11 months, 3 years and 
I month. 

c. Palliative operations (curettage and cauterization), 14 
cases, — we have been able to follow 12 of these cases : 8 were dead 
at periods of 3 days, 10 days, 3 weeks, i month, 3 months, 4 
month, 4^ months, 6 months and 7 months; 3 were living but 
suffering from recurrence at the end of 4 months, 6 months, and 
I year. In view of these deplorable results, we agree with 
Legueu that the benefit which such palliative operations may 
give is not sufficient to warrant exposing the patient to the 
operative risks which they entail. 

Jose Ribera Y Sans, of Madrid, reported upon 4 nephrec- 
tomies for malignant disease of the kidney; 3, sarcoma, and i, 
carcinoma. The last case died by recidive at the end of two 
months. The 3 cases of sarcoma remain well after periods of 
5 years, 5 years, and 7 years, respectively. For the purpose of 
the removal of such tumors the reporter makes a vertical incision 
parallel to the axillary line but 3 or 4 cm. behind it, from the 
inferior border of the twelfth rib to the crest of the ilium; from 
the centre of this incision he makes a transverse incision towards 
the vertebral column, ending at a point 6 or 7 cm. from the 
column; two flaps are thus formed. These incisions divide the 



124 



SURGICAL PROGRESS. 



following planes : The vertical one, the skin and connective tis- 
sue superficial aponeurosis, the external oblique, internal oblique 
and transversalis muscles, exposing at its bottom the fatty capsule 
of the kidney and the fold of peritoneum which involved the colon 
and small intestine; the transverse incision divides the external 
oblique and the layers of the aponeurosis of the transversalis, the 
sacrolumbar muscular mass and the quadratus lumborum muscle. 
By separating the flaps, one sees the posterior face of the kidney, 
the colon, the small intestine, but one does not touch the peri- 
toneum; that is to say, one may secure as great amplitude of 
operative field as one can by the incision of laparotomy, without 
danger of wounding the peritoneum, and one may obtain' the 
facility of operative manoeuvre which a transperitoneal operation 
would give, with the advantages of the lumbar incision. 

Five epitheliomas of the bladder, treated by extirpation, gave 
one operative death and 4 operative recoveries, but no permanent 
recovery ; 3 had recurred a few months after the operation ; the 
other case killed himself 6 months after the operation, so that it is 
impossible to say what would have happened in that case. 



TRANSACTIONS 

OF THE 

NEW YORK SURGICAL SOCIETY. 



Stated Meeting, October 28, IQ08. 
The President, Dr. Joseph A. Blake, in the Chair. 



STAB-WOUND OF THE LIVER. 

Dr. Forbes Hawkes presented a man, 50 years of age, who 
on August 19, 1908, was stabbed in the abdomen just below the 
right costal border at the outer edge of the rectus muscle. He 
was brought to the Presbyterian Hospital a few hours after the 
injury. He then presented slight dulness in both flanks, some 
suprapubic dulness and marked rigidity of the right rectus muscle, 
especially at its upper part. There was slight abdominal dis- 
tention. 

Exploratory laparotomy in the mid-epigastric region revealed 
the abdominal cavity full of dark blood, and a stab-wound of the 
liver just above the gall-bladder, about three-quarters of an inch 
long by half an inch deep. The liver was bleeding freely through 
this rent. Dry gauze pressure was used for a few minutes ; then 
a suture of plain catgut was inserted, approximating the edges of 
the rent in the liver. This entirely arrested the bleeding. A 
rubber tissue and gauze cigarette-drain was inserted through the 
laparotomy wound to the wound in the liver. The pelvis was 
drained through a small suprapubic opening. The original stab- 
wound was drained with gauze, and the patient was placed in 
Fowler's position. He made an excellent recovery. 

CYST OF THE SUPRARENAL GLAND. 

Dr. John A. Hartwell presented a woman, 37 years old, 
who was admitted to Bellevue Hospital, on August 17, 1908. Her 
family history was excellent. The patient gave a history of 

125 



126 NEW YORK SURGICAL SOCIETY. 

having had typhoid fever about twenty years ago and subsequently 
an attack of malaria. She was not alcoholic. Menstruation was 
normal and she was the mother of seven healthy children. 

Present History. — Two years ago, while being examined 
during a pregnancy, the patient was told that she had a large 
mass in the upper left side of the abdomen. She had never noticed 
this before and it had caused her no trouble. Following this con- 
finement, she began to have pain in the abdomen at the site of 
the mass ; this was of a shooting character, coming on intermit- 
tently. The pain increased, and was worse on exertion, "^par- 
ticularly on flexing the abdomen. The patient had lost consider- 
able weight during the past three months. Her appetite was poor 
and she had frequent attacks of vomiting. Constipation was 
pronounced. There were no urinary symptoms, and aside from 
the presence of the tumor and some loss of weight and strength, 
there were no symptoms referable to the tumor, unless possibly 
the rather obstinate constipation could be attributed to it. 

Physical Examination. — The patient was a rather spare 
woman, showing evidence of hard work, but not looking especially 
ill. Her general appearance gave no evidence of malignant dis- 
ease. The thoracic viscera were found to be normal. 

An examination of the abdomen revealed a tumor which 
was believed to be the spleen, although this was not positive. It 
was located to the right and just below the umbilicus, and had a 
rather marked excursion on a pedicle lying in the normal splenic 
region. The mass was about half as large again as the normal 
spleen, and revealed the splenic notch, though very indistinctly. 
Beneath the left costal margin there was a large area of resist- 
ance, percussion over which was flat, and pressure over which 
produced pain. The exact outlines of this area were not distinctly 
made out because it was confused with the physical signs of the 
surrounding organs. Various diagnoses were suggested, among 
them being possible cancer of the splenic flexure with an involved 
omentum; a tumor of the spleen itself, the movable mass being 
possibly not spleen ; a cyst of the mesentery, or a tumor of the 
kidney or connected with the pancreas. The patient's tempera- 
ture, pulse and blood findings were all normal, thus excluding any 
suppurating process. The urine, gastric contents and faeces were 
also normal. 

An exploratory operation was advised and done on Aug. 28, 



CYST OF THE SUPRARENAL GLAND. 



127 



1908. Under gas and ether anaesthesia a longitudinal incision 
was made near the outer border of the left rectus, just above the 
umbilicus. On opening the peritoneum, the exploring finger 
encountered the spleen in the position of the movable tumor above 
described. It was larger than normal, but otherwise showed no 
pathological change. The hand was then passed up under the 
left costal border and encountered a cystic tumor nearly as large 
as the adult head, occupying the vault of the diaphragm, and 
being closely packed in the costodiaphragmatic concavity, so that 
it protruded very little, if any, below the costal margin. Its 
growth had crowded the spleen toward the mid-line, and the 
splenic pedicle had sufficiently stretched to allow its great mobility. 
The wall of the cyst was of a dark purplish color, and it could 
not be ascertained whether it was covered with peritoneum or not. 
It was very slightly adherent to the diaphragm and to the anterior 
parietes, and could be easily separated from its surroundings. 
On its upper external and anterior surfaces toward the mid-line, 
however, it was adherent to the structures on the anterior aspect 
of the vertebral column, where large vessels could be seen running 
across it. It was remarkedly free from adhesions to any part of 
the alimentary tract. The stomach, the colon and the coils of 
small intestines were easily pushed out of the way, toward the 
right. The kidney lay below the cyst, and was not adherent to 
it. The cyst was then partly delivered and tapped ; the contents 
(about three quarts in amount) consisted of a dark reddish-black 
fluid, with some thick masses of red fibrin which had the appear- 
ance of being digested. This suggested the diagnosis of a hem- 
orrhagic cyst of the pancreas, with partial digestment of the con- 
tents. This diagnosis was further confirmed when it was found 
that the pedicle of the cyst lay on the tail of the pancreas. As 
much of the cyst wall as possible was caught in a large clamp, and 
the distal portion cut away. Releasing the clamp showed no 
tendency to any serious hemorrhage, the wall having a very poor 
blood supply. This procedure was repeated several times, remov- 
ing the cyst piece-meal until a very small portion of it remained 
attached to the deep structures overlying the vertebral column. 
At this point large vessels were seen coursing over the remaining 
portion of the cyst, so that it was deemed inadvisable to attempt 
its further removal. The remaining portion of the cyst cavity 
(3 or 4 inches in circumference) was cauterized with carbolic 



128 NEW YORK SURGICAL SOCIETY. 

acid and alcohol, its cut edge being drawn as near as possible to 
the centre of the abdominal parietes by a large clamp, and its 
cavity packed with gauze. The time of operation was slightly 
less than an hour, and the patient's condition at the close of it 
was good. 

During the day following the operation there was a moderate 
amount of discharge, and no evidence of other than a local reac- 
tion. The temperature was elevated to 104, and the pulse to 120 
or more, but both promptly fell to normal by removing the pack- 
ing. The wound was drained for about three weeks, when it was 
allowed to close. The patient was discharged on Sept. 18, with 
the wound entirely healed, and her general condition improving. 

Examination of the patient at the present time showed that 
the spleen had become reduced to its normal size, and was now 
barely palpable below the costal margin and only slightly movable. 
There was no evidence of any recurrence of the cyst. 

Pathological Report by Dr. Charles Norris. — The specimen 
consists of a cyst, the outer surface of which is covered by a 
glistening membrane, upon which are the remains of fine fibrous 
adhesions and small blood-vessels. The cyst is roughly globular 
in shape, and shows a few nodular protuberances. The wall, in 
its thinner portions, measures about i or 2 mm. in thickness. At 
one point there is a sacculated diverticulum, about as large as a 
plum. The inner surface of the cyst is uneven and granular, and 
adherent to it on all sides is a small amount of chocolate-colored 
blood clot. On section, the cyst wall has a laminated, fibrous 
appearance, save in the region of the diverticulum, where there 
are yellowish areas resembling the cortex of the adrenal in 
appearance. 

Sections were taken for examination, from various parts of 
the cyst wall. Microscopically, these sections from the various 
parts all show small islands of adrenal tissue. The wall in the 
main is made up of fibrous tissue, with some fat, the fibrous tissue 
forming a layer on the outside, within which are the areas of 
adrenal tissue, and within this, hemorrhagic areas. In the diver- 
ticulum mentioned, smaller hemorrhagic cysts are present, of the 
same general construction as the larger cyst, and the pale areas in 
the diverticulum are found to be made up of adrenal cortex cells. 

From these findings, it is probable that instead of being 
originally a hemorrhage into the adrenal, with organization, this 



LOCALIZED CEREBRAL TRAUMA. 129 

case is rather one of original cyst formation of the adrenal, into 
which hemorrhage has later taken place. This is particularly well 
seen from the microscopic study of the smaller cysts, which, as 
said, show the same general structure as the main cyst. 

Report of the Contents of the Cyst by Dr. Hastings. — The 
fluid from the cyst consists of serous fluid, dark reddish-brown in 
color, containing a small amount of grumous material suggesting 
pancreatic cyst-fluid in appearance. It contained none of the 
pancreatic ferments and no evidence of any proteolytic ferment. 

Diagnosis. — Hemorrhagic cystic fluid ; origin not known, but 
not from pancreas. 

LOCALIZED CEREBRAL TRAUMA; ASTEREOGNOSIS. 

Dr. Hartwell presented a man, 22 years old, who was 
admitted to Dr. Eliot's service at the Presbyterian Hospital on 
October 13, 1908, with a history of having received a trauma of the 
head immediately before admission. He was struck on the left 
side of the head, over the parietal bone, with a brick hurled by 
another person from a distance of a few feet only. He was 
unconscious for some time after he was brought to the hospital, 
and was vomiting. He had no headache nor vertigo when he 
regained consciousness, but complained of a pain over the wound. 
He had sensations of pins and needles from the right shoulder 
down to the hand, where it was most marked, especially along the 
ulnar border. 

Physical Examination. — Patient was seen in the accident 
ward. Over the left parietal region was a ragged, lacerated, deep 
scalp-wound, about 2 inches long, in the bottom of which could 
be felt an edge of bone indicating a depression about 34 i^ich deep. 
There was no bleeding from the nose ; no sub-con junctival hem- 
orrhage. Pupils were equal and active. Patient was perfectly 
rational; had some headache, and vomited once in the ward. 
Lungs and heart negative. Pulse 84, regular; tension normal. 
Careful examination of right hand shows a condition of astereog- 
nosis confined to the hand, but much more marked over the ulnar 
distribution. There was no apparent abnormality in pain, tactile 
or temperature sense. He says the reason he cannot distinguish 
the shape of an object is, that when he tries to feel of it, there is 
so much prickling that he cannot distinguish the real object from 
the general pin and needle sensation. The prickling sensation 

5 



130 NEW YORK SURGICAL SOCIETY. 

extends to a diminishing extent above the elbow. There is no 
evidence of injury of peripheral nerves in the arm. 

Operation. — Three hours after admission, under chloroform 
anaesthesia. Exploratory craniotomy. Elevation of depressed 
fragment, with removal. Position, dorsal, with head of table 
elevated. 

Procedure. — Scalp elevated in left parietal region, the wound 
being enlarged anteriorly and posteriorly to about 4 inches in a 
somewhat curved fashion, the convexity of the incision pointing 
inward. The periosteum was incised along this line. Fragments 
of depressed bone removed and elevated. The dura was then 
opened for exploration and electrical test. Dura was then re- 
sutured, and a cigarette-drain inserted at the posterior angle of 
the wound, and the scalp sutured. 

Findings. — ^A depressed fragment of bone about i inch in 
diameter, of more or less ovoid shape, with the inner table ^ inch 
in diameter separated and forced against the dura. No extra- 
dural hemorrhage. The dura was opened because there was no 
pulsation, but no intradural hemorrhage was found. The brain 
itself pulsated normally. The area of brain exposed did not 
respond to stimulation by faradic current as evidenced by any 
motor activity in the right arm or leg. There seemed to be some 
excess of fluid between the dura and pia, suggesting traumatic 
brain cedema. Patient made good recovery after operation. 
Wounds healed by first intention, except at the site of the drain. 

The following notes were made on Oct. 18. — Condition of 
astereognosis is still present, though less marked. The disability 
is much more noticeable in the distribution of the ulnar nerve 
than in the median. It decreases toward the elbow. Tactile sen- 
sation, as tested by the distinction of two points, is slightly less 
acute than on the left side. Temperature and pain senses are 
normal. The muscular sense is impaired in all the fingers and 
thumb. He is unable to state accurately the changes in position 
of different fingers when brought about passively, but he has no 
difficulty in placing them in any desired position with his eyes 
closed, by active effort. There is no loss of muscular power, and 
he is able to produce a given amount of pressure at will. 

Oct. 25, 1908: The condition in last note has gradually, 
though not completely, subsided. An accurate measurement of 
the skull shows that the depression lies directly behind the 



RECURRENT GOITRE. 



131 



Rolandic line, 2^ inches from the longitudinal fissure, thus indi- 
cating a position in the ascending parietal convolution, just behind 
the arm centre. 

The case is shown as one of interest in that it closely resem- 
bles an experimental lesion in its distinctly localized nature. Its 
situation immediately behind the Rolandic line, with no motor 
paralysis, emphasizes the experimental findings that the motor 
area proper lies only in front of this line. 

RECURRENT GOITRE. 

Dr. Ellsworth Eliot, Jr., presented a woman, 24 years 
old, who was admitted to the Presbyterian Hospital on May 23, 
1905. Her family and personal history was negative. The 
patient had always menstruated irregularly; otherwise, with the 
exception of an attack of dropsy twelve years ago, she had enjoyed 
good health until five years before, when she first noticed the 
sensation of a " foreign body " in the throat, and slight enlarge- 
ment of the thyroid. This swelling had gradually increased, par- 
ticularly in the past year, and for the preceding month she had 
complained of choking sensations and difficulty in swallowing. 
For five years she had suffered from bi-monthly attacks of palpi- 
tation, lasting from ten minutes to an hour. There was no head- 
ache; no exophthalmos. 

An examination of the neck showed a goitre about the size 
of an orange, elastic and symmetrically enlarged. The pulse 
ranged from 80 to 100. An operation for its removal was under- 
taken on May 29, 1905. After a few inhalations of ether, the 
patient's breathing became stertorous, she became cyanosed, and 
respiration apparently ceased and for ten minutes she was thought 
to be dead. Under artificial respiration she gradually revived, and 
at the end of three-quarters of an hour she was practically out of 
danger. The operation was postponed for a week. At that time, 
under cocaine, enucleation of the goitre was attempted. This was 
successful, so far as the separation of the goitre from the over- 
lying and lateral muscles was concerned, but its base proved to be 
adherent, and at this stage of the operation the patient became 
restless and complained of so much pain that further attempts 
at enucleation had to be abandoned. The cyst was thereupon 
opened, and two ounces of hemorrhagic fluid evacuated and the 
cyst wall removed from the thyroid gland. The wound was 



132 



NEW YORK SURGICAL SOCIETY. 



packed and allowed to heal by granulation. During this time 
there was a discharge of a considerable amount of necrotic 
material, which upon examination proved to be portions of the 
thyroid gland. Healing was complete at the end of the third 
month, the sinus having completely closed, leaving no sign of 
the goitre. 

The pathological report at this time was as follows. — Thyroid 
tissue somewhat bloody and distorted. Some tendency in places 
to papillation of the epithelium, which in certain areas is rather 
high columnar, but in others flat or cuboidal. Colloid contents of 
vesicles do not stain. Connective tissue scanty, and shows little 
or no inflammatory infiltration. 

The patient was re-admitted to the hospital on October 14, 
1907, with the history that six months before she had first noticed 
a recurrence. There was no exophthalmos nor palpitation. The 
swelling had steadily increased to its original size, but had not 
given rise to any symptoms of compression. Examination showed 
a broad scar adherent to the lower part of an irregular, ovoid, 
elastic tumor, typically thyroidal. The patient's urine was normal. 

Operation, October 16, 1907. — At this operation ether was 
administered, and was well borne by the patient. The left lobe 
of the thyroid was removed, and an examination of the specimen 
showed that it was made up of a number of communicating cysts 
around a central core, which was reddish in color. The wound 
healed without trouble. 

The pathological report on this specimen was as follows. — 
There is great hypertrophy of glandular tissue, which contains 
in places little or no colloid material; elsewhere, the alveoli are 
dilated and contain colloid material. The interstitial tissue in 
places is increased and shows hyaline degeneration. There are 
areas of hypertrophied glandular tissue in which are several layers 
of epithelium superimposed. The wall of a large cyst is composed 
of dense fibrous tissue. 

Diagnosis, cystic goitre. There were no signs of a further 
recurrence up to the present time. 

BUFFER ACCIDENT OF KNEE. 

Dr. Ellsworth Eliot, Jr., presented a man, 40 years old, 
who was admitted to the Presbyterian Hospital on January 24, 
1907, The history obtained was that on the day prior to his 



BUFFER ACCIDENT TO KNEE. 133 

admission his left knee was caught between the buffers of two 
street cars, and severely crushed. Inspection showed that the 
left knee was greatly distended with blood and serum, the pres- 
ence of blood being indicated by blood crepitus. The entire left 
leg was swollen, from the thigh to the ankle. Two days after 
admission, the measurement of the left leg, eight inches above the 
patella, was 25 inches, while that of the right leg at the same 
point was 20^^ inches. Four and a half inches below the patella 
the left leg measured 16^ inches and the right leg two inches 
less. At the patella the left leg measured 19^ inches and the 
right leg 15 inches. 

The left extremity showed evidences of extensive extravasa- 
tion of blood, but pulsation could still be detected in both the 
anterior and posterior tibial arteries. On February 10, about 
two and a half weeks after his admission to the hospital, although 
there had been no laceration of the overlying skin, there were 
indications of an inflammatory process on the outer side of the 
leg, opposite the external condyle of the femur. A large area of 
necrosis developed in this region, with slight oozing of blood, and 
the subsequent discharge of several fragments of bone. This 
condition, with alternate periods of healing and suppuration, con- 
tinued for two months, when the original wound healed com- 
pletely with the exception of a small sinus which persisted for 
six months. An X-ray was taken, which showed no free sequestra 
present. During February and March the patient was kept in 
a Buck's extension apparatus. His temperature, which on admis- 
sion ranged from 100 to 102, gradually fell to normal, and 
remained so up to the time of his discharge from the hospital, on 
May 10, 1907. Ten leucocyte counts were made during his stay 
in the hospital, and the highest was on March 15, when it reached 
16,200; the other counts were all below 12,000. 

When Dr. Eliot next saw the patient, about six months after 
the accident, he found upon examination that although the affected 
knee was capable of some movement, the ligaments had become 
stretched. To remedy this defect, the patient had an ordinary 
steel-hinge brace made which enabled him to walk without any 
trouble. The patient was given the choice between a resection, an 
amputation and the brace, and chose the latter. 



134 



NEW YORK SURGICAL SOCIETY. 



MURPHY BUTTON RETAINED FOR THREE YEARS IN 

MECKEL'S DIVERTICULUM; RESECTION OF 

ILEUM; END-TO-END SUTURE. 

Dr. Charles H. Peck presented a man, 32 years of age, who 
was admitted to Roosevelt Hospital on July 12, 1908, complaining 
of abdominal pain, fairly constant and severe, with colicky exacer- 
bations, of about two weeks duration. Three years ago he had 
been operated upon at another hospital for acute gastric symp- 
toms suggestive of ulcer, with impending perforation, and a 
gastro-enterostomy was performed with a Murphy button. His 
postoperative recovery at that time was prompt; his symptoms 
were relieved, and he was free from abdominal symptoms until 
the onset of the pain two weeks prior to his admission. There 
was no nausea or vomiting; no constipation; but the pain in- 
creased in severity and was aggravated by sitting, standing, and 
pressure, but not by taking food. Two days before admission the 
pain was especially severe, and he vomited for the first time. 

On admission, his abdomen was not distended. There was 
slight tenderness in the lower abdomen to the left of the median 
line ; no rigidity and no mass. Temperature, 99 ; pulse, 88. He 
improved somewhat under observation, and it was not until three 
days later that the fact that the Murphy button had never passed 
was elicited, and a radiograph showed its shadow near the sacral 
promontory. Median laparotomy was performed on July 17, 
1908. The loop of ileum containing the button was easily felt 
and drawn into the wound. The button was firmly incarcerated, 
and could not be moved from the site of impaction where it had 
lodged, end on, its large patent lumen giving free passage to the 
contents of the gut. Just proximal to it was a short, capacious 
Meckel's diverticulum, large enough to have held the button, 
the walls of which seemed thickened and hypertrophied (Fig. i). 
There was no ulceration of its mucous membrane. Resection of a 
portion of the ileum, including button and diverticulum, was per- 
formed with end-to-end suture, with linen thread. Convalescence 
was uneventful. Solid food was commenced on the 8th day ; the 
patient was out of bed on the i6th day and left the hospital well, 
18 days after operation. 

The button was a very large one, and had evidently been 
carried for three years in the diverticulum, becoming impacted at 



Fig. 




Murphy button impacted below Meckel's diverticulum, in which it had been retained 
for 3 years. Ulceration of wall of ileum which had been in contact with button shown 
in opened portion of gut. 



STAB-WOUND OF HEART. 135 

once when it finally attempted to move down the intestine. It 
was rusted and very tightly impacted. The mucous membrane of 
the ileum in contact with it had been destroyed by ulceration, and 
perforation would have soon occurred. The fact that it lodged 
end on and had an unusually large lumen prevented symptoms of 
obstruction. 

STAB-WOUND OF HEART (RIGHT AURICLE); SUTURE; 
RECOVERY. 

Dr. Charles H. Peck presented a negro woman, 24 years 
of age, who was brought to the Roosevelt Hospital in the ambu- 
lance about II P.M. on the evening of June 14, 1908, with the 
history that she had been stabbed three times in the chest with a 
pocket knife about half an hour earlier. One wound was over 
the right breast; one over the left breast, and one over the junc- 
tion of the left third costal cartilage with the sternum. The heart 
sounds could not be heard, and there was no pulse at the wrist, 
but a weak paradoxical pulse could be felt high in the brachial 
artery. Respiration was shallow, and the patient was in pro- 
found shock. Stab-wound of the heart was diagnosed, and she 
was taken at once to the operating room and etherized, about 
three-quarters of an hour after the injury. 

Operation at 11. 15 p.m. A quadrilateral flap, with its base 
at the left breast, and margins following second rib, centre of 
sternum, and sixth costal cartilage, was rapidly marked out and 
dissected back. A portion of the sixth costal cartilage was re- 
moved with bone forceps, and the fourth and fifth were cut at 
their sternal attachment. The third had been cut completely 
through by the stab-wound, close to its sternal attachment. The 
internal mammary vessels were ligated, and these three cartilages 
were again cut and broken at their junction with the ribs to make 
a hinge, and the flap thus formed of cartilages and intercostal 
muscles was carefully dissected up and turned back, the pleura 
being pushed away from its deep surface with gauze pads. Dur- 
ing this dissection, a small accidental wound of the pleura occurred 
in the lower part of the wound. This was temporarily closed 
with gauze pad pressure, as time was not taken to locate and 
suture it. The stab-wound of the pericardium was then found to 
be so close to the edge of the sternum that good exposure could 
not be obtained until a considerable portion of the sternum had 



136 NEW YORK SURGICAL SOCIETY. 

been removed with Rongeur forceps. The pericardium was then 
exposed by dissecting through a blood clot in the areolar tissue 
of the anterior mediastinum, and freely opened by a vertical 
incision about 3 inches long, one inch to the left of the stab-wound 
and the border of the sternum. Intrapericardial tension was so 
great that pulsation of the heart could not be felt, even with the 
finger directly on the pericardium. When the incision was made, 
dark blood under tension escaped with a gush, and the anaesthetist 
noted that the pulse improved immediately and could be felt at 
the wrist on relief of the intrapericardial tension. 

The rapidly beating heart, churning the blood free in the 
pericardium, made it very difficult to see where the fresh blood 
came from, but it soon became evident that the source was in 
the upper, right corner of the pericardial sac. Efforts to bring 
the heart wound into view failed until a transverse cut in the 
pericardium to the right gave more room. Then, by lifting the 
heart forward with the left hand and rotating it slightly to the 
left, a wound in the right auricle the size of a small lead pencil 
was brought into view. The heart was not lifted out of the peri- 
cardial sac. With each heart beat a stream of dark blood spouted 
about 2 or 3 inches. A suture of No. o chromicized catgut was 
passed on a curved intestinal needle, tied, and the ends left long; 
this helped to steady the heart while three similar interrupted 
stitches were added, four in all, which completely controlled the 
bleeding. A large clot was then removed from the pericardium 
near the apex. The remaining fluid blood was sponged out and 
the pericardial wound closed with No. 2 chromic gut, continuous 
suture. 

The flap was then carefully sutured in place; the deep 
structures with No. 3 chromic, the skin with silk-worm gut and 
silk, the suture of the soft parts closing the wound in pleura and 
stopping the sucking in of air. No drainage was used. The 
stab-wound in the soft parts was excised before suture of flap. 
The patient was given a saline infusion of 1200 c.c. on the table 
while the operation was in progress. The time of operation was 
65 minutes ; total anaesthesia 68 minutes ; chloroform and ether 
used. Her condition at the termination of operation was much 
better than at the beginning. 

Course. — On admission to the ward from the operating room 
the patient's temperature was 99.6; pulse, 136; respirations, 56. 



Fig. 




Suture of stab-wound of heart, (right auricle). Photograph 
taken 3 weeks after operation showing healed incision and scars of 
other stab-wounds. 



AVULSION OF THE BRACHIAL PLEXUS. 



137 



At 7.15 A.M. the radial pulse was again almost imperceptible, and 
another infusion of 900 c.c. was given. 

Temperature ranged from 100 to 102.8; pulse from 116 to 
136; respirations 24 to 36 for the first six days, and there were 
signs of pleurisy or a low grade pneumonia in the lower left 
chest, but little or no cough. From the eighth to the fourteenth 
day the temperature ranged to loi at night, the pulse gradually 
coming down to between 90 and 100, and the chest signs grad- 
ually cleared up. The wound healed by primary union through- 
out. The tension sutures were removed on the fifth day and all 
sutures on the eighth day. She was allowed out of bed on the 
seventeenth day, and left the hospital well on July 8, 24 days after 
operation, the pulse was of good quality and regular, ranging from 
80 to 96 ; the heart sounds were normal at the time of her dis- 
charge. The signs in the lung had entirely disappeared ; she had 
been walking about the ward for several days, and excepting 
that she was still weak, she seemed perfectly well, and has con- 
tinued so up to the present time (Fig. 2). 

Dr. George E. Brewer asked Dr. Peck how he dealt with 
the internal mammary artery at the time. In an operation of this 
kind, every step must be very quickly done, and he inquired what 
particular means he adopted to control the hemorrhage from this 
artery. 

Dr. Blake said he thought there were very few, if any, 
stab-wounds of the auricle that had recovered ; the recoveries were 
certainly much rarer than in wounds of the ventricle. The out- 
look in these cases became more serious as the thinner portions of 
the heart were involved, and the prognosis after auricular injuries 
was very grave. 

Dr. Peck, in closing, said the internal mammary had to be 
ligated above and below. The costal cartilages were cut close to 
the end of the sternum and turned back, so that ready access to 
the artery was secured. There was no particular difficulty in 
clamping it. 

AVULSION OF THE BRACHIAL PLEXUS. 

Dr. Frederic Kam merer presented a man of 30, who fell 
from a bicycle four months ago, striking his left shoulder on the 
ground. He was unconscious for a few moments, and when he 
recovered he immediately noticed that " he could not use his left 
arm and that he had no feeling in the same." This condition has 



138 NEW YORK SURGICAL SOCIETY. 

persisted since the injury. The region of the shoulder joint was 
contused at the time and he also sustained a dislocation at the 
elbow-joint, which was reduced at a hospital to which he was 
taken. 

An examination of the patient to-day easily allows the diag- 
nosis of a lesion of the brachial plexus. There is a complete 
motor and sensory paralysis of the entire arm, with the exception 
of sensation in the upper inner portions of the humerus (inter- 
costohumeral nerve). The sternomastoid, the trapezius, the 
serratus magnus and both the rhomboidei muscles are intact. 
The trunk of the sympathetic, or rather the communicating 
branches to the sympathetic from the ciliospinal centre in the 
cord are involved in the injury, as evidenced by the sinking in of 
the eyeball, the narrowing of the palpebral fissure, the contrac- 
tion of the pupil, and the anidrosis of the face and neck on the 
left side. All these symptoms point to a lesion of the brachial 
plexus in a line running from a point above and somewhat more 
to the outside of the spine to a point below where the communi- 
cating branches from the cord passed off to the sympathetic trunk. 

Dr. Kammerer said that a number of these cases had been 
published in medical literature. Dr. P. R. Bolton had presented a 
case at a meeting of this society six years ago. Dr. Frank 
Hartley, about the same time, published a case, and Dr. Bristow, 
in 1903, reported two further cases of his own. Surgical inter- 
ference had in general proved very unsatisfactory. Still, the 
speaker though it justifiable to make an attempt to find and suture 
the divided nerves. He intends to publish the result of operative 
interference in this case later on. 

Dr. Otto G. T. Kiliani said that in 1887 he saw a similar 
accident produced in a man whose arm was wrenched while he 
was in the act of shifting a belt on a transmission wheel. No 
operation was attempted in that case. 

Dr. Blake said that in the only case he ever saw similar to 
this the injury was received in the same way as in the case shown 
by Dr. Kammerer. The patient was thrown from a slowly mov- 
ing freight car, striking on his shoulder and producing a rupture 
of the brachial plexus. Upon operation, he found the brachial 
plexus so imbedded in connective tissue that it would have been 
a hopeless task to search for the constituent parts of the nerves 
and suture them. It was probably not necessary, the speaker 
thought, to unite each individual strand with its fellow. 



ADENOCARCINOMA OF RECTUM. 139 

Dr. Blake said he believed this was the same case that was 
subsequently operated on by Dr. Hartley. 

Dr. Arthur L. Fisk said that he showed a case of this kind 
to the society about five years ago. The patient was a plumber's 
helper, who had been struck on the left shoulder by a piece of 
sewer pipe falling from a height. When Dr. Fisk saw him at 
Trinity Hospital, some hours after the injury, he found that there 
was complete paralysis of the arm, and that there was no radial 
pulse at the wrist. The pulse in the right wrist was full and 
strong. Upon cutting down, avulsion of the entire brachial plexus 
was found and it was discovered, that the axillary artery had 
been torn across completely at the edge of the first rib. The 
plexus was sutured with fine catgut; gangrene of the extremity 
occurred subsequently, so that amputation at the shoulder was 
done. 

Dr. Kam merer, in closing, said this was the first case of the 
kind that he had ever seen, and he thought a distinction should be 
made between cases of avulsion of the plexus and those of direct 
lesion to the plexus at a certain point. In the latter cases the 
prognosis seems to have been favorable. In avulsions the indi- 
vidual nerve trunks were generally torn away at different levels, 
making search for the divided ends much more difficult ; often the 
nerves are torn away close to the spinal cord, and then there is 
little opportunity for surgical treatment. 

ADENOCARCINOMA OF RECTUM. 

Dr. Charles H. Peck presented a man, 57 years of age, who 
was first seen early in August, 1908, complaining of severe hem- 
orrhage from the bowels, which was first noticed about five weeks 
previously. There was no pain, no symptoms of obstruction, some 
weakness, but little loss of weight. 

Proctoscopic examination showed an ulcerated growth 3 or 
4 inches above the anal margin, nearly surrounding the circum- 
ference of the gut, involving about two inches of its length, but 
not constricting. 

Operation was performed on Aug. 19, 1908. After the usual 
preparation, a median posterior incision was carried back to the 
sacrum, and extended forward like a Y, part way only around the 
anus. It was deepened to the levator ani muscles, which were 
divided, and the rectum freed posteriorly and laterally by blunt 
dissection. Median division of the sphipcter posteriorly was then 



140 



NEW YORK SURGICAL SOCIETY. 



made ; the wound was retracted and the gut divided with scissors 
just above the internal sphincter, at least one inch below the 
growth. The open end was clamped, the gut freed from the 
hollow of the sacrum behind and the prostate in front, and drawn 
down so that about 4 inches, including the growth, could be 
removed and still allow the upper segment to come down to the 
anus. The mucous lining of the anal segment was then dissected, 
away, and the upper segment attached to the skin margin within 
the sphincter, the anterior attachments of which had not been 
disturbed. The wound and sphincter were then closed posteriorly 
by suture, a large gauze and rubber tissue drain extending from 
the hollow of the sacrum to the posterior angle of the wound. 

There was some sloughing of the cut end of the gut, and the 
stitches in the wound and sphincter gave way, leaving a wide gap 
posteriorly. Enough of the sutures in the gut held, however, to 
prevent much retraction. The large wound healed gradually by 
granulation, and the cut ends of the sphincter are now firmly 
implanted in the cicatrix, which has narrowed so greatly that 
there is very good control. 

Voluntary contraction of the sphincter has been good 
throughout, owing to the preservation of its nerve supply by 
leaving its anterior attachment undisturbed. He is able to go 
about is usual occupation, and has no incontinence except when 
diarrhoea is present, and even then he usually has warning enough 
to prevent soiling. 

There was practically no shock following the operation, and 
while there was wound infection, as was usual in these cases, con- 
stitutional symptoms were at no time alarming. Pathological 
report on growth, adenocarcinoma. The case is presented as an 
example of the utility of preserving the sphincter when feasible ; of 
the advantage of leaving the attachment of its anterior segment 
undisturbed to save a portion of its nerve supply; and to show 
some of the advantages of the perineal route with posterior 
division of the sphincter in suitable cases. 

NEPHRECTOMY FOR EMBRYOMA IN A CHILD: PRELIMI- 
NARY BLOOD TRANSFUSION. 

Dr. William A. Downes presented a child 2 years and 2 
months old, whose history previous to its present illness was nega- 
tive. It was admitted to the Babies' Hospital on September 3, 



NEPHRECTOMY FOR EMBRYOMA IN A CHILD. 



141 



1908, with the history that for the previous month it had lost 
flesh and strength and had become very pale. Three weeks before 
admission the parents had noticed a lump in the left side of the 
abdomen, and at the same time urination became more frequent. 
There was no evidence of pain. The bowels were normal. 

On admission to the hospital, there was marked emaciation, 
with protrusion of the abdomen. The entire left half of the 
abdominal cavity was occupied by an elastic, movable tumor which 
apparently involved the kidney. Examination of the urine was 
negative. Examination of the blood showed 12,000 leucocytes, 
4,960,000 red blood-cells and 45 per cent, of haemoglobin. The 
general appearance of the child was far from good. The lips were 
fissured and bleeding, the face drawn and the pulse rapid and 
feeble. It took its food very poorly. Under the circumstances, 
it seemed best to delay operation for a few days in order to see if 
forced feeding and good care would not cause some general 
improvement. This failed, and in the meantime there was a dis- 
tinct increase in the size of the tumor. It was then suggested 
that blood transfusion offered the best if not the only chance to 
get the child in suitable condition for operation. 

Accordingly, on the evening of September 11, eight days 
after admission, with the father as the donor, the child was trans- 
fused, the anastomosis being made between the left radial artery 
and the left internal saphenous vein, just above the internal mal- 
leolus, under local anaesthesia for both father and child. The 
haemoglobin was tested at the beginning and about every five 
minutes during the forty minutes which the blood was allowed to 
flow, and at the end of that time it was found that the haemo- 
globin had risen from 45 to 80 per cent. ; the pulse had become 
full, and the tension quite marked. There was a complete change 
in the child's appearance following the transfusion. Its color 
improved and it seemed stronger than at the beginning of the 
procedure. An examination of the blood on the following morn- 
ing, just prior to operation, showed that the haemoglobin had 
fallen to between 65 and 70 per cent., and it remained at about 
that level during the convalescence. 

Operation, September 12, 1908. — An oblique incision was 
made extending from the erector spinae muscle to the outer third 
of Poupart's ligament, revealing a tumor weighing one pound 
and two ounces springing from the left kidney. A nephrectomy 



142 NEW YORK SURGICAL SOCIETY. 

was done. The patient made an uneventful recovery, and was 
discharged on October i8, 1908, having gained 3 pounds in 
weight. Upon examination, the tumor of the kidney proved to 
be an embryoma. Dr. Downes did not wish to be understood as 
saying that the operation could not have been done successfully 
without the transfusion, but certainly the marked immediate 
improvement in the child and the entire absence of shock during 
and after operation warrant the statement that this procedure 
removed the case from the category of doubtful surgical risk to 
that of reasonable certainty. 

SUPPURATIVE PERICARDITIS. 

Dr. Ellsworth Eliot, Jr., read a paper with the above 
title, for which see page 60. In connection with his paper, the 
author presented a case of suppurative pericarditis. 

Dr. Kiliani said that about seven years ago he was called to 
see a patient in one of the medical wards of the hospital who was 
believed to be in a moribund condition. The case was one of 
rheumatic arthritis and peri- and endocarditis. A blood examina- 
tion showed a leucocyte count of 22,000. The man was at once 
taken to the operating room, and under cocaine Dr. Kiliani re- 
moved the fourth rib and cartilage, and incised the pericardium. 
This failed to produce the expected amount of serum or pus, 
which was explained by the fact that most of the exudate was 
posterior to the heart. After some manipulation, a few ounces 
of seropurulent fluid were evacuated and the man made prac- 
tically an uneventful recovery. Since then he had married and 
had returned to the hospital twice for attacks of rheumatism. 
He was last seen about three weeks ago. 

Dr. Blake said that on one occasion he opened the peri- 
cardium in the mid-axillary line, and so much pus escaped through 
the incision that it covered the entire patient and table. The case 
was interesting on account of the large amount of pus contained 
in the pericardial cavity. When a tube was introduced into the 
cavity, the patient complained bitterly of the pain it caused, and 
upon one occasion irrigation also caused great pain and collapse. 
A few days after the operation there were signs of pus further 
back, and an incision there revealed an empyema. In this case 
the pericarditis was secondary to a double pneumonia, and prob- 
ably to empyema. The patient finally died. 



TRANSACTIONS 

OF THE 

PHILADELPHIA ACADEMY OF SURGERY. 



Stated Meeting, October 5, 1908. 
The President, Dr. William T. Taylor, in the Chair. 



GUNSHOT-WOUND OF THE ABDOMEN. 

Dr. Charles F. Nassau presented three patients who had 
sustained gunshot-wounds of the abdomen. He said that it had 
always been his practice to immediately explore all gunshot- 
wounds in which there was a possibility that the ball might have 
entered the abdomen. Naturally, one should not do this, unless 
surrounded by the proper conditions and with the proper help to 
go ahead and perform any operation that the conditions found 
might necessitate. It seemed to him axiomatic that no gunshot- 
wound or stab-wound should be treated expectantly where there 
is the slightest suspicion of penetration of the abdominal cavity. 
The risks of delay are so disastrous and the danger of explora- 
tion so slight that the patient should be given the benefit in every 
instance. 

Case I. — A white woman, aged 22, married, was admitted 
to St. Joseph's Hospital January 16, 1906, with the history of 
having been shot by her husband. When seen by Dr Nassau 
about three quarters of an hour after the injury, she showed such 
marked symptoms of internal hemorrhage that she was removed 
at once to the operating room. She was etherized, scrubbed and 
operated upon at once. The wound of entrance was situated 
about two inches to the left of the middle of a line drawn from 
the anterior superior spine of the ilium of the umbilicus. The 
ball had travelled upward and inward for about three inches in 
the abdominal wall, before it penetrated the peritoneal cavity. On 
opening the abdomen, there was a free gush of a large quantity 

143 



144 PHILADELPHIA ACADEMY OF SURGERY. 

of bright red blood which was found to be coming from a large 
vessel towards the root of the mesentary of the small intestine. 
This was at once ligated. There were found altogether five per- 
forations of the small intestine, two perforations of the mesentery, 
and one each of the greater omentum and the gastrocolic omen- 
tum. The patient was given an intravenous transfusion of salt 
solution during the course of the operation. She was on the 
operating table one hour and twenty-five minutes. The abdom- 
inal wound was closed without drainage by a combination of 
buried and through-and-through sutures. Wound healing was 
by first intention. 

The patient's temperature fluctuated between loo and 102 
for 10 days. It came down to normal for four days ; then for 28 
days it ranged from 99 to loi ; then for four days from loi to 
104, followed by five days of normal temperature. There re- 
mained a slight elevation of temperature until her removal from 
the hospital on April 12, 1906. 

In explanation of this fever he stated that while she was 
being put to bed, after the operation, it was discovered that she 
had another bullet-wound, entering about two inches to the right 
of the eleventh dorsal vertebra. This bullet was lodged to the 
left of the spine, as shown by an X-ray plate, and had in its 
course completely divided the spinal cord. She was, of course, 
totally paralyzed from the waist down. This injury ultimately 
caused her death, some months after she was removed to her 
home. 

Case II. — Colored, aged 25, single. Shot at 11 p. m., March 
7, 1908. Walked four squares to the station-house, from which 
he was brought to St. Joseph's Hospital, in the patrol wagon at 
midnight. The patient walked from the patrol wagon to the 
receiving ward, suffering no distress whatever. He had not vom- 
ited, and his pulse, temperature and respiration were normal. 
The wound of entrance was one inch above the crest of the 
ilium in the mid-axillary line on the left side. The bullet could be 
felt under the skin one and a half inches to the right of the 
umbilicus. He was operated on at 1.30 a. m., and was on the 
table one hour and thirty-eight minutes. After exploring the 
wound of entrance, and determining that the peritoneal cavity was 
open, the abdomen was then opened along the outer border of 
the left rectus muscle from just below the margin of the rib to 



GUNSHOT-WOUND OF ABDOMEN. 



145 



within an inch of the piibes. There were found two perforations 
in the transverse colon ; these were so large and so close together 
that it required a sutured area nearly six inches in length to 
make a safe closure of the bowel. There were 12 perforations 
of the small intestine; two perforations of the mesentery of the 
small intestine with considerable bleeding ; one perforation of the 
descending mesocolon, just above the sigmoid flexure. At one 
spot the bowel was so abraded that it was almost a perforation. 
The abdominal wound was closed without drainage by buried cat- 
gut, and through and through silk-worm gut sutures. The tem- 
perature went up to 103 at 4 p. m. of the same day. It fell to 
100 during the night, and reached normal in three days. A por- 
tion of the upper angle of the wound broke down in about ten 
days, and healed by granulation, leaving a very small fistula at 
the upper end of the incision connected with the small intestine. 
Otherwise, in every way his recovery was normal. During the 
second week of September the patient had a bad cough and one 
day coughed so violently that he broke open his wound, and two 
loops of small intestine, about a foot in length, were extruded. 
Fortunately for him, this happened while he was in the hospital; 
the bowel was replaced by the resident physician, and the wound 
packed with iodoform gauze. The temperature went up to lOi, 
but came down to normal the next day. Condition October 4, 
1908, temperature normal, pulse 80, respiration 20. Dr Nassau 
said that he proposed to close the fistula shortly. 

Case III. — A white woman, aged 24, married, was admitted 
to the receiving ward at St. Joseph's Hospital July 7, 1908, at 
2.45 A.M., suffering from an accidentally inflicted gunshot- wound 
of the abdomen. She was vomiting great quantities of dark 
brown fluid, was much shocked, and seemed to be suffering an 
excessive amount of pain ; temperature was 97, pulse 102, respira- 
tion 26. She was operated upon at 4.30 a.m. She was on the 
table one hour and thirteen minutes. The wound of entrance was 
about two inches to the right of, and one and a half inches above 
the umbilicus. The abdomen was opened through the right rec- 
tus muscle, and in the peritoneal cavity there was much free 
blood ; this bleeding came from the wounds in the transverse 
mesocolon and from the stomach. There were found one per- 
foration in the hepatic flexure of the colon, two perforations in 
the transverse mesocolon, one being near its root and involving 



146 PHILADELPHIA ACADEMY OF SURGERY. 

a very freely bleeding vessel in the anterior layer which necessi- 
tated ligation, three perforations in the small intestine high up; 
one large perforation or slit, nearly three inches in length, just 
above the attachment of the gastrocolic omentum, about the junc- 
tion of the left and middle thirds of the stomach. The abdomen was 
closed without drainage by buried catgut, and through-and- 
through silk-worm gut sutures. While searching for the source 
of the hemorrhage, which came from low down in the meso- 
colon, he could see the point on the lateral internal surface of 
the abdominal wall, where the bullet had passed out from the 
abdominal cavity, and buried itself in the muscles of the back. 
This was just below the spleen and above the anterior surface 
of the left kidney. The temperature ranged from 100 to 102 
for five days, and then dropped to 99 and gradually came to 
normal. A portion of the wound healed by granulation. She 
was discharged from the hospital absolutely well, August 23, 
1908. 

About ten days after leaving the hospital she returned to 
the dispensary, and the bullet was removed from beneath the 
skin at a point just below the costal border, and about four 
inches from the spines of the vertebra on the left side. 

None of these cases were drained. During the course of 
the operation the intestines and abdominal cavity were flushed 
constantly and copiously with normal salt solution. He thought 
that none of these cases had waited long enough before opera- 
tion to involve any great amount of soiling of the peritoneum. 
The only question in his own mind was as to whether the va- 
rious points of perforation were adequately repaired. If these 
were not going to leak, then he did not see reason for drainage. 
Certainly, one could not attempt to drain the many numerous 
and small areas that might be infected ; therefore, he felt safe in 
trusting to the peritoneum whatever amount of infection might 
be left after his copious flushing. At all events, all the patients 
got well. In two of the three the bullet was recovered. All 
three were shot by a 32-calibre revolver at close range ; the great- 
est distance being about five feet, and in the last case probably 
not more than eighteen inches, as the woman's nightgown was 
set on fire. 

Dr. Nassau called attention to a condition that he observed 
in these three cases, and that he had also seen in several cases 



GUNSHOT-WOUND OF ABDOMEN. 147 

of perforation of the bowel during typhoid fever, where opera- 
tion was undertaken early. The intestinal walls, and the mesen- 
tery are of a pinkish color, and spread over them the vast net- 
work of lymphatic vessels seem to be over-distended, chalky 
white, and if any of these little branches be scratched with a 
needle point, a milky fluid exudes. In operation, as prolonged 
as any of these three, this condition, by the time the abdomen 
is closed, has almost entirely disappeared. Is this not nature's 
first great effort to do what she can to increase peritoneal 
resistance ? 

Dr. John H. Jopson spoke of three cases of penetrating 
wounds, with perforation of intestine in two cases, and of 
stomach and intestine in one case, which he had observed. 

Case I. — A white boy, aet. 14, was admitted to the Pres- 
byterian Hospital September 18, 1906. Four hours previous 
to admission he had received a wound in the right side of the 
abdomen, on a line above the umbilicus, by a 22-calibre rifle ball. 
On admission the temperature was 99 °, pulse 120, small and 
tense. The abdomen was slightly distended, tender, tympanitic 
in the centre, and dull in the flanks. Had vomited several times 
before admission. 

Operation seven hours after accident. The bullet-wound 
had taken a downward and outward direction through the ab- 
dominal wall, and was very dirty. The peritoneal cavity con- 
tained a large amount of free blood and some beginning serous 
effusion. There was a large opening in the lower ileum opposite 
the mesenteric border, single and irregular, and two openings in 
the caecum. All were closed by Lembert sutures of silk. The 
mesocolon was perforated, and digital examination discovered 
the much deformed bullet in the retroperitoneal tissues, from 
which situation it was recovered. Irrigation of abdominal cavity 
and drainage of pelvis by tube and gauze. There was consid- 
erable peritoneal reaction, free drainage and suppuration of the 
wound in the track of the bullet, but the boy made a good con- 
valescence, and was discharged from the hospital a month later. 

Case II. — A boy, aet. 6 years, was admitted to the Presby- 
terian Hospital December 28, 1907, having received an accidental 
wound by a ball from a 32-calibre revolver about a half hour pre- 
viously. The patient showed some evidence of shock on ad- 
mission ; his temperature was 98.4 °, pulse 120. Condition at 



148 PHILADELPHIA ACADEMY OF SURGERY. 

time of operation good. Operation about two hours after acci- 
dent. The bullet-wound lay in the median line, running down- 
ward from a point just below the ensiform cartilage. Oblique 
performation of the abdominal wall. There was a small amount 
of blood clot in the peritoneal cavity. The stomach and trans- 
verse colon were drawn out, examined carefully and found un- 
injured. The small intestine was then examined, and two per- 
forations found in the jejunum about three inches from its origin, 
opposite each other, at the mesenteric and antemesenteric bor- 
ders, and two openings in the mesentery. All were closed by 
suture of celluloid thread. The entire small intestine was gone 
over for other perforations, but none found. The ascending 
and descending colon could not be examined through the median 
wound, but as the bullet had apparently taken a direction 
obliquely backward it was thought they had escaped injury. 
Operation was well borne. Irrigation of the peritoneal cavity 
and a cigarette drain. The child had a fairly good night except 
for some restlessness. The pulse gradually increased in fre- 
quency and lessened in force. The temperature steadily rose. 
There was suppression of urine, but little vomiting. A little 
sanious discharge from the wound. The patient died 24 hours 
after operation. 

Examination of the abdomen, post mortem, showed no 
macroscopic peritonitis, but a perforation of the large intes- 
tine, exact location not detected by resident physician, but prob- 
ably of descending colon or sigmoid. The cause of death was 
probably a rapid peritonitis in spite of the absence of gross signs, 
clinical or pathological. The bullet was not traced or found, and 
before death the possibility of a wound of the kidney was con- 
sidered as the explanation of the suppression of urine. This 
was probably a toxic condition, however. 

Case III. — A lad, aet, 15 years, a sturdy, active boy, was 
shot on May 11, 1908, at 3.30 p,m., by a B. B. cap fired from a 
22-calibre rifle at a distace of about seven feet. The ball pene- 
trated clothing and abdominal wall. There was little pain and 
no shock, and the boy did not know he was wounded until a 
bystander examined him. He walked five or six blocks to a 
physiciam's office, who at once sent him to the Presbyterian 
Hospital. On admission he presented no symptoms whatever. 
There was a small wound of the abdominal wall about two 



GUNSHOT-WOUND OF ABDOMEN. 149 

inches below the border of the ribs on the left side and one inch 
outside the semilunar line. No rigidity or tenderness of the ab- 
dominal wall. Temperature 97.8 °, pulse 84, respiration 24. The 
ball could be felt beneath the skin of the back at the edge of 
the erector spinae. 

Operation five and one-half hours after accident. A four- 
inch incision was necessary to trace the small bullet wound 
through the muscular abdominal wall into the peritoneal cavity, 
which contained a small amount of blood. The splenic flexure 
cf the colon lay immediately beneath the wound, and was sur- 
rounded by a hematoma beneath its peritoneal covering. It was 
with difficulty brought up into the wound. Prolonged exam- 
ination failing to show the source of the hemorrhage, the per- 
itoneum external to the colon was divided and stripped forward, 
when two small perforations were found in the colon, one on 
its anterior and another on its posterior surface, which were 
closed by double continuous Lembert stitches of Pagenstecher 
thread. The anterior wound had been the source of the hemor- 
rhage. Blood and gas were seen to be coming upward from the 
direction of the cardiac end of the stomach, examination of 
which showed one perforation on the anterior and one on the 
posterior surface, very near the greater curvature. Both were 
closed by double layers of sutures. The intestine was gone over 
from the duodenum to the colon, examined, cleansed and re- 
turned. The upper abdomen was cleansed by wiping, and drained 
through the wound by cigarette drain and gauze packs. Partial 
closure of wound. The boy was turned on his side, and the 
skin nicked and the bullet removed from its subcutaneous loca- 
tion in the back. There was no shock and no diffusive peritoneal 
injection, although there was free drainage from the abdominal 
wound. Twelve hours after operation he drank all the water 
from a flower vase beside his bed. He was in the hospital a 
month and was discharged well. 

Dr. Jopson said further that the questions raised by Dr. 
Nassau applied to the cases he reported. As to the importance 
of immediate operation in civil practice, there can be no ques- 
tion. The figures collected by Moynihan in his book on Ab- 
dominal Operations, and based on an analysis of 112 cases of 
gunshot-wound of the stomach, show a rapidly increasing mor- 
tality where operation was delayed. 



I50 



PHILADELPHIA ACADEMY OF SURGERY. 



As to the site of incision in the cases of gunshot-wound, it 
seemed to him that where there is only one wound, and this well 
to one side of the median line, it is preferable to make the in- 
cision in this site rather than in the median line, but where 
there are several wounds one must rely on the median incision. 

In the second case a perforation in the descending colon or 
sigmoid was overlooked, and he did not see how this could have 
been discovered unless there had been added to the primary 
wound another on the left side of the abdomen. This question 
is one of considerable importance, as the responsibility of over- 
looking a gunshot-wound of the intestine is not lightly to be 
taken. 

Regarding the technic of suture of small wounds there is 
a little difference of opinion. Some surgeons think a purse- 
string causes too much narrowing. 

The question of drainage depends somewhat on one's pre- 
dilections. The importance of posterior drainage in gunshot- 
wounds of the stomach has been pointed out by Roswell Park. 
In cases of gunshot-wound of the cardiac end of the stomach, 
such as the one here reported, anterior drainage will probably 
often suffice. 

ACUTE CARCINOMA OF BREAST. 

Dr. William L. Rodman presented a woman, 45 years of 
age, who had been the subject of acute cancer of the mammary 
gland, the second he had encountered of this very rare affection. 

Her history is as follows: Her mother is living at seventy 
years, her father died at seventy-two. None of four sisters had 
mammary tumors. She has had but one child, who is now nine- 
teen years old. She never had abscess of the breast. 

In January, 1908, she noticed a marked retraction of the 
nipple of her left breast. The entire breast then began to enlarge 
and she very soon noticed that the greatest enlargement was in 
the axillary hemisphere. There was, however, no distinct tumor. 
In short, the process was a diffused, not a discrete one. About 
three years ago she accidentally struck this breast while getting 
out of the window. In March, 1908, she consulted one of the 
surgeons in one of the most prominent hospitals of this city, 
and a diagnosis of mastitis was made. If her condition in 
March was at all similar to what it was early in September, the 
mistake in diagnosis can easily be understood. 



ACUTE CARCINOMA OF BREAST. 



151 



When first seen by Dr. Rodman the gland was vividly red 
and covered by an eczematous eruption. Indeed, it closely sim- 
ulated mammary abscess. A careful examination of the supra- 
clavicular glands showed unmistakably enlargement of both 
chains. He could not believe that such enlargement was sympa- 
thetic and inflammatory, and therefore believed it to be acute 
cancer. Notwithstanding this, he took the precaution, as he 
always did in cases admitting of a doubt, to have a competent 
microscopist present at the operation; and the entire breast was 
not sacrificed until the examination of a frozen section confirmed 
the diagnosis. The report showed it to be medullary carcinoma. 
After the breast was entirely removed and the specimen carefully 
examined, it was shown that there were small deposits of pus 
throughout the gland. There was extensive carcinomatous in- 
filtration throughout the glandular structure. 

Dr. Rodman said that at first he hesitated as to whether 
or not operation was indicated because of its acute course and 
the involvement of the supraclavicular lymphatic glands. Cer- 
tainly, nothing short of a most radical procedure was indicated. 
This was carried out the next day and the subclavicular triangle 
was also attacked and cleared of enlarged glands and fat. The 
finger would be carried behind the clavicle from the wound above 
to the one below it. In spite of a very large wound he was able 
by extensive undermining of the flaps, to approximate their 
edges and secured primary union in both wounds. 

She made an excellent recovery and was sitting up in forty- 
eight hours; but two weeks had elapsed since the operation, but 
she was well enough to be presented before the Academy. 

He presented the case with the hope that others would re- 
port any cases of acute cancer in their practice, meaning by the 
term cases not only more than ordinarily rapid in their course, 
but so closely simulating mastitis as to have warranted the 
name by so good a surgeon and pathologist as Volkmann, who 
described it as " carcinomatous mastitis." In other words, there 
is no local or discrete growth in a part of the gland, but a 
general carcinomatous infiltration. He had seen quite a number 
of cases of both sarcoma and carcinoma occur in pregnant and 
lactating women. While such cases pursue at times a very rapid 
course, the patients he had seen had not, strictly speaking, acute 
cancer, as there were wanting inflammatory symptoms, the diag- 



1^2 PHILADELPHIA ACADEMY OF SURGERY. 

nosis was always plain enough, and only one of them simulated 
mastitis. Acute cancer is somewhat more likely to occur in the 
breasts of pregnant and lactating women, undoubtedly; but to 
warrant the term " acute cancer " there must be inflammatory 
symtoms simulating mastitis. In other words, a diffused, not 
a discrete lesion. 

Billroth reports a case where the tumor appeared in the 
breast five weeks before delivery, and the patient died one day 
after a normal labor. So that in less than six weeks from the 
beginning of the disease the patient was dead. 

In the first case that he saw, many years ago, in Louisville, 
Kentucky, the patient, a pregnant woman, never lived to be 
confined, but died within three months after the beginning of 
the growth. 

Dr. John H. Gibbon said that within the past few months 
he had seen two cases of acute carcinoma of the breast as de- 
scribed by Dr. Rodman. The first case was in Dr. Le Conte's 
service at the Pennsylvania Hospital. She was a young woman, 
had recently been confined, and the entire right breast was red, 
hard and brawny. It looked very much like an extensive mastitis. 
The second case he saw with Dr. E. P. Davis. She was a 
woman about 35 years of age and seven months pregnant at 
the time. The breast in this case was very large, red and in- 
durated; the entire breast was involved. This condition started 
last May, and the patient died a week or two ago. No operation 
was done in this case, as the growth was too extensive at the 
time that consent to operate was given. Dr. Davis did a Csesar- 
ean section in order to save the child, and the mother died about 
two or three weeks later as the result of the extension of her 
disease. This breast looked exactly like an infiltrating abscess 
of the breast, excepting that there were no soft areas. 

Dr. Edward B. Hodge said that he would add to the his- 
tory of Dr. Gibbon's first case just mentioned. The patient was 
a rather young woman, not over thirty. She was pregnant and 
she is now coming to his service at the Out-patient Department 
of the Pennsylvania Hospital with a granulating area. She has 
pain in her back, low down, and about the pelvis, which looks as 
if she might have a recurrence in the spine. Her pregnancy is 
over. Her general condition is poor. 

Dr. Charles F. Nassau said that a patient came to him 



STRANGULATED INGUINAL HERNIA. 153 

from New Jersey, who is at the Jefferson Hospital at the pres- 
ent time, with a breast tumor which has existed for eight or 
ten weeks. It was so acute, pained her so much, and had this 
redness that Dr. Rodman speaks of, and looked so like an ab- 
scess that her doctor had opened it for an abscess, but she had 
very extreme and extensive involvement of the axillary glands 
in her subscapular fossa, and the growth had attached itself to 
the ribs and sternum. This whole process had made its appear- 
ance very rapidly. He did not think it had been more than ten 
weeks since the patient was perfectly well. Her physician 
thought she had an abscess, but one which he acknowledged he 
could not cure, and suggested the removal of the breast. 

Dr. William J. Taylor said that he had had one instance 
of acute scirrhus of the breast in a young woman of 24 years. 
She was seen only a few weeks after the tumor appeared. At 
operation there was very extensive involvement of the axillary 
glands, and in six months she was dead from a recurrence. 

Dr. Rodman added that in case of acute cancer of the 
mammary gland both breasts are often involved. The right 
breast in the case presented is absolutely free of disease. There 
has been in most of the recorded cases of acute scirrhus a certain 
amount of purulent infiltration of the gland. In some there has 
been a well marked abscess, as in the case of S. W. Gross. Vivid 
redness and thickening of the skin, together with an eczematous 
eruption here and there, well justified Volkmann's name, " car- 
cinomatous mastitis." 

As regards the case presented he did not feel optimistic as 
to the ultimate result. 

STRANGULATED INGUINAL HERNIA. 

Dr. William L. Rodman reported the case of a man, 55 
years of age, who was brought into his service at the Medico- 
Chirurgical Hospital at 8 p.m., October 20, 1908, with a well- 
marked strangulated hernia. He had had a right inguinal hernia 
for years, which was controlled ordinarily by a truss. The 
hernia, however, had come down in the afternoon, and at 5 
o'clock he was taken with severe pain. He was then unable to 
reduce the tumor. He was admitted to the hospital at about 8 
o'clock. He had not vomited, nor had he had nausea at any 
time. The tumor was very tense. The operation was done and 



154 PHILADELPHIA ACADEMY OF SURGERY. 

he had never seen a tighter constriction at the end of three 
hours, excepting in one or two small tense femoral hernias. 
There was a loop of ileum which had been out only three hours, 
but was of a deep rose color, cold and clammy, and he was 
satisfied that necrosis would have set in and a resection of the 
gut have been necessary if the patient had gone until the fol- 
lowing morning for operation, — say twelve or fifteen hours after 
strangulation. 

Dr. Rodman said that he reported the case because in a 
pretty large number of herniotomies for strangulation he had 
never before encountered a case that did not vomit, excepting 
one or two epiploceles. He certainly had never seen an entero- 
cele nipped so tightly as to be on the point of necrosis that was 
unaccompanied by nausea and vomiting. The one symptom em- 
phasized by all authorities is vomiting; first, gastric contents, 
then bilious, finally stercoraceous in character. 

Dr. John H. Gibbon said that he did not think that vomit- 
ing always occurs in these cases, even where the bowel is 
gangrenous. Recently he had operated upon a man who was 64 
years of age, who had developed an irreducible hernia in the 
morning, and all day attempts at reduction had been made. 
The man's scrotum and penis were oedematous, and black and 
blue. He voided urine and it was found to contain sugar, 
diacetic acid and albumin. He had not vomited at all, nor 
had he any eructations of gas. Section was done with infil- 
tration anaesthesia, and four inches of ileum were found, which, 
if the man had not been a diabetic, he would have resected ; but 
he kept the wound open a long time, and the color of the gut 
improved so much that he restored it and did a Ferguson opera- 
tion without the removal of the lower portion of the sac. The 
oedema of the penis increased after his operation for the next 
12 or 18 hours, as if he was going to develop a diabetic gangrene 
of the scrotum and penis, but this is now much better. There 
is no doubt about it that this bowel was strangulated. One 
thing that made him hesitate to resect this bowel was the fact 
that the circulation of the mesentary seemed so good. There 
were no evidences of clotting in the vessels of the mesentery — a 
very important thing and a good criterion to go by in cases of 
strangulated bowel. 



INFUSION OF TWELVE PINTS NORMAL SALINE. 155 

APPENDICOSTOMY FOR CHRONIC DYSENTERY. 

Dr. William L. Rodman presented a man, who had been 
a soldier in the PhiHppines, where he was taken with amoebic 
dysentery. He was referred to him by Dr. Anders for appen- 
dicostomy, as he did not respond to ordinary treatment. He 
has been greatly relieved by it, and instead of having 60 actions 
a day, as in May, 1908, when he was operated, he now has only 
one of very good consistence. He irrigates himself daily. 

I did this operation a week ago on a case in the Presbyterian 
Hospital for diarrhoea, and the patient is greatly relieved since 
the two or three irrigations he has had. He believed that this 
procedure will be done very much more frequently in the future 
for chronic dysentery diarrhoea, and mechanical obstruction of 
the large bowel with acute exacerbation. It is a very easy mat- 
ter to overcome the acuteness of the symptoms by draining the 
appendix. There is no reason why the mortality in these cases 
could not be very greatly reduced by doing an ileosigmoid- 
ostomy and at the same time draining the bowel by an appendi- 
costomy. It would be infinitely better than an attempt at 
resection. 

Furthermore, it is possible to feed patients through the 
appendix in this way, where the rectum gives out and it is 
desirable to rest the stomach. 

INTRAVENOUS INFUSION OF TWELVE PINTS OF NORMAL 
SALINE SOLUTION FOR HEMORRHAGE. 

Dr. R. G. Torrey said that through the courtesy of Dr. 
Edward Martin he was able to report the case of a negro woman, 
32 years of age, who was brought to the hospital September 18, 
1908, with an incised wound of the abdomen. When seen on 
admission there was a prolapse of a number of loops of gut 
through a rather ragged incision on the right side of the lower 
abdomen some five or six inches in length, some external bleed- 
ing; a pulse which was very weak and running, the rate about 
150. Her skin was cold and leaking, and the respirations very 
shallow. The patient was conscious, but seemed profoundly 
shocked. 

A clean cover was placed about the exposed gut and the 
patient hurried to the operating room, where she was left on 



156 PHILADELPHIA ACADEMY OF SURGERY. 

the litter without being transferred to the operating table. She 
was sufficiently conscious to recognize her assailant at this stage, 
although she appeared too weak to speak. 

An intravenous infusion of normal saline solution was 
started at once and allowed to flow quite rapidly till nearly two 
pints had entered the circulation, when the flow was decreased. 
Hot towels had been placed over the gut and ether started at 
once. 

Two punctured wounds of the prolapsed portion of the small 
gut were encircled by purse-string sutures and closed, and the 
fecal matter carefully washed away. The edges of the wound 
were then retracted and a large amount of clotted and free blood 
removed from the abdominal cavity. 

The bleeding was considerable, and great difficulty was 
experienced in locating and ligating the bleeding vessels. After 
increasing the incision, four bleeding points were ligated and the 
bleeding seemed fairly well controlled. 

On further inspection of the intestines two more wounds of 
the small gut were found and inverted by purse-string sutures, 
and a contused area on the transverse colon, about i x i^ in., 
which was perforated at its central portion, was also inverted by 
a purse string and reinforced by a couple of Lembert sutures. 

During the search for bleeding points and the inspection of 
the gut, which occupied a considerable time, the patient's con- 
dition was much of the time alarming. 

The salt solution was taken up rapidly, and there seemed to 
be no opportunity to stop its administration, as the signs most 
of the time pointed to a failing circulation. When the pulse 
became very bad and the skin leakiness increased, the aorta 
was compressed and held closed for some time by a hand in 
the upper part of the cavity. This procedure seemed to have a 
good effect on the circulation and also may have facilitated the 
location of the bleeding points by reducing the hemorrhage in 
the abdominal cavity. 

While on the table the patient received about 10 pints of 
salt solution by the vein. There was a little leakage during the 
injection of the first pint, but after that not a drop was lost. 
About three pints of salt solution were poured into the abdo- 
men and the wound was closed by layers in the usual manner, 
with catgut continuous and silkworm-gut interrupted sutures. 



INFUSION OF TWELVE PINTS NORMAL SALINE. 



157 



Two Mikulicz drains inserted, one in the lower portion of the 
wound extending down, the other in the upper angle, directed 
at the wound in the transverse colon. 

In spite of the time occupied by the operation, about two 
hours, the patient left the operating room in remarkably good 
condition. In fact, after the bleeding was checked and the intes- 
tines returned to the abdominal cavity (the latter task no easy 
feat), the pulse became at once stronger, and the skin dry and 
of good tone. 

At the close of the operation the temperature was 95 ° and 
the pulse 156. There was a rapid readjustment of circulatory 
tone, the pulse rate dropping steadily and gradually, and the 
temperature rising until after eight hours the pulse rate was 
no and the temperature registered 100.2°. 

The piatient's condition was remarkably good for 48 hours, 
but at this time she began to complain of severe pain in the 
abdomen, most marked at the epigastrium and extending down- 
ward more on the left side than on the right. The upper abdo- 
men was distended and tympanitic. Peristalsis was active and 
rigidity slight. Patient became nauseated and retched consid- 
erably, but did not vomit. A stomach tube and a rectal tube 
were passed, and about a pint of very offensive fluid was with- 
drawn from the stomach. It was clear, almost colorless, and 
had a strong butyric odor. 

Considerable flatus was expelled during the next two hours 
and the relief from distress was almost complete. 

The skin-wound after three days began to show signs of 
infection, and two of the skin sutures were removed to allow 
of better drainage. In less than a week all of the skin sutures 
were removed. Union was secured only at the lower angle of 
the wound, but the fasciae seemed well united and have since 
remained firm. 

There was at no time a free discharge from the tubes. 
Oozing of a slightly blood-tinged fluid was present for two 
days, but after that the upper drain was almost dry and there 
was a small amount of thick pus in the lower tube at each dress- 
ing. There was marked tenderness in the vagina for three 
days after operation, but no bulging of the vault, and the tender- 
ness disappeared after the fourth day. 

Enteroclysis was continuous for more than 48 hours after 



158 



PHILADELPHIA ACADEMY OF SURGERY. 



operation and well tolerated. Nothing was given by mouth for 
24 hours, when small amounts of water and albumin water were 
allowed, followed by beef juice and Liquid Peptonoids. 

The urine has been negative throughout, though dysuria 
was present for a week. 

The blood after operation showed 45 per cent, haemoglobin, 
with 20,800 leucocytes and 3,370,000 red cells. Two days later, 
September 20, there was 38 per cent, haemoglobin; on the 24th 
the red cells numbered 2,080,000, with the haemoglobin at 42 
per cent.; on the 28th and 30th the haemoglobin stood at 48 
per cent., with the red cells about 2,700,000; on October 4 the 
haemoglobin had risen to 57 per cent., and the red cells were 
close to 3,000,000. A differential count on the 28th showed 74 
per cent, polynuclears and 22 per cent, lymphocytes. 

The temperature has twice reached 102 °. There has been 
a diurnal variation of about a degree, but the trend of tempera- 
ture and pulse has been steadily downward. 

The patient's present condition is perfectly satisfactory. The 
wound is granulating rapidly and is almost clean, the fasciae 
firm. There is no abdominal tenderness. Bowels move regularly 
and urine is voided freely. Except for a slight pleuritic pain in 
the left side convalescence seems now normal and uneventful. 

Dr. John B. Deaver said that through the saline solution 
and the skilful surgery this woman's life was saved, but without 
the saline solution he questioned if she would have survived. 
His experience had been more or less extensive with saline solu- 
tion, but he had never transfused so large a quantity; to him 
the results obtained in this case are striking indeed. He had 
seen profound shock, not alone where there has been much 
loss of blood, respond effectually to this treatment. 

Dr. Edward Martin thought the major point brought out 
by this case is the common-sense application of principles. The 
residents did what all residents should do, — they did not look 
on the dose of saline solution as one, two or three pints, but as 
sufficient to bring up the blood pressure. 

Another point worthy of remark was that they did not have 
time to bandage the extremities, but they took the quickest 
means of keeping the blood where it was of most use. One of 
the residents kept the aorta down with his thumb. The quantity 
of solution given by the bowel was enormous. They hesitated 



Fig. I. 




Frazier's operating table. 



Fig. 2. 




Table in position for elevation of head. 



Fig. 3. 




Showing patient supported in elevated head and lateral position. 



A NEW OPERATING TABLE. 



159 



to mention it, it being many gallons, and most of it was absorbed. 
The work done by the kidneys was extraordinary. 

The third point was the complication recorded. The second 
or third day there was acute gastric irritation, evidenced by 
enormous distension, by the presence of tympany, by the absence 
of tenderness, and by the profound effect upon the heart, pulse 
and respiration. Stomach tubes relieved it immediately. He 
had had one or two other cases of this kind where this acute 
gastric dilatation, taken in the early stage, yielded at once. After 
the stomach is over-stretched, it is like a piece of rubber over- 
blown, and cannot get back. 

Dr. Astley p. C. Ash hurst said that Dr. Martin had 
spoken of the results obtained by the use of large quantities of 
saline solution, and that this had recalled tO mind a case of 
rupture of the liver in which the results were very surprising. 
The quantity of salt solution used was much less than in Dr. 
Martin's patient, being only 5^/2 pints, but at the end of the 
operation, instead of blood coming from the live- it was salt 
solution; the patient died soon after the conclusion of the 
operation. 

AN OPERATING TABLE DESIGNED FOR OPERATIONS UPON 
THE HEAD AND NECK. 

Dr. Charles H. Frazier said that for many reasons it is 
desirable in operations upon the head and neck to have the 
patient's head and shoulders elevated to an angle of forty-five 
degrees. The greatest advantage to be gained from this posture 
is its influence upon hemorrhage ; particularly venous hemorrhage. 
Gravity so lowers the pressure of the blood stream within the 
veins that bleeding from this source is very noticeably diminished. 

If one elevates the head and shoulders of the patient on any 
operating table hitherto on the market the field of operation is 
so far above the floor that the operator's assistants and etherizer 
are compelled to stand on stools. This in itself is a matter of no 
little inconvenience. He presented a table, constructed for him 
by the Bernstein Manufacturing Company, of Philadelphia, which 
enables one to obtain the necessary elevation and yet have the 
field of operation at a level convenient to the operator as he 
stands on the floor (see Fig. i). In operating upon the thyroid, 
the cervical lymph-nodes, in excisions of the superior or inferior 



l6o PHILADELPHIA ACADEMY OF SURGERY. 

maxilla, in operations for the removal of malignant lesions of 
the face and neck he had found this table a very valuable addition 
to their equipment. 

Primarily, however, the table was designed for operations on 
the posterior cranial fossa. It has been his custom for several 
years to have the patient in the sitting posture when operating 
for lesions of the cerebrum, but in cerebellar operations this is 
manifestly impossible. In order to render the suboccipital region 
accessible the patient's head must be flexed and to control bleed- 
ing the elevated posture is desirable. Furthermore the majority 
of cerebellar lesions are in the cerebellopontile space, and he 
had found it most convenient to approach these from the lateral 
aspect along the posterior surface of the petrous bone. By plac- 
ing the patient on his side (see Fig. 2), elevating the table, and 
flexing the head, satisfactory conditions for cerebellar work can 
be obtained. 

In order that this position may be maintained and to prevent 
the patient rolling over on his face when under the relaxation 
of the anaesthetic a special device has been attached to the table 
which grasps the arm in the deltoid region. It is most important 
in cerebellar subjects that, when under the anaesthetic, through- 
out the operation respiration should not be interfered with. 

This device will be found serviceable for any operation in 
which it is desired to keep the patient on his side, as in operations 
on the kidney and thorax. 

Attention is called furthermore to an adjustable foot-board 
which may be moved up or down, according to the height of 
the patient, and by means of an automatic catch retains its posi- 
tion, thus preventing the patient from sliding off when the 
table is elevated. 

While the table was designed for a special field of surgery, 
the essential features of a general utility table were not sacri- 
ficed. The foot of the table will drop so as to enable one to 
place the patient in a position suitable for operations on the 
perineum or in the Trendelenburg position for pelvic work. 



Annals of S 



NNALS OF OURGERY 



Vol. XLIX FEBRUARY, 1909 No. 2 



ORIGINAL MEMOIRS. 



INTESTINAL OBSTRUCTION DUE TO VOLVULUS 

OR ADHESIONS OF THE SIGMOID COLON, WITH 

A REPORT OF FIVE CASES, AND A STUDY 

OF THE ETIOLOGICAL FACTORS. 

ONE CASE OF RECURRENT VOLVULUS OF SIXTEEN YEARS' DURATION, THIRTY- 
TWO ATTACKS, CURED BY RESECTION; SECOND, AN OBSERVATION 
AT OPERATION, OF ACUTE VOLVULUS SEVEN HOURS 

AFTER THE ONSET OF SYMPTOMS. ' 

BY JOSEPH C. BLOODGOOD, M.D., 

OF BALTIMORE, MD., 
Associate Professor of Surgery in the Johns Hopkins University. 

The object of this paper is not only to report two cases 
of volvulus which agree with the usual clinical picture and 
pathology of this rather rare form of intestinal obstruction, 
but to call attention to a distinct clinical picture of a more 
chronic nature which is associated with adhesions in the left 
side of the abdomen to the sigmoid colon or its mesentery. 
These adhesions may lead to acute volvulus or to recurrent 
attacks of abdominal pain or to definite attacks of partial 
obstruction. From this experience I am of the opinion that 
there may be a larger number of such cases which are treated 
for chronic constipation or under the diagnosis of an ab- 
dominal neurosis. The patients whom I have observed and 
whose histories are here reported have been relieved by opera- 
tive intervention. 

6 j6i 



1 62 JOSEPH C BLOODGOOD. 

The first case (Case I; see Chart i and Figs, i to 8) has 
previously been reported before the Southern Surgical and 
Gynaecological Association (" Transactions," vol. xix, 1906, 
p. 503). This case is of great interest, because it is an ex- 
ample of recurrent attacks of intestinal obstruction due to 
volvulus of the sigmoid. We can be certain of the correct 
diagnosis, because at the first attack the abdomen was opened 
and the huge twisted sigmoid reduced. In the next sixteen 
years there were thirty-two attacks. After the last attack the 
abdomen was opened and the giant sigmoid resected. There 
were no adhesions, but the mesentery of the sigmoid colon was 
thickened and the foot points were approximated closer than 
normal (Figs, i and 2), This case is of additional interest 
as it allowed thirty-two observations on the clinical history and 
picture of this fortn of intestinal obstruction. Such an ob- 
servation is of educational value, as rarely in any large surgical 
clinic in an equal period of sixteen years has such a number 
been observed. During this period in Professor Halsted's 
clinic of the Johns Hopkins Hospital, among 103 cases of 
intestinal obstruction, there has been but one other case of 
volvulus of the sigmoid colon. This case (Case i) is of 
further interest, as it demonstrates that acute volvulus of the 
sigmoid colon can be relieved by properly administered rectal 
enemata in the knee-chest position. It also brings out the 
fact that relief of a distinct volvulus of the sigmoid by this 
method or even by laparotomy and untwisting is but a pallia- 
tive procedure, and that one should look for the cause of the 
volvulus, a band of adhesions, and, in some cases, should 
consider primary resection. 

The second case gave me the opportunity to observe the 
first attack of an acute volvulus, to explore it seven hours 
after the onset of the first symptom and to find at the operation 
the band of adhesions which may have been the only etio- 
logical factor (Fig. 9). Primary resection was not done, the 
adhesions only were divided. One cannot look upon this 
patient as permanently relieved, because it is less than two 
years since the operation. In the first case reported here 



Fig. 1. 




Cash I. — Photograph, at operation, of the giant sigmoid colon. No adhesions; the 
apex of the " U "-shaped bowel reached almost to the ensiform cartilage. This photo- 
graph illustrates the approximation of the foot points. 



OBSTRUCTION DUE TO VOLVULUS. 



163 



there was an interval of two years between the first and second 
attack. 

In the third case the abdomen was opened five days after 
the onset of the acute symptoms and forty-eight hours after 
they had subsided. Nothing definite was found and nothing 
was done. The history, however, suggested a volvulus of 
the sigmoid colon, and this patient has been free from further 
attacks two years and four months. 

In the fourth and fifth cases a diagnosis of chronic ob- 
struction of the sigmoid colon due to adhesions was made, and 
these adhesions were found and relieved at operation. 

Further observation may demonstrate that the number of 
such chronic cases which do not go on to a volvulus with its 
acute symptoms, are more numerous, and that patients with 
chronic constipation and recurrent attacks of abdominal pain 
simulating left-sided renal colic may be relieved of their more 
or less chronic invalidism by operative intervention, just as 
to-day we are relieving many patients whose abdominal symp- 
toms are due to chronic appendicitis with which there are no 
definite acute* attacks. 

Case I.— Pathol. No. 7468 (Chart i, Figs, i to 8) ; W. M.; 
recurrent volvulus of the sigmoid, thirty-two attacks in sixteen 
years, resection of giant sigmoid after the last attack, recovery, 
well two years and four months since operation. 

Clinical History. — This patient was first admitted to the sur- 
gical wards of the Johns Hopkins Hospital in January, 1890. 
The operation was performed in August, 1906, five days after the 
thirty-second and last attack. 

I am able from this case to study the clinical history and 
physical examination of thirty-two attacks of definite intestinal 
obstruction, experienced by one patient. The first attack began 
when the patient was forty-seven years of age. He was admitted 
to the ward on the seventh day of the attack, and subjected by 
Dr. Halsted to immediate operation, at which the volvulus was 
untwisted. After this there was an interval without an attack of 
two years, when the patient sought treatment on the fifth day of 
the second attack. The obstruction was relieved by enemata. 
Seven days later the abdomen was explored by Dr. Finney, who 



1 64 JOSEPH C BLOODGOOD. 

found a large colon and a large sigmoid still twisted, although 
the patient had no symptoms. The intervals between attacks in 
the next four years were twenty, twelve, and sixteen months, the 
patient seeking relief on the second, third, and seventh day re- 
spectively. Relief in each instance was easily accomplished with 
the rectal tube. From this time on — from 1898 to 1906, a period 
of nine years — the attacks were more frequent. The longest in- 
terval of freedom was nine months, the shortest twenty-four 
hours. In the years 1900, 1902, 1904, and 1905 there were four or 
five attacks in each year. It was for this reason that the patient 
desired relief by more radical means. It is of interest to note 
that in all, except the first attack, the patient was relieved at once 
by the passage of the rectal tube. The finding at the second 
operation, — that the sigmoid was still twisted after an apparent 
relief from the rectal tube, — may explain the subsequent attacks 
which occurred twenty-four hours to a few days after the patient 
left the hospital apparently relieved, and one attack that occurred 
in the hospital while the patient was in bed a few days after 
successful treatment with the rectal tube. 

When I opened the abdomen five days after the thirty-second 
attack the sigmoid was untwisted, and there was no obstruction, 
but I could demonstrate clearly what little force was required to 
twist or untwist the horse-shoe-shaped giant sigmoid on its 
thickened mesocolon. 

The First Attack. — The patient was then forty-seven years 
of age. Fifteen years before he had suffered from an attack of 
typhoid fever without complications. For a number of years he 
experienced attacks of indigestion at intervals of from four to six 
weeks. During these attacks his abdomen was distended with 
gas and he felt nauseated. Further details of these attacks are 
not given. Three months ago he fell and struck the abdomen, 
while he was doing some heavy lifting. The present attack is of 
one week's duration. He had been constipated, when suddenly 
he experienced general abdominal colic and a constant desire for 
stool. From the onset there had been no passage of fecal matter 
or gas. The patient observed a little mucus, but no blood. The 
abdomen gradually distended. In spite of these symptoms the 
patient continued to take food and to work. Vomiting began 
after three days, and has been present off and on ever since. This 
vomiting is associated chiefly with food or the cathartics which 



OBSTRUCTION DUE TO VOLVULUS. 165 

he has taken. The initial acute pain of obstruction of the small 
intestine and the primary shock and vomiting were absent, but we 
have the symptoms of obstruction in the large intestine, — con- 
stipation, abdominal colic, secondary vomiting, distention. On 
admission the patient's condition was good, — the abdomen was 
uniformly and greatly distended. The operation was performed 
at once by Dr. Halsted. It is noted that the sigmoid colon was 
tremendously distended and protruded through the wound. The 
volvulus was complete; after untwisting, it is noted, the meso- 
colon was long. Now a rectal tube was introduced which evacu- 
ated large quantities of gas and fluid faeces. The wound was 
closed and the patient recovered without complications. 

The Second Attack. — According to the history there was no 
suggestion of an attack for two years. The symptoms were iden- 
tical with those of the first attack, except that vomiting began 
after forty-eight hours — two days earlier ; and it is also noted that 
he had referred pain to the left lumbar region (similar to my 
more recent observations). He walked to the hospital. The 
examination showed uniform extension and tympany. With a 
rectal tube, high enemata and massage, gas and fecal matter 
were evacuated, and the physical signs subsided. Dr. Finney 
opened the abdomen seven days later: small intestines adherent 
to scar of previous median-line incision and a loop of small intes- 
tine which was caught, but not obstructed by a band, was first 
encountered; this band was divided; transverse and ascending 
colon were larger than normal, and there was a double twist in 
the sigmoid ; this was untwisted, rectal tube passed, which brought 
away gas and fluid fecal matter. 

I wish to emphasize the finding at this, the second, operation. 
The patient was apparently relieved, yet the sigmoid was still 
partly twisted. 

Recurrent Attacks. — I have carefully read the clinical notes 
on the subsequent thirty admissions and made charts of the symp- 
tom of onset, the subsequent symptoms and the findings at exam- 
ination (Chart i). With very little variation each attack is a 
counterpart of all the others. Colic is the first warning. Now 
and then this has been preceded one or two days by constipation. 
On this special fact the history is often silent, but records 
seem sufficiently clear to demonstrate that during all these years 
if the patient went forty-eight hours without stool an attack 



l66 JOSEPH C. BLOODGOOD. 

was sure to follow. In the majority of the attacks one day's 
constipation was followed the next day by colic and the begin- 
ning of an attack. In a few attacks the colic was observed 
within twelve hours after an apparent normal evacuation. Once 
the colic appeared the symptoms of obstruction continued until 
the patient sought relief in the surgical wards by the rectal tube. 
On a few occasions, a new attack followed relief from an old 
attack at the hospital with the rectal tube within twenty-four 
hours. 

During the first seven years there were only five attacks, 
with intervals of from one to two years. In the next seven years 
there were twenty attacks with the longest interval of nine months. 
Among these twenty attacks nine were after very short intervals — 
twenty-four hours to ten days. In the following two years, 
although there were but six attacks, four of them were after 
brief intervals of freedom. The attacks, then, were becoming 
more frequent. As I look upon a short-interval attack as an 
evidence of incomplete reduction of the volvulus through the 
employment of the rectal tube and enemata, there is evidence, 
therefore, of an increasing number of incomplete reductions of 
the twist. 

The duration of the attack from the time of the first symp- 
tom to relief varied from twelve hours to seven days. As a rule 
the patient was sufficiently uncomfortable to seek advice at the 
end of the third day. During the last three years he came to the 
surgical wards usually after twenty-four hours, and never waited 
longer than two days. The patient did this not because he was 
more uncomfortable, but apparently influenced by our advice and 
the confidence of getting immediate relief. 

The patient never succeeded in relieving himself, although 
he frequently attempted this with rectal enemata. 

The attack, preceded by an interval of constipation, began 
with general abdominal colic, now and then with pain referred to 
the lumbar region and back ; then with distention of the abdomen, 
and if he delayed, vomiting. The latter was never a prominent 
symptom, except in those attacks in which the patient waited three 
to seven days. At the examination, except on the first two occa- 
sions, when the attack had been present five and seven days respec- 
tively, the distention was asymmetrical and confined chiefly to the 
left side of the abdomen, and peristalsis of the transverse and 



OBSTRUCTION DUE TO VOLVULUS. 167 

descending colon could be made out (Chart i). On not a single 
occasion was there any evidence of peristalsis of the small intes- 
tines. The percussion note was usually tympanitic. When the 
rectal tube was passed gas was evacuated first, then fluid faeces. 
The evidence seems to point to the fact that gas was the chief 
factor in producing the volvulus. 

In a few attacks there was slight variation in the symptoms. 
For example, in one, of forty-eight hours' duration, and in an- 
other, of three days' duration, vomiting and colic began together. 
In the other attacks there was a distinct interval between the 
onset of the colic and vomiting. With few exceptions vomiting 
was not present unless the attack was of forty-eight hours' dura- 
tion or longer. In a few, vomiting was absent even when the 
colic, constipation and distention had been present from two to 
three days. 

The first vomiting, with few exceptions, began after the 
patient had taken cathartics himself. When he took no food or 
cathartics vomiting was practically absent. It was never fecal. 

Constipation was absolute in every attack, and in only one 
it is noted that the patient passed some flatus. Distention with 
the rarest exceptions began within a few hours after the colic. In 
one or two attacks there were intervals of one to two days before 
the patient observed the distention. This is noted only in the 
early attacks before the patient had developed an acuteness of 
self-observation. There are two leucocyte counts : one of 18,000 
in an attack of three days, and one of 9,000 in an attack of five 
days. There was never fever, nor retention of urine. The 
patient's general condition was always good. 

The Symptoms of Volvulus. — From this study we may de- 
scribe the clinical picture of volvulus as follows : 

The patient will give a history of constipation, — the attack 
begins with colic, as a rule in the umbilical area and the left abdo- 
men, radiating from epigastrium to iliac fossa, with pain some- 
times referred to the left lumbar fossa and the back. Pain is 
never severe like the initial pain in obstruction of the small intes- 
tine, or strangulation. The intervals between the pains grow 
shorter and with this their intensity increases. The character of 
the pain suggest its relation to peristalsis of the colon, and this 
is confirmed at the examination, because when one sees the wave 
of peristalsis the patient complains of pain. 



l68 JOSEPH C. BLOODGOOD. 

The initial shock of small-intestinal obstruction or strangula- 
tion is absent. Initial vomiting is very rare. Following the 
colic the patient observes distention, chiefly on the left side, and 
most marked in the lower left quadrant; constipation continues; 
it is absolute ; rarely is flatus passed ; vomiting is a late symptom, 
and usually induced by cathartics or food ; belching and hiccough 
now and then are observed, the latter is infrequent; leucocytosis 
may be found. At the examination, the distention is asymmetrical 
and broad peristaltic waves are present in the epigastrium and the 
left side of the abdomen. The percussion note is tympanitic. 
The patient's general condition is good, even in attacks of from 
three to seven days' duration. 

The Mechanism of Volvulus. — In this case there is evidence 
to indicate that dilatation of the sigmoid colon was present be- 
fore the first attack. The cause of this cannot be ascertained. 
We have therefore to explain the mechanism of the recurrent 
attacks. There is every reason to believe that the sigmoid re- 
mained dilated (as shown in Fig. 2 and found at the operation). 
This dilated colon acted as a reservoir for faeces. I am im- 
pressed with the view that fermentation with the formation of 
gas in the dilated sigmoid colon is the first etiological factor, and 
careful observation would demonstrate that distention was the 
first symptom. This loop distended with gas is lifted up into the 
abdomen, just as the pregnant uterus is forced out of the pelvis 
by the growth of the foetus. As the sigmoid rises a kink is pro- 
duced at its junction with the descending colon, because this por- 
tion of the colon is fixed. I demonstrated this at operation. 
This of itself would be sufficient to produce obstruction and excite 
peristaltic action of the colon, giving rise to the first symptom 
observed by the patient, — colic. At this time there is no evidence 
of a kink in the rectum, but the sigmoid does not evacuate its 
contents because its walls are overdistended. The exact mechan- 
ism of the twist is difficult to establish, but as the dilated sigmoid 
rises and its upper arm becomes more and more tense on account 
of its attachment to the fixed descending colon, the lower portion 
of the sigmoid and the upper rectum, which are less fixed, rise, 
and as the least resistance is up and to the left, the distended 
lower portion of the sigmoid and the rectum move in that direc- 
tion, and the upper portion of the sigmoid is twisted downwards 
and to the right, while the lower portion moves upwards and to 



Fig. 2. 




rf ?■— This drawing IS made from the photograph (Fig. i) and the Kaiserling speci- 
men. It Illustrates the inflammatory changes in the mesentery, the approximation of the 
toot points of the sigmoid, and the thickening of the peritoneal coat of the sigmoid colon 
and rectum. In the lower half of the sigmoid, which is most distended, the longitudinal 
bands become indistinct. 



Fig. 3- 




,,oA hy SchcL^ 



Case 1— Photograph, at operation, with the clamps on the divided mesenteric vessels 
and sigmoid. This was performed before the gut was divided. 



Fig. 4. 




^i i ft ^ ^^ Sm Ill fill/ -^ ... ~« 



* /^itiiifliiiiiHtiii wHJBy. 



Case I.— Photograph, at operation, after the removal of the siant sigmoid colon. 
The closed ends of the rectum and colon are shown projecting from the wound with- 
out tension, in a convenient position for lateral anastomosis. 



Fig. s. 




Case I.— -This sketch demonstrates the relation of the inverted stumps of the rectum 
and descending colon to the mesentery after the removal of the giant sigmoid. In view of 
the close approximation of the foot points of the sigmoid there was very little folding of the 
mesentery, and in the mesentery left behind very little evidence of inflammatory changes. 

Fig. 6. 




iath.^! 



/Ji8 



Case I. — Sketch of the method of lateral anastomosis between the smaller descending 
colon and larger rectum. 



Fig. 7- 




Case I. — Sketch of the method of including the closed inverted ends 
of the descending colon and rectum (Fig. 6 B) in the suture of the 
parietal peritoneum of the wound. 



OBSTRUCTION DUE TO VOLVULUS. 169 

the left, and the twist is from right to left. This mechanism is 
also aided by the attachment of the mesentery to the left. The 
twist kinks the rectum, and we have a double obstruction. 

From the notes of the first two operations it can be established 
with considerable probability that this was the position of the 
twisted giant sigmoid colon, and at the third operation I was able 
to twist the sigmoid only in this direction. 

The Mechanism of Relief. — The rectal tube has to be forced 
past the kink in the rectum into the dilated sigmoid. If this is 
accomplished the gas immediately escapes followed by fluid 
faeces. On a number of occasions this could be accomplished 
only with the aid of water distending the rectum in front of the 
tube. It was found that when the patient was placed in the knee- 
chest position the rectal tube could be inserted with less difficulty. 
On a few occasions there was no difficulty whatever in passing 
the rectal tube, in any position of the patient, while on others it 
required repeated efforts in the knee-chest position. It seems 
easy to explain this by a variability in the extent of the twist. 
When there was little or no difficulty in inserting the rectal 
tube, the probabilities are that the twist was slight or not present 
at all, and in the most difficult cases the volvulus was complete. 

Findings at the Third Operation. — As the attacks were be- 
coming more frequent the patient quickly consented to an opera- 
tion which promised permanent relief without too large an ele- 
ment of risk. 

On August 2, 1906, under ether narcosis I opened the ab- 
dominal cavity through the left rectus muscle. The sigmoid and 
ascending colon occupied the entire lower left quadrant of the 
abdomen. There were some adhesions of the small intestines to 
the abdominal wall in the region of the first laparotomy wound. 
As these were to the medial side of the present incision they were 
not disturbed. The patient was placed in the Trendelenburg 
position. Now, without any difficulty, the giant sigmoid colon 
was lifted out of the wound and placed upon the sterile towels 
covering the upper abdomen, as shown in Figs, i and 2. The 
distention of the colon began 10 cm. from the splenic flexure, 
at the beginning of the sigmoid colon, involved the entire sigmoid 
and as much of the rectum as could be followed into the pelvis. 
The rectum below the promontory of the sacrum was covered 
with a thickened fold of peritoneum extending from the bladder. 



I^o JOSEPH C BLOODGOOD. 

All of the peritoneum over the pelvic floor felt thicker and had a 
more opaque whitish color than the normal peritoneum elsewhere. 
The mesocolon of the sigmoid was not unusually long and, in fact, 
rather short as compared with the size of the colon. The appear- 
ance of the peritoneum covering this mesocolon was entirely dif- 
ferent from the normal peritoneum. It was a thick, opaque, 
white membrane, and one could not make out the vessels between 
the folds. The peritoneal covering of the rectum and lower half 
of the sigmoid colon presented the same thickened, opaque, white 
appearance. On the sigmoid colon the peritoneum of its upper 
third was normal in appearance, although the bowel was dis- 
tended. The distention of the gut increased in diameter from 
the junction of the descending and sigmoid colon and reached 
its maximum in the upper portion of the rectum just below the 
promontory of the sacrum. Below this the distention was less, 
but the bowel was larger in diameter than the descending colon 
(Fig. 2). The thickened condition of the peritoneum, both on 
mesentery and bowel, increased with the distention of the bowel. 
There were, however, no adhesions. 

It was decided to resect, close the two ends by inversion and 
suture, and then perform lateral anastomosis. The point of resec- 
tion was chosen in both instances through the bowel at the level 
of the abdominal wound as the giant sigmoid lay on the upper 
abdomen, having been placed there with gentle traction only 
(Figs. 2 and 3). First the peritoneum of the mesosigmoid colon 
was divided (Fig. 3) at the base between the foot points of the 
" U," turned back like a cuff, and each vessel separately ligated. 
Now, when the mesentery was divided there was no hemorrhage, 
and it could be protected with gauze, while the gut was divided. 
The division was made between the usual clamps with strong, 
straight scissors and disinfected with pure carbolic acid. The 
Paquelin cautery would have been simpler and more efficacious, 
but unfortunately it was not available at that time. The divided 
ends of the intestine were inverted with catgut in the usual way. 
The peritoneum was then again approximated with interrupted 
fine black silk. The ligated stumps of the mesenteric vessels were 
covered with a peritoneal suture. The two blind ends of the 
intestine lay side by side in the lower portion of the abdominal 
wound (Figs. 4 and 5). A lateral anastomosis was made (Fig. 
6, a and b) beginning 1.5 cm. from the inverted end ; their mesen- 



Fig. 8. 




Case I. — Photograph of patient, 
December, 1908, two years and four 
months after operation. 



Fig. 9. 




Case II. — Sketch illustrating the findings at operation. 
B, band of adhesions between the upper third of the sig- 
moid and the parietal peritoneum of the iliac fossa. 



OBSTRUCTION DUE TO VOLVULUS. 



171 



teric surfaces came together to the medial side; a large opening 
was made. In closing the wound the inverted ends of this anas- 
tomosis were placed outside of, and included by, the peritoneal 
suture (Fig. 7). This anchoring was done for two purposes: 
first, because there is always danger of sloughing when intestines 
are inverted in this way, especially when the bowel has been dis- 
tended and its walls thickened, while when sutured in this manner 
any leak would take place extraperitoneally ; second I was of the 
opinion that the anastomosis would work better if the bowel was 
fixed to the abdominal wall. The wound was closed with a small 
piece of packing extending to the ends of the intestine. 

Following the operation, there were no complications and 
the wound healed without any evidence of leakage from the 
closed ends of the intestine. 

At this time, December, 1908 (two years and four months 
since the operation), the patient has had no further attacks of 
intestinal obstruction. He also informs me that his general health 
is better. There is no evidence of weakness in the scar, and the 
stools are normal in every respect (Fig. 8). 

My second observation is of interest, because it allowed 
me to see a volvulus in its acute stage and, perhaps, the etio- 
logical factor. 

Case II. — Pathol. No. 7999 ; Mr. F. R. S. — Diagnosis: acute 
intestinal obstruction tivo weeks after appendectomy. Opera- 
tion seven hours after the onset of the symptoms. Laparotomy: 
reduction of volvulus of sigmoid, division of a hand (Fig. 9) 
between the sigmoid colon and the peritoneum of the left iliac 
fossa. Recovery. 

Clinical History. — White male, aged 33. On February 19, 
1907, at the St. Agnes Hospital, I removed the appendix through 
a McBurney-Weir incision and closed the wound without 
drainage. 

Pathologic Findings at This Operation. — On opening the 
peritoneal cavity an unusually large caecum and ascending colon 
were exposed ; the mesentery of the caecum was longer than nor- 
mal and, covering the peritoneal surface of both extending to the 
mesentery, and in places to the parietal peritoneum at the base of 
the mesentery, there were numerous vascular bands of adhesions. 



172 JOSEPH C. BLOODGOOD. 

The appendix, 8 cm. long and free, was situated to the lower 
and median side of the caecum. The appendix was covered with 
a fine net-work of new blood-vessels which extended to the 
caecum. There was one band of adhesions producing an S-like 
constriction in the middle third of the appendix. These findings 
I have observed before in cases of enteroptosis of the colon. 
The adhesion producing a constriction of the appendix without 
doubt interfered with the emptying of this organ. The removed 
appendix showed an unusually large lumen and a wall thicker 
than normal. The right kidney was of normal size and in place. 
Clinical History. — The patient was referred to me with 
symptoms of renal colic. The first attack had taken place one 
year before. The attacks consisted of pain in the lumbar region 
and the right groin. These attacks were observed only when the 
patient was standing. The pain was of a dull character and was 
not associated with nausea or vomiting. The attacks have never 
been severe enough to confine the patient to bed. After the 
attacks the urine was cloudy, but there was no blood. The 
X-ray examination was negative as to renal calculi in kidney and 
ureter. On examination the kidneys could not be palpated, but 
on two occasions I felt in the right iliac fossa a movable finger- 
like mass. The urine contained a trace of albumin, oxalate 
crystals, and a few red blood-cells. 

Postoperative Notes. — The acute attack began two weeks 
after the appendectomy and after the patient had been out of bed 
about three days. He had been constipated twenty-four hours, 
but went to bed feeling first rate. At about three o'clock in the 
morning the patient was awakened out of a sound sleep with 
pain referred to the left loin posteriorly. The description of the 
pain answered somewhat to that of a renal colic. The pain in the 
first few hours was so intense that there were slight symptoms of 
shock (the so-called peritoneal shock, — an early sign of strangu- 
lation. There was the initial vomiting of acute obstruction. 
When the resident. Dr. Shaw, examined him one hour after the 
onset of the pain, the patient was rolling in bed from side to side, 
flexing the thighs on the abdomen. The face was pale, the pulse, 
recorded at 8 p.m., at that time about 8o, was now 120, the tem- 
perature (by mouth) subnormal. Morphia, gr. %, was given at 
once and repeated in three-quarters of an hour. This simply 
relieved the acuteness of the pain. Two enemata were ineffec- 



OBSTRUCTION DUE TO VOLVULUS. 



173 



tual. When the stomach was washed out nothing was removed 
but a httle bile-stained fluid. 

I saw the patient six hours after the first symptom. The 
pain now was of a dull character. The symptoms of peritoneal 
shock had disappeared. The pulse was 90, the temperature 99. 
The total leucocytosis was 36,000, on a second count 40,000. The 
urine contained red blood-cells, a trace of albumin and some 
casts. This finding, which had been present before the first opera- 
tion, had disappeared a few days later. When the foot of the 
bed was lowered for my examination (the patient had been placed 
in this position on account of shock) he complained of nausea 
and vomited; the pulse increased to 130. There was no recur- 
rence of the vomiting and the pulse dropped to 90. The area of 
pain was in the left loin to the outer side of a vertical line through 
the anterior iliac spine. This area, in my experience, was situ- 
ated lower and more to the median side than the pain in renal 
colic. On palpation, the patient stated that there was no tender- 
ness, but the left rectus and the left abdominal muscles were 
rigid, preventing deep palpation. I could make out no mass. 
On percussion, there was very slight obliteration of the liver dul- 
ness, although the abdomen was not distended, and in the left 
lumbar region there was a distinct zone of flatness not present 
on the right side. On further palpation, as the muscles relaxed, 
I was of the opinion that I could feel a tense, smooth tumor in 
the iliac fossa (Von Wahl's sign). The symptoms, — shock, 
initial vomiting. Von Wahl's sign, the inability to get faeces or 
gas with enemata — were, in my opinion, evidence against renal 
colic and in favor of obstruction. In addition, we had a previous 
X-ray as further evidence against stone. The attack of pain on 
this left side differed from those on the right in intensity. It 
seemed to me quite possible that the adhesions observed on the 
right side might also be present on the left side in the mesentery 
of the sigmoid colon. 

For these reasons I considered the diagnosis of volvulus as 
most probable and advised immediate operation rather than delay 
for attempts with further enemata. On opening the peritoneum 
through the left rectus muscle there was no fluid, and normal, 
non-distended small intestines were exposed. Pushing these in- 
testines upwards and to the median side I could see a very 
greatly distended sigmoid colon. It was not twisted. The veins 



174 JOSEPH C. BLOODGOOD. 

in the mesentery of this colon were tremendously engorged — an 
appearance in distinct contrast to the vessels in the mesentery 
of the small intestine, descending and transverse colon. This 
engorgement of the veins impressed me as the result of a twist 
in the sigmoid which had relieved itself, or which I had relieved 
in the manipulation necessary to expose it. The splenic and 
descending colon were distended. As I pulled the sigmoid colon 
out of the abdominal wound I observed an acute flexion in the 
upper third. From the mesentery at the apex of this flexion a 
definite band of adhesions passed down along the mesosigmoid 
to the peritoneum of the left iliac fossa (see Fig. 9). The foot 
points of the " U " of the sigmoid were close together. The 
entire sigmoid was distended, and this distention extended into 
the rectum as far as it could be inspected. Now a rectal tube 
was passed, and a large quantity of gas and fecal matter with- 
drawn. I was able to increase this quantity by compression of 
the colon and rectum, and then hard fecal masses which were 
not evacuated by the tube could be felt. 

As a rectal tube had been passed a few hours before operation 
with a negative result, it seems justifiable to conclude that the 
obstruction was relieved during the operation, because the rectum 
below the sigmoid was distended with gas and liquid fecal matter. 

A complete resection of the sigmoid colon with lateral anas- 
tomosis of its foot points would not have been a difficult opera- 
tion, but I decided to confine my intervention to division of the 
band only. After this band was divided the raw surface was 
covered with peritoneal suture. 

Twelve hours after operation there was a large liquid stool 
containing solid fecal masses. 

The convalescence from this operation was uneventful. One 
month after operation the patient had a slight attack of pain in 
the right hypochondrium. Three months later a second attack 
with nausea and vomiting. This attack was associated with 
constipation. At the present writing, December, 1908, one year 
and eight months since the second operation, there have been no 
further attacks. 

Case III. — Pathol. No. 7942. Clinical Diagnosis: Question 
between volvulus and carcinoma of the sigmoid. Patient ob- 
served five days after the onset of the acute attack of intestinal 
obstruction. Exploratory laparotomy ; negative findings. 



OBSTRUCTION DUE TO VOLVULUS. 



175 



Clinical History. — E. R. L., white, male, aged 40, was ad- 
mitted to the Johns Hopkins Hospital on August 22, 1906, and 
the following history was obtained from Dr. Carr, his physician, 
and the patient. In the previous history there is nothing sugges- 
tive except that four and two years ago there were distinct 
attacks of dysentery in which the stools contained blood and 
mucus. In the interval between these attacks there were no symp- 
toms, but the last year the patient has observed an increasing con- 
stipation with intermittent ribbon stools, but no loss of weight 
and no evidence of weakness or anaemia. 

The acute attack began five days before his admission to the 
hospital. The symptom of onset was pain beginning in the left 
lumbar area and extending from here into the left iliac fossa, the 
groin, and the left testicle. The pain began about ten in the 
evening, some hours after the last meal. Previous to the onset 
of the pain there had been no unusual constipation that the patient 
could remember. The pain began acutely, the patient feeling 
in perfect health before. The first attack of pain lasted four 
hours, and there was vomiting. Between Thursday and Sunday 
evening — a period of three days — there were four such attacks of 
pain. Except in the first attack the pain was not referred to the 
testicle. With each attack there was vomiting. As far as I 
could make out there was no marked shock. During this time 
he was given castor oil and numerous enemata without effect. 
When seen Sunday evening by Dr. Carr there was an indistinct 
tender mass in the left iliac fossa. After this examination there 
was a large stool following the administration of a high enema. 
Since this time there have been no further symptoms, and the 
mass and tenderness have practically disappeared. He entered 
the hospital Tuesday morning, about 36 hours after the end of 
the symptoms. The patient was not in discomfort, there was no 
abdominal distention, but on deep palpation in the iliac fossa one 
gets the impression of feeling a distended piece of bowel. The 
urine was negative, the leucocyte count 7,000. When I first saw 
the patient, although he was feeling comfortable, the bowels had 
moved and he did not feel nauseated, there was a distinct fecal 
odor to the breath, and one suggesting acetone, and during my 
examination the patient expectorated a thin brownish fluid which 
had a distinct fecal odor. For this reason I am inclined to the 
opinion that there had been fecal vomiting. This odor disap- 
peared within 24 hours. 



176 JOSEPH C BLOODGOOD. 

At this date, in 1906, over two years ago I was quite familiar 
with the clinical picture of volvulus from a study of the case 
reported first in this paper, because this patient (Case III) entered 
the hospital about three weeks after I had operated upon the 
patient in Case I. From this clinical history, however, one could 
not exclude a malignant tumor of the large bowel. 

In a study of a number of such cases I have been struck with 
the observation that in the previous history, acute attacks of intes- 
tinal obstruction, lasting from one to five days with recovery after 
enemata have been present in at least one-fourth of the cases. 
It is so unusual for a patient with acute intestinal obstruction to 
recover without operation, that such a history can he looked upon 
as evidence of a malignant tumor, but this more recent study of 
the rarer lesion — volvulus of the sigmoid colon — demonstrates 
that the same may occur here. 

At the operation in this third case on August 28, 1906, six 
days after the patient had been in the hospital without symptoms, 
I could find nothing abnormal. I could positively exclude a new 
growth. Whether there had been a volvulus I am not prepared 
to say. I carefully examined the mesentery of the sigmoid colon 
and could not find the adhesions observed in Case II and in Cases 
IV and V to be considered next. Whether at that time I over- 
looked some anatomical changes which I might recognize to-day 
from a larger experience, I am not prepared to say, but the gross 
lesions found in the other cases were not present. I am inclined, 
however, to the opinion that this patient had sufifered from a 
volvulus of the sigmoid colon, and perhaps during the two attacks 
of dysentery inflammatory changes in the mesocolon had led to 
certain changes which were the etiological factor of the volvulus. 
This was distinctly so in the fourth case about to be reported. 

At the present writing, December, 1908, two years and three 
months since the operation, this patient writes me that he is in 
perfect health and has had no further attacks. 

Case IV. — Pathol. No, 9149. Clinical Diagnosis: Chronic 
obstruction of the sigmoid colon. Operation: Freeing of adhes- 
ions between the parietal peritoneum of the iliac muscle and the 
mesocolon (Fig. 10). Recovery. 

This patient, a white male, aged 30, was brought to me by 
Dr. Gregg, of Florence, S.C., with a clinical history very sugges- 
tive of a stone in the left kidney. However, in going over the 



Fig. 




Case IV. — Sketch of the findings at operation showing the dense adhesions between the 
junction of the sigmoid and descending colon and the parietal peritoneum of the iliac fossa. 
The appendix is retracted into a " U "-shaped organ by a shortened mesentery. 




ss 



^ (U 



OBSTRUCTION DUE TO VOLVULUS. 



177 



facts in the history I came to the conclusion that I was dealing 
with a chronic obstruction in the sigmoid colon. It was my ex- 
perience with the cases just reported that led me to this belief. 
The X-ray showed no stone in kidney or ureter. 

We have in this case a history of dysentery ten years ago, 
lasting some months. The first attack of abdominal pain began 
four years after the dysentery. In these six years there was an 
interval of five years between the first and second attack of pain, 
and in the last four months there have been five attacks. The 
pain is referred to the same area described in Cases I and II. 
It is always preceded by constipation and associated with nausea 
and vomiting. The intense pain lasts from two to six hours. 
The relief is immediate when the enema is successful ; sometimes 
more than one enema is required. In none of these attacks has 
the pain been referred to the testicle. Three months ago he had 
a slight attack of pain in the right iliac fossa. 

The operation was performed at St Agnes Hospital in Au- 
gust, 1908. The sigmoid was explored through an incision at the 
outer border of the left rectus muscle with the patient in the 
Trendelenburg position. The findings were practically identical 
with those in Case II. The band of adhesions on the whole was 
broader and shorter (see Fig. 10). Influenced by the involve- 
ment of the appendix in Case II, I explored the appendix in this 
case through a McBurney incision, and removed it. The appen- 
dix was free and apparently normal, but hitched up by a short- 
ened mesentery (Fig. 10). 

It is four months since the operation, and the patient has had 
no recurrence, although in the three months preceding the opera- 
tion there had been three attacks. 

Case V. — Pathol. No. 9319. (Recent case). Clinical Diag- 
nosis: Chronic obstruction of the sigmoid colon of many years' 
duration. Operation: Freeing of adhesions (Fig. 11). Recovery. 

Clinical History. — White female, aged 38, married, no 
children. It was very difficult to get a clear clinical history. 
When I first saw the patient two years before the operation she 
had every symptom of a grave melancholia. However, from the 
history at that time, I was of the opinion that there was some 
mechanical obstruction in the sigmoid colon, and operation was 
advised. I did not see the patient again until October, 1908. 
During these two years, in spite of absolute rest and the most 
careful dietetic treatment, the symptoms had increased. 



178 JOSEPH C. BLOODGOOD. 

The patient had become a chronic invalid. She was in such 
a nervous state that she would not allow an examination of the 
abdomen. The slightest touch of the abdomen, the patient 
claimed, made her so nervous that she could not control herself, 
and it produced nausea. 

Evidently some fifteen years ago, shortly after marriage, 
there had been a pelvic peritonitis, perhaps of gonorrhoeal origin. 
Gradually after this illness she observed increasing constipation, 
and during the last six years, in order to move the bowels, it has 
been necessary to take larger doses of cathartics. The patient 
has administered to herself a proprietary " liver pill," and the 
doses gradually increased from two to sixteen and twenty a day. 
Formed stools have not been observed for five years, and during 
the last two years it was necessary that they should be liquid 
before an evacuation could be had. The patient states that during 
all this time she experienced pain in the left lower abdominal 
quadrant. The pain is worse when twenty-four hours intervene 
without a stool. If she allows the constipation to go longer she 
observes distention in the left side of the abdomen, increase of 
the pain, and now and then vomiting. For three years she has 
been unable to continue her profession as a dentist and has sought 
relief in rest and diet. Except for this definite history of con- 
stipation and localized pain and the absence of normal formed 
stools, the patient exhibits the exaggerated picture of a neurosis. 

I felt, however, from my experience in the other cases that 
there was a mechanical non-malignant obstruction. Its long 
duration excluded a malignant tumor; the old pelvic peritonitis 
suggested the etiological factor. 

The operation was performed at the St. Agnes Hospital 
November 7, 1908. The sigmoid was plastered by dense fibrous 
adhesions to the parietal peritoneum over the iliac muscle at the 
brim of the pelvis to the broad ligament, tube and ovary on the left 
side. The sigmoid could not be lifted from this bed. It was less 
movable than the lower half of the duodenum, and in this position 
there were two or three kinks (Fig. 11). The adhesions could 
be divided with the knife in such a way that the visceral peri- 
toneum of the sigmoid was not injured. After accomplishing this 
I could lift the sigmoid and demonstrate that its mesentery, 
although somewhat involved in the adhesions, was still intact. 
That is, the mesentery had not yet been converted into scar tissue. 



OBSTRUCTION DUE TO VOLVULUS. 179 

Both tubes and the left ovary were removed. There were adhes- 
ions between the uterus and the rectum which could be divided 
with the knife and scissors. The division of all these adhesions 
caused practically no bleeding. The raw surfaces could be 
covered with peritoneal suture. 

This patient, after operation, suffered for five days with 
distention of the abdomen. That is, the postoperative paresis 
of the intestines was much more marked than usual. After this 
had subsided and the patient began to take ordinary diet, normal 
formed stools were observed for the first time in years, and I 
was able to gradually reduce the cathartic pills to two a day. 

This patient is still in the hospital, one month after operation, 
because of a phlebitis of the right leg on the fifteenth day and a 
left-sided pleurisy on the twenty-third day. These complications, 
we know, are more frequent after pelvic operations. 

Remarks. — Volvulus of the sigmoid colon is one of the 
rarer forms of intestinal obstruction. Among 103 cases of 
intestinal obstruction observed in Dr. Halsted's clinic of the 
Johns Hopkins Hospital there have been but two examples 
observed. The first case is reported here ; the second observa- 
tion is an example of a recovery, although the operation of 
imtwisting was not performed until the sixth day after the 
onset, and it is interesting to note that in this case there was 
a recurrent attack within a year after the patient left the 
hospital which terminated fatally without operative inter- 
vention. 

Literature. — I have examined the literature since 1902, 
and it seems to be the opinion of the majority that the vol- 
vulus recurs if at the operation for relief the surgeon contents 
himself with only untwisting. No one, however, has advo- 
cated resection as a primary operation in all cases. If gan- 
grene is present resection, of course, is indicated. 

Kiwull, a Russian surgeon, in 1902 (Mittheilungen a. d. 
Grenzgehieten d. Med. u. Chir., 1902, vol. x, p. 105) gives a 
very good discussion of the diagnosis. He recognizes two 
types, — first, the acute volvulus in which the clinical history 
and symptoms are practically identical with my Case H, the 



l8o JOSEPH C. BLOODGOOD. 

initial vomiting and shock of which, so common in the so- 
called group of strangulated ileus, are here present; second, 
the subacute type, in which these symptoms are absent and 
the vomiting does not come on until later. In all cases there 
is usually a previous history of constipation, in some the acute 
attack follows a large meal, in others a trauma. In all of the 
cases absolute constipation of faeces and gas is observed, and 
if the examination is made early there is an asymmetrical dis- 
tention on the left side of the abdomen. In a few cases the 
palpation of the distended loop (Von Wahl's sign) has been 
made out. This sign is more readily obtained if the abdominal 
muscles are relaxed by placing the patient in a warm bath. 
Peristalsis, if present, is observed chiefly in the transverse and 
descending colon: rarely in the distended sigmoid loop 
(Chart i). Pain referred to the lumbar region, — a constant 
symptom in my cases, — is not mentioned prominently in the 
literature. 

Kiwull reports eight cases observed in his clinic. This 
number is not only unusually large, but the results of opyeration 
were unusually good. There was but one death from pneu- 
monia in a patient aged seventy-one. All of the patients were 
over forty years of age, and but one was a female. In the 
majority of his cases the operation was performed within 
forty-eight hours. It consisted in untwisting of the volvulus. 
In this report there are no observations of the condition of 
the mesentery. Gangrene was not observed, but in one case 
the circulation of the sigmoid looked impaired and for this 
reason the replaced intestine was isolated with iodoformized 
gauze. In the healing there was evidence of a fecal fistula 
which closed spontaneously. Kiwull expresses the opinion 
that the distended sigmoid is better evacuated of gas and faeces 
by the introduction of a rectal tube at the operation, rather than 
by colostomy. This view stands good to-day. Kiwull states 
that the seven patients which recovered from the operation 
have been examined repeatedly since and there have been no 
recurrent attacks. Nevertheless when we read the detailed 
histories in not a single instance do we find a note of a later 



OBSTRUCTION DUE TO VOLVULUS. 



i8i 



examination. For this reason I feel that Kiwull's statement 
as to results cannot be accepted. 

Kuhn contributes a monograph (Beitr. z. klin. Chir., 
1902, vol. xxxvi, p. 411), from Carre's clinic, in which he re- 
ports 9 cases from his clinic and 95 from the literature. 
Among these 104 cases, in 20, resection was perfomied with 
about 50 per cent, of recoveries. 

I have examined these cases of resection critically, and I 
am of the opinion that resection in acute volvulus is only indi- 
cated when gangrene is present. It is a simple procedure to 
untwist the volvulus and to evacuate the distended bowel by 
the passage of a rectal tube. In gangrene the loop must be 
brought out of the abdominal cavity. Now the question arises, 
what further should be done? I am of the opinion that a 
lateral anastomosis should be made between the descending 
colon and the rectum, the gangrenous sigmoid rapidly resected, 
and the two open ends of the gut sutured in the parietal peri- 
toneum for secondary closure. Kuhn reports one successful 
resection for gangrene, by Garre. 

Kuhn, from his study, is of the opinion that relief by the 
rectal tube and enemata will usually fail and that immediate 
operation is indicated, and that in the majority of cases, if 
resection is not indicated in the primary operation because of 
gangrene, it should be done at a secondary operation. 

Philipowicz (Arch. f. klin. Chir., 1906, vol. Ixx, pp. 678 
and 897) has had an unusual experience with volvulus of the 
sigmoid. In the first place his material is very large. Thirty- 
two among ninety-eight cases of intestinal obstruction ob- 
served in his clinic in Czemowitz, involved the sigmoid 
flexure. In the second place his mortality is unusually high. 
Of twelve patients not subjected to operation eight died, — a 
mortality of 66 per cent. Of twenty patients operated upon, 
thirteen died, — 65 per cent. This unusually large number of 
cases not subjected to operation and the high mortality of the 
operative intervention seems to be explained by Philipowicz's 
faith in the rectal tube which he attempts first in every case 
and he advises that operation should not be done before the 
third day. 



l82 JOSEPH C. BLOODGOOD. 

Scudder of Boston (Reprint 1908, reference not given) 
reports on 121 cases of acute obstruction from the Massa- 
chusetts General Hospital. Among- these there are nine cases 
of volvulus with nine deaths. Among these but two involved 
the sigmoid flexure. Resection was performed in one, 
colostomy in the other. 

Conclusions. — This study of volvulus of the sigmoid must 
be looked upon as incomplete. My own experience is limited, 
and the cases reported in the literature are not given with 
sufficient detail to draw definite conclusions as to the etiological 
factors. 

At the present time, I am of the opinion, that the symp- 
toms of acute or subacute volvulus of the sigmoid are suffi- 
ciently evident to allow treatment to be instituted in a stage 
in which the prognosis should be uniformly good. In the 
first place, the attempts at relief with the rectal tube and 
enemata should not be continued more than a few hours. 
During this time the patient should have no food and no 
cathartics. If this is unsuccessful the abdomen should be 
opened at once. When this is done resection is only indicated 
in the presence of gangrene. After untwisting the volvulus 
the bowel should be evacuated with the rectal tube. Now one 
should search In the region of the mesentery for bands or 
adhesions; these should be relieved and the raw surfaces 
covered with peritoneal suture. These patients should be care- 
fully instructed, after their recovery, as to their diet and the 
use of cathartics to prevent constipation. In the event of 
recurrent attacks resection, as in my Case I, is indicated. 

As to the other cases which I have reported in which the 
symptoms are chronic, laparotomy Is indicated not only to 
relieve these symptoms, but as a prophylactic measure against 
the development of acute volvulus. 



THE VALUE OF THE CAMMIDGE REACTION IN THE 
DIAGNOSIS OF PANCREATIC DISEASE.* 

FROM THE PRIVATE LABORATORY OF DR. JOHN H. MUSSER. 

BY EDWARD H. GOODMAN, M.D., 

OF PHILADELPHIA, 

Assistant Instructor in Medicine, University of Pennsylvania; Dispensary Physician, 
Presbyterian HospitaL 

The diagnosis of pancreatic disease is usually a matter 
of the greatest difficulty, and any symptom, sign, or test which 
is suggested as an aid to our diagnostic equipment, should be 
given a thorough trial before it is accepted or discarded. 

Great assistance has already been given by the laboratory 
worker, for the most part from the study of the faeces, though 
strangely enough the urine has been grossly neglected. Gly- 
cosuria has been urged as a symptom of pancreatic disease, 
but its absence in the majority of cases robs it of any diagnostic 
importance, and the same may be said of the other, almost 
forgotten, urinary findings. 

In the Arris and Gale Lecture for 1904, Cammidge ^ 
reported the result of his extensive research on pancreatic 
disease, and described a new laboratory test which he claimed 
to be of great value in diagnosing pancreatic lesions. Based 
on the fact that acute and gangrenous pancreatitis are usually 
associated with fat necrosis, and chronic pancreatitis not infre- 
quently, Cammidge believed that even in the latter condition 
when there was no visible sign of fat splitting, there might 
still be some change in the chemical composition of the blood. 
This change he believed might be due to glycerin, but after a 
few unsatisfactory examinations of the blood for this substance 
or its derivatives, he devoted his attention to the study of the 
urine. At this time he made use of two tests, the A and B 
reactions. Cammidge believed that in certain diseases of the 

* Read before the Philadelphia Academy of Surgery, November 2, 
1908. 

183 



1 84 EDWARD H. GOODMAN. 

pancreas the formation of crystals with the A reaction could 
be prevented by preliminary treatment of the urine with 
mercuric chloride, and this formed the basis of the B reaction. 

The very unscientific claims urged for the method by 
Cammidge, and the insufficient grounds for most of these 
claims, called forth a storm of criticism from subsequent ob- 
servers (Ham and Cleland,^ Schroeder,^ Gruner,^ Willcox,^ 
and Haldane ^ ) and the pancreatic reaction as first described, 
has fallen into almost universal disrepute. 

To render the test free of the personal bias of the investi- 
gator, Cammidge '^ has modified his reaction, making the 
technic a little more complicated, but at the same time making 
the result an absolute one. This third reaction has been named 
by him " improved method " or " C " reaction, and is the one 

1 have used in the present series of cases. 

A portion of the twenty-four hours' urine, or a portion 
of the mixed night and morning specimens, is examined for 
albumin and sugar. If albumin is present it is removed by 
boiling with the addition of a few drops of acetic acid, cooled 
and filtered. The removal of the sugar will be spoken of later. 
To 40 c.c. of the filtered, albumin-free, acid-urine are added 

2 c.c. of concentrated hydrochloric acid, and the mixture gently 
boiled on the sand bath for ten minutes following the first evi- 
dence of ebullition. A small flask, with a funnel as a con- 
denser, is used for the purpose. After ten minutes' boiling the 
flask is removed from the sand bath, cooled in a stream of 
running water, and the contents made up to 40 c.c. with dis- 
tilled water; 8 Gm. of lead carbonate are then added to neu- 
tralize the excess of acid, and after standing a few minutes the 
flask is again cooled in running water, and the contents filtered 
through a moistened, close-grained filter-paper.* 

At this stage of the procedure, if sugar has been found 
on qualitative analysis, a portion of yeast is added to the clear 
filtrate, and the flask placed in the incubator over night. The 
next morning the solution is filtered and the test is continued. 

* I have found the most satisfactory paper to be Schleicher & Schull 
589 Blue Ribbon. 



CAMMIDGE REACTION IN PANCREATIC DISEASE. 



185 



The acid filtrate is thoroughly shaken with 8 Gm. of 
tribasic lead acetate, and the precipitate removed by repeated 
filtration through a well moistened, close grained filter-paper. 
To get rid of the excess of lead, 4 Gm. of powdered sodium 
sulphate are added, the mixture heated on a wire gauze to the 
boiling point, cooled in running water to as low a temperature 
as possible, and the precipitate removed by careful filtration. 
Ten c.c. of the filtrate are put in a small flask, made to 17 c.c. 
with distilled water, and to this are added 0.8 Gm. of phenyl- 
hydrazin hydrochloride, 2 Gm. sodium acetate, and i c.c. 
of 50 per cent, acetic acid. The flask is then fitted with a 
funnel condenser and gently boiled on the sand bath for ten 
minutes, at the expiration of which time it is filtered hot 
through a filter-paper moistened with hot water. The filtrate 
if necessary is made up to 15 c.c. with hot distilled water, and 
the whole well stirred with a glass rod. 

" In well-marked cases of pancreatic inflammation a light- 
yellow, flocculent precipitate should appear in a few hours, but 
in less characteristic cases it may be necessary to leave the 
preparation over night before a deposit occurs. Under the 
microscope the precipitate is seen to consist of long, light-yel- 
low, flexible, hair-like crystals arranged in delicate sheaves, 
which, when irrigated with 33 per cent, sulphuric acid, melt 
away and disappear in ten to fifteen seconds after the acid first 
touches them. The preparation must always be examined mi- 
croscopically, as a small deposit may be easily overlooked with 
the naked eye, and it is also difficult to determine the exact 
nature of a slight precipitate by macroscopical investigation 
alone." (Cammidge, loc cit., p. 253.) 

The nature of the phenylhydrazin precipitate is unknown, 
though Cammidge believes that the body is a pentose, not 
preformed but obtained by hydrolysis. To quote his words 
{loc. cit., p. 251), "We are not in ^ position to make any 
definite statements with regard to the nature of the mother- 
substance from which the sugar is derived, but our earlier 
experiments proved that it was not the so-called animal gum 
of the urine, and the fact that a positive reaction has not, so 



l86 EDWARD H. GOODMAN. 

far, been obtained by the 'improved method ' with the urine, 
from any but pancreatic cases, suggests that it is probably a 
body resulting from change in the pancreas, and possibly de- 
rived directly from that organ. The relatively large proportion 
of pentose-yielding material in the pancreas (2.48 per cent.) 
. . . points to the pancreas as the most likely source. It can- 
not be denied, however, that the disintegration of other tissue 
may also at times influence the urine in this respect, and it has 
also to be remembered that the ingestion of large amounts of 
pentose-containing food-materials may also cause small quanti- 
ties of pentose to be excreted in the urine. Therefore while we 
maintain that a positive reaction by the * improved method * 
of performing the so-called * pancreatic reaction ' is strongly 
suggestive of inflammatory disease of the pancreas, we are not 
prepared to contend that it is pathognomic of pancreatitis." 

Cammidge's present attitude toward his reaction seems 
to be a very fair one, as the last sentence of the above quotation 
indicates. He has made 250 consecutive examinations, of 
which 125 were negative. These negative reactions were ob- 
served in 50 normal cases, 92 miscellaneous cases concerning 
which no further information is given, 10 cases of gall-stone 
in common duct, 11 cases of gall-stones in gall-bladder, both 
conditions unassociated with pancreatitis, and 12 cases of can- 
cer of the pancreas. Two cases of acute pancreatitis gave a 
positive reaction. There were no negative findings in cases of 
chronic pancreatitis sui generis or of pancreatitis accompanied 
by gall-stones. 

Control work on this " C " reaction has been slow in 
forthcoming, probably on account of the adverse criticism 
aroused by the previous reactions. 

Watson ^ in a series of 250 analyses from 120 consecutive 
cases found the reaction positive in such cases as acute and 
chronic pancreatitis, acute suppurative appendicitis and peri- 
tonitis, malaria (jaundice with epigastric tenderness) pneu- 
monia (arteriosclerosis), alimentary glycosuria and constipa- 
tion, duodenal ulcer and chronic pancreatitis, gall-stones in 
common duct (pancreas inflamed), pregnancy (alimentary 



CAMMIDGE REACTION IN PANCREATIC DISEASE. 187 

glycosuria), mitral stenosis (inflanmiatory disease of pan- 
creas), uraemia, colitis, gout, tuberculous enteritis, constipa- 
tion, chronic nephritis, cerebral hemorrhage, exophthalmic 
goitre, gastric ulcer, malignant disease of stomach, leukaemia, 
chronic bronchitis, arteriosclerosis, nephritis, simple catarrhal 
jaundice, and lymphosarcoma. 

This is a startling variety of conditions and would tend 
to invalidate Cammidge's claims. Watson arranges the cases 
giving a positive reaction in the following three sub-divisions : 

1. A group in which there is a definite clinical or patho- 
logical evidence of serious organic disease of the pancreas, 
for example, acute and chronic pancreatitis, usually associated 
with disease of the bile-ducts. 

2. A group in which the reaction in the urine is associated 
with pronounced arteriosclerosis, a condition usually accom- 
panied by more or less sclerosis in different glands. 

3. A group in which the reaction is dependent on conges- 
tion and catarrhal conditions of the gland duct and substance, 
with associated toxaemia, for example, advanced heart disease, 
appendicitis, pneumonia, malaria, and the like. 

Despite the many varying disorders which give a positive 
pancreatic reaction Watson believes the test will prove of great 
value to physicians and surgeons in the diagnosis and treatment 
of pancreatic disease. 

Edgecombe ® publishes the report of an interesting case of 
mumps in which, owing to abdominal pain and tenderness with 
vomiting, an examination of the urine for the pancreatic reac- 
tion was undertaken. Cammidge himself conducted the ob- 
servation and diagnosed " an active inflammation of the 
pancreas " based on a positive pancreatic reaction. 

Schroeder^^ found a positive reaction in chronic pan- 
creatitis, cancer of the pancreas, cancer of stomach, gall-stones, 
catarrhal jaundice, tuberculous peritonitis, and tumor of upper 
abdomen, probably of pancreas. Negative findings were seen 
in chronic pancreatitis, cancer of stomach, abscess of pancreas, 
gall-stones (three of four cases), catarrhal jaundice (three of 
four cases), cancer of liver, cholecystitis, and pulmonary tuber- 
culosis. His conclusions are as follows : 



1 88 EDWARD H. GOODMAN. 

1. It has been proved that inflammatory and destructive 
diseases of the pancreas may give rise to the appearance of 
certain as yet undefined bodies in the urine, belonging possibly 
to the sugars or related compounds. 

2. The reaction is not pathognomonic for disease of the 
pancreas in the clinical sense. 

3. Extensive clinical observation on the urine in pan- 
creatic and other diseases must finally determine the value of 
the pancreatic reaction. 

In making my observations on the pancreatic reaction, I 
purposely chose to exclude examination of any normal cases, 
as Cammidge has reported 50 normal urines of which none 
gave a positive reaction. I have so far examined 62 individual 
cases. In several of these, control-examinations were made, 
which I have not enumerated. The majority of these cases 
were from the practice of Dr. Musser, but additional cases 
were furnished me by Dr. J. B. Deaver, Dr. W. Wayne Bab- 
cock, Dr. Joseph Sailer, and Dr. Warfield T. Longcope, all of 
whom I wish to thank for their courtesy. Great kindness has 
been shown me by Drs. Sailer and Speese in allowing me to 
study the urines of their cases of experimental pancreatitis. 
Full details of these are omitted, as the question of the value 
of the Cammidge reaction based on experimental and patho- 
logical work will be presented in a subsequent paper in con- 
junction with Dr. Speese. 

My series includes only abdominal disorders, and I have 
tried to select several cases presenting the same disease, as a 
means of control. The list includes acute experimental pan- 
creatitis, acute pancreatitis, chronic pancreatitis, cancer of the 
pancreas, cirrhosis of the liver, cancer of the gall-bladder and 
liver, cholecystitis, cholangeitis, gall-stones, cancer of the 
stomach including cases of mural, pyloric, and cardiac car- 
cinomata, gastric ulcer, gastritis, hyperchlorhydria, gastropto- 
sis, enteritis, renal calculus, fibroid of uterus, autointoxication, 
and diabetes mellitus. These cases I have tried to arrange in 
a consistent table, but the combination of several diseases has 
prevented a systematic classification. 



CAMMIDGE REACTION IN PANCREATIC DISEASE. 189 

No. Pos. Neg. 
Experimental pancreatitis (acute) 4 2 2 

Acute pancreatitis i i o 

Chronic pancreatitis 2 2 o 

Carcinoma of the pancreas i o i 

Carcinoma of the stomach and pancreas... 211 

Carcinoma of pylorus 3 o 3 

Carcinoma of stomach wall i o i 

Carcinoma of cardia i o i 

Sarcoma of stomach i o i 

Gastric ulcer 2 o 2 

Hyperchlorhydria i o i 

Gastroptosis i i o 

Gastritis 2 o 2 

Cirrhosis of liver 10 o 10 

Carcinoma of gall-bladder 2 o 2 

Cholecystitis 4 o 4 

Cholangeitis i o i 

Gall-stones 2 2 o 

Enteritis i o i 

Abdominal tumor of obscure origin i o i 

Renal calculus i o i 

Fibroid of the uterus i o i 

Autointoxication 2 o 2 

Diabetes mellitus 14 i 13 

Myocarditis i o i 

Of the 62 cases studied, but ten cases gave a positive Cam- 
midge reaction and in six of these the diagnosis of a pancreatic 
lesion was confirmed at operation. The case of acute pan- 
creatitis died with all the classical symptoms of the disease, 
and the diagnosis of the case of carcinoma of the stomach and 
pancreas was corroborated post mortem. The case of gas- 
troptosis was sent me by Dr. Babcock, with symptoms sugges- 
tive of pancreatitis, but revealing a markedly ptosed stomach 
on examination. As this condition was the prominent feature, 
I have classed the case under this head, but it is not unlikely 
that a pancreatitis may have been associated with the gas- 
troptosis. The fourth case was a diabetic woman, a private 
patient of Dr. Musser, who had been troubled for some time 
with irregular attacks of indigestion and constipation. Von 
Noorden ^^ says, " To make a diagnosis of pancreatic diabetes 
in the absence of symptoms referable to marked pancreatic 
lesion is most daring " — and although this is very true, the 



190 



EDWARD H. GOODMAN. 



question of the concurrence of pancreatitis with many cases of 
diabetes must be borne in mind, even though no symptoms are 
present (Herzog/^ Ssobolew^^). 

Four cases of experimental pancreatitis were examined, 
two of which were positive and two negative. The two cases 
giving a negative reaction were found at autopsy to show 
barely discernible evidences of pancreatitis. The two positive 
cases were typical cases of acute hemorrhagic pancreatitis. 
Further work is being carried on in this direction, and will be 
reported in a later paper in collaboration with Dr. Speese. 

I have studied but one case of carcinoma of the pancreas 
per se, and this gave a negative reaction, agreeing with Cam- 
midge's results. Of two cases of carcinoma of the stomach 
with metastases to the pancreas, one was positive and one nega- 
tive, so of the three cases of pancreatic carcinoma, two were 
negative, giving a percentage of 33 per cent, positive reactions. 
Cammidge found four positive reactions in 12 cases of car- 
cinoma of the pancreas, or 33 per cent. 

The finding of a positive pancreatic reaction in gall- 
stones associated with pancreatitis is a common occurrence, 
according to Cammidge, but Schroeder found three negative 
reactions in four cases of cholelithiasis. My cases are not 
numerous, but confirm the report of Cammidge. 

The cases of cirrhosis of the liver were studied with a 
special object in view, inasmuch as they were all cases in which 
an alimentary levulosuria has been found after the ingestion 
of 100 Gm. of levulose. It has been stated by Steinhaus ^* 
that the principal reason why cirrhotic cases are not able to 
utilize levulose is because of the common association of a 
chronic pancreatitis with the cirrhosis. This was based on 
post-mortem findings, but has not been generally credited, so 
it was thought of interest to examine all cirrhotic cases for the 
pancreatic reaction. As will be seen from the table, ten cases 
were studied, but with no positive reaction. This would seem 
to point to another interpretation of alimentary levulosuria, as 
was mentioned in my preliminary report before the Section 
on Medicine of the College. of Physicians last January. 

All cases of glycosuria were examined for the reaction, 
and in but one case Was it obtained. 



CAMMIDGE REACTION IN PANCREATIC DISEASE. 



191 



I 



Conclusions. — Of 62 cases studied, but ten gave a positive 
reaction. In seven of these the diagnosis was confirmed by 
operation or autopsy. One case died with all the clinical symp- 
toms of acute pancreatitis, and in the other two a concurrent 
pancreatic lesion was not improbable. In no cases other than 
those presenting clinical evidence was a positive reaction 
obtained. 

I firmly believe the test to be a very useful one and to 
mark a decided advance in the diagnosis of pancreatic disease. 
The technic is long and complicated and requires great care, 
but is one that can be readily mastered and is within the scope 
of any clinician with facilities for laboratory work. Some- 
times the end-reaction is obscure on account of crystals form- 
ing which are not properly the osazon described by Cammidge, 
but observation as to structure and their insolubility in 33 per 
cent, sulphuric acid suffice to render the diagnosis less difficult. 

The test is not pathognomonic, and the discoverer him- 
self has never had the temerity to claim this property for it ; 
but taken in connection with the clinical history and examina- 
tion, and a careful study of the faeces, the Cammidge reaction 
is strongly suggestive of inflammation of the pancreas. 

Note. — Since reading this paper I have studied many more cases and 
have made between 150 and 200 examinations. The results of these ob- 
servations are in harmony with the above conclusions.' 

REFERENCES. 
' Cammidge : Lancet, March 19, 1904, p. 782. 

' Ham and Cleland : Australasia Med. Gazette, 1904, p. 399 ; Lancet, May 
14, 1904, p. 1378. 

• Schroeder : Amer. Med., 1904, p. 406. 
*Gruner: Lancet, 1904, May 21, p. 1459. 
•Willcox: Lancet, July 23, 1904, p. 211. 

' Haldane : Edinb. Med. Jour., 1906, n.s. xx, p. 418. 

' Robson and Cammidge : The Pancreas, Its Surgery and Pathology, 

1907, p. 252. 
"Watson: Brit. Med. Jour., April 11, 1908, p. 858. 

• Edgecombe : Practitioner, February, 1908, p. 194. 
" Schroeder : Jour. A. M. A., 1908, li, p. 837. 

"Von Noorden: Die Zuckerkrankheit, fourth edition, p. 158. 

"Herzog: Virch. Arch., 1902, clxviii, p. 83. 

" Ssobolew : Virch. Arch., 1902, clxviii, p. 91. 

" Steinhaus : Deutsch. Arch. f. klin. Med., igcw, Ixxiv, p. 537.. 



THE PREVENTION OF INTESTINAL OBSTRUCTION 

FOLLOWING OPERATION FOR 

APPENDICITIS.* 

BY FORBES HAWKES, M.D., 

OF NEW YORK, 

Surgeon to Trinity Hospital ; Associate Surgeon, Presbyterian Hospital; 

Consulting Surgeon, Nassau and St. Joseph's Hospitals, Long 

Island ; Instructor in Surgery, Columbia University. 

It may safely be said, I think, that in this country each 
succeeding year has brought with it an increasing number of 
cases of appendicitis which have been diagnosed as such at an 
earher period in the disease. With this advance in diagnosis 
has also come an increase in the number of cases that have 
been operated upon. In fact there is hardly at present a 
community of fair size that does not count among its numbers 
one or more surgeons who have operated a number of times 
for appendicitis. After having diagnosed the case properly, 
removed the diseased appendix, closed the wound with or 
without drainage as the case may be, and returned the patient 
to bed, there ensues for all surgeons a more or less anxious 
period lasting from several days to several weeks. Of the 
post-operative complications liable to occur during this period, 
intestinal obstruction and sepsis form a serious percentage. 

A number of cases of postoperative obstruction in which 
the writer has been called in to operate within the last few 
years have led hirn to consider more closely the causes of this 
complication in these individual cases and the methods by 
which it may usually be avoided. 

This postoperative complication is not an infrequent one 
— it varies from a fraction of one per cent, to ten per cent, or 
more according to the operator's skill and experience. 

The obstruction is usually either (a) mechanical or (b) 
septic, or a combination of both. There is also a so-called 

* Read before the New York Surgical Society, November 25, 1908. 
192 



OBSTRUCTION AFTER APPENDICAL OPERATIONS. 



193 



spasmodic form about which authorities differ greatly. The 
occurrence of this form is doubtless quite rare. It is not here 
considered, nor is that resulting from mesenteric thrombosis. 

a. MECHANICAL OBSTRUCTION. 

As a postoperative complication this occurs less often 
than we w;ould expect in the cases where the conditions would 
seem at first thought to be most favorable for it — namely in 
those of acute generalized suppurative peritonitis with the 
production of many adhesion bands. The reason that many 
cases of this kind are free from this complication is doubtless 
that here many of the loops are united to each other by the 
exudate while they are in a normal position and are thus held 
together for some time — the later process of absorption occur- 
ring pretty evenly over the various surfaces if the focus of 
inflammation has been removed. The comparative rarity of 
mechanical obstruction in cases of pyosalpinx, and especially 
tubercular peritonitis where the greatest amount of adhesive 
material is often formed, would tend to corroborate this 
view. 

The type of case most liable to this postoperative compli- 
cation seems to be that in which most of the peritoneal cavity 
is free from adhesions, permitting unrestricted intestinal 
motion, but where a few firm adhesions are formed after 
operation between the caput coli and an adjacent loop of small 
intestine. Gibson ^ in 1000 cases of postoperative intestinal 
obstruction found the small intestine involved in 95 per cent. 
McWilliams ^ collected 86 cases of postoperative obstruction 
— all in the small intestine — 69 following appendicular abscess. 

The following cases are fairly typical of this condition : 

Case I. — E. W., 25 years of age, male. Had been operated 
on by his physician on Long Island for chronic appendicitis on 
June 15, 1907. Considerable inflammation had been found at 
the tip of the appendix which had to be dug out from its adhesions 
over the pelvic brim. The appendix had been removed and a 

^Gibson, Anns. Surg. Vol. 32. p. 425. 
'McWilliams, Wash. Med. Ass. 1905. 
7 



ip4 FORBES HAWKES. 

cigarette drain placed to the stump area. The patient had done 
nicely for a few days following the operation and the drain had 
been withdrawn and partially replaced. He had then begun to 
vomit occasionally, the intervals between the attacks becoming of 
shorter and shorter duration. The bowels which had moved 
well at first had become constipated and finally the enemata had 
returned clear, only a very slight amount of gas being expelled. 
The pulse rate had remained 80 to 100 and the temperature 
normal. Nine days after the operation the vomiting had become 
fecal. I saw him late this same day for the first time ; he looked 
distinctly anxious, the pulse was about 100, with appreciable 
tension; the temperature was normal. The abdomen was mod- 
erately distended and a little tender ; no mass could be felt. On 
listening to the abdomen with a stethoscope for several minutes 
only two very faint gurgles were heard. No peristaltic waves 
could be seen; there was no dulness in the flanks. On rectal 
examination no mass could be felt and the examination was not 
painful. A diagnosis was made of mechanical intestinal obstruc- 
tion. Immediate operation was advised and accepted. Under 
gas and ether anaesthesia an incision was made (Dr. Hawkes) to 
the umbilical side of his previous incision, through the outer fibres 
of the right rectus muscle. The peritoneum was not adherent 
here. There was no free fluid in the general peritoneal cavity. 
A twisted loop of small intestine was found adherent to the caput 
coli at the site of the drain, on the umbilical side of the caput. 
The bowel above the obstruction was dilated and thickened, below 
it was contracted and entirely collapsed. There were no adhesions 
to be felt in the pelvis or elsewhere in the abdomen. The twisted 
loop was separated from its adhesion area to the caput coli. Its 
adhesion surface was oval, of about one to one and a half inches 
in diameter. In a few minutes the contents of the bowel above 
were slipping past the area of previous obstruction and the diam- 
eter of the bowel below was distinctly increased. After the 
separation from the caput coli the affected loop was seen to lie 
directly under the recent abdominal incision, where it was allowed 
to remain. The cigarette drain was removed from the old wound 
and a small piece of rubber tissue was introduced into the outer 
part only of the sinus tract. The fresh wound was closed in 
layers, leaving in only a small piece of gauze as a drain down to 
the peritoneum. The patient made a good recovery. His vomit- 



OBSTRUCTION AFTER APPENDICAL OPERATIONS. 195 

ing stopped and his bowels moved of their own accord within 
twelve hours and after that regularly. His convalescence was 
interrupted ten days following the operation by a small collection 
of pus which formed in the bottom of the pelvis (probably from 
a small amount of blood that had trickled down into the pelvis 
at the time of the second operation. This collection bulged 
toward the rectum, his physician reported, and was there opened 
by the finger. It went on promptly to complete healing. The 
patient was heard from six months later. He was then in per- 
fect health. 

Case H. — N. H., 20 years of age, male. Had been operated 
on by his physician in New York City, July 22, 1907, for gan- 
grenous appendicitis. The abdominal incision had been made at the 
edge of the right rectus muscle. The appendix had been found 
behind the caput coli imbedded in adhesions and its removal had 
been a difficult one. After its removal drainage had been insti- 
tuted through the abdominal incision. The patient had made a 
good recovery and his bowels had moved well for several days 
following the operation. Then he had begun to have abdominal 
pain with constipation and had vomited occasionally. On the 
ninth day following the operation, he had begun to have fecal 
vomiting, the rectal enemata had returned clear and no gas had 
been passed by rectum. The writer saw him about twelve hours 
after his fecal vomiting had begun. The clinical picture was 
almost precisely that described in Case I. Diagnosis was made of 
intestinal obstruction from a loop of small intestine adherent to 
the caput coli at the site of drainage and immediate operation 
advised; consent to this was not obtain^^d for about six hours. 
Under gas and ether an incision was then made (Dr. Hawkes) 
to the umbilical side of his previous incision through the fibres 
of the right rectus muscle. The peritoneum was not adherent 
here. A condition almost identical with the one described in 
Case I was found — a loop of small intestine twisted and adherent 
to the caput coli at the site of drainage to the umbilical side of 
the caput by an irregular shaped surface — distention and thicken- 
ing of the loop above the obstruction, collapse below it. After 
separating the loop it lay directly under the fresh incision, where 
it was left after its contents were felt and heard to slip down- 
wards, past the area of previous obstruction. The abdominal 
wall was sewed up in layers, a small gauze drain being inserted 



196 FORBES HAWKES. 

through the muscles only. The patient made an excellent recov- 
ery. The vomiting stopped almost immediately. The bowels 
were moved by enema on the third day and after that regularly. 
His convalescence was uneventful and he left the hospital in 
excellent condition. 

In both of these cases the obstruction in the loop of small 
intestine w:as not at the site of the appendix stump, but cor- 
responded to the area on the umbilical side of the caput where 
gauze drainage had been instituted. The prevention of the 
firm adhesion material or band formation in this locality may 
best be affected by: 

a. Making the operative entrance into the peritoneal 
cavity well out towards the anterior superior spine of the 
ilium directly over the caput coli. 

b. Instituting right iliac fossa drainage when necessary to 
the outer side of the caput coli. 

c. Instituting pelvic drainage likewise when necessary to 
the outer side of all intestinal coils, by means of a suitable 
drain, the drainage tract having for its outer wall the lateral 
parietal peritoneum of pelvis and of right iliac fossa. 

d. Protecting the coils of small intestine by means of an 
omental barrier. 

a. The Abdominal Incision. — By making the abdominal 
incision an oblique one from one to one and a half inches 
within the anterior superior spine of ilium (see Fig. i) and by 
splitting the fibres of the external oblique in the same line as 
the skin incision, a retraction of the outer part of the external 
oblique aponeurosis will expose the internal oblique muscle 
nicely; the fibres of the latter are then separated and the 
transversalis fascia and peritoneum divided halfway between 
the outer edge of the rectus muscle and the anterior superior 
spine of the ilium. This will in most cases give an opening 
into the peritoneal cavity directly over the caput coli. If one 
attempts to open quite near the anterior superior spine, the 
result may well be that the dissection will lead down ineffect- 
ually into the retroperitoneal tissue, leaving a pocket there 
for postoperative trouble, or the bowel may be opened without 



OBSTRUCTION AFTER APPENDICAL OPERATIONS. 



197 



getting into the general peritoneal cavity. If the opening be 
made too far out at the edge of the rectus muscle a coil of 
small intestine may present itself instead of the caput. This 
is an objection. 

b. The Proper Placing of the Drain to the Stump Area, 
in the Right Iliac Fossa. — This I consider to be of great post- 
operative importance in the cases where drainage is needed. 
Through such an opening as is recommended above a drain 
when indicated can be so placed that the secretion will be led 
up along the outer side of the caput coli and then into the 
outer dressings (Fig. i). A drain placed to the inner (i.e., 
umbilical) side of the caput coli in apposition with coils of 
small intestine (especially if it be a gauze drain) will of course 
cause marked adhesion formation and may well give rise to 
the complication existing in the two cases previously 
mentioned. 

In the gangrenous cases where in addition to the gangrene 
of the appendix there are spots of juxtaposition gangrene on 
the caput coli or small intestine, a piece of gauze either as a 
separate drain or as a part of the distal end of the stump area 
drain should of course be placed against such spots. Such a 
drain should, however, be surrounded by rubber tissue through- 
out the rest of its course in the wound and it should also be 
led to the surface to the outer side of the caput. It is hard 
to lay dowji exact rules as to the amount of drainage neces- 
sary in every drainage case. Clinically the principle here 
enunciated seems sound; one thing also seems certain; the 
lower abdominal and pelvic peritoneum in the male cannot take 
care of infection as does this organ in the female and requires 
as a rule provision for more ample drainage. Rubber tissue 
and gauze cigarette drains without gauze projection from the 
lower end unless there be a gangrenous spot to cover, repre- 
sent to my mind the best form of drain for the average case 
that requires drainage. 

c. The Institution of Pelvic Drainage. — When the pelvis 
is to be drained the pelvic drain should preferably be of rubber 
tissue and gauze, the rubber tissue being wrapped around the 



198 ■ FORBES HAWKES. 

gauze loosely, leaving likewise no gauze projection from its 
lower end. In this way the greatest amount of drainage with 
the minimum amount of adhesion formation is secured. This 
drain should always be introduced (under the guidance of the 
fingers of the other hand) so that it lies directly against the 
outer pelvic wall from the abdominal incision down to the 
very bottom of the pelvis. The failure to introduce such a 
drain to the very bottom of the pelvis may result in the for- 
mation of a pool in Douglas's or in the rectovesical pouch, 
which may in time give rise to further peritonitis causing 
mesenteric thrombosis or intestinal obstruction. This pelvic 
drain needs as a rule to remain in the pelvis not more than 
thirty-six hours in a comparatively recent case of spreading 
peritonitis with serum only or slightly turbid seropus in the 
pelvis. In the older cases, however, associated with heavy and 
scattered lymph plaques in the pelvis and localized pus collec- 
tions there, a more prolonged pelvic drainage is indicated. In 
these latter cases a too early discontinuance of the pelvic 
drainage may be followed by pelvic re-accumulation of pus 
with subsequent intestinal obstruction. Cases with a per- 
forated gangrenous tip located deep in the pelvis should be 
similarly drained. Localized collections of pus anywhere in 
the abdomen are inviting areas for intestinal obstruction. 
When it is possible it is advisable to open these so that the 
gravity drainage from them will be along the tract of the 
pelvic drain. Should this not be feasible they should be 
drained through that portion of the anterior or lateral abdom- 
inal wall which is nearest to them. 

Retrocsecal or retrocolic abscesses may best be drained 
usually through an additional counter opening in the flank (see 
Fig. I ) . Here on account of the position of the abscess plain 
gauze may be used as a drain or preferably a cigarette drain of 
gauze enveloped in rubber tissue but with an inch or so of 
gauze projecting from its lower end. The gauze portion soon 
becomes adherent to the retrocsecal or retrocolic cellular tissue 
and thus prevents this drain from being extruded by the action 
of the lateral abdominal muscles. About the fourth or fifth 



OBSTRUCTION AFTER APPENDICAL OPERATIONS. 



199 



day such a drain may be removed with very sHght discomfort 
to the patient. The writer does not feel that the introduction 
of sterile salt solution into the peritoneal cavity in cases of 
gangrenous appendicitis is advisable. Many of them have the 
gangrenous part of the lesion confined to the right iliac fossa 
or in a limited way to a small portion of the upper part of 

Fig. I. 




Diagram illustrating the propter placing of the various drains and of the protecting 
omentum. A. The drain to stump area, leading down on the outer side of the caput coli; 
rubber tissue and gauze cigarette drain without any projection of selvage gauze from the 
lower end. B. The pelvic drain, leading down to bottom of pelvis on the outer side of sdl 
intestinal coils; rubber tissue and gauze cigarette drain, no projection of selvage gauze 
from the lower end. C. Protective omentum placed between appendix stump site and small 
intestines. D. Drain leading to site of retrocaecal or retrocolic abscess by secondary " stab " 
opening in flank; rubber tissue and gauze cigarette drain with ^i in. selvage gauze pro- 
jection from inner end. E. Caput coli. F. Loops of small intestine. 

the pelvis. Here the salt solution may scatter a secondary 
previously localized form of infection to other parts of the 
lower abdominal and pelvic cavities. When a drain is used it 
should never be nipped at its exit from the peritoneal cavity 
by too tight suturing. If so it acts as a stopper, not as a drain. 
Of course the best way to prevent firm adhesion is to operate 
early if possible in cases of appendicitis at a time when drain- 
age will probably not be necessary. When the condition 



200 



FORBES HAWKES. 



demands drainage, however, the Hghtest form of adhesion pro- 
duction with the greatest amount of actual drainage should be 
aimed at. And here while on the subject of drainage it is 
pertinent to recall that if we wish to drain other parts of the 
abdominal cavity which are not in direct contact with the 
capillary drain, yet not shut off from it by adhesions, we must 



Fig. 3. 







The right flank is here seen one inch deeper than the pelvis. 
Fig. 2 a. 




The left flank is here seen even slightly lower than the right. 

avail ourselves of the forces of gravity toward this drain. 
A complete emptying of these other parts into the drain should 
occur within the first twelve to eighteen hours after the opera- 
tion, for it is exceedingly doubtful if any drainage occurs 
after this time (whatever form of drain be used) from portions 
not in contact with the drain. In the writer's experience the 
least irritating of all drains, the loosely rolled cigarette drain 
with rubber tissue covering without any projection whatever 
of gauze from its lower end, will drain adjacent regions per- 
fectly (if adhesions have not formed in them before opera- 
tion and if the fluid to be drained is not too thick) for twelve 
to eighteen hours, no more. 



OBSTRUCTION AFTER APPENDICAL OPERATIONS. 201 

Fortunately this is often sufficient if the drain is of ade- 
quate size and the patient kept in the proper position in bed. 
The accompanying diagrams reproduced in part from Dr. R. C. 
Coffey's ^ article and showing the various fossae to be drained 



Fig. 2 b. 



^ Horizontal Section through Base of Appendix. 







b 






^7 








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1 
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I I 
f t 

; 1 

\ 1 

! 1 
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\ 

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Considering Fig. 2 and Fig. 2 & together it will be seen that if the patient is first 
turned over on the right side while in the horizontal position, and then put up in " Fowler 
position," perfect gravity drainage of all fossae may be secured. 

explain at a glance the proper position in which the patient is 
to be placed for drainage in various classes of cases. For 
instance, in cases of retrocsecal abscess alone without free 
serum or free seropus in the abdominal or pelvic cavities the 
dorsal position with lumbar opening in the right loin is indi- 
cated. In a case of retrocaecal abscess with free serum or free 



"CoflFey, J. Am. Med. Ass., March 16, 1907. 



202 FORBES HAWKES. 

seropus in the abdominal and pelvic cavities pelvic drainage 
and lumbar counter-opening with the Fowler position for 
about twenty-four hours is best. Clinically the pelvis will by 
that time have drained off the serum or seropus that has 
gravitated from above and the patient may then be placed in 
the horizontal position, when the lumbar drain will continue its 
work ; or the patient may from the start be simply turned over 
entirely on the right side, for in this position the lumbar and 
pelvic drains together, if properly placed, should drain the 
whole abdominal cavity above. The former method, however, 
the writer believes to be the better one. 

The placing of gauze or of pads to the umbilical side of 
the caput coli in clean cases as a routine procedure during the 
operation seems to the writer to be a faulty technic; they are 
apt to cause adhesions, they often interfere with rapid and 
satisfactory manipulations, thereby causing delay, and they 
may very well produce displacement in the way of twisting of 
the small intestinal loops. When removed they probably often 
pull the small intestinal loops into abnormal positions where 
they become adherent. In the pus cases or in cases associated 
with great intestinal distention their use may be necessary ; as 
few as is possible, however, should be used. Their proper 
introduction is a very important matter. They should be 
introduced only after the exact site of the caput coli and 
appendix region has been noted. Care should be used that no 
coils be caught between them. 

A secondary infection of the peritoneum during the 
operation from the hands of operator, assistants, or nurses 
must be avoided. Sterile rubber gloves should be worn by all. 
The operator's gloves should be of the lightest weight to secure 
the greatest delicacy of touch, and the best appreciation of the 
exact pathological changes that have occurred in the operative 
field. 

The delivery of the caput coli outside the abdominal 
wound as a routine measure in hunting for the appendix is a 
procedure which is both unnecessary and injudicious. In 
many cases the location of the appendix can be made out after 



OBSTRUCTION AFTER APPENDICAL OPERATIONS. 



203 



the peritoneum has been opened, by introducing one finger to 
the lower part of the caput coli and exploring in this region. 
When thus located if there are softish adhesions they may be 
carefully separated by the finger until the appendix seems free 
and a small sponge or bit of gauze on a holder introduced 
below the appendix will then often deliver the appendix nicely 
into the wound, without a single coil of small or large intestine 
displaced out of the wound. Even in pus cases the same steps 
may be carried out after the sponging out of the abscess 
cavity. Of more importance still than the retaining of the 
caput in the peritoneal cavity is the retaining of all small intes- 
tine coils; these are very apt to become displaced with the 
caput and to be replaced in a wrong position. All peritoneal 
surfaces of the bowel that are handled and exposed to the 
air for any length of time are traumatized thereby and the 
musculature more or less temporarily paralyzed. It is not at 
all unusual to see appendectomy cases where no portion of 
the intestine except the appendix has been brought out of the 
wound during the operation, and where no pads have been 
introduced, recover their intestinal tone within twelve to four- 
teen hours as evidenced by the passage of quantities of gas by 
rectum within sixteen to eighteen hours after the operation. 

In women the pelvic drainage may be brought from 
Douglas's cul de sac through the vagina. There is a chance 
here, however, that a pool may form in the undrained fossa 
between the anterior surface of the uterus and the bladder. 
For this reason I prefer the pelvic drain which issues by the 
abdominal wound, and by having the patient, who is in 
Fowler's position, turned well over occasionally on the right 
side this fossa will drain into the pelvis nicely. In the writer's 
experience young children who toss about a good deal after 
operation thereby secure for themselves unwittingly excellent 
drainage. 

d. Omental Protection of the Small Intestines. — After 
the removal of the appendix (and the placing of the drain or 
drains if required) whenever possible a piece of the great 
omentum should be brought down from above and placed as a 



204 



FORBES HAWKES. 



barrier between the coils of small intestine and the stump site 
(see Fig. i). 

This latter procedure is not practised by many surgeons. 
The writer's statistics in postoperative appendix work lead 
him to regard this as a very valuable prophylactic procedure, 
which he has made use of as a routine measure for a number 
of years. It simulates in a way nature's method of preventing 
the further spread of peritoneal infection and adhesion forma- 
tion to intestinal loops. In most cases this omental protection 
can be effected. Where no omentum can be seen the appendix 
stump can often be placed under the fold of a divided meso- 
appendix, or under the ileocsecal fold, or a fatty tab from the 
caput can be brought over it. 

It would seem that mechanical intestinal obstruction is of 
more common occurrence in cases of appendicitis which have 
not been operated on, than in those where operation has been 
properly done and the after-care of the wound properly carried 
out. In the former type of case the adhesions being often 
older are apt to be more firm and unyielding. They do not tend 
so much to be absorbed because the cause of the adhesion for- 
mation still persists. Old adhesion strings found in the abdom- 
inal cavity at the time of operation had usually best be divided 
close to their origin. 

b. SEPTIC OBSTRUCTION. 

In most of the cases of septic obstruction following an 
operation for appendicitis, this condition is but the result of 
the further progress of the sepsis that existed before the opera- 
tion. The means to be taken therefore to prevent further 
spread of the septic peritonitis are the ones that should be used 
to ward off the secondary obstruction. In brief these are : 

a. Removal of the appendix (if it can be done quickly). 

b. Free drainage of the inflammatory area surrounding 
the appendix site, in the way mentioned. 

c. Free drainage of pelvis (if the infection has spread to 
it) according to the methods previously outlined. 

d. All operative measures to be instituted with the great- 
est rapidity consistent with safety. 



OBSTRUCTION AFTER APPENDICAL OPERATIONS. 205 

e. Assumption of Fowler's position directly after the 
operation (at an angle about 80°). 

f. Rectal instillation of hot normal saline solution, p. 0. 

g. Absolute intestinal rest by withholding all food and 
medication by mouth for 36-48 hours. 

h. Stimulation as indicated. 

i. Careful post-operative wound treatment. 

y. If the above are not sufficient then " ileostomy." 

In a case of spreading septic peritonitis following the 
operation, as soon as the diagnosis is certain, if the free drain- 
age above mentioned is insufficient, the surgeon should not 
await the advent of fecal vomiting but should open the loop 
of small intestine which is nearest to the caput coli in the 
wound; a rubber drainage tube of suitable calibre should be 
introduced into the proximal loop and retained therein by a 
purse-string suture. Should this loop be not adherent at the 
time to the surrounding surfaces a small piece of gauze should 
be placed around the suture line to produce protective adhe- 
sions. The resulting fistula may be closed later after the bowel 
has regained its tone. The following case demonstrates the 
value of this method. 

T. B., 50 years of age, dentist, had a mild attack of appen- 
dicitis in 1906 from which he recovered nicely ; he was laid up at 
that time for only a day. His physican advised him to have his 
appendix removed in the interval, but this advice was not fol- 
lowed. On May 2, 1907, he was seized with vomiting and 
abdominal pain. His physician saw him soon after the onset and 
found temperature and pulse rate normal, very slight abdominal 
tenderness and scarcely appreciable right rectus rigidity; his 
bowels moved well by enema. Within twelve hours, however, 
his pulse rate had advanced to 96, his temperature to 101° F., and 
he presented distinct rigidity over the right rectus and lateral 
abdominal muscles with exquisite tenderness over the appendix 
site; shortly afterwards he had a chill. Rectal examination was 
negative. He looked badly. The writer insisted on immediate 
operation and found a gangrenous appendicitis with a septic 
peritonitis confined to the right iliac fossa. The intestinal loops 
there seen were covered with lymph flakes, and the right iliac 



2o6 FORBES HAWKES. 

fossa contained a turbid yellowish serum. The appendix was 
rapidly removed and a rubber tissue and gauze cigarette drain 
of fair size placed to the stump area. During the first thirty-six 
hours after the operation the patient did not do well; vomiting 
occurred at intervals, at first mucous, then fecaloid, but not con- 
taining any fecal material; the abdomen became quite distended. 
No gas was passed by rectum. His septic peritonitis was evi- 
dently progressing and it was decided to institute freer drainage. 
The wound was opened, no mechanical obstruction was found, but 
a considerable amount of brownish-gray fluid with a foul odor 
around the bowel loops. This was sponged out and three cigarette 
drains were inserted; one above towards the liver, one to the 
stump area on the outer side of the caput coli, one into the pelvis 
on the right side along its outer wall. The patient was placed in 
Fowler's position. The vomiting, abdominal distention and abso- 
lute constipation, poor pulse, and general prostration persisted in 
spite of this free drainage. Very rarely a weak gurgle could be 
heard with a stethoscope over the abdomen. There was still 
evidently a progressing paresis of the gut, so it was decided to 
open the nearest loop of the small intestine. This was done 
about sixty-six hours after his first operation, a rubber drainage 
tube being sutured into the proximal loop and gauze appHed 
sparingly around the suture line for protective adhesion. This 
was followed by the expulsion of much gas through the tube and 
a little later of a large amount of foul smelling greenish material 
containing particles of undigested food which he had eaten more 
than four days before. Similar material was obtained after the 
operation by gastric lavage. Following this ileostomy the vomit- 
ing stopped almost immediately and in twelve hours the whole 
clinical picture had changed; the abdominal distention became 
less, the patient looked much better, the pulse was greatly im- 
proved. Within twenty-four hours the bowels moved with enema 
by the rectum with the passage of much gas; he then went on 
slowly to recovery. Later his ileostomy wound was closed. 

Postoperative Treatment of the Wound. — Where mul- 
tiple or deep drainage has been instituted the proper replace- 
ment of these drains at needed intervals is a matter of great 
importance to the patient. It is the writer's practice on this 
account to give an anaesthetic as a rule for the first dressing 



OBSTRUCTION AFTER APPENDICAL OPERATIONS. 



207 



in these cases, so that the proper replacement of the drains to 
the very bottom of the tract may not be interfered with by 
the reflex muscular contraction of the abdominal muscles, 
which otherwise often force the adjacent intestinal walls into 
the drainage tract and also narrow its mouth. I believe that 
where possible the operator himself should do the first dress- 
ing. An assistant will often fail to carry in his mind the exact 
depth and direction of the various drainage tracts and a pre- 
viously drained pocket may thus be left undrained. The value 
of a voluminous damp gauze dressing into which the ends of 
the drains are fluffed is beyond question and it is the writer's 
practice to change this every 8 hours for the first 2 days, for it 
promotes free drainage in a marked way. 

The giving of special drugs to produce marked intestinal 
motion or catharsis directly or within 2-3 days after opera- 
tion has always seemed to the writer an inadvisable procedure. 
Nature splints the abdomen when it is endeavoring to rid 
itself of septic material that is present, as shown by the pres- 
ence of muscular rigidity. We should take our cue from this 
and keep the coils quiet for 4-5 days usually, emptying the 
lower bowel by enema as required in the meanwhile. 



ACCIDENTS IN HERNIA OPERATIONS.* 

WITH ESPECIAL REFERENCE TO THE VESSELS. 

BY JOHN F. ERDMANN, M.D., 

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

In presenting this subject I have incorporated only those 
cases occurring in the practice of members of this Society; 
being impressed with the fact that the majority are teachers 
in medical schools, and that all members must be Visiting 
or Assistant Visiting Surgeons to some New York Hospital. 
This latter being the case, accidents of this nature by the 
members of such a society will have a marked relative value 
to the teaching surgeons, and also be of marked interest as 
a factor in impending or prospective suits. 

Consideration of the dangers during an operation for 
the radical cure of hernia, especially by the Bassini method, 
should include those of the bladder, intestines, vas deferens 
and the vessels. Reference only is made to the subject of 
injury to the vas, as no further serious outcome can result 
from this injury than sterility of the side of trauma, and even 
this can be obviated by proper suture of the divided structures, 
if recognized at the time of the operation. 

The bladder is a frequent enough content of hernia, and 
is made so, often enough, by dragging the sac farther down 
than necessary to meet with the proper technic relative to this 
step. Although several cases have been reported to me by the 
members, this subject has received sufficient attention in the 
literature of the day without my recording these cases. The 
point in question was well made in a paper recently written 
(but not yet published) by Dr. Roland E. Skeel of Cleveland, 
and read by him before the American Association of Obstetri- 
cians and Gynaecologists at Baltimore on September 24, 1908. 

♦Read before the New York Surgical Society, November 11, 1908. 
20S 



ACCIDENTS IN HERNIA OPERATIONS. 



209 



He further called attention to the fact that the bladder-wall of 
the paraperitoneal variety of vesical hernia occasionally was so 
thin, and lacked the usual vascular and muscular appearance of 
bladder-tissue, as to be mistaken for the sac wall of a hernia, 
and incised before the true condition was evident ; further stat- 
ing that the urine escaping from these incisions in several cases 
was taken for serum of the usual peritoneal variety. He advo- 
cated the administration of methylene blue for several days 
before the operation in all cases where there was a suspicion of 
the possibilities of the bladder being in the hernial protrusion, so 
that the colored urine escaping from the injured bladder would 
be recognized as such. He further stated that some of the 
injuries, one a case of his own, were due to tying the ligature 
of the sac about a portion of the bladder that was evidently 
dragged into this region by pulling the neck of the hernial 
sac far out, thereby producing the vesical hernia rather than 
having it at the beginning of the operation. This production 
of a hernia of the bladder was demonstrated by me in doing 
a repair for a direct hernia three weeks ago. While dragging 
on the sac to place a suture ligature the bladder fundus was 
observed for a length of one and a quarter inches to the 
inner angle of my wound. Germane to this is the following, — 
a portion of the replies sent me by Dr. George D. Stewart: 

" Another danger that I do not think is sufficiently em- 
phasized is that of wounding the bladder. This is more 
frequently the case in femoral hernias, of course, but it is 
also to be seriously considered in inguinal hernia. In two 
instances, which I recall, inflammation had caused adhesions 
of the sac to the bladder. The latter was dragged out through 
the inguinal canal as a part of the hernial mass. In two in- 
stances I have seen the bladder wounded, and in one I have 
opened it myself." 

Two cases of injury to the bowel are reported to me 
by members of this society, one in a large sliding or slipped 
hernia, where the sigmoid was opened and subsequently 
sutured without any following evil result. In the other the 
sigmoid was evidently grasped in one of the deep sutures, as 



3IO JOHN F. ERDMANN. 

a fecal fistula or artificial anus developed in a few days and 
continued for several weeks, with an eventual repair without 
secondary operation. 

Injuries to the femoral vessels in inguinal hernia are due 
to several important factors, among which are : ( i ) an anom- 
alous distribution of the branches; (2) the needle; (3) the 
suture material as a contributing rather than as a primary 
cause; (4) the method of passing the needle from above or 
from below; and (5) exposure, etc., of the ligament. In- 
juries to the femoral vessels in femoral hernia so far reported 
to me by members of the Society were of the vein, explained 
very easily by the relationship of the vein to the saphenous 
opening. The branches of the femoral vessels likely to be 
involved in passing the needle would be any of the ones above 
the profunda, and they are, from above downward, — the 
superficial epigastric, the superficial circumflex iliac, and the 
superficial and deep external pudics. The involvement of 
any of the above branches, except the superficial epigastric, 
would in a normally placed set of branches imply reckless 
suturing, and suturing not of the kind as described by Bassini. 
Two cases of injuries to the deep epigastric, supposed at 
first to have been the femoral, are reported to me by two of 
the members of the Society. 

In my case reported below, in passing the needle from 
above downwards I cut off the superficial epigastric flush with 
the wall of the femoral, and more than likely took of? some 
extra portion of the wall, as the subsequent dissection of the 
vessel preparatory to ligation showed a perfectly round open- 
ing upon the ventral aspect of the femoral the size of an ordi- 
nary silver probe, or about 2 mm. in diameter (see Fig. i). 

The Needle. — All kinds of needles have been used, and 
I find upon collecting the returns from the answers to ques- 
tions sent out by me to all the members, that the greater 
number use the ordinary Hagedorn. Some use a blunt needle, 
advocated some years ago as a preventative of the very class 
of danger under consideration in this paper. The needle in 
my case, without question, was the cause of my misfortune. 



ACCIDENTS IN HERNIA OPERATIONS. 



211 



Dr. Gerster also claims the same cause in his case. The needle 
which was given me was a large, full-curved, so-called fistula 
needle, or a powerful triangular surgical needle, the edges 
being as sharp as a knife. Objection was raised to such a 



Pig. 1. 



POUPARTSLlQc 



J^^Uqaturl 



\ 

4^^ L/QATURE 




I ^'''L&ATURS: 
(Temporary) 



Diagram showing relations of wound in artery. 

needle being given me, but I was told that no others were 
obtainable from the department at that time, and that the 
one I was given was the only one that would take the suture 
material, a cord-like one-and-a-half mm. kangaroo tendon. 
Although having misgivings, but taking extraordinary pre- 
cautions, I used the needle, passing it from above downwards 



212 JOHN F. ERDMANN. 

after having carefully palpated the pulsating femoral. The 
point passed readily and was grasped by the needle holder. 
A quick jerk to carry the large suture through was followed 
by a profuse flow of dark blood, which was suspected as 
coming from an injury to the femoral vein (see the history). 

There is now no question in my mind that as the full 
curve and sharp edges passed through the aponeurosis the 
superficial epigastric was cut, say just below its base, from 
the femoral (see Fig. 2 — the needle passing around the 
dotted line representing the superficial iliac artery). The 
suture material, dense, large, hard kangaroo tendon, such as 
I was forced to use on my case, is without question a dan- 
gerous suture material, as the necessary tugging, etc., to make 
it pass through the tissue in which a needle puncture may 
have accidentally been made in either vessel will not tend to 
any other result than that of enlargement of the puncture, 
while a soft or small suture material might act as a haemo- 
static in filling the puncture, and also in closing the opening 
by the final knot application. 

Passing of the Suture.^No particular light is obtained 
by the answers received from the members addressed. I can 
conceive only in an academic sense that the passing of the 
needle from above downward is less hazardous than in the 
reverse; that in passing the needle from below upwards one 
directs the point of the needle toward the wave pulsation of 
the vessel, while in the passing of the needle from above 
downwards one follows the stream, so to say, and the wave 
pulsation will cause the artery to strike the curve of the 
needle rather than the point, as in the method from below 
upwards. I fully believe that if the ligament is grasped and 
carried well upward it is not material how the needle is 
passed (see Fig. 2 — forceps grasps the shelving border of the 
ligament and pulls it upwards). 

The Ligament; Exposure and Traction Upon It. — Unless 
the ligament be thoroughly cleared, and traction be made upon 
its shelving border, as shown in the illustration, the danger 
of injury to the vessels is intensified. Should these arguments 



Fig. 2. 




Shows forceps grasping the shelving border of Poupart's ligament, to retract the same 
as far as possible from the vessels; also shows the needle being passed from above down- 
wards, and passing about the high-placed superficial epigastric (i). Normal site of the 
superficial epigastric (2). 



ACCIDENTS IN HERNIA OPERATIONS. 213 

be true, then as a prevention against these accidents it will 
be necessary to consider the needle, the method of passing 
the suture, the suture itself, and finally such precautions in 
regard to the ligament as will give us the best picture of 
the shelving border, and that which will give us the greatest 
room between the ligament and the vessel. 

The Needle. — Although a goodly proportion of the 
Society use the Hagedorn needle, I cannot but feel that safety 
will be enhanced by the use of a round needle with a suffi- 
ciently large eye to take the suture material. 

Passing the Suture. — In passing the suture one can follow 
down the artery with less danger of having the artery transfix 
itself upon the needle than by passing the suture from below 
upwards. The suture material should be soft and pliable, not 
stiff and wiry. 

The Ligament. — Clearing away all areolar tissue, having 
the field perfectly dry from blood so as to be able to observe 
the glistening interior surface of the aponeurosis, and then 
grasping the shelving border in a pair of forceps (see 
Fig. 2), preferably applied over the site of the femoral 
vessels, which have been previously well defined by the palpa- 
ting finger, and then passing the suture as advised above, will, 
I believe, minimize the danger of injuring either the vein or 
the artery in this operation. 

TREATMENT OF THE INJURED VESSELS. 

The Vein. — In this structure our ill-luck has a fortunate 
side to it. We can ligate laterally, and should the injury be 
too large for ligation suture can be done much more readily 
than in cases of arterial injury. 

The Artery. — Lateral ligation is out of the question, and 
either suture of the vessel, or allied methods of arteriorrhaphy 
of Brewer and " Halsted, or ligation distal and proximal to 
the injury must be done. 

There were forty-one responses by the honorary and 
active members of this Society to fifty-two requests sent out. 



214 JOHN F. ERDMANN. 

Some of the members were out of town at the time the final 
statistics of the paper were made up. The following cases of 
injury in inguinal hernia are recorded: 

Case I. — Iliac artery; ligation after unsuccessful trial at 
suture; no untoward result. 

Case II. — Femoral artery in a male; ligature; gangrene; 
amputation ; recovery. 

Case III. — Femoral artery (see history of my case). 

Case IV. — Femoral artery; ligature; gangrene; amputa- 
tion; death. 

By one member, three cases of the femoral vein. In two 
of these cases the bleeding was checked by tying the suture, 
while in the third a large hsematoma developed in ten hours, 
requiring removal of the sutures down to the kangaroo tendon, 
and then firm packing being applied, was successful in checking 
the bleeding. None of these cases were seriously involved. 

One member reports a case of injury to the deep epigastric 
artery, with ligature, and also one of injury to the deep epigastric 
vein with ligature. Another member reports two cases of injury 
to the deep epigastric vein, with ligation, supposed at first to 
have been of the femoral vein. He is not positive now, but 
thinks they were of the epigastric. Mass ligatures were used 
to check the hemorrhage. 

Two other cases, authentic, of injury to the femoral vein, 
are reported to me as occuring in the practice of members from 
whom I have not heard. Both these cases are said to have 
resulted favorably. 

In all these cases the injury was recorded as being due to 
the needle. 

Femoral Hernia. — No injury of the artery has been re- 
ported to me. The following are the instances of the vein being 
punctured : 

Case I. — Femoral vein; ligature drawn checked the bleed- 
ing; no bad result. 

Case II. — Femoral vein; nothing done; result perfect. 

A complete history of my case is reported below. No cases 
are recorded from the literature of this subject. 

Case I. — Dr. John F. Erdmann's service at Gouverneur 
Hospital, March 22, 1908. Mr. A. W., Norwegian, silver- 



ACCIDENTS IN HERNIA OPERATIONS. 



215 



smith, thirty-nine years old, entered the service for a radical 
operation upon a large right-sided inguinal (direct) hernia. No 
medical events of note crop out in his history until he was of 
sufficient age to acquire a gonorrhoea. From the same period 
of his life he drank a bit more than might class him with the 
moderate alcoholic, but not with the pronounced habitue. He 
does not recall the period of onset of his hernia, but knows that 
he has had it for years, and has never used any appliances for 
its cure or to retard its increase in size. For two months previous 
to his admission he has used alcohol to excess, and then found 
the hernia was a source of considerable discomfort. For a 
week he has had pains of varying degrees of intensity in the 
tumor, which would extend occasionally to the lowermost portion 
of his scrotum, and as a result of this pain he entered for 
treatment. 

His physical examination revealed a heart hypertrophied and 
tumultuous in character. No other physical lesions except the 
hernia are found. The hernia is found to be a complete (direct) 
one of considerable size, omental apparently, and reducible in 
part only. 

Operation on March 23. Owing to his late alcoholic habits, 
and his heart, local anaesthesia was used in the beginning. Upon 
exposure of the sac contents numerous and extensive adhesions 
were found. As these were likely to prove troublesome, and 
the patient was becoming restless, general anaesthesia with ether 
was given. The separate stages of the operation were passed 
over smoothly until the placing of the kangaroo tendon. A 
large fistula needle, perfectly new, with its triangular edges as 
sharp as a knife, and measuring one and three-quarter inches 
from tip to eye, was given me, threaded with a strand of hard, 
wiry kangaroo tendon, such as is supplied by the Bellevue and 
allied hospitals. Ordinarily I raise no objection to any needle 
passed me, but this one appeared to me so absolutely an instru- 
ment of danger that I called the assistant's attention to it, and 
requested a different needle. It seems that just at this time 
we were suffering from a dearth of needles and an inability to 
obtain more. This was forcibly brought to my mind by the 
assistant's reply that no needle in the hospital but the one given 
me would carry a tendon for suture. Bearing in mind the 
dangerous type of needle, and also the anatomy of this region. 



k 



2i6 JOHN F. ERDMANN. 

I was more than careful in palpating the site of the femoral. 
With a remark to the Staff that the femoral was under the 
finger I began to pass my suture from above (proximally) 
downwards. The point engaged below and emerged above with- 
out giving any evidence of blood, but upon drawing the needle 
through and giving a sudden jerk to pull the kangaroo through, 
there was a fearful gush of dark blood. I thought that the 
femoral vein was punctured, and so expressed myself. Tying or 
drawing the tendon did not diminish the current of blood. Finger 
pressure was made and Poupart's ligament cut over the course 
of the vessel, and an incision made down the thigh over the vessels 
for a distance of three and a half inches. A careful but rapid 
dissection was then made and a clamp applied in a pool of blood 
to the vessel. It was now noted that our artery was at fault, and 
incidentally the anaesthetist, as our black blood was due to his 
prodigality in administering the ether. A proximal ligature was 
applied, but before tying the knot traction was made with pres- 
sure on the ligature loop. This controlled the hemorrhage suffi- 
cient to allow orientation. The loop was slipped as near as 
practicable to the opening, and then tied. A distal loop was 
applied below the forceps and pressure made as in the former 
instance, and the clamp was then removed. It was now found 
that hemorrhage continued in a stream of several inches in 
height direct from the anterior surface of the femoral artery, 
demonstrating a good collateral supply at this point, at least, from 
the rear. Dissection showed a large branch, evidently anomalous, 
passing from the femoral directly behind the point of injury, 
and that the site of injury was without question that of the 
superficial epigastric, the opening being rather larger than usual, 
and I should say, higher placed than ordinary, being practically 
under the ligament rather than a few lines below. (See Fig. 
I.) My distal ligature was then placed proximally a full one- 
sixth inch more, as another posterior branch was found between 
the former site of the ligature and the source of collateral circu- 
lation. The ligature was then tied and the temporary one 
removed, a ligature was tied about the posterior supply source, 
and the wound closed with as near typical repair of the hernia 
as possible. Considerable blanching of the extremity was 
observed, but we were sure that some circulation was evident 
throughout the entire extremity. All proper precautions for 



ACCIDENTS IN HERNIA OPERATIONS. 217 

warmth, etc., were observed. No complaint by the patient upon 
his recovery from the ether. 

March 24, pulse felt by some of the Staff in the femoral; 
foot warm ; circulation apparently perfect, but not up to normal. 
No complaints from the patient, except such as ordinary hernia 
patients make; wonders why his leg and foot are so carefully 
protected. 

April I, circulation good ; absolutely no untoward evidences. 

April 24, patient has been kept on his back longer than the 
usual hernia case by two weeks. The reasons are evident. 
Discharged to-day perfectly well. 

Called for examination on October 4, hernia recurred to 
slight degree ; no trouble. 

Comments. — I feel quite satisfied that this injury was caused 
by the needle sweeping about or around a high placed superior 
epigastric artery, and as a result of using a large and sharp 
needle its inner edge cut this vessel from the artery, and in so 
doing cut it off at its funnel expansion of origin from the 
femoral; that had I had an ordinary round needle, or even a 
Hagedorn, the delivery of the needle from behind Poupart's 
ligament would not have been followed by injury further than 
that of including the epigastric in my ligature. That had it been 
in the artery or vein the pulling through of the ligature material 
would have very markedly enlarged the opening. That a suture 
of the artery was not practical here for more reasons than that 
of lack of proper needles for this work. That owing to anomalous 
branches posteriorly, which apparently corresponded to the anas- 
tomotic branches of the circumflex, etc., from the profunda, a 
better collateral circulation was present after the ligation, and 
saved in its entirety our patient's limb. 



A NEW CYSTOSCOPE FOR CATHETERIZING THE 
URETERS BY THE INDIRECT METHOD. 

BY PAUL M. PILCHER, M.D., 

OF BROOKLYN, N. Y., 
Surgeon to the German Hospital; Cystoscopist to the Jewish Hospital. 

Although there are many types of cystoscopes offered 
for sale, still there are but few distinct types which can claim 
originality in their construction. Kelly has perfected the 
method of using endoscopic tubes in women, but this has its 
limitations even in his restricted field. 

Nitze devised a cystoscope in which a catheter may be 
passed through the canal of the cystoscope into the bladder 
and then, by means of a mechanical device, the direction of 
the catheter may be so guided that it passes into the mouth 
of the ureter, 

Brenner presented a cystoscope in which it was not neces- 
sary to change the direction of the catheter after it passed 
through the cystoscope, but the cystoscope itself could be 
manipulated so that the catheter might be made to pass directly 
into the ureter mouth without becoming bent in its course. 

Tilden Brown, in 1898, devised a direct catheterizing 
cystoscope which was a great improvement over all other 
types of cystoscope of that class, and allowed the simultaneous 
catheterism of both ureters. 

Casper, of Berlin, in 1901, introduced an indirect double 
catheterizing cystoscope which was very cumbersome. 

Later Brown developed a composite cystoscope which com- 
bined a direct catheterizing device and examining telescopes, 
including a retrograde lens. A year or two later, Lewis, of 
St. Louis, presented a composite cystoscope which closely 
resembles the one devised by Brown. 

Two or three years ago, Bierhof , of New York, improved 
the Nitze cystoscope so that the sheath was constructed inde- 
pendently of the telescope which contained the lens and the 

218 



NEW CYSTOSCOPE. 219 

illuminating device; without moving the sheath the telescope 
could be revolved within the sheath so that every part of the 
bladder might be examined. This instrument, which is made 
in Europe, has certain distinct advantages. 

Each instrument which has been briefly described has 
certain disadvantages. The Kelly cystoscope requires a large 
amount of experience for its proper manipulation, and even 
in the hands of those who have used it most, the results ob- 
tained with it are not so satisfactory as those obtained by 
other methods. In the female, for removal of foreign bodies 
from the bladder and for local applications for the bladder 
it is far better; its size, and the consequent dilatation of the 
urethra which it occasions, are very decided disadvantages; it 
cannot be used in the male. 

The Nitze, which is an indirect cystoscope, is a very 
attractive instrument, but it, too, has certain disadvantages: 
first, it is large; second, if it gets out of order it must be sent 
to Europe for repairs; third, it employs a hot lamp and there 
is constant danger of burning the mucous membrane of the 
bladder; fourth, it is impossible to irrigate the bladder and 
change the medium therein without removing the instrument 
from the urethra, though it may be done after a very awkward 
and time-consuming manipulation of the instrument; fifth, 
the lens cannot be cleansed if soiled ; sixth, it is almost impos- 
sible, with safety, to withdraw the instrument from the blad- 
der and leave the catheters in place because of the direction 
of the catheters themselves in passing from the canals in 
the cystoscope to the ureters, as they are curved in their course 
and are twisted on their own axis, and bind between the 
cystoscope and the urethra, and are subjected to so much 
friction that one cannot be sure that the catheter is not with- 
drawn from the ureter at the same time that the instrument 
is withdrawn from the urethra ; seventh, the lever which directs 
the course of the catheter may easily become locked so that it 
does not lie flat upon the instrument and serious injury may 
be done to the mucous membrane ; and eighth, the instrument 
is so constructed that the complicated parts cannot be removed 
by the physician and properly cleaned. 



220 PAUL M. PILCHER. 

The Bierhof instrument was a distinct advance and al- 
lowed the dismemberment of the instrument so that the com- 
ponent parts could be much more easily cleaned. There is 
one danger connected with his lamp-containing telescope, and 
that is, the joint between the lamp-carrier and the telescopic 
tube is so placed that if the beak of the instrument should 
become caught in the bladder wall, it would be possible, in 
turning the handle of the instrument, to unscrew the lamp and 
leave it in the bladder. A second point of disadvantage is 
the difficulty experienced in preventing the fluid from leaking 
out alongside the catheter, so that only one size of catheter 
may be used ; also, the instrument presents the same difficulty 
found in the Nitze in removing it, the catheters are so twisted 
and bent that it cannot be done without the danger of pulling 
out the catheters from the ureters. 

In the instrument devised by the writer, the aim has 
been to eliminate some of these disadvantages: first, the in- 
strument is made up of three parts that may be dissembled 
and thoroughly cleaned ; all excepting the telescope, containing 
the lens, may be boiled and sterilized as you would any other 
instrument. The telescopic tube {Fig. A) is complete in itself, 
containing the lamp and lens; this may be used by itself as 
a simple examining cystoscope; its size is number 14 French. 
Attached to this telescope is the device which carries the 
catheter tubes and a new type of deflector; these catheter 
tubes may be open or closed as the user desires. The deflec- 
tor consists of a simple piece of steel hinged on a pinion be- 
tween two parallel steel-wire bars ; as the deflector is advanced 
it strikes a slightly inclined plane that diverts its axis so that 
it assumes gradually a position at right angles to the instru- 
ment; its relation to the ends of the catheter-carrying device 
being such that the catheters are deflected to almost any angle 
desired, the tips of the catheters being, when properly ad- 
vanced, always within the field of the lens. 

Figure B shows a view of the superior surface of the 
part of the instrument carrying the deflector and the catheter 
tubes; Figure C, 2l lateral view; and Figure D, the inferior 



I 



NEW CYSTOSCOPE. 321 

view of the same. This telescope and deflecting device are 
contained within a sheath shown in Figure E; the sheath 
is so constructed that when the beak containing the lamp is 
turned, as in the Bierhof instrument, the catheters projecting 
from their tubes lie horizontally and there is nothing to bind 
them or bend them in their course between the ureter open- 
ings and the tubes, so the instrument may be withdrawn with 
the slightest resistance and friction. Figure E shows the 
sheath with the deflector out of sight. Figure F shows the 
sheath and the relation of it to the deflector. Figure G shows 
the vesical end of the completed instrument; Figure H, the 
vesical end with the catheters deflected; Figure I, the exter- 
nal end of the completed instrument that contains the irrigat- 
ing tubes and the wheel for controlling the deflector and the 
electrical connection. 

The advantages of this instrument over those previously 
devised are : ( i ) that it may be properly sterilized after using ; 
(2) that a relatively large catheter may be used; (3) that the 
deflecting device is so constructed that it cannot injure the 
urethra in the withdrawal of the instrument; (4) that the 
bladder may be irrigated while the catheters are in place; (5) 
that the opening of the sheath is so constructed that the 
catheter may lie flat in withdrawing the instrument and there 
is nothing to bind it as in other instruments, which may be 
better shown in the last figure (Fig. i ) illustrating the catheter 
entering the ureter and the instrument prepared for removal. 
The illustrations give a fair idea of the construction of this 
instrument and, after using it for a year, the writer is satisfied 
with it for use in the female — the original instrument causing 
too much traumatism on the male urethra to be useful in men. 

About six months after the construction of this instru- 
ment for the writer, the same makers made for Dr. Buerger, 
of New York City, an instrument which shows some distinct 
improvements over the present cystoscope. The same opening 
in the sheath is retained and an obturator fitted to it that 
makes it easy of introduction in the male; the lamp is con- 
structed as part of the sheath and is not connected with the 



222 



PAUL M. PILCHER. 




NEW CYSTOSCOPE. 



223 



LU 





CO 




324 PAUL M. PILCHER. 

telescopic tube. Both instruments are made by the Wappler 
Electric Controller Company, of East 87th Street, New York 
City, and while the instrument of Buerger is an improvement 
over that of the writer, still it presents the disadvantage which 
the writer has tried to overcome in withdrawing the instru- 
ment, leaving the catheters in the ureters. 

Fig. I. 




Showing the cystoscope in place, with the catheter in the ureter, preparatory 
to removal of the instruments leaving the catheter in place. 

The writer presents this instrument fully realizing its 
defects, but he believes that it presents certain new principles 
in the construction of the cystoscope which will eventually 
lead to the production of a practical instrument that will 
encourage more surgeons to use the cystoscope in the diagno- 
sis of diseases of the kidney and bladder. 



A NEW INDIRECT IRRIGATING OBSERVATION 

AND DOUBLE CATHETERIZING 

CYSTOSCOPE. 

BY LEO BUERGER, M.D., 

OF NEW YORK, 

Assistant Adjunct Surgeon and Associate in Surgical Pathology, Mt. Sinai Hospital; 

Associate Surgeon, Mt.Moriah Hospital; Cystoscopist, 

West Side German Dispensary. 

In spite of the fact that a large number of modifications 
of the Nitze cystoscope have been offered to the genito- 
urinary surgeon during the past ten years, we still do not 
possess an ideal indirect vision instrument which will per- 
mit of irrigation while the process of double catheterization 
is going on. About nine months ago I)r. F. Tilden Brown 
designed an indirect vision telescope and catheter bed which 
could be attached to his " composite cystoscope " and which 
promised to fill this want. Working along similar lines, but 
adhering more strictly to the original type of the Nitze instru- 
ment, I have been able to develop an instrument in which 
the Brown sheath, with certain necessary changes, has been 
combined with the Otis telescope and the Albarran deflecting 
device, in such a manner as to overcome most of the objec- 
tionable features possessed by the older instruments. 

The instrument consists of three parts, the sheath, the 
obturator and the catheterizing telescope. The sheath is cir- 
cular on cross section, bears a very short lamp at its end, 
measures eight and one-quarter inches in length and possesses 
a large fenestra or window behind the lamp. Its calibre is 
24 of the French scale (Figs. 2 and 3). Save for the lamp, 
which points to\vard the concavity of the instrument and 
the window, the sheath has much in common with that em- 
ployed in Brown's direct vision cystoscope. 

The obturator, which closes the working aperture, is 
perforated so as to allow irrigation even when it is in situ, 
through the two lateral faucets in the sheath. 

8 225 



226 



LEO BUERGER. 



Fia. lb. 



Fig. 




f 



Fio. la. 



V 



T 






Sheath. 



Obturator. 



Catbeterizing telescope. 



CATHETERIZING CYSTOSCOPE. 



227 



The catheterizing telescope combines in one piece the 
optical apparatus, the mechanism for deflection (Albarran) 
and the catheter grooves or beds. A glance at Fig. ib will 
show that the telescope carries a double grooved bed upon its 
upper aspect. This is large enough to permit the lodgement 
of two number 7 French ureteral catheters. At the end near 
the lens this gives way to a closed ring in which the tips of 
both catheters are held secure. A large deflector or catheter- 
lift is implanted between the lens and the ring and hinges on 
a small wedge, which latter serves the double purpose of 
fulcrum and inclined plane for giving the catheters their pri- 
mary deviation. All the parts are exposed so as to permit 
easy cleansing and easy repair. 




Catheterizing telescope in place. 



The technic of its employment is as follows : The sheath 
with obturator in situ is introduced into the bladder; the 
obturator is then removed and the bladder irrigated through 
the open end of the sheath. After evacuation of the irrigating 
fluid the telescope with the two catheters in place is intro- 
duced. The bladder is now distended with the requisite 
amount of fluid through one of the two irrigating faucets. 
The catheterization of the ureters is effected in the same way 
as in the Nitzen-Albarran instrument. 

It may not be amiss to give the details of a procedure 
for catheterizing the ureters which varies somewhat from 
that which is usually laid down in the text-books, but which 
has given me the most satisfaction. 

I. The ureteral opening is found and the ocular end of 
the cystoscope is brought slightly to the opposite side of the 
patient. By raising the shaft the ureteral slit is made to oc- 
cupy a point just below the centre of the field. This position 
must be rigidly maintained during the next two steps. It is 



228 



LEO BUERGER. 



best to get a picture of the ureter which is about the normal 
size ; this is obtained when the objective is at a distance of i to 
1% inches (Figs. 5, 6 and 7). 

2. After the deflector has been shghtly raised (just suf- 
ficient to prevent the catheter from hugging the lens) the 



Fig. s. 




Position of cystoscope in normal ureteral catheterization. 



catheter is pushed forward about i to 1.5 centimetres beyond 
the limit of the field. Now the catheter appears enlarged, 
for it lies close to the prism (Figs. 8, 9 and 10). 

3. The deviation is gradually increased by raising the 
deflector, the movement of the catheter in the field being 
observed during this procedure. The tip of the catheter now 
comes into view, first appearing at the bottom of the field and 
gradually travelling upward, its size diminishing at the same 



CATHETERIZING CYSTOSCOPE. 



229 



time. When its tip is a short distance above ^ the ureter, it 
is usually in the proper position; in reality it then lies in front 
(nearer the neck of the bladder), above, and slightly to the 
inner side of the ureteral mouth (Figs. 11 and 12). 



Fig. 6. 




Normal ureteral catheterization: first move; cystoscope in normal poiition. 

Fig. 7. 




Cyttoscopic view: we see the ureter somewhat^below the centre of the field; 
view seen in Fig. 6. 

4. By now raising the shaft of the instrument, and at 
the same time passing it further into the bladder, the tip of 
the catheter is made to enter the mouth of the ureter. ^ There- 

* Apparently " above " — that is, " above " in the field ; or, if we wish 
to regard it so, "behind" in the field. 

* We must remember that when we raise the ocular, the ureter seems 
to travel down the field; when we push the instrument further into the 
bladder, the ureter goes up the field. Hence the degree motion of the 
cystoscope into the bladder must exceed the lifting of the shaft in order 
to make the ureter meet the tip of the catheter. 



23© 



LEO BUERGER. 



fore the cystoscope and catheter as a whole travel towards 
the opening and not the catheter alone (Figs. 13 and 14). 
In the picture we see the ureter ascend to meet the catheter 



Fio. 8. 




Normal ureteral catheterization: second move; the tip of the catheter lies beyond the field. 

Fig. 10. 
Pig. o. 





Fig. 9. — Cystoscopic view: the catheter is being pushed across the field. 

Fig. 10. — Cystoscopic view: the catheter lies beyond the field; view seen in Fig. 8. 

at about the middle of the field. When the catheter has en- 
gaged the ureteral opening it is pushed a short distance for- 
ward, the deflector is depressed somewhat, and, by still further 
raising the ocular, the introduction of the catheter becomes 
easy. 



CATHETERIZING CYSTOSCOPE. 



231 



The lid (deflector) is now turned down, the other ureter 
sought, and the same method employed. 

After a little practice we learn just how far to push the 
catheter before giving it the complete deviation,^ The amount 



Fio. II. 




Normal ureteral catheterization: third move; the catheter has received its full inclitiation. 

Fig. I a. 




Cystoscopic view: thecatheter tip lies Just above the ureteralopening; view'seen in Fig. 1 1 . 

of unsheathed or exposed catheter must be such that the 
catheter tip projects about i to 2 centimetres beyond the level 

• The primary deviation must be very slight, just enough to prevent the 
catheter hugging the lens. Of course if the catheter be deflected too much 
at the start, then a much greater portion can be pushed out before it 
reaches the periphery of the field. In using the Nitze instrument I usually 
make the catheter pass i to 1.5 centimetres beyond the field (no primary 
deviation having been given), then deflect it as described. 



232 



LEO BUERGER. 



of the tip of the lamp. This leaves sufficient room for the 
instrument to travel, and the chances of contact between lamp 
and bladder virall are very slight. 

Although this may be considered as a normal method, 
certain variations in technic will be required in difficult or 

Fig. 13. 




Normal ureteral catheterization: fotirth move; by the forward motion of the instru- 
ment and the ascent of the ocular, the tip of the catheter is made to enter the ureter. 



Fig. 14. 




Cystoscopic view; catheter has entered; view in position^'ig. 13. 



anomalous cases. Thus, we may find it advantageous to 
change the amount of deflection; or to retain the maximum 
deviation while pushing the catheter along the ureteral canal. 
If we see that the bladder wall is being raised considerably 
by the entering catheter, we know that the anterior wall of 
the ureter is being lifted up by the catheter. This occurs es- 



CATHETERIZING CYSTOSCOPE. 



233 



pecially when stiff catheters are used and when the deflector 
has been turned down too far. For in both instances the 
catheter has a tendency to seek a higher level, one approaching 
the plane of the shaft of the instrument. To overcome this, 
three manoeuvres are permissible, either raising the ocular 
so as to bring the ureters more nearly in the direction of the 
ureteral canal, or increasing the deflection, or a combina- 
tion of both. 



Fio 




Removal of sheath: first position; the telescope has been removed; the catheters lie loose 

in the sheath. 



If carefully carried out this procedure is far superior to 
that by which the catheter is " aimed " at the opening and 
pushed out to meet it. It affords a more certain way of hit- 
ting the mark, avoiding scraping of the bottom of the blad- 
der, and, with the long deflector provided in the new instru- 
ment, is extremely easy of execution. 

The catheter-bearing telescope and sheath have been so 
proportioned that even when two number 7 French ureteral 
catheters are being used, sufficient space is left to allow irri- 
gation of the bladder during the process of catheterization. 



234 



LEO BUERGER. 



The following manipulations will enable us to remove 
the instrument with ease, leaving the catheters in the ureters. 
After having introduced the catheters a little higher than we 
would if the instrument were to remain in the bladder, and 
after removal of the telescope, the following movements should 
be carried out : first, the ocular is depressed and carried a lit- 



FiG. i6. 




Removal of sheath: second position; with depressed octilar; the beak and catheter* 
are disengaged. 



tie to the left, thus separating the beak from the line of the 
catheters (Figs. 15 and 16) ; second, the whole instrument is 
rotated to the right on its longitudinal axis through an arc 
of 180 degrees, retaining the relative position just described, 
thus making the beak point upward (Fig. 17) ; third (still 
in the same plane, with the ocular a little to the left), the 
ocular is raised and brought back to the median line in order 
to bring the convexity of the beak against the trigone of the 
bladder (Fig. 18) ; and fourth, the sheath is removed, its 



CATHETERIZING CYSTOSCOPE. 



235 



inferior aspect being made to hug the posterior wall of the 
urethra. 

Should we desire to use the cystoscope for observation 
only, a telescope giving an extraordinarily large field can be 
inserted instead of the catheterizing apparatus, A retrograde- 
vision telescope or a small telescope with operating instru- 
ments may be also substituted. 



Fio. 17. 




Removal of sheath: third portion; the beak is turned up. 



Some of the special features may deserve mention before 
we sum up the advantages of this instrument. First, the 
small size of the lamp diminishes the likelihood of contact 
between lamp and bladder wall.* Second, the distance be- 
tween the distal end of the filament (which point corresponds 

*If we desire to use the instrument for observation alone a larger 
lamp may be screwed on; this is not essential. 



236 LEO BUERGER. 

to the brightest part of field) and the centre of the objective 
lens has been reduced as much as possible in order to attain 
the maximum illumination for any given sized lamp. Dr. F. T. 
Brown had already suggested this improvement for the Otis 
observation cystoscopy Third, the large size of the deflector 
gives firm support to the catheters. Fourth, the relative posi- 
tions of the lens, deflector and margin of the window are 
such that catheterization is easy, the catheters always remain- 
ing in the field when properly deflected ; and fifth, no difficulty 

Fig. 18. 




Removal of sheath: the sheath is being removed. 

is encountered in deflecting the second catheter even when 
number 7 French catheters are employed. 

The advantages of the combined indirect irrigating ob- 
servation, double catheiterizing and operating cystoscope over 
others of its type may be summed up as follows : 

1. The employment of a catheter for washing out the 
bladder is not necessary, the sheath serving this purpose. 

2. Because of its small calibre (24 French ),** its round 
shape, and its smoothness in the region of beak and window, 
the introduction of the instrument is easy and injury to the 
deep urethra is avoided. 

* If we are satisfied with the use of two No. 5 or 6 French ureteral 
catheters, the instrument can be constructed so that its calibre is 22 French. 



CATHETERIZING CYSTOSCOPE. 



237 



3. It carries larger catheters than any other indirect 
vision cystoscope, although its diameter is smaller. Two 
number 7 French catheters pass with ease. 

4. The telescope and sheath may be removed, leaving 
the catheters in (the ureters. 

5. Irrigation of the bladder may be very rapidly effected 
by removing the whole catheter-bearing telescope or by wash- 
ing through the faucets in the sheath. This may be continued 
whilst the process of catheterization is going on. 

6. By the employment of the grooved beds the catheters 
are separated in such a manner that friction between them is 
impossible; a new catheter can be inserted at any time with- 
out removing the telescope. This was borrowed from the 
improved Brown instrument. 

7. The proximity of lamp and objective lens gives the 
best illumination for catheterizing purposes. 

8. The small size of the lamp makes the chances of con- 
tact with the bladder wall small. 

9. Inasmuch as the catheter-bearing mechanism is sep- 
arable from the sheath and is not introduced until the bladder 
is clean, the likelihood of carrying infection into the ureters 
is reduced to a minimum. 

10. A large telescope for indirect or retrograde vision 
may be used in the same sheath. 

1 1. A small telescope will leave ample room for the intro- 
ducing of operating instruments of various kinds, 

12. The addition of a correcting prism to the ocular pro- 
duces an upright picture and enhances the brilliancy of illum- 
ination ^ (orthocystoscopy). 

It gives me great pleasure to acknowledge my indebted- 
ness to Dr. Abraham Wolbarst, Chief of the Genito-urinary 
Clinic at the West Side German Dispensary, for his kindness 
in having placed much of his large clinical material at my 
disposal; and further I vnsh to thank Dr. F. Tilden Brown 
for his kindly interest and encouragement. 

•The instrument was constructed for me by the Wappler Electric 
Controller Co. with the efficient aid of Mr. R. Wappler. 



COMPLETE DENUDATION OF THE PENIS. 
BY CHARLES A. POWERS, M.D., 

OF DENVER, COLO. 

On the afternoon of November 17, 1907, F., a lad of six 
years, while escaping from an angry farmer, hastily climbed 
through or over a barbed-wire fence. He tore his clothes, sus- 
tained some scratches and on arriving home found that he had 
injured his penis. He was not seen by a physician until the fol- 
lowing morning when Dr. P. V. Carlin attended him, sent him 
to St. Joseph's Hospital in Denver and kindly asked me to see 
him. 

Upon examination it was found that the skin at the base 
of the penis, just at its junction with the body, had been divided 
through its entire circumference and to the deep fascia as cleanly 
as though with a knife, this division including a little of the 
scrotum. The skin of the penis had then been completely everted, 
stripped off and down so that it was hanging as an inverted tube 
at its preputial attachment. The condition is shown in Fig. i : 
the skin was, however, hanging at its mucocutaneous junction 
rather than at the site of the corona as shown in the picture. 
The artery of the f raenum could be plainly felt. The boy had been 
urinating through this inverted tube, which, as said, had been 
peeled off much as one would invert the finger of a glove in 
removing it. 

The vitality of this inverted skin seemed questionable, at 
its cut end it tended to slough. Under ether the parts were well 
cleansed, the questionable tissue cut away, and the inverted skin 
tube replaced on the penis. The abdominal and scrotal skin were 
dissected up a little and the edges approximated by interrupted 
horse-hair sutures. 

About one-fifth of the skin at the base of the penis sloughed, 
this sloughing being rather greater on the left side than on the 
right. This condition is shown in Fig. 2, a sketch made from 
life on the eighth day. The parts closed in easily and promptly 
by granulation and at the end of four weeks healing was complete. 
The foreskin gradually retracted over the glans. At the end of 
238 



FIG 1. 



■'^m^>. 










X',,.:.:'' 




y/ 



f FIG. 2. 




v^'M 



\ 



^C I A'' ' 



" > 




i 



Fig. I.— Complete denudation of the penis. Condition eighteen hours after the accident. 
Fig. 2.— Complete denudation of the penis. Condition on the eighth day. 



Fig 3 




Complete denudation of the penis.— Condition at the end of eight weeks 



DENUDATION OF PENIS. 239 

the eighth week the condition resembled that following ordinary 
circumcision. Fig. 3 shows a sketch made at this time. There 
was no constriction at the base of the penis, the skin was fairly 
movable. 

At this time, one year after the accident, the boy notices no 
inconvenience. According to his account, carefully gained, urina- 
tion and erections are normal. There is no cicatricial constriction. 



THE OPERATIVE TECHNIC OF CARCINOMA OF 
THE PENIS. 

BY JAMES H. NICOLL, M.B., 

OF GLASGOW, 
Professor of Surgery in Anderson's College ; Surgeon to the Western Infirmary. 

During the past fourteen years I have employed the fol- 
lowing method of operating for removal of penile carcinoma. 
In November, 1905, in describing it to the Glasgow Patho- 
logical and Clinical Society (vide Glasgow Medical Journal, 
May, 1906), I made reference to the results in cases treated 
which had passed the three year period, and to tw;o cases which 
had not. Of these two cases, one (patient sent by Dr. John 
Maclntyre), in which there was extensive involvement of the 
deep inguinal glands, had fatal recurrence in the region of 
these glands within a year; the other (sent by Dr. Jas. Steven- 
son), in which the disease was in less advanced stage, is free 
from recurrence three and a half years after operation. Dur- 
ing the past three years I have not seen a case of penile car- 
cinoma, but within the past three months have operated on 
two in the Western Infirmary of Glasgow. The same method 
has been employed as in former cases. Its object is the re- 
moval, en masse, of the primary carcinoma, the fat and glands 
of the groins, and the lymphatic vessels intervening between 
primary growth and area of probable or actual secondary 
extension. This is, of course, the object of all modem opera- 
tions for carcinoma wherever occurring. 

In the penis, carcinoma is practically always an epi- 
thelioma originating on the surface of glans or prepuce, 
usually in the region of the corona. 

The lymphatics of the anterior half of the penis pass 
almost wholly to the dorsum, the main channels passing back 
on either side of the dorsal vein to the oblique set of super- 
ficial glands of the groin, in the first instance, secondarily 

240 



CARCINOMA OF PENIS. 



241 



thence to the deep inguinal glands lying along the external 
inguinal vessels on the brim of the pelvis. Few, if any, of the 
lymphatics from the anterior half of the penis pass to the deep 
lymphatic vessels of the root of the penis, which channels pass 
under the pubic arch to the intrapelvic glands. 

Epithelioma of the penis (prepuce and glans) like chancre 
in the same region, primarily extends along the dorsal 
lymphatic channels on either side of the dorsal blood-vessels 
and affects the glands of the groin and the deep inguinal glands 
along the brim of the pelvis. Only late in the progress of the 
disease does the growth infiltrate the corpora cavernosa and 
the posterior portion of the corpus spongiosum, and thus reach 
the lymphatics which are under the pubic arch, and, through 
these, the intrapelvic glands. When such infiltration of the 
proximal portion of the penis and invasion of the intrapelvic 
glands have occurred the case is inoperable in the vast majority 
of instances. For such advanced cases various extensive 
operations, including the bisection of the scrotum and the 
detaching of the crura penis from the pubic arch, have been 
introduced, and may possibly be justifiable in a few cases. 

The usual, operable, case of penile carcinoma presents a 
growth in the anterior fourth or third of the penis, with pos- 
sible extension along the dorsal lymphatics and involvement of 
the superficial glands of the groin, and, through them, the 
deep inguinal glands along the external iliac vessels. There 
is no infiltration of the posterior part of the penis, nor are the 
lymphatics under the pubic arch infected. Operative meas- 
ures should aim at the removal of the anterior two-thirds or 
three-fourths of the penis, plus the dorsal blood- and lymphatic- 
vessels (with their surrounding connective tissue) back to the 
pubes, and plus, further, the fat (and contained lymphatic- 
glands and channels) of both groins. All the structures men- 
tioned should be removed in one mass. In cases in which 
glandular involvement has extended under Poupart's ligament 
from the superficial inguinal to the deep inguinal glands, these 
latter must also be removed. 

The entire operation is carried out through a Y-shaped 



242 JAMES H. NICOLL. 

incision, — strictly a Y-shaped incision. The steps in its execu- 
tion are as follows : 

1. Having passed a sound, make the incision indicated 
in Fig. I. The " arms " of the Y extend along the folds of 
the groin — or along a line more or less parallel with that fold 
but somewhat above it — from a point at the root of the penis 
on the pubic crest outwards towards the superior iliac spine. 
The " leg " of the Y, carried along the dorsum of the proximal 
fourth of the penis, terminates in the loop which constitutes 
the " foot " of the Y, which loop obliquely encircles the penis. 
That loop is skin-deep only, the " leg " is carried more deeply, 
and the "arms" are ultimately deep wounds (see Fig. i). 

2. Dissect out all fat and contained lymphatic channels 
and glands, en masse, from both groins. Hemorrhage may 
be largely avoided by reflecting the lower skin flaps first, 
towards the thighs, thus securing at once the superficial epigas- 
tric, superficial circumflex and external pudic arteries and veins 
where they perforate the deep fascia. These vessels once se- 
cured, the upper flaps are reflected and the whole fat of the 
groins rapidly raised en masse from the deep fascia lata of 
the groins and the aponeuroses of the external oblique 
muscles. 

In cases in which the step is indicated, next open the 
fascia lata just below, Poupart's ligament, and, having exposed 
and opened the femoral sheath, and raised and repressed the 
peritoneum, remove the fat and glands along the external iliac 
vessels, pushing aside or tying the deep epigastric vessels. 

3. Dissect out the dorsal blood-vessels and lymphatic 
channels of the penis (with all surrounding fascia) leaving 
the sheaths of the corpora cavernosa bare on their dorsal aspect. 
Tie the dorsal arteries and vein close to the pubes at the sus- 
pensory ligament of the penis. The fat of the groins, and the 
fascia and vessels of the dorsum of the penis form one con- 
tinuous mass containing the unbroken lymphatic channels. 

4. At the line of the loop-incision round the penis, pass 
the knife between the corpus spongiosum and the two corpora 
cavernosa, and divide the latter. 



Fro. r. 




O incision. The " O " loop obliquely encircles the penis, and is merely'skin-deep. The 
" leg " extends along the dorsum of the penis. Through it the dorsal lymphatics are dissected 
out en masse with the dorsal blood-vessels and surrounding areolar tissue. The "arms" 
extend along the folds of the groins. They constitute deep wounds, through which are 
removed all the superfical inguinal glands and surrounding fat, and through which, also, 
are removed any deep inguinal glands found on exploration of the retroperitoneal fat around 
the iliac blood-vessels on the brim of the pelvis. 



FjG. 3. 




Penis removed. The corpus spongiosum is left longer than the corpora cavernosa, and 
is cut obliquely to leave the lower lip longer than the upper. The urethra and surrounding 
corpus spongiosum are shown in process of being split transversely. 



m 



Fig. 




Wound sutured, showing the long spout-like inferior lip of the urethral orifice, and the 
drainage tubes necessary to provide for the lymphorrhoea which follows the extensive 
removal of the lymphatics of the groin. 

NoTB. — In practice the portion of the penis left is shorter than is indicated in the 
illustration. 



FlO. 4. 




Photograph showing parts removed: i, anterior two-thirds of 
penis; a and 2', fat and contained glands of groins united to penis 
by the vessels, lymphatics, and fibrous tissue of the dorsum of the 
penis. 



CARCINOMA OF PENIS. 



243 



5. Withdraw the bougie, and divide the corpus spon- 
giosum. This should be done at a point somewhat anterior 
to the line of division of the corpora cavernosa, thus leaving 
the spongy body and divided urethra rather longer than the 
cavernous bodies. Further, it should be done obliquely, to 
leave the inferior lip of the divided urethra longer than the 
superior (Fig. 2). 

6. Split the urethra and spongy body transversely to the 
extent of one-third of an inch (Fig. 2). 

7. Secure the arteries of the corpora cavernosa, and the 
arteries of the corpus spongiosum. No -tourniquet is possible 
in the operation, and these vessels will have been temporarily 
clamped by pressure forceps on division of the penis. In the 
application of the forceps time and blood are saved by clamping 
each vessel en masse with some of the surrounding cavernous 
tissue. Similarly the ligature should include all that is held 
in the forceps. The penile tissue is occasionally so friable 
that attempts to isolate these vessels fail. Where hemorrhage 
proves difficult to control by ligature (a rare event) it may be 
checked by encircling the cavernous body by a suture having a 
" bite " in the tough penile sheath. Preliminary ligature of 
the internal pudics is unnecessary. 

8. Close the wound by suture as indicated in Fig. 3. The 
oblique direction of the skin incision encircling the penis, the 
fact that the spongy body is cut longer than the cavernous 
bodies, and the oblique division of the urethra itself all com- 
bine, when the wound is sutured, to the shaping of a meatal 
orifice with a " spout-like " inferior lip, a matter of prime 
importance in the subsequent comfort of the patient in 
micturition. 

9. Drainage is necessary (Fig. 3). One effect of the 
wholesale clearing of the fat and lymphatics from the groin 
is a lymphorrhcea through the groin-wotmds. This is usually 
sufficient to " bag " the wounds if undrained, and may be 
excessive, necessitating change of dressings several times daily. 
Such lymphorrhcea is unknown in the axilla after operation 
-for mammary carcinoma. 



244 JAMES H. NICOLL. 

10. A soft catheter is fixed in the urethra by sutures for 
several days — or regular catheterization is carried out for the 
same period. Thereafter the patient is permitted to i>ass urine. 

11. The method of dressing is of somewhat special im- 
portance. The wound is dressed in two parts : (a) the groins 
— the very free clearing out of the fat from the groins leaves 
the skin extensively undermined. As the patient lies in bed he 
naturally partly flexes his thighs. This brings the loose skin 
away from the subjacent parts, suspending it so far in mid 
air. To keep it in contact with the deeper tissues it is neces- 
sary to put in each groin a considerable mass of dressing. 
These masses are secured by a double spica bandage, (b) The 
penile stump is merely covered with a small guard of gauze, 
wrung from boracic or other bland fluid, and frequently 
renewed. This is secured by a couple of catch pins to the 
spica bandage. 



CARBOLIC ACID GANGRENE OF FINGER. 
BY JAMES A. KELLY, M.D., 

OF PHILADELPHIA, 

Visiting Surgeon, St. Mary's Hospital; Pathologist and Instructor in Surgery, Philadelphia 
Polyclinic Hospital and College. 

Considering the general use of carbolic acid in surgical 
antisepsis and its sale at drug stores without a prescription in 
solutions of all strengths, it is a remarkable fact that there 
are not more cases of gangrene seen following its indiscrimi- 
nate use. Those cases which are found are doubtless due to 
ignorance on the part of the laity in the use of weak and 
even moderately strong solutions, and on the part of the 
profession to gross carelessness. I wish to report the follow- 
ing case as an instance of the former practice. This case was 
observed in the surgical out-patient department of the Poly- 
clinic Hospital, in the clinic of Dr. Francis T. Stewart, to 
whom I am indebted for permission in reporting this case. 

E. W., a woman 27 years old, married. Polyclinic Hospital, 
Out-patient Department; on records No. 2T,yyy\ clinic of Dr. 
F. T. Stewart. Patient's family and previous history negative as 
far as they could have any bearing on the condition reported. 
First observed Feb. 24, 1908. The patient stated that on Feb. 21, 
1908, she punctured her index finger with a small splinter of 
wood, which was removed immediately. The following day the 
finger began to swell so that last evening, Feb. 23, 1908, she 
applied to the finger a cloth saturated with a weak solution of 
carbolic acid of unknown strength, which she had obtained at a 
drug store. This dressing remained in place from 11 p.m. until 
4 A.M. the next morning. It was removed on account of the pain 
in the finger. The dressing had become dry. She then noticed 
that the finger was numb, cold, discolored and dry, and at the 
base of the finger there was a distinct line of demarcation, and 
at this region there was intense pain present. When first seen by 
the writer the finger presented the following conditions : the ter- 
minal half of the left index finger was bluish white in color, which 

245 



246 JAMES A. KELLY. 

extended on the flexor surface to the middle of the proximal 
phalanx, and on the extensor surface to the first interphalangeal 
joint. At the tip of the finger there is a blister containing serum, 
slightly blood-tinged. The skin over this blister is yellowish- 
blue. To the proximal side of the line of demarcation, the finger 
is swollen, red, very tense, and painful on pressure. This redness 
gradually fades to the normal color of the skin as the base of the 
finger is reached. Complete, superficial, and deep anaesthesia of 
the involved portion of the finger is present. On puncture with a 
needle in the involved area the tissue of the finger is found to be 
dry excepting in the region of the blister above mentioned. The 
patient was advised to have the finger amputated, but refused. A 
dressing of boric acid ointment was then applied with the under- 
standing that the patient would return in two days for amputa- 
tion if the condition had not improved. The patient failed to 
return to the clinic, but went to another hospital two days later 
and then the finger was amputated at the metatarsophalangeal 
joint. 

Figs. I and 2 show the flexor and extensor aspect of the 
involved finger. 

That the condition is not a rare one may readily be seen 
from the reported cases in the literature. Honsell in 1897 
reported 48 cases; Von Bergmann states that in 61 cases 
collected, the strength of the solution used was i to 5 per cent, 
in 30 cases, and concentrated in 31 cases; Kortiim reports that 
he has observed gangrene following the use of moderately 
concentrated solutions of carbolic acid, in three to four hours ; 
Von Bruns and Peraire report cases in which gangrene fol- 
lowed the use of a i per cent, solution for 24 hours; and Levai 
cites cases in which a 2 per cent, solution applied for 12 hours 
produced gangrene. 

Kortiim regards the cause as neuropathic. Franken- 
berger states that " the epidermis is destroyed ; the submucous 
tissue shows considerable transudation, and the contents of 
the lymph- and blood-vessels are coagulated. Gangrene fol- 
lows the thrombosis of the vessels." 

Levai and Honsell made a series of experiments and 
arrived at the conclusion that " it is very probable that the 



Fig. I. 




Carbolic acid gangrene of finger. Flexor surface of hand. 



Fig. 




Carbolic acid gangrene of finger. Extensor surface of hand. 



CARBOLIC GANGRENE OF FINGER. 



247 



action of carbolic acid is not a specific one, but is analogous 
to that produced by mineral acids." 

Von Bergmann states, " Individual disposition probably 
plays a certain part, as I remember in my experience, during 
the period when carbolic acid was still used in the treatment 
of wounds ; and a difference in toleration was noticed." 

The author is inclined to consider that in the use of 
weak solutions of carbolic acid there is not a primary destruc- 
tion of the epidermis, as Frankenberger states, but that the 
primar}'^ changes are of a neuropathic character; this is fol- 
lowed by a slowing of the blood current in the part affected, 
with transudation of the elements of the blood, and that, 
following the blocking of the blood and lymphatic system, 
coagulation takes place as a specific result of the action of 
the carbolic acid, which necessarily becomes stronger in char- 
acter as the watery elements of the solution disappear through 
evaporation. 

In the treatment of this condition one should not hastily 
advise amputation. Very often only a superficial necrosis of 
the part is produced, and by conservative treatment the part 
may be saved, and the necrosed area covered by skin-grafting. 
When the part has become dry, and bluish-black in color, and 
it is evident that complete gangrene has taken place in the 
part, then, and only then, should amputation or exarticulation 
be performed above the line of demarcation. 



TRANSACTIONS 

OF THE 

NEW YORK SURGICAL SOCIETY. 



Stated Meeting, November ii, 1908. 
The President, Dr. Joseph A. Blake, in the Chair. 



ACUTE HEMORRHAGIC PANCREATITIS. 

Dr. John F. Erdmann presented a woman, 22 years old, 
who, when she was first seen by Dr. Erdmann, on August 13, 1907, 
gave the following history: On June 13 she had a pain in her 
abdomen, and for some time previous to that date she had 
suffered from " spoiled stomach." The pain in the abdomen was 
typical of gall-stones, the pain continuing for a few days, and 
was accompanied by vomiting. Between June 13 and August 
13, 1907, she had a number of similar attacks, and in one of 
them she became markedly jaundiced. On the 12th of August 
she had a sharp abdominal pain, intense and back-splitting, which 
immense doses of morphine failed to relieve. 

When the patient was brought to the sanitarium, she pre- 
sented more or less evidence of shock, with rise of temperature 
and rapid pulse, and intense pain in the epigastric region; this 
extended laterally into the back and also to the area of the gall- 
bladder. A probable diagnosis of acute hemorrhagic pancreatitis 
was made. A suggestion to open the abdomen that night was 
refused, but the following morning the conditions were so much 
worse that the members of the family themselves saw the change, 
and consented to an operation. 

Upon opening the abdomen there was a free gush of beef- 
broth-like fluid, and some evidences of fat necrosis. The pan- 
creas was rapidly exposed and found to be profoundly hem- 
orrhagic. The oedematous infiltrate extended retroperitoneally 
toward the hepatic flexure and the ascending colon. Palpation 

248 



GASTRO-ENTEROSTOMY FOR VOMITING. 



249 



of the gall-bladder showed that it was filled with numerous small 
stones, 70 in all being removed by cholecystotomy. The peri- 
toneum over the pancreas was punctured in several places, and 
a cigarette drain was inserted to its site. The patient reacted 
well from the operation, and for several days there was free 
drainage of a musty, mucilaginous material. The edges of the 
wound showed fat necrosis in the panniculus adiposus. The 
patient was placed in a semi-sitting posture in about two days 
and left the hospital at the end of the fourth week, the wound 
then being practically closed. Now, at the end of fifteen months, 
the patient is entirely well, with the exception of slight digestive 
disturbances. She had gained in weight. 

Examination of the urine at the time of the operation 
proved negative as to sugar. No Cammidge test was made on 
account of the emergency. 

GASTRO-ENTEROSTOMY (ROUX) FOR CONTINUED 
VOMITING. 

Dr. Charles A. Elsberg presented a woman, 23 years old, 
who was first operated on in Berlin three years ago by Prof. 
Israel for acute appendicitis. About a year later, on acccunt of 
symptoms of gastric ulcer, with vomiting of blood, she was oper- 
ated upon by Krause of Berlin, who did a gastro-enterostomy. 
After this operation she developed signs of vicious circle; she 
was again operated upon, and an anastomosis was made between 
the ascending and descending loops of the jejunum. After 
this last operation the vomiting ceased. 

The patient was admitted to the medical service of the Mt. 
Sinai Hospital in July, 1908, with the history of having suffered 
from vomiting and diarrhoea for the past three weeks. She was 
put upon rectal alimentation and careful treatment, but in spite 
of all that could be done the vomiting persisted and she ema- 
ciated rapidly. A number of times during the day and night she 
would expel from the stomach large quantities of green fluid, 
sometimes streaked with blood. 

Dr. Elsberg was asked to see the patient in consultation 
with Dr. Libman, and agreed with him that an exploratory 
operation was urgently indicated. On July 31 he opened the ab- 
domen through an incision to the left of the old scar, and found 
the stomach and intestines bound together by abundant adhesions. 



250 NEW YORK SURGICAL SOCIEtV. 

It was almost impossible to trace the course of the intestines 
until a large number of adhesions had been divided. Finally, he 
was able to follow the course of the duodenum and jejunum, 
and to understand, as he thought, the condition of affairs. From 
the duodenojejunal junction the bowel passed downwards, then 
upwards and to the right, underneath the first portion of the 
jejunum; then back again to the left side and then upwards 
to the anterior wall of the stomach, where the anastomosis had 
been made. There was also a broad anastomosis between the 
afferent and efferent loops of jejunum. Two fingers could be 
passed with ease through both of the stomata. The only point 
of note was that the anastomosis between the stomach and jeju- 

FlG. I. 




Condition found at first operation: A, gastro-enterostomy; B, entero-anastomosis; 
C, twist in jejunum. 

num had been made very high up on the fundus. The jejunum 
that formed a loop underneath the first part of the jejunum was 
compressed and could not be freed. Evidently, an anterior 
gastro-enterostomy with a large loop had been made, and this 
loop had become twisted upon itself in the manner described. 
The pylorus felt normal. Believing that the trouble lay in 
the twisted loop of jejunum. Dr. Elsberg made an anastomosis 
between the jejunum beyond the old gastro-enterostomy and 
the twisted loop of jejunum (see Fig. 2). 

In spite of this operation, the vomiting continued, enormous 
quantities of bile being expelled from the stomach at frequent 
intervals. The patient was carefully examined for evidences 
of some other disease to which the vomiting might be secondary, 



GASTRO-ENTEROSTOMY FOR VOMITING. 



251 



and the possibility of a neurosis or hysteria was considered, but 
nothing could be found. Inasmuch as all parts of the jejunum 
were now well drained (see Fig. 2), the only possibility was 
that on account of the position of the anastomosis there was 
a valve formation at the stoma high up, near the cardia. The 
patient's condition became progressively worse, and another 
operation was decided upon. The abdomen was again opened 
through the old scar, and as the various anastomoses were found 
patent. Dr. Elsberg said he determined to do an entirely new 
gastro-enterostomy, and chose the method of Roux. A very 
large mass of adhesions had to be divided before the transverse 
mesocolon near the pyloric end of the stomach could be exposed. 

Fig. a. 




After second operation: D, entero- anastomosis made at first operation; E, E', gastro- 
enterostomy en Y made at second operation. 

An opening was made into it, the jejunum divided (see Fig. 
2), and an anastomosis was made between the jejunum and 
the posterior surface of the stomach near the pylorus, by suture. 
Before this was done, an end-to-side anastomosis was made 
between the proximal jejunum and the peripheral jejunum by 
means of a Murphy button. One part of the button was pushed 
down into the peripheral jejunum in the manner described some 
years ago by Dr. Robert F. Weir. 

The patient stood the prolonged operation well, and for 
two days the vomiting was slight. Then, in spite of all treat- 
ment, she began to vomit again, and this continued for ten 
days, no matter whether food was taken into the stomach or 
not. At this time the button was passed, and within 24 hours 



252 



NEW YORK SURGICAL SOCIETY. 



the vomiting ceased. The patient began to take food regularly, 
and she rapidly gained flesh and strength. The wound healed 
by primary union, excepting for a small drainage opening. 
Since the last operation she had gained about 30 pounds in 
weight; she felt perfectly well and had resumed her work as a 
nurse. 

RESECTION OF INTESTINE PRESENTING UNUSUAL 
FEATURES. 

Dr. Elsberg presented a boy, fourteen years old, who had 
been operated on in August, 1907, for acute appendicitis, with 
abscess and diffuse peritonitis. In January, 1908, he was re- 
admitted into Mt. Sinai Hospital with symptoms of acute intes- 
tinal obstruction of 36 hours' duration. At the operation, which 
was done at once, a loop of ileum was found gangrenous and 
constricted by a broad band. In spite of the presence of fecal 
vomiting, the patient's condition was so good that a radical resec- 
tion was determined upon. Twelve inches of the ileum were 
removed and an end-to-end anastomosis made by suture. After 
twenty-four hours the fecal vomiting ceased, and thereafter the 
boy made a steady recovery for ten days. At that time, when 
only a sinus remained, he suddenly developed symptoms of 
acute obstruction, and within a few hours his general condition 
was very serious. Just prior to his removal to the operating 
room it was noted that there was a slight feculent discharge 
from the sinus. 

The abdomen was again opened through the first scar, and 
a large loop of intestine, including the former anastomosis, was 
found constricted by a band, and its vessels thrombosed. Through 
the distention of the affected loop, the anastomosis had given 
way at one point. This time about three feet of intestine were 
removed, the peripheral end being near the ileocaecal junction. 
The patient's condition was so poor that all operative manipu- 
lations had to be rapidly done. The bowel was removed in 
the usual manner, the ileocaecal end closed by a double layer of 
sutures, a tube tied in the ileum, and the end of the bowel fixed 
in the wound, thus forming an iliac anus. Although the patient 
was in extremely poor condition at the end of the operation, he 
recovered after energetic stimulation. After a few days the 
tube came away, and it was impossible to control the discharge 



EXCISION OF COLON. 



253 



of faeces from the bowel. The patient was continually bathed 
in faeces, and was in a deplorable condition. 

Ten days later Dr. Elsberg opened the abdomen a third 
time, this time by an incision to the left of the median line, as 
far away as possible from the artificial anus. After some diffi- 
culty, the ileum which led down to the anus was found, and at 
a point about two feet from the artificial anus an ileocolostomy 
by lateral anastomosis was done, by suture. By this means he 
hoped to divert the faeces into the colon, but in spite of the 
fact that a large opening had been made and that the stoma 
was patent (as was proven by the injection of fluid into the 
rectum and its appearance at the artificial anus), most of the 
faeces still came out of the artificial anus. Every possible means 
to control this, by means of distended rubber bags in the bowel, 
^y pressure, by keeping the boy in the Trendelenburg posture, 
etc., were tried, but without success. He was continually bathed 
in faeces, his skin was raw and very tender and he was rapidly 
emaciating. 

At the fourth and last operation the speaker said he planned 
to close the bowel peripherally to the ileocolostomy, and then 
extirpate the intestine down to the artificial anus. On account 
of the many adhesions, this could not be done, so he united the 
ileum beyond the ileocolostomy again to the descending colon by 
lateral anastomosis, by suture, closed the gut just beyond the 
stoma, and extirpated the entire bowel distal to this point. 
The removal of the bowel, about eighteen inches long, was ren- 
dered very difficult through many old adhesions. It was accom- 
plished by the following method : The mesentery was first tied 
and cut off, the end of the bowel grasped by a clamp, inverted 
into itself, and made to emerge through the artificial anus on the 
right side. It was excised from there as soon as the left abdom- 
inal incision had been closed. The patient made a good recovery 
from this operation; he rapidly gained flesh and strength, and 
was discharged, cured, one month after the operation. 



EXCISION OF THE GREATER PART OF THE COLON. 

Dr. John F. Erdmann presented a man, 33 years old, who 
gave a history of having suffered for about two years with at- 
tacks of indigestion and cramp-like pains, and that he had 
lost from 35 to 40 pounds in weight. When Dr. Erdmann first 



254 NEW YORK SURGICAL SOCIETY. 

saw him, on November i6, 1907, he gave no record of having 
lost flesh, and only a brief history of spasmodic pains in the 
abdomen, simulating a gall-bladder or mild appendix attack. His 
temperature at this time was 100° ; pulse about 80, and there 
was no point pressure anywhere in the abdomen excepting over 
the appendix. There was no history of any associated trouble 
in the abdominal cavity, which pointed to the conditions found 
at the subsequent operation. He had been under the care of 
some of the best internists, and a diagnosis of gall-bladder and 
appendix invasion had frequently been made. 

Operation. — Through a Kammerer incision the appendix 
was exposed and removed. It was seven inches long, about half 
an inch in diameter, its lumen was widely distended and its 
coats were thin, and it was adherent in the pelvis. No evidence 
of intestinal obstruction or disturbance was found at this time. 
The patient was relieved from all abdominal symptoms for a 
period of three days, and stated that he felt better than he had 
for months. Movements of the bowels were obtained until the 
fifth day, when he began to be restless and showed marked evi- 
dences of abdominal cramps, the centre of the disturbance being 
near the splenic region. It was evident at this time that some 
gross lesion, obstructive in nature, was present, and it was sus- 
pected of being in the large intestine. The patient was observed 
for another twelve hours. He then began to vomit fecal material, 
and was immediately submitted to operation for intestinal ob- 
struction. The stomach was washed out and then the abdomen 
was rapidly opened. The site of the obstruction was found to 
be at the splenic flexure, and consisted of an annular growth 
about an inch in length, and completely surrounding the colon. 
Owing to the distention of the small intestine, an enterotomy was 
done ; the intestines were stripped and washed with salt solution. 
The opening was then sutured and the sigmoid attached to the 
caecum by means of a Murphy button. After the completion 
of the sigmoidocsecostomy, the patient's condition was such that 
it was deemed inadvisable to remove the growth, and this was 
deferred to a later day. The patient was put to bed in a condi- 
tion of collapse. The button was passed on the eighth day, and 
the patient left the institution in the third week, refusing to 
have the excision of the growth done until he had recuperated 
by going away for a short time. 



SUPRAPUBIC PROSTATECTOMY. 255 

He finally consented to have the tumor removed on Feb- 
ruary 29, 1908, a little over three months after the second opera- 
tion. At this time, the growth was exposed without difficulty: 
it had increased to almost twice its former size, and a few 
glands were evident in the mesocolon. The colon, owing to 
the invasion of the glands, was excised from the ascending 
to the beginning of the descending colon, the free ends being 
simply turned in and left as blind pouches. The patient made a 
speedy recovery, and had since gained thirty pounds in weight. 
He had previously gained twenty pounds between the second 
and third operations. Up to the present time there were no 
evidences of a recurrence. Pathologically, the growth was re- 
ported as being a colloid carcinoma. 

PROSTATECTOMY. 

Dr. John F. Erdmann presented a man, 41 years old, who 
was referred to Dr. Erdmann by Dr. John F. Moore in April, 
1908. There was no history of gonorrhoea, syphilis or any 
genito-urinary trouble. Three years before, or at the age of 
38, he had suffered with difficulty in voiding urine, having to 
get up three or four times during the night, and voiding small 
amounts every fifteen to sixty minutes during the day. There 
had been slight evidence of blood in the urine for the past year. 
An analysis of the urine showed some albumin and considerable 
pus and decomposed material. 

Examination showed a bladder distended almost to the um- 
bilicus. The patient complained of considerable pain, with inabil- 
ity to voi^ urine, and suffering from a dribble overflow. The 
catheter withdrew sixty ounces of urine. He stated that he had 
been catheterized once in forty-eight hours for the past two 
weeks, drawing off a large quantity of urine each time. A No. 
20 F. catheter passed easily, and no evidences of prostatic en- 
largement were made out. 

When the patient returned for examination the following 
day he was again catheterized, withdrawing thirty-five ounces 
of urine. Attempts at cystoscopy failed, due to ultra-sensitiveness 
and cloudy urine. He was then admitted to the Private Hospital 
Association, and for a week was kept under observation with 
careful catheterization, irrigation, etc., and at the end of that 
time it was decided to do an exploratory operation in case 



256 NEW YORK SURGICAL SOCIETY. 

cystoscopy under anaesthesia revealed the causes of the obstruc- 
tion. Opon one occasion, 100 ounces of urine were withdrawn 
at a single catheterization. 

On April 18, 1908, an attempt at cystoscopy failed on 
account of the current being out of order. It was deemed advis- 
able, as the patient had given his consent, to do a cystotomy 
and make a direct examination. This revealed a small nodule, 
ball-valve in character, about the size of a marrow-fat pea, 
springing from the upper margin of the inner meatus. The 
prostate, by internal palpation, was of about normal size. 
Further examination of the bladder showed the ureteral orifices 
sufficiently dilated to admit the tip of the little finger. The 
prostate, together with the so-called enlargement, which acted 
as a ball-valve, was removed. The patient, who had previously 
been in a very poor state of health, reacted promptly from the 
operation, and since then his weight had increased from 128 
to 159 pounds, his usual weight being about 170 pounds. From 
the time of the operation up to the present time he has been 
able to void his urine spontaneously, with a varying amount of 
residual, between two and six ounces. He was now able to 
pass a stream with perfect ease. The urine at present was clear, 
and presented absolutely no evidence of decomposition. No 
tubercle bacilli nor coli commune were found in the urine during 
his stay in the sanitarium. Since then he had been seen about 
once a month, the catheter introduced and the residual with- 
drawn, no effort being made at irrigation. No cystoscopic ex- 
amination had been made, the residual urine being attributed 
in all probability to atony. At the present time, dilatation of 
the urethra and internal meatus was being done once a week. 

HYDRONEPHROSIS FROM ABNORMAL URETERAL 
IMPLANTATION. 

Dr. John P. Erdmann presented a man, 28 years old, who 
was admitted to the hospital on July i, 1908. The history he 
gave was that he had been irregular in his habits as regards 
eating and sleeping, and that he had used alcoholics moderately. 
He had no recollection of having had any of the diseases of 
childhood, nor any venereal disease. His first illness, about three 
years ago, began with dull pain in the left lumbar region; this 



HYDRONEPHROSIS. 



257 



would last for two or three days and then disappear for several 
months, only to recur. Recently, the intervals between these 
attacks of pain had been shorter. 

His present illness began about ten days ago, with pain 
in the left lumbar region, which became so severe and sharp that 
he could not sleep nor lie still in bed, nor could he walk about. 
This pain had persisted for several days. 

Upon examination, the abdomen was not quite symmetrical. 
There was moderate bulging of the left side, between the crest of 
the ilium and the first rib. There was tenderness, moderate 
rigidity and flatness over this tumor, which seemed to be over 
the left kidney or the kidney pelvis site. There was dulness, 
swelling and tenderness over the left lumbar region, extending 
around to the spine. The patient complained of constant and 
great pain over this tumor. The extremities were normal. An 
X-ray, taken by Dr. Caldwell, was negative of kidney calculus. 
The urine was also negative. 

Operation, July 3, 1908. — An incision, six inches long, was 
made parallel with the crest of the ilium and two inches above 
it, beginning at the tip of the twelfth rib posteriorly. The 
kidney was easily exposed and brought into the wound. The 
following conditions were found: (i) A small, hydronephrotic 
sac at the lower pole of the kidney. (2) A very small, narrow 
ureter issuing from the lower part of this sac, and kinked upon 
itself when the kidney was in its abnormally usual position of 
nephaptom. (3) The kidney was much smaller than usual, and 
was prolapsed. 

An incision into the ureter showed that its lumen was 
patent, but very narrow. A grooved director, passed through 
the cortex, revealed no stones. The kidney was packed up 
higher in the lumbar region by means of gauze about the lower 
pole, to replace it normally, thus relieving the ureteral kink. 
The small incision into the ureter was left unsutured, a gauze 
drain being passed down to the ureteric incision and brought 
out to the lumbar wound. All dead spaces were packed with 
gauze, and the wound sutured in tiers with No. 2 chromic gut, 
leaving a space about the middle for exit of the drain ends. 
Dry dressing. 

The patient's postoperative course was normal. There was 
very little leakage; the wound closed, and the patient left the 
9 



258 NEW YORK SURGICAL SOCIETY. 

hospital in three weeks. Since then he had had no further 
attacks of pain. 

Dr. Willy Meyer said that during the past summer he 
had to operate on a case of intermittent hydronephrosis where 
there was a very large sac, and where the ureter was turned on 
itself so that it came in contact with the sac. The case was 
treated by doing a plastic operation by the Finney method, and 
the patient made a perfect recovery. 

SYMMETRICAL ADENOLIPOMA OF THE NECK. 

Dr. Elseerg, for Dr. Howard Lilienthal, presented a man, 
45 years old, with an extensive development of adenolipomata on 
both sides of the neck and extending down on the chest. The 
interesting feature of the case was the symmetrical character of 
the growths. Some of these tumors had been excised and exam- 
ined, and had been found to contain only fatty tissue. A similar 
case had been shown at a meeting of the Society some years 
ago by Dr. Erdmann. 

Dr. Elsberg said that at least fifty per cent, of these cases, 
according to Charcot and Marie, succumbed to pulmonary tuber- 
culosis within five years after the inception of the disease. This 
patient thus far showed no pulmonary symptoms. 

SPLENECTOMY FOR SPLENIC ANJEMIA (RESECTION 
OF COSTAL ARCH). 

Dr. Willy Meyer presented a man, 41 years old, who en- 
tered the German Hospital on October 27, 1907, with all the 
symptoms of a chronic severe disease of the blood. After care- 
ful examination the case was regarded as one of pernicious anae- 
mia. At the time of the patient's admission, he was lemon- 
colored. The heart and lungs were normal. There was marked 
enlargement of the spleen; the liver was slightly enlarged, and 
there was some glandular enlargement. An examination of the 
blood showed 1,260,000 red blood corpuscles, 4800 whites, and 40 
per cent, of haemoglobin. His condition was so poor at this time 
that the house surgeon. Dr. Ottenberg, made a transfusion from 
man to man by the method devised by himself, a description of 
which appeared in the Annals of Surgery (1908, xlvii, 486). 
The possibility of the case being one of Banti's disease was also 
considered at this time. Under various methods of treatment, the 



SPLENECTOMY FOR SPLENIC ANEMIA. 



259 



blood condition slightly improved. He left the hospital, in Feb- 
ruary, 1908, but returned again on March 13, 1908, complaining 
of such intense abdominal cramps in the region of the enlarged 
spleen that he demanded operative relief, if possible. The direct 
transfusion had not been of much benefit, inasmuch as he had 
the same percentage of haemoglobin and number of whites as 
formerly, the red blood-corpuscles were 2,072,000. After further 
study of the case by D. F. Kaufmann, of the German Hospital, 
it was thought that removal of the spleen might effect a cure. 
This operation was done on March 23. The spleen was ex- 
posed through a median incision; it was much enlarged, and 
upon introducing the hand into the vault of the diaphragm, a 
few adhesions were found anteriorly, and a broad band poster- 
iorly, adherent to the diaphragmatic and third dome posterior 
abdominal wall. A transverse incision at right angles to the 
first, just above the umbilicus, and meeting the tip of the tenth 
rib, was added, and in order to gain more room it was length- 
ened still further toward the tip of the eleventh rib, parallel with 
the costal arch. The incision downwards was then lengthened, 
with excision of the umbilicus, and osteoplastic resection of the 
costal arch done. For the latter purpose the linea alba was 
incised to the left laterally, and the sheath of the rectus opened. 
The muscle was then loosened from the posterior sheath and 
peritoneum, and the arch exposed. The superior epigastric 
artery and vein, sending many branches to the muscle, required 
numerous ligations, between which the branches were divided. 
The seventh, eighth, ninth and tenth costal cartilages were then 
divided with the knife immediately in front of the ribs, also 
the union of three at the sternum, and the resection of the costal 
arch completed without the infliction of any injury to the sur- 
rounding structures. 

The skin flap was now turned back and the arch raised by 
an assistant. This gave decidedly more room, and the spleen 
could now be freely luxated. It measured about 15x6x4 inches, 
and there was a firm broad band binding it down to the parietal 
peritoneum at the diaphragm and the descending colon. These 
were divided between ligatures under guidance of the eyes. The 
pedicle of the spleen was firmly adherent to the tail of the pan- 
creas, and because of hemorrhage, a clamp was placed around 
the latter; it was then firmly compressed and a chromicised cat- 



26o NEW YORK SURGICAL SOCIETY. 

gut ligature put in place, a second clamp having been placed 
nearer the spleen temporarily. The parts were then divided and 
the spleen thus removed with a portion of the pancreas. Then 
the wound closed. The patient made an uneventful recovery 
from the operation, and since then his general condition had 
steadily improved. Whereas before the operation the red blood- 
cells numbered 2,072,000, they now numbered 4,300,000, the 
white 13,000 and the haemaglobin has increased from 40 to 90 
per cent. 

Dr. Meyer said he had resorted to osteoplastic resection of 
the costal arch in four cases, three of them being operations on 
the spleen and one on the stomach. It should only be done in 
those cases where its line of descent interferes with the proper 
exposure of the parts. 

IMPERMEABLE CICATRICIAL STRICTURE OF THE 

(ESOPHAGUS; FEEDING THROUGH GASTRIC 

FISTULA FOR TWELVE YEARS. 

Dr. Meyer presented a boy, eighteen years old, who in Feb- 
ruary, 1896, swallowed, by mistake, a large quantity of caustic 
lye, resulting in an oesophageal stricture. The case was orig- 
inally presented by Dr. Meyer before the New York Surgical 
Society on January 7, 1904, and was subsequently reported in 
full in The Medical News, October 29, 1904. Ten days after 
swallowing the lye he was admitted to one of the city hospitals, 
where gastrotomy and division of the stricture by Abbe's string 
method, at the same sitting, were done one month later. Under 
suitable after-treatment, the boy was soon able to take food again 
by way of the mouth. In spite of all that was done, however, 
the oesophagus showed great tendency to re-contraction. After 
a few months the stricture had re-formed, and a gastric fistula, 
according to Witzel's method, had to be established. All attempts 
at passing the stricture of the oesophagus from above or below 
were unsuccessful, and the boy had to be fed entirely through 
the gastric fistula. Seven years later (September, 1903), when 
the patient was brought to the German Hospital, the entrance 
into the stricture was so tight that it was impossible to pass even 
a filiform bougie into the stomach by way of an oesophageal fis- 
tula at the neck, which had been made for the purpose. On 



PERICARDIOTOMY. 26 1 

December i, 1903, an osteoplastic gastrotomy was done by Dr. 
Meyer in order to gain a passage through the oesophagus from 
below, raising the costal arch, but this also failed. 

At the present time, twelve years after the original injury, 
the boy was still being fed through his gastric fistula, and Dr. 
Meyer thought it would be futile to make any further attempts 
to re-establish the patency of the oesophagus, which was evidently 
the seat of a very extensive cicatricial obliteration. The patient 
was fairly well nourished. He had gained 26 pounds within 
the last two years, and now weighed 106 pounds. The method 
by which he was fed was as follows: He was instructed to 
partake of a mixed ordinary table diet, and in order to get the 
benefit of the admixture of the saliva, which was doubtless an 
important factor in digestion and nutrition, and at the same 
time to enjoy the taste of his food, he masticated his food thor- 
oughly and then removed it from his mouth into a cup and 
introduced it into the stomach with the help of a large syringe 
through the gastric fistula. The boy was a very hearty eater 
and had at present a tremendously enlarged stomach. Recently, 
he had been seized by epileptiform attacks, and he had been 
instructed to wash out his stomach regularly, and take six or 
eight small meals during the day instead of three large ones, with 
a resulting improved condition. This was one of the very rare 
cases that had been successfully nourished through a gastric 
fistula for many years. 

PERICARDIOTOMY FOR TUBERCULOUS EFFUSION. 

Dr. Meyer presented a man, 33 years old, who had been 
an inmate of the German Hospital for some time. His left 
pleural cavity had been repeatedly tapped and large quantities of 
a straw-colored fluid had been evacuated. No tubercle bacilli 
had been found in this fluid. However, the Calmette test was 
positive. The man's general condition was poor. Examination 
showed the presence of fluid in the pericardium. 

On March 10, 1908, at the request of Dr. Kaufmann, a 
large needle was introduced by the speaker into the pericardium 
in the sixth intercostal space, close to the sternum; it was 
pushed upward and outward, and immediately gave exit to a 
large quantity of black fluid, about 1250 c.c. being withdrawn. 
The man was much improved after this operation, but eight days 



262 NEW YORK SURGICAL SOCIETY. 

later he again showed symptoms pointing to a recurrence of 
the pericardial effusion. On March 17 the needle was again 
introduced, evacuating about 1000 c.c. of the same black fluid. 
Ihere was but slight improvement after this second operation, 
and again the fluid rapidly re-accumulated. 

On March 23, 1908, under local anaesthesia, an incision 
was made from the middle of the sternum over the course of 
the sixth rib. The cartilage was divided with Gigli's saw near 
the rib, then elevated and cut through with the scissors at 
the sternum, and the remains removed with the rongeur forceps. 
On dividing the tissues parallel with the sternum, the internal 
mammary artery was exposed and ligated. The pleura was 
punctured, and a large amount of straw-colored serous fluid 
escaped. In order to gain more room, an excision of the sev- 
enth cartilage was necessary. The rent in the pleura was cov- 
ered with a pad of gauze, and the pericardium exposed. It was 
aspirated, giving exit to the same black fluid that had been 
found at the former paracentesis. The pericardial membrane 
was then freely incised, evacuating at least three quarts of fluid. 
The finger was introduced into the large pericardial cavity, but 
the heart could not be felt. On pushing the finger upward, a 
mass of coagulated fibrin was felt, which, when cleared away, 
allowed the heart beats to be felt. The rest of the fluid was 
then thoroughly evacuated, and by prolonged use of sponges 
on handles all the fibrin of grayish-black color was removed. 
A large-sized drainage tube was then introduced, and the peri- 
cardium irrigated with warm saline solution. By holding apart 
the edges of the incision in the pericardium, which was enlarged 
by a short transverse incision inwards, the cavity of the peri- 
cardium could now be beautifully illuminated with the electric 
light, and the comparatively small pulsating heart was clearly 
seen, high up, hanging on its vessels. By this time the patient's 
condition had materially improved. Two long drainage tubes 
were introduced into the pericardium, and the skin incision 
was closed with a few silk-worm gut stitches. The patient was 
put to bed in excellent condition, the upper end of the bed 
being raised. He made a rather slow, but perfect recovery. His 
condition at the present time is excellent. 



ACCIDENTS IN HERNIA OPERATIONS. 263 

ACCIDENTS IN HERNIA OPERATIONS, WITH ESPECIAL 
REFERENCE TO THE VESSELS. 

Dr. John F. Erdmann read a paper with the above title, for 
which see page 208. 

Dr. William B. Coley said that from personal communi- 
cations, he knew of four instances of injuries to the arteries or 
veins from needle puncture during the insertion of the deep 
sutures in Poupart's ligament. The results in these cases were 
of interest. In one case, the operation was done for strangu- 
lated hernia. The iliac vein was badly injured during opera- 
tion, and the leg had to be amputated. In the second case the 
vein was opened; it was closed by lateral suture, with unevent- 
ful recovery. In the third case the right iliac vein was injured 
during operation for inguinal hernia in a girl of 18. In this case 
the needle was introduced from above downwards, and the 
surgeon stated that it required an extensive dissection in this 
region before the opening of the vein could be caught with for- 
ceps, and a lateral ligature applied. The remaining steps of 
Bassini's operation were then completed, and a satisfactory recov- 
ery followed. 

In the fourth case, the patient, 64 years old, had been oper- 
ated on for strangulated inguinal hernia on one side, and after 
that operation was completed, a further operation for a large, 
irreducible hernia on the other side was performed. The notes 
of the surgeon who did the operation stated that when passing 
the needle through the under surface of Poupart's ligament, he 
removed his finger from the tissues about the iliac artery too 
quickly, caught it with the needle, and when tied, the thread cut 
through the atheromatous artery. When he removed the stitch, 
a deluge of blood followed, showing that the external iliac artery 
had been wounded. It was compressed with the fingers until it 
could be secured by a clamp, and a ligature above and below 
was then applied. The patient made a tedious recovery, with 
slight sloughing of the calf and heel. 

Dr. Coley said he believed that this accident could be always 
avoided if the following precautions were observed: The first 
and most important of these, he thought, was to see that the 
needle was always inserted in Poupart's ligament from below 
upward instead of from above downward {i. e., it should be first 
introduced into the internal oblique muscle, and then into Pou- 



264 NEW YORK SURGICAL SOCIETY. 

part's ligament, instead of vice versa). (2) The ligament should 
always be pulled slightly upwards and inwards by thumb for- 
ceps during the introduction of the sutures. (3) If the needle 
be held with the fingers instead of a rigid needle-holder, the 
danger of injuring the vessels will be still further lessened. 

Dr. Coley said he had personally operated upon upwards of 
2,200 cases of inguinal and femoral hernia, 1,000 adults and 
1,200 children, without ever having met with an accident of any 
kind. At the Hospital for Ruptured and Crippled, 2,340 opera- 
tions had been performed by Drs. William T. Bull, John B. 
Walker and himself, without accident, due largely, he thought, 
to the observation of the precautions stated. 

As regarded injury in bladder hernia, in practically every 
hernia of the bladder that he had seen there had been present 
a large amount of properitoneal fat. In the presence of this 
fatty tissue outside of the sac he was always suspicious of a 
bladder hernia, and took the usual precautions. Thus far he 
had never injured the bladder. 

Dr. Erdmann said that when he had described his method 
of inserting the needle as from above downwards, he meant from 
the proximal to the distal position of the body as it lies on the 
operating table. 

Dr. Walker said that in operating for femoral hernia he 
had never seen the bladder. He could recall only one case where 
a vessel was injured during a herniotomy, and in that instance 
the needle was passed downward through the Poupart's ligament 
and then upward through the internal oblique. The tip of the 
needle perforated too deeply through the ligament, tearing into 
the epigastric artery. Troublesome hemorrhage followed. A 
clamp was applied to the site of the vessel and removed at the 
end of forty-eight hours. A normal recovery followed. 

Dr. Blake said the expressions, "passing the needle from 
above downwards " or from " below upwards," were somewhat 
ambiguous, unless it was understood that they were to be taken 
in an anatomical sense, and not in relation to the position of the 
patient. 

OPERATION FOR PULMONARY EMBOLISM. 

Dr. Willy Meyer described the operation proposed by 
Prof. Trendelenburg, of Leipsic, before the last German Surgi- 
cal Congress, for embolism of the pulmonary artery. He ex- 



TUBERCULAR PERITONITIS. 



265 



hibited the instruments that were used, and presented to him by 
Prof. Trendelenburg, to facilitate the operation, which was a 
delicate one, requiring a resection of the three ribs with their 
cartilages and the opening of the pleura and pericardium. The 
operative work naturally involved great skill and dexterity. Dr. 
Meyer said that one could not but feel great admiration for 
Trendelenburg, who at an advanced age had the energy and 
courage to initiate and carry on the experiments for the relief of 
this condition in animals, and test it afterwards in the human 
being. Although his patients operated on had not definitely 
recovered, the feasibility of the operation had been clearly dem- 
onstrated. With proper training of nurses and assistants, to 
promptly recognize the trouble, the hope might be entertained 
that a number of these otherwise hopelessly lost patients might 
be saved in the future. 



Stated Meeting, November 25, 1908. 
The Vice-president, Dr. Ellsworth Eliot, Jr., in the Chair. 



GENERAL TUBERCULAR PERITONITIS. 

Dr. Irving S. Haynes presented a girl of eight years who 
was admitted to the Harlem Hospital on January 14, 1908. Ac- 
cording to her family history, one maternal aunt and uncle died 
of tuberculosis. The patient had measles two years ago, and 
had suffered from bronchitis and cough for several years. 

Present History. — About December 15, 1907, the mother 
noticed that the child's abdomen was beginning to grow larger. 
This had continued up to the present time. There had been no 
pain. The urine had been diminished in quantity. She had had 
fever and night-sweats. 

Upon examination, the abdomen was found to be generally 
enlarged. It was flat on percussion, excepting over an area above 
the umbilicus, which was tympanitic. This tympanitic area 
changed with a change of position, and the presence of free fluid 
in the abdominal cavity was shown by percussion and ascitic 
waves. The urine was normal. Temperature, 103; pulse, 132. 



266 NEW YORK SURGICAL SOCIETY. 

An examination of the blood showed 8,500 white cells and 
2,240,000 red cells. 

The case was diagnosed as one of tubercular peritonitis, and 
was operated on by Dr. Haynes on January 16, 1908. An inter- 
muscular incision, two inches long, was made over the appendix. 
Free, blood-tinged fluid was found in the peritoneal cavity. The 
peritoneum, intestines and omentum were thickened, and of a 
deep red color. The superficial blood-vessels were prominent, 
and the surfaces were studded with tubercles. The mesenteric 
glands were enlarged. The appendix was removed, its stump 
cauterized and inverted into the caecum by a purse-string suture. 
A saline irrigation was then given for its possible curative eflfect 
on the tubercular process. The abdomen was closed by layer 
sutures. 

Following the operation, the child's temperature gradually 
fell from 103 to 99, and the pulse from 130 to 90. The wound 
healed by primary union, and the patient's health steadily im- 
proved. Internally, she was given cod-liver oil and guaiacol 
carbonate. She left the hospital on February 2, 1908. About a 
month later the abdominal wound opened throughout its entire 
extent, discharging a bloody serum, with small cheesy masses. 
The wound was treated with injections of balsam of Peru, argyrol, 
and aristol. The child was kept out of doors, with careful atten- 
tion to her general nutrition, and the guaiacol carbonate was 
continued for several months. The abdominal sinus gradually 
closed, and finally healed about October i. The patient had in- 
creased in weight and was apparently in good health at the present 
time. 

Dr. Howard Lilienthal said he had seen quite a number of 
cases of tuberculous peritonitis in individuals varying in age from 
very early childhood to late adult life, and most of the cases he 
had operated on had recovered. He believed that operation un- 
questionably had a great deal to do with the favorable outcome, 
in spite of the fact that that question was still under discussion. 
He had noticed that the most favorable cases for operation were 
those where the abdomen contained a large amount of fluid, while 
the dry form was less favorable for surgical intervention, although 
they may be proper cases for operation on account of the obstruc- 
tive symptoms. 

During the past four years. Dr. Lilienthal said, he had been 



TUBERCULAR PERITONITIS. 



267 



using the old tuberculin as a supplement to the surgical treat- 
ment, beginning with one forty-thousandth of a milligram, and 
not running the dose high enough to cause a reaction. He was 
convinced that this was of real value, and that it should be used 
more frequently. In the case shown by Dr. Haynes there was a 
decided irregularity of the abdominal outline in one area, sugges- 
tive of the presence of adhesions and a probable recurrence of 
intestinal obstruction in the near future. 

Dr. Alexander B. Johnson said that his experience, in com- 
mon with that of others, was that those cases of tubercular peri- 
tonitis associated with a considerable accumulation of serum in 
the abdomen were the only ones that were usually notably bene- 
fited by surgical intervention, and even those had not always 
done well. In that group of cases attended by localized accumu- 
lations of broken down tubercular material and infiltration of the 
intestinal coils with tubercles, the results had not, in his hands, 
been satisfactory. In those cases where the process was a dry 
one, and one found simply an obliteration of the peritoneal cavity, 
his results had not been very favorable. While those patients 
had not been injured by operation, they had not been benefited. 

Dr. Johnson said that about ten days ago an elderly woman 
was brought to the hospital with symptoms of obstipation. The 
bowels had been extremely difficult to move, and upon examina- 
tion he found what he considered to be a number of distended 
coils of large intestine. After repeated enemata he could still 
feel a large sausage-shaped tumor along the course of the descend- 
ing colon. Upon opening the abdomen in the left iliac region he 
found a tubercular peritonitis, with complete obliteration of the 
peritoneal cavity. The tumor that had been felt proved to be a 
mass of tubercular omentum. 

Dr. John Rogers called attention to the fact that a fecal 
fistula occasionally followed operative interference with these 
cases, particularly those of the adhesive type. If that accident 
occurred, there was no escape from a fatal outcome. 

Dr. John B. Walker mentioned the case of a girl of sixteen 
years who was operated on for a tubercular peritonitis which 
apparently originated in the appendix. A fecal fistula followed, 
and the case resulted fatally in about six months. 

Dr. Lilienthal thought the statement made by Dr. Rogers 
was rather too sweeping, unless he limited it to true fecal fistula 



268 NEW YORK SURGICAL SOCIETY. 

(of the small intestine). Personally, he could recall two cases 
of fecal fistula of the colon following operation for tuberculous 
peritonitis, and in both instances the patients recovered. 

Dr. Rogers mentioned two cases in which a fecal fistula re- 
sulted, in spite of the great care that was taken not to tear or 
manipulate the gut. The abdomen was simply opened and 
flushed out. 

Dr. Johnson said that about two months ago an Italian 
girl, about i6 years old, was brought to the hospital complaining 
of swelHng of the abdomen, pain, tenderness and fever. There 
was marked increase in the leucocyte count, with a relatively 
high increase of the polymorphonuclears. No positive diagnosis 
was made prior to operation. Upon opening the abdomen he 
found an ovarian cyst of considerable size, containing perhaps a 
quart of fluid, which proved to be tuberculous. There was also a 
very large abscess outside of the ovarian cyst, the contents of which 
had a very strong fecal odor. The coils of small intestine, as far 
up as the umbilicus, were the seat of a peritonitis. In separating 
the various adhesions and emptying the cyst, he came upon a large 
lumbricoid worm, but it was impossible to locate the perforation 
in the small intestine from which the worm had escaped. After 
the operation practically all the contents of the small intestine 
escaped through the wound, but by careful attention to the after- 
treatment, regulating the diet, keeping the wound packed and 
strapped, the patient finally recovered. The tract leading to the 
fistulous opening was deep and this he believed rendered the 
chances of spontaneous closure better. 

Dr. Arthur L. Fisk said that about fifteen years ago he 
was asked to operate upon a young man of 25 years, who had 
typical signs of appendicitis, with a mass in the right iliac fossa. 
The usual incision was made over the site of the appendix, and 
when the peritoneum was opened, the caput coli was seen thickly 
studded with tubercles, and the wall of tlie bowel was greatly 
infiltrated. The abdominal incision was closed without any 
drain; no operation was performed on the bowel. Within three 
weeks after, a fecal fistula developed in the site of the abdominal 
incision; the patient died within two months thereafter. 

Dr. Fisk recalled four other cases of tubercular peritonitis, 
which he had operated upon ; in three of these the peritoneum was 
covered with tubercles and there was fluid within the peritoneal 



TUBERCULAR PERITONITIS. 



269 



cavity, these cases were all benefited by the operation; but the 
fourth case was of the dry adhesive variety, and this case was 
neither helped nor injured by the operation. 

Dr. Walker mentioned the case of a woman, about thirty, 
upon whom he operated for tubercular peritonitis, evacuating a 
large amount of fluid. Five years later the patient was again 
operated, this time for appendicitis, and at this operation no 
adhesions were found, and no evidences of the former peritonitis. 

Dr. John A. Hartwell said that in discussing this subject, 
we should bear in mind the different forms of tubercular perito- 
nitis. In the case shown by Dr. Haynes, the inflammatory process 
was apparently limited almost entirely to the peritoneum, without 
any involvement of the other intra-abdominal structures except 
the possibly primary focus in the appendix. The cases where the 
intestines were intensely matted together belonged to another 
class, and their treatment was entirely different. Under those 
conditions, a simple laparotomy was very apt to produce a fecal 
fistula, whether the intestines were handled or not. The speaker 
said he had seen several such cases at the Lincoln Hospital in 
colored patients, and in spite of every precaution a fecal fistula 
developed in three or four of them, with fatal results. Those 
could not be properly classified as simple tubercular peritonitis. 

Dr. Hartwell said that in a case seen at Bellevue Hospital, 
the patient, in addition to the tubercular peritonitis, had tubercu- 
losis of the ascending colon, which was occluded to such an 
extent by the inflammatory process that it barely permitted the 
passage of a probe. Such cases he did not think could be bene- 
fited by operation, unless it were possible to remove such foci, 
which, in those cases with extensive intestinal involvement, it is 
impossible to do. 

Dr. Fisk said that the distinction between these different 
forms, which Dr. Hartwell made, was not the usual one. These 
varieties are progressive stages of the same disease — tubercular 
peritonitis. The early stage is characterized by the formation 
of tubercles over the peritoneum and fluid within the cavity; a 
later stage by great thickening of the walls of the bowels, adhes- 
ion (cohesion better) between the peritoneal surfaces of the 
different coils of the intestines, even to obliteration of the peri- 
toneal cavity ; and, possibly, finally the formation of abscesses. 
Dr. Ellsworth Eliot, Jr., said that he had seen two cases of 



270 NEW YORK SURGICAL SOCIETY. 

tubercular peritonitis with the subsequent formation of fecal 
fistula, one of the large and one of the small intestine. The 
first patient was a girl of twelve years upon whom laparotomy was 
done for a simple serous tubercular peritonitis. The fluid was 
removed without damage to the intestines and the wound closed 
without drainage. The patient left the hospital healed but sev- 
eral weeks later developed an intestinal fistula which discharged 
for months. Eventually, the fistula closed spontaneously, the 
child gained in strength and flesh and five years after the opera- 
tion was still in perfect health without sign of relapse. 

The other case was one of advanced tubercular peritonitis of 
pelvic origin with evidences of beginning cheesy degeneration. 
Laparotomy and drainage of an extensive pyosalpinx was resorted 
to. The bladder and rectum subsequently became involved in the 
tuberculous process and about two months later, the laparotomy 
wound being still open, the patient developed a spontaneous fistula 
of both of those organs communicating with each other and with 
the drainage sinus. The patient succumbed about six weeks 
later to general miliary tuberculosis. In a third case of tubercu- 
lar peritonitis of the connective-tissue type in a man 22 years 
of age, laparotomy was done, but accomplished nothing save the 
separation of adhesions. Subsequently, his abdominal wound 
healed, his constitutional symptoms disappeared, and he remained 
in perfect health and able to work for six months. He then de- 
veloped a tubercular meningitis which proved fatal. 

Dr. Johnson said he wished to record another case of tuber- 
cular peritonitis involving the caecum and ascending colon in which 
he operated with the idea that he had to deal with an appendicitis. 
Upon opening the abdomen, he found the caecum converted into 
a thick-walled tube, infiltrated with tubercle. The patient was a 
girl of fourteen years who had been operated on for tubercular 
glands of the neck by Dr. Johnson, and after the wound in the 
neck healed she developed symptoms referable to the abdomen. 
Subsequent to the abdominal operation she developed a fecal 
fistula, for which she was afterwards operated on at the City 
Hospital by Dr. H. D. Collins, who resected the caecum and a 
portion of the ascending colon and then made an anastomosis. 
After this the girl remained well for many months, and finally 
died of tubercular meningitis. 



OBSTRUCTION DUE TO TUBAL PREGNANCY. 



271 



INTESTINAL OBSTRUCTION DUE TO TUBAL PREGNANCY. 

Dr. Walton Martin presented a woman, 24 years old, who 
entered St. Luke's Hospital on July 17, 1908. Ihree days be- 
fore admission she had been seized with severe, cramp-like 
abdominal pain, which persisted and was so severe that on the fol- 
lowing day she fainted. She gradually grew weaker, and when 
admitted to the hospital she was in a state of collapse. Since 
the onset of her attack there had been no movement of the bowel, 
and vomiting had been incessant. During the past twenty-four 
hours the abdomen had become distended. 

Previous to this illness, the patient had enjoyed good health. 
Menstruation had always been regular until three months ago. 
Since that time there had been no regular menstruation, but 
she had noticed on several occasions and at irregular intervals 
slight bleeding from the vagina. 

On examination, she was seen to be in shock, very pale, with 
the skin cold and clammy. The pulse was weak and rapid. The 
abdomen was distended and very tense; the lower abdomen was 
tender. On vaginal examination the cervix was soft, and the os 
admitted the tip of the finger. There was a feeling of fulness 
in the posterior fornix. The patient's temperature was 102; 
pulse, 140; respirations, 24. The leucocyte count was 11,300; 
the differential count showed 91 per cent, poly nuclear cells; 
the haemoglobin was 35 per cent. 

The patient was immediately prepared for operation. Under 
ether anaesthesia the abdomen was opened in the median line, 
and a large quantity of dark-colored blood escaped as soon as the 
peritoneum was incised. The left tube was apparently normal 
in size and appearance at its uterine attachment, but near the 
ampulla a mass the size of an egg could be felt lying above the 
brim of the pelvis, and fixed. A loop of small intestine below this 
mass was flattened, while the coils above were distended. On 
freeing the mass and bringing it out through the wound, it was 
seen to be made up of the ampulla of the tube, the ovary and a 
bag of membrane containing a foetus. This hung from the end 
of the tube and had evidently compressed the loop of bowel, for 
on removal of the mass, gas passed into the flattened intestine. 
The wall of the intestine showed no evidence of interference with 
circulation. The tube, ovary and foetus were removed, and the 
abdomen closed. At the completion of the operation the patient 



272 NEW YORK SURGICAL SOCIETY. 

was in very bad condition, the pulse being 150 and very feeble. 
A saline intravenous infusion was given. On the following day 
there was a gradual improvement. Flatus was passed, and on 
the second day the bowels moved. From that time on her con- 
valescence was uninterrupted, and she left the hospital on Au- 
gust 9, twenty-one days after the operation. 

The uncommon cause of the ileus in this case, Dr. Martin 
said, seemed to him of sufficient interest to record. 

THE PREVENTION OF INTESTINAL OBSTRUCTION FOLLOW- 
ING OPERATION FOR APPENDICITIS. 

Dr. Forbes Hawkes read a paper with the above title, for 
which see page 192. 

Dr. Charles L. Gibson called attention to the fact that 
in some instances some antecedent condition of the patient was 
entirely responsible for any postoperative complication rather 
than the operation itself. Many of these patients gave a long- 
standing history of repeated attacks of appendicitis, and the post- 
operative obstruction might be the result of adhesions and fixa- 
tion of the intestine at a point remote from the site of the 
operation. 

Another point to which Dr. Gibson referred was that since 
we had learned to do away with multiple incisions and the inser- 
tion of a large amount of gauze drainage, we were less apt to 
get adhesions than formerly, but in spite of this fact a certain 
number of the cases did badly. Where a large raw surface was 
left and free drainage was indicated, he preferred to use a Miku- 
licz tampon made of heavy rubber dam, such as dentists em- 
ployed. It should be suitably provided with openings and in- 
serted into the depth of the wound and plugged with gauze. It 
could be left there almost indefinitely (ten days or more), the 
gauze only being changed, and did not cause any irritation of 
the intestines. He looked upon this as the most efficient method 
where free drainage was indicated. 

Dr. Haynes said that about twelve years ago he had a 
peculiar postoperative experience. After an operation for the 
removal of pus tubes there was postoperative intestinal obstruc- 
tion and the abdomen was opened a second time. The small in- 
testines, the caecum, and ascending colon, were distended with 



1^ 



OBSTRUCTION AFTER APPENDICAL OPERATIONS. 



273 



gas, but the rest of the large intestine was collapsed. On draw- 
ing the ascending colon downward a kink at the hepatic flexure 
was straightened out, the intestinal contents began to pass through 
the collapsed intestine and the bowels operated through the 
natural passage while the patient was on the table. The obstruc- 
tion seemed to be due to an exaggeration of the hepatic flexure, 
and after the gas once began to accumulate in the ascending colon 
and distend this portion of the intestine the obstruction became 
complete. There were no evidences of any inflammatory action 
at the site of the obstruction. The patient did not recover from 
the shock of the second operation. 

In speaking of drainage. Dr. Haynes said he thought the 
most efficient method was to employ either a medium-sized tube, 
or two small ones. The flow was due not so much to capillary 
action as to the vis a tergo from the intra-abdominal pressure. 
All we had to do was to provide a proper vent, and the intra- 
abdominal pressure would do the rest. In some cases it was 
necessary, for the purpose of drainage, to insert a strip of gauze 
to the site of the pelvic wound or intestinal anastomosis or gall- 
bladder stump; this was left for five, seven or perhaps ten days, 
and its removal was then usually attended with considerable 
difficulty. He recalled a case where a man was shot through 
the stomach, and stomach contents had escaped into the great 
omental bursa which consequently was drained by a gauze wick. 
On attempting to remove this drain after about two weeks the 
adhesions were so firm that it was thought dangerous to persist 
in the usual way by twisting and loosening different parts of the 
gauze and the following device was utilized, which has proven 
to be a time- and pain-saving measure. It consisted in threading 
a small uterine curette over the gauze; by a rotary motion the 
adhesions were easily severed. After appendix operations, the 
speaker thought it was better to invert the stump after excision 
and ligation. Dr. McWilliams had shown that intestinal obstruc- 
tion might follow in cases where the appendix was simply ligated 
and the stump removed, and the speaker thought it was better to 
invert the stump. 

Dr. L. W. Hotchkiss said that about seven years ago he 
read a paper before this Society upon the subject of intestinal 
obstruction following acute appendicitis. In that paper he had 
reported three cases of his own, and some twenty cases that had 



274 



NEW YORK SURGICAL SOCIETY. 



been recorded by other members. The result of that investiga- 
tion confirmed the observation just made by Dr. Gibson, that in 
a certain number of these cases, the obstruction was due to ad- 
hesions resulting probably from the character of the infection and 
from other factors over which we had no control. The speaker 
recalled one reported case where the loop of intestine which was 
the seat of the obstruction had been found on the opposite side 
of the abdomen. 

Dr. Hotchkiss said the more common use of the cigarette 
drain and the less frequent use of gauze packing no doubt had 
much to do with the diminution in the number of cases of obstruc- 
tion following abdominal operations. Personally, he believed in 
using comparatively little drainage in appendicitis operations unless 
it was necessary in the presence of local necrosis or for the purpose 
of removing extensive exudations, and then he thought it should 
only be used as a temporary measure and removed as soon as 
possible. In inflammatory conditions about the appendix, we 
had often to deal with essentially a protective process, which 
resulted in the formation of more or less fibrinous adhesions 
between the adjacent coils of intestine, in the effort to wall in the 
infectious foci. These adhesions rendered all efforts at effective 
drainage futile and under these conditions, gravitation did not of 
course lead to the pooling of the secretions in some one dependent 
part of the abdomen from which they could easily be drained. 
As to the reintroduction of gauze drainage, the speaker said he 
did not feel convinced that it was a preventive of secondary 
abscesses in itself. Most surgeons were getting away from pro- 
longed drainage with results that were certainly better than be- 
fore. He was in favor of removing the drain at the earliest pos- 
sible moment, and allowing the wound to heal. The tube or flask 
drain was useful in some cases, but its own presence if prolonged 
doubtless led to an increase in the secretions and the production 
of troublesome sinuses. 

Dr. Hawkes, in closing, said he was fully in accord with 
what had been said in regard to the possibility of intestinal ob- 
struction occurring after appendicitis in spite of the most careful 
attention to technic. Still, there were cases in which the accident 
was distinctly traceable to faulty technic. 

In regard to drainage, the speaker thought we could fairly 
conclude that we did not get actual peritoneal drainage from any 



OBSTRUCTION AFTER APPENDICAL OPERATIONS. 



275 



point remote from our drainage tract for more than eighteen 
hours after operation. Then we simply got serum from around 
the drain. In reply to Dr. Haynes, the speaker said he had never 
attached the omentum to the stump; he had simply pulled down 
a free piece of omentum over the stump, so that the upper part of 
the omentum rested on the caput coli. Personally, he had never 
had a case of intestinal obstruction result from that method of 
treating the omentum, nor had he ever inverted the stump of the 
appendix. He simply tied it off quite short, touched it with a 
little carbolic acid, and covered it with omentum when possible. 
A number of times he had had the opportunity to see the results 
of this method subsequently, and he was scarcely able to find any 
trace of where the stump had been. 



TRANSACTIONS 

OF THE 

PHILADELPHIA ACADEMY OF SURGERY. 



Stated Meeting, November 2, 1908. 
The President, Dr. William J. Taylor, in the Chair. 



CONGENITAL DISLOCATION OF THE KNEE. 

Dr. John B. Roberts said that at the meeting of the Ameri- 
can Surgical Association on May 9, 1901, he presented a paper 
reporting a case of arthrotomy for congenital anterior dislocation 
of the tibia.^ The girl, who was aged five years, was operated 
upon in March of that year through a large horse-shoe incision 
made across the front of the knee. After division of the ligament 
of the patella and almost complete section of the lateral ligaments 
of the joint the dislocation was easily reduced. A partial section 
of the four-headed extensor muscle of the leg was necessary in 
order to repair the cut ligament of the patella. Some infection of 
the wound occurred and it became necessary to open it and thor- 
oughly drain the knee-joint, using also irrigation with mercuric 
chloride solution and subsequently with formaldehyde solution. 
After a number of weeks the child returned to her home with the 
bones in proper position, though there was still great restriction 
of motion at the knee-joint. 

He presented illustrations showing a skiagraph and photo- 
graphs of the child before operation. The photograph now pre- 
sented (Fig. i) shows the child as she is at the present time. 
Her physician. Dr. F. S. Nevling, reports that the child, who is a 
dwarf, can now use the operated leg just as well as the other and 
needs no brace or support for it. She can run and jump just like 

* Transactions of the American Surgical Association, 1901 ; and 
Annals of Surgery, August, 1901. 
276 



I 



Fig. 




Showing result of arthrotomy for congenital dislocation of the knee at the end of seven years. 



POSTOPERATIVE RECURRENT APPENDICITIS. 



277 



any other little girl. She is now about thirteen years old and 
has long since ceased to grow. The doctor thinks she is little, 
if any taller than when she was operated upon at the age of 
five. Inspection of the photograph indicates that she is prob- 
ably a cretin. She has a large head and prominent abdomen. 
Her expression, however, is not that of a child of very defective 
intellection. The scar of the operation on the left knee is shown 
on the picture; and the legs appear to be of the same length. 

She is somewhat defective mentally, but Dr. Nevling says 
she can care for herself and ask for everything she wants, but 
that she gets very cross, if not humored. The parents have 
treated her like a baby and have not sent her to school. The 
physician mentioned has advised that they send her to school, 
but this has never been done. The other children are normal and 
bright. She has two brothers of adult age who are nearly six 
feet tall and weigh from 160 to 180 pounds each, and two sisters 
aged 17 years and 19 years who are bright and weigh from 125 
to 150 pounds. There is another brother older than she and one 
younger. The latter is now 10 years old and weighs about 90 
pounds. There have been no other deformities in the family, 
and Dr. Nevling thinks that possibly the dislocation of the knee 
was caused during delivery of the mother, as she says that she 
had a very hard time at that particular confinement. He can give 
no reason for the child's ceasing to grow and being a dwarf. 

RECURRENT ACUTE APPENDICITIS AFTER OPERATION. 

Dr. George G. Ross said that to a patient who has been 
operated on for an acute suppurative appendicitis and whose 
appendix has not been removed, the possibility and danger of 
another attack is no small matter. The actual occurrence of such 
an attack is not a rarity, and these cases offer additional difficul- 
ties at the second operation and bring to both the surgeon and the 
patient a realization of the shortcomings of the first. 

During the past three months he had operated on three such 
cases, all at the German Hospital. In two the occasion for a 
second operation was an acute attack of appendicitis, in the third 
the procedure was for the relief of a persistent abdominal sinus. 

The details of these cases are as follows : 

Case I. — Mr. H., aged 37. On September 27, 1907, patient 
was taken ill with appendicitis. He was treated medically, appar- 



278 PHILADELPHIA ACADEMY OF SURGERY. 

ently improved, and at the end of the second week passed about 
three pints of pus by the bowel in several evacuations. His chills 
and evening temperature however persisted, as did the tenderness 
and distress in the right iliac fossa. He lost forty pounds during 
his illness. He was finally sent to the Hospital and on October 31, 
1907, an abscess to the right of the ascending colon was opened 
and drained. The appendix was not searched for. The patient, 
after a long convalescence, made an apparent recovery. On 
August 23, 1908, he was admitted to the German Hospital. He 
complained of not feeling very well and of a tenderness at the site 
of the old scar, which had been present for six months. Physical 
examination revealed an exquisitely tender mass the size of a 
man's fist beneath the old scar, which had given away, leaving an 
incisional hernia. An incision removing the superficial scar was 
made, opening the peritoneum in the line of the original incision. 
The adherent intestines were separated from the cicatrix and a 
postcaecal abscess cavity opened. Within it was found a gan- 
grenous appendix sloughed in two. The appendix was ligated 
and removed, the abscess cavity cleaned out and drained by a 
rubber tube through the loin, and gauze anteriorly. The patient 
made an interrupted recovery. 

Case H. — Mr. C. S., age 30, had been operated on three 
years before at the Bellevue Hospital, New York, for acute appen- 
dicitis. His wound was drained and he was told that his appen- 
dix had been removed. He was admitted to the German Hospital 
of Philadelphia, August 3, 1908. 

His present illness began one week ago, when after an in- 
discretion in diet he had an attack of diarrhoea lasting all night. 
Since then he has had a desire to have his bowels move very often, 
yet passes but little fecal matter each time. At the same time he 
has had general abdominal pain. The night before admission the 
pain became acute and was localized to the right iliac fossa. He 
vomited once. 

Physical examination shows the absence of rigidity or dis- 
tention. There was an excessively tender mass beneath the old 
scar. 

Operation, September, 1908: old scar excised; intestines 
walled off with gauze pads and a pericaecal abscess exposed ; the 
small amount of pus found was wiped away and an inflamed 
necrotic appendix found, which was ligated and removed; the 



POSTOPERATIVE RECURRENT APPENDICITIS. 



279 



abscess cavity was drained by the means of a rubber tube and 
gauze. Patient made an uninterrupted recovery. 

Case III. — Mr. C. G., age 24, at the end of November, 1907, 
was operated on for acute appendicitis. He had been ill for 
three days before admission and had been treated by his physician 
with purgatives. At the operation an abscess containing very 
foul pus was opened and drained. The record of the case states 
that a gangrenous appendix was found and removed as a slough. 
It is of interest in this case, that threatened obstruction from 
contracting adhesions was averted by repeated daily doses of 
castor oil. 

Ever since the operation the patient has had a discharging 
sinus, for which he came for operation in June, 1908. 

At this operation, after placing a probe within the sinus, the 
old scar was dissected out in the usual way and the intestinal 
adhesions separated. The sinus was found to communicate with 
the lumen of the remaining one-inch-long portion of the appendix. 
This inch of appendix was removed, a small drain introduced and 
the wound closed. The recovery was uninterrupted and did not 
recur. 

Dr. Ross further said that a consideration of the cases cited 
would direct our inquiries to several points: (i) the liability to 
recurrence after the simple opening and drainage of an appendi- 
ceal abscess; (2) the propriety of removing the appendix in 
cases in which the trouble outside of the organ is marked; (3) 
the importance of operation before the trouble becomes extra- 
appendiceal. 

The Liability to Recurrence. — There can be no doubt that as 
long as any portion of the appendix in communication with the 
caecum remains, recurrent attacks are to be feared. Could we 
predict in any particular instance what the subsequent behavior 
of the appendix would be it would be easy for us to determine 
whether to be content with the simple evacuation of an abscess 
or to search more thoroughly for the appendix. Yet this is 
manifestly impossible. 

Sir Frederic Treves states that of 100 cases of appendiceal 
abscess operations which came under his observation, 16 had 
recurrences and 8 subsequently had the formation of inflamma- 
tory exudates in the right iliac fossa, no doubt appendiceal in 
origin — 24 per cent, then really had recurrences after operation. 



28o PHILADELPHIA ACADEMY OF SURGERY. 

And while this distinguished author states that of lOO patients 
operated on by simple drainage of the abscess 84 did not have 
recurrence, I would reverse this method of presenting the facts 
and emphasize the point that 16 per cent, to 24 per cent, did have 
recurrence. 

Nor can any given patient, under such circumstances, be sure 
at any time, however remote, that he will not again be the victim 
of an attack of appendicitis. It is almost impossible for us to 
calculate the hindrance that such a constant apprehension must be. 

It is only in those cases in which the appendix has sloughed, 
disintegrated and really become a portion of the abscess mass that 
a recurrence is unlikely, and these, unfortunately, we are unable 
to recognize at operation unless one searches for the caecum to 
locate the origin of the appendix. Twice in making such a search 
I have discovered a hole in the caecum where the appendix had 
sloughed off. Several times in making a search for the appendix, 
unsuspected, isolated collections of pus have been discovered. 

Nor is it necessary for the whole appendix to be present for 
us to have a re-awakening of the old trouble. Instances have 
been reported of cysts and infections of appendiceal stumps and 
Treves in his series of 100 cases found two in which subsequent 
trouble was due to pus formation in a mere stump of an appendix. 

The leaving of such a portion of the appendix may occur in 
two ways: 

1. The operator may do this by faulty technic. This is 
doubtless a rare occurrence, particularly at the hands of any one 
who has had the benefit of observation before attempting to 
operate. 

2. After opening an appendiceal abscess the sloughed appen- 
dix may be removed and a portion inadvertently be left. This 
would also seem not likely to occur, yet Case III is an illustration 
of this. 

On the other hand while the distal end of the appendix may 
be comparatively free, the proximal may be a portion of an abscess 
wall which the operator does not wish to disturb. 

Should the appendix be already sloughed off an examination 
of the caecum will often reveal the fact that the line of separation 
is some distance removed from the junction of the caecum and the 
appendix and that therefore a considerable stump is left, which 
must be removed. 



POSTOPERATIVE RECURRENT APPENDICITIS. 28 1 

This was the case in an instance encountered recently by 
a colleague, Dr. Whiting. In a case which he operated on the 
thirteenth day of the attack, the entire distal end of the appendix 
was a slough, a whitish string almost, while a distinct stump 
was left, the lumen being closed by healing that had already taken 
place. 

As regards such spontaneously healed appendiceal segments 
we know that they can also remain harmless and retain their 
nourishment for indefinite periods and that their reinfection and 
inflammation gives rise to attacks and lesions entirely similar to 
an acute appendicitis. 

Williams (Brit. Med. Jotirn., 1907) has lately cited the 
curious instance of acute inflammation in an appendix entirely 
separated from the csecum, causing a typical appendicitis. 

The lesions which we may expect from the remnant of the 
appendix, or rather the pathological processes to which it may 
give rise, may be classed as follows : ( i ) acute appendicitis, with 
or without abscess; (2) continuation of primary infection or 
residual abscess; (3) fistula. 

An appendix left at operation for abscess is somewhat less 
liable to give another attack of appendicitis than one left un- 
operated in a mild attack. Yet the possibility is not remote. As 
might be expected in cases where there has already been so much 
damage to the structures of the right iliac fossa, abscess formation 
in these cases is common. Case II is an example of this class. 
Here a man, in good health for three years after an appendix 
operation, becomes subject to another very acute attack with 
abscess formation. 

A residual infection, or one in which there has probably 
never been an entire subsidence of the infection about the appen- 
dix, and a gradual abscess formation takes place as shown in 
Case 1. As to symptomatology they furnish us with a picture 
of slow abscess formation with mild infection as opposed to the 
acute signs as in cases of class 2. As to pathological conditions 
within the abdomen, and their treatment, they furnish us with 
nothing that varies from those of the first class. 

In class 3, the fistula cases, we may really have two varieties : 
(a) those in which the appendix portion or stump acts solely as 
an irritant in keeping open a sinus tract; (b) those in which the 
sinus communicates with the lumen of the appendix, either of the 



282 PHILADELPHIA ACADEMY OF SURGERY. 

appendix proper or of a sloughed segment, as in a case reported 
by Dr. Deaver. 

It is not always possible to ascertain when the appendix is 
the underlying cause of the persistence of a sinus. Should we be 
able to exclude the possibility of the presence of a portion of 
ligature, etc., it will be probable that the fistula either arises from 
the stump of the appendix or is kept active by the presence of a 
fecal concretion, etc. It is but in a few instances that we see a 
sinus or fistula of long standing in which at operation some such 
cause is not demonstrable. 

The treatment of such recurrent infections, residual abscesses, 
or fistulae, is based upon one general principle, viz., to remove the 
primary cause of the trouble and to repair the damage done by it. 

To leave the appendix a second time in abscess cases would be 
only to invite another attack and the formation of another abscess 
with a continuation of local infections finally leading to a general 
infection. 

But far more important than the treatment of these conditions 
is the question of their avoidance at the primary operation. It 
is known that they occur after abscess or pus cases. The question 
then arises : What is the proper operative treatment for appendi- 
citis and abscess ? 

The treatment of appendiceal abscess cases must have been 
carefully considered by every one who has had occasion to deal 
with a number of these cases. 

Authorities have differed greatly as to the mode of approach, 
the method of incision and of drainage and the after treatment. 
Equally have they differed as to the method of dealing with the 
appendix in these cases. 

Amongst many surgeons the simple evacuation of an appendi- 
ceal abscess is held to fulfil all the indications in such a case, ajjd 
that the treatment of a case is such as would be applied to a 
simple abscess anywhere in the body. This is a method of treat- 
ment much more in vogue upon the continent of Europe and 
especially in Germany than among American and English sur- 
geons. Mr. Bottle has recently advocated secondary operation 
for the removal of the organ before the patient passes out of the 
surgeon's hands. 

Others, such as Dr. Morris, of New York, speak for the 
removal of the appendix in every case regardless of its location 
or relationship to the abscess wall, etc. 



POSTOPERATIVE RECURRENT APPENDICITIS. 2S3 

The large majority of surgeons heretofore, however, have 
taken the position held by Dr. Deaver, — that it is advisable to 
remove the appendix whenever it is not so situated in the wall 
of an abscess that to remove it would be to spread infection over 
the general peritoneal cavity. 

As will be seen the meaning of this statement varies largely 
with the surgeon applying it. In the opinion of the reporter 
the incision and drainage of an appendiceal abscess represents the 
most unsatisfactory of all operations for acute appendicitis. To 
operate upon a resultant pathological condition and leave the 
original focus and cause of infection in situ is opposed to all 
the fundamental principles of surgery. 

A primary incision with secondary operation for the removal 
of the appendix is no less unsatisfactory. As a rule patients can- 
not be induced to return when they are feeling well even if they 
know that they may at any time become most gravely ill. This 
method also exposes the patient twice to anaesthesia and the dis- 
comfort and inconvenience of operation. Not only this but a sec- 
ond operation shows us instead of a free appendix or one covered 
by fresh adhesions, easily loosened, an appendix hidden and 
covered by adhesions often so dense that the removal of the organ 
becomes a surgical procedure of the greatest difficulty and 
danger. 

A decision must be made, between those who would always 
remove the appendix, and those who advise its removal as a rule 
but do not regard its remaining as a serious matter. 

He was not willing to say that the appendix should be re- 
moved in absolutely every case. But his experience with these 
recurrent cases that he had himself operated, and others that had 
come under his observation, leads him to believe that the cases in 
which the appendix should not be removed are rare indeed. Sur- 
geons have been too fearful of hunting for the appendix in the 
presence of small amounts of pus, too prone to hesitate in remov- 
ing it from among adhesions or from the limiting membrane of 
an abscess. 

The leaving of the appendix in an acute abscess case is a 
serious matter. Such an incomplete procedure simply tides the 
patient over the acute condition and one should not be satisfied 
until the offending organ is in a bottle of alcohol. Until this 
happy event takes place the patient remains in a condition of no 
uncertain danger. 



2^4 PHILADELPHIA ACADEMY OF SURGERY. 

He had left an appendix in but one case for two years and had 
not lost one of these cases as a direct result of the removal. 

But one other point remains, — instead of reoperating in 
abscess cases, surgeons should not have to operate on abscess cases 
at all. A case of appendicitis, diagnosed and operated early, 
cannot give rise to a fraction of the complications that delay 
brings with it. Operation should follow diagnosis at once and 
there would result clean cases, without drainage, mortality or 
complications. 

Unfortunately we seem to be far from this happy state of 
affairs. Sometimes it seems as if we were still in the pre-surgical 
stage, when the evacuation of an appendiceal abscess into the 
intestines, as in one of these cases, was esteemed a most fortunate 
result. 

To the average layman the word appendicitis is spelled 
OPERATION. Where then lies the fault for the large 
percentage of appendiceal abscesses still encountered? 

Of 194 cases of acute appendicitis on the records filed so far 
this year, January to September inclusive, at the German Hospital 
but 79 or 40 per cent., were clean i.e., early cases. 

Of 23 cases that he operated there during the summer but 
10 were clean cases that could be closed without drainage. 

Since January i, 1907, he had operated 161 cases of appendi- 
citis, — 100 at the German Hospital, 56 at the Germantown Hos- 
pital, and 5 at other institutions. Of these, 105 were clean cases 
which were closed without drainage, this included both chronic 
and acute cases. There was one death. The patient was a Jew 
and had, in addition to his appendix troubles, enlargement of the 
lymphatic glands of the mesenteric chain as far as the finger could 
reach. After operation he was extremely restless, became actively 
delirious and died promptly of exhaustion. A partial postmortem 
revealed nothing about the seat of operation to account for death. 
The glands were not malignant, probably tubercular. 

Fifty-six cases required drainage for pus, either in localized 
collection or involving the entire peritoneal cavity. 

So far as he could recall, or the records state, there was but 
one case in which the appendix was not removed. This man 
had been operated a year before at the Bellevue Hospital, N. Y., 
and reported at the German Hospital, September, 1907, with a 
sharply outlined abscess in the right iliac fossa, which was opened 



POSTOPERATIVE RECURRENT APPENDICITIS. 285 

extraperitoneally by an incision parallel to and above Poupart's 
ligament. He recovered and was discharged nineteen days 
later. 

Three died, — two of these had general peritonitis and sepsis 
which was very profound before operation and which did not im- 
prove, one of these died in the operating room of acute septic 
oedema of the lungs, the other had had intestinal obstruction for 
four days before admission. The third case was one of local- 
ized abscess presenting in the median line. The pressure of the 
collection had caused complete occlusion of the rectum. The 
surroundings of the abscess were necrotic from pressure necrosis. 
The patient had been ill for two weeks. 

As far as could be traced the three cases of peritonitis were 
infections of the retroperitoneal space. Total mortality, 2.4 per 
cent. ; non-drainage cases, 0.9 per cent. ; drainage cases, including 
general peritonitis, 5.3 per cent. 

Dr. John H. Jopson mentioned three cases of this kind oper- 
ated within a few months of each other. One case was a patient 
Dr. Wharton operated upon, with the assistance of Dr. Jopson, 
the other two cases were his own. These three cases emphasized 
the necessity of removing the appendix in all cases of abscess. 
He could recall only two cases in recent years where he could not 
remove the appendix. In one a careful examination of the caecum 
showed it sloughed off, and in the other it could not be found. 
In one of his own cases the child had had an operation for drain- 
age of an appendiceal abscess a year or two previous, then had a 
second abscess at the time the appendix was removed, and a 
third abscess after removal of the appendix. 

It always seemed to him that to open an abscess and leave 
the appendix was a very unsatisfactory procedure and incomplete 
surgery. It had frequently been his experience when removing 
the appendix where there was an abscess, to find fresh pockets of 
pus behind and around it. 

One hears much less advice now in favor of leaving an appen- 
dix which " forms part of the abscess wall." It is much less dan- 
gerous to remove such an appendix, after careful protection of 
the uninvolved peritoneum, than to leave it and run the risk of 
overlooking other purulent collections. 



286 PHILADELPHIA ACADEMY OF SURGERY. 

AMPUTATION AT THE SHOULDER-JOINT FOR EMPHYSEMA- 
TOUS ("TRAUMATIC") GANGRENE. 

Dr. Astley p. C. Ashhurst reported the case of Laurence 
S., aged 14 years, who walked into the receiving ward of the 
Episcopal Hospital on December 27, 1907. While at his usual 
work in a yarn factory he had caught his right arm in the 
machinery, and had had the skin squeezed off it from just above 
the elbow to above the wrist, by the revolution of two rollers. 
The skin hung loose like the inverted sleeve of a coat, A some- 
what similar case, in which the skin had been squeezed off the 
hand from the wrist to the fingers, had recently been under treat- 
ment in the hospital, and as a considerable portion of this hand 
had been saved by conservative measures, the Resident Surgeon 
determined to attempt to save this second patient's arm. Accord- 
ingly, after thorough cleansing of the parts, the skin was stitched 
in place, leaving ample spaces for drainage through various rents 
in the tissues. The arm was surrounded with hot water bottles. 
It was considered barely possible, as the deeper structures were 
not injured, that some degree of union might take place, and that 
amputation, if it had to be done eventually, might be done through 
the forearm, and not at the middle of the humerus, as would have 
been necessary had it been done on admission. 

The patient did well for twenty-four hours, when his tem- 
perature rose abruptly to 102" F., his pulse however not exceeding 
104 per minute. On the third day after admission, at the morn- 
ing dressing, a little emphysema was noticed in the forearm. The 
temperature had fallen to 100° F. The patient was isolated by 
direction of Dr. Frazier. When seen by Dr. Ashhurst in the 
afternoon, the emphysema had spread, and he urged amputation 
below the shoulder. Consent of the family could not be obtained, 
however; and in accordance with the advice of Dr. Neilson, the 
sutures were all cut, and the limb was placed under constant irri- 
gation, this being the only form of palliative treatment that 
seemed available. Free incisions were also made throughout the 
emphysematous tissues, thus relieving the patient's pain, and giv- 
ing exit to quantities of frothy fluid. A culture was made from 
this fluid, and it was found that an air-producing bacillus was 
present; but unfortunately, owing to changes in the laboratory, 
the culture was mislaid before it was possible to determine 
whether the growth was due to the bacillus of malignant oedema. 



SHOULDER AMPUTATION FOR GANGRENE. 



287 



to the Bacillus aerogenes capsulatus, or to some other gas- 
producing micro-organism. 

The next morning, December 30, the patient appeared better, 
and the local condition was no worse : the fingers were absolutely- 
gangrenous, and the whole forearm, as well as the elbow, was 
numb. The temperature was 100" F., and the pulse 90 to 100, 
rather weak, and very irregular. The patient was clear in his 
head, as on the previous days, and did not present the aspect of 
one who was seriously ill. The accompanying photograph 
(Fig. 2), made on this date, shows the appearance of the arm. 
As the emphysema had not spread toward the trunk, being sharply 
limited by the circular wound above the elbow, where the skin 
had been torn loose, it was considered safe to postpone amputa- 
tion, in the hope that a line of demarcation might form. As a 
matter of fact, the next day, December 31, there was a suggestion 
of a line of demarcation at the border of the skin surface above 
the circular slough in the lower third of the upper arm. The 
notes for this day read : " Forearm is emphysematous and gan- 
grenous. Gangrenous process does not appear to pass beyond 
point of sutures at elbow. Several incisions made in forearm to 
liberate gas and fluid. Upper arm is discolored for about two 
inches above line of incisions. General condition good. Pulse is 
irregular and slow, but of good volume." The pulse, on this 
and the preceding day, varied from 52 to 94 per minute. No 
digitalis had been given. 

On the morning of January i, 1908, it is noted that " there 
is slight crepitation for about one inch above line of suturing, and 
the discoloration seems to have spread nearer the shoulder, the 
upper arm is somewhat more swollen. Pulse irregular and not 
so strong." The temperature was just below 98° F., and the 
pulse from 64 to 68 per minute. 

As it was evident that the infection by the gas bacillus had 
crossed the barrier set up by the solution in continuity of the skin 
and subcutaneous tissues, produced by the original injury in the 
lower third of the upper arm, amputation was decided upon at 
once. It was found that the inner surface of the arm almost to 
the fold of the axilla was greenish in hue, and that the only 
region from which a flap could be obtained was the deltoid; 
accordingly amputation at the shoulder joint was done by Dupuy- 
tren's method, using Wyeth's pins and an Esmarch band for 



288 PHILADELPHIA ACADEMY OF SURGERY. 

haemostasis, cutting the deltoid flap from without inward, and 
the inner, short flap, from within outward, after disarticulating 
the humerus at the shoulder. A large rubber tube was left in the 
stump for drainage, and the flaps were not sutured tightly. The 
patient was much shocked, though only a few drachms of blood 
had been lost, and the operation had been completed with reason- 
able speed (about 25 minutes). 

After the amputation the patient's temperature rose in a few 
hours to over 103° F., and by 4 a.m. the next morning reached 
105.6° F., his pulse being about 138-148. At 4.30 a.m. he was 
given one pint and a half of saline solution, intravenously. This 
somewhat improved the force of his pulse. From the time the 
boy came out of ether, on the afternoon of January i, to the morn- 
ing of January 5, he suffered from the most frightful and violent 
traumatic delirium : he shrieked and yelled constantly, acting over 
and over again in his delirium the scenes of his accident, and 
throwing himself around on the bed so vehemently that he was 
with difficulty kept off the floor, even by strapping his ankles to 
the bed, and fastening his body by a sheet. During the first 'J2 
hours succeeding the operation he obtained only six and one-half 
hours sleep, in two periods of about three hours each, in spite of 
the generous use of morphine, chloral, and hyoscine. Finally on 
the night of January 4, after a dose of paraldehyde, but perhaps 
merely as a result of exhaustion, he slept seven hours and a half, 
and awoke the next morning clear in his head. His temperature 
had gradually fallen, and after this date did not rise above 100° F. 

The wound was dressed on the second day after the operation, 
to make sure that the gangrene had not affected the flaps; for- 
tunately these were found in excellent condition. 

To combat the toxaemia which seemed to be the cause of his 
delirium, he was forced to take as much liquid diet as possible. 
On the day after the operation, only 16 ounces of liquid nourish- 
ment could be taken, but this was supplemented by giving him a 
pint and a half of saline solution intravenously, as already men- 
tioned. On the second day he took by mouth 68 ounces of fluid ; 
and on the third day 65 ounces. No doubt it would have been 
beneficial to administer more saline solution intravenously, or by 
hypodermoclysis, but his delirium and tossing were so absolutely 
uncontrollable, that it would have been impossible to do either 
without the administration of a general anaesthetic. No record 



Fig 




Emphysematous gangrene. 



Fig. 3- 




Amputation at shoulder joint for emphysematous gangrene. 



SHOULDER AMPUTATION FOR GANGRENE. 



289 



could be kept of the amounts of urine excreted, as these, as well 
as his bowel movements, were passed in the bed. 

Two days after he came to his senses, he was removed from 
isolation, and returned to the general ward. His recovery hence- 
forth was uneventful, A photograph made four weeks after 
operation, shows the appearance of the stump (Fig. 3). 

This case is deemed worthy of record because of the rarity of 
recovery from emphysematous gangrene, even after prompt ampu- 
tation. Although a case of this form of gangrene is received at 
the Episcopal Hospital every few years, this is, so far as can 
be determined, the first case to recover. In 1902, a man was 
admitted to the service of Dr. Neilson with compound fracture 
of the left elbow-joint ; one morning, a few days after his admis- 
sion, he was found to have developed emphysematous areas in 
his arm above the elbow. Three or four hours later, when seen 
by Dr. Neilson, the emphysematous crackling had invaded the 
thorax, and all thought of operation was abandoned, the patient 
dying the same afternoon or evening. In the summer of 1907, 
a patient who had been operated on for typhoid perforation, in 
Dr. Deaver's service, developed emphysematous gangrene in the 
abdominal wound, and died in a few hours. 

Dudgeon and Sargent (Trans. Pathol Soc, London, 1905, 
Ivi, 42) refer to two cases of emphysematous gangrene due to the 
Bacillus aerogenes capsulatus, following crushes, both patients 
recovering after amputation, Gayet (Revue de Chir., 1908, i, 
575) has recently reported the case of a patient with compound 
fracture of the forearm, which was repaired by operation, and 
who developed " benign gaseous gangrene," but recovered without 
amputation in three months and a half. 

Writers in general recognize two main forms of " traumatic " 
or spreading gangrene ("gangrene foudroyant") — the more 
serious form of malignant oedema, caused by Koch's Bacillus, in 
which variety the formation of gases is a secondary and minor 
characteristic ; and a less serious form, due to any one of a num- 
ber of gas-producing micro-organisms, of which that most fre- 
quently encountered is the Bacillus aerogenes capsulatus of 
Welch. Among other bacteria which may be the cause of emphy- 
sematous gangrene. Freeman (" Keen's Surgery," Phila., 1906, 
vol. i, p. 340) mentions the Bacillus proteus vulgaris. Bacterium 
pseudo-oedematis maligni, and \he Bacterium coli commune, 
10 



290 PHILADELPHIA ACADEMY OF SURGERY. 

The infection in the present case was probably due to one of 
the less malignant bacteria ; and it seems not impossible that the 
delay in the emphysematous gangrene spreading toward the trunk 
may have been due to the form of the injury, which ripped the 
skin and subcutaneous tissues from around the arm above the 
elbow, thus leaving a gap in the lymphatic and cellular tissues 
between the infected and healthy parts, which completely encircled 
the limb, and prevented extension of the infection upward. 

The slowness of the pulse (52 to 64), and the absence of local 
inflammatory reaction before the operation, are also noteworthy. 
These features, as well as the fact that emphysema developed be- 
fore the parts became gangrenous, show that the condition was not 
one merely of putrefaction in already mortified tissues; a fact 
which is further testified to by the finding of gas-producing bacilli 
in the fluids of the part, before the gangrene itself was evident. 

Dr. Ashhurst expressed his indebtedness to his chiefs, Dr. 
Chas. H. Frazier, and Dr, G. G. Davis, in whose services the 
patient was treated, for the privilege of operating, sn^ of reporting 
the patient's history. 

TEMPORARY PARALYSIS OF LEFT VOCAL CORD AFTER 
EXCISION OF TUBERCULOUS CERVICAL LYMPH-NODES. 

Dr. Ashhurst also reported the case of Frank J. S., aged 
four years, who was admitted to the Children's Hospital on July 
28, 1908, in the service of Dr. E. B. Hodge, Jr., to whom he was 
indebted for the privilege of operating and of reporting the opera- 
tion. In February, 1908, this patient had had his tonsils removed 
at the Children's Hospital by Dr. F. R. Packard, and shortly after- 
ward developed measles, on account of which he was sent home. 
During his convalescence from the measles the lymph-nodes in 
the left submaxillary region became enlarged, and in spite of pal- 
liative treatment the swelling persisted. When he returned to 
the hospital in July, there was a firm, nodular mass in the left 
submaxillary region, the size of a goose egg, seven or eight more 
or less fused nodes being palpable through the skin. Operation 
was undertaken July 30, 1908. Through Dowd's incision parallel 
with the border of the mandible, and about an inch below it, the 
mass of lymph-nodes was removed entire: they surrounded the 
great vessels for a distance of about two inches and a half, a dis- 
tinct groove being left in the specimen where the vessels ran. 



POSTOPERATIVE PARALYSIS OF VOCAL CORD. 



291 



The hypoglossal nerve and descendens hypoglossi had to be dis- 
sected out of the inflammatory mass, and in so doing profuse 
hemorrhage arose, thought to be from a puncture of the internal 
jugular vein. The bleeding vein was clamped, but as the hemor- 
rhage was then seen to come from a longitudinal slit, and not 
from a mere puncture of the vein, it was impossible to apply a 
ligature satisfactorily, so the rent in the vein was sutured with 
fine chromic catgut. When the hemorrhage had thus been effec- 
tually stopped, it was seen that the tear had not been in the inter- 
nal jugular itself, but in the temporomaxillary vein close to the 
trunk of the jugular; as part of the mass of lymph-nodes lay 
below this vein, it was accordingly ligated in two places and 
divided between the ligatures, in order to facilitate the operation. 
The deep fascia was closed with buried sutures of chromic gut, 
and the skin with silk-worm gut, a small gauze wick being inserted 
for drainage. The duration of the operation was one hour. 

As the child had shrieked continuously for fifteen minutes 
before the anaesthetic was started, it was without much surprise 
that he was noticed to be very hoarse the next day. But as this 
hoarseness persisted with no appreciable diminution for two 
weeks, it was considered wise to have a laryngoscopical examina- 
tion made, as it was feared the superior laryngeal nerve had 
been injured. Dr. Packard very kindly examined the child's 
larynx, and reported as follows : " I only saw him once and it was 
pretty hard to make an accurate diagnosis as he was very nervous. 
I thought at the time that there was a partial paralysis of the 
vocal cord on the side upon which the operation had been per- 
formed, and which I attributed to injury of the recurrent laryn- 
geal nerve. Of course, if his superior laryngeal had been injured 
there would have been loss of sensation in the laryngeal mucous 
membrane, and the paralysis in such cases is never quite as 
marked as it appeared to be in the case which I examined. I 
have seen at least one other case of this kind, in an adult who 
had had tubercular cervical glands removed from her neck, follow- 
ing which she developed hoarseness and the vocal cord on the side 
which was operated upon was in a cadaveric condition. She 
regained the use of her voice completely. I think in these cases 
the recurrent laryngeal must be injured by being pulled upon or 
pressed, and as it is not completely severed, it recovers spon- 
taneously after a greater or less lapse of time." 



292 PHILADELPHIA ACADEMY OF SURGERY. 

The hoarseness gradually diminished, and eventually disap- 
peared completely, as did the slight facial paralysis present imme- 
diately after the operation. 

If the injury had been to the recurrent laryngeal nerve, it 
seems certain that it must have been produced indirectly, by pull- 
ing upon the trunk of the vagus while dissecting the lymph-nodes 
off the great vessels ; if the paralysis of the vocal cord was not 
due to injury of the fibres of the recurrent laryngeal nerve, then it 
must have been caused by injury to the superior laryngeal, which 
supplies the cricothyroid muscle and through stimulation of this 
muscle elongates the vocal cord of the same side, by elevating the 
anterior border and depressing the posterior border of the cricoid 
cartilage. 

ACUTE PANCREATITIS. 

Dr. John B. Deaver presented the following case history: 
Male, age 27 years. One year before admission to hospital had 
four or five attacks of abdominal pain accompanied by jaundice. 

Two and a half weeks before admission had severe attack of 
epigastric pain accompanied by nausea and vomiting. Pain con- 
tinued to day of admission, with frequent exacerbations. Pain 
started in epigastrium, referred to lower abdomen, back and 
shoulders. Has been jaundiced more or less ever since onset of 
this attack. 

Physical Examination. — Patient is jaundiced, the respiratory 
excursions are limited, the respirations are short. Liver extends 
from the sixth interspace to two finger-breadths below the costal 
margin in the mammillary line. There is slight epigastric fulness 
and spasticity of both recti muscles. Some tenderness over en- 
tire epigastrium, quite marked over Mayo Robson's point. The 
pain continued without relief up to the time of operation. Tem- 
perature on admission 98.4°, and, during entire course of illness, 
febrile for only about three days after operation, with a maximum 
of 100.4.° 

Operation. — Incision through right rectus. The gall-bladder 
was found adherent to colon and omentum and contained calculi. 
Posterior to the stomach there was a soft, fluctuating mass about 
the size of two fists, pushing the stomach forward. The finger 
placed in the foramen of Winslow found this to be in the position 
of the pancreas. The gall-bladder was walled off with gauze pads 
and aspirated. Forty cubic centimetres of mucopurulent fluid 



Cammidge reaction in pancreatic disease. 293 

were removed. This was sterile, as shown by culture. The 
gall-bladder was then incised and four large and twenty-four small 
stones were removed from it and the cystic duct, which was 
dilated. Tube drainage was introduced into the gall-bladder and 
the gall-bladder sewn to the parietal peritoneum. The chole- 
dochus was patulous. The laparotomy wound was closed after 
placing a gauze drain in the subhepatic space. 

The patient was then placed on his right side and an incision 
made in the left loin, extending down 7 cm. from the costal mar- 
gin and just external to the outer border of the erector spinae. 
In the fatty capsule of the kidney there was much fat necrosis. 
An abscess was evacuated in the location of the pancreas and 
about half a litre of bloody purulent fluid escaped. The cavity 
was drained with a large rubber tube and two pieces of gauze. 

The patient made an uneventful and practically afebrile re- 
covery. The drain was left in the gall-bladder eleven days, and 
in the posterior incision for several weeks, although the drainage 
gauze in this incision was all removed in six days. The discharge 
from this wound was found to be very irritating to the skin. 

Dr. Deaver remarked that this case presented these points 
of interest: (i) The slow pulse and afebrile course; (2) the 
presence of biliary calculi, — for which the operation was per- 
formed; (3) the presence of fat necrosis in the abscess cavity; 
(4) the irritating character of the pancreatic discharge. 

THE VALUE OF THE CAMMIDGE REACTION IN THE 
DIAGNOSIS OF PANCREATIC DISEASE. 

Dr. Edward H. Goodman read a paper with the above title, 
for which see page 183. 

Dr. John H. Musser (by invitation) said that in the main 
he agreed with the writer, feeling that there is in this test a 
symptom or sign of great significance in the diagnosis of pan- 
creatic disease. In the previous reactions as described by Cam- 
midge, however, he had felt that there was very little of satisfac- 
tion, and he had so reported at the Association of Physicians a 
few years ago. There were good chemical reasons for one to feel 
that perhaps the reactions were artificial rather than arising from 
the occurrence of any pancreatic disease or any change in the urine 
the result of pancreatic disease. The C. reaction has proven 
much more satisfactory, however, in the few cases observed, but 
as Dr. Goodman has said, one must consider it only an aid, a 



294 



PHILADELPHIA ACADEMY OF SURGERY. 



suggestive, but certainly not a pathognomonic, sign in pancreatic 
disease. 

He had just recently put on record nine cases of acute pan- 
creatitis. Four had been under the care of surgeons and three 
got well. The fourth was seen very early in our studies of pan- 
creatic disease, as long ago as 12 or 15 years, and while an 
abdominal section was done in the presence of the extraordinarily 
large accumulation of blood, it rather made the surgeon hesitate to 
go further than to do an exploratory operation, and in conse- 
quence — or perhaps it would have happened anyway — the patient 
died. In the present time more heroic measures might have 
been carried out and the patient's life been saved. Of the five 
remaining cases three died and two got well, so that a person with 
pancreatic disease may get well without surgery, and therefore 
one must consider that acute pancreatic disease is in part, — that 
is up to a certain degree, — a medical affection, but the time comes 
very soon when it is a surgical disease. That borderland, so 
far as known at the present time, is not so distinct as one would 
like to have it, but it cannot really be said that in every case of 
pancreatitis an operation should be done, and perhaps more par- 
ticularly not because of the pancreatitis but because of the asso- 
ciated features in connection with the various cases. Pancreatitis 
is more frequently seen in patients past 50 or 60, who have other 
lesions, particularly degenerative lesions of the heart and blood- 
vessels, which may prevent operative interference. Under such 
circumstances perhaps life is not in quite as much peril as if opera- 
tion were resorted to. In his experience the patients who got well 
were both young subjects; for the patient who died, an autopsy 
confirmed the diagnosis of pancreatitis. It is not an easy matter 
to make a diagnosis of pancreatic disease in acute pancreatitis. 
Of the nine cases mentioned five were women, four men, and five 
of the number were over 50 years of age. 

Dr. William L. Rodman said that this test of Cammidge 
had been too long neglected by American physicians and chemists. 
It has been used with great advantage in England. In Leeds six 
years ago Robson and Moynihan spoke optimistically of this test 
in pancreatic disease and cholelithiasis. Neither liked to do an 
operation without the opinion of Mr. Cammidge, and both have 
reported, at that time and subsequently, that he was almost in- 
variably right. He did not know why it was that the test had not 



HERNIOTOMY WITH THREATENED GANGRENE. 295 

been more satisfactory in this country, unless perhaps it was due 
to the fact that it is such a complicated procedure and requires 
a skilful technic in order to obtain results. It is certain that in 
the right hands and made in the right way it is a good test. The 
experience he had had with the test led him to believe that it was 
most valuable. Of course, it may not be a pathognomonic sign, but 
that it is a really substantial aid in cholelithiasis and in pancreatic 
disease there was not the slightest doubt. The test is not apt to 
be positive in carcinomatous pancreatitis. It is in chronic pan- 
creatitis that it finds its best field of usefulness. 

Dr. John B. Deaver, in closing, said that he was inclined to 
take the same view that Dr. Goodman had brought out in his 
paper. He agreed with Dr. Musser entirely when he speaks of a 
case of acute pancreatitis as being medical in the beginning of the 
attack. He also agreed with him as to the difficulty of diagnosis 
in the great majority of these cases, and certainly he felt that this 
test should be made, at any rate before operative interference was 
resorted to, particularly in acute pancreatitis. His expreience in 
acute pancreatitis, — and he had seen a number of cases, — was 
that one should not be in too great a hurry to open the abdominal 
cavity. In cases where he had had the best results he had oper- 
ated posteriorly, and this is what he proposed doing in the future 
if he could locate the lesion. 

THE VALUE OF OPERATING IN TWO STAGES IN STRANGU- 
LATED HERNIA WITH THREATENED GANGRENOUS 
PERFORATION. 

Dr. John B. Roberts said that inspection of the intestine 
after opening the sac of a strangulated hernia sometimes leaves 
the surgeon in doubt as to the wisdom of returning to the abdo- 
men a coil, upon which there are dark spots suggesting approach- 
ing gangrene. This is not an infrequent occurrence after expos- 
ing to view a portion of gut, which has been tightly constricted 
by Gimbemat's ligament in femoral hernia. 

Resection of the suspicious area or the formation of an arti- 
ficial anus at the time the kelotomy is done are eminently proper 
procedures, when there is no doubt of the impending death of 
portions of the wall of the gut. Pushing the suspected part of 
bowel just within the inner ring of the hernial canal and provid- 
ing for drainage have often been used. 



296 



PHILADELPHIA ACADEMY OF SURGERY. 



A year ago he operated with local anaesthesia upon an old 
Avoman in feeble health with a tightly strangulated femoral hernia. 
He found a black line running around the gut where the liga- 
ment of Gimbernat had exercised linear pressure. The general 
condition of the patient and the suspicious character of this dark 
line made him doubtful as to what was the safest procedure. Re- 
section seemed a serious risk and to replace the gut without 
waiting for more definite knowledge of the extent of damage 
appeared unwise. He finally concluded to allow the intestine 
which had been relieved of constriction to hang out of the wound. 
It was covered with a sterile dressing with the idea that in a day 
or two, he would know definitely whether or not perforation 
would take place from devitalization. The result justified this 
action ; for a day or two afterwards the healthy condition of the 
exposed loop showed that all danger of gangrenous perforation 
had passed. He then, without general anaesthesia, loosened up 
the plastic adhesions which were easily broken and reduced the 
hernia. The wound was then closed and the patient made a 
prompt recovery. 

It is likely that many surgeons have acted in this way under 
similar circumstances, but he had never done so, being willing in 
other cases to finish the kelotomy in one stage. 

THE RELATIVE MERITS OF SUPRAPUBIC AND PERINEAL 
PROSTATECTOMY. 

Dr. John B. Deaver presented three specimens of prostate 
glands recently taken out, the smallest of which was removed for 
a chronic prostatitis with persistent urethrovesical catarrh, and 
the two larger for obstruction, both of which were of the soft 
adenomatous type. The larger of the prostates weighed 9 ounces, 
and was the largest gland he had ever taken out. Both of the 
patients were 80 years of age; they were both sitting up in bed 
on the fourth day after operation. 

The points he wished to raise for discussion were the follow- 
ing : That the suprapubic method is the method of choice in large 
adenomatous prostates under all circumstances ; that the small 
adenomatous, as well as the hard prostates, be they fibrous, tuber- 
cular, carcinomatous, or sarcomatous, are possibly best attacked 
by the perineum, the so-called Young operation; that greater 
damage to the bladder results from the infrapubic removal of the 



SUPRAPUBIC AND PERINEAL PROSTATECTOMY, 



297 



prostate in large adenomatous prostates (and the hard prostate 
where the sheath of the gland is closely adherent) ; that the rectum 
is more likely to be injured in the infrapubic operation; that a 
permanent fistula, urinary incontinence and secondary hemorrhage 
are more likely to follow the infrapubic operation. 

When secondary hemorrhage occurs after the infrapubic 
operation, the control of which entails packing the perineal wound, 
urinary incontinence and fistula are greatly favored. The pri- 
mary bleeding, while it is greater in some cases in the suprapubic 
operation, it is more easily arrested by packing the cavity made by 
removal of the gland, and particularly purse-stringing with a 
catgut suture the mucous membrane around the opening of the 
cavity. Secondary hemorrhage seldom occurs following the 
suprapubic, while this cannot be said to be the case in the infra- 
pubic operation. Though the prostatic urethra is destroyed in 
the majority, if not in nearly all suprapubic operations, the ulti- 
mate result is as good as when the urethra is saved. The one 
thing however in favor of leaving the prostatic urethra is the 
lessened chance of stricture following. That stricture follows 
both the suprapubic and the infrapubic method in a percentage of 
cases is true. The question of preserving the ejaculatory ducts 
in the large adenomatous prostates, occurring as they do at an 
advanced time of life, to his mind cuts no figure. Again, he 
deemed it better practice to remove the adenomatous gland entire 
than to leave the portion forming the floor of the prostatic 
urethra on account of the likelihood of recurrence of obstruction 
from increased growth. 

That the power of voiding urine occurs as early in the supra- 
pubic as in the infrapubic is quite true. That the infrapubic 
operation calls for a master hand, if it is to be carried out with 
the least amount of risk to the surrounding structures he admitted 
to be so, but in either operation the more expert the operator the 
better must be the results. That the mortality of the two opera- 
tions is practically the same in equally good hands is true; pro- 
viding the statistics are honestly made and not doctored. That 
the ultimate comfort of the patient is greater following the 
suprapubic method in the class of cases he regarded as fitted for 
it, he was sure was so. He had done a sufficient number of opera- 
tions by both routes to convince him that he was correct in 
making this statement. 



298 PHILADELPHIA ACADEMY OF SURGERY. 

That the chief factors in the mortaHty following either opera- 
tion in advanced life are governed by the functionating ability of 
the kidneys and especially the great care and judgment in the 
after-treatment, he knew to be so. 

One of the most important symptoms in connection with en- 
largement of the prostate, and fortunately comparatively rare, is 
free hemorrhage. Free bleeding endangers the life of the patient 
from retention and clotting in the bladder, which can only be thor- 
oughly emptied by suprapubic incision. It was his experience that 
the danger to life under these conditions is greater than the opera- 
tion of suprapubic prostatectomy under favorable circumstances. 
He had known patients to loose as much as one pint of blood at a 
urination. A repetition of the loss of this amount of blood 
demands at least that prostatectomy be seriously considered. 

The infrapubic removal of the prostate in some of the cases 
of gonorrhoeal chronic prostatitis and vesico-urethral infection is 
the only thing that offers permanent relief. This will not be 
disputed by those who have had much experience with this 
troublesome class of cases and with the operation under these 
conditions. He protested, however, against the indiscriminate 
selection of these cases, and wished to warn the young surgeon 
of the responsibility he assumed when advising the removal of 
the prostate in this type of cases. Further, he never performed 
this operation without having told the patient of the risk of injury 
to the ejaculatory ducts ; this should not occur, however, yet that 
it can occur is true. 



BOOK REVIEWS. 



Diseases of the Breast, with Special Reference to Cancer. By 
William L. Rodman, M.D., LL.D., Professor of Surgery 
in the Medico-Chirurgical College of Philadelphia. P. 
Blakiston's Son & Co., 1012 Walnut Street, Philadelphia, 
1908. 

The present treatise forms a connecting link between our 
present-day knowledge of it and the works of Cooper and Gross 
on this subject. Although the author's own opinions are ex- 
pressed most positively, due consideration has been given to those 
of other well-known operators and investigators, as is indicated 
by continual references. The literature of the subject has been 
very exhaustively reviewed. Statistical investigations seem to 
have been accorded a most careful review, and the results derived 
from the compilation of the reports of inany hospitals give the 
author opportunity to draw conclusions from a much larger num- 
ber of cases than any that have been published hitherto, and are 
in some instances at variance with those which are usually 
accepted. Thus, for example, a study of a large number of cases 
of tumor shows that benign growths are more frequent than they 
have been supposed to be; and, again, that sarcoma is less fre- 
quent. The more important of these statistics are shown graphi- 
cally in order that the relative frequency, age, incidence, etc., of 
various neoplasms can be seen more readily without having to 
refer to the text. 

Carcinoma, as might naturally be supposed, is given the 
greatest amount of consideration ; its pathology, symptoms, diag- 
nosis, prognosis and treatment are very fully and analytically dis- 
cussed, and throughout one is impressed continually with the 
strong plea which the author makes for early and radical operative 
interference, stating quite positively that such treatment will offer 
a cure of the disease in a large number of cases. The most 
approved operative procedures are described in detail and the 
relative value of each discussed, the successive steps of the opera- 

299 



300 BOOK REVIEWS. 

tion being plainly portrayed in numerous illustrations. The 
author's technic is shown in ten full-page plates. 

The author states that when a carcinomatous tumor is situ- 
ated in the upper hemisphere it is his custom to make a supra- 
clavicular incision and to explore the posterior triangle of the 
neck. And, again, on page 296, he states that the chain of 
lymphatic vessels passes from the breast over the clavicle to empty 
into glands in the posterior cervical triangle. The importance 
of the subject would perhaps have warranted some more specific 
and detailed directions on this head. Attention might well be 
directed to the fact that there is a distinct set of vessels draining 
the upper part of the breast, which passes over the clavicle into 
the supraclavicular glands ; also that there is a subclavian channel 
given off from the posterior surface of the mamma, which, after 
perforating the pectoralis major, runs between this muscle and the 
pectoris minor to empty into the subclavian glands; the former 
are situated for the most part in the supraclavicular triangle — or, 
as it is possibly better called, the subclavian triangle — bearing also 
an intimate relation to the sternocleidomastoid muscle, and, fur- 
ther, have tributaries extending to the apex of the anterior 
triangle, particularly in its inferior carotid or muscular section. 
Thus in removing any traces of metastasis, the lymphatic chain 
which bears an intimate relation to the subclavian vein, and those 
which are in relation to the sternocleidomastoid muscle, and, 
again, those which are found in the lower portion of the anterior 
triangle, should also be sought for and dissected out, as well as 
those which the author seeks in his exploration of the subclavian 
triangle. It is probably this that he has intended to convey in 
the text and that it is only the phraseology used which makes it 
confusing. 

The inflammatory diseases of the breast, the chronic, infec- 
tious granulomata and benign neoplasms have been accorded the 
space which their importance deserved. Particular attention 
should be called to the chapter on tuberculosis and to the method 
of removing benign neoplasms by Warren's operation of plastic 
resection of the breast. 

The illustrations of the book are exceptional in their number, 
accuracy of portrayal and beauty of execution, many being in 
colors which are very realistic. 



BOOK REVIEWS. 



301 



Diseases of the Rectum, Anus, and Sigmoid Colon. By 
F. SwiNFORD Edwards, F.R.C.S., Senior Surgeon to St. 
Mark's Hospital for Diseases of the Rectum; Surgeon to 
the West London Hospital, etc. Third Edition; Octavo; 
442 pages; 102 illustrations. London: J. & A. Churchill, 
Philadelphia : P. Blakiston's Son & Co., 1908. 

The last edition of this book, published sixteen years ago, 
had become more or less obsolete, so that a complete revision 
has been necessitated in order to bring it up to present-day teach- 
ings on the subjects treated. To the former work have been 
added chapters on the sigmoidoscope and the operative treatment 
of malignant disease of the rectum and sigmoid colon. The chap- 
ters on fistula, procidentia recti, sigmoidopexy and colotomy 
have been especially amplified. The author, in dealing with the 
subject of hemorrhoids, makes particular mention of the Salmon 
operation, it being, in his experience, the most expedient ; excep- 
tion, I think, may be taken by many men to this conclusion. The 
procedures, as described in the operative treatment of malignant 
disease, are, in many cases, not clear; certainly there is much 
more to be said on the subject than has been stated in this book. 

The trend of the work impresses one as schematic, in many 
instances, the treatment of the various conditions being merely 
indicated, and not specifically stated. The book forms, as a 
whole, rather a review of the work of the author himself during 
the past thirty years, than a comprehensive review of other 
authorities, and may be better appreciated by the specialist than 
by the general practitioner, while the personal element really adds 
to the interest and value of the book. 

A Synopsis of Surgery. By Ernest W. Hey Groves. John 
Wright & Sons, Ltd., Bristol, 1908, pp. 486. 

" Epitomes " and " synopses " are sometimes pitfalls instead 
of aids to the student. If they encourage him to mere memor- 
izing they are certainly harmful. On the other hand, if they are 
associated with and subordinate to wider and fuller teachings, 
and used only as jogs to memory, not as the main source of in- 
formation, they may be of great value. 

With this limitation, Mr. Hey Groves' " Synopsis " is worthy 
of hearty commendation. 



302 



BOOK REVIEWS. 



It is based on sound teachings, is systematic, and is full 
enough to present the salient facts of surgical practice in an 
orderly and convenient manner, so arranged by means of head- 
ings, type and indented margins that they can be easily and 
rapidly referred to. 

The book gives internal evidence of having been made up, 
as the author states, from notes used in preparing students for 
examinations, but there is little to criticise. There are trifling 
omissions, e.g., there is no description of fractures of the foot, 
or of its separate bones, or of fracture of the sternum; and 
under Potts' fracture there is no adequate mention of the com- 
mon posterior subluxation ; and there are a few slight errors of 
fact, — thus it is said that in cases of loose body in the knee-joint 
" locking does not occur," which is much too absolute ; occasion- 
ally the English is not above reproach, — in the treatment of 
antral disease one method recommended is " removal of offending 
tooth and drainage through a metal tube inserted into this"; 
and there are a few typographic errors, — " Fracture of Scapular " 
(in index). 

On the whole, however, it is a very good book, and if one 
were asked to name a t?etter one of its kind and size it would be 
found difficult to do so. 

Emergency Surgery, for the General Practitioner. By 
John W. Sluss, A.M., M.D., Professor of Anatomy, Indiana 
University School of Medicine, With 584 illustrations. 
P. Blakiston's Son & Co., 1012 Walnut Street, Philadelphia, 
Pa., 1908. 

This book forms the fifth in a series of eight medical manuals 
which are to be published by P. Blakiston's Son & Company. 
The volume is of convenient size to be carried by the general 
practitioner and lends itself to this end by its flexible cover and 
rounded corners. It does not in any way attempt to take the 
place of any of the larger text-books of surgery, and does not 
go into various methods of operative procedure; the most ap- 
proved method being usually the only one mentioned. The illus- 
trations are profuse and instructive, particularly those illus- 
trating the reduction of hip and shoulder dislocations. Con- 
sideration of some of the subjects cannot really be included under 
the head of emergency surgery; that, however, does not detract 
from the usefulness of the book. 



CORRESPONDENCE, 



VAS DEFERENS ANASTOMOSIS. 

Editor Annals of Surgery : 

In the issue of the Annals for November Dr. Gwillym G. 
Davis reports a plastic operation upon a divided vas deferens. 
As a further contribution to the subject, I desire to call attention 
to an article concerning a method of securing anastomosis of 
such a vas, which was published by me in the British Medical 
Journal, January 2, 1904. The followmg is the method I used in 
the case under my care : 

An oblique incision was made along the course of the inguinal 
canal similar to that used in the operation for the radical cure 
of an inguinal hernia, the spermatic cord was exposed, and the 
testis dislodged through the wound, carrying with it a swelling 
the size of a large pea which was situated in the course of the 
spermatic cord about one inch above the testis. This turned out 
to be a collection of semen confined in a fascial sheath between 
the ends of the divided vas deferens. The vas was found to be 
completely divided and its ends were separated for about half an 
inch. 

The testicular end of the vas deferens was cut obliquely by 
means of a cataract knife. The distal or urethral portion of the 
vas was split up longitudinally for about one inch ; this free end 
was further divided up for about half an inch from its extremity 
so as to provide two tails of equal size ; in other words, each tail 
consisted of one-half of the longitudinally split vas deferens. The 
obliquely cut free end of the testicular portion of the vas was 
placed with its lumen in contact with that of the testicular portion, 
and was fixed by means of fine silk sutures as closely applied as 
the whipcord-like tube would admit. The two tails of the distal 
end were then enveloped round the testicular portion of the vas in 
order to counteract the disruptive force of the weight of the testis. 
Afterwards layers of fascia were wrapped round the anastomosed 
vas deferens and fixed by sutures. 

303 



304 CORRESPONDENCE. 

I found it necessary to form the tails in order to secure a 
firm and permanent approximation of the divided end. It seemed 
to me that end-to-end anastomosis was not practicable, owing to 
the smallness of the tissues for suturing. Invagination of the 
ends was impossible on account of the rigidity and size of the 
walls of the vas deferens. 

One can demonstrate the practicability of the above method 
of anastomosis of the vas deferens on the cadaver by injecting 
fluid along its lumen by means of a syringe. 

As far as I know this case is unique, and I venture to record 
the method I devised on account of its being, I believe, a suitable 
operation in the conservative surgery of an injured vas deferens. 

In this case there has occurred absolutely no atrophy of the 
testis. 

J. Lynn Thomas, C.B., F.R.C.S. 

Cardiff, England. 



To Contributors and Subscribers : 

All contributions for Publication, Books for Review, and 
Exchanges should be sent to the Editorial Office, 386 Grand Ave., 
Brooklyn, N. Y. 

Remittance for Subscriptions and Advertising and all busi- 
ness communications should be addressed to the 

Annals of Surgery, 
227-231 South Sixth Street, 
Philadelphia. 



Annals of S 



NNALS OF OURGERY 



Vol. XLIX MARCH, 1909 No. 3 



ORIGINAL MEMOIRS. 



THE INTRA-ABDOMINAL ADMINISTRATION 
OF OXYGEN. 

A FURTHER CONTMBUnON, WITH REPORTS OF ADDITIONAL CASES.* 

BY WILLIAM SEAMAN BAINBRIDGE, M.D., 

OF NEW YORK CITY, 

Clinical Professor of Surger>'. New York Polyclinic Medical School and Hospital ; 

Consulting Surgeon, Manhattan State Hospital ; Surgeoti, New York 

Skin and Cancer Hospital ; Associate Surgeon, Woman's 

Hospital. 

In a previous communication ^ I endeavored to give, as 
briefly as possible, a resume of the medical and surgical uses 
of oxygen, tracing the therapeutic history of the gas from the 
time of its discovery to the present day. 

In reviewing the literature of the subject I touched briefly 
upon what has been accomplished with the gas by inhalation in 
various conditions, by subcutaneous injections, by intravenous 
infusion, in obstetrics, in children* s diseases, in gyncecology, in 
general therapeutics, and in surgery. 

Following this I reported a series of sixteen cases in which 
oxygen had been employed intra-abdominally according to 
the method detailed below. These cases were selected from a 
number in which the gas had been administered in various 
ways in my services at the New York City Children's Hos- 

* Read before the Society of the Alumni of City (Charity) Hospital, 
New York, December 9, 1908. 

' " Oxygen in Medicine and Surgery — A Contribution with Report of 
Cases," New York State Journal of Medicine, June, 1908. 

II 305 



3o6 WILLIAM SEAMAN BAINBRIDGE. 

pitals and Schools, the New York Skin and Cancer Hospital, 
and the New York Polyclinic Medical School and Hospital, 
as well as in private practice. 

The clinical experience from which these cases were 
drawn was chiefly surgical, and extended over a period of 
about five years, during which time the gas was employed 
in the following ways: (i) by inhalation; (2) by infusion 
into the pleural cavity; (3) by injection into abscess cavities, 
carbuncles, furuncles, and other inflammations, acute and 
chronic; (4) by injection into tuberculous joints; (5) by in- 
fusion into the abdominal cavity, allowing the gas to be 
gradually absorbed, in the following conditions : (a) tubercu- 
lous peritonitis, with ascites; (b) after removal of ascitic 
fluid from whatever cause; (c) following severe laparotomies, 
for the control of shock, for its influence upon hemorrhage, 
cyanosis, nausea, and vomiting, and for the prevention of 
adhesions. 

ANIMAL EXPERIMENTATION. 

In the paper to which reference has been made I also re- 
ported animal experiments, which were conducted for the 
purpose of determining to what extent clinical deductions 
were capable of verification by laboratory methods. In the 
conduct of those experiments I received the valuable assist- 
ance of Dr. Harold Denman Meeker, Dr. James T. Gwathmey, 
and Dr. D. R. Lucas. 

The work was executed with the following definite objects 
in view: 

1. To determine the absorbability of oxygen. 

2. To determine its effect upon (a) blood-pressure, (b) 
pulse, (c) respiration, (d) degree of anaesthesia, (e) time 
of recovery after anaesthesia. 

3. To effect a comparison between the results upon the 
above when oxygen is employed and when air is employed. 

4. To determine the danger-point of intra-abdominal pres- 
sure as manifested by a fall in blood-pressure, respiratory 
embarrassment, and cardiac failure. 



INTRA-ABDOMINAL USE OF OXYGEN. 



307 



5, To determine the effect of oxygen upon adhesions in 
the abdominal cavity. 

From these experiments the following deductions were 
made: 

(i) Oxygen is completely absorbed in the abdominal 
cavity. (2) It is a slight respiratory stimulant. (3) It is a 
slight cardiac stimulant. (4) It has but little effect upon 
blood-pressure when the pressure of the gas is moderate. (5) 
It tends to bring an animal quickly from deep anaesthesia. 
(6) It hastens the recovery of an animal after discontinuance 
of the anaesthetic. (7) A pressure of more than 1500 mm. 
of water may cause collapse. (8) Oxygen tends to prevent 
the formation of adhesions. (9) It quickly changes a dark 
blood to scarlet in cases of anoxaemia. (10) It stimulates 
intestinal peristalsis. (11) It is not an irritant to the peri- 
toneum or abdominal viscera. 

While the conclusions drawn from the experiments re- 
ported in my previous paper have not been in accord, in 
every instance, with those reached by other workers from 
similar investigations, in no case have the discrepancies seemed 
of sufficient importance to warrant a change of view with 
reference to the possible clinical value of this application of 
oxygen. Therefore, since the publication of the paper re- 
ferred to above, I have continued to test the utility of the 
intra-abdominal administration of oxygen wherever it seemed 
to be indicated. In this research the field of usefulness has 
gradually enlarged, as I shall presently show. It is now 
administered for the following purposes: 

1. To lessen shock, hemorrhage, nausea, and vomiting. 

2. To overcome negative intra-abdominal pressure after 
removal of large tumors. 

3. To prevent the formation of adhesions. 

4. For its effect upon tuberculous peritonitis of certain 
types. 

5. For its effect upon pus-producing organisms and their 
toxins. 

METHOD OF ADMINISTRATION. 

In the abdominal administration of oxygen I have em- 



3o8 WILLIAM SEAMAN BAINBRIDGE. 

ployed the so-called pure gas.* The gas is warmed, usually 
to a temperature of from 90°-! 00° F. This is accomplished 
by passing it through a rubber tube from the tank in which 
it is compressed into a wash-bottle filled with hot water. From 
this bottle the partially warmed gas passes through the exit 
tube, which is coiled in a basin of hot water. This long exit 
tube is again connected with a piece of glass tubing, and to 
this, in turn, is attached a piece of sterile rubber tubing 
through which the gas is introduced into the abdominal cavity. 
In this last piece of tubing, at the distal extremity, are two 
openings, one in the end, which is cut off obliquely, and the 
other in the wall of the tube, near the end. 

Instead of the rubber coil in the basin of hot water, a 
Leiter's coil, or a special metal coil which will allow of the 
heating of the oxygen, may be employed. 

The abdominal wound is closed, except at the lower or 
upper end, as the case may be, where the free end of the 
tube is placed within the abdominal cavity. One stitch is 
introduced above and one below the tube, and these are tied. 
An interrupted stitch is placed in the peritoneum at this 
point, ready to be tied, and a purse-string suture is introduced 
around the tube in the peritoneum, left long but not tied. 
All layers of the abdominal wall are closed, up to the skin, 
and the stitches tied, with the exception of those in juxta- 
position to the tube. These, layer by layer, are tied after 
the purse-string stitch has been fastened. 

When the desired amount of gas has been introduced the 
tube is carefully withdrawn and the purse-string stitch tied, 
all the others being then fastened layer by layer. Care should 
be taken, of course, to prevent intracellular emphysema, which, 
while not harmful, may be a source of some discomfort to 
the patient. 

The amount of oxygen to be administered depends upon 

* The gas which I now employ has been shown by analysis to contain 
from 94.3 per cent, to 97 per cent, oxygen; 2.37 per cent, to 4.5 per cent, 
nitrogen ; a trace of carbon dioxide ; no chlorine ; no nitrous oxide. Simi- 
lar relative purity of the gas used should be insisted upon by the surgeon. 



INTRA-ABDOMINAL USE OF OXYGEN. 



309 



the exigencies of the case. Where there is abdominal dis- 
tention from ascites or tumor, the girth of the abdomen 
should be measured before operation, and after removal of 
the fluid or the tumor the abdomen should be distended to 
the same or perhaps a little less degree by the admission of 
oxygen. Where there is no distention of the abdomen a crude 
yet practical test in the average case is found by first deter- 
mining that the liver is not adherent to the chest wall and 
is of approximately normal size, then administering enough 
oxygen to obliterate liver dulness. A gauge such as is used 
in measuring the amount of oxygen in animal experiments 
may be employed. 

So far as I have been able to ascertain from a careful 
review of the literature of the subject, the intra-abdominal 
administration of oxygen where the gas is allowed to remain 
ill situ until absorbed, had not been employed previous to my 
own work in this line. With the use of oxygen in its nascent 
state, as in hydrogen peroxide, all are familiar, Thiriar and 
others have employed the gas in a continuous stream, thus 
flushing out the abdominal cavity after laparotomies and after 
evacuation of ascitic fluid in tuberculous peritonitis. The 
application of the gas in this manner is made with a view 
of stimulating the tissues, preventing the extension of the in- 
flammation, causing increased phagocytosis and leucocytosis, 
destroying the germs or diminishing their virulence, neutra- 
lizing their toxins, and " substituting an oxygenated emphy- 
sema for the microbian emphysema." The gas is introduced 
in a continuous stream, 40 to 50 litres of oxygen being used 
at one treatment, always with a free outlet. 

In the cases detailed in my previous communication, and 
in those which I shall now report, the abdomen was bal- 
looned with the gas and the wound carefully closed, accord- 
ing to the method which I have described, the oxygen being 
allowed to be absorbed gradually by the tissues. In the cases 
of abdominal distention with ascitic fluid, in certain forms 
of tuberculous peritonitis, and in some cases where large 
tumors were removed, the gas was introduced, as previously 



310 



WILLIAM SEAMAN BAINBRIDGE. 



Stated, to the point of distention caused by the fluid or by 
the tumor. 

In this manner the negative intra-abdominal pressure 
which follows the removal of fluid or tumors is overcome 
by a means which gradually and imperceptibly to the patient 
lessens the pressure, at the same time distending the neces- 
sarily torn and bruised tissues until such time as there is 
very little danger of the formation of adhesions. This, it 
seems to me, is better than the pressure-pads so often used. 

In cases where there is no undue abdominal distention by 
the pathological process, and yet where the surgical inter- 
vention is such as to entail the possibility of severe shock or 
extensive capillary hemorrhage, with subsequent nausea, vom- 
iting, and abdominal tenderness, oxygen is introduced to the 
point of removal of all liver dulness, or according to the 
exigencies of the case. 

Thus, in addition to whatever phagocytic and bactericidal 
action the oxygen may exert, we have a lessening of shock, 
a control of hemorrhage from small vessels, a decrease of 
cyanosis, an early improvement of the pulse and respiration, 
and in many instances such response to the oxygen stimulus 
that more anaesthetic is necessary in order to keep the patient 
anaesthetized until the completion of the operation. As a 
rule, the nausea, vomiting, and abdominal tenderness which 
so often follow severe operations are much less than one may 
reasonably expect. 

The following additional cases admirably illustrate the 
action of the oxygen in the manner just described. While some 
of the cases were of such nature that there is reason to believe 
recovery would have taken place in any event, the oxygen 
merely acting as a temporary stimulant, in others the con- 
dition of the patient at the time of operation was so bad, or 
the shock from the operation was so great, that the result 
without some such support as oxygen seemed to give would 
have been questionable.^ 

' For report of cases I to XVI, inclusive, see New York State Journal 
of Medicine, June, 1908. 



INTRA-ABDOMINAL USE OF OXYGEN. 



311 



Case XVII. — A. C, female, aged 44, married, laundress. 
Prolapsus uteri. Operation, April 2, 1908, divulsion, curettage, 
appendectomy, suspension of uterus. Condition very poor. Pulse 
and respiration immediately improved upon the intra-abdominal 
administration of oxygen, and more anaesthetic had to be given. 
Recovery uneventful. 

Case XVIII. — G. V., male, aged 51. Seen in consultation 
with Dr. Henry Franciscus, of Brooklyn, April 24, 1908. Ad- 
mitted to the New York Skin and Cancer Hospital, April 28, 
1908. Irremovable gastric and intestinal carcinoma. Operation 
May 4. Gastro-enterostomy performed. The patient's general 
condition was very poor, and the shock from the operation was 
so great that he came near dying on the table. He rallied, how- 
ever, as soon as oxygen was introduced into the abdomen. The 
wound healed by primary union, and the patient did as well as 
could be expected for three or four days, but coincidental with 
the total absorption of the oxygen he began rapidly to lose 
ground, and died, May 11. Postmortem revealed the fact that 
all of the gas had been taken up by the general system, and that 
there remained no changes in the peritoneum which could be 
attributable to the action of the oxygen. 

Case XIX. — J. B., female, aged 38, married, housewife. Endo- 
metritis, both ovaries cystic. Operation May 7, 1908. Divulsion 
and curettage. Left ovary removed ; multiple punctures in right 
ovary ; appendectomy. Oxygen administered intra-abdominally 
exerted a stimulating effect which was distinctly observable. 
Abdominal tenderness following the operation was less marked 
than is usual in such cases. Recovery uneventful. 

Case XX. — G. P., female, aged 39, married. Seen in consul- 
tation with Dr. M. W. Barnum, of Ossining. Ovarian cyst. 
Operation at the Ossining Hospital May 16, 1908. Left ovarian 
cyst weighing six pounds with beginning cancerous degeneration 
removed; right ovary, also diseased, removed; appendectomy. 
Shock considerable. The introduction of oxygen caused im- 
mediate improvement in the patient's condition. Recovery 
uneventful. 

Case XXI. — S. A., female. Chronic appendicitis, with many 
peritoneal adhesions. Operation May 23, 1908. Adhesions 
broken up and appendix removed. Oxygen administered in this 
case chiefly with a view to preventing the formation of adhesions. 



312 WILLIAM SEAMAN BAINBRIDGE. 

Recovery was uneventful, and subsequent history has revealed 
nothing that could be attributed to the return of adhesions, despite 
the chronic nature of the condition. 

Case XXII. — S. B., male, aged 26. Carcinoma involving 
omentum, peritoneum, and intestines. Operation, New York 
Skin and Cancer Hospital, June 4, 1908. The general condition 
of the patient was so bad and the disease so extensive that 
nothing more than exploratory laparotomy could be done. 
Oxygen was introduced, and in a few minutes the patient came 
out of the anaesthetic and made vigorous attempts to get off 
the operating table. 

Case XXIII. — D. H., male, aged 35. Admitted to the New 
York Polyclinic Medical School and Hospital, June 19, 1908. 
Abdominal distention of six months' duration. Had been 
previously tapped six times. Refused Talma's operation for 
cirrhotic liver. Fluid withdrawn under local cocaine anaesthesia 
and oxygen administered. Patient said he was " buoyed up " 
by the oxygen and felt better after this than he had for a long 
time. He noticed a difference in his feelings on this and previous 
tappings. He insisted upon returning to his home in Florida 
next day. Oxygen, while diminishing, was still present in the 
abdomen. 

Case XXIV. — C. E., female, aged 22, married, housewife. 
Admitted to the New York Skin and Cancer Hospital, June 10, 
1908. Extra-uterine pregnancy, ovarian cyst, pelvic peritonitis. 
Extra-uterine pregnancy, right tube and right ovary removed. 
Many adhesions around the appendix broken up and appendec- 
tomy performed. Oxygen was introduced intra-abdominally. 
The patient's condition improved at once, her color became 
better, breathing easier, pulse fuller and slower, and the patient 
came out quickly from the anaesthetic. Recovery uneventful. 

Case XXV. — M. D. S., female, aged 33, single. Admitted 
to the Alston Sanitarium June 24, 1908. Fibromyoma of uterus. 
Operation June 26. Removal of tumor weighing six pounds; 
right tube and ovary removed; extensive adhesions broken up. 
Shock very great. Immediately upon the introduction of oxygen 
into the abdomen the condition of the pulse and respiration im- 
proved. There was slight postoperative vomiting, practically no 
nausea, and very little abdominal soreness. Appetite good im- 
mediately following the operation; all food retained. Recovery 
uneventful. 



INTRA-ABDOMINAL USE OF OXYGEN. 313 

Case XXVI. — R. J., female, aged 30, single, teacher. Retro- 
poised uterus; pelvic peritonitis; chronic appendicitis. Opera- 
tion, Jamestown Hospital, Jamestown, N. Y., July 12, 1908. 
Many adhesions around the appendix broken up ; appendectomy ; 
uterus suspended. Considerable shock, which was promptly 
overcome by the intra-abdominal administration of oxygen. 
Recovery uneventful. 

Case XXVII. — W. E., female, aged 68, married. Referred 
by Dr. H. T. Wolf, of Yonkers. Abdominal carcinosis, kinking 
of the gut, with intestinal obstruction. Operation April 14, 1908, 
at St. John's Riverside Hospital, Yonkers, assisted by Dr. Getty 
and Dr. John, of the attending staff. The case was so extreme 
that operative procedure was warrantable only upon the ground 
of attempting to control the vomiting, which was almost fecal 
in character. A large amount of fluid was removed from the 
abdomen, and the intestine straightened. Adhesions around the 
left ovary broken up and the ovary removed. The patient was 
practically pulseless. The intra-abdominal administration of 
oxygen was followed by prompt improvement in pulse, respira- 
tion, and general condition. The patient rallied from the 
operation. There was no subsequent vomiting, except just be- 
fore her demise. The bowels moved easily, and it would seem 
that the patient did as well as could be expected so long as 
the oxygen was in the abdomen, but when this was all absorbed 
she succumbed from asthenia, four days after operation. 

Case XXVHI. — F. W., female, aged 37, married, housewife. 
Referred by Dr. William W. Van Valzah. Anaemia, hemorrhoids, 
chronic appendicitis; left ovary prolapsed and cystic; uterus re- 
troverted and large; many abdominal adhesions. Operation, 
Woman's Hospital, June 3, 1908. Curettage; modified Gilliam; 
adhesions broken up; appendix removed; left ovary removed. 
Considerable shock. Condition perceptibly improved upon the 
introduction of oxygen and remained good. Recovery uneventful. 

Case XXIX. — R. V., aged 29, female, married, housewife. 
Exploratory laparotomy, June 12, 1907, at the New York Skin 
and Cancer Hospital. Papillomatous degeneration of uterus, 
tubes, and ovaries found, extending to the intestines and well up 
toward the liver. A detached portion was removed for micro- 
scopic examination, the report being " malignant papilloma." 
Ten days later panhysterectomy was performed and a large 



314 WILLIAM SEAMAN BAINBRIDGE. 

amount of fluid evacuated. A large papillomatous mass in the 
pelvis was also removed. On November 12, 1907, and again 
on January 11, 1908, exploratory laparotomy was performed for 
the purpose of removing fluid and more of the papillomatous 
masses. At the first two operations no oxygen was administered. 
In each instance there was considerable nausea and vomiting, 
and decided abdominal tenderness and soreness. At the last 
two oxygen was introduced into the abdominal cavity. The 
patient was absolutely free from pain in each case, there was 
no nausea, no vomiting; her skin was pink when she left the 
operating table; she came out of the anaesthetic very promptly, 
and a few hours ofter the operation nourishment was taken with 
relish and retained. 

On March 6, 1908, the patient returned to the Skin and 
Cancer Hospital, when paracentesis abdominalis under local 
cocaine anaesthesia was made, and eleven pints of serosanguinous 
fluid evacuated. Oxygen was administered through the para- 
centesis needle until normal liver dulness disappeared. Patient 
felt exhilarated. Returned home forty-eight hours later in good 
condition. 

On November 2, 1908, patient was again admitted to the 
hospital, and on November 4 laparotomy was performed. More 
adhesions broken up; a number of retroperitoneal cysts in the 
mesentery evacuated; a mass of friable, papillomatous tissue, as 
large as two fists, removed from the upper surface of the liver. 
On account of the tremendous shock the effects of the intra- 
abdominal administration of oxygen were not so noticeable at 
the time, but the patient made an uneventful recovery except 
for persistent vomiting and reverse peristalsis for some days 
after operation. This, however, soon disappeared, and the sub- 
sequent history presents no notable features. This patient is now 
at home in very fair condition, able to do light housework.^ 

Case XXX. — M. O., female, aged 53, housewife. Referred 
by Dr. J. H. Jenkin, of Shrub Oak, N. Y. Right ovarian cyst; 
multiple uterine fibromata. Operation at the New York Skin 
and Cancer Hospital, November 18, 1908. Median incision 8 
inches in length. Several pints of ascitic fluid evacuated from 

■Reported in previous paper as Case XII. Present report embodies 
subsequent operations. 



INTRA-ABDOMINAL USE OF OXYGEN. 315 

the peritoneal cavity. Left ovary and tube normal. Right ovary 
the seat of a very large cyst, which had become adherent to the 
stomach and other viscera in the upper abdomen. One large and 
several small fibroids. Panhysterectomy, only the tip of the 
cervix being left. The entire mass removed weighed 61^ 
pounds. Shock very great. Oxygen introduced until the abdo- 
men was ballooned up to very nearly the size it was before the 
operation. Patient's condition improved. During the entire time 
the oxygen seemed present in the abdomen (between thirteen and 
fourteen days) the face was somewhat flushed, the lips more 
than ordinarily moist and red. The bowels moved without 
catharsis and with only a small enema, at the end of thirty-eight 
hours. There was no nausea, no vomiting, and no paralysis of 
the gut, despite the previous intra-abdominal pressure. Recovery 
uneventful. 

From the series of cases previously reported and from 
those detailed above, it will be noted that the gas was first 
employed in the manner described for its effect upon pulse, 
respiration, etc., as outlined; also that our laboratory ex- 
periments were directed toward the verification of the clinical 
experience along these lines. We are now, however, carry- 
ing on a series of animal experiments, to be published later, 
for the purpose of determining the effect of oxygen upon 
various organisms, both aerobic and anaerobic, particularly 
upon the common organisms of sepsis encountered within 
the body cavities. 

Along similar lines, acting upon the suggestions held forth 
by the work of Thiriar and others, Burkhardt, in Germany, 
has conducted a series of experiments upon dogs and rabbits, 
for the purpose of determining the action of oxygen on 
wounds and infections.'* He confined his attention to the 
effect of the gas upon staphylococci and streptococci and their 
poisonous products. Pure cultures of Staphylococcus pyo- 
genes aureus exposed to a continuous stream of pure oxygen 
showed after a few days very badly developed colonies, 
which grew quickly after removal from the oxygen atmos- 

* Deutsche Zeitschrift fiir Chirurgie, vol. xciii, No. 2. 



3i6 WILLIAM SEAMAN BAINBRIDGE. 

phere. In the incubator the inhibition of growth was less 
marked, but there was nothing in his experiments that led 
him to believe that oxygen would entirely inhibit the develop- 
ment of these organisms. 

A large part of his investigation was concerned with the 
question of the extent to which infection of the peritoneum 
could be influenced by injections of oxygen. It is possible, 
as he points out, that the filling of the peritoneal cavity with 
the gas changes the resorptive conditions, or that the oxygen, 
similarly to normal salt solution, increases the reactive capacity 
of the peritoneum to infection by bringing about hyperleuco- 
cytosis. In the beginning of peritoneal infection there is 
an energetic absorption, but just as soon as there is a serous 
or purulent secretion into the peritoneal cavity resorption 
decreases. As soon as there is a localization of the con- 
dition, however, a slowing of absorption is better for the 
patient because of the danger, in the presence of rapid ab- 
sorption, that a large amount of bacteria or their toxins 
may find their way into the blood, thus producing general 
infection. Oxygen introduced into the peritoneal cavity re- 
tards this absorption. 

Up to this point our own experiments coincide with those 
of Burkhardt. He found, however, that oxygen is an irritant 
to the peritoneum. This has not been our experience. There 
may be a temporary injection of the capillaries, but certainly 
no harmful degree of irritation, either in the animals ex- 
amined, or in the human subject where it has been possible to 
observe this point. 

As I have previously stated, we are now conducting a 
series of experiments to determine the action of oxygen on 
certain bacteria and their toxins. In the meantime, we are 
bearing this feature of the question in mind in our clinical 
work. While I am certainly not ready to advocate the use 
of oxygen in every case of septic peritonitis — as I assuredly 
do feel warranted in using it in tuberculous peritonitis of the 
cystic or fibrocystic type — nevertheless, in the following cases 
the gas has been employed so successfully that it gives hope 



INTRA-ABDOMINAL USE OF OXYGEN. 



317 



of some definite utility in septic conditions in the peritoneal 
cavity. 

Case I. — E. J., male, aged 16 years. Seen in consultation 
with Dr. A. Austin Becker, Jamestown, N. Y. Acute appendicitis. 
Operation at the Jamestown Hospital, July 10, 1908. The ap- 
pendix was found to be gangrenous, with two or three points of 
ulceration, one ruptured into the peritoneal cavity. The peri- 
toneum was congested for some distance from the caput coli, 
in the neighborhood of which was a considerable amount of pus 
and seropurulent material, which was mopped out as far as was 
possible. The appendix was removed, oxygen introduced, and 
the wound closed without drainage. Temperature dropped to 
normal in twenty-four hours, remaining so. Convalescence un- 
eventful, except for an abscess which formed in the deep layers 
of the wound. This was opened July 16, and allowed to drain 
for several days. The boy was up and well in two weeks. 

Note. — The fact that this wound was infected from within 
is important in relation to the oxygen. There is no question 
but that this was a septic peritonitis and that the wound was 
infected from the peritoneum; but where the oxygen was in 
contact with the infected tissues there was no extension of the 
trouble. Where, however, the infectious material had come in 
contact with the walls of the wound not bathed by oxygen, the 
growth of the bacteria continued. 

Case II. — A. A., female, aged 27, domestic. First seen 
April 16, in the evening, during an acute attack of appendicitis. 
Operation, 2 a.m., April 17. The abdomen was found to con- 
tain turbid fluid, and the peritoneum to be congested around the 
caput coli. Some adhesions around the appendix, which was 
swollen, dark in color, filled with fecal matter, and apparently 
on the point of rupturing. Adhesions broken up and appendix 
removed. Oxygen administered intra-abdominally. Temperature 
dropped to normal within twenty-four hours, remaining so. Re- 
covery uneventful, patient out of the hospital in two weeks. No 
drainage employed. 

Cultures were taken from the peritoneum, and many bacilli 
coli communis and pus organisms were found. 

Dr. J. B. Greene, of Mishawaka, Ind., has furnished me 
with the data concerning an interesting case in which he em- 



3i8 WILLIAM SEAMAN BAINBRIDGE. 

ployed oxygen according to the method above described. 
With the Doctor's kind permission I give below an abstract 
of the history. 

Case III. — S. B., female, aged 24, married, two children. In 
an attempt to produce an abortion by means of a wired silk-fibre 
catheter the patient had punctured the fundus uteri, torn the 
cervix, and lacerated the vagina on the right side. This occurred 
at 10 A.M., September 3, 1908. A violent chill followed, the 
patient went to bed, and another physician was called at 2 p.m. 
At 8 P.M. patient was taken to the South Bend Hospital, and 
at 10.30 P.M. she was first seen by Dr. Greene. She was almost 
in extremis at the time, presenting the typical picture of pro- 
found sepsis. Believing death to be imminent otherwise, Dr. 
Greene and his consultants decided to give the patient the only 
chance afforded by surgical intervention. The abdomen was 
promptly opened, with as few preliminaries as possible. There 
was an outpour of blood and fecal matter from the abdominal 
cavity. The pelvic cavity was filled with clots, fecal matter, and a 
two months' foetus. The ascending colon was torn from two 
inches above the ileocsecal junction, down through the caecum, 
an irregular triangle, including the appendix, which had been 
torn from the caecum. The uterus was lacerated from the right 
cornu through, into, and including the vaginal wall, and the 
right ureter was torn off. The bowel was repaired, the uterus 
removed, the ureter brought up and fastened in the upper angle 
of the abdominal wound. After as thorough cleansing as was 
possible under the circumstances, the abdominal wound was 
closed, with a small rubber drainage tube in the lower angle. 
Collodion and cotton were applied around the junction of the 
skin with the tube, and through the tube oxygen was admitted 
until the abdomen was fairly well distended. The tube was 
then compressed to retain the gas, which was allowed to escape 
after about fifteen minutes. The abdomen was again distended 
with oxygen, the tube tied securely, dressings applied, and the 
patient put to bed. Only once after the operation did the tem- 
perature go above normal. The patient made an uneventful 
recovery in sixteen days. 

On September 26 the abdomen was again opened and the 



INTRA-ABDOMINAL USE OF OXYGEN. 



319 



ureter grafted to the bladder. Uneventful recovery from this 
operation also. 

A WORD OF CAUTION. 

It should be observed that in all severe laparotomies where 
oxygen is employed in the manner described, it is of the ut- 
most importance to watch for signs of failing strength after 
the oxygen is absorbed and the patient no longer receives 
this stimulus. While we do not believe in " postponed shock," 
there may be a postponed depression after the oxygen is 
absorbed, and it is then that one should resort to stimulation 
by other means, in order to tide the patient over. This 
depression is in no wise due to the fact that oxygen was 
administered — it has merely been delayed by the oxygen 
stimulus — and as soon as noted it should be overcome by 
the administration of the usual stimulants given under such 
circumstances. In ordinary cases the gas is absorbed in 
from thirty-six to seventy-two hours. 



CONCLUSIONS. 

Final deductions concerning the clinical value of oxygen 
administered intra-abdominally, according to the method above 
described, cannot be made as yet, but our experience warrants 
the following tentative conclusions : 

1. From Cases I to XVI, reported in my former paper, 
and from Cases XVII to XXX, detailed above, it may be 
safely said that oxygen, intra-abdominally administered, has 
a distinct field of usefulness in lessening shock, hemorrhage, 
nausea, and vomiting; in overcoming negative intra-abdomi- 
nal pressure after removal of large tumors ; in preventing the 
formation of adhesions, or, when broken up, lessening the 
liability of their return; and in influencing favorably certain 
types of tuberculous peritonitis. 

2. From Cases I to II (my own), and Case III (Dr. 
Greene's), in which the gas was introduced into the peritoneal 
cavity in septic peritonitis, sufficient beneficial effect was noted 
to warrant the hope that further clinical experience may 
establish the efficacy of the gas as an adjuvant in the treat- 
ment of this condition. 



PLASTIC SURGERY OF BLOOD-VESSELS AND 
DIRECT TRANSFUSION OF BLOOD.* 

BY ISAAC LEVIN, M.D., 

OF NEW YORK. 

Until very recently the only aim of surgery in the treat- 
ment of injuries of blood-vessels was to bring on a perfect 
h?emostasis. If the injured vessel is the main source of the 
circulation of blood in an organ, then gangrene follows the 
vascular trauma, and the organ has to be excised or the limb 
amputated. Plastic surgery of blood-vessels, i.e., an operative 
procedure where the final aim is not to arrest the bleeding only 
but to produce a free circulation of blood through the impaired 
blood-vessels, is one of the great achievements of modern 
experimental surgery. 

The late development of vascular surgery is due to the 
special difficulties encountered in dealing with this organ. A 
blood-vessel is an elastic tube filled wjth a fluid streaming under 
high pressure, and coagulating under the influences of the 
slightest injury. In repairing a loss of continuity of such a 
tube the surgeon, besides the usual aseptic precautions, has to 
take into consideration the possibility of a secondary hemor- 
rhage and the formation of thrombosis, with subsequent arrest 
of the circulation and embolism in some vital organ. Only 
in 1889 were reported by Jassinowsky ^ the first successful 
results of suturing of arterial wounds with preservation of 
the lumen of the vessels. Since then quite a number of inves- 
tigators have studied the subject. Some have used different 
mechanical devices to unite the severed ends of the blood- 
vessels; others produced the anastomosis with the help of 
sutures of various forms. Of the former may be mentioned 
Payr,^ Exner,^ and Hopfner.* The direct suture method was 

* Read before the Section on Surgery of the New York Academy of 
Medicine, January 8, 1909. 
320 



PLASTIC SURGERY OF BLOOD-VESSELS. 321 

developed by Murphy,^ Carrel and Guthrie,® and Carrel aloneJ 
The last investigator developed the finest technic and obtained 
the most brilliant results in this domain of experimental 
surgery. 

Plastic surgery of blood-vessels may consist, according to 
S. T. Watts,^ in lateral sutures of veins and arteries, when the 
wound of the blood-vessel is either a longitudinal one, or a 
transverse one which does not completely sever the two ends. 
The circular suture of arteries and veins is used in complete 
transverse wounds of vessels. Arteriovenous anastomosis is 
a circular suture between an artery and a vein and finds its 
most important application in the direct transfusion of blood. 
Transplantation of arteries and veins means an implantation 
by the aid of a double circular suture of a segment of an artery 
or a vein between the two cut ends of an injured blood-vessel. 
This is certainly technically the most difficult vascular opera- 
tion. Carrel classifies these transplantations as incomplete, 
when the vascular segment is allowed to retain its collaterals 
and its normal relations with the surrounding tissues, and 
complete, when the segment is completely extirpated before 
the anastomosis is performed. He also distinguishes an auto- 
plastic transplantation, when the segment is taken from the 
same animal; homoplastic, when the segment is taken from 
another animal of the same species; and heteroplastic, when 
the segment is taken from an animal of another species. 

Now, in connection with these transplantations, there 
arises the question as to the nature of the factors which make 
success possible. This question has a technical, operative, and 
a general physiological interest. To implant an arterial seg- 
ment successfully means to avoid the formation of an intra- 
vascular thrombus after the operation. 

According to the generally accepted theory of Briicke, 
blood remains fluid as long as it circulates in a vessel lined with 
an unimpaired living endothelium. Should the endothelium 
be injured through infection or trauma, a thrombus is formed. 
In incomplete transplantations the segment certainly remains 
alive. In complete autoplastic and homoplastic transplanta- 



322 



ISAAC LEVIN. 



tions, it seems probable that the implanted segments remain 
alive. But in implantation of arterial segments of different 
animal species, and segments that had been kept for days 
in the refrigerator at a temperature between o and i° C, the 
question presents itself whether or not these segments really 
remain alive; and if it is possible to implant devitalized 
arterial segments, the theories of intravascular coagulation 
of blood have to be revised. 

I have therefore performed, in collaboration with Dr. John 
H. Larkin,^ a series of experiments on the transplantation 
of devitalized arterial segments. The technic followed in our 
operations was the one elaborated by Carrel. A space on the 
abdominal aorta of a dog or cat, near the branching off of the 
renal arteries, is selected. The temporary haemostasis is done 
either with a serre-fine protected with a rubber tubing, or with 
a tape which is twisted and then clamped with an artery for- 
ceps. After section of the vessel, the external sheath of the 
adventitia is pulled over the vessel wall proper and resected. 
For the suturing I use No. i6 cambric needles and fine silk. 
Fixing ligatures are placed at equidistant points corresponding 
on both vessels, and the intervals between the ligatures are 
sewed together by continuous sutures. The ligatures as well 
as the sutures perforate the endothelium. The only slight 
deviation from the Carrel technic which we may mention, is 
that in small-calibre vessels two fixing ligatures, instead of 
three, are sufficient. We also came to the conclusion that 
when the adventitia of the blood-vessel is sufficiently well 
separated off and both lengths of the silk together are not 
thicker than the needle, we could do the work just as satisfac- 
torily when we moistened everything with physiological salt 
solution, instead of with vaseline or paraffin oil. In the first 
series of our experiments, we transplanted into the abdominal 
aorta of two dogs and two cats, segments of the abdominal 
aorta of the same species of animals placed for a few minutes 
in boiling water. In the second series we transplanted into 
the abdominal aorta of two dogs segments of a human ureter 
procured at a fresh autopsy and hardened in 4 per cent, 
formalin. 



PLASTIC SURGERY OF BLOOD-VESSELS. 323 

In both series the circulation in the femoral arteries ceased 
very soon after the operation; there developed paralysis of 
the lower extremities ; and the animals died within twenty-four 
hours after the operation. The autopsies showed that the 
implanted segment had collapsed and presented a much smaller 
lumen than the abdominal aorta of the host. 

In the third series of experiments we implanted in the 
abdominal aorta of two dogs and two cats, segments of the 
abdominal aorta of the same species hardened in 4 per cent, 
formalin. The segments were selected so as to have the 
same lumen as the aorta of the host, but as soon as the anasto- 
mosis was completed, one could see that both the afferent and 
the efferent parts of the aorta became wider than the implanted 
segment, which naturally remained rigid and narrower than 
the rest of the vessel. The result in every experiment was 
the formation of a thrombus, paralysis of the posterior ex- 
tremities, and death within two or three days after the 
operation (Fig. i). 

We then decided to select segments which would have at 
the time of the operation a wider lumen than the aorta of the 
host, though this would increase the technical difficulties. We 
selected the pectoral aorta of a dog, which was hardened in 
4 per cent, formalin, and implanted into the abdominal aorta 
of another dog. In order to be able to perform the anasto- 
mosis, the cut in the abdominal aorta had to be made, not 
perpendicularly to its long axis, but slanting. The operation 
was done on two dogs. The first did well for ten days ; there 
was normal pulsation in both femoral arteries. On the 
eleventh day, the animal was found in the morning with pro- 
truding intestines. A secondary laparotomy was performed, 
but the dog died during the day. Both anastomoses held 
perfectly ; the implanted piece was patent, without any thrombi. 

The other animal did well for ten days ; there was normal 
pulsation in the femoral arteries. On the eleventh day we 
gave the animal anaesthesia in order to dress the wound, and 
it died in a few hours, apparently from the influence of ether. 

The specimen of the aorta presents a very interesting con- 



324 ISAAC LEVIN. 

dition. The distal part of the segment is free from thrombus ; 
the anastomosis is perfect; in the proximal portion there is a 
large thin parietal thrombus covering the suture line, and also 
a small gangrenous part of the segment (Fig. 2). 

An analysis of these results will show that for ten days the 
circulating blood was passing through a dead canal and it 
remained fluid. 

It seems, then, that blood need not necessarily run through 
a vessel lined with living endothelium in order to remain fluid. 
The implanted tube need only have a very smooth inner sur- 
face, its lumen correspond perfectly to the lumen of the rest 
of the blood-vessel, and the line of anastomosis be perfectly 
smooth and even. The implantation of formalin-hardened 
segments is technically a great deal more difficult than of seg- 
ments freshly obtained or even of those kept in a refrigerator, 
as these both retain their elasticity and are able to stretch to 
some extent under the pressure of the stream of blood; while, 
when a formalinized segment of the same calibre as the rest of 
the artery is implanted, it becomes immediately narrower than 
the rest of the artery, and thrombosis results. 

Carrel found similar difficulties in the implantation of 
venous segments. To quote him : " Thrombosis occurs more 
frequently [in venous implantation], due, perhaps, to the 
difference of calibre of the vessels generally used." 

The formation of a thin parietal thrombus covering a hole 
formed by absorption of the segment, indicates that if circu- 
lation of the blood is maintained for a sufficient length of 
time, there may form a complete new tube over the skeleton of 
the implanted segment. The complete interstitial transforma- 
tion with loss of the elastic framework described by Carrel,^** 
may also be explained by the gradual absorption of the im- 
planted segment and the formation of a new tube. Such 
knowledge of these great natural repairing powers ought to 
give us more courage and stimulate more frequent use of 
plastic vascular surgery. 

Whether it will really be possible to replace organs of such 
complicated functions as the kidneys by the same organs of 



Fig. I. 




Occluding thrombus bcRinning above the proximal line of 
anastomosis of a formalinized segment. 



Fig. 2. 




Parietal thrombus, covering the suture line of the proximal portion 
of the formalinized segment. 



I 



PLASTIC SURGERY OF BLOOD-VESSELS. 325 

another animal of the same species, is a question which re- 
quires a great deal of physiological study. It is possible that 
such an organ would sooner or later become toxic to the host. 
It is interesting to note in this connection that while Carrel's 
animals in which the kidneys were extirpated and replaced 
by kidneys from another animal of the same species lived at 
the most only a few weeks, a dog in which both kidneys were 
extirpated and one of his own kidneys then replaced, lived in 
perfect health for eight months. 

But if during a kidney operation the renal artery should 
be accidentally torn, an attempt should be made to unite both 
ends by a transplantation before a nephrectomy is done. The 
same is true in regard to traumatic injuries of the main arter- 
ies of the extremities. Even if a thrombus should form slowly 
along the line of anastomosis, time may be given to the 
collateral circulation to form, and a gangrene which would 
have been the result of a ligature, may be prevented. Ward *^ 
has shown this recently experimentally in his transplantation 
of rubber tubing into the aorta of a cat. While in both of his 
animals an occluding thrombus formed, there was sufficient 
collateral circulation to give pulsation in the femoral arteries. 
The same result was obtained by Abbe ^^ with the insertion 
of a glass tube into the aorta of a cat. 

The next plastic operation which is of clinical importance 
is the arteriovenous anastomosis. This operation was tried 
by Jaboulay,^^ Hubbard,^* F. T. Stewart,^^ and others, in cases 
of gangrene of the foot, in order to reverse the circulation of 
the leg from the arteries into the veins, but with hardly any 
success. I believe the failure is due to some extent to the loss 
of elasticity of the arteries. An artery with endarteritis oblit- 
erans certainly resembles greatly an artery hardened in 
formalin. 

But the main practical application of this operation is in 
the direct transfusion of blood. The therapeutic use of blood 
transfusion is as old as the history of medicine. But both the 
transfusion of defibrinated blood and the direct transfusion 
were extremely dangerous procedures. Consequently, when 



326 ISAAC LEVIN. 

Goltz/® some thirty years ago, expressed the opinion that 
death in severe acute bleeding is not due to the fact that the 
organism lost the cellular elements of the blood, which are 
needed for the life-metabolism of the tissues, but to the impair- 
ment of the mechanics of the circulation due to the loss of 
fluid, and advised that an infusion of physiological salt solution 
will save life, the matter found ready acceptance. Since then, 
and until to-day, it is quite a universally accepted idea that 
a saline intravenous infusion will do all that a transfusion of 
blood can do. 

Still a number of investigators have shown that intravenous 
saline infusion is not a life-saving measure in cases of fatal 
loss of blood. Maydl,^*"^ Feiss,^^ and Schramm ^® have studied 
the subject experimentally in the following way. They first 
determined the amount of blood it is necessary to let out to kill 
a. dog. The necessary quantity is between 4.5 per cent, and 
5.5 per cent, of the body weight of the animal. They then 
gave the animals an intravenous saline infusion immediately 
after such a bleeding, and found that the animals could not 
be saved by the infusion. Men like Landois ^^ and v. Ziems- 
sen ^^ came to the conclusion on the strength of these experi- 
ments and their own work, that when the loss of blood is such 
that the remaining quantity cannot sustain the life functions 
of the organism, then a saline infusion cannot save life ; at the 
most it can afford a temporary relief. 

With the new development of blood-vessel surgery, the 
question of direct transfusion of blood again came to the front, 
and Crile ^^ with his associates has done a great deal of work, 
both experimental and clinical, to further the subject. 

While the operation of direct transfusion has lost most 
of its dangers, it is still a more serious undertaking than a 
saline infusion, and it is consequently necessary to investigate 
whether the former has real advantages over the infusion, and 
what the advantages are. I have undertaken to approach the 
question experimentally, and in the following way. A dog was 
bled from the carotid until the blood ceased to flow out from the 
cannula inserted in the carotid, and the heart stopped beating. 



PLASTIC SURGERY OF BLOOD-VESSELS. 



327 



Then at the last gasping respiratory movements, a direct trans- 
fusion from another dog began. The anastomosis between the 
carotid of the donor and the external jugular vein of the recip- 
ient was prepared at the beginning of the experiment. The 
transfusion continued as long as the heart of the donor was 
beating. Usually within the first minute from the beginning 
of the transfusion the heart of the recipient began to beat 
again, and within the first five minutes from the beginning of 
the transfusion the dog, which was previously, to all appear- 
ances, dead from exsangniination, seemed in just as good 
condition as at the beginning of the experiment. The quantity 
of blood lost by the first dog was between 4.5 per cent, and 
5.5 per cent, of its bodyweight. This experiment was re- 
peated eight times with uniform results. As a control experi- 
ment, I bled a dog also until the heart and respiration stopped, 
and then made a saline infusion of a quantity of fluid at least 
double the amount of blood lost, which was 4.5 per cent, to 
5.5 per cent, of the bodyweight. This experiment was re- 
peated six times. While in every case the heart began to beat 
again for a time, it was impossible to revive the animals. 

As was stated before, a loss of blood of 4.5 per cent, to 
5.5 per cent, of the bodyweight is fatal to a dog, and in 
accordance with the results of Maydl, Feiss, and Schramm, 
my experiments show that an intravenous saline infusion does 
not help in such an acute fatal hemorrhage, while the direct 
transfusion of blood is undoubtedly a life-saving operation. 
When an organism has lost so much blood that there is not 
enough left to sustain the vital functions of the organism, a 
direct transfusion of blood is the only operation of value, 
though a saline infusion may help, until the surgeon is ready 
for the transfusion. 

On the other hand, it seems to me that in cases of surgical 
shock where the low arterial pressure is not due to a depletion 
of the vessels, a saline infusion ought to be sufficient to improve 
the action of the heart, and increase the blood-pressure, while 
an addition to the number of the cellular elements of the blood 
is not needed. Whether direct transfusion will be of any 



328 ISAAC LEVIN. 

benefit in cases of poisoning, intoxications, and diseases of the 
blood (pernicious anaemia, leukaemia) future work will have to 
demonstrate. It would seem to me, a priori, that whatever 
etiological moment affected the blood of the host originally 
would act on the new blood as soon as it was transfused. 

A review of the results achieved so far in this field 
leads to the conclusion that the therapeutic value of 
plastic vascular surgery is neither as broad nor as general as 
the most enthusiastic would lead us to believe. Still the prog- 
ress is great enough already. When one stops to consider 
besides that it comprises the work of only five years, with 
barely half a dozen workers engaged in it, one cannot help 
thinking that if clinical surgeons, with the technical skill which 
they possess, would devote a small fraction of their time to the 
study of this and other questions of experimental surgery, the 
clinic would gain by it a great deal. 

Fig. t,. 




Levin's transfusion clamp. 



While in plastic vascular surgery the suture has proved 
to be of more value than the different cannulas, the temporary 
anastomosis required for the direct transfusion of blood is 
more readily and quickly accomplished with the aid of some 
mechanical appliance. I have designed a clamp which I think 
requires a less complicated technic and less time for the per- 
formance of the operation than Crile's instrument does 

(Fig- 3)- 

This instrument presents an artery clamp without the 

grooves. At the tip of each blade there is attached a small 



PLASTIC SURGERY OF BLOOD-VESSELS. 



329 



cannula with a smooth bore. At the inner edge of each can- 
nula there are attached four small pin-points, and on the outer 
surface of the cannula there are cut out four grooves. When 
the clamp is closed, the pins of one cannula lie in the grooves of 
the other. The cannulas have a pyramidal form because the 
pins are bent outward. At the beginning of the operation the 
two halves of the cannula are separated. The vein is pushed 
through one cannula and its wall is hooked on the pins. The 
same is done with the artery and the other half of the clamp. 
Then both halves of the clamp are united and clamped. I 
believe that when we deal with small blood-vessels it is much 
easier to hook the walls on the pins than to turn them back like 
a cuff. When the clamp is closed, both blood-vessels are 
connected with the serous surfaces. Another advantage of 
this clamp is that when a thrombus obstructs the transfusion 
the instrument can readily be opened, without disturbing the 
walls of the vessels, the clots removed, and the clamp closed 
again. 

BIBLIOGRAPHY. 

^ Jassinowsky : Cit. Watts. 

* Payr : Arch. f. klin. Chin, 1903, p. 32. 

* Exner : Wiener klin. Woch., 1903, No. 10. 
*H6pfner: Arch. f. klin. Chir., Ixx, 1903, p. 417. 

* Murphy : Medical Record, Jan. 16, 1897. 

* Carrel and Guthrie: Surgery, Gynaecology, and Obstetrics, ii, 1906, 

p. 266. 

* Carrel : Johns Hopkins Hosp. Bull., xviii, Jan., 1907. 
' Watts : Johns Hopkins Hosp. Bull., xviii, 1907. 

* Isaac Levin and J. H. Larkin : Proceedings of the Society for Experi- 

mental Biology and Medicine, v, 1908. 
" Carrel : Journal of the Amer. Med. Assn., Nov. 14, 1908. 
"Ward: Medical Record, Oct. 17, 1908. 
"Abbe: New York Medical Journal, Jan, 13, 1894. 
"Jaboulay: Semaine medicale, 1902, p. 405. 
" Hubbard : Annals of Surgery, Dec, 1908, xlviii. 
" F. T. Stewart: Annals of Surgery, Dec, 1908, xlviii, p. 152. 
" Goltz : cit. Landois. 
"Maydl: Wiener med. Jahrbucher, 1884. 
"Feiss: Virchows Arch., 1894, cxxxviii. 
" Schramm : Wiener med. Jahrbucher, 1885. 
*■ Landois : Eulenbergs Real-Encyclopadie, xxiv, 1900, p. 410. 
"v, Ziemssen: Miinch. med. Woch., 1895, xlii, p. 14. 
" Crile and Dolley : Journal of the Amer. Med. Assn., xlvii, 1906, p. 189. 



NERVE INVOLVEMENT IN THE ISCHiEMIC PA- 
RALYSIS AND CONTRACTURE OF VOLKMANN.* 

BY JOHN JENKS THOMAS, M.D., 

OF BOSTON, MASS., 

Assistant Professor of Neurology, Tufts College Medical School ; Physician for Diseases 

of the Nervous System, Boston Citjr Hospital; Assistant Neurologist, Boston 

Children's Hospital; Consulting Neurologist. Quincy Hospital. 

Volkmann's ischaemic paralysis or contracture, as it is 
variously termed, is a condition which has more often attracted 
the attention of the orthopaedic surgeon than that of the gen- 
eral surgeon or the neurologist, as it is most frequent in chil- 
dren. The condition is apparently fairly frequent but rather 
to my surprise the reported cases are not at all numerous, 
probably because the condition is often thought to be due to too 
tight bandaging or neglect. As we shall see by the published 
cases this is by no means always the case, though interference 
with the circulation is probably necessary for the production 
of the condition. In view of the comparatively small number 
of reported cases, and the widely varying views in regard to 
the pathology and the proper treatment of the affection, it has 
seemed worth while to me to collect and review the published 
cases, and to add four cases which I have seen during the past 
few years, as these illustrate a number of the points which have 
seemed to me the most interesting and important. 

Case I. Dorothy S., 7 years, a patient of Dr. Hunting, of 
Quincy, was seen by me in consultation on Dec. 26, 1900. In 
July of that year she had a fall and fractured the right radius. 
Splints were applied, and were used for four weeks. These 
splints caused pressure sloughs on both the flexor and extensor 
surfaces of the forearm. It was then found that the head of 
the radius was out of place, and in September an operation was 
done to correct this, and splints were applied again for a time 
,after the operation. This account of the accident and the treat- 

* Read before the American Neurological Association, May 22, 1908. 
330 



ISCHEMIC PARALYSIS AND CONTRACTURE. 



331 



ment is not as full as one could wish, but the accident had taken 
place in a distant part of the country, and more accurate 
information could not be obtained. It could not be learned how 
soon after the injury the contractures of the muscles had been 
noticed. 

The examination at that time showed that the head of the 
radius was still displaced to the outer side so that it was outside 
of the external condyle of the humerus. There was also bowing 
of the ulna. On both the flexor and extensor surfaces of the 
forearm were red, indurated scars. One of these which was 
somewhat adherent to the deeper tissues was on the flexor side 
just below the fold of the elbow. Others were just outside the 
head of the radius, and along the subcutaneous surface of the 
ulna. There was a contracture of the flexors of the hand and 
also of the fingers and of the thumb, but the fingers could be 
almost completely extended when the wrist was flexed. There 
was well marked atrophy of both the thenar and hypothenar 
eminences. The muscles of the forearm, both flexor and exten- 
sor, responded well to direct stimulation by the faradic and also 
by the galvanic current. The interossei, abductor minimi digiti, 
abductor, adductor, opponens, and flexor brevis of the thumb did 
not respond to faradism, and to the galvanic current showed a 
typical reaction of degeneration, with slow contraction and anodal 
closure contraction greater than the cathodal closure reaction. 
The sensation for light touch was lost, and that for pain and 
temperature was much diminished, over the whole hand to the 
level of the wrist, the diminution being greater however in the 
portion of the hand supplied by the ulnar nerve. In the forearm 
there was no disturbance of sensation. 

The child was referred to Dr. E. H. Bradford and taken 
into the Children's Hospital for operation. There it was noted 
on Jan. 2, 1901, that the head of the radius was dislocated out- 
ward and there was a bend of the ulna at about the centre. The 
elbow- joint allowed nearly perfect flexion. Supination was im- 
possible and pronation almost completely limited. On Jan. 3, 
1901, Dr. Bradford operated. An incision about three inches in 
length was made over the middle of the forearm on the anterior 
surface, dissection was made down to the superficial muscles. 
Here all the muscles and tendons were found to be imbedded 
together in a mass of scar tissue in such a way that they could 



332 JOHN JENKS THOMAS. 

not be individually identified. Myotomy was done and tenotomy 
of constricting tendons and muscles so that the fingers could be 
partially extended. The wound was closed at the lower part 
with subcutaneous catgut sutures, and above with continuous 
catgut suture. The wound healed with slight discharge from 
its lower part, and the child was discharged on Jan. 12. 

She was again admitted to the Hospital on Feb. 11, 1901. 
At this time the condition was much the same as at the previous 
examination, except that the ring and little fingers could be 
extended about two thirds the normal amount, and there was 
considerable gain in the extension of the fore and middle fingers. 
On Feb, 12, she was operated upon again. An incision about 
7 cm. in length was made over the inner side of the palmar 
surface of the forearm, and dissection was made down to the 
tendons. The tendons, as at the previous exploration, were 
bound together in an unrecognizable mass of scar tissue. The 
tendons were freed by blunt dissection so that the little and 
ring fingers could be almost completely extended, and the first 
two fingers and thumb extended to about four-fifths the normal 
range. The wound was closed with catgut. She was discharged 
Feb. 21. 

The child was seen again by me on April 4, 1901. At that 
time the small muscles of the hand had practically recovered, 
the muscles responding normally to the faradic current, and the 
movements of adduction and abduction of the fingers and thumb 
being possible. She could not quite extend the fingers fully and 
the grasp was quite weak, though flexion could be performed. 
The muscles of the forearm all reacted to faradism though the 
response in the flexor sublimis digitorum was not a good one. 
After treatment of electricity, passive movements and exer- 
cises was advised. The child returned to her home, and has 
not been seen since, though Dr. Hunting tells me that the im- 
provement has continued, and she has fairly good use of the 
hand at the present time. 

This case showed the usual course of an injury to the fore- 
arm with the use of splints, followed by a slough and subse- 
quent contraction of the flexor muscles of the forearm. The 
points to which I wish to call attention are the involvement 
of the ulnar and median nerves by the scar-tissue, and the 



I 



ISCHEMIC PARALYSIS AND CONTRACTURE. 333 

recovery from this condition when the pressure upon the nerves 
has been reheved by the operation upon the dense fibrous tissue 
which had replaced the flexor muscles of the forearm to a large 
extent. 

Case II. Concetta B., six years of age, in Aug., 1904, fell 
and broke the left arm. The fracture was treated by a physician, 
but we were unable to learn the exact details. On Oct. 3, 1904, 
she was admitted to the Children's Hospital. At that time it 
was noted that there was marked deformity at the left elbow, 
with a spicule of bone projecting outward. There was no 
crepitus but the joint was rigid and flexed at an angle of 45 
degrees. The fingers were contracted into the palm, with the 
first phalanges extended and the second and third ones flexed, 
and could not be opened, and there was wasting of the small 
muscles of the hand. Sensation could not be tested satisfactorily. 
The wrist was moderately flexed. On Oct. 21 an incision was 
made along the intermuscular septum and across the internal 
condyle to the upper part of the forearm two and one-half inches 
in length. The ulnar nerve was found on the surface of the 
triceps muscle just under the fascia. It was blanched and flattened, 
and appeared compressed by surrounding fibrous tissue. The 
internal condyle appeared nearer to the olecranon than normal. 
The nerve was freed from its fibrous bed, dissected clear of the 
internal condylar groove and followed downward through the 
flexor carpi ulnaris muscle. After it was released the nerve 
rounded out, and the color changed to pink. It was then trans- 
posed to a point anterior to the internal condyle, the fascia being 
sutured under it, leaving the nerve between the fascia and the 
subcutaneous fat. The fascia was sutured with interrupted cat- 
gut sutures and the skin with subcutaneous horsehair sutures. 

On Oct. 27 it was noted that the color of the hand was 
better. The abductor minimi digiti did not react to faradism, 
and to galvanism there was a reaction of degeneration, the 
response being slow and the anode producing contractions with 
less current than the cathode. Flexion of the elbow had in- 
creased so that it could be brought to a right angle, and ex- 
tension was about three-quarters of the normal. Supination was 
normal. Extension of the wrist was possible to nearly the full 
extent, and the contraction of the fingers was less. On Nov. 3 



334 JOHN JENKS THOMAS. 

the response to the faradic current in the small muscles of the 
hand was still absent, and there was a degeneration reaction. 
The sensation of the skin supplied by the ulnar nerve tested for 
pain seemed good. On Nov. 9 there was still some limitation 
of extension of the wrist, and slight extension of the first phal- 
anges with flexion of the second and third, and a reaction of 
degeneration. On Nov. 24 the small muscles of the hand reacted 
slightly to faradism. On Dec. 21 there was good voluntary ex- 
tension of the wrist and fingers including the terminal phalanges, 
as well as abduction and adduction of the fingers. The contrac- 
ture of the flexors was less but some remained and the hand 
could not be fully extended with the fingers straight. On April i 
the movement of the fingers was normal, but there was still some 
shortening of the flexor muscles. There was good functional 
use of the hand in every way in spite of the slight shortening 
of the flexors. 

This case can be differentiated from one of pure injury 
of the ulnar nerve by the amount of contracture in the flexor 
muscles, as well as by the condition found at the operation, 
and shows plainly how the usefulness of the hand may be 
impaired by the paralysis of the small muscles of the hand as a 
complicating condition, while the ischaemic contracture is com- 
paratively trifling. 

Case III. Alice M., four years of age, was first seen on 
Jan. 16, 1907. Early in July, 1906, she fell in running and broke 
both bones of the left forearm. It was treated by splints, and 
a week later it was reset after an X-ray photograph had been 
taken. The splints were worn for six weeks after this. The 
father thinks the hand was swollen and painful. When the 
splints were removed there was a slough on the flexor surface 
of the forearm and another on the back, and it was noticed 
that the fingers were contracted so that the hand could not be 
opened. 

On examination there was a movable superficial reddish 
scar at the junction of the middle and upper thirds of the 
flexor surface of the left forearm, while the deeper muscular 
tissue was firm and hard though the skin was not adherent. 
This scar was irregularly circular, and about three-quarters of 



ISCHEMIC PARALYSIS AND CONTRACTURE. 



335 



an inch in diameter. There was another scar somewhat irregular 
in shape about two and one-half by half an inch in measurement 
on the dorsum of the arm, nearer the elbow and running down 
along the radius, which like the first one was movable. There was 
no voluntary flexion of the proximal phalanges, extension of 
the terminal ones, or adduction or abduction of the fingers pos- 
sible. The grasp was practically nil. Supination was weak, 
but could be performed nearly to the full extent. The thumb 
lay in the palm of the hand, and could not be opposed. There 
was moderate atrophy of the small muscles of the hand. There 
was slight extension of the first phalanges of the fingers and 
flexion of the second and third, with marked contracture of the 
flexors of the hand and fingers which could be partly overcome. 
The muscles of the hand supplied by the ulnar nerve did not 
react to strong faradism, while all the other muscles did, in- 
cluding the flexor muscles in the forearm. The prick of a 
pin was felt on the ulnar side of the hand, but there was per- 
haps diminished sensation in this area. The fingers could be 
extended fully only when the hand was at right angles with the 
arm. 

Passive movements and electricity were advised and the 
treatment was followed out very faithfully, and power gradually 
returned in the small muscles of the hand, so that in six months 
adduction and abduction of the fingers, and opposition of the 
thumb was fair, and these muscles all responded to faradism, 
and the atrophy had disappeared. The child could pick up a 
piece of paper and hold it with the fingers of this hand. There 
was some further improvement so that at the end of a year 
after she was first seen there was no evidence of the former 
trouble with the muscles supplied by the ulnar nerve. The grasp, 
though not strong or complete, had improved, and the child could 
carry a considerable weight in the hand, and by using moderate 
force the hand and fingers could be brought into the line of 
the forearm though not beyond, and when the tension was re- 
laxed the hand was flexed at an angle of about 30 degrees from 
the direct line, but there was good functional use of the hand 
in spite of the moderate contracture remaining. 

Case IV. A boy, William I., 12 years of age, was first seen 
in consultation on Sept. 26, 1907. On July i of that year 
while running he fell and struck the elbow and was said to 



336 JOHN JENKS THOMAS. 

have fractured the ulna just below the elbow-joint. He was 
treated by the application of a right angled internal splint 
for three weeks as the mother said, but the boy himself said 
for five weeks. The night of the accident he suffered severe 
pain all night, but after that he did not have much pain, but the 
arm felt dead and the next day he could not move the fingers 
and the hand was swollen. When the splint was removed he 
was given passive movements. Only later was it noticed that 
the wrist and fingers were contracted. An X-ray picture that 
was taken showed the fragments in good position. 

Examination showed that with passive motion the right 
arm at the elbow could be fully extended, but flexion was to an 
angle of 80 degrees only, supination nearly full, and pronation 
to about ID degrees beyond the mid-position. Strength in 
flexion, extension, and supination was good while pronation was 
weak. Flexion of the wrist was done with fair strength, as 
was extension of the wrist. The grasp was fair. Abduction and 
adduction of the fingers could be done, but was very weak, and 
the same was true of flexion of the proximal phalanges and 
extension of the second and third ones. Extension of the 
proximal phalanges was good. There was marked atrophy of 
the hypothenar eminence, and to a less extent of the thenar. 
There was a contracture of the flexors of the fingers. The fore- 
arm muscles reacted well to faradism. The small muscles of 
the hand (abductor minimi digiti) reacted very slightly to strong 
faradism, and showed no response to direct stimulation by the 
galvanic current with moderately strong currents. The hand was 
slightly cyanotic. Sensation for light touch was lost in the whole 
hand, and much diminished for the prick of a pin, but this 
diminution was greater over the region supplied by the ulnar 
nerve than in the other parts of the hand. The internal condyle 
was in good position. A firm mass, similar to scar tissue, could 
be felt in the flexor muscles of the forearm at about the middle, 
and a little to the ulnar side. Massage and the faradic current 
was advised. 

He was next seen on Jan. 8. During this interval some 
operation had been done at some hospital, apparently upon the 
head of the radius, as there was a scar about an inch and a 
quarter long on the flexor surface of the arm just below the 
fold of the elbow. The contracture of the flexor muscles of 



ISCHyEMIC PARALYSIS AND CONTRACTURE. 



337 



the arm remained about the same, as also the strength of the 
grasp. The atrophy of the small muscles of the hand had prac- 
tically disappeared, and the movements of the fingers such as 
adduction and abduction were much stronger, while all the small 
muscles of the hand reacted well to the faradic current, as did 
the flexor and extensor muscles in the forearm, and there was 
good functional use of the hand. The massage and passive 
movements were continued. 

The study of the cases of ischsemic paralysis and contrac- 
ture reported in the literature shows verj-- clearly that this con- 
dition varies greatly in severity in different instances, and 
that in many of the cases we are dealing with complications of 
the primary trouble from secondary involvement of some of 
the nerve trunks of the arm which produce disturbances which 
cannot be relieved by the treatment of the contractures only. 
So that the individual case must be carefully examined with 
the question of nerve involvement in mind and this condition 
considered in determining the treatment. This condition often 
and perhaps usually explains the great variation in results ob- 
tained in different cases by the same method of treatment, so 
that in one case a nearly perfect result is reported and in 
another practically no improvement is obtained, though of 
course the result varies also with the completeness of the de- 
struction of the muscle tissue. The adaptation of the treatment 
chosen to the varying conditions present is then the problem 
with which the surgeon is confronted. 

The first report of this condition of the muscles is usually 
accredited to Volkmann in 1875, but the same case is found 
in an earlier edition of the same book published in 1869, ^^^ 
in addition Hildebrand quotes a case of Hamilton's in 1850 
without giving the reference, and I have been unable to find 
the original article or book. The credit of calling general at- 
tention to the condition, however, belongs to Leser, and the 
affection is sometimes called the Volkmann-Leser contracture. 
The pathology has been fairly well understood from the time 
Volkmann called attention to the condition, and especially since 
the appearance of Leser's article in 1884. There has been con- 
siderable dispute however over the mechanism of the process, 



338 



JOHN JENKS THOMAS. 



TABLE OF REPORTED CASES 



No, 



Author 



Sex, 
age 



Character of injury 



Treatment of 
injury 



Pulse 



Pain 



Swelling 



13 



16 



18 



19 



Volkmann . 

1869 
Laser 

1884 
Leser 

1884 

Leser 

1884 
Leser 

1884 
Leser 

1884 

Leser 

1884 

Leser 

1884 

Sonneiikalb 

1885 

Petersen . . . 

1888 

Nolle 

1889 

Hildebrand 

1890 
Niessen 

1890 

Niessen 

1890 

Davidsohn . 
1891 

Pingel 

Pingel 

1892 

Keferstein . 
1893 

Keferstein . 
1893 



M 

16 

M 
child 

M 
child 

M 

? 

F 

child 

M 

? 



M 



M 



M 
4M 



F 
child 



M 



M 



M 



Hydrops of knee 

Fracture humerus 

Fracture right hume- 
rus above condyles 

Fracture elbow-joint 

Contusion 

Fracture of forearm, 
direct violence 

Fracture mid-forearm 
Fracture radius 



Fracture middle left 
humerus 



Fracture humerus 
close to elbow 



Supracondylar frac- 
ture right humerus 



Fracture middle right 

radius 
Fracture styloid left 

radius 



Fracture lower epiphy- 
sis of humerus 



Fracture lower third 
forearm 



Fracture humerus into 
joint 



Fracture left humerus 
near elbow 



Fracture left forearm 



Fracture middle right 
radius 



Posterior 

splint 

Plaster and 

reapplied 

Plaster 



Plaster 

Plaster 

Splint, then 
plaster 

Plaster 



Plaster 



Splints 



Pasteboard 

splint and light 

bandage 



Splint 



Splints 

Plaster, splints 
for 6 weeks 



Splint for 3 
days 



Splint 

Plaster 
Plaster 
Splints 
Splints 



3 days 
3 hours 
Few hrs. 

Yes 
Yes 



3 hours 
Some 

Yes 
Yes 



Yes 



No 



Dim. 



2 hours 



Yes 

(next 
Yes 



Yes 



Soon 



Yes 
3 days 



Yes 



Yes 



Yes 



Yes 



Yes 



Yes 
day) 
Yes, 
soon 



Yes 



Yes 



Yes 



Yes 



Yes 



Yes 



^K ISCHJEMIC PARALYSIS AND CONTRACTURE. 339 

GATHERED FROM LITERATURE 



Elect, reactions 



F. 



G. 



Sensation 



Atrophy 



Pressure 
scar 



Trophic 



Contrac- 
tion 



Paralysis 



Treatment and result 



Dim. in 

j;astroc. 
Arm muscles 

o si. 

Arm muscles 
si. 

: muscles 
si. 

1 muscles 
si. 
ad muscles 
si. 



nd muscles 
_ si. 

Arm muscles 

o si. 

Hand muscles 

si. 

Arm muscles 

o si. 

Arm muscles 

o si. 



No 



Normal 



Normal 



Yes 



Normal 



Lost in 
hand 



Dim. in 
fingers 



Yes 



No 



Yes 



Blue and 
cold 



Arm muscles 

very si. 

Hand muscles 

si. 

Flexors 



Hand 



Arm muscles 

dim. dim. 

Hand muscles 

dim. dim. 

Thumb muscles 

almost o R. D. 

Arm muscles 

o o 

Hand muscles 

o o 

Arm muscles 



Hand muscles 



Arm muscles 

si. 

Hand muscles 



Lost in 
ulnar re- 
gion 

Lost in 
hand, 

more in 
ulnar 

region 

Normal 



Lost in 
fingers 



Lost in 
fingers, 
dim. in 

arm 
Numb, 
lost in 

hand 

Dim. 



Yes 



In arm 



In arm 



Arm mus- 
cles hard 



In arm, 

muscles 

hard 

In both 

arm and 

hand 

In arm 



Yes 



Yes 



Cyanosis 
skin, 
shiny 
ulcers 
Cold 



Blisters 
on fingers 



Blisters 



Blisters 

on arm, 

hand cold 

Blisters, 
cyanotic 



Blisters, 
cyanotic 



Gastroc. 
Yes 
Yes 

Yes 
Yes 
Yes 

Yes 

Yes 

Yes 

Yes 

Slight 

Marked 

Yes in 5 
days 

Yes 
Yes 

Yes 

Yes 
Yes 
Yes 



No motion 
of fingers 

No motion 
fingers 



Slight motion 
fingers 



Extension 
ist, flexion 
2d and 3d 
phalanges 



Yes in fore- 
arm and in- 
terossei 



No motion 
of fingers 



No motion 
fingers ex- 
cept meta- 
carpal joint 
Paralysis fin- 
gers, thumb 
in plane of 
hand 



No operation. Slow re- 
covery. 

No operation. Slight im- 
provement. 

Displacement of frag- 
ments. No operation. 
Improved. 

No operation. Slight im- 
provement. 

No operation. Slight im- 
provement. 

Dislocation of upper frag- 
ment. No union. Oper- 
ation on pseudo-joint. 
Improved. 

No operation. Improve- 
ment. 



No operation. Almost 
complete recovery. 



No operation. Improved. 



Operation. Median nerve 
compressed. Artery in- 
jured and obliterated 
Delow. Improved. 

Bandage used for exten- 
sion left on and com- 
pressed arm . Spli nt ofl 
in 24 hours. Medical 
treatment. Well in 16 
weeks. 

Massage and stretching. 
Improved. 

Massage and electricity. 
Improved. Could 
work. 

Massage and electricity. 
Improved. 



Tendons lengthened . 
Moderate good move- 
ment. Reaction of de- 
generation remained in 
thumb muscles. 

Massage and movements. 
No improvement. 



Movements (stretching). 
No improvement. 
Same condition 16 yrs. 
later. 

Passive motion. 12 years 
later no motion in fin- 
gers, which were flexed 
in 2d and 3d phalan- 
ges. Sensation normal. 



340 



JOHN JENKS THOMAS. 



TABLE OF REPORTED CASES 



No. 


Author 


Sex, 
age 


Character of injury 


Treatment of 
injury 


Pulse 


Pain 


Swelling 






M 
(>% 

M 
8 


Supracondylar frac- 
ture humerus 

Fracture left humerus 
near elbow 


Pasteboard 
splint, bandage 
to upper arm 

only, 5 days 
Plaster 2 days, 
splint 2 weeks 




Yes 

(first 


Yes 




1893 




night) 
Yes 




1893 










M 
9 


Fracture of elbow 


Splint 


Did not 
bleed 
when 
stuck 


Yes 


Yes 




1893 




23 




M 
6 


Fracture left elbow- 
joint 


Plaster 






Yes 


1893 








24 




M 

25 


Crush right forearm, 
open wound 


Splints 








1893 








25 




F 

50 


Embolus left arm 


Quick stretch- 
ing 


Gone, 

later 

returned 


Yes 


Yes 


1895 




26 




M 
10 














1895 












27 


Battle 


M 
12 


Fracture forearm 


Splints 








1896 








28 


Henle 




Fracture right forearm 


Plaster 




Yes 


Yes 




1896 


9 






29 




M 
12 


Fracture forearm 


Splints 




Yes 




1897 






30 


Kaempf 

1897 


M 
4 


Fracture humerus just 
above elbow 


Plaster 






Yes 








31 




M 

S 


Fracture lower end 
humerus 


Splints 








1898 








32 






Fracture upper fore- 
arm 










1898 












33 




F 
3 


Fracture about elbow 










1898 











p 



ISCHEMIC PARALYSIS AND CONTRACTURE. 341 

GATHERED FROM LITERATURE— Continued 



Elect, reactions 



Sensation 



Atrophy 



Pressure 
scar 



Trophic 



Contrac- 
tion 



Paralysis 



Treatment and result 




Arm muscles 



Hand muscles 
o R. D. 



Normal except 
hand muscles, 
where R. D. 

Normal 



Arm muscles 
o R. D. 

Hand muscles 
o R. D. 



Normal 



Lost in 
ulnar re- 
gion and 
tips 

fingers 



Lost in 
hand ex- 
cept ra- 
dial area 
and 
thumb 

Much 

dim. in 

whole 

hand, less 

in thumb 

and first 

finger 



Paraes- 

thesia. 

Lost in 

hand 



Normal 



Normal 
every- 
where 

Dim. 



Normal 



Yes 



Arm and 

hand 

muscles 

hard and 

lump in 

middle 

arm 



Of hand 
muscles 



Thenar 
muscles 



In hand 

and arm 

Muscles 

bard 



Flexors 
in arm 



Blue 



Ulcers on 
fingers 



Ulcers on 
fingers 



Yes 



Yes, fin- 
gers and 
wrist 



Yes 



Yes, flex 
orshard 



Extension 
ist, flexion 2d 
and 3d pha- 
langes 

Small hand 
muscles, ist 

phalanges 

extended, 
others flexed 



ist phalan- 
ges extend- 
ed, others 
flexed 



Yes, ad- 
herent 



Yes 



Yes 



Fingers 

cold and 

red 

Cyanosis 



Yei 



Of flex- 
ors, mus- 
cles hard 



Severe. 

Fingers 

into palm 

In flexors 



Yes 



Yes 



Yes 



Yes 



Yes 



ist phalan- 
ges extended 



Hand mus- 
cles 



Muscles 
fibrous 



Muscles 
fibrous 



Yes 



1st phalan- 
ges extend- 
ed, 2d and 3d 
flexed. No 
abd.oradd. 
fingers 



Stretching. Improved. 
In 1902 had returned. 
No grasp and hand 
cold. 

Projection of fragment 
prevents flexion elbow. 
Operation for this, then 
electricity and mas- 
sage. Improved. Lost 
claw-hand. 19 months 
later some grasp. Hand 
cold. 

Operation on fragments 
of radius. Movements 
and electricity. No mo- 
tion of thumb. Slight 
grasp only, i year 
later contraction had 
returned. 

Stretching. Some im- 
provement. 



Stretching under ether. 
Movements. Improved, 
but not a good iist. 

Movements. Slight im- 
provement. 



Shortened bones and 
operated on contrac- 
ture at elbow 

Exercises and galvanism. 



Resection bones. Slow 
union. Great improve- 
ment. 

Operation advised. Too 
soon to know result. 



Movements. No change. 



Operation. Nerves found 
normal at seat of injury. 
Resection of bones. Fi- 
brous union only, but 
position of hand satis- 
factory. 

Operation of lengthen- 
ing tendons. Satisfac- 
tory results. Median 
nerve found healthy. 

Projection of humerus re- 
moved. Lengthening 
tendons. Could not flex 
fingers. Could move 
thumb. 



342 



JOHN JENKS THOMAS. 



TABLE OF REPORTED CASES 



No. 


Author 


Sex, 
age 


Character of injury 


Treatment of 
injury 


Pulse 


Pain 


Swelling 


34 


Davies-Colley 
















1898 














35 


Clarke 


M 
6 


Fracture lower end 
humerus 


Splints 










1899 (quoted Powers) 








36 


Thomson 


F 

4 


Dislocation backward, 
both bones forearm 


Splints with 
passive move- 
ments 










1900 








37 


Edington 


F 
child 


Dislocation backward, 
both bones forearm 


Splints 










1900 








38 


Page 


M 

4% 


Fracture lower end 
humerus 


Splint 








1900 








39 




F 
8 


Fracture lower end 
humerus 


Splints 5 weeks 






Yes 


1900 








40 


Littlewood 


F 
6 


Fracture about elbow, 
and both bones fore- 








Great 


1900 
















arm 










41 




M 
30 


Fracture both bones 
forearm few inches 
from wrist 


Splints, tight 




Yes 


Yes 


1900 






42 


Schloffer 


M 
18 


Gunshot wound of 
thorax. Embolus 


None 


None 


Yes 


Yes 


1901 




43 


Wallis 


F 

2} 


Operation, fracture 
ulna, lower third 


Splint 






Yes 


1901 








44 




F 

3 


Fracture both bones 
forearm 


Splints 




No 




1901 






45 


Barnard 


M 
4 


Crush of forearm, no 
fracture; hemor- 
rhage and swelling 


Splints, light 
bandage 








1901 








46 


Henle 


M 
8 












1903 












47 






Comp. fracture fore- 
arm 










1902 


child 










48 




M 

33 


Crush forearm, no in- 
jured bones 


Splints 






Yes 


1902 








49 




F 

15 


Crush of finger 


Elastic band- 
age 2 days, 
gangrene 








1902 










isch;emic paralysis and contracture. 343 

GATHERED FROM LITERATURE— Continued 



Elect, reactions 



F. 



Arm muscles 
dim. dim. 



Arm muscles 

R. D. 

at first 



ind musdes 
R.D. 



ect. muse es 
R.D. 



E. D. 



E. D. 



Irm muscles, 

qualitative 

changes 

Hand mascles, 

quantitative 

changes 



Sensation 



Normal 



Ulnar an- 
sestbesia 



Dim. 
ulnar reg. 



Little 

feeling in 

hand 

Dim .hand 
and arm, 
normal in 

upper 
arm 

Lost in 
median, 

radial, 

ulnar 



Not defi- 
nite 



Atrophy 



Wasted 

and 
fibrous 

arm 



Flexors 
in arm 



Slight 
wasting, 

first in- 
terossei 



Hypothe- 
nar group 



Hand 
muscles 



Thumb 
muscles 



Inarm 



In arm, 
not in 
hand 



Pressure 
scar 



Yes 



No 



Yes 



Yes 



Yes 



Yes 



Trophic 



Hand 

livid and 

cold 

Livid and 
cold 



Cyanosis 

arm and 

hand 



Red, cy- 
anotic 



Whitlow 



Skin 

glossy, 

hand 

cold, 

Whitlow 



Contrac- 
tion 



Yes 
Yes 
Yes 
Early 
Marked 
Yes 
Yes 
Yes 
Yes 

Yes 

Yes 
In 5 weeks 

Yes 
Yes 
Yes 



Paralysis 



Median and 
ulnar com- 
pressed by 
scar tissue 



Main en 
griffe 



Main en 
griffe 

Main en 
griffe 



Flaccid 4th 
and 5th fin- 
gers, 
contracted 
thumb, 2d 

and 3d 
Anchylosis 
finger and 
hand joints 



Treatment and result 



Tenotomy. No menti6n 
of function. 



Tendons lengthened. 
Good motion, but not 
complete flexion. 

Tendons lengthened . 
Good result. Makes 
fist. 

Projection above elbow- 
muscles hard. Ten- 
dons leng^thened. Use- 
ful hand. 

Tendons lengthened. 
Some flexor power. 



Resection bones. Ten- 
dons lengthened. No 
union. Resection re- 
peated. No solid union. 

Muscles hard. 



Massage. Then tendons 
lengthened and me- 
dian nerve freed from 
fibrous tissue. Sensa- 
tion improved in me- 
dian area, not in ulnar. 
Motion improved. 

Tendons lengthened. 
Muscles fibrous and 
dry. Fair grasp. Not 
fist. Half normal. 

Tendons lengthened. 
Fair grasp. Half nor- 
mal. 



Resection bones. Good 
results. Hand useful. 

Tendons lengthened . 

Grasp good. Perfect 

function. 
Not stated. 



Not stated. 



344 



JOHN JENKS THOMAS. 



TABLE OF REPORTED CASES 



No. 


Author 


Sex, 
age 


Character of injury 


Treatment of 
injury 


Pulse 


Pain 


Swelling 


50 




M 

10 


Fracture left elbow, 
1896 








1902 










51 




F 
5 


Fracture humerus just 
above elbow 


Splints 






Yes 


1902 








5a 




M 
20 


Forearm struck by 
hammer 


Splint, then 
plaster 2 weeks 




Slight 


Yes 


1902 






53 
54 




M 
5 

F 
4 


Fracture forearm , both 
bones, upper and 
middle third 

Fracture humerus just 
above elbow 


Splints 
Plaster 




Tender 
No 


Slight 
Yes 


1902 




1902 






55 


Ward 


F 
21 


Crush, no fracture 


Sling 




Yes 


Yes 


1902 






56 


Ward 


M 
12 


Fracture forearm three 
years before 


Splint 








1902 








57 






Fracture humerus 
near elbow 


Plaster 






Yes 


1903 


5 








58 




M 
9 


Fracture forearm 


Splints 




No 




1903 






59 




M 
8 


Fracture forearm 


Splints 




No 




1903 






60 




F 

7 


Fracture forearm 


Splints 




Yes 


Yes 




1903 






6t 




F 
32 


Septic infection fore- 
arm at 15 years 


Multiple in- 
cisions, splints 










1903 








6? 


Hohn 






Splint 










1903 










■••^ 


62 


Martin, C. and F 

1903 


F 

45^ 


Fracture both bones 
forearm 


Splints 






Yes 










64 
65 
66 


Martin, C. and F 


M 




Apparatus 
Plaster 








Lycklemaand Nyeholt. . 


5}i 
M 










7 
F 
6 


Fracture both bones 
forearm 


Splint 




Yes 


Yes 




1904 






67 




M 
7 


Fracture elbow-joint 


Plaster 




Yes 


Yes 




1904 






68 




M 
14 


Fracture arm 


Splints 










1905 








69 




F 

6 


Fracture both bones 
forearm, middle 
bruised 


Splints 




No 


Yes 


1905 






70 




M 
6 


Fracture elbow 


Splints 




Yes 


Yes 


1905 










GATHERED FROM LITERATURE— (r<?«/»««^rf 



Elect, reactions 



G. 



Sensation 



Atrophy 



Pressure 
scar 



Trophic 



Contrac- 
tion 



Paralysis 



Treatment and result 



Normal nerve 
{ ' and muscle 

3 years later 
nerve and mus- 
cle normal 
Normal, 3 years 

later normal 

irmal except 
ulnar 

Bm. dim. 
lonths later 
11 normal 
Lost 



Practically nor- 
mal 

Partial R. D. 

ulnar 2^ years 

after, later 

normal 

Normal 9 ra. 

later 

Arm and hand 
norm. norm, 
■except dim. 
All good except 
thenar muscles 
dim. 



Normal 
Normal 
Normal 
Normal 

Normal 



Dim. in 

median 

and ulnar 

Normal 



Dim. ul 
narregfion 



Inarm 



In arm 



Slight in 
arm 

In arm 



Yes 



No 



Hand 
cold 



No 



Yes 



Hand 
cold 



In arm 



Normal 



Yes 



Yes 



Yes 



Yes 



Lower 
forearm 



Skin 
shiny, liv- 
id; ulcers 



Cold and 
blue 



Blisters; 

lividskin, 

glossy 



Dim. in 
hand 



Normal 



In hand 



No 



Yes 



Yes 

Yes 

Yes 

Insweeks 

Yes 

Yes 

Yes 

Yes 
Yes 

Yes 
Yes 
Yes 
Yes 
Yes 

Yes 



No motion 
hand or fin- 
gers 

Interossei 
act fairly 

All move- 
ments dimin- 
ished 



Modified, later 
normal 

In contracted 

muscles 
no R. D. 



Normal 



Normal 



Modified, 

later 

normal 

Lost me- 
dian 
nerve 

Normal 



In arm 



Thumb 
muscles 



Yes 
Yes 



Skin 
changed 

No 



In arm 



Yes 



Yes 



Hand 
blue, chil- 
blains 



Yes 
lYes 
Yes 
Yes 

Yes 



Extension 
ist, flexion 2d 
and 3d pha- 
langes. In- 
terossei fair 



Extension 
ist, flexion 2d 
and 3d pha- 
langes 



Partial ulnar 
supply 



Extension 
ist, flexion 2d 
and 3d pha- 
langes. No 
motion 



1st phalan- 
ges extend- 
ed, others 

flexed 
Claw-hand 



Stretching in 1898. Con- 
tracture at wrist; has 
improved motion. 

Massage. No improve- 
ment. 

Massage and electricity. 

Good extension but 

tendons short. 
Massage and galvanism. 



Massage and passive mo- 
tion. Motion remained 
limited. 



Depression in belly of 
muscle. Tendons 
lengthened. Fair grasp 
and motion. 

Tendons lengthened. In- 
fection. Result not 
known. 

Massage and faradism. 
Improved. 

Massage and electricity. 
One year later resec- 
tion. Union. Great im- 
provement. 

Resection bones. Union. 
Great improvement. 

Tendons lengthened. 



Resection bones. Im- 
proved. Slight motion. 

Elastic extension. Im- 
provement. 



Osteotomy. Fair result. 

Tendons lengthened. 
Stretching. Improved. 

Tendons lengthened . 
Could hold needle. 
Some contracture. 

Operation. Myotomy, 
freeing nerve. Great 
improvement. 

Electricity. Massage. 
Considerable improve- 
ment. 

Resection bones. Union. 
Good grasp. Later ten- 
dons lengthened. Much 
interstitial fibrosis. 

Resection bones. Makes 
fist. Spreads fingers. 
Slight contracture. Use 
perfect. 



346 



JOHN JENKS THOMAS. 



TABLE OF REPORTED CASES 



No. 


Author 


Sex, 
age 


Character of injury 


Treatment of 
injury 


Pulse 


Pain 


Swelling 


71 


Kob 


M 
10 


Fracture elbow 


Plaster 






Yes 




1905 








72 


Bardenheuer 


F 
6 


Fracture lower epiph. 
humerus 


Plaster 










1906 








73 


Bardenheuer 


M 
adult 


Fracture clavicle 


Tight bandage 


Gone 








1906 






74 




M 
8 


Fracture humerus, su- 
pracondylar 




Absent 




Yes 




1906 








75 


Bardenheuer 


F 

5 


Fracture, supracondy- 
lar 


Plaster 










1906 








76 




M 
adult 


Rupture popliteal ar- 
tery 




Lost 








1906 








77 




M 
12 


Injured leg at opera- 
tion 








Yes 




1906 










78 


Bardenheuer 


M 
40 


Fracture both bones 
leg, injured artery 




Lost 








1906 






79 


Hamilton 


M 
9 


Fracture humerus, su- 
pracondylar 












1850 (quoted by Hil- 
debrand) 










8n 






Fracture humerus, su- 
pracondylar 












(Hildebrand) 












Rt 






Fracture humerus, su- 
pracondylar 


Plaster 










(Hfldebrand) 










S-r 






Fracture elbow 


Splints 










(Hildebrand) 










83 






Fracture elbow 


Plaster 








(Hildebrand) 










84 






Fracture humerus just 
above elbow 


Plaster 








(Hildebrand) 










85 






Fracture humerus, su- 
pracondylar 


Plaster 








(Hildebrand) 










86 






Fracture radius, mid- 
dle 


Splints 










(Hildebrand) 










87 






Fracture forearm 


Splint 








(Hildebrand) 










88 






Fracture radius, mid- 
dle 


Splints, tight 










(Hildebrand) 










89 


Helferich 




Fracture humerus 


Plaster 








(Hildebrand) 











ISCHEMIC PARALYSIS AND CONTRACTURE. 



347 



GATHERED FROM LITERATURE— Co«//««^rf 



Elect, reactions 



F. 



G. 



Sensation 



Atrophy 



Pressure 
Scar 



Trophic 



Contrac- 
tion 



Paralysis 



Treatment and result 



Muscles 

good 

nerves, radial, 
median, ulnar 



I 

Changes in 

median and 

ulnar 



Arm muscles 
dim. 



Hand muscles 



Lost in 
hand 

except 
radial 

Normal 



Lost 
whole 

hand 
First nor- 
mal, then 

dim. 



Lost 



Lost at 

first, later 

turned 



Slight in 

arm, 

thenar 

muscles 



Yes 



Yes 



Cyanosis 



Much 
dim. hand 
and arm 

Normal 



Dis- 
turbed 
median, 
ulnar, 
radial 
Lost in 
fingers 

Disturb'd 



Disturb'd 



None 



Lost in 
hand 



Yes Skin glos- 
sy 



Yes 



Yes 



Flexors 
in fore- 
arm 
Yes 



Yes 



In calf 



Tendon 

hard, 

swelling 

in calf 



Cold 



Yes 
Yes 
Yes 

Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 

Yes 



Paralysis 
all nerves 

In median 
supply 



Ulnar paraly- 
sis, extension 
ist phalan- 
ges, others 

flexed 
Muscles par- 
alyzed 

Paralysis of 
nerves 



Nerves nor- 
mal 

Extension 
ist phalan- 
ges, flexion 
others 



Hand mus- 
cles 



Massage and electricity. 
Later resection bones. 
Improvement. Thumb 
could be opposed. 

Massage. Improvement. 



Operation. Artery oblit- 
erated. Median nerve 
compressed. Nerve 
freed. Complete recov- 
ery. 

Operation. Artery oc- 
cluded. Freed nerves. 
Dissect ofiE muscles. 
Fingers recovered. 
Slight improvement. 

Later necrosis. Amputa- 
tion. Fibrous changes 
in muscles. 

Later dry gangrene. 



Superficial ^ngrene. Is- 
chemic mflammation 
in calf. 

Median nerve felt over 
projection of bone. 
Operation on defor- 
mity. No improvement. 

Some improvement. 



Improved. 



Freed median nerve. No 
improvement. 

Little improvement. 



Improved. 

Recovered. 
Sensation returned. 



348 



JOHN JENKS THOMAS. 



TABLE OF REPORTED CASES 



No 


Author 


Sex, 
age 


Character of injury 


Treatment of 
injury 


Pulse 


Pain 


Swelling 


90 


Helferich 




Fracture humerus at 
elbow 


Plaster 








(Hildebrand) 










91 




M 
24 


Fracture humerus 


Splint, pad in 
axilla 




Yes 


Yes 


1906 






92 




M 
10 


Fracture humerus, 
lower part 


Bandage, frag- 
ments 
displaced 








1906 








93 




M 

13 


Fracture elbow and 
lower third radius 










1906 










94 




M 
7 


Fracture humerus 


Plaster 








1906 








95 




M 

9 


Fracture both bones 
forearm at middle 


Splints 








1906 








96 




F 

12 


Fracture humerus, 
lower part 


Splints, tight 








1906 








97 




M 

17 


Stab wound 


Esmarch 25 
hrs., splints 


Present 


Moderate 


Moderate 


1907 




98 




M 

5 


Fracture both bones 
forearm 


Splints, then 
plaster 








1907 








99 




F 

5% 


Fracture humerus just 
above elbow 


Splint 




No 


Yes 


1907 










F 
6 


Fracture humerus, 
lower third 




Absent 








1907 








lOI 


Wallstein 
















1907 


















M 
7 


Fracture humerus, su- 
pracondylar 

Fracture elbow, both 
condyles, X-ray 


Plaster 
Splint 


Absent, 

brachial, 

weak, 

radial 






103 


1907 


Yes 


Yes 


1908 






104 




F 

7 


Fracture radius, dis- 
placement head 


Splints 








1908 








105 




F 
6 


Fracture elbow, dis- 
placement 










1908 










106 




F 
4 


Fracture both bones 
forearm 


Splints 




Yes 


Yes 




1908 






107 


Thomas 

1908 


M 
12 


Fracture ulna, near 
elbow 


Splints 




Yes 


Yes 







I 



ISCHEMIC PARALYSIS AND CONTRACTURE. 



349 



GATHERED FROM LITERATVRE— Concluded 



Elect, reactions 



F. 



G. 



Arm muscles 

o o 

Hand muscles 

o o 

Muscles normal 

o o 

Ulnar n. 

R.D. 

Arm muscles 



Hand muscles 
norm. 



Arm muscles 
responded 



Arm and hand 



Muscles of me- 
dian 
or dim. 



Uncertain 



Arm muscles 
si. dim. si. dim. 
Hand muscles 

o R.D. 

Hand muscles 

o R.D. 



Arm muscles 
dim. 



Hand muscles 



Arm muscles 
norm. 



Hand muscles 
dim. o 



Sensation 



Present in 
fingers 

Lost in 
ulnar reg. 



Dim. in 

thumb 

and first 

finger 



Normal 



Lost in 
hand 



Lost in 

arm and 

hand 



Dim. 
ulnar 
region 

Lost in 
ulnar 



Arm nor- 
mal, hand 
much 
dim. 



Dim. ul- 
nar region 



Dim. in 
hand, es- 
pecially 
ulnar 



Atrophy 



Arm and 

hand 
muscles 



In hand 



In arm 



In arm 



In arm 



In arm 
and hand 



Hand 
muscles 



Hand 
muscles 



Hand 
muscles 



Hand 
muscles 



Pressure 
scar 



Yes 



Yes 



Yes 
Yes 



Yes 



No 



Yes 



No 



Trophic 



Hand 

blue and 

cold 



Hand 
cold 



Blebs arm 

and hand, 

skin 

shiny 



Ulcer on 
fingers 



Hand 
blue 



Hand cy- 
anotic 



Contrac- 
tion 



Yes 
Yes 

Yes 

Yes 

Yes 
Yes 

Yes 

Yes 

Yes 
Yes 
Yes 

Yes 

Yes 

Yes 
Yes 
Yes 

Yes 
Yes 



Paralysis 



Of fingers 



Of hand mus- 
cles 



Median sup- 
ply 



No motion in 
hand 



Extension 
ist phalan- 
ges, flexion 
2d and 3d 
No motion 
fingers 



Claw-hand 



Extension 
I St phalan- 
ges, flexion 

others 
Hand mus- 
cles 



Hand mus- 
cles 



Hand mus- 
cles 



Moderate 
paralysis 
hand mus- 
cles 



Treatment and result 



Operation. Dissected out 
compressed nerves. 
Little effect. 

Operation. Muscles 
fibrous, nerves com- 
pressed. Recovery 
function of nerves. 

Freed and dislocated 
nerve. Sensation im- 
proved. Could make 
a fist. 

Freed, resected, and dis- 
located median and ul- 
nar nerves. 

Lengthened tendons. 
Freed median and ul- 
nar nerves and 
stretched them. Im- 
provement. 

Tendons lengthened. 
Nerves found com- 
pressed. Sensation im- 
proved. Fair use. 

Freed median and ulnar 
nerves. Sensation im- 
proved. No active mo- 
tion. 

Resection bones. Union. 
Improvement. Half 
normal motion. 

Massage. Improvement. 



Collateral circulation 
about condyle. Ten- 
dons lengthened. Good 
results. 

Tendons lengthened. 



Massage. Later resec- 
tion. Normal union. 2d 
operation. Slow union. 

Ulnar nerve stretched 
and dislocated. Prac- 
tical recovery. 

Myotomy. Tenotomy. 
Jan. , 1901. Hand mus- 
cles recovered. Grasp 
fair. 

Oct. 21, 1904. Dislocation 
ulnar nerve. Hand 
muscles and sensation 
recovered. Slight con- 
traction. Practical re- 
covery. 

Electricity and passive 
movements. Hand 
muscles recovered. 
Grasp fair. Moderate 
contracture remained. 

Electricity and passive 
movements. Hand re- 
covered. Moderate 
contracture remained. 



350 JOHN JENKS THOMAS. 

some authors calling cases of pure flaccid paralysis of muscles 
after thrombosis of arteries an ischaemic paralysis. 

Mannkopf published such a case under the title of peripheral ischae- 
mic paralysis in 1878 where he examined the nerves and vessels. This 
was a case of embolism where there was a complete flaccid paralysis 
of both legs. He found in the nerves, degeneration of the nerve fibres 
and also alterations in the nerve sheath, which is evidence of both a 
parenchymatous and interstitial neuritis, while the muscles showed loss 
of striations, fine granular cloudiness and increase of the sarcolemma 
nuclei. Both nerves and muscles thus showing changes due to the 
cutting off of circulation. 

MoLiTOR in 1889 published a similar instructive case of dislocation 
of the elbow with injury of the brachial artery where the hand became 
cold and without sensation and marked swelling and oedema developed 
with absence of the pulse in the radial, ulnar, and lower part of the 
brachial arteries, and an effusion of blood at the bend of the elbow. 
At operation it was found that the median nerve was uninjured and 
the hsematoma was removed and the sensation in the hand improved. 
Eight days later the arm was amputated and on examination it was 
found that the forearm muscles were little changed, being cedematous, 
the arteries empty, the veins full and in some places there was some 
round cell infiltration while the muscle fibres were larger than normal, 
cedematous, homogeneous, somewhat irregular in outline with loss of 
the transverse striations, together with marked diminution of the nuclei 
of the muscle fibres. The nerves were not examined. 

Chvostek in 1892 examined a case in a man of 35 who had arterial 
syphilis, who developed a sudden paralysis of the right leg evidently 
due to embolism, as the pulse in the popliteal artery was absent while 
present in the femoral. The limb was cold, pale, tender on motion, with 
flaccid paralysis and absent reflexes. He died three days later and the 
thrombosis was found. The crural nerve stained with osmic acid showed 
the sheath more deeply stained than normal but not swollen or broken 
down. The muscles examined fresh with osmic acid, and hardened in 
alcohol, and stained with alum carmine, and alum hsematoxylin and 
carmine, showed loss or indistinctness of the striations, swelling, homo- 
geneous, opaque and cloudy fibres, a few of them showing granules 
stained by the osmic acid, while the sarcolemma nuclei were absent 
and showed hyaline degeneration. Chvostek argued for an injury of 
the nerve endings to account for the flaccid paralysis, though interference 
with conduction in the nerves and the condition of the muscles them- 
selves seems sufficient. Hoynck in 1892 had a similar case of paralysis 
of the leg after embolism in a syphilitic woman of 26 with flaccid 
paralysis, loss of sensation and diminished reflexes. Sensation returned 
partially, gangrene set in and the patient died six days later, the paralysis 
having remained flaccid all through. The muscles and nerves were pre- 
served in Miiller's fluid, and stained by Marchi's method, hsemalum, 
and Van Gieson's stain. The nerves showed degenerations; the muscles 



ISCHEMIC PARALYSIS AND CONTRACTURE. 351 

a hyaline degeneration with coagulation of contractile substance, loss of 
striations, and a partial loss of nuclei and in places an increase of inter- 
stitial tissue. 

Herzog in 1899 collected 63 cases of traumatic gangrene from rup- 
ture of the inner coats of the arteries. In 33 of these cases gangrene 
followed. Seven died of shock or complicating injuries before gangrene 
set in. Twenty-three cases showed no gangrene. In these cases the 
diagnosis was proved by autopsy after death from another cause once, 
and in the remaining cases by operation and excision of the thrombosed 
vessel. In two of these cases there remained a firm mass in the muscles, 
and in the other twenty-one cases there was apparent complete recovery. 

These results of thrombosis are important because some 
cases of Volkmann's paralysis and contracture have followed 
embolism, as in the cases of Langer and Schloffer, while in 
Bardenheuer's case of fracture of the clavicle where the arm 
was tightly bandaged to the side, in Barnard, Dudgeon's and 
Ward's cases after contusion of the forearm without fracture, 
in Bardenheuer's case of rupture of the popliteal artery and his 
case of injury of the leg during operation, in those of Powers 
and Riedinger after the use of the elastic bandage, we evi- 
dently have the condition following disturbances of circulation. 
These investigations of Chvostek and the cases just quoted it 
seems to me clearly show that the usual condition after simple 
interruption of the arterial blood supply is one of flaccid 
paralysis, and that to produce the contractures seen in Volk- 
mann's paralysis something more than this is required. The 
same thing is true of the paralysis usually following the use of 
Esmarch's bandage. Bernhardt, Kobner, and Von Frey — to 
mention no others — ^have plainly showed that after the use of 
an elastic bandage we usually have to deal with a flaccid 
paralysis, with no contractures in the paralyzed muscles and 
distinct electrical changes, and this is the common experience 
certainly in the cases in adults such as I have seen, and the 
great majority of those in children also. 

In Volkmann's paralysis on the other hand we have a 
condition in which he emphasized certain points, especially in 
his second article, which was published in 1881. His statement 
is that the condition follows the use of too tight bandages, par- 
ticularly in the arm, and more rarely in the leg, that the 



352 JOHN JENKS THOMAS. 

paralyses, which are followed very early by contractures in 
the affected muscles, are ischaemic in origin, and due to the 
cutting off of the arterial blood supply, while the generally 
observed and often severe venous stasis seems only to hasten 
the onset of the paralysis. He thinks that the muscles too long 
deprived of oxygen die, the contractile substance coagulates, 
breaks down, is absorbed, and so the process resembles the 
changes in rigor mortis. Third, he states that another charac- 
teristic of this condition is that the paralysis and contracture 
always come together, or at least almost so, while in paralysis 
due to nerve injuries the contractures form gradually. Fourth, 
that another characteristic is that there is great rigidity from 
the first. Fifth, that this rigidity increases from the contrac- 
tion of scar-tissue which is formed. Sixth, that the condition 
is also seen after ligation, rupture, and contusion of blood- 
vessels, and possibly after extreme cold. Seventh, that the 
ischsemia is not complete, and so we do not have gangrene, and 
the severity of the result depends upon the severity of the 
ischsemia. Eighth, the prognosis depends upon the amount 
of destroyed muscle tissue. The severest cases he thought 
were incurable, especially in the hand — while the outlook was 
better in the leg, as tenotomy there was of more help. Ninth, 
he maintained that only mechanical treatment helped, and 
advised stretching in recent cases, while he stated this to be 
useless in old cases where bones would break or tendons rup- 
ture before the muscles would yield. 

Volkmann's clinical description of the trouble can in gen- 
eral hardly be bettered, but on certain points the study of the 
cases of other writers shows that his views must be modified, 
especially in regard to the treatment of the condition remain- 
ing, in which it would certainly seem strange if no advance 
had been made in forty years. 

The condition is one in which after a fracture, usually of 
the humerus very near the elbow-joint, or of the forearm, and 
after the application of fixation by one or another method, 
sometimes with tight bandaging, but by no means invariably 
so, and at times where there has been no fracture and no band- 



ISCHyEMIC PARALYSIS AND CONTRACTURE. 353 

aging, there comes on usually within a short time swelling 
and blneness of the extremity with more or less pain, and 
within a varying time when the apparatus is removed, or within 
a short time after this, there is a swelling of the muscles more 
marked in the flexors, which gradually shorten so that the 
fingers and wrist are held flexed, while in almost every case 
the joints are unaffected and the fingers can be extended if the 
flexion of the wrist is increased, and the wrist more or less 
completely extended when the fingers are allowed to flex, thus 
showing that the contracture is greatest in the flexors of the 
fingers, while those of the carpus are but little affected. The 
muscles are hard and much more dense than normal, and often 
there is a pressure slough or scar which may or may not be 
adherent to the deeper tissues. In a good many cases such 
a scar is absent, and these cases and that of Edington, where 
it was low down, show that the process in the muscles is not 
an extension of the superficial trouble into the deeper tissues. 
These are the essential changes, but they by no means complete 
the picture, though the remaining conditions vary greatly in 
the individual cases. Some of these are the defects of motion 
of the elbow- joint from displacement of bones, or projection 
of bony fragments; limitation of supination and pronation, 
which is quite frequent, and seems to be due to muscle changes 
in the muscles concerned in these movements ; and very often 
evidences of disturbance of circulation in the extremity, such 
as coldness and blueness of the hand or trophic changes such 
as a glossy condition of the skin or ulcers and blebs. In addi- 
tion there are frequently seen changes which can only be due to 
disturbance of function of the nerves. These are disturbances 
of sensation which are limited to the areas supplied by one or 
more of the nerves of the forearm, most frequently only in 
that part of the hand supplied by the ulnar nerve, but some- 
times that of the median or radial, and occasionally all three 
nerves, or paralysis of the small muscles supplied by these 
nerves, or atrophy of these muscles. It is evident in cases 
where the injury is in the forearm or to the humerus that this 
condition can be due only to injury of the nerves of the arm at 



354 JOHN JENKS THOMAS. 

the time of the injury or subsequently. With reference to the 
frequency of such evidence of involvement of the nerves I have 
analyzed the published cases, with few exceptions in the orig- 
inal reports and always where these have been accessible to me, 
and in 6 1 of the 107 cases included in the table conditions were 
noted as present which could be produced only by injury of the 
nerves, and this number is undoubtedly less than that in which 
the condition was present, as some of the cases are reported 
without full details. 

In regard to the pathological condition present in Volk- 
mann's paralysis there have been numerous reports, and con- 
siderable experimental work has also been done. The first 
examinations of the affected muscles were made by Leser in 
three of his cases. He describes an increase of connective 
tissue and loss of the nuclei. Petersen examined the muscles 
in his case and found similar changes. Bernays is the first 
American writer to describe the microscopical changes in the 
muscles. He speaks of the muscle fibres as irregular in 
arrangement and of unequal thickness, while in some, vacuoles 
were present. The most characteristic thing was the absence 
of nuclei, there being often only a little granular detritus in 
place of the nucleus. The transverse striations of the muscle 
fibres were lost. In more advanced cases he found round-cell 
infiltration and increase of connective tissue and finally atrophy 
and disappearance of muscle fibres. Edington examined an 
excised portion of muscle and describes increase of connective 
tissue, irregular, swollen, and hyaline muscle fibres with loss 
of transverse striations, while in other places the atrophic 
changes were more marked, and there was increase of sarco- 
lemma nuclei and in places lymphocyte infiltration and begin- 
ning connective tissue growth about the blood-vessels. Row- 
lands simply speaks of much interstitial fibrosis in the muscles. 
Powers found great hyperplasia of connective tissue, atrophy 
and fragmentation of muscle fibres, which had lost their nuclei 
and transverse striations, while others appeared homogeneous 
and hyaline, but nowhere fatty changes in the muscles. Vari- 
ous writers, where there was no microscopical examination 



ISCHEMIC PARALYSIS AND CONTRACTURE. 



355 



made, speak of the muscles being firm, harder than normal, 
yellow in color — and often also of all the muscles being matted 
together so that they could not be separated or distinguished 
from one another, as Davies-Colley, Owen, Wallis, Barnard, 
Schramm, Drehmann, Bardenheuer, Hildebrand, Ferguson, 
and Bradford in the first case reported in this paper. The 
changes in the muscles found soon after the injury was re- 
ceived reported by Mannkopf and Molitor have already been 
spoken of. 

Attempts have also been made, not with great success 
however, to reproduce these contractures experimentally. 

The first of these was by Leser, who used rabbits and frogs. The 
results in the latter were unsatisfactory, as he got paralysis but no in- 
flammatory reaction. In the rabbits in 23 cases he bandaged the leg for 
three hours and produced a flaccid paralysis with absence of reaction 
to faradism and swelling of the leg muscles, which became hard. In 
all of the animals the inflammation subsided in from eight to fourteen 
days and in three weeks all traces of paralysis had disappeared and he 
was entirely unable to produce contractures. Lapinsky tied the artery 
in 10 rabbits and observed changes in motility, sensibility, reflexes, elec- 
trical irritability and parenchymatous neuritis, but he produced only 
flaccid paralyses and no contractures. Bardenheuer's assistant, Lossen, 
repeated Leser's experiments, bandaging for six hours however, and pro- 
duced contractures, but in three months these had disappeared, while 
if the bandage was tighter he got gangrene. From these results Barden- 
heuer infers that simple anaemia of muscle is not sufficient to produce 
these peculiar contractures. Hildebrand in his experiments tied the 
artery, then bandaged the limb and in some cases injured the nerve also. 
This was done in 7 cases and he produced paralysis with fatty de- 
generation and atrophy of muscles but not the condition found in 
ischaemic paralysis. 

In reports of operation upon these cases a number of 
writers speak of the condition found in the nerves. Petersen 
in 1888 was the first I have found who speaks especially of the 
condition of the nerves, and also the first to call attention to 
an occlusion of the arteries in this condition. In his case the 
radial pulse was deficient and sensation was much diminished 
in the hand, so that he cut down upon the median nerve, and 
found this compressed, and that the brachial artery had been 
occluded. Davies-Colley in one case found both the median 



356 JOHN JENKS THOMAS. 

and ulnar nerves small, and purplish in color below the scar- 
tissue in the forearm. Wallis exposed the median nerve 
which he found surrounded by fibrous tissue which was adher- 
ent to the nerve sheath. Drehmann found the median nerve 
so embedded in scar-tissue that he was unable to isolate it. 
Bardenheuer in his third case found the artery thin and empty 
and the median nerve compressed by scar-tissue, and the same 
condition in the median and ulnar nerves in his fourth case. 
Hamilton in 1850 in operating on a projecting fragment of 
bone found the median nerve stretched over the sharp end of 
the projection and thinned and got improvement from the 
correction of this condition. Hildebrand found all three 
nerves compressed and gray in color in his first case. In the 
second case the radial nerve was much thinned and compressed 
while the median was pressed out of place by a projecting frag- 
ment of bone and the nerves recovered function after he re- 
moved this projection and allowed the nerve to slip to one side. 
In his third case the median was thinned for a distance of 10 
cm., and in the fourth, the median was also small and ansemic. 
Ferguson found the median and ulnar nerves nodular in places, 
and smaller than normal. In Powers' case the median and 
ulnar nerves were found buried in dense connective tissue and 
thickened. In two of the cases reported in this paper the 
nerves were found at operation to be involved. In the first 
case Dr. Bradford found it impossible to isolate the nerves in 
the forearm, so firmly were they embedded, and in the second 
case Dr. Gushing found the ulnar nerve flattened and ansemic. 
A study of the views of writers upon Volkmann's contrac- 
ture shows considerable difference of opinion in regard to the 
mechanism of the production of the condition. 

As we have seen, Volkmann and his follower, Leser, thought the 
ischaemia of the muscles was the essential factor, yet the attempt to 
reproduce the condition in this way by experiment failed, showing that 
something more was necessary. Nevertheless there are a number of 
cases which show that the condition is certainly due to disturbance of 
circulation. Examples of this are the cases of injuries of arteries such 
as Petersen's case; Keferstein's fifth case, which did not bleed when 
stuck; Langer's and Schloffer's cases of embolism; the case of Hoffman; 



ISCHEMIC PARALYSIS AND CONTRACTURE. 357 

Kleinschmidt's, in which the pulse was lost; that of Peters quoted by 
Drehmann, but which I have been unable to find, where no splint was 
used; one of Hildebrand's cases, where there was a pad placed in the 
axilla; Riedinger's case where an elastic bandage was left on for two 
days; and Nolte's, where a tight bandage used for extension was left on. 
These cases, with those due to embolism or injuries of arteries, where 
no bandages were applied, show that the disturbance of the circulation 
is the essential thing. 

Wallis in his discussion lays emphasis on the presence of hyperaemia 
in producing the contractures. Edington in his second article calls 
attention to the fact that the condition of the muscles is not an ex- 
tension from the superficial slough which is often present and may leave 
the skin adherent to the deeper structures, as in one of his cases the 
scar was low down while the muscles were affected in the upper part 
of the forearm; and we may add that a number of cases are recorded 
in which there was no scar from pressure slough. Bardenheuer in 
his discussion of the etiology emphasizes various points. He thinks 
it is necessary to have an injury of the intima or media of the artery, 
but that venous stasis also is important, and shows by some of his cases 
where this was absent that the inflammatory reaction in the muscles was 
much less. He argues that the reason why these contractures are more 
frequently found in children, while injuries of arteries in adults usually 
result in more or less extensive gangrene, is due to the greater ease 
and rapidity with which collateral circulation is established in children. 
Hoffmann in his case where the brachial artery was injured found well 
marked evidence of collateral circulation about both the internal and 
external condyles. 

Hildebrand thinks the changes in the muscles the most important 
factor in the formation of these contractures, but argues for involve- 
ment of the nerves also. He emphasizes the fact of pressure preventing 
the formation of collateral circulation and the frequency of injury of 
the arteries and thrombosis. He also states that where there has been 
no bandage used there is always effusion of blood to prevent the 
collateral circulation. He considers the predominance of the affection 
of the flexor muscles as due to the fact that the median nerve is more 
often injured, while in fact more cases show involvement of the ulnar 
than of the median, and Oppenheim in his text book speaks of injury 
of the ulnar nerve as the only condition likely to be confounded with 
Volkmann's contracture. Hildebrand argues for a momentary crushing 
of the nerves, and later speaks of the frequency of continuous pressure 
upon the nerves from scar tissue, and says that rupture of nerves is 
rare. He states however that paralysis from nerve injury does not 
necessarily belong to the picture and that in most cases this is of 
gradual onset later, both of which statements I can confirm, the first 
in particular by a case recently seen which is not included in this 
paper in which the changes were limited practically entirely to the 
flexor profundus digitorum, with marked contracture, while there was 
not the least evidence of involvement of any of the nerves of the fore- 



3S8 JOHN JENKS THOMAS. 

arm. Hoffmann also argues for the involvement of nerves as well 
as arteries. Kleinschmidt thinks that the venous stasis is essential 
for the production of these contractures. 

It seems to me a strong argument for the primary condition 
being dependent upon circulatory disturbances, and probably 
an anaemia of the muscle with obstruction to the venous 
circulation also, that cases have occurred from embolism, 
and especially such cases as that of Nolte, where a bandage 
was applied to the arm for extension and left on, compressing 
the arm severely, and Riedinger's second case, where a girl 
of 15 crushed her finger and an elastic bandage was applied 
to the upper third of the forearm and left for two days on 
account of the hemorrhage, where the subsequent atrophy of 
the muscles stopped where the bandage ended, and the hand 
muscles where no bandage had been applied remained normal 
also. These are clearly cases produced by disturbance of 
circulation and probably by this alone. While it may be im- 
possible to say that nerves are not at all involved in the pro- 
cesses which produce the changes in the muscles, the facts seem 
to me to show that if this is the case it can be only the terminal 
muscle branches that are necessarily so affected, and that this 
is of secondary importance, and such facts as the involvement 
of part of a muscle only by the connective tissue formation 
with a good response of the remaining portion of the muscle 
to electrical stimulation as I have seen it, in my opinion shows 
that the nerve involvement in the primary process is not a 
necessary factor. On the other hand secondary affection of 
nerve trunks from involvement in connective-tissue overgrowth 
is frequent. Disturbance of sensation in the hand can only 
be produced in this way, especially when it is limited to the 
area of skin corresponding to the distribution of one of the 
nerves of the arm. The same thing is true of atrophy of the 
small muscles of the hand, and the presence of the reaction of 
degeneration in these muscles, a positive evidence in these 
cases of involvement of the nerve trunks, as destructive inflam- 
matory processes in muscle in itself can produce only dimin- 
ished or absent electrical reaction. Paralysis of these hand 



ISCHEMIC PARALYSIS AND CONTRACTURE. 



359 



muscles can only be due to nerve involvement and this point 
is the one most frequently overlooked. One must remember 
that the movements of the fingers performed by these muscles 
are those of abduction and adduction, flexion of the first 
phalanx, and extension of the two distal phalanges, and that 
paralysis of muscles in the forearm while they may limit these 
movements cannot cause their entire absence. In case of 
paralysis of these small muscles we get from contraction of the 
opponents an extension of the first and flexion of the second 
and third phalanges. This flexion would of course be favored 
by the contraction of connective tissue in the flexor sublimis 
and profundus digitorum, but this formation of contractures 
in the flexors cannot produce the extension of the first phalanx 
which was noted in many of the reported cases. If then we 
assume the presence of one of these conditions as evidence of 
involvement of nerve trunks we find that this existed in 62 
of the 107 cases contained in the table, and probably was pres- 
ent in a portion of the other cases, as in many papers the details 
of the examination were not given. 

In regard to other factors in the cases of Volkmann's 
contracture a study of the reported cases shows the following 
things. Of the 107 cases included in this paper the sex was 
stated 89 times, of which 62 were males and 27 females, the 
predominance of males being undoubtedly due to their greater 
liability to accidents. 

The predominance of children is very striking. In 18 
cases the age was not stated, and in 2 it was simply stated that 
they were adults, and in 6 children. Of the 81 cases where 
the age was given the youngest was 2 years and the oldest 50, 
but of these 81, 66 were 15 years or less, and 62 were 12 
or less. 



2 years 


I case 


II years 


case 


21 years 


I case 


3 years 


2 cases 


12 years 


6 cases 


24 years 


I case 


4 years 


5 cases 


13 years 


I case 


25 years 


2 cases 


5 years 


10 cases 


14 years 


I case 


30 years 


I case 


6 years 


13 cases 


IS years 


2 cases 


32 years 


I case 


7 years 


7 cases 


16 years 


I case 


33 years 


I case 


8 years 


6 cases 


17 years 


I case 


34 years 


I case 


9 years 


5 cases 


18 years 


I case 


40 years 


I case 


10 years 


7 cases 


20 years 


2 cases 


50 years 


I case 



360 JOHN JENKS THOMAS. 

The most frequent injury was fracture and the marked 
predominance of this at or near the elbow- joint with its great 
liabiHty to injury of the brachial artery to which Bardenheuer 
has especially called attention is very striking. Of these 107 
cases 5 were in the leg, and 102 in the arm. The injury 
consisted in: 

ARM. 

Fracture of the arm, region not stated 5 times 

Fracture humerus, part not stated 4 times 

Fracture humerus, middle i time 

Fracture humerus, above condyles 28 times 

Fracture humerus, into elbow- joint 15 times 

Fracture forearm, middle or upper 24 times 

Fracture forearm, lower 5 times 

Fracture radius 5 times 

Fracture forearm, region not stated 2 times 

Dislocation both bones of forearm 2 times 

Fracture clavicle, and tight bandage i time 

Contusion of forearm 6 times 

Elastic bandage 2 times 

Septic infection of arm i time 

Embolus of arm i time 

LEG. 

Splint for fluid in knee i time 

Fracture of both bones of leg i time 

Rupture of popliteal artery i time 

Injury of leg at operation i time 

Embolus I time 

Total 107 times 

The treatment of the primary injury was as follows (but 
often it was stated that the splints and bandages were lightly 
applied, and at times that the splints were of pasteboard or of 
similar character) : 

Splints 52 cases 

Splint, in cases of stab- wound or in infection 2 cases 

Plaster-of- Paris 28 cases 

Apparatus i case 

Bandage 2 cases 

Sling I case 

Quiet 3 cases 

Not stated 18 cases 

Total 107 cases 



ISCHEMIC PARALYSIS AND CONTRACTURE. 



361 



As to the frequency of mention of the chief symptoms I 
have found as follows : Pain was stated to be present 32 times; 
muscles tender i time, though this was also found in many 
of the cases where there was pain present, and this was espe- 
cially noted as absent 7 times; swelling, immediately after the 
injury, was noted 50 times. The pulse was noted as absent or 
much diminished 10 times, and once it was stated that the 
hand did not bleed when stuck. A slough or a scar from a 
former slough was present 37 times. Various trophic changes, 
showing disturbance of circulation, such as coldness, cyanosis, 
shiny skin, ulcers on the fingers, or blebs, were noted 37 times. 

Symptoms of involvement of the nerves of the forearm 
were present in 62 of the cases, nearly 60 per cent, of the 
whole number, and these were as follows : 

SYMPTOMS OF NERVE INVOLVEMENT OF FOREARM. 

Disturbance of sensation in the hand 34 times 

Atrophy of small muscles of the hand 27 times 

Paralysis of the small muscles of the hand 36 times 

CHANGES OF ELECTRICAL REACTIONS IN THE HAND. 

Loss or diminution to faradism 24 times 

Loss or diminution to galvanism 10 times 

Reaction of degeneration 10 times 

CHANGES OF ELECTRICAL REACTIONS IN ARM MUSCLES. 

Loss or diminution to faradism 26 times 

Loss or diminution to galvanism 14 times 

Reaction of degeneration 6 times 

When we turn to the treatment of this contracture we 
find several interesting facts. As we have seen, Volkmann 
advocated stretching the contracted muscles under an anaes- 
thetic, but looked upon the severe cases as incapable of im- 
provement. Keferstein in 1893 reported a number of cases 
treated by this method of stretching, and a number of his 
cases were looked up by Kaempf, whose paper was published 
in 1897, or only four years later, and cases i, 2, 3, 4 and 5, 
seen one or more years after the treatment, were unimproved, 
the contracture having been unrelieved or having returned. 
The first operations reported consisted in chiseling away pro- 



362 JOHN JENKS THOMAS. 

jecting portions of bone, and improving the position of the 
fragments. Petersen, in 1888, seems to have made an attempt 
to free the compressed nerves by operation, and obtained con- 
siderable improvement, but his report attracted little attention. 
Hildebrand in his article in 1890, and Niessen in the same 
year, reported considerable or great improvement from gradual 
stretching of the contractures, and this seems to have given 
more permanent results than the forcible procedure under an 
anaesthetic, especially when supplemented by massage and 
electrical treatment. Martin in France in 1903 also advocated 
the use of a device to exert a continuous pull upon the muscles, 
but also used resection of the bones, and Lycklema and Nye- 
holt in 1904 advised the same procedure, combining it with the 
operation of lengthening the tendons, while Jones of Liver- 
pool relies greatly upon continued stretching of the muscles. 
Davidsohn, writing in 1891, seems to have been the first to re- 
port results from attempts to improve the contractures by 
operation, having lengthened the flexor tendons, and getting 
good extension of the fingers and moderate motion in them, 
though no improvement in the atrophy of the muscles of the 
hand supplied by the median nerve, for which he attempted 
no relief. Page in England, writing in 1900, practised length- 
ening the tendons, and was followed in 1901 by Little wood, 
both apparently not knowing of the previous work of David- 
sohn, but Davies-Colley in 1898 had done a tenotomy, after 
which there was no active flexion of the fingers, though there 
was of the thumb. These men were followed in England 
by Wallis, Barnard, Edington, Ward, Rowlands and others. 
The first report of an operation in America that I have been 
able to find was one of tendon lengthening reported by Gallo- 
way in 1902. 

Garre in 1895 appears to have been the first to resort to 
resection of the bones of the forearm, and obtained an im- 
proved position of the fingers. He was followed in 1896 by 
Henle. Dunn in England, in an article published in 1897, 
had advised an operation, but at the time of writing, it had 
not been done. Johnson, independently of the German work- 



ISCHEMIC PARALYSIS AND CONTRACTURE. 363 

ers, reported cases in 1898 treated by this method. Owen, 
writing in the same year, spoke of the operation of division of 
the tendons giving an unsatisfactory result, and thought resec- 
tion the most promising operation, and he reported cases 
treated by this operation combined with tendon lengthening 
in 1900. Bernays wrote the first article upon this subject that 
was published in America so far as I have been able to find, 
and though he speaks of two cases of his own he did not report 
them, evidently thinking the condition due to carelesness of 
the surgeon, but he thought that resection was the only opera- 
tion likely to prove useful. Dugeon in his second article, pub- 
lished in 1903, gives the same opinion. Other advocates of this 
procedure are Willmann and Kob, both writing in 1905, Hun- 
tington in this country in 1907 and Kleinschmidt in Germany 
in the same year. 

In 1904 came the first reports from Germany of repeti- 
tions of the operation of lengthening tendons, when Schramm 
reported a case. Drehmann, writing in the same year, speaks 
of this operation having been done by Alapy, whose article I 
have been unable to find. Drehmann however did rather more 
than the simple tendon operation, as he attempted (though 
not successfully) to dissect out the median nerve, which was 
embedded in scar tissue. He separated the muscles of the 
ulnar side of the foreann from the artery and each other, 
and by incisions of the contracted muscle and scar tissue 
lengthened them until he was able to extend the fingers, and 
then sutured these muscles to the healthy flexor profundus. 
This operation gave marked improvement with good use of the 
hand except of the thumb, evidently due to the involvement 
of the median nerve, which he had been unable to free. This 
is the first report of any operation in the nature of a myotomy 
which I have been able to find, but I wish to call attention 
to the fact that this was practically what was done by Bradford 
in 1 90 1 in the first case reported in this paper. Hoffmann 
and Wollstein in Germany returned to tendon lengthening. 
Bardenheuer in a case reported in 1906 dissected off the con- 
tracted muscles and freed the nerves, and Hildebrand in the 



364 JOHN JENKS THOMAS. 

same year reports cases in which he dissected out the com- 
pressed nerves in the forearm, and in one case placed the nerve 
over the sutured muscles, suturing the fascia over the nerves, 
and in another case he resected a portion of a nerve. Fergu- 
son in America in 1906 and Powers in 1907 also freed the 
nerves. Quinby in 1908 at an operation on one of these cases 
where there were symptoms of compression of the ulnar nerve 
stretched this nerve and placed it above the condyle, with relief 
of the symptoms produced by the compression of the nerve, 
and at this time he did not know of the case of which I 
am going to speak. The second case reported in this paper, 
where Gushing, of the Boston Children's Hospital, dissected 
out the ulnar nerve and placed it in front of the condyle, was 
done in 1904, thus antedating by several years similar pro- 
cedures done independently by Hildebrand and Quinby. 

Because of the various degrees of involvement of muscles, 
in many cases supination and pronation being limited by these 
changes, while in others only a moderate destruction of the 
flexor sublimis may be present, as well as the fact that dis- 
turbances of circulation and trophic changes vary greatly in 
amount or may be absent, to say nothing of the possible com- 
plication from secondary involvement of nerve trunks, it is 
difficult to analyze the results from the various forms of treat- 
ment adopted in different cases. So far as this can be done 
the reports are as follows : 

FROM CASES TREATED BY SUCH MEANS AS STRETCHING OF CONTRACTURES 

WITH OR WITHOUT THE USE OF MASSAGE AND ELECTRICITY, 

THE RESULTS WERE GIVEN AS: 

No improvement 8 cases 

Slight improvement 9 cases 

Improved 19 cases 

Good 4 cases 

Results of treatment not given 14 cases 

Tenotomy 2 cases 

TENDON LENGTHENING. 

Not stated 5 cases 

Slightly improved 2 cases 

Improved 11 cases 

Good 4 cases 



ISCHEMIC PARALYSIS AND CONTRACTURE. 365 

RESECTION OF BONES. 

Non union 2 cases 

Not stated i case 

Slight improvement i case 

Improved 7 cases 

Good 3 cases 

FREEING NERVES. 

No improvement 2 cases 

Slight improvement 2 cases 

Improved 5 cases 

Good 4 cases 

MYOTOMY. 

Improved 2 cases 

amputation: One case. 

The frequency of this condition is probably greater than 
the pubHshed cases would indicate, many cases not being put 
upon record because of the widespread impression among the 
profession that it is due to the improper application of splints, 
as indeed is sometimes the case. For instance. Ward states 
that he thinks he has seen an average of one case a year from 
1877 to the time of this writing (1902), — that is twenty-five 
cases, — though he reports but two. Rowlands speaks of hav- 
ing had seven cases, and knowing of four unpublished ones, 
where resection was done. Bernays thinks the condition fre- 
quent. There have been two or three cases at the Children's 
Hospital which I have not included in this paper simply because 
I did not happen to have the opportunity of examining them 
myself. One of these Goldthwait operated upon, lengthening 
the tendons, with a fairly good result. Goldthwait also has 
told me in a verbal communication that he has treated two or 
three other cases with good results by the method of gradual 
extension of the fingers and wrist by means of apparatus advo- 
cated by Jones of Liverpool at the meeting of the American 
Orthopaedic Association in Washington in 1907. On the other 
hand Schramm, in his article, states that the case he reported 
was the first one he had seen in nineteen years. Probably 
the experience of surgeons varies with the number of cases 



366 JOHN JENKS THOMAS. 

of children's affections they see, and partly also with the sur- 
gical skill and judgment of the practitioners in their neighbor- 
hood, — the number of " natural bone setters." 

The relative merits of different procedures must vary with 
the severity of the case and the particular features present, and 
this is true both of the primary trouble, and of the secondary 
involvement of the nerve trunks. I have seen nerves recover 
under treatment by electricity and massage, as well as finding 
instances of this among the published cases, while in other cases 
these measures have proved of no avail. The same statement 
is true of the various methods of extension, though stretching 
the contracted muscles under an anaesthetic is often followed 
by marked inflammatory reaction and has proved to be of little 
or no value, the contracture usually returning quickly. The 
method of gradual extension by passive movements or appa- 
ratus is often all that is necessary, especially when the contrac- 
ture is confined to the flexor stiblimis digitorum. In the severe 
cases, and those where there is limitation of pronation and 
supination, a cutting operation seems to offer the most chance 
of a good result. Resection of the bones, while it corrects 
the deformity from the contracture, must weaken the extensors 
and has the not inconsiderable danger of non union, and often 
gives no increased usefulness to the crippled hand. The 
process of lengthening the tendons has given better results on 
the whole than resection, but is open to the objection of the 
greater liability to infection from the great number of sutures 
required, and the great difficulty of afterwards breaking up 
the numerous adhesions within the tendon sheaths, to say 
nothing of the difficulty and consequent length of the operation, 
a thing to be considered in young children. On the whole 
myotomy or dissection of the affected muscles from their 
attachments and suture in other positions as has been done by 
Drehmann and Hildebrand and by Bradford seems the most 
promising procedure in the severer cases requiring operation, 
while for the compression of nerve trunks there seems no need 
to despair, at least in cases where they can be identified, as 
Owen does when he remarks in his article that the question of 



ISCHEMIC PARALYSIS AND CONTRACTURE. 367 

nerve injury is an interesting one, but that he does not know 
where to look for it, nor what to do for it if he found it. 
The work that has been done since this was written in 1898 
shows that the freeing of nerve trunks, the placing them away 
from the contracting muscles under the skin, where I may say 
that in our case with Gushing they have caused not the slight- 
est inconvenience, and at times the resection of a portion of a 
nerve and its suture, or in some cases as has been suggested by 
Quinby by a longitudinal disassociation of the nerve fibres, 
if there is evidence of scar tissue within the nerve sheath, such 
as has met with success in the hands of Delbet and Babcock, 
offers us the choice of methods of great promise. 

In all cases in which operative measures are decided upon 
the importance of after treatment can hardly be exaggerated. 
This should be by means of passive and active movements, 
massage, and in many cases stimulation of the muscles by the 
faradic current, and these measures must often be continued 
for many months in order that the full benefit of the improved 
conditions from the operation may be obtained. If this is not 
done, in many cases the only result from operation will be a 
greater range of passive movement with no improvement in 
the functional use of the limb. 

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368 JOHN JENKS THOMAS. 

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anatom. Untersuchungen der Nerven und Muskeln, Inaug. Dissert, 

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Hildebrand, O. : Die Lehre von den isch. Muskellahmungen und Kon- 

trakturen, Samml. klin. Vortrage, 1906, N. F. 437, No. 122 (Quotes 

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Huntington, T. W. : Isch. Paralysis and Contracture treated by Bone 

Shortening, Cal. State Jour, of Med., 1907, v, 161. 
Johnson, R. : Meeting Harveian Soc, London, Mar. 3, 1898; Lancet, 

1898, i, 722. 



ISCHyEMIC PARALYSIS AND CONTRACTURE. 



369 



Kaempf, E. : Beitrage z. Casuistik der ischam. Muskellahmungen und 

Contracturen, Inaug. Dissert., Berlin, 1897. 
Keferstein: Ein Beitrag zur Kasuistik der isch. Muskellahmungen, etc., 

Inaug. Dissert., Gottingen, 1893. 
Kleinschmidt, P. : Zur Behandlung isch. Muskelkontrakturen, zugleich 

ein Beitrag zur Pseudoarthrosenheilung, Deut. med. Woch., 1907, 

xxxiii, 679. 
Kob, B. : Ueber die Behandlung der isch. Lahmungen des Vorderarms 

durch Resektion der Vorderarmknochcn, Inaug. Dissert., Konigsberg, 

1905. 
Kobner: Ein Fall von gleichzeit. traumat. (Druck) Lahmung der Nervi 

rad. ulnar, und med., Deut. med. Woch., 1888, xiv, 186. 
Kriege, H. : Ueber Gangran und Contracturen nach zu fest an^elegten 

Verbanden, Vierteljahrschrift f. gericht. Med., 1903, xxv, Suppl. 

Heft. 55- 
Langer, A. : Ein Fall von isch. Lahmung durch Embolic einer Armarterie 

bewirkt, Jahrbuch der Weiner k. k. Krankenanstalt, 1895, iv, 375. 
Lapinsky, M. : Ueber acute ischam. Lahmung nebst Bemerkungen iiber 

die Veranderungen der Nerven bei acuter Ischamie, Deut. Zeitsch. 

Nervenheilk., 1900, xvii, 322. 
Leser, E. : Untersuchungen uber ischamische Muskellahmungen und 

Muskelcontracturen, Volk. Sammlung klin. Vortrage, 1884, No. 249. 
Little wood, H. : Some Complications Following on Injuries about the 

Elbow- joint and their Treatment, Lancet, 1900, i, 290. 
Lycklema-a-Nyeholt : Die Behandlung der isch. Contracturen, Naderl. 

Tijdschrift voor Geneeskunde, 1904, i. No. 20; Ref. in Zentralbl. f. 

Chir., 1904, xxxi, 1229. 
Mannkopf: Ueber periph. isch. Lahmung., Erlenmeyer's Centralblatt, 

1879, i, 258. 
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traites par des tractions lentes et continues, Congres frangais de 

Chirurgie, Paris, 1903, xvi, 934. 
Molitor, E. : Ueber mit Zerreissung der Art. brach. complicirt Luxationen 

des Ellbogengelenks und die dabei vorkommenden isch. Muskelver- 

anderungen, Beitrag zur klin. Chir., 1889, v, 447. 
Niessen, W. ; Isch. Muskellahmung und Muskelcontractur in Verbindung 

mit Sensibilitatsstorungen, Deut. med. Woch., 1890, xvi, 796. 
Nolte : Ueber Heilbarkeit isch. Muskellahmungen, Allg. med. Central 

Zeitung, Berlin, 1889, Iviii, 24, 25. 
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xxiv, 287. 
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xxxvii, 675. 
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Greifswald, 1892. 
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Am. Med. Ass., 1907, xlviii, 759. 

13 



370 JOHN JENKS THOMAS. 

Quinby, W. C. : The Treatment of Trophic Nerve Lesions, Boston Med. 

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OPERATING UPON THE CRANIAL VAULT. 
BY H. C. MASLAND, M.D., 

OF PHILADELPHIA, PA. 

The achievements of the last few years in the realm of 
cranial surgery have awakened increasing attention to the de- 
velopment of a more satisfactory method of entering the skull. 
The crucial question is to lift a goodly sized osteoplastic flap 
with no injury to the sublying tissues and to prevent the sud- 
den hemorrhage that all too frequently jeopardizes the success 
of the operation and even the life of the patient. The pioneers 
in this practically new field are realizing the inadequacy of 
what might be called the hand instruments and are turning to 
the mechanically driven instruments. Of these the only ones 
of importance are the spiral osteotome and the circular saw. 

The spiral osteotome, while a valuable instrument, pos- 
sesses certain defects of considerable moment. The inside 
guard fixed to the drill is incapable of adjustment to permit 
of preliminary separation of the dura, but must be forced along 
only as the side cutting drill cuts the way. The drill clogs 
quickly, and is especially troublesome in hard and thick skulls. 
It also heats quickly, a source of injury to itself as well as the 
tissues concerned. To be practical the drill must be so large, 
making thereby a proportionately wide incision, that an ap- 
preciable degree of sinking of the bone flap occurs after 
reposition. This feature is especially undesirable in the opera- 
tions for decompression. It is hardly to be denied that the 
circular saw, possessing certain qualities of inherent superiority, 
is the desirable instrument if it can be efficiently controlled. 
The principles of my instrument (Fig. i) by which this has 
been accomplished have been given in detail in earlier publica- 
tions,^ and it is not necessary to repeat them. One point that 
seems to have been misunderstood is the advantage of having 
the saw, the handle, the arm and the eye of the operator all in 

* Jr. A. M. A., March 4, 1905 ; Annals of Surgery, Aug., 1906. 

371 



372 H. C MASLAND. 

line in making the section. This is the natural method used 
by the carpenter and all mechanics. It gives a flexible wrist, a 
better use of the sensitiveness of the fingers, an easy and full 
control that is not accorded to the same degree by a saw at 
right angles to a slender handle. 

Turning to the real purpose of this paper it is my aim to 
state a few details of technic that show the nicety and certainty 
with which the bone can be cut, with absolute protection to the 
sublying tissues. After making the two preliminary openings, 
preferably at the thinnest and the thickest angles of the con- 
templated flap, the thickness of the skull is ascertained. The 
outside guard is then set to cut through the greater portion of 

Fig. I. 




the thickness so determined. The side being operated upon is 
then quickly cut to this depth. I prefer the use of the outside 
guard at this time because it leaves but a small portion of the 
inner table to be cut when using the inside guard. While this 
procedure is not essential it does permit, by a little, a greater 
degree of attention to the safety of the dura. To make the 
final section the inside guard is attached to the handle. Now 
keeping the saw with the power oif and away from the hone, 
the guard is carefully insinuated along the inner wall of the 
skull. Sole attention is thus given to the thorough dissection 
of the dura and blood-vessels away from the inner table before 
the saw is brought into play. When this is accomplished the 
power is turned on full, the saw is lowered into the cut and 
the incision is made down to the guard. Then drawing back- 



OPERATING UPON THE CRANIAL VAULT. 373 

ward the incision is completed throughout the length to which 
the guard has penetrated. The saw is now lifted, the guard is 
advanced, the dura is further dissected away, and the opera- 
tion repeated as before. After cutting the three sides the 
remaining isthmus is broken up with chisels as is usually done. 
The operator should have one assistant devoting his atten- 
tion to the motor. One hand should hold the controller, using 
the current as indicated. The other hand loosely supports the 
cable in the palm, thus removing all side drag from the instru- 
ment and by keeping the cable at an easy curve increasing its 
effectiveness. The cable is preferable to the belt drive because 
it can be sterilized more satisfactorily. Either, however, can 
be used for the purpose. A hand-motor could be used where 
the electric current is not available. For decompression work 
the circular saw is the instrument par excellence. Whereas 
other devices j>ermit sinking of the flap, with the saw the flap 
is actually elevated when replaced. Should one desire a per- 
fect replacement, this can be done by snipping off the spurs on 
the fractured side of the flap sufficiently to accomplish the 
purpose. 



THE SURGICAL TREATMENT OF INTERNAL 
HYDROCEPHALUS.* 

BY RUSSELL S. FOWLER, M.D., 

OF BROOKLYN, NEW YORK, 

Chief Surgeon, German Hospital; Surgeon, Methodist Episcopal (Seney) 
Hospital. 

In internal hydrocephalus, from whatever cause, the free 
circulation of cerebrospinal fluid is mechanically interfered 
with. For the cure of this condition but two courses are open : 
either the free circulation of the fluid through its normal chan- 
nels must be restored by removing the obstructive cause, or a 
new channel must be provided by which the imprisoned fluid 
can find its way to the subarachnoid space or be carried to 
a part of the body where its continuous absorption can take 
place. 

The choice of which of these two courses to pursue will 
depend upon a study of the individual case in regard to the 
etiology and location of the obstruction. Before the results 
of the studies of Leonard Hill were made known (to whose 
studies concerning the pathology and physiology of the cere- 
bral circulation it is owing that to-day we can approach the 
cure of internal hydrocephalus with something approaching 
certainty) many unsuccessful attempts were made to get rid 
of the fluid. Single and repeated punctures of the lateral 
ventricles were made even so far back as the Roman era. As- 
piration with injections of iodine have been employed in some 
cases. In 1891 Quincke advocated single and later repeated 
lumbar puncture, withdrawing a small amount of fluid each 
time. In the same year Keen employed continuous external 
drainage in a single case; an interesting feature of this case 
being that the convulsions that followed the too rapid drain- 
age of the fluid were allayed by the distention of the ventricle 
with warm boric acid solution. None of these methods met 

* Read before the Brooklyn Surgical Society, December 3, 1908. 
374 



INTERNAL HYDROCEPHALUS. 



375 



with success. Subsequent to Hill's investigations, attempts 
at surgical treatment rested on a firmer scientific basis. In 
1898 Parkin trephined the occipital bone one inch below the 
superior curved line and to the right in order to free basilar 
adhesions and open the fourth ventricle; of four cases, two 
recovered. In March, 1898, Bruce and Stiles reported a case 
much improved after trephining the occipital bone in the 
median line just above the foramen magnum, tying the sinus 
in the falx, opening the dura and re-establishing the com- 
munication of the fourth ventricle. In the same year Miku- 
licz established drainage between the lateral ventricle and the 
subaponeurotic tissues of the scalp by means of a gold tube. 
The case died in six weeks. In a second case the same opera- 
tor established drainage between the lateral ventricle and the 
arachnoid space by means of a drain of glass wool. In this 
case the disease was arrested. In October, 1898, Souther- 
land and Cheyne reported two cases in which ventriculo- 
arachnoid drainage was established by means of catgut. In 
both cases the distention was relieved. One case died in three 
months from basilar meningitis; the second case was living 
six months after similar drainage was performed on the oppo- 
site side and was much improved. In 1903 Brewer operated 
on three cases, turning down an osteoplastic flap, opening the 
dura and forcing rubber tissue into the most dependent por- 
tion of the lateral ventricle, thus establishing ventriculo- 
arachnoid drainage. These cases died; one which lived six 
weeks showed a three-inch decrease in the circumference of 
the skull. In 1903 Nicholas Senn reported a case of sub- 
aponeurotic drainage in which the circumference of the head 
decreased two inches, the child dying on the ninth day. In 
1904 Taylor established ventriculo-arachnoid drainage in six 
cases with a bundle of chromic catgut surrounded with car- 
gile membrane: two cases were benefited: one markedly, 
physically and mentally, the other not so marked at the time 
of report as to afford much encouragement of subsequent 
improvement; three died as a result of the operation and one 
of intercurrent disease ten weeks after the operation. In 



376 RUSSELL S. FOWLER. 

1908 Gushing, in a preliminary note, mentions twelve cases in 
which he established permanent drainage between the spinal 
canal and postperitoneal connective tissue, using a silver tube 
and first determining the continuity of circulation between the 
lateral ventricles and the spinal canal. Both laparotomy and 
laminectomy are included in the operation. Without going 
into detail he reports a considerable measure of success. He 
also states that two previous attempts have been made to drain 
the subarachnoid space into the surrounding tissue, one by 
Quincke, who made a blind incision following lumbar punc- 
ture, the other by Essex Wynter, by performing laparotomy 
for this purpose. 

From a review of the foregoing methods and a con- 
sideration of the etiological factors it is clear that the chances 
for success in treatment depend entirely on employing an 
operation fitted to the individual case. Should the history of 
a case permit of the diagnosis of tumor so located as to occlude 
the fourth ventricle, following the demonstration of the arrest 
of circulation between the ventricles and spinal canal, a basilar 
exploratory operation is indicated even to the extent of remov- 
ing half of the cerebellum, should this prove necessary in 
order to reach the tumor (Frazier). Should the tumor be 
irremovable the operation will have helped the patient tem- 
porarily by relieving pressure. Later, if desirable, ventriculo- 
arachnoid drainage may be employed. Following meningitis 
adhesions may result at the base, shutting off the foramina 
of Magendie, Key and Retzius, thus causing distention of all 
the ventricles, or adhesions about the cerebellum may close the 
lower end of the fissure of Sylvius or ependymitis may close 
one or both lateral ventricles, or adhesion may occur at all 
these points. The first step in such cases would consist in 
determining whether or not there existed a communication 
between the ventricles and the spinal canal. If such is found 
to be the case Cushing's operation of connecting the spinal 
canal with the postperitoneal connective tissue should be per- 
formed. If such is not the case, ventriculo-arachnoid drain- 
age by Taylor's method may be done. If doubt is felt as 



INTERNAL HYDROCEPHALUS. 



377 



to the causative lesion an exploratory basilar operation may be 
performed and the causative lesion removed, if possible, or if 
not Taylor's operation done later. Before performing an 
exploratory operation on the base the tension of the fluid in 
the ventricles should be considerably and slowly lowered by 
preliminary puncture, for the sudden lowering of the tension 
by the escape of the fluid through a basal dural opening after 
raising up the cerebellum and separating the adhesions is apt 
to prove fatal. Following along the lines of thought set in 
motion by Keen's case, previously quoted, it may add an 
element of safety if, subsequent to suture of the basal 
dura, saline were introduced into the lateral ventricles to 
equalize the pressure of blood in the blood-vessels. 

Case I. — L. S., male, aged 8 months, parents healthy ; sister 
aged 4 years healthy. Was a full term baby ; instrumental deliv- 
ery. When the child was ii weeks old, the mother thought the 
head disproportionately large and consulted various physicians. 
The child was given mercury and potassium iodide for several 
months without effect. The head continued to enlarge, and the 
eyes became crossed. The child nursed regularly and except for 
the increasing size of the head, the internal strabismus, and the 
lack of the usual mental development was healthy. The case 
was referred to me April 26, 1908, by Dr. Burton Harris. My 
examination showed a well-nourished strong baby, without 
paralysis, who supported his enormous head well. The head 
measured 24 3^ inches in the fronto-occipital diameter. The 
parietal bones were separated from each other and from the 
frontal and occipital bones. The baby did not notice its sur- 
roundings nor grasp with its hands. There was marked internal 
strabismus. Operation was advised. On April 28, at the Ger- 
man Hospital, the left lateral ventricle was tapped at Kocher's 
point and 30 ounces of fluid was drawn. This resulted in a fall- 
ing in of the parietal bones but the frontal and occipital bones 
were not much affected, the fronto-occipital diameter being re- 
duced but one inch. A compressing and supporting dressing 
was applied. Examination of the fluid showed it to be faintly 
alkaline, with a trace of albumin and a large amount of chlorides. 
The fluid rapidly reaccumulated and at the end of forty-eight 



378 RUSSELL S. FOWLER. 

hours the head had assumed its former proportions. A hollow 
needle was now introduced into the left lateral ventricle at 
Kocher's point and a second needle into the spinal cord between 
the fourth and fifth lumbar vertebrae in order to determine if 
there existed a communication between the spinal canal and the 
ventricles. Closure of the open end of the needle in the ventricle 
caused a faster flow of fluid from the needle in the spinal canal. 
Only an ounce of fluid was withdrawn by the spinal needle in 
order to avoid the possibility of an accident such as happened in 
one of Cushing's cases, when the withdrawal of a large amount of 
fluid by spinal puncture resulted in a hernia of the brain into the 
foramen magnum with subsequent death. Two days later under 
warm ether anaesthesia the abdomen was opened, and the body 
of the fourth lumbar vertebra trephined, first displacing the aorta 
to the right, a specially small quarter-inch trephine on a French 
drill handle being used. On removing the small button of soft 
bone, spinal fluid in a good-sized jet immediately flowed from 
the opening. The abdomen was then closed. The after course 
was uneventful. The head under compression with adhesive 
plaster decreased to 22 1/^ in., but by the tenth day had increased 
to 23)4 inches. Tapping of the ventricle reduced the fronto- 
occipital diameter to 22^ inches; 15 ounces of clear fluid were 
removed. The vertex of the head did not present the dome- 
shaped appearance that was so pronounced before the operation. 
The internal strabismus was not so marked but still present. Dis- 
charged from the hospital May, 1908. On June 19, 1908, the ven- 
tricle was again tapped, as the head had increased to 24 J^ inches, 
and there was considerable tension at the anterior fontanelle. 
The strabismus was again marked. Eleven ounces were with- 
drawn. 

A second operation for the purpose of introducing a silver 
tube to permanently connect the peritoneal and spinal cavities was 
advised. This was done September 8, 1908. Head measurement 
24 inches. Under warm ether anaesthesia the abdomen was 
opried, the intestines displaced, the peritoneum over the aorta 
at its bifurcation incised and the aorta retracted to the right. 
No trace of the former trephine opening was seen. The body of 
the fourth lumbar vertebra was trephined into the spinal canal as 
shown by the escape of the spinal fluid, and the female half of a 
silver spinal-drain was introduced. (The spinal-drain consisted 



INTERNAL HYDROCEPHALUS. 379 

of two portions, one fitting snugly within the other, each ^ 
inch long, 34 inch calibre with a }i inch flange.) A laparotomy 
sponge was placed in the wound and the patient turned back 
uppermost. The spines of the third, fourth, and fifth lumbar 
vertebrae were exposed and the third and fourth removed with 
part of their laminse. The cord, quite well marked, was retracted 
with an aneurism needle and the male half of the drain intro- 
duced — one hand in the abdomen greatly facilitated this. It was 
not necessary to remove much of the laminae as by using retraction 
the canal could be quite well exposed. The wound in the back 
was closed. The tube was inspected through the abdominal 
wound and seen to be draining. The abdominal wound was 
closed. The after course was uneventful. September 12, 1908, 
head measurement 23% inches; September 24, 24 inches. The 
strabismus was much less marked and the child evinced interest 
in its surroundings. There was an entire absence of tension in 
the fontanelles. The top of the head became flattened. Dis- 
charged September 27, 1908. Final examination December i, 
1908, showed: No return of strabismus; child active, mentally 
and physically; vertex flat; no tension; fronto-occipital measure- 
ment 24 inches. The disease seems to be arrested. The child 
is normal for its age in every way except the size of the head. 
This, however, has not increased in the past two months. 

Case II. — J. H., male, aged 5 months, parents syphilitic; 
referred by Dr. John Horni. The child was well until 2y2 
months old (but was not bright), when the mother noticed that 
the head seemed to be larger than normal and the eyes rolled from 
side to side. The head continued to increase in size. When seen 
by me September 7, 1908, the patient presented the typical appear- 
ance of hydrocephalus; there was nystagmus; no paralysis; the 
baby was very stupid. Operation was advised and the patient 
was sent to the Methodist Episcopal Hospital. On September 9, 
1908, free communication between the ventricles and the spinal 
canal was determinated in the usual manner. September 14, the 
lateral ventricles were tapped and 10 ounces of fluid withdrawn. 
On September 17, Cushing's spinal peritoneal anastomosis with a 
silver tube was done. September 18, 1908, the head had decreased 
}i of an inch; September 20, the head had increased in size to 
2054 inches. September 11, spastic flexion of the forearms and 
spastic extension of the feet were noted. September 22, the 



38o RUSSELL S. FOWLER. 

spastic condition continued. This was not relieved by ventricular 
puncture and removal of 3j^ ounces of fluid. September 24, as 
the spastic condition still persisted and the baby was semicomatose, 
further operation was undertaken as a last resort. Puncture of 
the spinal canal above the tube level not being followed by any 
fluid, it was thought perhaps the pressure of the fluid in the skull 
had crowded the cerebellum into the foramen magnum and so 
shut off the free communication which had been previously 
demonstrated. The ventricles were punctured and 12 ounces 
of fluid withdrawn. Cushing's decompression operation was done 
on the base of the skull, removing half of the foramen magnum. 
The dura was incised, and the following condition disclosed ; there 
was no obstruction of the foramen magnum ; there was a de- 
ficiently developed brain held to each side of the skull by the 
lining of what would under normal conditions have been the walls 
of the ventricles ; the cerebellum was represented by two masses 
about the size of a hazelnut to either side and several inches from 
the foramen magnum; there was no connection between the two 
halves of the brain save at the medulla; this large central cavity, 
representing all the ventricles, was smooth and contained about 
20 ounces of fluid, part of which escaped through the opening 
in the dura. It was decided that nothing further could be done 
as the stoppage was in all probability a plastic inflammation of 
the spinal cord and membranes at some point above the tube. 
The wound was closed. The patient's condition continued bad 
and death intervened ten hours later. The fact of particular 
interest in this case, is the occurrence of an adhesive inflammation 
above the tube in the spinal canal taking place some days after 
operation and preventing drainage. This has not hitherto been 
noted as a complication in these cases. 

Case III. — P. C, male, aged 9 months (referred by Dr. 
Aronson), was well until 6 months old when he suffered an attack 
of cerebrospinal meningitis. On examination the head was found 
enlarged, fontanelles distended, head measurement 18^ inches; 
baby apathetic, poorly nourished and unable to support the head. 
Operation advised and case sent to Methodist Episcopal Hospital. 
On September 21, 1908, it was determined in the usual manner 
that there existed no communication between the ventricles and 
the spinal canal. Several ounces of fluid were removed from the 
lateral ventricle. September 24, Cushing's basilar decompres- 



INTERNAL HYDROCEPHALUS. 381 

sion operation was performed with the idea of freeing the adhes- 
ions around the cerebellum and base which interfered with the 
free circulation of cerebral fluid. The condition was demon- 
strated, the adhesions below, in front, and to the lateral aspects of 
the cerebellum freed, a probe passed along the fissure of Sylvius, 
and a free discharge of cerebrospinal fluid obtained. The dura 
was sutured and the soft parts about to be closed when the patient 
expired without warning, 

BIBLIOGRAPHY. 

1896. Leonard Hill : The Physiology and Pathology of the Cerebral Cir- 
culation, London. 

1898. Bruce and Stiles : Scottish Med. and Surg. J., March. 

1898. Southerland and Cheyne : Brit. Med. J., Oct. 15. 

1891. W. W. Keen: Surgery of the Lateral Ventricles; Verhandlungen, 
des Zehnte Internatt. Medicinischen Congress, 1891, Bd. 3. 

1903. Brewer: Text-book of Surgery. 

1903. Nicholas Senn: International Clinics, vol. i, ser. 13. 

1904. A. S. Taylor: Am. Jour. Med. Soc, vol. 128. 
1908. H. Cushing: Keen's Surgery, Phil, and London. 



OPERATIONS INVOLVING FREE OPENING OF 
THE THORAX. 

INFLATION OF THE COLLAPSED LUNG WITH OXYGEN AT THE MOMENT OF 
CLOSING THE CHEST CAVITY AFTER OPERATION. 

BY A. E. ROCKEY, M.D., 

OF PORTLAND, OREGON. 

The simplicity and effectiveness of this procedure was so 
well demonstrated in the following case, that it is reported 
with the belief that its further use may be of value in opera- 
tions involving the opening of the thorax. 

Case. — Sarcoma of wall of thorax; excision of tumor-bearing 
portion of thorax wall and diaphragm; successful attempt to 
inflate collapsed lung with oxygen; recovery. 

Man aged 52 sustained a fracture of the middle of the tenth 
rib on the right side a year ago. After several months a growth 
was noticed over the site of the injury. It increased steadily and 
was treated by various domestic applications until it attained 
the size of a goose-egg, when he consulted a physician who 
diagnosed it sarcoma, and sent him to me for operation. 

Colonic anaesthesia was given by the oxygen-ether method of 
Cunningham as modified by Leggett and used at the Roosevelt 
Hospital. 

Warned by one nearly fatal experience of over-etherization 
at the time the change was made from the inhalation anaesthesia 
to the rectal, I adopted the recently-announced plan of Klapp, 
the sequestration of unetherized blood in the lower extremities 
by placing elastic bands about the upper part of the thighs before 
etherization is commenced. It proved fortunate, too, that we 
had this reserve, for after the beginning of the operation and 
before the chest was opened the patient became cyanosed, breathed 
badly, and his pupils were widely dilated. 

Loosening of the bands to liberate the unetherized blood re- 
lieved the condition at once, and the rectal anaesthesia was con- 
tinued with caution, using very little ether, and with entire 
satisfaction to the conclusion of the operation. 
382 



OXYGEN INFLATION OF COLLAPSED LUNG. 



383 



The tumor, which on the inside was larger than a man's 
fist, was excised with the entire thickness of the chest wall, in- 
cluding an elliptical piece of skin over the most prominent part, 
about six inches of the eighth, ninth, and tenth ribs, with the 
pleura and a portion of the diaphragm about two inches wide 
in the centre and six inches long, and the adjoining part of the 
abdominal muscles and the peritoneum. The peritoneum over 
the inner side was lightly adherent to the liver by a plastic 
adhesion that did not bleed when it was detached. 

In closing, the diaphragm was firmly sutured to the chest 
wall with a continuous suture of heavy catgut. Before the last 
inch of the incision was closed, the tube from the oxygen cylinder 
was introduced into the nostril with only an intervening pres- 
sure-regulating bulb like the second bulb on a Paquelin cautery. 

The other nostril and the mouth were closed by the hand and 
the oxygen turned in, with the result that the residual air in the 
pleural cavity hissed through the unclosed part of the incision 
until the lung was filled. Finger pressure by the assistant on the 
under surface of the diaphragm closed the pleural cavity until 
the remaining stitches were introduced. 

The inflation of the lung required only a very short time, 
seemingly less than a minute. Immediately after the conclusion 
of the operation normal breath sounds were heard over the en- 
tire lung, and there were no physical signs of pneumothorax. 

There were several features present in this operation that 
are worthy of special mention. Opening of the right chest 
cavity with consequent collapse of the right lung was not 
attended by any disturbance due to embarrassment of respira- 
tion, which was, of course, subsequently carried on entirely by 
the left lung. 

How much the oxygen used in the rectal anaesthesia con- 
tributed to the general oxygenation of the blood must be left 
to the surgical laboratories to determine by animal experi- 
mentation. 

As the chest cavity and the abdominal cavity were open 
simultaneously, and as colonic anaesthesia was used, the in- 
flation of the colon was readily observed. The distention was 
moderate and at no time did it give trouble by protrusion into 



384 A. E. ROCKEY 

the field of operation, being readily retained by a large moist 
gauze pad held under the hand of an assistant. 

The inflation of the lung with oxygen was done without 
any attempt to prevent the entrance of gas into the stomach, 
either by intubation of the larynx or introduction of a tampon 
into the oesophagus. 

It is, of course, self-evident that without such aids, if the 
inflation had been continued, the stomach would also have been 
distended. 

It is of important interest to note that the lung was 
filled, pushing the air out of the pleural cavity before dis- 
tention of the stomach occurred. This simple and almost 
momentary procedure must prove of great value in chest 
operations, when the more complicated apparatus for positive 
pressure-inhalation is not accessible. 

The exact time of the operation was not noted, but the 
assistant who managed the colonic anaesthesia and then trans- 
ferred the oxygen-tube to the nostril thinks that the time from 
the opening of the chest cavity until the last stitch fastening the 
diaphragm to the chest wall was tied was about twenty minutes. 

The patient made an uncomplicated recovery. The micro- 
scopical diagnosis was large round-celled sarcoma. The rough 
ends of the fractured rib without any attempt at callus formation 
projected into a degeneration cavity in the interior of the tumor. 



THE VALUE OF THE LEUCOCYTE AND DIFFEREN- 
TIAL COUNTS IN APPENDICITIS/ 

BY GEORGE N. PEASE, M.D., 

OF NEW YORK. 
Interne, Presbyterian Hospital. 

A GOOD many papers have appeared recently in regard 
to the value of the blood counts in appendicitis. So far we 
do not seem to have reached any definite conclusions as to 
what part of the blood count will enable us to judge most ac- 
curately of the pathological lesion present. To add to the 
data already published, and to see how the cases in this hos- 
pital compare with those already presented is the purpose 
of this paper. 

The following series of 300 cases is taken from the 
services of Drs. McCosh and Eliot in this hospital. They 
are the last 300 cases operated on in this hospital. All the 
cases presented went to operation, and in each case a definite 
determination of the pathological lesion was possible. In 
almost all of the cases the blood counts were taken on the 
day of the operation, or the day before the operation, and 
no count dates back more than 24 hours previous to the 
operation. 

The leucocyte counts in each case were made by the 
junior surgical interne in the hospital. The differential counts, 
on the other hand, were practically all made by the pathologi- 
cal interne, and were therefore counted by the same individ- 
ual, which, in a series of cases like the present, should make a 
very reliable comparison of the different cases. 

The following classification was adopted as best group- 
ing and indicating the pathological lesions present : 

1. Chronic appendicitis, including acute cases that have 
subsided and all interval cases. 

2. Simple acute appendicitis, — cases presenting signs and 
symptoms of an acute process localized to the appendix itself, 
but without gangrene. 

385 



386 



GEORGE N. PEASE. 



3. Acute gangrenous appendicitis, — simply a further de- 
velopment of acute appendicitis. 

4. Appendicitis with abscess formation, — cases with 
pus walled off about the appendix. 

5. Appendicitis with local peritonitis limited to the region 
of the appendix, or spreading to neighboring regions such as 
the pelvis, but not yet general. 

6. Appendicitis with general peritonitis. 

TABLE I * 



Variety 





Average 


Number of 


number of 


cases 


polynuclear 




leucocytes 


63 


69 f. 


47 


77% 


28 


85% 


14 


88% 


lOI 


88% 


47 


89% 



Average 
number of 
leucocytes 



Chronic 

Simple acute 

Gangrenous 

With abscess 

With local or spreading peritonitis. 
With general peritonitis 



I2,9CO 

14,700 
19,400 
22,200 
21,100 
21,800 



*This shows the number of cases of each variety of apjjendicitis in this series, and the 
average number of leucocytes and polynuclear cells present in each class of cases. 

The above table shows, as we have already learned to 
expect, that the more severe the pathological lesion the higher 
is the leucocyte count, and the higher the percentage of poly- 
morphonuclear cells in the differential count. An apparent 
exception to this is the leucocyte count in appendicitis with 
localized abscess, as compared with the count in cases with 
general peritonitis. In case of abscess, the average leucocyte 
count was a little higher than in general peritonitis, yet we 
classify general peritonitis as a much more severe lesion. The 
explanation of this probably lies in the fact that in many cases 
of general peritonitis the infection was so virulent that it 
completely overwhelmed the bodily resistance, and there was 
no reaction to the invasion. For example a good many of 
the cases of general peritonitis gave counts like the following : 

Leucocytes, 5,000 Polynuclears, 71 per cent. 

Leucocytes, 8, 100 Polynuclears, 68 per cent. 

Leucocytes, 7,500 Polynuclears, 79 per cent. 



VALUE OF BLOOD COUNT IN APPENDICITIS. 



387 



Such count would, of course, greatly reduce the general 
average leucocyte and polymorphonuclear counts in the cases 
of general peritonitis. 

TABLE 2* 



Variety 



Under 


10,000 


15.000 


30,000 


25,000 


10,000 


to 

15,000 


to 

30,000 


to 

25,000 


to 
30,000 


20 


23 


16 


I 


3 


II 


15 


II 


7 


I 


2 


6 


10 


6 


3 


I 


3 


2 


4 


2 


5 


16 


29 


29 


9 


4 


II 


10 


^ 


3 



Over 
30,000 



Chronic 

Simple acute 

Gangrenous 

With abscess 

With local or spreading peritonitis . 
With general peritonitis 



o 

I 
I 
2 

13 
II 



♦This shows the leucocyte counts in the individual cases of the six varieties of appendi- 
citis mentioned above. 

From the above table (Table 2) we see that it is im- 
possible to decide upon the pathological lesion present from 
the leucocyte count alone. For example, we have 20 out of 63 
cases of chronic appendicitis with leucocyte counts of over 
15,000, and 21 out of loi cases of localized or spreading 
peritonitis, and 15 out of 47 cases of general peritonitis with 
leucocyte counts under 15,000, — the latter two varieties, of 
course, being much more severe lesions, should, if the rule 
were absolute, have leucocyte counts far above 15,000. Practi- 
cally all that can be said from the leucocyte counts alone is, 
that the majority of cases with leucocyte counts of over 15,000 
are severe cases, and the majority of cases under 15,000 are 
mild cases, but there are many cases of both types that do not 
conform to this rule. 

TABLE 3* 



Variety 



Under 

75 
percent 


75-80 


80-85 


85-90 


90-95 


Over 


per cent 


percent 


percent 


percent 


95 
percent 


41 


II 


8 


2 


I 





17 


9 


7 


II 


3 





5 





6 


II 


5 


I 





I 


4 


5 


2 


2 


4 


10 


16 


27 


36 


8 


4 


4 


4 


19 


13 


3 



Total 
cases 



Chronic , 

Acute 

Gangrenous , 

Abscess 

Local or spreading peri- 
tonitis , 

General peritonitis 



63 
47 
28 

14 

lOI 

47 



* This shows the percentage of polynuclear cells in the individual cases of the different- 
varieties of appendicitis. 



388 GEORGE N. PEASE. 

On examining Table 3, we find that we can judge much 
more accurately of the pathological lesion present from the 
polynuclear count than from the leucocyte count. We see 
that practically two-thirds of all the more severe cases show 
a polynuclear count of over 85 per cent. By the more severe 
cases we mean the last four varieties in the table, — namely, 
(i) gangrenous appendicitis; (2) appendicitis with abscess; 

(3) appendicitis with localized or spreading peritonitis; and 

(4) appendicitis with general peritonitis. And we see that 
cases with a polynuclear count of over 90 per cent, are cases 
with peritonitis either localized, spreading, or general. 

Cases with a polynuclear count below 80 per cent, we 
see are, as a rule, cases of chronic and simple appendicitis. A 
few cases with peritonitis come below 80 per cent., and these 
are the exceptional cases which we cannot classify by any 
method. Between 80 and 85 per cent, we find a number of 
cases of all varieties, and it only seems possible to designate 
cases in this column as " doubtful." 

Our conclusions then from Table 3 would be : 

1. A polynuclear count between 85 and 90 per cent, 
indicates the presence of a severe process. 

2. Above 90 per cent, a dangerous condition probably 
complicated by peritonitis. 

3. Below 80 per cent., safety for the time being. 

4. Between 80 and 85 per cent., doubt. 

5. These rules hold good for about four-fifths of this 
series of cases, there being many exceptions to each rule. 

It is not the object of this paper to form any definite 
rule by which we can tell from the blood count when to operate 
and when not to operate in a given case of appendicitis. In 
fact, one point and probably the most important that this in- 
vestigation has taught the writer is, that it is impossible to de- 
cide from the blood count alone what pathological condition we 
shall find, or even to determine whether the case is severe or 
not. There are many exceptions, and these we must learn to 
Interpret by other means at our command. 

One of the most recent methods and one which has 
aroused more investigation along the line of the value and 



VALUE OF BLOOD COUNT IN APPENDICITIS. 



389 



interpretation of the blood count in appendicitis, is that sug- 
gested by Dr. C. L. Gibson, of New York City (Annals of 
Surgery, April, 1906, " The Value of the Differential Leu- 
cocyte Counts in Acute Surgical Diseases"). He advanced 
the idea that the relation between the total leucocyte count 
and the percentage of polymorphonuclears gave the most 
valuable information. Ten thousand leucocytes with 75 per 
cent, of polymorphonuclears was taken as a base line repre- 
senting the normal relation. For every rise of 1000 leucocytes 
there should be a corresponding rise of i per cent, of poly- 
morphonuclears to maintain the normal relationship. Lines 
were drawn from the leucocyte count to the polynuclear 
count and designated as horizontal, rising, or falling lines 
according to the relationship between the leucocyte and the 
polynuclear count. In brief he says : " If the line connect- 
ing the levels of the leucocyte count and the polymorpho- 
nuclear count runs pretty near horizontal, — whether up or 
down, — with only 2 to 4 points difference, it indicates that a 
lesion whether severe or not is well borne, and therefore of 
good prognosis. If the difference of level between the two 
points is considerable, say 10 or more units, we are quite sure 
to have a pretty severe lesion." 

The following table (Table 4) gives the result of apply- 
ing Dr. Gibson's method to our series of cases. 

TABLE 4* 



Variety 



Rising; 
line 


Falling 
line 


Horizon- 
tal line 


Rising line 
five units 
or more 


13 


41 


9 


3 


M 


15 


8 


9 


14 


10 


4 


7 


9 


5 





5 


58 


37 


6 


36 


23 


23 


I 


19 



Total 
cases 



Chronic 

Simple acute 

Gangrenous 

With abscess 

Spreading or local peritonitis. 
With general peritonitis 



63 

47 
28 

14 
101 

47 



*To explain the totals: it must be remembered that the cases in column four, namely those 
showing a rising line of five units or more are included in column one, namely, those cases 
showing a rising line. 



On examining Table 4, we see that the conclusion sug- 
gested by Dr. Gibson holds good in only about one half of the 



390 



GEORGE N. PEASE. 



cases of this series, — for example, of the 47 cases of general 
peritonitis, only 19, or less than half, showed a rising Hne of 
over five units, which is supposed to indicate a pretty severe 
lesion. Twenty-three of the cases of general peritonitis 
showed, on the other hand, a falling line, and this is supposed 
to indicate a mild process. Yet we must admit that no case 
of general peritonitis is considered a mild process. Again 
only 58 or a trifle over one-half of the loi cases of localized 
or spreading peritonitis showed a rising line, and of these 58, 
only 30 showed a rising line of over five points. In other 
words, less than one-third of the cases of localized or spread- 
ing peritonitis would be considered severe cases according to 
Dr. Gibson's chart, and more than two-thirds of the cases 
would be considered cases of good prognosis. By far the 
greater part of these cases, however, proved on the operating 
table to be severe cases. 

Dr. R. H. Fowler, of St. Luke's Hospital, in this city 
{Surgery, Gynecology, and Obstetrics, September, 1908, 
" The Relation of Appendicitis to the Leucocyte Count ") 
reports 278 cases of appendicitis. After a thorough examina- 
tion of these cases, he comes to the conclusion that the stand- 
ard chart of Dr. Gibson offers the best method. 

Dr. Noehren, of the German Hospital, this city (Annals 
OF Surgery, February, 1908, " The Value of the Differential 
Leucocyte Count in Acute Appendicitis"), reports 69 cases. 
He concludes that the estimation of the percentage of poly- 
morphonuclears alone is more reliable than any method that 
has so far been suggested — also, that a polymorphonuclear 
percentage of 90 per cent, or more indicates a severe process 
that calls for immediate operative interference; a percentage 
below 78 per cent, means a " safe," or mild process ; a per- 
centage between the two extremes speaks for the one condition 
or the other, according as it approaches the one extreme or 
the other. 

With the first conclusion, — namely, that the percentage 
of polymorphonuclears is the most reliable method, — the con- 
clusions reached in this paper agree; but with the second 



i 



VALUE OF BLOOD COUNT IN APPENDICITIS. 391 

conclusions, — namely, that operation is indicated, or not indi- 
cated, according as the percentage of polymorphonuclears is 
above 90 per cent, or below y^ per cent., — we cannot agree. 
It may hold good in a certain number of cases, but the larger 
the series the more exceptions occur, and it seems best not to 
draw any hard or fast rules from our blood counts. 

The writer wishes to thank Drs. McCosh and Eliot for 
permitting him to use their cases as material for this article. 



TYPHOID FEVER WITH MULTIPLE PERFORA- 
TIONS, REPEATED OPERATIONS FOLLOWED 
BY ULTIMATE RECOVERY. 

BY ALBERT J. ROBERTS, M.D., 

OF BRIDGEPORT, CONN., 
Assistant Surgeon to the Bridgeport Hospital. 

D. N. P., male, 17 years old, was seen at his home on 
August 17, 1908. He had been ill two days. His pulse was 84 
and temperature 102°. Although he lived in the country the sur- 
roundings of his home were very unsanitary. He was fairly de- 
veloped but poorly nourished. Physical examination was 
negative. 

Fever persisted and three days later he entered the Bridge- 
port Hospital. On entrance he had a negative Widal, but on 
August 26, the eleventh day of the disease, his spleen was easily 
palpable and Widal positive. The treatment was dietetic with 
sponge baths when the temperature was over 103°. There was 
no delirium and the course was uneventful until September 4, 
the twentieth day. At noon he felt as well as usual, and at 1.30 
he had a natural bowel movement. At two o'clock he complained 
of dull pain in the lower abdomen, not localized. Dr. A. J. Men- 
dillo, House Physician, reported this by telephone, and kept the 
patient under constant personal observation from that time. 
Immediately afterward he had a chill which lasted thirty minutes. 
The pain continued. The pulse was of good quality, but intermit- 
tent at times. Rate 78. He was tender three inches above the 
pubes a little to the right of the median line. There was no mus- 
cular rigidity and no distention. The abdomen was dull for three 
inches above the pubes and in the right flank. Liver dulness 
normal. 

Patient was catheterized and four ounces of urine obtained. 
Area of dulness remained unchanged. He had the characteristic 
facies of acute peritonitis. At 5.40 o'clock, under ether, an incis- 
ion was made through the right rectus below the umbilicus. On 
opening the peritoneum the small intestines were found injected 
and the mesenteric glands swollen and enlarged. A loop of ileum 
392 



MULTIPLE TYPHOID PERFORATIONS. 393 

was delivered and followed down, each portion being returned 
to the abdomen as soon as examined. About fifteen inches from 
the ileocaecal valve a perforation, the size of an ordinary slate 
pencil, through a Peyer's patch was found, purse-stringed and 
Lemberted with fine silk. The rest of the small intestine was 
whole though the Peyer's patches were swollen and injected. A 
considerable amount of liquid contents had leaked into the peri- 
toneal cavity. This was sponged dry and drained with rubber 
tubing through a counter opening in the right lower quadrant 
opposite the repaired gut. The original incision was closed in 
layers. The patient made a good recovery from ether. 

For several days there was a copious serous discharge 
through the tube. As this lessened the tube was shortened daily 
and finally left out. His bowels moved regularly until September 
14, ten days after the operation, when he showed signs of obstruc- 
tion, temperature rose and relapse was feared. 

The stitches were removed from the median incision on the 
following day and faeces allowed to discharge from a second 
perforation. 

During the night of September 17, the patient began to vomit. 
His temperature at this time was 100.6° and pulse 82, both of 
which dropped the following morning. As he was now tender 
with some rigidity in the left lower quadrant, it was thought 
best to explore for pus. Under local cocaine an incision was 
made in the left lower quadrant and the diagnosis confirmed. 
Ether was then given, a counter opening made in the left flank, 
and rubber-tube drain inserted. Both wounds were left open. 
On the third day faeces were discharged through the drainage 
tube, and for several days, whenever an enema was given, most 
of it came out through the left flank wound. 

The patient was now starving to death and regular solid diet 
was begun. This was supplemented by cod-liver oil inunctions 
daily. On September 28, a localized, dull, tender area appeared 
in the epigastrium midway between the umbilicus and the ensi- 
form, accompanied by vomiting and pain. Another operation 
was considered, but fortunately the abscess drained spontaneously 
by the opening in the left lower quadrant. From then on the 
convalescence was uninterrupted. 



ANGEIORRHAPHY. 

SUTURE OF A DOUBLE STAB WOUND OF THE FEMORAL ARTERY AND VEIN.* 

BY FRED. B. LUND, M.D., 

OF BOSTON, MASS. 

Miss M., aged 14 years, was seen in consultation with Dr. 
E. Frederick Murphy on March 31, 1908. She was a healthy 
little girl, who, nine days before, had met with the following in- 
jury. She was getting the meat out of a cocoanut with the large 
blade of a jack-knife, when the knife slipped and penetrated the 
mner side of the left thigh just below the middle, making a small 
puncture and nearly burying the knife-blade. The wound at first 
bled rather freely, but the bleeding was stopped by her brother, 
who boiled a rag and stuffed it in the wound. She remained in 
bed after the injury, the thigh swelled somewhat, and seven days 
later there was a profuse hemorrhage from the wound. Dr. 
Murphy, who was called, found localized swelling around the 
wound; he applied an antiseptic dressing and on March 31 called 
me to see her. 

I found a small wound just below the middle of the left 
thigh; a pulsating timior could be seen and felt surrounding it. 
There was a distinct thrill on palpation, suggesting arterio- 
venous aneurism. The pulsation in the left dorsalis pedis was 
markedly less than in the right. The foot was warm and there 
was no swelling of the lower leg or foot. 

Operation. — The next morning an incision was made over the 
tumor and as soon as the blood clot was expressed there was a 
smart gush of blood from the femoral artery. A tourniquet was 
applied. The femoral artery was dissected out from the upper end 
of Hunter's canal and found to present an oval opening one- 
quarter of an inch long in the front of the artery and a smaller 
slit in the back of the artery. There was a slit in the front of 
the femoral vein, which did not gape, however, on account of 
the weakness of the circular fibres. There was a small slit in the 
back of the vein (Fig. i ) . The artery was lifted out of the way by 

* Read before the Boston Medical Library and the Surgical Section 
of the Suffolk District Medical Society on January 6, 1909. 

394 



ANGEIORRHAPHY. 



395 



a loop of gauze, and the openings in the vein sutured, cxx) silk 
sutures were used and No. 14 sewing needle; mattress sutures 
were employed. They were passed through all the coats of the 
vessels, so as to evert the edges and bring intima to intima, leav- 
ing the least possible silk in contact with the blood current. 
Then the posterior slit in the artery was sewn, and, last of all, 
the oval opening in the front of the artery was sutured; five or 

Fig. I. 




Stab wounds of femoral artery and vein in Hunter's canal (left leg). A, femoral artery 
drawn aside to expose femoral vein; B, femoral vein; C, sartorius muscle; D, adductor mag- 
nus muscle. The perforations on the outer aspect of both vein and artery are indicated in 
white. The perforations on the inner aspect are indicated in black. (From pen and ink 
drawing made by Dr. H. B. Smith, who attended at the operation.) 

six sutures were required for this, and when the suture was 
completed, the opening being closed parallel to the axis of the 
vessel, the lumen was somewhat narrowed. On removing the 
tourniquet there was bleeding from two points, at either end of 
the anterior suture. Crile's clamps were applied to the artery 
above and below and these openings closed by two more sutures. 
The sartorius muscle was allowed to fall into place and the skin 
sutured with silk-worm gut. A rubber tissue drain was placed, 
and left in for twenty-four hours. A few moments after the 
operation there was slight pulsation in the dorsalis pedis. The 



396 FRED B. LUND. 

foot was swathed in absorbent cotton, and on April i6 the 
circulation in the foot was good. There was at no time any 
oedema of the foot or ankle, although at first it seemed as if the 
foot was a little blue. The case was shown May 2 and slight 
pulsation could be distinctly felt in the dorsalis pedis. In October, 
1908, six months later, the little girl, who is now living out of 
town, was reported to be perfectly well. 

The case is reported as one in which recent progress in 
the technic of arterial suture has undoubtedly saved the leg 
and foot of a patient. Ligation of either the artery or vein 
in Hunter's canal might not perhaps have resulted in gangrene 
of the foot; but ligation of them both, as would have been 
necessary had we not been prepared for arterial suture, would 
have imdoubtedly had this result. The absence of subsequent 
phlebitis makes it evident that the lumen of the vein healed 
without thrombosis. The early return of pulsation indicates 
the same result in the case of the artery. A very similar case 
has been recently reported by Harry M. Sherman,^ of San 
Francisco, with a similar result. His report is a good one and 
well worth reading. 

To anyone but an antivivisectionist, it would seem as if 
the saving of the limbs of this girl and boy were worth the 
sacrifice of the temporary comfort or perhaps occasionally the 
life of a few dogs and cats. For we are compelled to acknowl- 
edge that our knowledge of the technic of blood-vessel suture 
is due to animal experimentation. The lateral and circular 
sutures of blood-vessels are among the simplest problems con- 
sidered in the great field of arterial surgery, a field to which 
American surgeons have contributed much. The pioneer work 
of Dr. Matas will always remain a monument to him and to 
American surgery. Not only his operative skill, but his rare 
enthusiasm and thorough scholarship have combined to arouse 
the interest of surgeons all over the world in the work, and 
his operation has become the standard treatment for aneurism 
the world over. 

' California State Medical Journal, February, 1908. 



ANGEIORRHAPHY. 3^7 

Of the more complicated procedures in the fascinating 
field of arterial surgery — such as the transplantation of organs, 
the replacement of severed limbs, and the like — procedures 
which in the hands of such men as Carrel, Guthrie, and others 
have opened up almost limitless possibilities for the future, I 
have not the time to speak. With the exhaustive articles of 
Watts, Carrel, Sweet, and others, to which references are 
found at the end of this paper, we are all familiar. 

It is my intention to take up only a few of the simpler and 
more practical points which interest us as surgeons, who may 
be called upon to treat accidental wounds or complete divisions 
of arteries and veins. Personally having had no opportunity 
to suture a completely divided artery, my previous experience 
has been limited to a suture of the axillary vein torn in the 
removal of a malignant growth (the rent being closed by 
three everting sutures, with excellent result), and lateral liga- 
tions applied to the injured internal jugular vein, which have 
also proved satisfactory. An operation for arteriovenous 
anastomosis of the femoral artery and vein, however, has given 
me an opportunity to compare an end-to-end suture in an 
accessible location, Scarpa's triangle, with the lateral suture in 
Hunter's canal, and I have no hesitation in saying that the 
former is the easier procedure. The depth of the dissection 
and the consequent difficulty in accurately placing the sutures 
in the under side of the vein readily account for this. I should 
in the future approach an end-to-end suture in an accessible 
location without great anxiety as to success. 

The matter of temporary haemostasis is important. When 
possible in wounds of the artery a tourniquet should be em- 
ployed. In this case, intending to employ Crile's clamps in 
the belief that less collateral vessels would be cut off, I thought 
I could dissect above and below the opening sufficiently to apply 
them while the opening was plugged by the blood clot in and 
about the wound. As soon as the pressure of the skin and 
muscles was removed, however, the blood stream forced out 
the clot, and I had to put on the tourniquet in a hurry. After 
the suture had been completed, however, the clamps came in 



398 FRED B. LUND. 

handily for the application of the two extra sutures which 
were necessary owing to leakage between the sutures already 
placed in the artery. Here the re-application of the tourni- 
quet would have taken too much time and disturbed the opera- 
tive field too much, while the clamps were easily slipped on. 
Hsemostats or purely metallic clamps are out of the question on 
account of the danger of wounding the intima. Finger pres- 
sure, which has been recommended as the safest method, is not 
to be preferred because fingers take up too much space and 
get tired. A clamp with a screw and guarded by rubber, such 
as Crile's, and carefully applied, is the method of choice when 
the tourniquet cannot be used. 

The point which stands out in a review of both the experi- 
mental and the clinical work which has made possible the 
suture of blood-vessels, is the importance of the avoidance of 
thrombosis. It may be of interest to know that the first 
successful closure of a wound in an artery was made in 1759 
by Hallowell, an English surgeon, who closed a small wound 
in the brachial artery by placing a pin through the lips of the 
wound and passing a thread around it. In pre-antiseptic days, 
as was to be expected, little success was attained, nor were 
the earlier experimenters in the antiseptic era much more suc- 
cessful — Gliick in 1881 and others till 1889 — when Janissowski 
first proved by publishing the results of his experiments that 
arterial wounds could be sutured with preservation of the 
lumen of the vessel. Janissowski used interrupted sutures of 
fine silk and did not penetrate the intima, in order to avoid 
the presence of suture material in the interior of the repaired 
vessel, which might favor thrombosis. Later, Murphy, in 
1897, published his experiments, recommending avoidance 
of the intima, as also did Silberberg. In 1899, Dorfler rec- 
ommended the use of sutures penetrating the intima, and since 
then this has been the method of choice. Mattress sutures, 
either continuous or interrupted, may be used, and proved 
satisfactory in this case. The idea was to approximate firmly 
intima to intima, just as in intestinal suture endothelium is 
brought in contact with endothelium. This method is just 



ANGEIORRHAPHY. 399 

the reverse of the Connell intestinal suture — the arterial wall 
is everted, the intestinal wall inverted. In circular sutures, 
however, Carrel has shown that by taking three guide sutures 
and by them holding the vessel wiall on the stretch, enough 
eversion may be attained by a simple running continuous suture 
of the intervening spaces. This is very quickly and neatly 
performed, and his experiments demonstrate that thrombosis 
does not occur. 

Successful sutures of accidental wounds of arteries in man 
have been reported by Heidenhain, Israel, Sabanayeff, Orlow, 
Lindner, Garre, Seggel, Veau, Heinlein, Baum, Torrance, 
Sherman, and others. Successful circular sutures of divided 
arteries have been reported by Murphy, Djemil Pascha, 
Krause, Kummell, Payr, Brougham, and others. Murphy's 
invagination method of circular suture, while ingenious and in 
his hands successful, has not been generally accepted, since it 
has been found that by careful suture without invagination 
and consequent doubling of the thickness of the vessel wall, 
leakage can be prevented. 

After the completion of a suture, pressure with a sponge 
for a short period will stop leakage from stitch holes, owing 
evidently to the formation of small thrombi. Leakage between 
the stitches which does not stop by pressure for a short time 
may be stopped by placing one or two additional sutures, as 
I found both in this case and in my case of arteriovenous 
anastomosis. Dr. Sherman points out that while the ideal 
suture would be both blood and water tight and not depend 
upon clotting, such ideal suture could not be attained, because 
if tied " water tightly," so to speak, the suture would cause 
necrosis of the tissues in its bight. Some clotting must evi- 
dently take place to close the little cracks, because the function 
must be taken up at once, without an enforced period of rest 
for healing. 

Thrombus formation in animal experiments, according to 
Carrel, is usually due to sepsis, and he thinks a " stricter 
asepsis " is required for vascular operations than others. 
Sweet rightly objects to discussion of the degrees of asepsis. 



400 FRED B. LUND. 

Asepsis either is or is not, and partial asepsis does not exist. 
Asepsis, I think, rarely exists, and we have always known that 
in the presence of blood clot a higher degree of care is neces- 
sary to get primary union than in wounds in which the sur- 
faces are not kept apart by that most excellent culture 
medium, a bit of thrombus. Inasmuch as in this operation we 
employ blood clot to calk our suture lines, it must always be 
there, and I am inclined to think Carrel is right in saying a 
special effort at asepsis should be made, in order to avoid 
the secondary clotting which would accompany infection, 
although a certain amount of primary thrombosis is essential 
to success. 

As chief aids in preventing thrombosis, we must avoid as 
much as possible handling of the edges of the arterial wound 
with forceps, or even sponging any more than necessary. 
After one or two guide sutures are placed, we can often get 
along with the minimum use of forceps, lifting our vessel wall 
merely with the point of the needle. When, as happened in 
this case and in the arteriovenous anastomosis, little clots form 
in the lumen of the vessel, a medicine dropper filled with salt 
solution will wash them out quickly and neatly and thus avoid 
sponging and handling. This suggestion, which I got from 
Dr. Hubbard, I found of the greatest aid in both cases. The 
impregnation of the sutures with sterile vaseline and the smear- 
ing of the vessel with the same lubricant were employed in my 
arteriovenous anastomosis, but not in the case being reported. 
It is a great help, as the fine silk sutures when greased run 
through much more easily, with no tendency to stretch and 
tangle and knot. I think in addition to the fine, straight 
needles (which are easily procured, if married, from one's 
wife's work-basket) — fine enough for the femoral artery at 
least — we ought to have curved needles to sew up the under 
side of deeply situated veins. Beading needles are good, but 
very long, too long for use in a deep hole. For very small 
arteries the finest sewing silk may be untwisted, and one of 
the three strands of which it is made employed as a suture. 
Fine needles and the finest silk sutures are now kept threaded 



ANGEIORRHAPHY. 



401 



at the City Hospital for use in accidents and operative cases 
where there is danger of wounding large arteries. It costs 
nothing but a little time and patience, of which, as is well 
known, hospital surgeons have always an unlimited supply on 
hand, to sew up injured vessels instead of tying them. If it 
does not succeed, they can be tied later. I believe that with 
ordinary care it will succeed, and that by the exercise of a 
little patience we can occasionally save a limb. 

BIBLIOGRAPHY. 

Carrel, A. : Surgery of Blood-vessels, etc., Johns Hopkins Hosp. Bull., 

Bait., 1907, xviii. 
Munro, J. C. : Ligation of Ductus Arteriosus, Ann. Surg., Phila., 1907, 

xlvi. 
Pozzilli, P. : Contributo sperimentale e clinico alia sutura delle arterie, 

Policlin., Roma, 1907, xiv. 
Sherman, H. M. : Report of a Successful Suturing of a Double Stab 

Wound of the Femoral Artery, and a Single Wound of the Femoral 

Vein, Calif. State J. M., San Fran., 1908, vi. 
Sweet, J. E. : The Surgery of the Blood-vessels, Internat. Clin., Phila., 

1907, Ser. xvii, 3 ; Technic of Blood-vessel Suture, Ann. Surg., Phila., 

1907, xlvi. 
Watts, S. H. : Suture of Blood-vessels ; Implantation and Transplantation 

of Vessels and Organs; An Historical and Experimental Study, Ann. 

Surg., Phila., 1907, xlvi ; Johns Hopkins Hosp. Bull., Bait., 1907, xviii. 



14 



PERFORATING WOUND OF THE KNEE-JOINT. 

A CASE IN WHICH A PIECE OF STEEL WAS DRIVEN THROUGH THE KNEE-JOINT, 

FRACTURING THE PATELLA AND CUTTING A CHIP OF BONE OUT OF THE 

EXTERNAL CONDYLE; FUNCTIONAL RESULT PERFECT. 

BY GASTON TORRANCE, M.D., 

OF BIRMINGHAM, ALA., 
Surgeon to St. Vincent's and The Hillman Hospitals. 

O. H. B., white, aged 30, a machinist. On Feb. 14, 1908, while 
having a piece of six-inch steel shafting cut with a steam hammer, 
the piece of steel ( J^ x 2 inches) used for cutting was broken by 
the force of the hammer and a portion of it was driven through 
the left patella, tearing away the lower third and passing through 
the joint, cutting the posterior capsule of the joint near the upper 
margin of the articular surface of the external condyle of the 
femur and chipping out a fragment of the condyle about 2 cm, 
square. 

He was seen first by Dr. E. C. Rosamond, who applied a 
sterile dressing without any attempt to probe or discover the 
extent of the injuries. I saw him with Dr. Rosamond a few hours 
later and had him removed to St. Vincent's Hospital for 
operation. 

Under ether the limb was carefully cleansed and the wound 
irrigated and every precaution used to prevent infection. On 
opening the wound the above injuries were found with some 
clotted blood in the joint ; this was removed with the gloved finger 
and irrigation. 

The wound in the posterior capsule extended into the car- 
tilage and in suturing it back a flap of cartilage had to be sutured ; 
a small, curved, round needle with No, 2 chromic catgut was used 
and interrupted sutures were passed and tied so that the knots 
lay in the cavity in the condyle and presented a very small por- 
tion of gut on the joint surface ; in places the suture was passed 
through the cartilage of the condyle and through the fragment 
of cartilage, bringing cartilage to cartilage; on the outer side 
the sutures were passed and tied in the same manner, having all 
of the knots external ; the capsule beneath the patella was sutured 
and the fragments coapted and the patella ligament sutured over 
them, no attempt being made to suture the patella. 
402 



PERFORATING WOUND OF KNEE-JOINT. 403 

A few strands of silk-worm gut were placed between the 
fragments of the patella to drain this space and a similar drain 
was placed in the cavity in the condyle, this being so placed as to 
drain the joint-cavity. The skin was closed with Mechel clips. 
The knee was wrapped in dry, sterile gauze and a posterior splint 
was snugly applied. 

The dressing was changed the following day, there was no 
swelling or distention of the joint and only a small amount of 
synovial fluid on the dressing. The drains were removed on the 
third and the skin clips on the fourth day. 

There was never the slightest sign of infection and the 
wound healed by primary union. There was no pain or discom- 
fort and he remarked to me on the morning of the seventh day 
that he thought he could walk home if he were given a cane. 

He was removed to his home on the fourteenth day, the 
wound was perfectly healed and the joint was normal in appear- 
ance and size and was free of tenderness and effusion ; the patella 
was freely movable and slight manipulation of the joint did not 
demonstrate any restriction of motion. 

A splint made with a hinge was put on at the end of three 
weeks, which allowed free motion up to a certain limit; this was 
removed at the end of five weeks and he was allowed to use the 
limb with only a firm bandage over the knee. 

At the end of six weeks flexion was practically normal and he 
used the limb as well as before the accident. 

After walking on it for several months he says he cannot 
tell that he has ever had an injury and every function and motion 
seems to be perfectly normal. 



AN APPARATUS FOR THE INTRODUCTION OF 
SALINES INTO THE RECTUM.* 

BY GORDON J. SAXON, M.D., 

OF PHILADELPHIA, PA., 
From the Laboratory of Experimental Surgery of the University of Pennsylvania. 

The plan of the apparatus here presented is the outgrowth 
of observations of the various methods of administration of 
the Murphy treatment. Inquiries have also been made into 
the method generally employed; and while all have for their 
common end the slow continuous introduction of salt solution 
into the rectum, there is a great divergence regarding many 
of the smaller details of technic. 

The matter of regulating the relation between the intra- 
abdominal pressure and the hydrostatic pressure in the appa- 
ratus employed is by no means an easy one, when economy 
of time and the labor of nurses in the crowded wards of a 
hospital are to be considered. It is stated in the directions for 
treatment that the hydrostatic pressure be slightly in excess 
of the intra-abdominal pressure. If the reservoir employed 
for holding the salt solution be placed at such an elevation 
that the two pressures be alike, then there will be no flow. 
If now the reservoir be placed one inch higher the external 
pressure will be the greater and the flow will begin. Since 
only a comparatively few minutes are required for the salt 
solution to lower itself one inch, it follows that the two 
pressures will again be similar and the reservoir will again 
require elevation; in other words, almost constant attention 
is necessary if this nicety of adjustment of pressures be kept 
in mind. 

Another observation which will be more fully explained 
on the basis of some physical experiments will show that as 
ordinarily given the salt solution enters the rectum after the 

♦Demonstrated before the Philadelphia Academy of Surgery, Decem- 
ber 7, 1908. 
404 



INTRODUCTION OF SALINES INTO RECTUM. 



405 



first half -hour of administration at a temperature only slightly 
above that of the room. 

With these things in mind it was my object to design an 
apparatus from which the flow could be controlled in a man- 
ner which would not interfere with the quick passage of flatus 
or the sudden expulsion of salt solution back through the tube 
and from which the fluid would enter the rectum at a tempera- 
ture ranging from 100° to 115° F. Many forms of mechanism 
might be devised which would fulfil the above-mentioned 
conditions perfectly. Thermostatic regulators, " Thermos " 
reservoirs, etc., have been suggested, but in the administra- 
tion of a treatment so widely used as that laid down by 
Murphy it is essential that the apparatus be as inexpensive as 
is consistent with fair work. To aim too strenuously toward 
perfection would make the cost prohibitory. It is not unusual 
in a large hospital to see as many as six patients at a time 
receiving continuous proctoclysis. 

In order to get accurate data on the subject of heat radia- 
tion some laboratory experiments were done. To this end 
an improvised apparatus consisting of a reservoir surrounded 
by a chamber for holding a warming fluid was used. An 
attempt was made to keep the water in the reservoir at a 
fairly constant temperature and accurately to record the tem- 
perature of the fluid as it emerged from the end of the tube. 
The tube was four feet long and three-eighths of an inch in 
diameter. In the first experiment the fluid in the reservoir 
was kept at a temperature never above 130° F. nor below 
124° F. and the rate of flow was regular, 350 cubic centimetres 
per hour. The temperature of the water at the end of the tube 
was obtained by having a thermometer bulb placed within 
its lumen, and readings were taken every ten minutes. Be- 
ginning with 129° F. they were as follows: 120° F., 92° F., 
86° F., 84° F., 83° F., 82° F., 80° F., 79° F., 78° F., 80° F., 
and 78° F. From this it will be seen that at the end of two 
hours the temperature had dropped from 129° F. to 78° F. ; 
in other words, it dropped to within two degrees of room 
temperature. 



406 GORDON J. SAXON. 

In a second experiment the same apparatus was used and 
temperatures were taken at the exit every ten minutes, the 
rate of flow being 400 cubic centimetres per hour. The reser- 
voir stood at 129° F. and water was emerging at 110° F. At 
the end of fifty minutes the same readings were 100° F. and 
86° F. respectively. 

In a third experiment an irrigating bottle was filled with 
water at 185° F. and the whole was placed in a basin of 
constantly boiling water. A tube four feet long was used and 
the rate of flow was 400 cubic centimetres per hour. The 
first thermometric reading at the distal end of the tube was 
176° F., and in twenty-five minutes it had dropped seventy-six 
degrees. The room temperature was 74° F. 

A fourth experiment was conducted to meet as nearly as 
possible the directions given by Murphy in the June, 1908, 
number of Surgery, Gyncecology, and Obstetrics. In an irri- 
gating bottle was placed water at 120° F. On either side hot 
water bottles at 180° F. were suspended. The distal end 
reading began at 100° F. and in one hour it had dropped to 
81° F. The rate of flow was 500 cubic centimetres per hour 
and the reservoir remained at 120° F. 

From these results it will be seen that not only must the 
water in the reservoir be kept at a higher temperature than is 
usually employed, if water at 100° F. to 110° F. be desired to 
enter the rectum, but some advantage must be taken of a means 
to prevent radiation from the tube. To meet this a tube was 
constructed which consisted of an inner tube wound with 
asbestos and over this a larger tube was placed enveloping 
completely the inner tube and its windings. The asbestos was 
used to prevent the two tubes from coming into contact and 
to entangle within its substance an air space. With the use 
of such a tube and the apparatus about to be explained the 
results were striking. Salt solution after running at a rate 
of only 300 cubic centimetres per hour was entering the 
rectum at 115° F. at the end of the first hour, 110° F. at 
the end of the second hour, and 92° F. at the end of the third 
hour. The solution was placed in the reservoir at 140° F. and 



Fig. 




An apparatus for the introduction of salines into the rectum. Side view. 



Fig. 




An apparatus for the introduction of salines into the rectum. Top view. 



INTRODUCTION OF SALINES INTO RECTUM. 407 

was surrounded by boiling water. No change was made in 
either of the waters until the end of the third hour. If the 
warming fluid had been changed the second hour the solu- 
tion would have entered the rectum not lower than 105° 
F. The experiment just referred to was done on a patient 
and continued from 2 p.m. until 2 a.m. It was conducted by 
pupil nurses of the Germantown Hospital Training School. 
The rate of flow was controlled by a pinch-cock on the proxi- 
mal end of the tube. The salt solution was renewed only 
twice and the warming fluid only three times. The rate of 
flow was as slow as 250 cubic centimetres per hour (a con- 
dition most favorable to heat radiation) ; and only once did 
the fluid at the thermometer at the distal end of the tube 
register as low as 92° F. Salt solution stained with fecal 
matter was expelled back into the shunt reservoir from time 
to time as the patient would cough, or strain from the pains 
of an existing acute pyosalpinx. 

A description of the apparatus as per accompanying photo- 
graphs is as follows: 

A copper bucket provided with legs on which to stand it, 
a handle by which it can be hung, and a lid for prevention 
of excessive heat radiation has in its bottom a central opening 
and on its side a faucet. 

Through the central opening passes the curved nozzle of 
a graduated litre glass chamber. This is supported and made 
to press firmly against a rubber washer which surrounds the 
hole in the bottom of the bucket by a frame and movable 
fasteners. In this manner a warming fluid is held within 
the bucket and made to surround the reservoir which con- 
tains the salt solution by a layer of water two and one-half 
inches thick. This can be quickly changed by running it off 
through the faucet and pouring boiling water in the top. 

The tube is constructed throughout as above explained; 
that is, two tubes with a layer of asbestos between. One foot 
from the proximal end a Y-tube is interposed, and just proxi- 
mal to the Y, and on the tube running from the reservoir, a 
pinch-cock is placed in order that the flow may be controlled. 



4o8 GORDON J. SAXON. 

On the other proximal end of the Y is placed a shunt tube 
which fastens to a receiving bottle provided with an opening 
in either end, and attached to the side of the bucket. In this 
manner the flow can be exactly regulated and at the same 
time the salt solution or flatus can be easily expelled. This has 
worked very successfully in actual experiment on patients. 
There is allowed a to-and-fro movement of the fluid as easily 
as if no pinch-cock were used. From the distal end of the Y 
the tube continues to within seven inches of the rectum, at 
which point an enclosed thermometer is interposed. This in 
itself not only records the temperature, but it serves as a 
guide to the rapidity of the flow. If the flow be too slow the 
mercury falls and if it be too rapid the mercury rises. The 
tube is three and one-half feet long and is so constructed that 
a flow of from 400 to 500 cubic centimetres per hour will 
enter the rectum at 105° F. to 115° F., provided salt solution 
be placed in the reservoir at 140° F. and the warming fluid 
be used at the boiling point. The tube should not be over 
three and one-half feet long. This permits the placing of the 
apparatus at or near the foot of the bed. The warming fluid 
should be changed every two hours. 

Directions for Use. — Fill the warming chamber with boil- 
ing water. Fill the reservoir with salt solution at about 140° 
F. Open the pinch-cock and allow the fluid to flow freely 
until the tube is well warmed. Close the pinch-cock until 
about two drops per second are flowing. To judge this hold 
the rectal tube point upward not more than four inches below 
the level of the water in the reservoir; otherwise one will be 
deceived by the rapidity with which the tube will empty itself 
distal to the stop-cock when the rectal nozzle is held too low. 

Place the rectal tube — of the type directed by Murphy — 
in the rectum and strap to the inner surface of the thigh. 
Place the apparatus on an adjustable stand or tree, four to 
ten inches above the level of the anus. 

If salt solution be expelled into the bed or back into the 
shunt bottle the apparatus may be lowered and the rate of 
flow slightly decreased. If the patient persists in expelling 



INTRODUCTION OF SALINES INTO RECTUM. 



409 



the solution discontinue the treatment for one hour and then 
proceed as before. 

I wish to make known my indebtedness to Drs. A. D. 
Whiting and George Lord de Schweinitz for criticisms and 
for the use of clinical material in the wards of the German- 
town Hospital, and to Mr. Keen, of Chas. Lentz & Co., for 
this trial apparatus constructed for my use. 



THE SITTING POSTURE; ITS POSTOPERATIVE AND 
OTHER USES. 

WITH A DESCRIPTION OF A BED FOR HOLDING A PATIENT IN THIS POSITION. 

BY WILLIS D. GATCH, M.D., 

OF BALTIMORE, MD., 
Assistant Resident Surg-eon in the Johns Hopkins Hospital. 

Since the Fowler position has come into general use in 
the treatment of peritonitis, there have been described a num- 
ber of devices for keeping a patient upright in bed. The essen- 
tial principle of most of these has been elevation of the knees, 
whereby the trunk, when elevated, is prevented from slipping 
downward. The plan of putting a pillow under the knees is 
ineffectual, as the support is too yielding. Baldwin (Journal 
American Medical Association, vol. xlix, p. 1043) advises the 
use of an ordinary rocking chair. Allaben {J. A.M. A., vol. 
xlix, p. 556) describes a back rest on the principle of a " double 
inclined plane." Gillian (J. A.M. A., vol. li, p. 1133) advocates 
the use of a steamer chair. Finally, McGuire {J. A.M. A., 
vol. 1, p. 1 01 9) gives the plan of elevating the head of the 
bed, and using an adjustable seat to keep the patient from slip- 
ping downward. All of these devices, under various circum- 
stances, are no doubt very useful. 

The bed described below has been used for about a year 
in the service of Prof. Halsted at the Johns Hopkins Hos- 
pital. While similar to the devices of Alleben and Gillian, it 
has several original features which, I hope, justify its descrip- 
tion. Like all of the above inventions, it was planned for the 
treatment of peritonitis. But we have found it so easy to use 
and so comfortable to the patient, that we have employed it 
for a number of other conditions, for some of which the sitting 
posture has a value almost as great as for peritonitis. 

The apparatus consists of an oblong frame of stout 
boards, to the upper surface of which are hinged three movable 
flaps. The frame is of the exact length and width of a stand- 

410 



Fig. {. 




The iron bed in position on the springs of a ward bed. Draw sheet arranged as for continuous 

irrigation of bladder. 



Pig. 





r^ 


\v,.„ W 














4 

-** 








1 


^ 


1 


"^ 




fe^ 




mi 


^Lm 


r 


JMI 


^^mm 








mmam 


• 


in T 



The wooden bed. showing ease with which an extremely heavy patient (the woman shown weighed 250 

lbs.) can be kept sitting. 



POSTOPERATIVE SITTING POSTURE. 



411 



ard ward bed, on the springs of which it is intended to rest. 
The photographs (Fig. i and 2) show the relative length of 
these flaps, and the plan of elevating or lowering them. The 
flap which supports the trunk should be about 36 inches long; 
the smaller flaps should be 14 to 16 inches long. 

To cover the bed we used at first a mattress hinged at the 
points of bending. But we found that an ordinary " Oster- 
moor " mattress, if strapped down, would bend as much as 
necessary. The straps should be sewed to the under surface 
of the mattress at a point about 6 inches from the edge, so as 
to allow the covers to be tucked in between mattress and strap. 
A rubber draw sheet under the patient's buttocks keeps the 
bedding dry. 

Such a bed can be made by any carpenter at a very small 
expense, or it can be made of steel with woven wire backs for 
the frames. If desired, a hole can be cut through the mattress 
and the underlying flap of bed, so as to allow the placing of a 
bed pan without moving the patient. But this complicates the 
contrivance, necessitates a special mattress, and is of doubtful 
convenience. 

It would, in fact, be perfectly easy to have every hospital 
bed equipped with movable frames of this kind, but with de- 
tachable canvas backs which could be buttoned to them when- 
ever it became necessary to have the patient sit up. 

The advantages of the bed are, that it is simple; that it 
permits of the patient's lying flat or sitting at any angle of 
elevation desired ; that it holds a patient in the sitting posture 
all the time, and without any effort on his part ; that it permits 
of continuous irrigation of the bladder, rectum, or adjacent 
parts without wetting the bed or the patient ; and finally, that 
it readily adapts itself to the comfort of a large class of 
patients who need to sit up more or less of the time. 

Passing now to the therapeutic uses of the sitting posture, 
we may roughly divide the cases benefited thereby into two 
groups, the operative and the non-operative. In the former 
group it has, I think, four general uses : ( i ) to drain the peri- 
toneal cavity; (2) to lessen the danger of pulmonary compli- 



412 WILLIS D. GATCH. 

cations; (3) to permit of certain continuous irrigations; and, 
(4) to promote the comfort and general well-being of the 
patient. In the non-operative group, there are numerous cases, 
of pulmonary and cardiac disease, of incontinence of urine or 
fasces, of paralysis, etc., who may be greatly benefited, or taken 
care of more easily, when kept sitting. Some of these con- 
ditions merit a brief consideration. 

In peritonitis the Fowler position, to be at all effective, 
must be maintained all the time. Fowler advises that the pa- 
tient, if his condition will permit, be propped upon the stretcher 
which transports him from the operating table to the bed. 
Buxton (Journal Med. Res., March, 1907) has shown that 
there is an almost instantaneous rush of bacteria into the 
lymphatics of the diaphragm whenever infectious material 
comes in contact with it. If, therefore, the patient's body 
be allowed to slip down, even occasionally, from the elevated 
posture, the entire surface of the diaphragm will be periodi- 
cally flooded with poisonous exudate. This is precisely what 
happens when one tries to maintain a patient in the Fowler 
position by means of a simple back-rest or by pillows. The 
constant lifting made necessary is exhausting alike to attend- 
ants and patient. Yates (Surg., Gyncscol. and Obst., Nov. 
1908) has shown the vital importance of absolute rest in 
this condition. Cofifey (J. A.M. A., March 19, 1907) by means 
of an ingenious cast of the peritoneal cavity has shown that it 
is necessary to elevate a patient's body as high as 45 to 50 
degrees to insure drainage of the lumbar depressions of the 
abdomen. 

For preventing postoperative pulmonary complications 
the sitting posture has a life-saving value scarcely less than 
it has for peritonitis. Especially is this true for fat patients 
who have undergone laparotomies for conditions of the 
upper abdomen, such as gall-stone disease, gastric troubles, or 
umbilical hernia. The respiratory distress of such patients is 
dreadful and the danger from pneumonia grave. The follow- 
ing case illustrates the benefit they derive from sitting upright. 



POSTOPERATIVE SITTING POSTURE. 



413 



C. C, negress, aged 40, weight 205 pounds. History and 
physical signs typical of gall-stone disease. Heart and lungs 
normal. General physical condition excellent. 

Operation: Oct. 15, 1908. Cholecystostomy and drainage 
of common duct. Removal of gall-stones from gall-bladder, com- 
mon and cystic ducts. 

Patient withstood the operation well and was returned to the 
ward in good condition. In four hours her temperature was 
103°, her pulse 130, and her respirations 52 to the minute. A 
bed of the kind described above not being available, an effort 
was made to prop her up on a back rest to relieve her respiratory 
distress. But she was so heavy that she sank deep down into 
the bed with only her head and neck elevated, so that her 
dyspnoea was even worse than when she was lying flat. Her abdo- 
men remained soft and was not tender on palpation except in the 
immediate neighborhood of the wound. On Oct. 16 her condition 
continued grave; her temperature remained elevated, her pulse 
was thready, and her breathing shallow and gasping. She was 
constantly nauseated. Showers of fine moist rales could be heard 
over the bases of both lungs in the back. At 5.30 p.m. this day 
an adjustable bed was obtained and she was placed upon it, her 
trunk being elevated to an angle of about 40 degrees. There 
was an immediate and striking improvement in her condition. 
Her temperature sank in four hours to 100° and her breathing 
became perfectly easy. Her convalescence from this time was 
uninterrupted, but it was necessary to keep her sitting for two 
weeks, as she had difficulty in breathing whenever lying flat. 

The clinic has had a series of cases like this, all similarly 
managed and with similar good results. With the postopera- 
tive treatment so conducted the operative risks are diminished. 

It has long been the practice at this hospital whenever the 
wound-condition will permit, to have patients who are old, 
feeble, or who have pulmonary emphysema or bronchitis, to sit 
up as soon as they have recovered from the anaesthetic. Hypo- 
static congestion of the bases of the lungs is then not likely to 
occur, and the liability to pneumonia is lessened. Provided the 
patient is held upright without any eflfort on his part, there is 
no increased strain on an abdominal wound from this posture. 



414 WILLIS D. GATCH. 

Closely related to the question of postoperative lung com- 
plications is that of abdominal distention following laparotomy. 
Here too the sitting posture is of advantage, and for two 
reasons : in the first place, because the diaphragm and abdom- 
inal muscles can compress the viscera more powerfully ; and in 
the second place, because in this position the action of the heart 
is less impeded by the upward pressure of the distended intes- 
tines. The pulse of such patients almost always becomes 
slower and stronger when they are made to sit up. Perhaps 
some of the benefit of the Fowler position in peritonitis 
depends upon this latter factor. 

We have found the bed very convenient in managing con- 
tinuous irrigations of the bladder, in treating infections or 
bums of the thighs, genitalia or abdomen, and in caring for 
patients with incontinence of urine or faeces. 

These patients are placed on a rubber draw-sheet (Fig. i ) 
extending from shoulders to knees. Shoulders and knees are 
then moderately elevated. Fluids then gravitate to the 
patient's buttocks and are there drained off at the side of the 
bed, without soiling mattress or covers. Excoriations of the 
abdomen from the discharges of fecal fistulse can thus be 
admirably treated by a slow continuous irrigation. 

This method is especially adapted to the postoperative 
care of cases of perineal or suprapubic prostatectomy. Many 
of these patients are feeble old men, liable both to urinary 
complications and to pneumonia. When the patient is kept 
lying flat, it is almost impossible to manage a continuous irri- 
gation of the bladder without soaking bed and patient. If, 
however, the patient's buttocks are placed in a Kelly pad and 
his knees and shoulders elevated as above described he can be 
kept perfectly dry. In this posture he will generally drink 
water better, and he is certainly less predisposed to pneumonia 
than when lying. 

Of the non-operative or purely medical cases, the bed has 
been found most useful for patients with advanced heart dis- 
ease and orthopnoea. These cases need to be held upright 
constantly, otherwise they are tortured by sleeplessness, caused 



POSTOPERATIVE SITTING POSTURE. 415 

by the attacks of dyspnoea which occur whenever they doze and 
sHp down from the sitting position. Patients with pneumonia 
and asthma are similarly made more comfortable. 

In the absence of circulatory depression it is hard to see 
why nearly every patient confined to bed for a long period 
would not be greatly benefited by sitting upright part of the 
time, provided, of course, that the sitting posture can be main- 
tained without any muscular strain on his part. Fever alone is 
no contraindication. Patients when sitting can breathe better, 
can take food and liquids better, and are less liable to pul- 
monary trouble. As this position takes the pressure off the 
bony prominences of the back, they are in less danger of bed 
sores. And, finally, the vasomotor tone of the arteries is better 
preserved and the patients are not so liable to dizziness and 
swelling of the feet when they finally walk. In short, cause 
should be shown for keeping a patient lying, rather than for 
making him sit up. 

I desire to thank Prof. Halsted and Dr. R. T. Miller for 
the privilege of making an extensive practical test of the bed 
described, and for encouragement in the preparation of this 
article. 



A METHOD OF SPLINTING SKIN GRAFTS. 
BY JOHN STAIGE DAVIS, M.D., 

OF BALTIMORE, MD., 
Assistant Surgeon in the Out-patient Department of Johns Hopkins Hospital. 

Every surgeon has his own pet method of dressing skin 
grafts, and fairly good results are obtained when the grafted 
wound is dressed with gauze moistened with normal salt, or 
borax solution, i : 40; with overlapping strips of rubber protec- 
tive; with dry gauze or powders; with silver foil; or when 
it is simply left exposed to the air without any dressing. How- 
ever, there are many partial takes and failures for the reason 
that the grafts are not properly splinted after they are applied, 
and in consequence slip down with the dressings, or are floated 
off by blood or serum collecting beneath them. In order to 
overcome this difficulty it is necessary to reinforce the grafts 
with some material which has enough body to act as a splint, 
and at the same time is not too rigid to shape itself readily to 
any desired location. It is also very important that it should 
not adhere to the grafts and granulations, or cause too much 
pressure, and also that there be free escape of any secretions 
into the dressings. 

After experimenting with various materials, I tried a 
coarse meshed net, such as is used for curtains. It is made of 
loosely woven bars of cotton thread, surrounding openings 
about I cm. in diameter. It is necessary to have the openings 
approximately this size as smaller ones often become clogged. 
This proved too flimsy, and also became adherent to the grafts. 
So in order to increase the body of the fabric, after washing 
out the sizing and drying, I soaked the material in a rubber 
solution made up of pure gutta-percha, 30 parts, and chloroform 
150 parts, and found that after the chloroform had evaporated 
and the material was dry there was enough stiffness to 
give a very satisfactory splinting material. When prepared 
the net should be of a light grayish-brown color throughout. 

416 




Fig.. 



Shows the actual size of the 
openings of the mesh. 




Shows the material splinting a whole- 
thickness graft on ulcer following osteo- 
myelitis of tibia. Note cuts to allow 
accurate fitting. Photograph taken tour 
days after application of mesh. 



Fig. 4- 



Fig. 




Shows the close fitting of the mesh over Thiersch graft 
on deep breast wound following excision of carcinoma on a 
very fat woman. 




Shows ihf mesh over whole- 
thickness graft on bum, with the 
overlapping edges resting on gran- 
ulation tissue. Photograph taken 
seven days after application. 



METHOD OF SPLINTING SKIN GRAFTS. 417 

The sterilization before application is as follows: 

Cut in pieces as large as may be desired and separate them 
with one or two thicknesses of gauze. Place in a sterile jar, 
and fill it with i : 1000 bichloride of mercury solution. 
Change this solution three times with twelve-hour intervals, 
and finally allow the mesh to remain permanently in i : 1000 
bichloride solution. It can be kept for a considerable time in 
this way (I have used it after keeping it nine months in the 
bichloride solution), although it is better to make up small 
quantities and often. The dry permeated material will keep 
indefinitely. No hot solutions must come in contact with the 
mesh during the sterilization or application. 

Technic. — After the grafts are in place the mesh is taken 
out of the bichloride solution and thoroughly rinsed with salt 
solution, then dried with a sterile towel. A piece is cut large 
enough to allow a margin around the grafted area of from 
5 to 10 cm. Then the material is applied and pressed snugly 
down on the grafted area and surrounding skin or granula- 
tions. Should the conformation of the part or wound not 
permit the mesh to be evenly applied, a few cuts with scissors 
will allow an infolding and accurate fitting, which is necessary 
in order that the splinting may be successful. The overlap- 
ping edges may be secured to the skin by strips of adhesive 
plaster when necessary. After the net is in position the dress- 
ing selected is applied, and the whole secured by a bandage. 

Where the overlapping material rests on granulation tis- 
sue, it will be found that it can be lifted up at any time without 
causing pain or bleeding, as the granulations do not adhere 
to or grow into the bars of the impregnated material. 

With this mesh in place the grafts can be observed from 
time to time with little or no danger of displacing them. The 
first dressing is usually made 36 to y2 hours after operation, 
and if the gauze next to the mesh has dried out, it must be 
thoroughly soaked with salt solution, and then carefully lifted 
with an instrument, while with a pledget of gauze the net is 
held down, as the dressing is raised from it, in order to guard 
against any displacement. Then the wound is irrigated with 



4l8 JOHN STAIGE DAVIS. 

salt solution, and any secretions wiped away. The mesh is 
left in place from four to ten days, and then can be removed 
without difficulty. 

Any type of dressing may be used over this material, — 
silver-foil, wet or dry gauze, etc., and I have found it particu- 
larly desirable in those cases where the grafted area was ex- 
posed to the air. 

Conclusions. — The use of such a material permeated with 
rubber is advantageous in that it splints the grafts without too 
much pressure, and is easy to apply and secure in place. It 
does not adhere to the grafts or to granulations. It allows 
the free escape of any secretions which may form, and thus 
prevents maceration. Any sort of dressing may be placed over 
it. The progress of the healing may be observed at any time 
without danger of displacing the grafts. Should any blisters 
form and serum or blood collect beneath the grafts, it can be 
removed at once. 

I have used this open-mesh material over Thiersch and 
" whole thickness " grafts, on nearly every part of the body, 
and have found its use a distinct advantage. 



TRANSACTIONS 

OF THE 

NEW YORK SURGICAL SOCIETY. 



Joint Meeting with the Nezv York Pathological Society, 
December 9, 1908. 

The President, Dr. Joseph A. Blake, in the Chair. 



AN EXPERIMENTAL STUDY OF THE PATHOLOGY 
AND METABOLISM OF DELAYED CHLORO- 
FORM POISONING. 

Drs. John Rowland and A. N. Richards presented an 
elaborate review of this subject. The paper gave in detail the 
results of an experimental study of the pathology and metabolism 
of delayed chloroform poisoning and was illustrated by means of 
charts and microscopical projections. The pathological experi- 
ments were made upon numerous dogs, the metabolism experi- 
ments were carried out on three dogs. None of these latter 
animals died from the immediate effects of the anaesthetic. 

The first dog was anaesthetized for three hours and a half, 
seemed always well thereafter and was killed on the morning 
of the fourth day following anaesthesia, when the general appear- 
ance of the animal and the metabolism showed her to be, as far 
as one could tell, perfectly normal. 

The second and third dogs died as the result of delayed 
poisoning on the third and fourth days after the anaesthetic. 
In all three dogs, great pathological changes were found in the 
liver, the most important of which was necrosis. 

Their metabolism showed an enormous increase in the excre- 
tion of total nitrogen, which was divided among the nitrogen- 
containing substances in an almost normal ratio except that crea- 
tinin was always diminished and the creatin, in the fatal cases, 
greatly increased. 

419 



420 



NEW YORK SURGICAL SOCIETY. 



The total sulphur was also increased and proportionately 
higher than the nitrogen ; this increase was due chiefly to an in- 
crease in the neutral sulphur. 

The changes were the same in the dog apparently recovering 
as in the two cases of fatal poisoning, from which the authors 
conclude that the metabolic differences between ordinary pro- 
longed anaesthesia and delayed poisoning are of degree only and 
not of kind. They found further no basis for the view that 
cases of delayed poisoning are due to acid intoxication. 

They were able to produce in dogs necrosis of the liver after 
a single anaesthesia of an hour and intense fatty changes when 
chloroform was given for a much shorter period. They believe 
that every prolonged anaesthesia with chloroform produces intense 
liver changes in animals and that what is true of animals in this 
connection is undoubtedly true of human beings. 

Dr. George E. Brewer said he would limit himself to the 
clinical aspects of this very important pathological condition. The 
condition itself was a frightful one, and the death rate was high. 
It was not generally understood, for the reason that the cases were 
exceedingly rare. Still, in the literature covering the past decade 
a sufficient number of cases were described to enable us to formu- 
late some definite rules regarding it. The cases could be classi- 
fied under three distinct heads : 

1. Those occurring generally in childhood in which the 
symptoms came on almost immediately after the use of the anaes- 
thetic. In these cases, usually, the anaesthesia was of long dura- 
tion, requiring the use of a good deal of chloroform, and they 
were apt to be associated with a profound degree of shock. The 
symptoms usually observed in these cases were prolonged vomit- 
ing, great prostration, coma and death. 

2. This type, Dr. Brewer said, was also seen in chil- 
dren, and was distinctly an evidence of delayed chloroform 
poisoning. In a typical case of this character which he re- 
ported five years ago in the Annals of Surgery, the patient 
was a child, about twelve years old, who was operated 
on for appendicitis, with a limited peritonitis. Chloroform was 
administered, the anaesthesia lasting only about twenty minutes. 
The child recovered quickly from the effects of the anaesthetic, 
and passed a comparatively restless night. His temperature 
dropped to normal, and the following day he was quite com- 



DELAYED CHLOROFORM POISONING. 



421 



fortable. The abdominal distention disappeared, there was no 
evidence of marked tenderness about the abdomen, the patient's 
mind was clear, his temperature normal and he was considered 
convalescent. On the third day after the operation he suddenly 
awoke about midnight with a terrific scream; this was repeated 
a number of times — then he fell asleep again. About six hours 
later he again awoke, shrieking, and apparently terror-stricken 
and frightened, and then dropped off to sleep again. These 
paroxysms were repeated over and over again. Finally, his 
periods of sleep deepened into coma, and death occurred. During 
his waking periods there was restlessness and delirium of the wild- 
est sort. There was no fever nor vomiting. An examination of the 
blood in this case showed that it was loaded with acetone and 
diacetic acid. Dr. Brewer said that Dr. Bevan, of Chicago, had 
reported a case almost identical with this. 

3. The third type of cases of delayed chloroform poisoning 
was illustrated by the following instance, which had come under 
his observation : The patient was a man of 56 who had been 
operated on for an appendicitis of moderate severity. The opera- 
tion presented no special difficulties, and was of short duration. 
Chloroform was selected as the anaesthetic, because of the condi- 
tion of the man's kidneys. For forty-eight hours that patient did 
perfectly well ; his temperature dropped nearly to normal and he 
had no untoward symptoms. Suddenly he became somnolent, 
and when aroused he would seem to be somewhat dazed. On the 
third day icterus developed and the following day he was the 
color of an orange. His somnolence progressed, coma developed 
and death followed. At the autopsy, the liver was found to be 
softened and yellow. 

In reviewing the clinical histories of these cases, Dr. Brewer 
said, the following symptoms seemed to stand out prominently: 
Vomiting was quite generally present, although it had been re- 
ported absent. Restlessness was almost invariably noted in the 
beginning. Delirium was reported in those cases associated with 
acetonuria. Icterus was sometimes present; sometimes absent. 
Coma was always present before death. Fever was not usually a 
symptom, although in a few cases it had risen as high as 107° F. 
Cyanosis, air hunger and dyspnoea had been observed in a certain 
number of cases. 

In those cases where the symptoms came on shortly after 



422 NEW YORK SURGICAL SOCIETY. 

the administration of the anaesthetic, and associated with evidences 
of considerable shock, certain unknown factors might be present, 
but in the late cases an exceedingly virulent type of intoxication 
must be looked for as the result of the chloroform itself. In 
addition to the cases reported. Dr. Brewer said he had seen several 
milder cases with somnolence and traces of acetone in the urine, 
in which the symptoms cleared up under liberal doses of bicar- 
bonate of soda. The severe cases, he believed, almost invariably 
ended in death. 

Dr. James Ewing said that when chloroform was first intro- 
duced, Magendie called attention to the possible dangers attend- 
ing its use. It was a remarkable fact, the speaker said, that in 
spite of the commissions that had from time to time been appointed 
to investigate the subject of chloroform anaesthesia, little or no 
attention had been paid in their reports to this condition of 
delayed chloroform poisoning. This was especially so in England, 
where chloroform anaesthesia had been repeatedly investigated, 
and where Guthrie had reiterated his warnings in regard to the 
dangers attending this form of poisoning. The same condition 
held in France. In 1905, two French writers, in the French 
Archives of Experimental Medicine, described several cases of 
so-called toxic appendicitis with extensive alterations in the liver. 
The findings were practically identical with those observed in 
cases of delayed chloroform poisoning, although the authors did 
not mention the possibility of such an explanation ; they simply 
referred to them as examples of a peculiar form of toxic appendi- 
citis. They were probably dealing with cases of delayed choloro- 
form poisoning. In their article, they quoted from half a dozen 
of the prominent French surgeons, each of whom had seen and 
reported similar cases. In one or two of their cases, the diagnosis 
of hystero-epilepsy had been made. 

The worst offenders in this connection. Dr. Ewing said, were 
doubtless the obstetricians. In the practice of that branch of 
medicine, chloroform was very commonly used and a considerable 
number of the cases of so-called toxic pregnancy were really in- 
stances of delayed chloroform poisoning. The speaker said he 
could not entirely agree with the statement of Dr. Brewer in 
regard to the infrequency of this condition. On the contrary, 
he thought it was relatively common. 

In discussing the pathological findings in these cases. Dr. 



DELAYED CHLOROFORM POISONING. 423 

Ewing said that possibly some interesting additions to the facts 
might be learned by a study of the nervous system. Another 
question that arose was whether the findings in dogs were appli- 
cable to the human being. It was quite certain that the dog was 
a little more susceptible to these lesions than the rabbit, which 
was perhaps due to the fact that the latter animal could not be 
chloroformed as long as the dog. Rabbits were apt to die quickly 
under the influence of this anaesthetic. Whether man was more or 
less susceptible to the action of chloroform than the dog he did not 
know, but he was inclined to think that he was less so. The 
sjanptoms of delayed chloroform poisoning in the dog, however, 
as well as the pathological and gross findings, were apparently 
identical with those observed in the human being. Still, he 
thought it would be well to be cautious before interpreting these 
lesions as being due to the chloroform, as identical lesions 
occurred in man in certain diseases without the aid of chloroform. 

In discussing the metabolic findings in these experimental 
studies reported by Drs. Howland and Richards, the speaker 
said he was surprised to find that there was so little change in 
the nitrogen partition and such a marked change in the sulphur 
output, and here again the objection arose to comparing metabolic 
studies in the dog with those in man. Spontaneous conditions in 
the human being in which we found these marked changes in the 
nitrogen excretion were not to be compared with the experimental 
condition produced in animals and covering a very short period. 
In the latter, the changes in the liver occurred very early, before 
the metabolic changes, while in the spontaneous condition it was 
quite the opposite. 

Dr. Charles C. L. Wolf said that through the kindness of 
Dr. Howland, he had had the privilege of going over the results 
in the metabolism in delayed chloroform poisoning which he had 
presented, and while it might appear at first sight that the ana- 
lytical results did not present changes commensurate with a fatal 
outcome, it seemed to him that they were particularly instructive 
in view of the direction which urine analysis had tended to take 
in the last few years. Instead of the routine analysis for urea 
by the hypobromide method, an accurate knowledge of the distri- 
bution of nitrogen was now desired, and this was given in the 
form of results similar to those of Dr. Howland. The speaker 
said that in the course of the work to which his entire attention 



424 



NEW YORK SURGICAL SOCIETY. 



had been directed during the past four or five years, he had come 
across many conditions which bore out Dr. Rowland's results in 
every detail. 

Dr. E. Libman, the President of the New York Pathological 
Society, said he agreed with Dr. Ewing that this condition of 
delayed chloroform poisoning was not an infrequent one, particu- 
larly in its lighter form. While a discussion of this kind should 
not lead us to the other extreme, and blame everything on chloro- 
form, we should nevertheless appreciate this possible occurrence 
of delayed poisoning from the effects of chloroform, particularly 
in those who suffered from some illness which predisposed them 
to acetonuria. 



TRANSACTIONS 

OF THE 

PHILADELPHIA ACADEMY OF SURGERY. 



Stated Meeting, December 7, 1908. 
Dr. Gwilym G. Davis in the Chair. 



CARCINOMA OF PYLORUS; HOUR-GLASS STOMACH. 

Dr. William L. Rodman presented a woman, 43 years of age, 
who had given the history of chronic gastric trouble since she was 
fifteen. Six months ago her dyspeptic symptoms returned in a 
more pronounced way than ever before. She vomited irregularly, 
usually every two or three days. Her stomach contents did not 
show excess of hydrochloric acid or presence of lactic acid. A 
tumor near the pylorus was made out. The symptoms and signs 
clearly indicated an hour-glass stomach and a skiagram demon- 
strated such a condition. The pyloric compartment was very 
small and the cardiac compartment very large. There was 
considerable gastroptosis. 

Three weeks ago this patient was operated on, and a large 
tumor was found near the pylorus. The pyloric end of the 
stomach was adherent to the liver and the pancreas. She bore 
the anaesthetic badly, and it was thought best to limit the surgical 
interference to a gastrojejunostomy, as the cardiac compartment 
was so large and the pyloric so small that they were practically 
dealing with a dilated stomach. 

She has never vomited since the operation and her improve- 
ment has been steady and uninterrupted. She now claims that she 
never felt so well in her life. This, Dr. Rodman was satisfied, 
was a case of cancer ingrafted on the base of an old ulcer. 

PERFORATING TYPHLITIS. 
Dr. Rodman presented a girl, aged 17 years, who was brought 
to him from Cape May, N. J., during a most pronounced attack 

425 



426 



PHILADELPHIA ACADEMY OF SURGERY. 



of what was thought to be appendicitis. He saw her thirty-six 
hours after the onset of symptoms, which seemed to have followed 
eating peanut candy. Her pulse was 120, her temperature 103°, 
the rigidity of the right rectus muscle was most marked, and her 
pain was intense. 

As soon as the abdomen was opened, thin pus and faeces were 
seen to be escaping from a hole in the caecum about one inch from 
the base of the appendix. The latter was not free, but bound 
down in the mass of adhesions. The caecum was very red, soft, 
and friable. He did not think it wise either to remove the appen- 
dix or to attempt to suture the opening in the caecum. Therefore 
gauze drainage was made, one piece protecting the general cavity 
centrally, one passing downward to the pelvis, one upward 
towards the liver, one in the flank. The fifth piece led down to 
the opening in the caecum. The superficial wound was not 
sutured. The Fowler position with Murphy's continuous irriga- 
tion was instituted at once after operation. 

At the end of two weeks the pus and fecal discharge had 
ceased, and a second operation was done to remove the appendix. 
No perforation of the appendix was found, and it was easily 
removed in spite of the great amount of inflammation existing a 
fortnight previously. The wound was closed with tier sutures, 
and her recovery has been smooth and uneventful. This was evi- 
dently a case of typhlitis, rather than appendicitis. Dr. Rodman 
said that he had seen two or three other cases like it, each showing 
a marked perforation in the caecum, in one of them as large as 
a quarter of a dollar. 

SARCOMA OF THE BREAST. 

Dr. Rodman presented a woman from whom a very large 
sarcoma of the breast was removed two weeks ago at the Presby- 
terian Hospital. It was a periductile sarcoma. Sarcoma of the 
breast is a rare neoplasm. He had operated upon but three cases 
in his life, two of these, strangely enough, in the last year. 

S. W. Gross estimated that sarcomata comprised 8 per cent, 
of mammary neoplasms. Roger Williams examined 2300 cases 
and found that sarcomata comprised 3.8 per cent. Dr. Rodman 
had carefully examined the statistics covering 5000 cases of mam- 
mary neoplasms with the result that sarcomata comprise less than 
3 per cent, of mammary growths. 



OMENTAL CYST. 



427 



Although a diagnosis of sarcoma was made in this case, a free 
axillary dissection was carried out just as in cancer of the breast. 
He thought that this should always be done, inasmuch as sarcoma 
not infrequently causes infection of the neighboring lymphatic 
glands. 

PERFORATION OF FEMORAL ARTERY BY OSTEOPHYTE. 

Dr. Rodman presented a man, aged 30, from North Carolina, 
who had suffered for fifteen years with disease of the right femur. 
There had been from time to time sinuses through which small 
pieces of dead bone were discharged. He came to the Presby- 
terian Hospital for treatment September i. A few days after- 
wards another abscess formed ; it was opened, nothing further be- 
ing done. Within forty-eight hours afterwards he had hemor- 
rhage from the popliteal. The wound was packed with iodoform 
gauze and the hemorrhage in this way controlled. Each time the 
packing was removed, hemorrhage recurred. The femoral artery 
was ligated under cocaine at the apex of Scarpa's triangle. This 
controlled the hemorrhage for a week, when another free bleeding 
occurred, presumably when the circulation was re-established. 
The femoral was again ligated under cocaine just below Poupart's 
ligament. The hemorrhage was controlled for another week. 
Recurring, it was deemed best to amputate the thigh. He almost 
perished from shock. After the limb was removed, two spiculae 
were found, sharp as the prongs of a fork, sticking backwards 
in the popliteal space, which had cut both artery and vein across. 
The specimen presented shows clearly enough the injury to both 
vessels. 

It is hard to understand why gangrene did not ensue. The 
femur was two and a half or three times its normal size, the result 
of chronic osteoplastic osteitis. The amputation was made in 
the upper third of the thigh. He has gained twenty pounds in 
weight and all of his septic symptoms disappeared promptly 
after operation. 

OMENTAL CYST. 

Dr. Rodman presented a girl, aged 17, who was operated 
upon three weeks ago in the Medico-Chirurgical Hospital for an 
enormous cyst of the abdomen weighing sixty pounds. It had 
been variously diagnosticated by different surgeons as a pancreatic 



428 PHILADELPHIA ACADEMY OE SURGERY. 

cyst, an ovarian cyst, and as free fluid in the peritoneal cavity. 
She had been tapped three times, the fluid being clear and limpid 
as spring water. The tumor was beneath the parietal peri- 
toneum, covered over by an additional layer of peritoneum, but 
superior to the great omentum. It had no pedicle at all. But a 
single vessel was tied, and that a small one. It shelled out as a 
walnut from its covering. The cyst was unilocular. Seemingly, 
it was a cyst of the omentum. No abdominal viscus was seen 
during the operation. 

Her recovery was rapid and complete. 

■ SARCOMA OF BREAST. 

Dr. John Speese presented, for Dr. Jopson, a specimen of 
sarcoma of the breast, occurring in a colored woman fifty years 
of age, in which the macroscopic appearance suggested that of 
the cystosarcomata described by many German pathologists. 
Several cysts were present, the contents having undergone coagu- 
lation. Microscopic examination revealed a malignant growth of 
connective-tissue origin, consisting of great numbers of spindle 
cells. The glandular portions of the breast also showed evidences 
of hyperplasia, the epithelial cells being heaped up in the ducts 
and tubules, but not infiltrating the surrounding tissues. 

HYPERNEPHROMA OF THE KIDNEY. 

Dr. John H. Gibbon presented a man 54 years of age, who 
was received into the medical wards of the Pennsylvania Hospital 
on September 18, 1908, under the care of Dr. Stengel. Three 
weeks before admission he began to have pain in the upper right 
quadrant of the abdomen, which he stated was increased by taking 
food. At this time a distinct tumor was easily palpated below the 
costal border, and apparently was connected with the liver. 
There was nothing in the repeated urinalyses to suggest any in- 
flammatory condition of the kidney. The patient's haemoglobin 
was. 55 per cent; color index, 0.674; leucocytes, 4100; and his 
red cells 4,360,000. An X-ray plate was made but showed noth- 
ing. It was thought that the tumor was probably connected with 
the kidney. Ureteral catheterization was done by Dr. Stewart, 
and proved of great diagnostic value. The catheters were in- 
serted in the ureters and the glasses attached at 11.45 o'clock; 
at 12.05 ^ four-grain capsule of methylene blue was given. At 



SARCOMA OF THE KIDNEY. 429 

2 P.M. the methylene blue appeared in the urine from the left 
ureter, and in the urine from the right kidney not until more than 
an hour later. The catheters were removed at 3.07, during which 
time there were excreted from the left kidney 97 c.c. of urine, and 
from the right 9 c.c. There was no pus in the urine and the 
patient had no leucocytosis. 

An incision was made through the sheath of the right rectus 
and the peritoneum overlying the tumor was divided. In separat- 
ing the tumor from the surrounding tissues a projecting mass 
from the posterior surface was found, which was probably an ex- 
tension of the disease beyond the capsule, so that its complete 
removal was made more difficult. The operator finally, however, 
was able to get completely around this mass, although it was 
densely adherent to the spine. The ureter and vessels of the 
pelvis were ligated separately and the tumor removed. There 
was considerable oozing from the large cavity left after removal 
of the tumor, and a gauze drain was inserted. No sutures were 
placed in the posterior peritoneum in this case. The anterior 
wound was closed excepting at the point of drainage. The 
patient stood his operation well and made a good recovery. He 
had an X-ray burn which has now healed. For a time he had 
oedema and tenderness in the posterior abdominal wall. This 
entirely disappeared, however, and he seems now in a fair way to 
make a complete recovery from his operation, although recur- 
rence is to be expected. 

The pathological diagnosis of the growth in this case was 
hypernephroma of the kidney. 

SARCOMA OF THE KIDNEY. 

Dr. John H. Gibbon presented a boy, four years of age, who 
was operated upon a year ago at the Jefferson Hospital. The case 
occurred in the practice of Dr. George T. Tracy, of Beverly, New 
Jersey, and was seen by Dr. Gibbon in consultation with Dr. E. E. 
Graham. The boy at that time had an enormous tumor involving 
his right kidney. This tumor was first noticed a few weeks before 
admission. It was large enough to be easily seen at a consider- 
able distance. Because of the size of the growth the prognosis 
was particularly grave, nevertheless the patient's parents were 
anxious that operation should be done. 

The child was given chloride of ethyl-ether anaesthesia, and the 



430 PHILADELPHIA ACADEMY OF SURGERY. 

peritoneal cavity opened over the tumor. The posterior peri- 
toneum over the tumor was then divided and the entire mass 
removed. There seemed to be no extension beyond a well-defined 
capsule. The tumor was delivered through the abdominal wound 
before the pedicle was ligated. After ligating the blood-vessels 
of the pedicle an attachment to the lower portion of the tumor 
came into view, which turned out to be composed of kidney sub- 
stance, and extended across the spinal column to the opposite side, 
where it was attached to the other kidney. It was about the size 
of a little finger. The left kidney seemed normal in shape, and 
had a distinct pelvis. The connecting link passed to its lower 
pole. There was no evidence of any disease in this isthmus, 
which was then ligated and divided. The posterior peritoneum 
was closed and the abdominal wall closed in layers without drain- 
age. After removal the tumor was split and the growth foimd 
to be one which completely surrounded the kidney but only par- 
tially involved this organ. It had apparently started from the 
suprarenal. The specimen is nearly as large as the child's head. 
The ureter and calices were normal in size. One calix extended 
into the isthmus which had been divided. 

Pathological diagnosis of this growth was spindle-celled 
sarcoma. 

The boy made a prompt and very satisfactory convalescence. 
About a month after his operation he passed some blood in his 
bowel movements. Since that time, however, he has steadily 
improved in spite of an attack of measles, of chicken-pox, and 
one or two attacks of croup. He has gained ten or twelve pounds 
in weight and is passing a satisfactory amount of normal urine. 
There is no evidence of any hernia at the site of the incision, nor 
is there any evidence of any recurrence of the trouble. The boy 
has a good color and seems perfectly well. These large sarcomata 
involving the kidney are peculiarly fatal, and recurrence after 
removal usually takes place promptly. 

Dr. Henry R. Wharton thought it rather remarkable to have 
a child doing well a full year after an operation for sarcoma of 
the kidney. He recalled two similar cases in which recurrence 
took place within six months, proving fatal in a short time, and 
he had never had a case in which recurrence has not taken place 
sooner or later. 



EXCISION OF HEAD OF HUMERUS. 



431 



THE RESULT FIVE YEARS AFTER EXCISION OF THE HU- 
MERAL HEAD FOR CONGENITAL SUBACROMIAL DIS- 
LOCATION OF THE HUMERUS. 

Dr. John B. Roberts presented a boy, eight years of age, 
who was operated on for congenital dislocation of the left 
humerus at the Methodist Hospital five years ago.^ The head of 
the humerus was excised at that time. Examination shows the 
left humerus to be very much shorter than the right, but . the 
motions of the arm as a whole are much more free than at the 
time he was seen previous to operation. 

Measurements from the tip of the acromion to the external 
condyle are difficult to make with accuracy because of the boy's 
perpetual movements, but the right arm is apparently 9^ in. 
in length from the points mentioned; the left, 7 in. The upper 
end of the humerus seems to move quite freely under passive 
motion made by the surgeon and there is marked grating. 

When the child places his left hand on his right shoulder 
or on his head the scapula, however, moves with the humerus. 
He can put his left hand on the opposite shoulder, on the top of 
the head, and on the back of his neck, and move it from the 
occipital region to the vertex without difficulty and without using 
the right hand to aid the left arm by lifting the elbow as he did 
originally. He cannot raise the left arm outward much above the 
horizontal line, though he can sling it higher than that. 

Both arms hang at the side with the thumbs out and with 
the humerus quite near the chest. External rotation of the hand 
carries the thumb of the left hand nearly as far outward as on the 
right side. There is, however, no rotation made at the shoulder 
joint as on the normal side. The entire external rotation is in 
the forearm. The humerus can be rotated outward passively, 
but the little boy does not do it himself. It is a little difficult to 
get a true estimate of the ability to make the voluntary motions 
desired because of the boy's restlessness and inattention. The 
grasp of both hands is apparently the same, and the power of 
flexing and extending the elbow- joint seems alike on both sides. 
The biceps on the left side shows the abnormal swelling due to 
the loss of the proper attachment of one head, but the flexion of 
the elbow seems to be about as strong as on the other side. Su- 
pination of the hand is a little restricted. 

^ American Journal of the Medical Sciences, Dec, 1905. 



432 PHILADELPHIA ACADEMY OF SURGERY. 

The boy can bring the upper arm quite close to his ribs and as 
stated before can place the palm upon the neck and head with 
ease. He can pull his left ear and right ear, and can place the 
left hand readily behind him and touch the lumbar region with the 
back of the hand. 

There is some atrophy of the muscles in the supraspinous and 
infraspinous fossae of the scapula, as there is of the muscles of 
the forearm and upper arm. When he attempts to elevate the 
left arm, as in using the deltoid, he has to give it a swing, and the 
scapula moves with the humerus. He can then bring the arm 
up quite well, though he cannot retain it above the horizontal 
line. 

There is little, if any, lateral spinal curvature. 

There is shortening of the left clavicle, which from the sternum 
to the scapula measures 5^ in., whereas the left is 6 in. long. 
The ulna on the abnormal side appears to be the same length as 
that on the normal side, measuring 8% in. from the insertion of 
the triceps to the head of the ulna at the wrist. 

Dr. Gwilym G. Davis said that the bulk of these luxations 
seem to be congenital, very likely produced at the time of birth, 
traumatic ones acquired after birth being comparatively rare. 
He thought the congenital cases are more common than is usually 
supposed. It is usually caused by the internal rotation of the 
arm, and it would be interesting to know whether in this case 
there was a history of difficulty in birth. 

Dr. John B. Roberts said that these dislocations are supposed 
by many to be results of parturition. There have, however, been 
reported a few cases of bilateral dislocation, and several cases of 
the occurrence of this dislocation more than once in the same 
family. It seems unlikely that a child would get double sub- 
acromial dislocation of the humerus in parturition, or that two or 
three children in one family would have the same accident. He 
could not but believe that they are as much congenital as dislo- 
cations of the hip. Some believe them to be due to paralytic 
conditions of the arm produced at birth. They are interesting 
and deserve more study than is given them, for they are rare. 
Dr. Roberts believed them to be true congenital dislocations. He 
had seen but two such cases, the one operated upon and another in 
which the patient's friends objected to operation. 



Fig. 




Congeniial subacromial dislocation of the left humerus. Boy, aged three years Ob- 
serve abduction and mward rotation of humerus. Before operation, a, olecranon points 
directly outward and external condyle forward, b. head of humerus 



Fio. 



Fig. 3 





Excision of head of left humerus five years 
ago for congenital subacromial dislocation of 
humerus. Boy is now (Dec. 7, 1908) eight 
years old. Observe shortening of arm. 



Excision of head of humerus five years 
ago for congenital subacromial dislocation of 
humerus. Boy is now (Dec '7, 1908) eight 
years old. Observe shortening of arm and 
the ease with which left elbow is carried near 
chest. 



Fig. 4. 




Hand on head rest is up as high as he can get it with- 
out twisting body. Before operation five years ago he 
could not raise left arm without aiding it with other hand. 



Fig. s- 




Congenital subacromial dislocation of the left humerus before operation. Observe 
abduction rotation of humerus, shown by the elbow being held away from the thorax, 
with olecranon pointing outward. 



Fig. 6. 




_ Congenita] subacromial dislocation of the left humerus, after excision of the head. 
Skiagraph taken about three months after excision of the head of the humerus. 
Observe the absence of abnormal rotation of the humerus, which is seen in the skia- 
graph taken before operation. The abduction of the humerus seen here is voluntary. 



FRACTURE OF THE PELVIS. 



433 



FRACTURE OF THE PELVIS WITH RUPTURE OF THE 
ABDOMINAL WALL. 

Dr. Astley p. C. Ashhurst reported the case of a man, 26 
years of age, who was admitted to the Episcopal Hospital, in the 
service of Dr. Davis, Jan. i, 1908. He had been caught between 
two trains, his pelvis having been crushed laterally. There was 
no marked shock on admission. There was a comminuted frac- 
ture of the crest of the right ilium, from the region of the anterior 
superior spine backwards for about four inches, the larger frag- 
ment being about two inches in breadth and four inches long. 
There were no particular symptoms of intra-abdominal injury. 
Urine drawn by the catheter was clear. There were numerous 
abrasions and contusions, and there were several immense hsema- 
tomata in the subcutaneous tissues of right flank, external iliac 
fossa, right buttock, upper part of thigh, sacrum, and lumbar 
spine. Below the right costal border a rent in the abdominal 
muscles was clearly palpable through the skin, which was nowhere 
perforated. As the hsematomata steadily increased in size, it 
was determined to attempt the repair of the abdominal wall and 
the replacement of the fractured bones, and to exclude intra- 
abdominal injury by exploration. 

Accordingly, at midnight, four hours after the injury, a trans- 
verse incision was made at the level of the umbilicus, over the 
most evident seat of injury. This incision extended from the 
right semilunar line outward for three or four inches. Over a 
pint of fluid and clotted blood was evacuated, and a large and 
ragged rent was found in the oblique and transversalis muscles of 
the abdominal wall, with the lower intercostal nerves, apparently 
intact, spanning the gap like fine silken threads; a coil of gut, 
covered only by the parietal peritoneum, bulged into the wounded 
area. Tlie peritoneum was opened, and two fingers inserted for 
exploration at once caught hold of a long, thick, and rigid 
appendix, which was drawn out for inspection : The appendix 
was not inflamed, but contained a firm concretion near its tip, and 
its lumen was distended with fecal matter of the consistence of 
putty, thus accounting for its rigidity. The appendix was re- 
moved. A gauze sponge, passed into the pelvis, found no evi- 
dence of blood or faeces, so the peritoneum was closed. The rup- 
ture in the transverse muscles was repaired in layers, by buried 
sutures of chromic gut, and the skin incision was then enlarged 

15 



434 PHILADELPHIA ACADEMY OF SURGERY. 

at right angles to the first, downwards over the site of the fracture 
of the pelvis. Here the oblique muscles were found completely 
detached from the crest of the ilium, and the iliacus also was torn 
loose from the internal iliac fossa for two inches towards the 
sacro-iliac joint. The whole crest of the ilium was broken loose, 
and was drawn downwards and outwards on to the buttock, by 
those few fibres of the glutei muscles which had not themselves 

Fig. 7. 



Fracture of crest of right ilium, with rupture 
of the abdominal wall. (Shaded area represents 
haematomata.) 

been ruptured. Much liquid and clotted blood was evacuated 
from this region also. The displaced fragments were pulled back 
to their normal relations, and were held there by passing inter- 
rupted mattress sutures of heavy chromic catgut, by means of a 
Reverdin needle, from the gluteal muscles below, through the 
remains of periosteum and muscular tissue on the crest of the 
ilium, and up through the oblique muscles of the abdominal wall, 
and then back again to the starting point in reverse order, so that 
when these mattress sutures were pulled tight and tied, they 
drew the gluteal muscles up from below, and the oblique muscles 



Fig. 8. 




Fracture of pelvis with rupture of abdominal wall. Counter- 
incision in loin to drain haematoma. 



EXTRAPERITONEAL RUPTURE OF BLADDER. 



435 



down from above, and thus fixed the ihac crest with reasonable 
security between the two. Drainage from the fractured area was 
provided for by a rubber tube and two pieces of gauze. The 
superficial fascia was sutured with buried sutures, and the skin 
with silk-worm gut. Finally, an incision was made over the 
haematoma in the kidney region, and this was drained by a rubber 
tube. No attempt was made to evacuate all the blood in the 
various haematomata, as to do so would have required incisions 
all down the thigh as well as over the sacrum. Yet the sound of 
the liquid blood splashing about in these cavities was sufficiently 
alarming as the patient was lifted off the operating table, the ad- 
mission of air to the cavities making the sounds very audible 
even across the room. The duration of the operation was fifty 
minutes. 

The patient did well, and it was noted the next day that there 
was no pain except on motion. By the third day all the other 
hsematomata had drained out through the one opening. Three 
weeks after the operation (Jan. 21, 1908) there was high fever, 
and considerable constitutional disturbance, due to the damming 
up of a haematoma in the loin. This was opened through the 
original incision in the loin, and the temperature reached normal 
the next day. At this time the abdominal incisions were prac- 
tically healed, only a small sinus remaining. The bone seemed 
firmly fixed in place. 

The patient sat up in a chair on February 17, and was dis- 
charged about the first of March, walking with a moderate limp. 
He has been an out-patient since that time, and now walks with- 
out any limp, and has no disability of any kind. A small sinus, 
due to slight caries at the site of fracture, persists, but it requires 
to be dressed only once in ten days, there being almost no dis- 
charge. The abdominal wounds are firm, and there is not the 
slightest tendency to hernia or bulging of that portion of the 
abdomen. He has been doing light work all summer, but has 
not yet returned to his work of railroad brakeman. 

EXTRAPERITONEAL RUPTURE OF THE BLADDER, WITHOUT 
FRACTURE OF THE PELVIS— TWO CASES. 

Dr. Ashhurst related the histories of the following two 
cases : 

Case I. — Archibald McD., aged 43 years, was admitted to 
the service of Dr. Davis, Jan. 30, 1908. While at work, in a 



436 PHILADELPHIA ACADEMY OF SURGERY. 

stooping posture, he had been struck across the right loin by a 
falHng telegraph pole, and was crushed to the earth. On admis- 
sion he was seen by Dr. Davis ; at this time there was moderate 
shock (temperature, 97.2° F. ; pulse, 88; respiration, 32), and 
it was ascertained that two ribs on the right were fractured ; there 
were no other symptoms. About five hours later, signs of inter- 
nal hemorrhage began to be evident, the patient having recovered 
from his shock. There was great tenderness over the right kid- 
ney region, and some abdominal rigidity. Nearly pure blood, 
with no clots, was drawn by catheter. Small amounts of boric 
acid solution injected by the resident into the bladder were all 
recovered. (Later it was learned that only two ounces at a time 
had been injected.) Examination at this time showed evidences 
of deep haematoma in the right lumbar region, with swelling, 
dulness, and marked tenderness. Dr. Ashhurst thought it prob- 
able that there was an extraperitoneal rupture of the right kidney. 
Operation at 9.45 p.m., about eight hours after the injury. 
An oblique right lumbar incision was made, retroperitoneal; a 
moderate-sized hsematoma was evacuated from among the lumbar 
muscles, but the kidney when brought into the wound was found 
to be uninjured. The lumbar wound was closed without drain- 
age. The patient was turned over on his back, and a hypogastric 
incision through the right rectus muscle was made. Free extra- 
peritoneal hemorrhage was found in the space of Retzius, but 
it was decided to explore the other kidney and the ureters as a 
matter of precaution. The peritoneum was therefore opened: 
the intestines were normal, and there was no free fluid; the left 
kidney was found normal on palpation, and no evidence of intra- 
peritoneal injury could be discovered. There was a large haema- 
toma in the extraperitoneal tissues of the left pelvis and the left 
iliac region. The median hypogastric incision was closed without 
drainage; and a third incision was made through the left rectus 
muscle, close to the pubic bone, opening the extraperitoneal 
hsematoma, which seemed to have its origin around the neck of 
the bladder and the prostate, though no definite rupture of the 
bladder could be found. A catheter passed by the urethra showed 
the bladder to be empty, and no rupture could be brought to view. 
The oozing areas around the neck of the bladder were packed with 
iodoform gauze, and the bladder was opened at its dome, was 
stitched to the abdominal wall, and drained by a large rubber tube. 
The operation lasted one hour. During most of it the patient 



EXTRAPERITONEAL RUPTURE OF BLADDER. 437 

was pulseless, and only by the use of saline solution intravenously 
did he leave the operating room alive. 

The next morning the patient appeared to have some chance 
of recovery; four ounces of nearly clear urine had drained from 
the bladder, and there was very little hemorrhage from the pelvic 
tissues. Up to the time of death, twenty-nine hours after opera- 
tion, eleven more ounces of urine drained from the bladder, or 
fifteen ounces in all since the operation. As there was no further 
bleeding, and no evidences of peritonitis, death was attributed to 
shock. 

Case II. — Fred S., aged 20 years, was admitted to the service 
of Dr. Frazier, Nov. 23, 1908. While driving a wagon it rolled 
down an embankment, killing one of the horses, and crushing 
the patient. On admission there was considerable shock (tem- 
perature, 97° F.) ; there was inability to pass urine, and pure 
blood was drawn by the catheter. It was impossible to recover 
any fluid which was injected. There was great abdominal pain 
and rigidity, with dulness in the flanks, which seemed to be varied 
by the position of the patient. There was dulness in the supra- 
pubic region, and no change was produced in this dulness by in- 
jections through the catheter. No fracture of the pelvis could 
be demonstrated even by rectal examination. On account of the 
great abdominal rigidity and tenderness, with the doubtful mova- 
ble dulness in the flanks, it was considered wise to explore the 
abdomen, though the diagnosis of intraperitoneal rupture of the 
bladder was not definitely made. 

A median hypogastric incision was made six hours after the 
injury. There was blood in the space of Retzius, and on opening 
the peritoneal cavity a little bloody fluid was found. This came 
from a rent of the bladder, involving the serous coat only, to the 
left of the middle of the posterior wall. This area was sutured 
with a continuous Lembert suture of linen. The lower angle of 
the peritoneal incision was closed, and a gauze drain from the 
pelvis was brought out of its upper angle. Then, through the 
same hypogastric wound, but extraperitoneally, the bladder was 
detached from the pelvic wall, and liquid blood and clots were 
evacuated from the extraperitoneal region to the left of and in 
front of the bladder. No bleeding points could be detected, and 
no definite rupture of the bladder could be found. Two gauze 
packs were placed to the oozing area around the triangular liga- 
ment and neck of the bladder, both extraperitoneally. The blad- 



438 



PHILADELPHIA ACADEMY OF SURGERY. 



der was then opened, and bloody urine escaped; the end of the 
catheter in the urethra could not be felt within the bladder ; evi- 
dently it had passed into the haematoma to the left of the bladder, 
through a rupture in the neighborhood of the prostatic urethra. 
The bladder was drained by a rubber tube, through the supra- 
pubic wound, and the middle of the abdominal incision was closed, 
leaving the peritoneal drain emerging at the upper end and the 
extraperitoneal and bladder drainage emerging at the lower end. 
The time of the operation was forty-five minutes. 

The patient rallied well from the operation, but died in twenty- 
four hours with ursemic symptoms (restlessness, delirium, slight 
dyspnoea, etc.) ; there were no symptoms of peritonitis. Ex- 
amination of the wound after death showed no fluid in the 
peritoneal cavity, no inflammatory lymph, no adhesions, and no 
injury to any viscera except bladder. There had been no more 
hemorrhage from the extraperitoneal region where the rupture 
of the bladder was supposed to be. No fracture of the pelvis was 
detected. 

Dr. Ashhurst said that in order to gain some idea of the mor- 
tality and complications of cases of fracture of the pelvis, he had 
searched the records of the Episcopal Hospital from Jan. i, 1895, 
to Dec. I, 1908. During that period there had been treated in 
the wards 57 patients with fracture of the pelvis; 18 of these 
patients died, a mortality of 31.57 per cent. Of these 18 fatal 
cases, there were no visceral injuries in 8, death in most of these 
cases being due to other injuries (crushes of the extremities, frac- 
tures of the skull, etc.). There were 10 cases complicated by 
visceral injury, as follows : 

Cases. Recovered. Died. 

Rupture of the urethra 4 i 3 

Extraperitoneal rupture of bladder. .4 i 3 
Rupture of undiscovered portion of 

urinary tract i i 

Rupture of liver I i 

10 2 8 

In addition to the above cases of extraperitoneal rupture of 
the bladder, there had been treated 3 other cases (all fatal) with- 
out fracture of the pelvis, including the two cases reported by 
Dr. Ashhurst to-night. Among the entire series of 7 cases of 
extraperitoneal rupture of the bladder, only one patient recovered 
(see Case VI in appended list). 



EXTRAPERITONEAL RUPTURE OF BLADDER. 



439 



As to the relative frequency of intraperitoneal and extra- 
peritoneal ruptures of the bladder, it was generally stated that 
the latter were much rarer, forming only lo to 20 per cent, of all 
cases of rupture of the bladder ; and this statement had been made 
by Dr. Ashhurst himself, in publishing statistics of no cases of 
intraperitoneal rupture of the bladder treated by laparotomy 
(Amer. Jour. Med. Sc, 1906, ii, 17). But as he had found only 
3 cases of intraperitoneal rupture at the Episcopal Hospital, to 
7 cases of extraperitoneal rupture, he was inclined to think the 
rarity of the latter had been overestimated. It must be acknowl- 
edged, however, that in many of these, as in most other cases of 
extraperitoneal rupture reported, no definite rupture had been 
found, the diagnosis being based on the presence of bloody urine 
both inside the bladder and in the extraperitoneal pelvic tissues. 

In regard to ruptures of the abdominal wall from crushing 
force, they must be acknowledged to be extremely rare. Besides 
the case now reported, where there was also fracture of the pelvis, 
only one other case had been found at the Episcopal Hospital since 
1895. This was in a patient of Dr. Neilson's (C. W., 23 yrs., 
April 24, 1900), who also had extraperitoneal rupture of the 
bladder, but no fracture of the pelvis. Although the abdominal 
wall was repaired as well as possible, death occurred the next day. 

CASES OF FRACTURE OF PELVIS COMPLICATED BY VISCERAL INJURY, 

(Episcopal Hospital, Phila., 1895-1908.) 

I. Fracture of Rami of Pubis and Ischium, Rupture of Urethra. — Frank 
D., 29 yrs. Adm. March 26, 1896. Treated by catheterization. Recov- 
ered. 

IL Fracture of Pelvis, Fracture of Skull, and Rupture of Urethra. — 
John B., 23 yrs. Adm. March i, 1897. Developed emphysema of abdomi- 
nal wall, and peritonitis. No operation. Died in 2 days. 

in. Compound Fracture of Ilium and Pubes, Rupture of Urethra. — 
Chas. P. M., 22 yrs. Adm. May 24, 1905. Railroad crush. All muscles 
of thigh and buttocks completely torn out. Bleeding from urethra. 
Wounds packed. Catheter in urethra. Died in 2 days. 

IV. Fracture of Left Pelvis, Rupture of Urethra, Dislocation of Left 
Femur, Rupture of Left Lung. — Frank K., 32 yrs. Adm. May 9, 1907. 
No operation. Died in i day. 

V. Compound Fracture Left Ilium, Extraperitoneal Rupture of Blad- 
der, Rupture of Femoral Vein. — Alfred M., 25 yrs. Adm. Aug. 27, 1903. 
Existing wound enlarged by resident, Dr. Havens, femoral vein ligated, 
extraperitoneal pelvic tissues packed. Died in 2 hours. 

VI. Fracture of Pubic Ramus, Crush of Left Leg, Extraperitoneal 
Rupture of Bladder.— James B., 23 yrs. Adm. Oct. 8, 1903- Leg ampu- 



440 



PHILADELPHIA ACADEMY OF SURGERY. 



tated on admission ; bloody urine by catheter, but no other pelvic symp- 
toms. Two weeks later, a fluctuating swelling in left groin was opened by 
Dr. Hutchinson, urine and blood evacuated from extraperitoneal pelvic 
tissues, and rupture in anterior wall of bladder found. Bladder drained 
by tube. Recovered. 

VII. Fracture of Rami of Pubis and Ischium, Both Sides; Extraperi- 
toneal Rupture of Bladder. — Frank B., 46 yrs. Adm. Sept. 2, 1907. No 
operation. Died in 4 hours. 

VIII. Fracture of Descending Ramus of Right Pubis, Hcematoma in 
Space of Retzius. — Harry F., 48 yrs. Adm. May 17, 1908. Operation by 
Dr. Neilson 24 hrs. after injury. Peritoneum opened, intestines punc- 
tured for flatus, no obstruction found. Extraperitoneal pelvic tissues 
packed to control hemorrhage, possibly from obturator artery. Blood in 
urine; but no definite rupture of bladder found. Died in 7 hours. 

IX. Fracture Near Right Sacro-iliac Joint; Perhaps Rupture of Ureter. 
Adam M., 59 yrs. Adm. Aug. 14, 1905. Fell 35 feet. Fluid injected into 
bladder all recovered. Operation by Dr. Deaver, 7 hours after injury. 
Free fluid, mostly urine, in peritoneal cavity ; no rupture of bladder. Then 
right lumbar incision, no rupture of kidney found, none could be found 
in ureter or its pelvis. Packed. Died in 12 hours. 

X. Fracture of Right Pelvis, Rupture of Liver. — John F. McG., 24 yrs. 
Adm. March 26, 1906. Symptoms of internal hemorrhage. Patient re- 
fused operation for 24 hours. Then operation by Dr. Davis ; pint of free 
blood in peritoneum, large laceration in liver packed; sponged dry. Did 
well for 2 days, then developed peritonitis, and died on 5th day. 

APPARATUS FOR THE CONTINUOUS ADMINISTRATION OF 
SALINES BY THE RECTUM. 

Dr. Gordon J. Saxon, by invitation, made a demonstration 
of an apparatus for the continuous administration of saline by the 
rectum. For the description of this apparatus see page 404. 

Dr. a. D. Whiting said there are two or three advantages of 
this apparatus. One is that the rapidity of the flow can be 
regulated very readily by means of the pinch-cock. Without the 
shunt there is no way for the patient to relieve himself of gas, 
and if the bowel becomes distended by the solution not being 
absorbed there is bound to be contraction of the muscle and 
expulsion, if there is not some way by which the solution can flow 
back. It can readily be seen that this prevents the soaking of the 
bed. There is always free circulation and the gas can be seen 
passing into the bottle, and very often colored solution coming 
back from the rectum. One of the most important things is the 
tube, which prevents to a great extent the reduction in tempera- 
ture of the solution. As employed at the Germantown Hospital 
the temperature of the solution as it enters the rectum has ranged 
from above 90° to 105° for two or three hours, and the benefit 
to the patient is much greater than if a cooler salt solution is given. 



BOOK REVIEWS. 



General Pathology. By Ernst Ziegler, late Professor of 
Pathological Anatomy and of General Pathology in the Uni- 
versity of Freiburg, in Breisgau. Translated from the 
Eleventh Revised German Edition (Gustav Fischer, Jena, 
1905). Edited and brought up to date by Alfred Scott 
Warthin, Ph.D., M.D., Professor of Pathology and Director 
of the Pathological Laboratory in the University of Michi- 
gan. With 604 illustrations in black and in colors. William 
Wood & Company, New York, 1908. 

The present copy of this work is the American translation 
of the eleventh edition, which was published by Ernst Ziegler 
in 1904 ; less than a year later. Dr. Ziegler died, so this will be 
the latest record which he leaves to the medical profession. Hi« 
fame certainly rests more upon his text-book than upon the 
results of his investigations, although among these are included 
a number of very important contributions. The book itself has 
been translated into several languages and has become a familiar, 
and in many cases a final, authority that has been referred to 
wherever the study of pathology was prosecuted. The ideas 
which his work embody form a particularly splendid example of 
a scientific text-book as free as possible from subjectivity, one- 
sidedness and prejudice. Its influence heretofore upon the more 
recent developments of medicine has been very marked, especially 
because of the late idea which has been fostered that the publica- 
tion of text-books should be discouraged when compared to the 
prosecution of research work. Of the intrinsic worth of a volume 
such as the one under consideration, there can be no question and 
it is particularly fortunate that we have had in the late Dr. Ziegler 
a man who has rendered to the world as great a service as if his 
efforts had been directed to that of pure investigation, instead of 
so wisely sifting the great mass of collected investigations, judging 
them as to their worth without prejudice, and bringing from the 
chaos a tangible order and scheme. 

The last few years have been so replete with new ideas which 

441 



442 BOOK REVIEWS. 

have, in many cases, been found to embody important facts, that 
it has become almost impossible to review all of the great mass 
of literature concerning the new strains of pathogenic micro- 
organisms and their effects on the human organisms. But the 
essential facts, and those which represent actual advance in our 
knowledge of pathological processes, the author has incorporated 
in the contents of this book. Special mention should be made of 
the researches of Shaudinn on the spirochaetse and parasites of 
malaria, also of the work done on the trypanosomata, various 
pathogenic bacteria, the agglutinins, precipitins, cytolysins, and 
the hsemolysins, as well as the numerous investigations and theo- 
retic observations that, based upon Ehrlich's side-chain theory, 
have been carried out concerning the toxic action of bacterial 
products, and the formation of antitoxic and antibacterial 
substances. 

Of interest, also, at the present time, is the question of tuber- 
culosis. The author's views concerning its etiology and genesis 
seem not to have been materially altered, and he concludes that 
Koch's view as to the difference between human and bovine 
tuberculosis is applicable only in so far as certain differences 
in the characteristics of the two strains of bacilli are concerned; 
for all these differences, it is true that bovine tuberculosis is com- 
municable to man, and that domestic animals may become infected 
from tuberculous human beings. The theory, which seems very 
plausible, that infants may be easily infected through milk, has 
merely confirmed well-known facts; however, his attempt to 
refer all cases of tuberculosis to intestinal infection during infancy, 
is hardly tenable. 

The recent investigations concerning the etiology, genesis, 
and morphology of neoplasms have received analytical consid- 
eration, and it is to be noted that their greatest value has been 
reached in the researches on the histogenesis of tumors ; the 
later views of Ribbert and Borrmann that the tumor development 
is to be found in the isolation, disconnection and misplacement 
of germinal anlage or of single cells during embryonal or extra- 
uterine life, together with those of Crompecker that the epithelial 
cells can become transformed into connective-tissue cells, have 
been discredited by the authors. 

Significant advances over the former edition are also noticed 
in the theories of fatty degeneration and glycogen deposit. The 



BOOK REVIEWS. 



443 



arrangement of the book is left, on the whole, as in the last 
edition. In the translation, which seems to have taken an excep- 
tional amount of time, the original matter has been given without 
change or omission. 

The progress of pathological knowledge, however, has been 
so rapid that the American editor has found it absolutely essential 
in a great many instances to insert paragraphs and data at the 
end of the various chapters, in fine print; these addenda are 
particularly noticeable regarding the recent observations on the 
effect of Rontgen irradiation, heredity, phagocytosis, opsonins, 
blood-plates, thrombosis, necrosis, cloudy swelling, fatty degen- 
eration, regeneration, inflammation, malignant neoplasms, tuber- 
culosis, syphilis, relapsing fever, spirochaetae, protozoa, etc., and 
has thus made the attempt to bring the work up to the date of 
issue. The styles of the two authors are very distinct, that of the 
translator, in many cases, tending to theoretical rather than to 
actual advances. In some instances it is noticed that he has 
repeated some of Dr. Ziegler's remarks; a case in point may be 
found by referring to pages 169 and 132. We also note that 
he does not, in all instances, keep within the province and mean- 
ing of the work ; for instance, on page 197, we find that he makes 
a lengthy consideration which is almost entirely in the domain of 
physiological chemistry. The book in general is merely a com- 
pilation of facts ; it is in many cases disconnected and does not 
read easily. 

Pre-eminently it is the duty of the pathologist, as teacher, 
to train the student in habits of medical thought and to show how 
such data as may be at hand are to be weighed, and what deduc- 
tions may logically be drawn therefrom, and to put these remarks 
into such form that the investigator of a particular case may 
recognize individual symptoms not as isolated facts but as corre- 
lated pathological conditions, and thus form a judgment regarding 
the causation and meaning of the symptom-complex of a case. 
This one finds very difficult to accomplish from the reading of 
the work in question. As Bacon says : " Vere scire est per causas 
scire," which axiom, as far as regards medicine or surgery, can 
only be gained by the most thorough knowledge of the teaching 
of our great pathologists, among whom Dr. Ziegler is certainly 
to be accounted one. 



444 BOOK REVIEWS. 

A Text-book of Operative Surgery, Covering the Surgical 
Anatomy and Operative Technic Involved in the Operations 
of General Surgery. By Warren Stone Bickham, Ph.M., 
M.D., Visiting Surgeon to Charity and Touro Hospitals, 
New Orleans. Third Revised Edition. Octavo of 1206 
pages, with 854 illustrations. W. B. Saunders Company, 
Philadelphia and London, 1908. 

In reviewing this, the third edition, of Dr. Bickham's " Text- 
book of Operative Surgery," one can not help but remark the 
painstaking labor that must have been expended in its prepara- 
tion. The general character of the text is that which has been 
used in the preceding edition. 

The book is divided as follows, — Part I : Operations of Gen- 
eral Surgery. Part II : Operations of Special Surgery. 

The subject is well systematized and arranged in an entirely 
original manner. Preceding each operation, whether in Part I or 
Part II, the following scheme is used: (i) Surgical anatomy 
of the region or organ; (2) Surface-form and landmarks; (3) 
General surgical considerations; (4) Instruments used in the 
particular operation; (5) Description of the operation; (6) 
Preparation of the patient; (7) Position of the patient, surgeon 
and assistant; (8) Landmarks of operation; (9) The incision; 
(10) Steps of operation; (11) Comments. This scheme, as 
might be imagined, entails some degree of reiteration where cer- 
tain operations resemble each other in their various steps; how- 
ever, this is brought to a minimum by a reference to steps in 
preceding descriptions. 

Critically considered, there are many objections which may 
be raised. In considering the anatomical relations of various 
regions, the author introduces an unnecessary amount of text; 
tills could be obviated by the insertion of a suitable diagram 
with a concise description that would give the information desired 
much more clearly and more comprehensively to the reader. A 
case in point may be found on page 149, where one finds a particu- 
larly dry description of the surgical anatomy of the anterolateral 
aspect of the neck. It is to be noted, also, that while the author 
has introduced a large number of illustrations showing the rela- 
tions of nerves, arteries and veins, they are not clear, and have to 
be studied for some time in order to find out which structure one 



BOOK REVIEWS. 



445 



is looking at. This might be obviated and, at the same time, give 
a marked attractiveness to the book, if the artery, vein and nerve 
were depicted in colors ; and there would also be a marked saving 
in the amount of text used. 

The consideration of operations upon the abdominopelvic 
region is very complete and explicit. It is to be noted, however, 
that the description of McBurney's intramuscular incision and 
operation for appendectomy is repeated on pages 807-8 and 
900! This is unfortunate and unnecessary. Under the caption 
of the colostomies, we find the comment that caecostomy is rarely 
performed ; exception, I think, may be taken to this. The author 
includes in the same section the description of lumbar colostomy ; 
this has become so obsolete that it might well be omitted with 
value to the book. In considering excision of the rectum, we 
find no description of the combined abdominal and sacral routes 
in conditions where the superior part of the rectum is involved ; 
nor is there any description of excision of the rectum through the 
vaginal route. Unnecessary space is accorded the subject of 
cholecystolithotrity ; this should be entirely omitted. 

The book is well illustrated by accurate and original draw- 
ings ; the text is clear and succinct. The author, in his com- 
ments, might have devoted a little more space to the comparative 
value of the various operations. The book forms as a whole a 
most convenient reference for all operative procedures, and repre- 
sents the most approved surgery and surgical technic of the 
present day. Any one following Dr. Bickham's technic will start 
right at any rate, and a careful reading of his admirable descrip- 
tions and consideration of their accompanying illustrations will 
put the operator a long way ahead of the one who takes his initial 
steps erroneously. 

The Popes and Science, By James J. Walsh, M.D., Ph.D., 
LL.D., Professor of the History of Medicine and of Nervous 
Diseases at Fordham University School of Medicine ; etc. 
Pages 431. Fordham University Press, New York. 

This book is a history of the papal relations to science during 
the Middle Ages and down to our own time, written from the 
standpoint of a loyal son of the Church, who has been moved to 
undertake the task by what he believes to be the misstatements of 



446 BOOK REVIEWS. 

many English-speaking historians and, more particularly, as is 
evident from the references in the text, of Andrew D. White's 
*' Warfare of Science with Theology." It is necessarily, there- 
fore, controversial in its tone, but nevertheless will richly reward 
the reader for the time given to its perusal. Aitdi alteram par- 
tem is a good motto for universal adoption. In the heat of con- 
troversy, and especially political and religious controversy, erron- 
eous and exaggerated statements are inevitable, and such state- 
ments by much repetition may become ultimately accepted as 
unquestioned truth. Dr. Walsh himself says that in his earlier 
professional years he had accepted the general opinion that there 
had been many papal documents issued, which, intentionally or 
otherwise, hampered the progress of science. His later personal 
investigations of the subject had brought him, however, to an 
opposite conclusion. The results of his investigations and the con- 
clusions to be derived from the facts thus brought out have been 
embodied by him in the present volume. He finds that the sup- 
posed papal opposition to science was practically all founded on 
an exaggeration of the significance of the Galileo incident. As 
a matter of fact, the popes were as liberal patrons of science as of 
art. In the renaissance period, when their patronage of Raphael 
and Michael Angelo, and of other great artists did so much for 
art, similar relations to Columbus, Eustachius, Caesalpinus and 
later, to Steno and Malpighi, had like results for science. He 
says that for seven centuries the popes selected as their physicians 
the greatest scientists of the time, and the list of papal physicians 
is the worthiest series of names connected by any bond in the 
history of medicine, far surpassing in scientific import even the 
roll of the faculty of any medical school. The material bearing 
upon this point is now gathered into compact form for the first 
time. The author makes out a good case, and one rises from a 
perusal of the book with a feeling that the attitude of the Roman 
Catholic Church to science was, perhaps, not so bad as it has 
been painted. Such had been the conclusion which the reviewer 
had come to from his own independent and fragmentary re- 
searches. Many things which were incident to the times and were 
expressions of the rude and imperfect development of thought 
at the period, have been attributed to the Church itself because 
the Church was the dominating figure of the period, overlooking 
the fact that the Church in its relations to men partook in large 



BOOK REVIEWS. 



447 



measure of the mental conceptions and social manifestations of 
each succeeding period, preserving through all, however, an 
ameliorating and saving influence, so that it has been a marked 
factor in the progressive betterment of the world. On the other 
hand, it is not to be denied that in the more recent centuries 
knowledge has progressed most satisfactorily in those countries 
which were the freest from the overwhelming dominance of 
religious dogma. 

Surgical Memoirs and Other Essays. By James G. Mum- 
ford, M.D., Instructor in Surgery, Harvard Medical School, 
etc. Moffat, Yard & Co., New York, 1908. Octavo, pp. 
350 ; numerous illustrations. 

This is a book worthy of more than passing notice. It is 
a series of historical studies, and must tend to help any surgeon 
who reads it to a wider and more philosophical view of his pro- 
fession, and make him a better and broader surgeon. More than 
one-fourth of the volume is made up of a reprint of Dr. Mum- 
ford's chapter, " History of Surgery," that appeared as an intro- 
duction to Keen's " System of Surgery." Then follows an excel- 
lent chapter on " Teachings of the Old Surgeons," in which he 
shows that some of our surgical fathers did good work, notwith- 
standing their limitations, an acknowledgment which the surgeons 
of the present time, in their state of exaltation as to modern 
achievements and possibilities, are prone to forget. Biographical 
essays upon Astley Cooper, Benjamin Brodie, John Collins Warren 
and Jacob Bigelow further pursue the same thought in detailing 
more at length the characteristics and achievements of these mas- 
ters in surgery of the past. Very properly the book concludes with 
an address upon History and Ethics in Medicine, for really the 
whole book is a contribution to history and ethics. Dr. Mum- 
ford's style is pleasing ; what he has to say he says in such a way 
as to attract attention to his thought and to leave a clear impress 
upon the mind of the reader. The book is entertaining as well 
as profitable. 



CORRESPONDENCE. 



INTESTINAL INTUSSUSCEPTION COMPLICATING TYPHOID 

FEVER. 

Editor Annals of Surgery : 

In connection with the report in the January number of the 
Annals of Surgery of cases of Intussusception Complicating 
T}'phoid Fever, I desire to place on record the following case in 
my own experience : 

A female child, aged eight and a half years, had passed 
through an attack of typhoid fever of moderate severity. On 
the morning of April 25, 1907, her temperature was normal; 
that night, about a half-hour after a bowel movement, she was 
taken with severe pain in the abdomen, which was referred espe- 
cially to the right iliac region ; there was considerable nausea, 
slight vomiting, marked collapse, pulse 140, body covered with 
perspiration. A hypodermic of morphine, with hot applications, 
relieved the pain and so improved the general symptoms that it 
was thought best to wait for morning before further intervention. 
With the morning there was found present slight abdominal dis- 
tention and pain, but the right rectus was very rigid so that the 
presence of a perforation was felt to be probable. 

She was removed to the Cohoes Hospital where, at 2 p.m., the 
abdomen was opened. Examination revealed no peritonitis, but 
an intussusception of the ileum about eight inches from the 
caecum ; the telescoping was about three-quarters of an inch in 
extent ; this was relieved and the patient went on to uninterrupted 
recovery, leaving the hospital on the fourteenth day. 

J. F. McGarrahan, M.D., 
Cohoes, N. Y. 



448 



Annals of S 



NNALS OF OURGERY 



Vol. XLIX APRIL, 1909 No. 4 



ORIGINAL MEMOIRS. 



AN ANALYTICAL AND STATISTICAL REVIEW OF 
ONE THOUSAND CASES OF HEAD INJURY. 

BY CHARLES PHELPS, M.D., 

OF NEW YORK CITY, 
Surgeon to Bellevue and St. Vincent's Hospitals. 

The analysis of so large a number of complicated cases of 
head injury is necessarily prolix, but can hardly fail to have 
interest and value to those who study cranial and intracranial 
injuries. It will serve as a supplement to an earlier work 
(" Traumatic Injuries of the Brain and its Membranes," 
Phelps, 1 897-1 902), and will practically corroborate the gen- 
eral statements made at that time. 

The cases cited are limited now, as they were then, to 
those personally observed ; and all inferences, conclusions, and 
statements of fact are based exclusively upon that observation. 
Extracranial injuries other than fractures have not been noted, 
as with the advent of aseptic precautions they have ceased to 
be of practical importance except as aids in the diagnosis of 
intracranial lesions. Cutaneous wounds which through 
neglect have become infected are still readily amenable to 
local antiseptic treatment, even in the exceptional instances in 
which they are responsible for secondary intracranial in- 
flammations. 

Head injuries, as they will be considered, are most con- 
veniently classified primarily as fractures of the cranial vault, 
16 449 



450 



CHARLES PHELPS. 



fractures of the cranial base, and independent injuries of the 
cranial contents. They most frequently complicate each other, 
and possibly in a majority of cases all these conditions are 
present together; but any one may exist practically by itself, 
and its separate existence may be recognizable and may de- 
termine prognosis and treatment. 

SUMMARY OF CASES. 

Cases Recoveries Deaths Necropsies 

Fractures of cranial base 570 259 311 203 

Fractures of cranial vault. .. 213 152 61 46 
Independent injuries without 

demonstrable fracture .... 217 130 87 63 

Totals 1000 541 459 312 

The class last mentioned includes cases in which the absence 
of fracture is assumed from the absence of characteristic 
symptoms ; and as in many instances a fractured base has been 
discovered post mortem when no indications had existed dur- 
ing life, it doubtless includes a very considerable number of 
cases which were really cases of fracture. 

It is perhaps the most notable feature of this table that the 
recoveries exceed the deaths in number; and that even with 
fractures that involve the cranial base, which were long sup- 
posed to be almost if not quite invariably fatal, the recoveries 
so nearly approximate the fatalities. 

Fractures of the Skull. — These may be as variously 
classified in accordance with their character and location as 
are those of the extremities; but their simple division into 
fractures of the vault and fractures of the base is distinctive 
and therefore the most convenient. Each of these grand di- 
visions may be subdivided into simple, compound, depressed, 
punctured, and complicated, as are other fractures, and occur 
with varying degrees of frequency and importance as they 
aflfect one region or another. 

It has been found in this collection of cases that the vast 
majority of fractures of the base originate in the vault, and 
are continuations of fissures, which, beginning at the point 



CASES OF HEAD INJURY. 45 1 

upon which the impact of external violence was received, fol- 
low the line of least resistance into the corresponding basal 
fossa, where they terminate, or whence they extend into the 
adjacent or even into all the fossae. They should be considered 
as fractures of the base rather than of the vault because it 
is from implication of that region that their characteristic 
conditions depend. Various theories explanatory of the ex- 
tension of fractures from the vault to one region of the base 
rather than to another were noted in that earlier work (lib. 
cit.) to which reference has been made, and to which it will 
often be necessary to refer hereafter. The larger experience 
has suggested no modification of what was then said, and its 
repetition may be avoided as not essential to the present 
purpose. 

Direct Fractures. — The whole number of cases in which 
with force transmitted from the vault the fracture was con- 
fined to the base, as verified by subsequent necropsy, was 
forty-six. In seven of these there was coincident but inde- 
pendent fracture of the vault, which sometimes involved the 
base in some distant region. It is not impossible that there 
were unrecognized direct fractures among cases which termi- 
nated in recovery, or in death without post-mortem examina- 
tion, since of those discovered many did not contribute to 
the fatal result, and fully one-half were unaccompanied by 
symptoms indicative of fracture. 

There were additionally cases of fracture of the base from 
force directly applied. These include eighteen of pistol-shot 
origin, a small number of perforations of the orbit with punc- 
tured wound, and three or possibly four in which orbital or 
ethmoid fracture was produced by great violence inflicted in 
the orbital or nasal region. 

No history was obtainable in one-third of the cases in 
which fracture was limited to the base ; in one-half the number 
the patients had fallen variable distances, as from the mizzen 
top into the hold of a vessel to a mere fall on the street or to 
the floor from a bench in a police station; in the remaining 
cases they were struck upon the head or knocked down by some 



k 



452 



CHARLES PHELPS. 



moving vehicle; and in two exceptional instances the head 
was forcibly flexed in the occipitomental diameter upon an 
unyielding obstruction by a descending elevator. 

Any one or more of the basal fossae may be involved in 
a direct fracture, or it may be limited to the petrous portion. 
All the fossae were included in two cases, and all but one 
anterior fossa in three others. The middle fossa was alone 
fractured in twenty cases, and was implicated in thirteen 
more. A single orbital plate, or the petrous portion, was 
sometimes the only part to be involved. So far as it was 
possible to determine the point or region upon which the 
force of impact had been exerted, its relation to the site of 
fracture was inconstant. It is not as obvious that the direct 
basal fracture was produced in the line of least resistance, as 
it seemingly was in the cases where fracture was prolonged 
from a point of impact upon the vault. In some instances in 
which a fracture limited to an orbital plate or to a sphenoid 
process followed a blow upon the eye, force must have been 
transmitted directly through the soft parts. In the larger 
number of cases fracture was produced indifferently upon 
the side of injury, or upon its opposite, or in any of the cranial 
diameters. In such case it becomes difficult to determine 
whether transmission was through the bone or through the 
cranial contents, as well as clinically unimportant. There were 
two instances in which force was transmitted from the feet 
through the body; but in one, which was fatal, there was no 
fracture.* The other, terminating in recovery, is of sufficient 
interest to quote in brief. 

Case I. — ^A man fell nine stories to the ground, striking upon 
his feet, his fall having been broken by several pieces of project- 
ing timber. He was found sitting upon the ground, conscious, 
rational, and complaining of severe pain in his head ; temperature 
98.8" ; pulse 60 ; respiration 1 5 ; free hemorrhagfe from his right 
ear. On admission to the hospital his general symptoms were 
unchanged. He was subsequently restless, irritable, and delirious, 

* Phelps : Traumatic Injuries of the Brain and Its Membranes, Case 
CXCVI. 



CASES OF HEAD INJURY. 453 

with temperature rising to 103° on the second day. Oozing from 
the ear continued till the fourth, and delirium till the sixth day. 
Vesical and rectal control was retained. 

The intracranial complications which attend direct basal 
fractures do not differ from those which may occur when the 
fracture has its beginning in the vault, and like them they are 
usually concomitant rather than resultant. The exceptional 
instances were those in which the middle meningeal artery or 
a basal sinus was ruptured; and two in which a frontal lobe 
was lacerated by fragments of an orbital plate. 

The subjoined cases are illustrative of this form of 
fracture. 

Case II. — Patient knocked down by a bicycle ; right eye closed 
by hsematoma; abrasions of head and face; comminution of cor- 
responding orbital plate, with fissures ; one fissure running upward 
into frontal bone, and two backward and respectively through 
opposite clinoid process and through corresponding greater sphe- 
noid wing into petrous portion and finally into foramen lacerum 
posterius. 

Case III. — No history obtainable; contusion of both eyes; 
comminuted fracture of one orbital plate with displacement of 
fragments and fine fissures ; one fissure ran through ethmoid and 
sphenoid bodies, one through middle fossa and along anterior 
petrous surface, and one through optic foramen. 

Case IV. — No history obtainable; hsematoma of right orbit; 
transverse fracture of corresponding orbital plate. 

Case V. — Patient fell in the street. No external injury; 
separation of greater wing of sphenoid from squamous portion of 
temporal bone. 

Case VI. — Patient fell ten or fifteen feet through a hatchway ; 
fissure through internal auditory meatus and into tip of greater 
wing of sphenoid bone. 

Case VII. — No history obtainable; wound in right occip- 
ital region; linear fracture running transversely across middle 
of right petrous portion. 

Case VIII. — No history obtainable; wound over occipital 
tuberosity ; fine fissure confined to posterior petrous border. 

Case IX. — Patient jumped from fifth story window; two 
independent fissures, each limited to a petrous portion. 



454 



CHARLES PHELPS. 



Case X. — Patient fell one story ; struck upon left side of head 
and body ; scalp wound in left temporal region ; fracture extend- 
ing from outer part of anterior surface of right petrous portion 
through body of the sphenoid bone into its lesser wing. 

Case XL — No history obtainable; occipital wound; fracture 
beginning at foramen magnum, and extending upward into oppo- 
site inferior posterior fossa. 

Case XII. — No history obtainable; fracture extending from 
anterior petrous surface to foramen spinosum, lacerating arteria 
meningea media. 

Case XIII. — Patient fell from his seat in a police station; 
two fractures of the vault, and one limited to the base running 
along whole length of anterior petrous surface. 

Case XIV. — Patient fell down one flight of stairs; fracture 
of both orbital plates, left greater wing of sphenoid bone, left 
petrous portion, and basilar process of occipital bone. 

Case XV. — Patient fell from the mizzen top into the hold of 
a vessel ; fractures confined to the base ; six fissures involving all 
the basal fossae ; one primary fissure began at the foramen magnum 
and formed five subdivisions, and a sixth was independent and 
confined to the crista galli and sella turcica. 

Case XVI. — Patient was struck upon the occiput by a descend- 
ing elevator and his head forced forward upon a railing ; fracture 
confined to anterior fossae, and extending from posterior border 
of cribriform plate by a wide curve forward and outward, and 
then inward through both orbital plates to a corresponding point 
on the left side. The roof of each orbit was elevated and tilted 
forward, and the frontal sinuses were made continuous with the 
cranial cavity. The right frontal lobe was extensively lacerated 
by an orbital fragment. 

SYMPTOMS AND DIAGNOSIS. 

The symptomatology of cranial fracture has been much 
confused by a failure to distinguish the symptoms of the 
fracture itself from those of the intracranial complications 
which so frequently accompany it, and give to it a factitious 
importance. The abnormalities of pulse, temperature, and 
pupils — the loss of. consciousness and other morbid condi- 
tions — which are still enumerated as symptoms of fracture, 



CASES OF HEAD INJURY. 455 

indicate intracranial lesions which are only in rare in- 
stances even dependent upon the fracture which they ac- 
company. They equally occur when no cranial injury has 
been sustained, and are then manifested by the same general 
indications. They result from a common cause, but are 
essentially independent of each other. It is only occasionally 
that an osseous fragment may rupture an important vessel or 
lacerate the cerebral substance. 

The distinctions between symptoms of a fracture and those 
of the concomitant cerebral or meningeal lesions have more 
than an academic interest, since a well-defined conception of 
the significance of symptoms is essential to correctness of 
prognosis and treatment. 

The direct symptoms are few, and not difficult to discover. 
Fractures confined to the vault are to be considered apart 
from those which primarily or secondarily involve the base. 
They are to be recognized by tactile or by visual sense, which 
are always practicable methods; and there is no justification 
for the neglect to resort to both when one is insufficient for 
exact diagnosis. If the fracture be compound there can be 
no doubt of its existence, provided the wound be of sufficient 
size to disclose the osseous surface. If the wound be too small 
for thorough exploration the fracture may be regarded as 
essentially of the simple variety. The simple fracture if de- 
pressed may often be recognized by palpation through the 
layers of the scalp; but if doubt exists, or if from symptoms 
of intracranial complication suspicion arises, certainty should 
be attained by incision and direct inspection. This covers the 
whole ground of diagnosis — tactile or visual examination — 
and if necessary to that purpose sufficient and unhesitating 
incision down to the cranial surface. It may happen that a 
fracture confined to the vault, or extended to the base, afifords 
no local indication of injury having been sustained — 
neither wound, haematoma, nor contusion. There is then, in 
the absence of intracranial symptoms, no warrant for explora- 
tion; and it is fair to assume that if fracture exist it is 
immaterial. 



4S6 



CHARLES PHELPS. 



The diagnosis of fractured base is sometimes incidentally 
made in the course of an exploration of the vault by establish- 
ment of the continuity of a fissure from one region into the 
other; this, however, is exceptional and likely to be confined 
to cases in which the vault is extensively comminuted, or in 
which search is being made for the source of an epidural 
hemorrhage. 

Hemorrhage. — The one indication of basal fracture, and 
the only one upon which dependence can be placed in the great 
majority of cases, is a cranial or intracranial hemorrhage 
which through some channel becomes visible upon or beneath 
the surface. Its source may be the vessels of the diploe, the 
meninges, or the brain; and its escape may be from the ear, 
nose, or mouth, or into the subconjunctival or subcutaneous 
tissue. 

The absolute and comparative frequency of these several 
forms of hemorrhage is indicated in the following table. 

Recovered Died Total Necropsies 

Hemorrhage from the ear. . . i66 iig 285 69 
Hemorrhage from nose and 

mouth 39 SI 90 32 

Subconjunctival hemorrhage. 9 8 17 7 

_ , ( mastoid 3 6 

Subcutaneous^ cervical o 3 ^ I3 9 



hemorrhage j ^^^^j^^ ^ ^ ^ 

40s 

The hemorrhage from the ear is not only the most fre- 
quent, but also is the one of paramount importance. As a 
positive sign it may be considered pathognomonic of fracture 
of the petrous portion of the temporal bone involving the 
internal auditory passage and followed by rupture of the 
tympanum from pressure of extra vasated blood. The single 
exception to this as an absolute rule was encountered in a case 
of gunshot wound inflicted at short range immediately in front 
of the ear, in which a slight hemorrhage was occasioned by 
rupture of the tympanum from concussion. In every other 
instance in which ruptured tympanum and hemorrhage oc- 



CASES OF HEAD INJURY. 457 

curred, post-mortem examination showed a petrous fracture 
through the auditory canal, and in no instance in which hemor- 
rhage from the ear had been absent was such a fracture 
disclosed. If a petrous fracture did not involve the internal 
auditory canal it would, of course, afford no outlet for the 
blood, which may come from either the osteal or meningeal 
or even from the cerebral vessels. The large number of cases 
observed would seem to warrant the conclusion that no ex- 
tremity of violence otherwise inflicted upon the cranium can 
rupture the tympanum by concussion ; and that the instances of 
such rupture from atmospheric disturbance or bullet impact 
are very exceptional. 

In making this diagnosis care must be exercised in examin- 
ing the external auditory meatus, as the cranial or intra- 
cranial hemorrhage is occasionally simulated by a hemorrhage 
into that passage from an external wound. There were nine 
such exceptional cases in the present series, in four of which 
the absence of fracture was further verified post mortem. In 
each instance blood had trickled into the meatus from some 
wound of the scalp or external ear, or had issued from some 
wound within the meatus itself; and in each it had been mis- 
taken on primary and cursory examination for the usual 
indication of fracture. The necessity for this precautionary 
examination of the external parts for the source of an aural 
hemorrhage is so apparent that reference to it would seem 
supererogatory were it not that it is so generally neglected. 
The wound in the tympanum is not often visible after the 
hemorrhage has ceased because it is usually simple, and 
primary union is the rule; but the absence of any possible 
external source of hemorrhage is quite sufficient for diagnosis. 
The flow may be trivial or profuse ; it may cease at once or be 
prolonged for days ; but neither the quantity nor the duration 
of the flow is material. 

The nasal and subconjunctival hemorrhages though often 
noted are much less frequently indicative of fracture. Their 
dependence upon local injury in many cases is evident, and 
their intracranial origin in many others is scarcely less open to 



458 CHARLES PHELPS. 

question; but their significance in perhaps a majority of 
cases is purely conjectural. It follows that their frequency 
as symptoms of cranial fracture cannot be stated with the 
positive certainty which was possible in cases of hemorrhage 
from the ear, and that their number as stated in the preceding 
tabulation must be regarded as only approximate. 

If a subconjunctival hemorrhage appears at once, together 
with an orbital or palpebral ecchymosis, it is probably a part 
of the general local contusion; but if it appears only after an 
interval of several hours, or of one or more days, and without 
subcutaneous extravasation, it is fair to assume a fracture 
involving some part of the orbital wall. If the hemorrhage 
from the nose or mouth is profuse and there is no local lesion 
or history of injury to the face, it is probably the result of 
fracture through the anterior or middle fossae. On the other 
hand, the beginning of a slow oozing from the nose after the 
• lapse of twenty-four hours has a similar significance. 
Hsematemesis in head injuries, in the absence of other explana- 
tion, always suggests cranial fracture, partly as an evidence 
of the profusion of nasal hemorrhage, and in part as a possible 
result of fracture through the osseous wall of the pharynx. 
The concurrence of sjonptoms of intracranial complication 
will confirm the existence of a fracture which the nature of 
the hemorrhage has rendered probable. 

The cases of nasal and subconjunctival hemorrhage 
tabulated were in each instance uncomplicated by other hemor- 
rhages. In addition somewhat more than 40 per cent, of 
hemorrhages from the ear were accompanied by one or the 
other or by both of these, but usually by the one from the 
nose. The subsidiary hemorrhages, as they may be termed, 
then ceased to be of diagnostic importance, except as indicat- 
ing the possible extent of the fracture. 

The subcutaneous hemorrhages of cranial or deeper origin 
are usually manifest in the mastoid region, and, together with 
the exceptional instances occurring in the posterior cervical 
region, are with proper limitation of observance as path- 
ognomonic as are hemorrhages from the ear. There were, in 



CASES OF HEAD INJURY. 459 

addition to the nine cases in which there was no other than 
mastoid hemorrhage, thirteen in which it was compHcated by 
hemorrhage from the ear, and two by hemorrhage from the 
nose. Seven of these tw"enty-four cases, of which five were 
simple mastoid hemorrhages, afforded opportunity for post- 
mortem examination; the mastoid ecchymosis was observed 
primarily in all, and was found post mortem to be continuous 
with a large extravasation into the occipital region of the 
scalp. The fracture in each traversed an inferior occipital 
fossa, and in five involved the groove for the lateral sinus. 
In other cases, including most of the recoveries, the mastoid 
ecchymosis, which was sometimes accompanied by oedema, did 
not appear till later — from the second to the sixth day — and 
in succession to a hemorrhage from the ear. These would 
seem to be cases of fissure extending from the petrous portion 
into the mastoid process. 

It is possible that blood from a temporal or temporoparietal 
hsematoma may gravitate into the mastoid area ; but sufficiently 
careful examination will serve to exclude this source of error. 
Such a possibility having been excluded, a mastoid ecchymosis 
may be regarded as an unfailing indication of fracture, the site 
and extent of which may be inferred from attendant 
conditions. 

An cedema of the mastoid region without hemorrhage was 
noted in only two instances. One of these was cited in the 
earlier series,^ in which a fracture traversed the groove for 
the lateral sinus, and was accompanied by obstruction of that 
vessel by thrombosis. The occurrence of this symptom will 
necessitate the joint condition of a venous obstruction to cause 
the cedema and of a fracture to permit its appearance in a 
cranial region. 

In some instances the mastoid extravasation extended into 
the neck, and occasionally a subcutaneous hemorrhage was 
limited to that region ; in either event the hemorrhage followed 
extensive occipital fracture. The earlier and the more con- 
siderable the visible hemorrhage, the greater the probability 

' Librcit~Csise LXII. 



460 CHARLES PHELPS. 

of the existence of cranial comminution or of open fissures. 
A simple closed fissure would rarely be attended by external 
hemorrhage sufficiently large to become subcutaneous, and 
then only after the lapse of some days. 

The mastoid and cervical are perhaps the only subcutaneous 
hemorrhages likely to be brought in question as indicating 
basal fracture. In a single instance perceptible orbital hemor- 
rhage resulted wholly from comminution of an orbital plate. 
Punctured fractures when they occurred in this cavity were 
usually attended by such hemorrhage, but it was the result of 
the wound of the soft parts rather than of the bone. A 
hemorrhage into the zygomatic fossa from fracture of the 
greater wing of the sphenoid bone is conceivable, but if recog- 
nized would hardly be distinguishable as such. 

Symptoms of basal fractures, aside from hemorrhage, are 
few and of exceptional occurrence. They are : 
Serous Discharges ; 
Extrusion of Brain Tissue ; 
Implication of Cranial Nerves ; 
Localized Pain, 

Serotcs Discharges. — These were observed in twenty-six 
cases, nine of which proved fatal, with nine necropsies. They 
were all from the ear with the exception of one from the 
vault, and one from the nose. In one instance the discharge 
was from the pharynx as well as from the ear. In a certain 
number of cases the source of the discharge may be considered 
uncertain ; in the remainder all the sources to which it has been 
ascribed were exemplified. The fluid itself may be the serum 
of blood extravasated within the cranium, the cerebrospinal 
fluid, the serous effusion of an arachnitis, or the viscid dis- 
charge of a middle-ear inflammation. The determination of 
its nature must be based upon the period of its occurrence, its 
relation to hemorrhage, its chemical and physical properties, 
and the significance of concomitant symptoms. The chemical 
characters of the discharge were not given much attention as 
they were usually unimportant in diagnosis and the discharge 
difficult to obtain in sufficient quantity for examination. 



CASES OF HEAD INJURY. 461 

There was primary hemorrhage in twenty-one of these 
cases, of which seven were fatal. The hemorrhage in seven- 
teen cases preceded the discharge by an interval of from a 
few moments to several (6) days; and in four they were 
synchronous. In all such cases the serous discharge has no 
importance in diagnosis, as the certainty of fracture is already 
assured by the fact of hemorrhage. In one of the five cases 
in which there was no hemorrhage from the ear there was 
primary mastoid ecchymosis and oedema. 

An analysis of the twenty-six cases shows that in four 
the discharge was accompanied by other undoubted symptoms 
of aural inflammation; that in four it was the result of a 
declining stage of inflammation ; and that in fourteen it was the 
cerebrospinal fluid, as it probably was in four others in which 
there was more or less reason to question its exact character. 
The recognition of cerebrospinal fluid was based in all the 
recovering cases upon profusion, limpidity, and immediate 
occurrence; and in cases followed by necropsy upon the addi- 
tional evidence of positive and negative conditions — the pres- 
ence of fracture and absence of simple or infected subarach- 
noid serous effusion, and the absence of notable epidural or 
subdural hemorrhage. 

Extracts from the histories of some of the cases of serous 
discharge from the ear will serve to illustrate the several 
conditions under which it occurs. 

Case XVII. — Serous Discharge from an Inflamed Ear; Ne- 
cropsy. — The patient fell down stairs ; slight primary hemorrhage 
from the right ear and subconjunctival hemorrhage on the second 
day; progressive stupor, and on the eighth day unconsciousness, 
with considerable serous discharge from the ear, which became 
purulent on the day following; temperature on admission 100.8°, 
and then normal until the twelfth and last day of life, when it rose 
to iolS**. 

Lesions. — ^Limited areas of meningeal contusion, each i in. by 
15^ in. in its diameters, just posterior to fissure of Rolando; 
minute opening in posterior surface of right petrous portion 
through which pus exuded; large subarachnoid serous effusion 



462 CHARLES PHELPS. 

in right posterior basal fossa ; suppuration and disintegration of 
mastoid cells. 

Case XVIII. — Serous Discharge, Probably from an In- 
flamed Ear; Recovery. — The patient fell from a ladder and struck 
upon his head; semiconscious with vertigo on his admission to 
the hospital ; mastoid swelling and profuse hemorrhage from the 
right ear, which continued till the third day ; oozing from the ear 
on the fifth, which ceased on the sixth, and recurred on the 
seventh day; previous delirium increased; severe pain in the 
ear, which was continuous up to the day of his discharge from 
the hospital on the fourteenth day. 

Case XIX. — Serous Discharge from the Ear in a Declining 
Stage of Hemorrhage; Recovery. — The patient fell from a second 
floor window; coma and profuse hemorrhage from the mouth 
and left ear ; followed by hsematemesis ; hemorrhage from the ear 
continued thirty-six hours and was succeeded by a gradually 
diminishing discharge of bloody serum. 

Case XX. — Discharge of Cerebrospinal Fluid from the Ear; 
Recovery. — The patient, ten years of age, fell 40 feet; transient 
loss of consciousness ; synchronous hemorrhage and watery dis- 
charge from the right ear; watery discharge continued till the 
fourth day ; temperature normal ; no general symptoms. 

Case XXI. — Late Discharge of Cerebrospinal Fluid from the 
Ear; Necropsy. — Primary hemorrhage from nose and both ears, 
and later profuse hemorrhage from the pharynx ;/ moderate dis- 
charge of watery fluid from the left ear on the fourth day. 

Lesions. — Fracture through both middle basal fossae; com- 
minution of left petrous portion; extensive pial hemorrhage on 
the right side ; marked cerebral oedema ; no subarachnoid effusion, 
but convolutions of the left hemisphere flattened. 

Case XXII. — Discharge of Cerebrospinal Fluid from Both 
Ears; Recovery. — The patient, three years of age, was knocked 
down by a street railway car ; no hemorrhage ; primary free flow 
of a watery fluid of a bluish tint, without tinge of blood or vis- 
cidity; ceased in twenty-four hours; no general symptoms; tem- 
perature rose to 104° and then gradually receded. 

Case XXIII. — Late Sero purulent Discharge from the Ear, 
Probably a Subarachnoid Inflammatory Effusion; Necropsy. — 
The patient was thrown from his truck and struck upon his 
head; free hemorrhage from right ear with mastoid ecchymosis, 



CASES OF HEAD INJURY. 463 

followed at once by severe frontal headache and high temperature ; 
hemorrhage continued till third day, becoming more and more 
serous in character; discharge seropurulent on the fourth day; 
death on the sixth day, having had marked symptoms of 
arachnitis. 

Lesions. — Fracture extending from occipital region along 
groove for lateral sinus, and through mastoid process, into petrous 
portion ; pial hemorrhage in right occipital fossa ; small hemor- 
rhages into substance of pia mater, each of the size of a pea, 
in the right frontal region ; and pial vessels much distended over 
the whole vertex; subarachnoid seropurulent effusion over right 
hemisphere; lateral ventricles filled with a brownish fluid. 

Case XXIV. — Discharge of Cerebrospinal Fluid from the 
Nose; Recovery. — The patient was found unconscious in the street 
with profuse hemorrhage from mouth and nose, much orbital 
ecchymosis, and a fractured nasal process of the superior maxil- 
lary bone; copious sanguinolent discharge from the nose on the 
eighteenth day, which began to diminish three days later and 
ceased only on his discharge from the hospital at the end of 
another week. The fracture was found to extend into the eth- 
moid plate. 

Case XXV. — Discharge of Cerebrospinal Fluid and Later of 
Subarachnoid Iniiammatory Effusion from Ear and Pharynx; 
Necropsy. — The patient was knocked down by a bicycle and 
struck his head upon the pavement; could stand up and walk. 
On admission to the hospital: Slight hemorrhage, with a syn- 
chronous escape of considerable serous fluid from the right ear; 
back of pharynx blood-stained; no general symptoms. Second 
day : Constant expectoration of straw-colored fluid ; free and con- 
stant discharge of watery fluid from the ear, which continued till 
his death on the fifth day. The patient became restless on the 
second day, with retching and vomiting; and on the fourth day 
delirious with twitching of the muscles of the extremities and 
exaggerated reflexes, which continued till his death. Tempera- 
ture rose to 104.6°. 

Lesions. — Fissure began at the left clinoid process, ran for- 
ward through the ethmoid bone, comminuted the right orbital 
plate, and then divided into two branches — one running forward 
into the vertical part of the frontal bone, and one backward into 
the right middle fossa and through the petrous portion into the 



464 



CHARLES PHELPS. 



foramen lacerum posterius with a subdivision running upward 
through the squamous portion of the temporal into the parietal 
bone; thick epidural clot extending from right orbit into middle 
fossa and over parietal region anteriorly; slight opacity of the 
arachnoid membrane ; hyperaemia of the pia mater ; moderate cere- 
bral hyperaemia and oedema and moderate amount of bloody fluid 
in the lateral ventricles ; basal ganglia sodden and flattened ; brain 
convolutions much flattened. 

The fluid which primarily escaped from the ear in this 
last case could only have been the normal cerebrospinal secre- 
tion ; but the recurrence of the discharge in greater quantity on 
the second day coincidently with the development of symptoms 
of inflammation suggested a change from the secretion to 
the effusion of a subacute arachnitis. This view is strength- 
ened by the post-mortem observations of the flattening of the 
cerebral convolutions and the sodden appearance of the basal 
ganglia, and by the absence of the effusion, by which these 
conditions must have been occasioned. 

Extrusion of brain tissue, as a symptom, requires little 
consideration; that it involves fracture as a necessary prece- 
dent is self evident. It occurs in a certain proportion of 
cases of crushing fractures of the vault, and may then be 
important as indicating the extent of injury. The loss of 
large masses of brain matter with recovery of the patient has 
been often noted. Many instances have been recorded in 
which with almost entire destruction of the right frontal lobe 
there has not been even temporary functional impairment. 
Some of these, as well as a case of recovery after similar 
destruction of the right cerebrum, were referred to in the first 
of the two papers upon " Left Frontal Lobe Localization." ^ 
Two of the original cases which comprised the series published 
m that connection were also of the same character. One, in 
which at least two-thirds of the right frontal lobe was de- 
stroyed, recovered without serious symptoms, though he be- 
came epileptic eight years later; the other, with somewhat less 

* Phelps : Am. Jour, of Medical Sciences, Majr-June, 1902. 



CASES OF HEAD INJURY. 465 

extensive destruction of the left lobe, was temporarily de- 
mented, but with ultimate restoration of the mental faculties. 

The escape of brain matter from the ear occurred in three 
cases, of which two were fatal. In one of the latter it was 
accompanied by profuse primary aural hemorrhage; in the 
other it was also primary and accompanied by hemorrhage 
from the nose and mouth, but by none from the ear. Death 
ensued in the first on the fourth day, and in the second 
after a few hours. The recovering case was included in the 
series collected in the " Treatise upon Intracranial Injuries," * 
and is again noted among the illustrative cases of the present 
publication. It occurred on the second day, followed profuse 
primary hemorrhage from the ear, and continued for twenty- 
four hours. It is of interest as showing that loss of brain 
tissue with basal fracture is no more necessarily fatal than 
fracture of the vault; and also as a direct demonstration that 
recovery may follow inaccessible cerebral lacerations. 

There was extrusion of brain matter through the nose in 
one case which was fatal ; and it also occurred into the orbit in 
a case of gimshot wound and was discovered in the course of 
operation for excision of the eye. 

Implication of the Cranial Nerves. — This accident like the 
extrusion of brain matter is of very exceptional occurrence; 
and before its causative relation to functional loss or dis- 
turbance can be admitted, intracranial lesion must be absolutely 
excluded. It is possible that any cranial nerve may suffer 
structural injury in its exit from the cranium; but, except in 
case of the second and seventh pairs, it is in the highest degree 
improbable, and even with these, as was stated, it is excej)- 
tional. Some degree of facial paralysis is among the frequent 
symptoms of head injuries, and the petrous portion of the 
temporal bone through which the facial nerve passes is in the 
line of fracture in a large proportion of basal fractures; yet 
a lesion of the nerve in its petrous canal has been disclosed 
upon necropsy in not more than one instance, or at the most 
two instances, of the whole series. 

*Lib. cit., Case CCLXIV. 



466 CHARLES PHELPS. 

The compression of the optic nerve by orbital fragments 
was rather more frequent, but occurred in only six cases, 
scarcely more than i per cent, of the 570 basal fractures. All 
of these were comprised in the first series of 500 cases. 

" Four were recognized only upon necropsy, and of these 
three had died without recovery of consciousness, and the 
fourth had suffered no loss of vision. In the two cases in 
which life was preserved the patient upon restoration of intelli- 
gent consciousness discovered that he was blind. Ophthalmo- 
scopic examination in the first case, made on the third day, was 
negative, though the pupil did not respond to direct exposure 
to light; fifteen days later atrophy of the optic nerve had 
begun. In the second case the ophthalmoscopic examination 
was not made until the fourth week; the pupil was then 
insensitive to light, and atrophy of the nerve was in progress. 
Entire loss of vision was permanent in both cases." ^ 

If there were other cases of this character they could have 
been only among those of deaths without restoration of 
consciousness and without necropsy. 

Callan,^ who has the histories of twenty-five cases, states 
that " monocular blindness is immediate, and generally with 
total loss of light perception. The eyeball protrudes and 
diverges, and the pupil is enlarged and non-responsive to light. 
Optic nerve atrophy begins within two weeks." 

The two cases cited conform to this description except that 
hemorrhage chanced to be insufficient to cause ocular protru- 
sion or divergence. 

Localised pain is not included in the usual category of 
symptoms of basal fracture. It has been often noted, how- 
ever, in this series of cases, and its significance often estab- 
lished in subsequent post-mortem examinations. Its intensity 
and narrow limitation serve to distinguish it from the more 
diffused frontal or occipital headaches of intracranial injuries, 
and it is disproportionate to the amount of superficial 
contusion. It is most likely to be serviceable in the diagnosis 

• Lib. cit, p. 25. 

•Jour. Am. Med. Assoc, March 5, 1892. 



CASES OF HEAD INJURY. 467 

of fractures beginning in the occipital fossa, and is sometimes 
the only direct symptom present. Its seat in such cases may 
be either in the occipital region or over the mastoid process. 
How many cases of unrecognized and unsuspected basal 
fractures there may be is problematical. That there are such 
is evident from their occasional disclosure post mortem, when 
none of their enumerated symptoms have existed. It might 
be reasonable to infer that the more pronounced the indications 
of intracranial lesion, the greater the probability of the exist- 
ence of fracture; but it is also to be borne in mind that 
equally severe and characteristic symptoms of intracranial 
injury may exist when fracture is absent. 

PROGNOSIS. 

The results of a study of these cases, so far as it concerns 
prognosis and treatment, must by reason of limited space be 
stated in an abbreviated and perhaps somewhat dogmatic form. 

Linear fracture, comminuted fracture without loss of sub- 
stance, and depressed fracture in which the fragments have 
been replaced in their normal position, unite by definitive 
callus; and no trace of the osseous lesion remains. Three ex- 
ceptional cases were observed: one in which a basal fracture 
through both middle fossae had imited with some displace- 
ment of the segments; one which crossed the frontal bone 
immediately above the orbital ridges and had similarly united 
with slight displacement; and a third in which an open fissure 
in the median line of the frontal bone, with appreciable 
separation and mobility, remained after five years had 
elapsed. 

A loss of osseous substance is replaced by a dense fibrous 
structure composed of the thickened and consolidated dura 
mater and periosteum; and is a source of danger in so far as it 
is a loss of efficient protection from external violence. This 
danger is commensurate with the extent of osseous deficit and 
modified by its cranial site. Completely detached fragments 
separated from periosteum and dura mater, when unremoved, 
will necrose and may become the medium of infection. 



468 CHARLES PHELPS. 

Depressed fragments are confined to the vault and to the 
orbit, and with early elevation have in general no more serious 
results than when unattended with displacement. The prog- 
nosis may be said to depend largely upon t