iCM
OPERATIVE
THERAPEUSIS
OPERATIVE
THERAPEUSIS
EDITED BY
ALEXANDER BRYAN JOHNSON, Ph.B., M.D.
VOLUME I
NEW YORK AND LONDON
D. APPLETON AND COMPANY
1915
Copyright, 1915, by
D. APPLETON AND COMPANY
Printed in the United States of America
PKEFACE
Books special and general on surgical topics exist in large numbers. Un-
less, therefore, in offering this work to the medical profession, something more
generally useful can be produced, it has no excuse for being, and in the follow-
ing paragraphs I will demonstrate this assertion.
The entire field of surgical treatment is covered, both operative and non-
operative. The indications, and contra-indications, for and against surgical
procedures, are carefully elaborated.
After-care, postoperative complications and postoperative operations are
given very fully and describe the very latest advances, and I believe that sev-
eral desirable objects have been attained.
Aseptic operative technic constitutes naturally the bulk of the work and is
invaluable and eminently practicable.
It often happens, more especially in the country and in the smaller towns,
that the family physician is left in charge of the case after operation. These
chapters give exactly the information he may need under such conditions. The
methods described are those accepted as the best by the profession at large. In
addition thereto many new methods are here offered to the profession for the
first time. These are original with the contributors to this work.
The work was planned by selecting as contributors men who lived in
Greater New York City exclusively. The majority of these men have been
associated with me in hospital work ; their ideas, methods and capabilities are
well known to me. They are nearly all comparatively young men, who, though
old enough to have had large experience, have still abundant enthusiasm. They
were selected because of special fitness to write on some particular topic in
which each was especially interested, experienced and skillful.
The book contains the very last word on surgical therapeusis and its aim
is to tell in a practical and accessible form WHAT TO DO AND HOW TO
DOIT.
It will be noted that overlapping occurs in some sections. Such overlapping
is largely intentional on my part, and occurs chiefly where new and original
methods of technic have been devised by the authors and where each method is
good ; but where a difference of opinion and a choice are entirely permissible, I
think that such different viewpoints are a desirable addition to the work.
Diagnosis and pathology have, for the most part, been omitted. The two
vi PKEFACE
chapters on the X-ray diagnosis of the alimentary and urinary tracts are intro-
duced because they are so important and contain so much not yet known to the
greater number of the profession.
The illustrations are with few exceptions line drawings, most of them orig-
inal. A large proportion were made from sketches of actual operations on the
living body or upon the cadaver, showing what is actually visible during opera-
tive work, and not what may be imagined.
I desire to thank the contributors to "Operative Therapeusis" for their cor-
dial and enthusiastic cooperation with me in the effort to have the book ready
for publication at the earliest possible moment. Many of the articles are really
exhaustive monographs covering every phase of the topic treated, and several
might well have appeared as separate works.
ALEXANDER BKYAN JOHNSON.
LIST OF CONTRIBUTORS
Fred Houdlett Albee, A.B., M.D.
Archibald H. Busby, M.D.
Schuyler A. Clark, M.D.
Howard D. Collins, M.D.
Karl Connell, M.D.
John F. Cowan, M.D.
Colman W. Cutler, M.D.
William Darrach, A.M., M.D.
John Douglas, M.D.
Francis G. Edgerton, M.D.
Charles A. Elsberg, M.D.
Charles E. Farr, M.D.
Russell S. Fowler, M.D., F.A.C.S.
Robert T. Frank, A.M., M.D.
David Geiringer, M.D.
John C. A. Gerster, M.D.
Nathan W. Green, M.D.
Anthony H. Harrigan, M.D.
Forbes Hawkes, M.D.
James M. Hitzrot, A.B., M.D.
Ranson S. Hooker, M.D.
Lucius Wales Hotchkiss, M.D.
Henry Janeway, M.D.
Alexander Bryan Johnson, Ph.B., M.D.
James H. Kenyon, M.D.
Leon Theodore Le Wald, M.D.
Henry H. M. Lyle, M.D.
Jerome Morley Lynch, M.D., F.A.C.S.
Walton Martin, M.D.
Frank S. Mathews, M.D.
Clarence A. Me Williams, M.D.
Alexis V. Moschcowitz, Ph.G., M.D.
Alfred T. Osgood, M.D.
Eugene H. Pool, M.D.
Joseph C. Roper, M.D.
Henry S. Satterlee, M.D.
T. Laurance Saunders, M.D.
Norman Sharpe, M.D.
William Sharpe, M.D.
J. Bentley Squier, Jr., M.D.
W. E. Studdiford, M.D.
Alfred S. Taylor, A.M., M.D.
Howard C. Taylor, M.D.
William S. Thomas, M.D.
Franz Torek, A.M., M.D.
Percy R. Turnure, M.D.
F. T. Van Beuren, Jr., M.D.
Arthur Seymour Vosburgh, M.D.
George G. Ward, Jr., M.D.
John Martin Wheeler, M.D.
I
CONTRIBUTORS TO VOLUME I
A. SCHUYLER CLARK, M.D.
Assistant Physician and Chief of Clinic, New York Skin and Cancer Hospital.
HOWARD D. COLLINS, M.D.
Surgeon to the City and Knickerbocker Hospitals.
KARL CONNELL, M.D.
Assistant Surgeon, Roosevelt Hospital; Instructor in Surgery, College of Physicians and Surgeons,
Medical Department, Columbia University, New York.
JOHN F. COWAN, M.D.
Instructor in Surgery, Leland Stanford Junior University
CHARLES E. FARR, M.D.
Assistant Surgeon, St. Mary's Free Hospital for Children; Deputy Surgeon, New York Hospital,
O.P.D.; Surgeon, Seton Hospital.
JAMES M. HITZROT, A.B., M.D.
Assistant Professor of Clinical Surgery, Cornell Medical School; Associate Surgeon, New York
Hospital.
RANSON S. HOOKER, M.D.
Instructor in Clinical Surgery, College of Physicians and Surgeons, Columbia University, New
York; Assistant Surgeon, Bellevue Hospital, New York.
ALEXANDER BRYAN JOHNSON, PH.B., M.D.
Consulting Surgeon to the New York Hospital and to the Hudson Street Hospital (House of Relief),
New York; Professor of Clinical Surgery in the College of Physicians and Surgeons of Columbia
University; Fellow of the American Surgical Association; Member of the New York Surgical
Society; Author of "Surgical Diagnosis."
JAMES H. KENYON, M.D.
Assistant Surgeon, Fordham Hospital; Babies Hospital, St. Francis Hospital, and the Neuro-
logical Institute.
WALTON MARTIN, M.D.
ssor of Clinical Sureerv.
York;
Professor of Clinical Surgery, College of Physicians and Surgeons, Columbia University, New
:; Attending Surgeon, St. Luke's Hospital, New York; Consulting Surgeon, White Plains
Hospital.
JOSEPH C. ROPER, M.D.
Associate Attending Physician, New York Hospital; Formerly Clinical Pathologist, New York
Hospital.
ix
x CONTBIBUTOBS TO VOLUME I
HENRY S. SATTERLEE, M.D.
Assistant Attending Physician, Willard Parker and Riverside Hospitals, New York.
ALFRED S. TAYLOR, A.M., M.D.
Consulting Surgeon: Hospital for Ruptured and Crippled, Tarrytown Hospital, White Plains
Hospital, Letchworth Village. Visiting Surgeon: Fordham Hospital. Associate Surgeon: New
York Neurological Institute. Assistant Surgeon: Babies Hospital; Professor of Operative Surgery
at Cornell Medical School; Special Lecturer on the Surgery of the Peripheral Nerves at Cornell
Medical School.
PERCY R. TURNURE, M.D.
Attending Surgeon, French Hospital, New York; Associate Surgeon, New York Hospital,
New York.
F. T. VAN BEUREN, JR., M.D.
Assistant Surgeon, Roosevelt Hospital; Instructor in Surgery, College of Physicians and Surgeons,
Columbia University.
ARTHUR SEYMOUR VOSBURGH, M.D.
Assistant Surgeon, Bellevue Hospital; Instructor in Surgery, College of Physicians and Surgeons,
Columbia University.
CONTENTS
CHAPTER I
ASEPTIC SURGICAL TECHNIC
HOWARD D. COLLINS
PACK
INTRODUCTION . . . . 1
AGENTS OF INFECTION 2
SOURCES OF INFECTION 2
METHODS OF PREVENTION AND COUNTERACTION 2
Mechanical Means of Sterilization 3
Germicidal Agents 3
SUTURE MATERIAL 5
DRESSINGS . . • 8
Bandages 11
Adhesive Plasters 12
DRAINAGE TUBES 13
HYPODERMIC AND ASPIRATING SYRINGES 14
INSTRUMENTS 14
PREPARATION OF HANDS . 16
SKIN OF PATIENT ... .21
AUTOCLAVE OR STEAM STERILIZER . 22
BIBLIOGRAPHY 26
INTRODUCTION
INCISIONS .
HEMOSTASIS
CHAPTER II
GENERAL OPERATIVE TECHNIC
HOWARD D. COLLINS
27
28
28
rii CONTENTS
PACK
TRAUMA TO TISSUES .31
BONE OPERATIONS . 31
CLOSURE OF WOUNDS . . 32
DRAINAGE 34
DRESSINGS .34
USE OF INSTRUMENTS 35
OPERATING THEATER 37
POSITION AND ARRANGEMENT OF PATIENT . . 43
SURGEON'S DRESS . 44
CHAPTER III
SURGICAL ANESTHESIA
KARL CONNELL
INTRODUCTION 47
LOCAL ANESTHESIA 47
Local Anesthesia by Physical Agents . . 48
Local Anesthesia by Chemical Agents 48
Regional Anesthesia 61
Resume 71
GENERAL ANESTHESIA 71
Theory of General Anesthesia 72
Ether 72
Chloroform % .... 105
Nitrous Oxid . . .110
Ethyl Chlorid 125
Anoci-association 127
Differential Pressure Methods in Anesthesia 128
The Newer Mechanical Methods of Artificial Respiration . . .'••'. 130
The Connell Anesthetometer 131
Accidents of Anesthesia 134
CHAPTER IV
PREPARATION OF PATIENTS FOR OPERATION
CHARLES E. FARR
INTRODUCTION
• . . 143
GENERAL DIRECTIONS ^ -.,-
CONTENTS xiii
CHAPTER V
RELATIONS OF MEDICAL DISEASE TO SURGERY
ALEXANDER BRYAN JOHNSON AND JAMES H. KENYON
PART I
ALEXANDER BRYAN JOHNSON
PAGB
ANEMIA 151
TYPHOID FEVER 152
TYPHUS FEVER . 154
SMALL-POX 154
CHICKEN-POX 154
SCARLET FEVER . . . 155
MEASLES . 156
DIPHTHERIA 156
WHOOPING-COUGH 157
MUMPS 157
INFLUENZA 157
EPIDEMIC CEREBROSPINAL MENINGITIS 157
ERYSIPELAS . . . . 158
STATUS LYMPHATICUS 161
External Appearances .... . . . . • . . .162
LOBAR PNEUMONIA 163
ALCOHOLISM 164
USE OF OPIUM AND MORPHIN 168
USE OF COCAIN 170
SYPHILIS 172
TETANUS 173
DIABETES MELLITUS 174
OBESITY 182
RICKETS 182
SCURVY 183
ACUTE POLYARTICULAR RHEUMATISM 184
GOUT 184
POISONING BY BICHLORID OF MERCURY . . . . . . . 184
PHOSPHORUS POISONING • • 185
TUBERCULOSIS 186
PART II
JAMES H. KENYON
DISEASES OF THE DIGESTIVE SYSTEM • 187
DISEASES OF THE RESPIRATORY SYSTEM 189
_iv CONTENTS
PAGE
190
DISEASES OF THE CIRCULATORY SYSTKM . ^
DISEASES OF THE BLOOD AND Dn TI.KSS GLANDS
192
DISEASES OF THI: KIDNEY •
iyo
DISEASES OF THE BLADDER
DIM:\SES OF THE CKXTRAL NERVOUS SYSTEM . ...
TROPICAL DISEASES . .....••
SKIN LESIONS ..•*-*
CHAPTER VI
THE PROPHYLACTIC AND THERAPEUTIC ADMINISTRATION OF
VACCINES AND SERA
JOSEPH C. ROPER
IMMUNITY . • . •
VACCINES •" 20*
APPLICATION OF VACCINE AND SEKUM THERAPY TO VARIOUS DISEASES . 205
TUBERCULIN THERAPY . • 215
FIXATION OF COMPLEMENT • 221
SERUM SICKNESS 223
SERUM THERAPY .224
TRANSFUSION OF BLOOD 225
DEFENSIVE FERMENTS (ABDERHALDEN) 225
CHAPTER VII
ASPIRATION AND ASPIRATING DEVICES IN OPERATIVE SURGERY
JAMES H. KENYON
METHODS OK PRODI-CIV; SUCTION . . 229
T^KV VM> A I»\\\TV<;ES OF CONTINUOUS SUCTION . . . . .« . . 235
Application to Various Parts of the Body . . . . ... 236
CONTINUOUS SUCTION AND ITS POSTOI-KU \TIVE APPLICATION . . . 239
Applications to the Various Regions of the Body ... . 240
Use in Production of Hyperemia ...... . 246
BIBLIOGRAPHY . . . . . . . . 246
CONTENTS
CHAPTER VIII
THE PRINCIPLES AND TECHNIC OF OPERATIONS UPON BLOOD
VESSELS
FREDERICK T. VAN BEUREN, JR.
PAGE
GENERAL CONSIDERATIONS . 249
Surgical Procedures . 250
Anatomical Points to Be Noted 251
Instruments Used 253
Methods and Choice of Methods 255
Dangers and Difficulties : Causes of Failure : Complications : Results . 255
OPERATIONS UPON ARTERIES 255
Operations to Check Bleeding 255
Operations to Restore or Reestablish the Circulation ..... 259
OPERATIONS UPON VEINS . 285
Anatomical Considerations . 285
Operations to Check Bleeding . 286
Operations to Restore or Reestablish the Circulation . . . 286
Operations for Drainage of Cavities, etc . 295
Operations to Alter Blood or Circulation for Stimulation or Medication . 295
Operations to Remove the Cause of Circulatory Disturbance Due to Vari-
cose Veins 320
Operations to Prevent Embolic Infection . 326
OPERATIONS UPON CAPILLARIES 327
Operations to Check Bleeding 327
Operations to Obliterate the Vascular Channels in Small Angiomata and
Nevi 328
OPERATIONS UPON THE LYMPHATICS 330
Handley's Operation 330
BIBLIOGRAPHY . . 333
CHAPTER IX
A SPECIAL METHOD FOR THE TRANSFUSION OF BLOOD WITH THE
USE OF PARAFFIN AND HIRUDIN
RANSOM S. HOOKER AND HENRY S. SATTERLEE
HISTORY 337
Syringe Methods of Recent Times 340
Defibrinated Blood 341
Paraffin Methods . 342
THEORETICAL CONSIDERATIONS AND PRINCIPLES UNDERLYING THE AUTHORS' METHOD . 342
1*
xvi CONTENTS
PAGB
METHOD OF OPERATION WITH PARAFFIN-COATED PIPET . .
o45
Instruments •
o4o
Apparatus
Operation .-•••' 0*0
Preparation of Pipets with Paraffin Coating . . . . •
METHOD OF OPERATION WITH HIRUDIN . . . . .
355
BIBLIOGRAPHY .'
CHAPTEK X
THE SURGICAL TREATMENT OF ANEURYSM
JAMES M. HITZBOT
REFRIGERATION 363
COMPRESSION 364
Li-. MI I:K 365
NKDUNO . . . 369
WIHI 369
l in vMoKKHAl'HY AND ANEURYSMOPLASTY (THE MATAS OPERATIONS) . . 370
:^MF.(ToMY 377
Ideal Aneurysm Operations 377
The Treatment of Arteriovenous Aiieurysms 379
Till: TUKATMKXT OF SPECIAL ANKURYSMS 379
Thoracic Aneurysms ........... 379
Aneurysms of the Abdominal Aorta 383
Aneurysms of the Renal Arteries 385
Innominate Aneurysms ........... 385
Common Carotid Aneurysms 386
Internal Carotid Aneurysms 386
Subclavian Aneurysms 389
Axillary Aneurysms 390
Aneurysms of the Iliac Arteries . . . 391
Femoral Aneurysms . . . . . . . . . . 393
Popliteal Aneurysms . . 393
BIBLIOGRAPHY 395
CHAPTER XI
LIGATIONS OP ARTERIES IN CONTINUITY
WALTON MARTIN
MIGRATIONS . OQQ
« . . Ooa
MIX ATE ARTERY . 4.nq
• • rrvO
COMMON CAROTID ARTERY .405
I:\VL CAROTID ARTI:H\ 408
CONTENTS xvii
PAGE
INTERNAL CAROTID ARTERY 411
SUPRA-ORBITAL ARTERY 413
SUBCLAVIAN ARTERY 413
Ligation of the Third or Second Portion of the Subclavian Artery . . 417
VERTEBRAL ARTERY 41 S
INTERNAL MAMMARY ARTERY 419
AXILLARY ARTERY 420
BRACHIAL ARTERY 422
RADIAL ARTERY . . 425
ULNAR ARTERY 428
ABDOMINAL AORTA 430
COMMON ILIAC ARTERY 431
INTERNAL ILIAC ARTERY 434
GLUTEAL ARTERY 435
SCIATIC ARTERY 437
INTERNAL PUDIC ARTERY 437
EXTERNAL ILIAC ARTERY 438
DEEP EPIGASTRIC ARTERY 439
DEEP CIRCUMFLEX ILIAC ARTERY 439
FEMORAL ARTERY 439
POPLITEAL ARTERY 441
POSTERIOR TIBIAL ARTERY 443
PERONEAL ARTERY 445
ANTERIOR TIBIAL ARTERY 445
DORSALIS PEDIS ARTERY 447
BIBLIOGRAPHY . . . 449
CHAPTER XII
PLASTIC SURGERY INCLUDING HARELIP AND CLEFT PALATE,
ALSO THE PLASTIC SURGERY OF THE LIPS, CHEEKS,
EYELIDS AND EARS
PERCY R. TURNURE
GENERAL PRINCIPLES . . . . . . '« 451
METHODS USED IN PLASTIC SURGERY ... . . 452
HARELIP AND CLEFT PALATE ..... 456
Varieties of Harelip and Cleft Palate . . 457
Treatment of Harelip ..... .460
Treatment of Cleft Palate . .... . . . ' . .467
xviii CONTENTS
PAGE
PLASTIC SURGERY OF THE LOWER LIP; CHEILOPLASTY
Operations for Excision of Papilloma, Angioma, or Other Non-malignant
Growths • 494
Operations for Epithelioma of Lower Lip .
PLASH. SURGKBY OP THE UPPHt I*IP • 503
Pi \ -TIC SURGERY OF THE EAR; OTOPLASTY 504
Malformations of the Lobule 504
Malformations of the Auricle 505
Malposition of the Auricle 506
PLASTIC SURGERY OF THE CHEEKS; MELOPLASTY 508
AUTOPLASTICS OF THE CHEEK KEGION 513
PLASTIC SURGERY OF THE EYELIDS; BLEPHAROPLASTY 517
Ectropion . . 517
Restoration of the Eyelid 518
SKIN-GRAFTING
ALEXANDER BRYAN JOHNSON
SKIN-GRAFTING . . . . 520
BIBLIOGRAPHY 522
CHAPTER XIII
OPERATIONS ON THE PERIPHERAL AND CRANIAL NERVES.
UNILATERAL LAMINECTOMY
ALFRED S. TAYLOR
OPERATIONS ON THE PERIPHERAL NERVES 525
Operations for Relief of Pain 526
<>!><Tations for Relief of Spasticity 528
Operation for Relief of Spasmodic Torticollis 533
Operations for the Relief of Paralysis and Repair of Injury to Nerves . 535
Operations for Tumors of the Nerves 563
OPERATIONS «>\ THK ('I:\MU. NERVES 564
Fifth Cranial Nerve 564
Seventh Cranial Nerve . 583
Eighth Cranial Nerve . 600
Tenth Cranial Nerve 600
ni;il Nerve . 601
Twelfth Cranial Nerve 602
UNILATERAL LAMINECTOMY 602
BIBLIOGRAPHY .... 609
CONTENTS
xix
CHAPTER XIV
OPEEATIONS UPON THE MUSCLES, TENDONS, BURS.E, AND FASCIJE
ARTHUR SEYMOUR VOSBURGH
PAGE
THE MUSCLES 613
Injuries of the Muscles 613
Diseases of the Muscles 615
THE TENDONS . 622
Injuries to Tendons 622
Transplantation of Tendons 626
Tenotomy 627
Tendon Shortening 628
Thickening and Modulation of the Tendons 628
Ganglion 629
BURS^E AND TENDON SHEATHS . . ... 630
Inflammations of the Bursse 630
Diseases of Special Bursse 632
The Tendon Sheaths 634
THE FASCLE 643
CHAPTER XV
GUNSHOT WOUNDS AND THEIR TREATMENT
ALEXANDER BRYAN JOHNSON
GENERAL CONSIDERATIONS • 647
Wounds Received in Civil Life .648
Wounds Received in Warfare 651
GENERAL TREATMENT OF GUNSHOT WOUNDS ...... . 655
WOUNDS RECEIVED IN LAND WARFARE
Wounds Due to Rifle Bullets .
Wounds Produced by Projectiles from Artillery and Hand Grenades . . 671
WOUNDS RECEIVED IN NAVAL WARFARE . • 674
CHAPTER XVI
THE TREATMENT OF WOUNDS AND THEIR DISEASES
JAMES M. HITZROT
INTRODUCTION
SUBCUTANEOUS WOUNDS (CONTUSIONS)
OPEN WOUNDS ....
Poisoned and Infected Wounds ... .
1
CONTENTS
PAGE
BURNS DUE TO HEAT AND COLD, ACIDS, ELECTRICITY, AND LIGHT KAYS; POISONING
BY CARBON MONOXID, ETC. ACCIDENT CASES PRODUCING MULTIPLE IN-
«»» ..... ...... 5"
Burns and Sral.K ............ °y'
T!u> Effects of Cold on the Tissue . . • . . 702
The Treatment ,.f Illuminating Gas Poisoning; Carbon Monoxid and Car-
IH.M Hisulphid Poisoning .... .702
The Treatment of Accident Cases, Kailroad Injuries and Other Forms of
Mechanical Violence Producing Multiple Injuries . 703
I5IUI.I.N;HAI'|IY ........... 705
CHAPTER XVII
PREPARATION AND APPLICATION OF PLASTER-OF-PARIS
DRESSINGS
J. F. COWAN
INTRODUCTION 707
PREPARATION OF PLASTER-OF-PARIS BANDAGES 707
\l\TKurvLsNECESSARYFORTHEApPLICATIONOFPLASTERDRESSINGS. . . . 708
l'i \-TKR-OF-PARIS DRESSING FOR FRACTURES 708
KR-OF-PARIS DRESSING FOR SPECIAL FRACTURES 714
Epiphyseal Fracture of the Upper End of the Humerus . . . . 714
Fracture of the Surgical Neck of the Humerus . . . . . . 715
Fracture of the Shaft of the Humerus 716
Fractures of the Lower End of the Humerus 717
Fracture of the Olecranon Process . 720
Fracture of the Coronoid Process . 721
Fracture of the Head and Neck of the Radius ...... 722
Fracture of Both Bones of the Forearm r 722
Fracture of the Shaft of the Ulna . 723
Fracture of the Shaft of the Radius 723
Colics' Fracture 724
Fracture of the Bones of the Hand 725
Fractures of the Femur 726
Fracture of the Patella 734
Fractures of the Tibia and Fibula or of the Tibia Alone .... 736
tures of the Fibula Alone 740
Pott's Fracture 749
Fracture of Bones of the Foot . . . ... . . 741
I'i wn .1; .1 \, KETS 742
Application of Jacket with Patient Suspended (Sayer) . . . .742
Application of the Jacket with Patient -in the Recumbent Position
(Prone) . 744
Application of Jacket with Patient in Recumbent Position (Supine) 745
Thr CaM .lackct m
Application of Jacket for Fracture of the Vertebra . , . 749
Bnoif K..U CASH «>K CUMJKMTAL DISLOCATION OF THE HIP 749
CONTENTS xxi
PAGE
CIRCULAR PLASTER DRESSING FOR CLUB-FOOT . 751
CIRCULAR PLASTER DRESSING FOR FLAT-FOOT 752
MANIPULATIONS FOR KEDUCTION OF COMMON DISLOCATIONS 752
Dislocation of the Lower Jaw 752
Dislocation of the Shoulder 753
Dislocation of the Elbow 754
Dislocation of the Thumb 755
Dislocation of the Hip 756
Dislocation of the Knee Joint 757
Dislocation of the Ankle Joint 757
Dislocations at the Wrist . 757
DEESSINGS FOR FRACTURE OF THE CLAVICLE
HOWARD D. COLLINS
DRESSING FOR FRACTURE OF THE CLAVICLE ... ... . 758
BIBLIOGRAPHY 760
CHAPTER XVIII
RADIUM IN SURGERY
A. SCHUYLER CLARK
INTRODUCTION ... . . 761
THERAPEUTICS OF RADIUM IN SURGERY * ^63
LIST OF ILLUSTRATIONS
ASEPTIC SURGICAL TECHNIC
HOWARD D. COLLINS
no. PAGE
1. — Gauze pads ; handkerchiefs ; rolls ; rubber gloves ; drainage tubes ... 9
2. — Method of using Z. O. plaster without irritating the skin . .13
3. — Instrument boiler 15
4. — Autoclave .23
5. — Sectional view of Figure 4 .23
6. — Double tank water sterilizer 25
GENERAL OPERATIVE TECHNIC
HOWARD D. COLLINS
1. — Showing suture of skin and subcutaneous tissues down to the deep fascia
in one layer . . 33
2. — Assortment of instruments .... 36
3. — Markoe operating table . . .39
4. — Patient in celiotomy position ... .40
5. — Trendelenburg position 40
6. — Rose position .... .41
7. — Nephrotomy position showing use of Cunningham bridge . . 41
8. — Kelly instrument table . .42
9.— Hand bowls .... .43
10. — Irrigating stand ...
11. — Face mask and gown • •
12. — Another type of face mask
SURGICAL ANESTHESIA
KARL CONNELL
1. — Refrigeration by ethyl chlorid .
2. — Infiltration anesthesia: furuncle
3. — Infiltration anesthesia for repair of small inguinal hernia .
4. — Infiltration anesthesia for repair of scrotal hernia . 58
xxiii
xx iv LIST OF ILLUSTRATIONS
no.
5. — Infiltration anesthesia for hemorrhoids . . . • .... 59
0. — Infiltration anesthesia: region of knee . . . . . • • .59
7. — Infiltration anesthesia of the toes . . . . • • • • .60
X. — Hraehial plexus anesthesia . . . • 62
9. — IVrineiiral nmdnet i\ -e anesthesia of the finger ... . . .63
10. — Nerves of the right index finder . . 63
1 1 . — Cross-section of finger through first phalanx .
12. — The Bier intravenous method of regional anesthesia 71
13. — Vapor pressure of ether in tidal air for induction and maintenance of full
anesthesia V 80
14. — Plot of ether vapor pressure in pulmonary tidal air and ether tension in .
body in first hour of ideal anesthesia 81
15. — Plot of ether tension in body . . . . . . • . . .82
16. — Zones of ether anesthesia 83
17. — Technic of intratracheal intubation 93
18. — Connell nasopharyngeal tube 95
19. — Foot bellows of air compressor for vapor anesthesia . 97
20. — Generator for compressed air : Connell portable model ... .98
21. — Surface vaporizer .99
'2-2. — Zones of nitrous oxid-oxygen anesthesia in normal man without supplemental
narcosis 114
The Hoothby apparatus for nitrous oxid-oxygen, air and ether mixtures . . 116
('oiniell nitrous oxid oxygen, ether flow control ... . . 117
25. — Pharyngeal insufflation with rebreathing 122
26. — The anesthetometer, original hospital and laboratory model .... 132
27. — The Connell anesthetometer 133
28. — The Connell pharyngeal breathing tube 136
TIIH PROPHYLACTIC AND THERAPEUTIC ADMINISTRATION OF
VACCINES AND SERA
JOSEPH C. ROPER
1. — Cell with receptors or haptines 198
2. — Toxin molecule with haptophore (combining) group H and toxophore (en-
zyme-like) group E . . . 198
3. — Cell with toxin molecules attached by combination of haptophore group and
receptor . . 198
4. — Re.-eptors cast off constituting free receptors or antitoxin . . . .199
5. — First order of antibodies free receptors or antitoxin having only a single
ip. the haptophore or combining group 199
6. — Stroll. I order of antibodies having a combining group II and an agglutina-
plu.ro group A 199
Third order of antibodies having two combining groups (amboceptor) . . 200
8. — Apparatus for "fractional" sterilization of vaccines 202
9. — Capillary pipet 9Q3
1°- — Diagram to illustrate the binding of complement which takes place on mix-
ing r«.Mipl«nient with homologous antigen and antibody .... 222
11- — Diagram to illustrate the lack of complement binding when complement is
mixed with heterologous antigen and antibody . . » 222
LIST OF ILLUSTRATIONS xxv
FIG- PAGE
12. — Diagram to illustrate lack of hemolysis when red cells and hemolytic serum
are added to mixture illustrated in figure . . . . . . 222
13. — Diagram to illustrate occurrence of hemolysis when red blood cells and
hemolytic serum are added to mixture represented by figure . . . 223
14. — Veins from which blood may be most advantageously drawn and into which
vaccines and sera may be introduced . 224
ASPIRATION AND ASPIRATING DEVICES IN OPERATIVE SURGERY
JAMES H. KEN YON
1. — Filter pump ; filter pump in section 230
2. — Steam ejector; steam ejector in section 230
3. — Method of connecting the ejector with the water pipe and the suction bottle
and tube with the operative field 231
4. — Suction tubes 233
5. — Double suction tubes . 234
6. — Double tubes for continuous suction in postoperative treatment . . . 234
7. — Method of connecting long tube from pleural cavity to bottle containing
sterile water 242
THE PRINCIPLES AND TECHNIC OF OPERATIONS UPON BLOOD
VESSELS
FREDERICK T. VAN BEUREN, JR.
1. — Threaded needle mounted on slip of paper for convenient handling . . 252
2. — Serrefmes with smooth blades 252
3.— Crile's clamps 252
4. — Dorrance clamp 252
5. — Serrefine with tape or gauze strip 253
6. — Jeger's clamps, straight and curved . . 253
7. — Fine scissors and forceps, straight and curved 254
8. — Suture of longitudinal wound in blood vessel 260
9. — Suture of transverse wound in blood vessel 260
10. — Stewart's clamp for isolating portion of lumen of vessel 261
11. — Lateral suture of longitudinal wound with lock stitch, using tension sutures 261
12. — Dorrance suture of transverse wound . . . 262
13. — Briau-Jaboulay interrupted suture . . 262
14. — Lateral suture with continuous overhand stitch . . 262
15.— Cutting off the adventitia ... .263
16. — Murphy's earlier method; traction sutures introduced . . 264
17. — Murphy's earlier method ; imagination completed by circular suture . . 264
18.— Murphy's recent method of end-to-cnd anastomosis by invagination . 264
19.— Hoepfner-Stich clamp . . 264
20.— Payr's end-to-ond anastomosis with magnesium ring . 265
21. — Jeger's holder for Payr's ring . . • -(i">
22.— Jeger's modification of Ptiyr's magnesium cylinder for deeply placed vessels . 265
23. — Salomoni's method of cnd-to-end suture 266
XXVI
no.
LIST OF ILLUSTEATIONS
24.— Briau-Jaboulay method of end-to-end suture ...
25. — Dorrance's method of end-to-end suture . 26t
26.— Dorrance's method . . ....... 266
27._Le8pinasse and Eisenstaedt method of end-to-end anastomosis . . .267
28.— Gentile's syringe . . . • 267
29.— Artery isolated on black field sheet 268
30. — Carrel's method of end-to-end anastomosis 268
31.— Carrel's method 269
32.— Carrel's method 269
33.— Carrel's method 269
34. — Correct direction of needle introducing stay suture . ... 270
Tying the stay suture .270
36.— Angrulating the vessel to facilitate insertion of continuous suture . . 271
37. — Reinforcement of the anastomosis with a strip of fascia or peritoneum . . 271
38. — Horsley's tension suture holder 271
39. — Jeger's tension suture holder 272
40. — Dobrowolskaja's flap incision for widening small vessels at the line of union . 272
41. — End-to-end arteriovenous anastomosis : approximation of the ends . 275
42. — End-to-end arteriovenous anastomosis : application of continuous suture . 276
43. — End-to-side anastomosis: oval opening into vein . . . 276
44. — End-to-side anastomosis: fixation sutures introduced 276
45. — End-to-side anastomosis: completed . • 276
46. — Carrel's patching method : small vessel excised with part of large , . . 276
47. — Carrel's patching method: stay sutures inserted 277
48. — Carrel's patching method: suture completed 277
49. — Side- to-side anastomosis 277
50. — Side-to-side anastomosis 277
51. — Side-to-side anastomosis completed showing extra end sutures of Guthrie . 277
52. — Bemheim's anastomosis 278
53. — Bernheim's anastomosis 278
54. — Bemheim's anastomosis 278
55. — Bernheim's anastomosis 279
56. — Beniheim's anastomosis 279
57. — Vein anastomosis, end-to-end . . . 288
58. — Vein anastomosis, end-to-side 290
59. — Vein anastomosis, end-to-side 290
60. — Vein anastomosis, end-to-side 290
61. — Jeger's 3-blade clamp for isolating parts of two vessels without interrupting
the circulation in the remainder 291
62. — Vein ;mastomosis, side-to-side 291
63. — Cutting artery to match vein and putting in stay sutures .... 293
fi:il defect filled by double end-to-end suture with venous transplant . 294
65.— I nt ravenous infusion: cannula introduced into vein at elbow . . . 298
iMimla 303
<'rilt'-i method of anastomosis for transfusion with cannula .... 304
cannula 305
Bernheim'i 2-piece transfusion tube 306
70, hcriiheim's method of transfusion 307
71. l:»Tiiheim's method of transfusion . . 307
TL'. iH-rnhciiii's method of transfusion . . 308
'raiisfusion ttil><- 308
74. — Fauntleroy'fl mollification of Brewer's tubes . 309
LIST OF ILLUSTRATIONS xxvii
FIG. PAGE
75. — Vein-to-vein transfusion with S-shaped tube 309
76. — Curtis and David's apparatus for indirect transfusion 310
77. — Kimpton's cylinder for indirect transfusion, Nos. 1 and 2 . . . .311
78. — Lindeman's cannula, assembled 313
79. — Lindeman's cannula, separated 313
80. — Mayo's dissector for varicose veins; Mayo's adhesion forceps for varicose
veins 322
81. — Friedel's spiral operation for varicose veins 323
82. — Delbet's operation after Hesse and Schaack 324
83. — Krogius's subcutaneous ligature for larger angiomata 329
84. — Purse-string ligature for small angioma of scalp 329
85. — Handley's operation for lymphatic drainage : upper extremity, anterior view 331
86. — Handley's operation, posterior view 331
A SPECIAL METHOD FOR THE TRANSFUSION OF BLOOD WITH THE
USE OF PARAFFIN AND HIRUDIN
RANSOM S. HOOKER AND HENRY S. SATTERLEE
1. — Sectional view of lower part of pipet 344
2. — Donor's cannula 345
3. — Recipient's cannula 345
4. — Pipet and aspirating tube with air-filter containing sterile cotton . . . 346
5. — Irrigating apparatus .... 346
6. — Recipient's cannula with obturator in vein 347
7. — Donor's cannula with obturator in vein 348
8. — Obturator removed from donor's cannula and pipet about to be introduced
into donor's vein 349
9. — Aspiration of blood from donor's vein 349
10. — Obturator removed from recipient's cannula and pipet, full of blood, at the
moment of introduction . 350
11. — Blood being delivered through recipient's cannula 350
12. — Use of plug in donor's cannula when giving saline infusion .... 351
THE SURGICAL TREATMENT OF ANEURYSM
JAMES M. HITZROT
1.— Method of Antyllus 365
2.— Method of Anel ... .367
3.— Method of Desault and Hunter . 367
4. — Brasdor's operation .
5. — Wardrop's operation .
6. — Diagram of obliterative endo-aneurysmorrhaphy .
7. — Diagram of restorative endo-aneurysmorrhaphy . . 372
8. — Diagram of reconstructive endo-aneurysmorrhaphy . 373
9.— Diagram of method of obliterating the sac in obliterative endo-aneurysmor-
rhaphy .... .376
10. — Diagram of a method of obliterating the sac in the restorative and recon-
structive operations
11, — Halsted aluminum bands • 384
xxviii LIST OF ILLUSTRATIONS
LIGATIONS OF ARTERIES IN CONTINUITY
WALTON MARTIN
no.
1.— The stay knot . 400
i'.— A — infolding of vessel walls by the ligature without rupturing them; B —
"(•elusion of the lumen by the infolding of the vessel wall .... 401
3. — Pinching up the sheath of the vessels in a transverse fold .... 402
4. — Anterior mediastinum 403
5. — The sternocleidomastoid drawn backward with the external jugular vein with
its continent veins, facial, lingual, pharyngeal, etc 406
<'». — Ligature of the left external carotid 409
7.— Relations of the internal and external carotids 410
8. — Dissection of neck, left side 412
9. — Course and relation of the subclavian and axillary arteries .... 414
1<>. — Superior clavicular region 417
11. — Line of left pleura, lung and internal mammary artery 420
12. — Neurovascular bundle in axilla 421
13. — Libation of the axillary artery 422
14.— Kxposure of the axillary and brachial arteries . 424
!."».— Li gat ure of the left brachial at the bend of the elbow 425
16. — Exposure of the brachial artery in the cubital fossa and of the radial and
ulnar arteries 426
17. — Lines of incision for ligature of brachial artery 427
18. — Deep volar arch 428
Abdominal aorta and common iliac arteries 430
20. — Scheme of the different types of relation of the ureter and iliac vessels . . 432
21. — Ligature of the left internal iliac . . . 433
22. — Ligature of the right internal iliac . 435
2'-'>. — Tin- g lu teal and sciatic arteries 436
24. — L« ft f« -moral artery exposed by incision of the integument and the cribri-
form fascia . 440
-lire of the femoral artery . . 441
2*'*.— Kx po>i i re of the popliteal artery 442
Tin- Bourse and relations of the posterior arteries of the leg .... 443
Exposure of posterior tibial behind the medial malleolus . . . 444
B9, Exposure of the anterior tibial of left leg 446
i nd arteries of the leg and dorsum of the foot ..... 447
Line of dorsal artery of the foot and of the anterior tibial . . 448
PLASTIC 8UBGERT INCLUDING HARELIP AND CLEFT PALATE
ALSO THE PLASTIC SURGERY OF THE LIPS, CHEEKS,
EYELIDS AND EARS
1'l.KCY R. TtJRNURE
Method of dosing defect by suture and tension .... 453
Method of .-losing ,l,,f,.,.t by undermining the skin
M. thod of elosing defect by single gliding flap . . 454
LIST OF ILLUSTRATIONS xxix
FIO. PAOE
4. — Method of closing defec* by double gliding flap 454
5. — Method of closing triangular defect by gliding Hap 454
6. — Method of closing triangular defect by double gliding flap .... 455
7. — Method of closing triangular defect 455
8. — Pocket method of closing defect 455
9. — Median harelip 458
10. — Simple unilateral harelip 458
11. — Simple unilateral harelip with deformity of nostril 458
12. — Simple bilateral harelip 459
13. — Complicated bilateral harelip 459
14. — Method of paring and suturing for simple unilateral harelip . . . 461
15. — Method of paring and suturing for single complete harelip . . . 463
16. — Method of paring and suturing for double harelip 463
17. — Showing advantage of resecting quadrilateral area in septum . . . 405
18. — Konig's method of paring and suture 466
19. — Hagedorn's method of paring and suture 466
20. — Malgaigne's method of paring and suture 406
21. — Hagedorn's method of paring and suture for double harelip .... 466
22. — Modification of Hagedorn's method of paring and suture .... 466
23.— Kose position 469
24.— Smith's cleft palate gag . 470
25. — Instruments used in operation on harelip and cleft palate .... 471
26. — Berry and Legg raspatory . 472
27. — A rectangular needle for inserting sutures; a curved needle for inserting
sutures ; a needle with double elbow 472
28. — Berry and Legg operation 473
29. — Berry and Legg operation 474
30. — Berry and Legg operation 475
31. — Berry and Legg operation 476
32. — Brophy operation . . 479
33. — Brophy operation 479
34. — Brophy operation 480
35. — Davies-Colley operation 481
36. — Davies-Colley operation 482
37. — Two-loop method of passing silver wire through superior maxilla . . . 483
38. — Brophy osteoplastic operation . 483
39. — Brophy osteoplastic operation .... . . 484
40. — Flap raised and fixed in position . . 486
41. — Cleft of a breadth sufficient to require the employment of a flap from the
entire alveolus . 486
42. — Flaps sutured in position . 487
43. — Lane operation for broad cleft involving almost the entire palate . . 487
44. — Flaps in position
45. — Lane operation when the width of the cleft is extreme . . 488
46. — Flaps in position
47.— Lane operation when the width of the cleft is extreme .
48. — Flaps in position - 490
49. — A simple V-incision for removing non-malignant growth of lower lip 494
50. — Double triangle method for removing non-malignant growths of lower lip . 495
51. — Restoration of lower lip .
52. — Restoration of lower lip .
53.— Restoration of lower lip 498
LIST OF ILLUSTRATIONS
54. — Merest in's operation for carcinoma of the lower lip -. - 49!
55. — Morestin's operation showing incision for the formation of the flaps
-Morestin's operation showing flaps drawn down . . 500
57. — Morestin's operation . . . . ; 500
58.— Morestin's operation for extensive loss of substance of the lips and cheeks . 501
59. — .M«.rrst iii's operation • • • 501
60. — Morestin's operation showing flap suture and new mouth formed . . 501
61. — Dowd's operation 501
62. — Jaesche's operation 502
63. — Syme's operation 502
64. — Kstlamler's operation 502
65. — Sedillot's operation 503
66. — ICalgaigne's operation • . . . 503
67. — Method of repair of small defect in upper lip by freshening the edges and
suture 503
68.— Dieffenbach's operation ' . 504
69.— Sedi Hot's operation 504
70. — Szymanowski's operation 504
71.- — Joseph's method for diminishing size of enlarged lobule .... 505
72. — Kolle's operation for abnormal enlargement of the auricle .... 505
73. — Park hill's operation for abnormal enlargement of the auricle .... 506
74. — Monk's operation for abnormal enlargement of the auricle .... 506
75-76. — Kolle's operation for malposition of auricle 507
77. — Israel's operation 508
78. — Israel's operation 509
79. — Israel's operation 509
80. — Israel's operation 510
81. — Hacker's operation 510
82. — Lerda's operation . 511
H3. — Lerda's operation 511
*4.— Lerda's operation 511
I.' nla's operation 511
86. — Ilotrhkiss's operation 512
87. — Ilotehkiss's operation 512
Hot<-hkiss's operation 512
89. — Kraske-Gersuny operation 512
90. — Kraske-Gersuny operation 513
91. — Kraske-Gersuny operation 513
92. — Ksman-h-Koleralzig operation 513
93. — Dieffenbach's method for ectropion of lower lid .... . 517
94.-' operation by a pregraf ted flap on restoration of lower lid . . .518
95. — I )ietfe M bach's method of restoration of lower lid . . . 519
Hasner's method of restoration of canthus .... 519
&7.~ V. Langenbeck's method of restoration of lower lid . . . . .519
OPERATIONS ON THE PERIPHERAL AND CRANIAL NERVES.
UNILATERAL LAMINECTOMY
ALFRED S. TAYLOR
1. — Nerve hook with blunt point 507
-Nerve compressed by strong clamp to prevent bleeding on section . 527
LIST OF ILLUSTRATIONS xxxi
n°- PAQB
3. — A — Epineurium removed from nerve ends and through-and-through suture
passed ready for tying. B— Through-and-through suture tied to approxi-
mate nerve-ends . 537
4- — A — Side sutures which have been passed through the epineurium and tied so
as to get a side hitch on epineurium. B — Lateral sutures tied and a few
peripheral sutures to prevent lateral displacement of ends . . . 537
5, 6 and 7. — Phases of nerve anastomosis 539
8. — Bridge between two ends of damaged nerve 540
9. — Gap between nerve ends bridged by means of chromic catgut loops ; Cargile
membrane used to complete tubulizatioii 541
10. — Schematic representation of brachial plexus 546
11. — Plexus exposed by means of oblique incision across base of neck and almost
at right angles to course of nerves 547
12. — Brachial plexus exposed by an oblique incision from junction of middle and
lower thirds of the sternomastoid muscle down and out to junction of
middle and outer third of clavicle 547
13. — Eight arm shows typical deformity of an old neglected severe brachial birth
palsy . 548
14. — This shows maximum power of elevating hand toward mouth before opera-
tion 548
15. — Nine months after operation — Note improvement in size and position of
right upper extremity, especially of hand 548
16. — Two years and seven months after operation patient could raise right hand
to his mouth 548
17. — Typical deformity in a child less than two years old 549
18. — X-ray picture showing shoulder girdle in a four-year-old boy who had suf-
fered a right-sided brachial birth palsy 549
19. — Deformity following complete rupture of left brachial plexus . . ' . . 550
20. — Three years after repair of plexus child was able to play with left arm and
to support a heavy doll with it 550
21. — Three years after repair of plexus child could also grasp a light-weight doll
with her fingers and hold it in front of her 550
22 and 23. — Traumatic Erb's paralysis in adult 551
24. — Schematic brachial plexus showing relation of nerve roots to nerve supply
of peripheral muscles .... ... 552
25. — An electrode which can be sterilized by boiling 553
26. — Leather-covered steel brace made for each operative case .... 554
27. — Head, neck and shoulder held in close approximation during healing, so pre-
venting any strain on nerve sutures . . . 554
28. — Characteristic wrist-drop resulting from musculospiral paralysis . . . 556
29. — Typical deformity resulting from ulnar paralysis . . 557
30. — Typical deformity in Volkmann's ischemic paralysis (left hand) . . 560
31. — Sensory supply of perineal region . . . 561
32. — Multiple neuromata .
33.— Silver rivets ... .566
34. — 1 — Supra-orbital nerve and artery. 2 — Supratrochlear nerve. 3 — Infra-
orbital nerve emerging from infra-orbital foramen . . 567
35. — Avulsion of central end of infra-orbital nerve . . 568
36. — A straight line running from supra-orbital notch and passing between the
two bicuspid teeth will also run through infra-orbital and mental fora-
mina ....
37. — Glass syringe, needle and stilet for alcoholic injection of fifth cranial nerve . 571
xxxii LIST OF ILLUSTRATIONS
no. PAGE
Hj :;.| .—Side and front view of position of needle for injection of second di-
vision of fifth nerve 572
,,1 41.— Position of needle for injection of third branch of fifth nerve . . 573
li'. Auriculotrmpnral approach to the Gasserian ganglion (1) .... 578
Auriculotemporal Approach to the Gasserian ganglion (2) . . . 579
44.— Auriculotemporal approach to the Gasserian ganglion (3) . . . 580
Infratcmporal approach to the Gasserian ganglion (1) . . . . . 581
[nfratemporal approach to the Gaseerian ganglion (2) 581
17. I ntYatemponil approach to the Gasserian ganglion (3) ..... 582
Krlati" us of the facial nerve 584
49. — Schema showing relations of nuclei of vii, xi and xii cranial nerves in
cortex and medulla 587
t oi i iv and relations of the facial nerve 588
51. — ('hi>ds convenient for removing lower part of canal in which facial nerve
runs so as to obtain a slightly longer peripheral facial stump for anas-
tomosis • 589
52.— Mallet 589
53. — Slender knife for splitting the hypoglossal, and special needle with a fixed
handle for passing sutures through hypoglossal sheath .... 589
in technic of faciohypoglossal anastomosis 590
f>5. — Xerve anastomosis 591
f»ii. — Xerve anastomosis 592
Complete facial paralysis following mastoid operation . . . . 594
58. — Same boy, three years after faciohypoglossal anastomosis showing ability to
laugh almost symmetrically . . . 594
59. — ('«>rrut:ator supercilii muscles acting equally well on both sides . . . 594
60. — Nerve anastomosis . . 595
61. — Xerve anastomosis 596
62. — Intracrnnial nerve section 598
Kxposnre of spinal accessory by a transverse incision following natural
wrinkles of skin of neck 601
64. — Retractor especially designed for laminectomy 603
65. — Periosteal elevator 603
IVriosteal elevator for lifting muscles from spinous processes and lamina? . 603
67. — Hudson set . 603
68, 69, 70 and 71. — Rongeurs for removing bone in unilateral laminectomy . . 604
72. — Scissors designed to allow rapid cutting of dura without damage to under-
lying structures . . . 605
Lane needle-holder and needles 605
74. — Peaslee needle 605
rvical vertebra 606
76. — A dorsal vertebra 606
77. — A lumbar vertebra 607
TV I'n i lateral laniineetoiny from D xii to S v . . . . 608
79.— Same dissection with dura split and held open by 6 silk suture retractors
-ln.winir cauda equina 608
niT.K'ATIONS UPON THE MUSCLES, TENDONS, BURS^E AND FASCLE
ARTHUR SEYMOUR VOSBURGH
1.— Relaxing sutures: distant and mattress ...... 614
2. — Distant suture : immediate suture . . . „ . 614
LIST OF ILLUSTRATIONS xxxiii
PAGE
FIG.
3. — Rupture of inner belly of right gastrocnemius ... .014
4. — Paralysis of trapezius 615
5. — Anterior view of Figure 4 616
6. — Volkmann's ischemic contracture .... c,17
7-9. — Methods of tendon suture 624
10. — Method of tendon suture 624
11. — Method of tendon lengthening, single flap ..... . 625
12. — Tendon lengthening, double flap . .... . 625
13.— Tendon lengthening: Hibbs-Sporon method . . 625
14. — Tendon lengthening: Hibbs-Sporon method ... ... 625
15. — Tendon transplantation . 626
16. — Snapping fingers . 628
17. — Tumor causing trigger finger ; enlargement of deep flexor . . ... 629
18. — Position of the palmar arches . 634
19.— Fetal type ........ .635
20.— Usual type 635
21. — Occasional type 635
22. — Large ulnar bursa of the palm showing invaginations of the sac . . 636
23. — Synovial sheaths of palm, injected 637
24. — Synovial sheaths of the extensor tendons, injected 637
25. — Diagrammatic representation of the situation of the pus . 638
PREPARATION AND APPLICATION OF PLASTER-OF-PARIS
DRESSINGS
J. F. COWAN
1. — Treatment of compound fracture (infected), involving the knee-joint . .712
2. — Long plaster spica including the foot 713
3. — Plaster-of -Paris spica applied to arm and thorax 715
4. — Moulded plaster-of -Paris splint for use in treatment of fractures of shaft of
humerus 717
5. — Anterior and posterior plaster splints applied 719
6. — Moulded plaster splint for fracture of the olecranon 721
7. — U-shaped moulded plaster splint for fracture of forearm .... 722
8. — Moulded plaster splints for Colics' fracture 725
9, A and B. — Hodgen's suspended splint 728
9, C. — Plaster spica for fracture of neck of femur, limb in abduction . . . 730
10. — Plaster spica for fracture of shaft of femur 731
11. — Plaster-of-Paris used for fractures of the shaft of the femur or of the neck
of the femur 732
12. — Circular plaster dressing for fracture of bones of the leg . . . 735
13. — Circular plaster dressing for fracture of bones of the leg .... 737
14. — Posterior and U-shaped plaster splints for fracture of bones of the leg . . 738
15. — Plaster traction splint for fracture of bones of leg . .... 739
16. — Stocking or bivalve splint for fracture of bones of leg with considerable
swelling of soft parts .... . 740
17. — Posterior and external lateral plaster splints for Pott's fracture . . . 741
18. — Lateral plaster splints for fracture of bones of leg . . 742
19. — Application of jacket with patient in the recumbent position .... 744
xxxiv LIST OF ILLUSTKATIONS
no. PAGE
20. — Application of jacket with patient in the recumbent position .... 745
21. — Frame for the application of plaster jacket in dorsal position .... 746
22. — Steps in application of grand jacket . . . 747
2.'*.— Grand jacket completed . .748
24. — Plaster dressing applied after correction of club-foot 751
25. — Method of reduction in dislocation of lower jaw 752
2U. — Kocher's method of reduction in subcoracoid dislocation of shoulder . . 753
27. — Kooher's method of reduction in subcoracoid dislocation of shoulder . . 753
28. — Kocher's method of reduction in subcoracoid dislocation of shoulder . . 754
29. — Kocher*s method of reduction in subcoracoid dislocation of shoulder . . 754
30. — Reduction of dislocation of shoulder by traction 755
31. — Reduction of dislocation of hip by traction . . . . . . . 756
DRESSING FOR FRACTURE OF THE CLAVICLE
HOWARD D. COLLINS
32. — Dressing for fracture of the clavicle 758
33. — Dressing for fracture of the clavicle 759
34. — Dressing for fracture of the clavicle 759
OPERATIVE THERAPEUSIS
VOLUME I
CHAPTER I
ASEPTIC SUEGICAL TECHNIO
HOWAKD D. COLLINS
The discovery of the causes of surgical infections and the means of com-
bating and eliminating their activities has done more to widen the scope of
surgery than any other factor. The ancients certainly appreciated that the
differences between clean and unclean healing were brought about by some
definite agents ; but superstition played so prominent a part in their beliefs that
as often as not their efforts to overcome wound infections were directed to
assuaging the anger of some malign deity. Nevertheless, a few ancient and
medieval surgeons learned by experience that in many cases their patients
promptly healed if the surgeon abstained from too active treatment of the
wounds. Others, groping in the dark, used one medicament after another,
charm after charm, hoping that each would prove to be the long-sought panacea.
These two groups were the forerunners of aseptic and antiseptic followers. Not
until 1871, under the leadership of Lord Lister, were the causes of wound in-
fections appreciated and methods initiated for relief. Since Lister's time our
knowledge along these lines has leaped with bounds until to-day we feel that a
large part of the subject has been mastered. Science, however, is infinite, and
the years to come may prove us to be to-day, only at the threshold of our knowl-
edge of repair.
The march of time will, in a few years, all too soon, eliminate from the field
of active surgical endeavor those masters of their art who, trained in their sub-
ject in the preaseptic days, lived long enough to see the new era, take advantage
of its knowledge and perfect themselves in the new methods. They are indeed
masters of surgery, for in their early years they learned to treat wounds with
respect and conserve the energy of their patients. Without the adjuncts of the
laboratory and X-ray they trained their powers of logical reasoning, their
sense of touch and respect for the damage they could do. With such an equip-
ment it is not strange that they should stand out so preeminently when all the
new magic was put at their disposal.
2 1
ASEPTIC SUKGICAL TECHOTC
AGENTS OF INFECTION
The varieties of streptococci and staphylococci with their protean mani-
festations are the commonest causes of surgical infection, but it must be borne
in mind that a host of other germs may be introduced into wounds so as to inter-
fere with aseptic results, such as tubercle bacilli, Spirochsetse pallidse, gas-
producing bacilli, pyocyaneus, anthrax, etc. The most resistant of these causes
of infection are the spores of anthrax, and such agents as will destroy the
anthrax spores will produce complete annihilation of all other pathogenic
forms.
SOURCES OF INFECTION
Lord Lister ascribed the main source of infection to the germ-laden
air and directed his principal attention to the antiseptic action of a
spray of carbolic acid so as to sterilize the air about the field of opera-
tion. At present we regard the air to be of but little moment as a
source of infection, and seek to remove or destroy the germs at such
points where they may already have found lodgment. The germs of in-
fection lodge in the skin of the patient, the hands of the surgeon, in
clothing, instruments, weapons, and the earth itself, so that traumatic
wounds, either accidental or intentional, are prone to infection unless the
inflicting objects are sterile, or means are promptly taken to render
inert the germs introduced.
METHODS OF PREVENTION AND COUNTERACTION
Schimmelbusch formulated a list of the means to prevent and counteract
surgical infection, which was as follows :
1. Mechanical means
2. Germicidal agents, heat and chemicals
3. Agents that arrest bacterial growth within the body
4. Agents directed against ptomain products
5. Agents increasing bodily resistance
The last three methods imply that infection already exists and so their em-
ployment would be strictly antiseptic. The ideal condition we seek is asepsis,
and this can only be obtained by complete sterilization before the wound is made'
so we must direct our attention to the first two methods. The handling of
infected wounds and general infection is fully covered in another chapter of "this
work.
METHODS OF PREVENTION AND COUNTERACTION 3
MECHANICAL MEANS OF STERILIZATION
Mechanical means are uncertain, but they should be our first step toward
sterilization and are best accomplished by the vigorous use of soap, hot water,
and scrubbing brush or cloth. All articles intended for surgical work which
will not be injured by such a procedure should be thoroughly scrubbed with
liberal applications of soap and hot water to remove palpable dirt, grease, etc.
Instruments, rubber goods, glassware, surgeon's hands and patient's skin should
all be so treated.
GERMICIDAL AGENTS
Heat. — Heat is the most valuable of all our germicidal agents, and wher-
ever possible should be the agent employed. Boiling in clean water is the best
form of heat available, for boiling water will destroy anthrax spores in two
minutes. Next to boiling water comes live steam — by live steam we mean satu-
rated or air-free steam — which may be used at normal pressure, or better yet if
superheated, i. e., under increased pressure (7% kilos or 15 pounds, twice the
normal atmospheric pressure, raises steam to 121° C. or 250° F.). Steam un-
der such a pressure will enter all crevices and interstices of gauze, cotton cloth-
ing, etc., unless they be compressed very tightly. Live steam destroys anthrax
spores in 15 minutes or less.
HOT AIE.— Hot air at 140° C. or higher is a fairly valuable sterilizer, but
requires about 3 hours to kill anthrax spores.
CAUTEKY. — The actual cautery is positive as a germicide, but of course
destructive to tissue. An unclean surface, as an ulcer for example, may be ren-
dered completely sterile by its use, although, of course, at the expense of all the
superficial tissue.
Careful study of the results of sterilization by boiling or steam (our most
efficient means) has shown that the ordinary pathogenic bacteria, as well as
anthrax spores, are destroyed in a short time, but cultures made of the sterilized
objects at the end of 24 hours have often shown the development of isolated and
attenuated growths of spores whose effect on the body has not been determined.
That these spores are probably harmless is proved by the nearly uniform asepsis
of wounds where reliance has been placed on the ordinary processes of steriliza-
tion of surgical materials by boiling and steam. Nevertheless, as long as any
development does take place, the material cannot be considered perfectly sterile
in a strict scientific sense. To render materials absolutely germ-free it is neces-
sary to submit them to fractional sterilization. This consists in subjecting the
materials, catgut, gauze, etc., to three, four or even five separate boilings or
impregnations with steam at intervals of 24 hours. This method renders surgi-
cal supplies absolutely germ-free, but is a refinement hardly called for in order
to destroy the recognized infectious bacteria.
Chemicals. — Chemicals are in many instances active germicidal agents and
form a valuable armamentarium in our aim for asepsis. No chemicals can com-
4 ASEPTIC SUKGICAL TECHNIC
pare with boiling or live steam for efficiency, but much of our material will not
submit to boiling or steam, and so perforce we must resort to chemicals. The
lists suggested as being active germicides are appalling, and gradually the sur-
gical world is confining itself more and more to a few of the highly recognized
germicidal chemicals.
BICHLORID OP MERCURY. — At the top of the list should be placed bichlorid
of mercury. This chemical, in strengths of 1 : 300,000, checks but does not de-
stroy growths of anthrax spores. Used in strengths of 1: 1,000 it is a most
valuable agent for sterilizing glassware, rubber goods, etc., if the articles are
free from grease and allowed to remain immersed in the solution for a suffi-
ciently long time — one hour. Even under these conditions anthrax spores are
not destroyed. Bichlorid of mercury solution has but little power to penetrate
unbroken skin unless applied for a long time, and so is of no use in destroying
bacteria underlying the more superficial skin layers. Bichlorid of mercury on
raw surfaces forms an albuminate of mercury coating which is a serious bar-
rier to further activity of the drug, and the destruction of healthy surface cells
is of more harm than the value of its application. But little reliability should
be placed on its use for sterilization of the patient's skin or surgeon's hands.
Bichlorid of mercury should not be employed in sterilizing metal instruments,
as it is destructive to the metal itself.
CARBOLIC ACID. — Carbolic acid was the mainstay of the early days of anti-
sepsis, and in strengths of 1 : 20 to 1 : 40 is germicidal for most pathogenic
organisms, but not for spores. In greater strengths it is highly injurious to the
tissues of the body. It presents one advantage over bichlorid of mercury in that
it is not destructive to metal instruments. As an application to the skin it is
decidedly superior to bichlorid of mercury, owing to its increased permeability
of unbroken skin, but the weak solutions necessary for safety are so mildly
antiseptic as to render it but of slight value. Lysol, creolin and other
coal-tar products act in a similar manner to carbolic acid, but are less dan-
gerous.
IODIN.— lodin (in tincture) has a powerful germicidal action, and has in
the last few years attained great and deserved popularity as an agent for steriliz-
ing the skin, catgut, etc.
POTASSIUM PERMANGANATE. — Potassium permanganate (1: 20) is a good
sterilizer of skin, but its stain is deep and fairly lasting, requiring decoloriza-
tion by a saturated solution of oxalic acid.
IODOFORM— lodoform, it is claimed, has a specific action in arresting tu-
bercle bacilli growths and stimulating the tissues. Its objectionable odor and
poisonous properties counteract its value to some extent.
ALCOHOL.— Alcohol (95 per cent.) is a valuable destroyer of the ordinary
bacteria <>f infection, but of little value against spores. It has great efficacy,
however, as a stimulating and soothing dressing, preferably when used in
strengths of 50 to 60 per cent.
SUTURE MATERIAL 5
FORMALDEHYD GAS. — Formaldehyd i»as is a powerful disinfectant and is
extensively used for disinfecting clothing, rooms, etc. This gas is the best agent
known for sterilizing zinc oxid adhesive plaster and gutta-percha tissue. An
aqueous solution (40 vols. of gas) is a valuable disinfectant but irritating to the
living tissues.
In addition to the chemicals already mentioned, the list could be greatly
extended by mentioning ether, hydrogen peroxid, boric acid, acetate of alu-
minum, salt solution, etc. — all chemicals possessing more or less active germi-
cidal properties.
The selection of one or more of the individual drugs mentioned in the fore-
going list is highly proper for the treatment of infected wounds. Practically,
but little reliance is placed on most of them .to-day for the purpose of ren-
dering aseptic the field and appliances for a modern surgical operation.
Their indications and uses in the treatment of infected wounds will be
taken up in its proper place, and such of the chemicals used in the preparatory
stages of operative procedure will be discussed in detail when called for.
SUTURE MATERIAL
The surgeon should bear in mind that sutures only serve to hold in apposi-
tion the tissues of the body until such time as agglutination of the tissues them-
selves is sufficiently strong to hold the parts together without danger of disrup-
tion by muscular retraction or pressure from within or without until complete
continuity or healing has occurred.
It is impossible for any suture to hold the parts, be they skin, fascia, muscle
or bone, together for any length of time in the presence of retraction unless
agglutination takes place; for without adhesion of the opposed surfaces and in
the presence of traction, the suture is bound to cut through in time and thus
vitiate its purpose.
Now the length of time required for agglutination and healing to be accom-
plished, and in its absence or delay the time required for a suture to cut its way
through the tissues, is a variable and difficultly determinable factor ; and in our
selection of material, size and method of application of the suture material we
must be guided by the healing force of the patient, the character of the tissues
and the strain to which they will be subjected during repair.
If the foregoing proposition be accepted as a fact, the corollary to it will
have to be conceded ; namely, our suture should be of such a size and strength
and so placed as to serve only until agglutination and repair be well established
and by its fineness and smoothness be as little irritating as possible and, further-
more, when its purpose be accomplished, that it disappear either by absorption
or removal.
It is a common practice, which the writer deprecates, to use very long-lasting or
non-absorbable suture material with the claim that "the patient's tissues may drag on
6 ASEPTIC SURGICAL TECHNIC
those sutures for a lifetime without danger of the sutures breaking." If repair of the
parts does not occur the sutures are bound to cut through, and that is equivalent to
their rupture. It is absurd to repair a hernia or a fractured patella with silver wire,
basing our hope of a cure on the wire not breaking and that the resistance to muscular
traction will be transmitted for all time through the wire. The use of heavy non-
absorbable material, if it serve the purpose until repair is complete and then when
properly buried cause no irritation, is right enough; but how much more ideal the
condition, if after the suture has served its purpose, it be removed.
Catgut. — Of all suture material at our disposal, catgut to-day presents the
nearest to the ideal. It may be had in any size from but little coarser than hair-
line thickness to a heavy strand. Its strength is very great, its period of
absorption hastened or delayed by methods of preparation, and what is most
important, it can be completely sterilized.
PREPARATION OF CATGUT. — Catgut is obtained from the submucosa of the
small intestine of the sheep which has been macerated and treated stf as to de-
stroy the serous and mucous layers. The gut is then "spun" into strands of
various sizes and lengths. As it comes from the manufacturer the gut is strong,
soft and pliable, but highly infected with countless bacteria. The first stage in
its surgical preparation is to wash and soak the gut in ether for 24 hours to
remove the grease, etc. After this a number of different procedures have been
devised of which the oldest, and theoretically the most ideal, method was to boil
the gut for half an hour. Water, as the solution in which to boil the gut, was of
course out of the question, for water turned the material into a gelatinous pulp.
Alcohol does not destroy the character of the gut, but the boiling point of alcohol
is too low to be of use in destroying many forms of bacteria. The plan then
used was to boil the gut in alcohol under pressure sufficiently great to raise
supposedly the boiling point of the alcohol to that of water. This method re-
quired a complicated apparatus, and was expensive and dangerous, owing to the
highly inflammable quality of alcohol. In practice it is found that even the best
appliances fail to raise the boiling point of alcohol to that of water (100° C.).
Furthermore, the absolute alcohol of commerce contains % per cent, of water,
and unless infinite pains be taken in the manipulation, the alcohol readily picks
up I/, to 1 per cent. This amount interferes with the reliability of the gut as
to strength, consistency, etc.
CUMOL METHOD. — The cumol method consists in heating the gut in a bath
of cumol. Cumol is a highly inflammable but non-explosive hydrocarbon with
a boiling point of 170° C. The cumol is heated in a vessel standing in a sand
bath to a point just short of boiling and the catgut, previously thoroughly dried,
s put into the cumol. The junit is kept for one hour in the cumol at 165° C.,
when it is ready for use and may be stored in jars of sterile alcohol. There is
no question but that catgut can be rendered absolutely sterile by this method;
but the preservation of the gut in a sterile condition requires considerable care
s subject to easily committed errors in technic. It is customary to store
the gut in jars of sterile absolute alcohol. It has already been pointed out that
SUTURE MATERIAL 1
under these conditions the alcohol easily absorbs water and thus interferes with
the value of the catgut. The removal of a spool of gut from time to time from
a general reservoir is hazardous from the standpoint of asepsis.
The large commercial purveyors of surgical supplies have adopted the cus-
tom of furnishing catgut sterilized by the cumol method in hermetically sealed
glass tubes filled with sterile absolute alcohol. Each tube contains only a few
feet of gut, and thus the amount wasted at an operation is but small. The
glass tubes may be and should be boiled in water at the time of the operation,
so as to render the outside of the glass tube sterile, permitting of its being han-
dled for the purpose of opening by sterile hands. Catgut so prepared by re-
liable commercial houses can be absolutely depended upon to be as nearly uni-
formly sterile and of proper strength as could be desired.
The mechanical appliances for preparing and preserving the catgut by the
above described methods are too complicated to render them practical for use on
a small scale. To overcome these difficulties the preparation of gut by the iodin
method was devised.
IODIN METHOD. — Several methods of procedure have been suggested. One
of the earliest and simplest was that of Claudius, which consists in immersing
the catgut for eight days in an aqueous solution of iodin and potassium iodid
(1 per cent, of each). Various modifications of this method have been
adopted, several of which are a combination of sterilizing the catgut in a bland
oil (albolene or cumol) with a high boiling point, and then storing the gut
in an iodin tincture. (This is practically the cumol method plus iodin
storage.)
Moschcowitz . has originated the method of sterilizing the catgut (previously
warmed to drive off all moisture) in a 5 per cent, alcoholic solution of iodin. The gut
is left in the tincture for five days, then dried in a sterile towel and stored dry in a
sterile jar. Moschcowitz has shown by a series of ingenious experiments that catgut
so prepared is not only sterile in itself, but checks all growths in its vicinity when
placed on artificially contaminated culture media. For over six years catgut so pre-
pared has been used extensively at the Mount Sinai Hospital, New York City, with
most excellent results. The simplicity, cheapness and proved results call for the
heartiest commendation of Moschcowitz's method.
In addition to the foregoing methods, catgut has been prepared by steriliza-
tion in formalin, bichlorid of mercury, silver salts, etc. These methods present
no advantages over the cumol or iodin processes.
CHROMICIZED CATGUT. — Many surgeons feel that the life of a strand of cat-
gut buried in living tissue is too short to fulfill the purpose for which the suture
or ligature is intended, and so the gut should be treated in such a way as to
lengthen its period of absorption. This is best done by soaking the gut for 24
hours in a 4 per cent, aqueous solution of chromic acid, which raises the time
of absorption of the gut by 10 to 20 days or even longer. The gut so treated
is sterilized in the usual way (moist heat in cumol, albolene, etc.). The iodin
8 ASEPTIC STJKGICAL TECHOTC
method in itself renders the catgut less absorbable than plain gut, and so it is
not usual to chromicize gut that is sterilized by the iodin process.
Kangaroo Tendon. — Kangaroo tendon is another suture material derived
from animal tissue and behaves in the same way as catgut, but is less readily ab-
sorbable and has greater tensile strength. It is prepared in the same way as
catgut.
Silkworm-Out. — This is prepared from the contents of the silk sacs of the
silkworm. It is a fine, pearly white strand, very springy like fine steel wire,
non-irritating but non-absorbable. It is very popular as a firm tension suture to
pass through and roughly approximate several layers of tissue, but should never
be buried. Silkworm-gut is sterilized by simply boiling in water. It must be
used in a wet state.
Silk. — The product of the activities of the silkworm is the oldest of all suture
material. Commercially it is obtained in long strands of various thicknesses,
either twisted or braided, bleached or dyed black. Silk is soft and pliable and
its knots seldom slip. It is non-absorbable and should never be buried except
occasionally under cover of the peritoneum. Silk is sterilized by boiling.
Pagenstecher's Thread. — This consists of a plain linen thread treated with
celluloid. It presents similar characteristics to silk, but size for size is stronger,
and owing to its celluloid coating is smoother. It is sterilized by boiling and,
like silk, it should not be buried except in the peritoneum.
Silver Wire. — Made from ordinary "sterling" silver or pure silver, this is
a very reliable non-absorbable suture and is extensively employed for retention
purposes in bone work. The surgeon should always plan to remove the wire
after it has served its purpose of holding the parts together until living union
has occurred. Silver wire should always be annealed before using, by passing
through a Bunsen or alcohol flame until a dull red. The annealing renders the
wire more pliable, less brittle, and at the same time thoroughly sterilizes it. If
the wire has been previously annealed it may be sterilized by boiling.
Aluminum Alloys.— Aluminum is known to be absorbed in time by the tis-
sues, and aluminum or various alloys of aluminum are used as substitutes for
Iver wire. The uncertainty of the time of absorption is so great as to interfere
with their usefulness. Aluminum and its alloy wires are sterilized by boiling.
DRESSINGS
Material for surgical dressings should be capable of freely absorbing exn-
ates and discharges from wounds, and be easily and perfectly sterilized.
..JM.XOOT cheese cloth" fulfills these conditions admirably. Cheesecloth as
from the cotton mills, comes in lengths of about fifty yards by one
i fineness or coarseness varies in accordance with the number of
to the mch-the intermediate numbers being best suited to ordinary
r.heese cloth in its preparation at the mill is usually submitted
DKESSINGS
9
to a process of "sizing" or coating with a solution of starch, which interferes
seriously with the absorbent powers of the material. To free the goods from
the sizing it is necessary to boil the cloth in a 1 per cent, solution of sodium
carbonate. The manufacturers of surgical supplies furnish gauze free from
sizing in various sized packages hermetically sealed and already sterilized.
Gauze so furnished can be depended upon with reasonable confidence, but it is
much safer to resterilize gauze before use.
Gauze. — Gauze is best sterilized by superheated steam for thirty minutes in
an autoclave, and should be subjected to fractional sterilization (2 or 3 steri-
«"*
f,
w/ , • .,, , - -/ *»
FIG. 1. — GAUZE PADS; HANDKERCHIEFS; ROLLS; RUBBER GLOVES; DRAINAGE TUBES.
lizations at intervals of 24 hours). The technic is as follows: The gauze
is cut and folded into squares of suitable size and placed in metal cylinders or
boxes which are so designed as to have perforations in the top and bottom to
permit the free passage of the steam through the material; furthermore, the
receptacles are equipped with sliding covers, which when slipped into place
tightly cover over the perforations and prevent contamination of the gauze
during storage. Caution should be exercised in packing the gauze in the boxes
before sterilization not to compress the gauze tightly, as this interferes with the
ready flow of the steam.
I have gauze cut and folded in the following shapes for various uses:
Gauze handkerchiefs, about 1 yard square and fluffed up ; squares about 4 by
6 inches of 4 thicknesses of folded gauze ; abdominal sponge pads 1 foot square
of 4 to 6 thicknesses with the edges stitched together and a piece of tape 6 inches
long sewed to one corner; "leg rolls" 6 inches wide, 2 yards long, of 6 layers of
10 ASEPTIC SURGICAL TECHNIC
gauze ; narrow drainage strips from % to 1 inch wide of various lengths and 2
to 4 thicknesses; sponge pads 2 by 2 to 4 by 4 inches of 4 thicknesses. In
folding the gauze to make these various sized pads great care must be taken
to so enfold the "raw" edges of gauze that these edges are placed in the center
of the pad so as to prevent shreds entering the wound.
The assortment of pads is packed in metal boxes or cylinders, as already
described, or put into large towels so folded over and pinned as to practically
seal the package from the air at normal pressure. The whole is sterilized in an
autoclave. [The packages may be further covered with paraffin paper.—
EDITOR.]
Cotton. — Cotton is an indispensable member of our list of surgical dress-
ings. It is furnished either as non-absorbent cotton, which is the raw cotton
cleansed and beaten and then rolled into flat sheets about 1 inch thick and 18
inches wide, or as absorbent cotton, which is the same as the other, only bleached
and freed from oil. Non-absorbent cotton is more springy and, being non-
absorbent, does not become matted when wet, and is of great value under splints.
Absorbent cotton, as its name implies, is capable of retaining a great amount
of moisture, and is of inestimable value in absorbing pus, blood, and other dis-
charges.
Cotton is sterilized by steam in the same manner as gauze. In using ab-
sorbent cotton as a surgical dressing it is not a good plan to put the cotton next
to the wound, but several thicknesses of gauze should intervene. Flat sheets of
cotton about one foot square put into a "pillow case'7 of gauze is a practical
way to use it for a dressing.
Lamb's wool, moss, oakum, felt, etc., have their advocates as outside dress-
ings. Some of these substances are absorbent and can be used in extensively
discharging wounds. Others are springy and serve as excellent padding. All
can be sterilized by dry steam heat. They have no advantage over cotton.
Sponges. — No material is as efficacious for absorbing blood and discharges
from a wound during an operation as the natural sea sponge', but the well-nigh
impossible task of rendering a sea sponge sterile has led to the universal aban-
donment of this material. About the only "sponges" in use to-day for surgical
work are squares of gauze folded as already described. Little balls of absorbent
cotton 2 inches in diameter and covered with a piece of gauze gathered at the
top and tied with a bit of cotton thread are used by some.
Impregnated Gauze. — The practice of antiseptic surgery called for the use
iii/c impreiniated with various chemicals, to be placed on or into wounds
with the idea that the chemicals so exhibited would serve to destroy the patho-
genic bacteria. In discussing on the previous pages the various chemical germi-
cides the writer lias tried to make dear that the substances at our disposal are
either so irrilat in»- to the tissues of the body as to do more harm than good, or
e|>e are so feeble in their bactericidal action as to be of little or no avail. The
oae of impregnated naii/e or dustinir powders on supposedly clean wounds is a
frank avowal of lack of faith in one's asepsis.
DRESSINGS 11
The argument might be raised that, given a wound already septic, is it not
a wise plan to use impregnated gauze to destroy the bacteria now manifestly
present ? Our answer is yes, if there be a drug capable of destroying the bac-
teria which does not at the same time do harm to the body cells. My belief is
that the function paramount of gauze packed into wounds is to absorb and im-
prison the discharges and to hold the wound open and prevent pocketing. As
soon as the gauze has reached the limit of its power of absorption it should be
removed and fresh packing introduced. The saturated gauze has removed in its
meshes many noxious germs and detritus, all well rid of, but the real struggle
takes place beneath the surface of the walls of the wound and no germicide in
the form of antiseptic packing can penetrate to the scene of conflict without
having harmed the superficial cells, the very guardians on whom we place part
of our reliance. If we use such mild substances as not to injure the body cells,
the bactericidal action is wanting and no harm results except that the absorbent
power of the gauze is much diminished, as many of its meshes are filled to
occlusion by the drug.
Most surgeons have seen very satisfactory results from the injection of
Beck's paste or iodoform wax into tuberculous or simple suppurative sinuses.
In such cases the satisfactory results depend not so much on any germicidal
action as on the distention of the walls of the sinus, thus obliterating folds and
pockets, and at the same time the waxy paste furnishes a smooth surface along
which the discharges readily run to the outer dressings.
The usual way to prepare medicated gauze is to dip or roll strips of gauze
of the desired size in solutions of selected strength of the drug, as, for example,
bichlorid of mercury, 1 :1,000, boric acid saturated solution, balsam of Peru,
etc.
Iodoform gauze is prepared as follows: Strips of gauze are dipped into
and allowed to become thoroughly impregnated with a mixture consisting of 1
part iodoform powder, 2 parts glycerin, and 2 parts alcohol, all previously
sterilized. On removal the gauze is kept in air-tight sterile jars.
BANDAGES
The usual bandages are made from unbleached muslin and from gauze in
varying lengths and widths. A particularly desirable bandage, but quite expen-
sive, is made from a material similar to an "Oxford shirting" known as "mull."
This bandage is much more pliable and elastic than the muslin bandage and
firmer than a gauze one. Starch bandages are made from "crinoline," a cotton
gauze of firm weight highly sized (treated with starch). This bandage is wetted
before application, and when dried out in place is much firmer than gauze or
muslin without the objection of the weight of plaster-of -Paris. It is an excel-
lent bandage for scalp wounds.
Plaster-of-Paris bandages are made by rolling gauze or crinoline in fine
dental plaster, rubbing the plaster well into the meshes of the gauze. The work
12 ASEPTIC SURGICAL TECHNIC
shmiM only l)o done in dry weather and the bandage carefully preserved in tight
boxes to keep the plaster from being air slacked.
In applying plaster-of-Paris dressings the bandages are first soaked in warm
water and rolled on in the usual manner. Care must be taken that all bony
prominences are well covered with canton flannel or cotton, for the amount of
discomfort and danger that can be caused to a patient by the continual irrita-
tion of the hard plaster pressing on prominent points is considerable. Ke-
en tWrini: plaster-of-Paris dressing is on the same principle as reenforced con-
It is best accomplished by inserting between the turns of the bandage
verv thin (1/16 to % inch) strips of wood, one inch wide and long enough to
extend the length of the dressing. The procedure adds very materially to the
strength of the dressing with little addition to its weight. (See also Vol. II,
Chap. III.)
Silicate of soda or water glass was much more extensively used in former
times than now. The methods used were either to soak bandages in a watery
solution of silicate of soda and apply as plaster-of-Paris bandages or to apply
the bandages first and paint over with the solution. The objections to silicate
of soda are its extra weight over plaster-of-Paris and the length of time re-
quired to harden it (12 to 24 hours). These objections have caused its prac-
tical disuse.
ADHESIVE PLASTERS
The old-fashioned moleskin plaster is to-day the best plaster to apply
directly to the skin, where it is intended to allow the plaster to remain a long
time, as, for example, in Buck's extension, but the moleskin plaster requires ta
l»e heated so as to soften the waxy surface before it can be made to adhere. This
is an objection. [Its surface may be wiped with benzin or ether. — EDITOR.]
The Z. O. plaster of to-day is rubber plaster improved by the addition of
zinc oxid. It is not so irritating to the skin as plain rubber plaster, but more
so than moleskin. Z. O. plaster can be had in big sheets or rolls of varying
width.
Caution should be exercised in the too frequent renewal of strips of plaster over
niic area. Some skins are very susceptible to irritation by Z. O. or any other
I'l;i-t» -r>. and if the strips be torn off every two or three days and fresh ones applied, a
«li-tn--inir excoriation may result. It is the writer's custom to cut the plasters
at the point where they pass from the skin to the dressings, leaving the skin portion
mnlisturln-«l. :m<] in re-applying the fresh plaster the new piece is superimposed on the
old piece still adherent to the skin. In this manner 6 or 7 layers may be formed cor-
• ml ing to an equal number of dressings. After a week or 10 days the proliferation
and <l«-s.|tiamation of the epithelium loosen the plaster so that a new foundation must
!••• la ill on the skin, but this is new skin and not irritated by the frequent tearing off
of the plaster, and so no irritation results. Another very good way to avoid frequent
changes of plaster is to apply strips of plaster to the skin on either side of the dressing,
1 raving a long end to extend part way over the dressing. This long end is then folded
back on itself so as to obliterate its adhesive surface. The tip is perforated and, with
DRAINAGE TUBES 13
a tape inserted through the holes in each pair of plaster strips, the dressings may be
tied in place. This method does not hold the dressing as firmly as the preceding.
Benzm dissolves the rubber and is useful in cleansing the skin after using plaster.
Narrow Z. O. plaster strips placed across a wound serve to hold its edges in approx-
imation nearly as well as sutures and are preferred to sutures by many surir<,(IH
Plaster strips so used must be sterilized, for they come in direct contact with a fresh
FIG. 2. — METHOD OF USING Z. O. PLASTER WITHOUT IRRITATING THE SKIN.
wound. It is a most doubtful plan to attempt to sterilize Z. O. plaster after it is once
manufactured, the usual way being to expose the plaster for a long time to formal-
dehyd gas. Reliable sterile strips, however, may be had from the manufacturers.
DRAINAGE TUBES
At one time glass drainage tubes were extensively employed because of
their rigidity in keeping sinuses open and the ease with which they could be
sterilized. Their brittleness and unyielding pressure on the tissues have led to
their abandonment.
Rubber tubes are much more satisfactory and may be used plain or with
perforations cut into their sides, or the tube may be split lengthwise or spirally
and a strip of gauze laid into the channel. Tubes so inserted should always
be fastened at their outer end, for it not infrequently happens that a tube, unless
so fastened, may slip into a long sinus and be temporarily lost, only to be re-
covered, after many weeks of mystifying absence of healing, by some rival
practitioner.
The Cigarette Drain.— The so-called "cigarette" drain consists of a strip of
gauze about which a sheet of rubber tissue has been wrapped. The gauze
should project at either end beyond the tissue. The advantage a cigarette drain
offers over a plain gauze packing is that the rubber tissue prevents adhesions
14 ASEPTIC SUEGICAL TECHNIC
between the gauze and the canal in which the drain lies, thus permitting the easy
and less painful removal of the drain.
Rubber or gutta-percha tissue folded into strips of several thicknesses and
from % to % inch wide is an excellent drainage material for slight discharges.
Rubber tissue is obtained in large sheets of writing paper thickness or even
thinner, is not elastic, and tears across the sheet with readiness, but not length-
wise. This should be borne in mind in making "cigarette" and other rubber
tissue drains. The tissue should be folded with the "grain," for if this pre-
caution is not taken it may so happen that a distal segment of the tissue may be
left behind when the tissue is withdrawn from a wound.
Rubber tissue cannot be sterilized by boiling or steam. To prepare rubber
tissue it should be thoroughly washed in soap and tepid water, rinsed off, and
then immersed in bichlorid of mercury 1 :1,OOQ, or formalin, for several hours.
Before using the bichlorid or formalin should be removed by washing in sterile
water.
Strands of horse hair, silk, or catgut are sometimes used for drains. Rub-
ber darn may sometimes be substituted for rubber tissue. It can be boiled.
HYPODERMIC AND ASPIRATING SYRINGES
Syringes having leather packing about the plungers cannot be sterilized
without injury by boiling, the most efficacious but still unreliable method being
to soak the syringe in an antiseptic solution like strong carbolic acid (1 :20) or
alcohol. Bichlorid of mercury injures the metal, and formalin destroys the
leather packing. All-metal or all-glass syringes with the plungers so accurately
ground into the cylinders as to give a perfect fit are now readily purchased, and
are so superior to the older types as to more than offset their increased cost and
shorter lives. Such syringes can be boiled like any instrument.
INSTRUMENTS
are
ha
as
The modern armamentarium of the surgeon discards all instruments that
not exclusively made of metal so as not to be injured by boiling. Bone,
hard rubber, and ivory are things of the past. In selecting instruments avoid
as much as possible tools that are complicated or constructed with deep recesses
and grooves which retain dirt, grease, dried 'blood, etc., adding to the difficulty
of sterilization.
Instruments with aluminum handles had at one time quite a vogue, the
advantage claimed beinir lightness. The very lightness is in the writer's opinion
an objection. A -cncrously made and fairly heavy instrument is far more
agreeable to use than one of very light weight or of such small diameter as to
Strain the hand in order to maintain a firm grasp. Aluminum does not resist
INSTRUMENTS 15
well the action of certain chemicals, particularly alkalies, so in time the metal
becomes pitted and roughened.
Good steel, heavily nickel-plated, is the generally adopted material. In-
struments should, after use, be well scrubbed with soap, brush, hot water, and
then boiled; after sterilization they should be well dried and, if necessary,
complicated joints touched with a very light lubricating oil (like "3 in !")•
To permit of easy cleaning, instruments that consist of two or more parts, like
the blades of scissors or the two limbs of hemostatic forceps, should be equipped
with the French lock or similar device for the easy separation of the com-
ponent parts. [The editor prefers scissors with a screw joint. The blades hold
closely together and cut longer at the points.]
Before using, instruments should be boiled for twenty minutes in water to
FIG. 3. — INSTRUMENT BOILER.
which 1 per cent, of carbonate of soda has been added. The soda plays a triple
part: first, it raises the boiling point of the solution slightly above 100° C. ;
second, it destroys any oil or grease that may be present; third, it prevents
rusting.
Any large metal tank with a cover suffices for an instrument boiler. The
instruments are wrapped in a towel and placed in the boiling solution. After
sterilization the bundle is removed and the instruments placed on a sterile towel
spread on a suitable table, and then covered with another sterile towel, care, of
course, being taken not to contaminate the instruments during their arrange-
ment.
The accompanying cut shows a small convenient instrument boiler, the
principal feature being a perforated tray with deep sides into which the in-
struments are placed, and after sterilization the tray containing the instru-
ments is removed, the water draining off immediately. This obviates wrapping
the instruments in a towel as described in the preceding paragraph.
The proper sterilization of keen-edged instruments like knives and razors
16 ASEPTIC SURGICAL TECHOTC
(with metal handles) has led to much difference of opinion. Some surgeons
Haim that, the tine knife edge is impaired by boiling, and this is doubtless true
if the knives be placed in the boiler with other instruments where they are apt
to k> struck. These sinuous have even gone so far as to content themselves
with knives soaked in carbolic alcohol or some other antiseptic solution, a
practice which our theories of sterilization cannot condone. Wrapping the
blades in wisps of cotton and then placing the knives in the boiler with other
instruments protects to a great extent the knife edge from being knocked off,
hut 1 believe that the practice of dragging off the sheath of wet cotton markedly
dulls the instrument.
Knives and razors, without other instruments, should be so placed in the
instrument sterilizer that there is no danger of their striking one another, and
then boiled without any cotton or gauze wrapping. A little rack of wire may be
used if desired, serving to keep the knives apart and from being jolted by the
boiling water. Knives should not be placed naked in a steam sterilizer, for the
1. lades unprotected by nickel plate will be badly rusted. Grosse (2), of
Munich, has conducted experiments showing that knives put into glass test-
tubes with the mouth plugged with cotton and then put into a steam sterilizer at
100° C. can be sterilized in ten minutes without rusting the blades. The ex-
planation given by Grosse is that the small amount of moisture of the air in
the tube produces sufficient steam to accomplish the sterilization, and on cooling
the mixture is deposited on the relatively cooler glass, and not on the steel
plates.
PREPARATION OF HANDS
By all odds the hands of the surgeon and his assistants and the skin of the
patient do more to infect a surgical wound than all the other causes put to-
gether, and for that reason the greatest care must be taken in their preparation.
In the great majority of instances the operative site on the patient's body is
where the skin is not exposed to hardening and roughening. If it is so thick-
ened, we have as a rule sufficient time to soften and prepare the skin so as to
afford a reasonable assurance of sterility. On the other hand, the surgeon can
devote but a short time each day to the sterilization of his hands, and were he
to employ drastic measures he would soon put himself Jiors de combat.
Before the days of rubber gloves the care the surgeon had to take of his
hands in order to prevent roughness, cracks, hang-nails, etc., and the irritating
.-«.] ut ions and time necessary for hand cleansing were serious items, which to-day
have, thanks to rubber gloves, been largely robbed of their terrors. One must
not assume that proper care of the hands and cleansing before operation are no
Ionizer necessary, for a leaky or torn glove may vitiate all our dependence on
irlovcs as a sterile hand covering, and so, to avoid infection as far as possible, we
should have, our hands in good condition and well cleansed.
The conscientious use of gloves in all operations and dressings, especially
PREPAKATION OF HANDS 17
if the latter be suppurating, keeps the hands out of pus and the virulent patho-
genic bacteria ; such hands are more readily cleansed than those that have dipped
into blood and pus.
None of the means of sterilizing the hands have been proved by laboratory
tests to be perfect each and every time, and so we must content ourselves with
such methods as give a reasonably high efficiency test and at the same time per-
mit of frequent application.
The prime factor in the preparation of hands is the prolonged and liberal use of
warm water, green soap and a scrubbing brush. The brush should be sterilized and the
water running from the spigot, which latter should be controlled by pedals so as not to
require the surgeon to manipulate the faucet by hand. This scrubbing should be
conscientiously done for ten minutes and cover all parts of the hands and forearms and
particularly the nails. The writer believes that the complete and accurate carrying
out of this step accomplishes about all one can hope for in hand cleansing, but most
good surgeons are not content to rest there, but finish their hand cleansing with one
of the numerous chemical agents extensively advocated. The simplest and probably
the best is immersion of the hands in sterile alcohol (75 per cent.) for from 5 to 10
minutes.
Bichlorid of mercury 1 : 1,000 is advocated by many, but to be of any avail requires
from 15 to 20 minutes' immersion, and the irritation and chapping of the skin result-
ing from its frequent and long-continued use render subsequent sterilization more
and more difficult. A momentary swish of the hands in a bowl of bichlorid is a farce.
Soaking the hands in a strong solution of permanganate of potash, followed by
immersion in a warm saturated solution of oxalic acid to decolorize the staining of
the permanganate, is highly approved of by many.
Scrubbing the hands with a paste made by moistening a small lump (*/2 oz.) of
chlorid of lime in the palm and rubbing with a similar quantity of carbonate of soda
is a process of great efficacy for loosening thickened epithelium and is a good disin-
fectant. [This is the best means of hand disinfection known. — EDITOR.]
A great many more processes have been advocated; those mentioned are the ones
endorsed by most surgeons. Whichever methods are used, the hands are finally rinsed
off in sterile water and dried with a sterile towel; the surgeon, however, must decide
whether he will depend on the efficacy of his hand preparation or protect his patient
and himself by the use of gloves.
Rubber Gloves. — About fifteen years ago the question of the use of some
form of glove to be employed in operative manipulations was revived. (1. Col-
lins.) While not a new proposition, the discussions aroused at that time were
listened to with much interest by American surgeons, and particularly by those
in New York City. "As is always the case in the problems of the medical pro-
fession, there were numerous arguments advanced by the opposing factions,
although the great majority recognized the immense superiority of the glove
over the naked hand from the standpoint of asepsis. There was, though, much
division of opinion as to the kind of glove to be worn, the method of use, and
whether or no the surgeon's skill was handicapped.
It would not be of value to review these arguments now, but it is of interest
to note that at that time there were but very few operators in this country who
3
18 ASEPTIC SURGICAL TECKNTC
made any attempt whatever to wear gloves as a routine during operations. At
that time the practical use of gloves was limited to occasional instances as a self-
protection when operating on highly infectious cases. Now, on the other hand,
the majority of surgeons look upon the use of gloves as much a matter of course
as anv of the rest of our aseptic technics.
The consensus of opinion is in favor of a glove made of pure, impervious
India rubber, and a gum glove is the kind almost universally adopted.
The foremost argument in favor of the use of rubber gloves is the fact that
it is impossible to assume beyond all question that one can by the use of anti-
septics prepare the hands of all persons employed in an operation so as to be
confident that each and every hand is sterile for each operation. Of course,
many times some of the hands are aseptic, but one cannot be sure that all are
invariably so.
Gloves of pure rubber can be unfailingly rendered aseptic by boiling or
steam. Another point of greatest value is that impervious gloves preclude the
possibility of exfoliations and detritus from the hands entering the surgical
wound. A third point is that during an operation a smooth surface like a rub-
ber glove can be more readily freed of coagulated blood and other materials
than can the rough skin of the hand.
The actual preparation of the gloves is often very carelessly done, and unless
they are simply picked from the boiler with a sterile instrument and handed
hot and wet to the surgeon, there are many chances for error in their prepara-
tion by thoughtless and imperfectly instructed persons.
The best and pleasantest use of gloves is to put them on dry with sterile
talcum or lycopodium as a lubricant.
Gloves may be properly prepared by either steam sterilization or boiling.
The first method is as follows: The gloves are thoroughly washed and dried,
the cuff of the glove is then turned back about two inches and the whole inside
of the glove thoroughly dusted with talcum or lycopodium powder. One pair is
then wrapped in a small towel and put into the autoclave for sterilization in the
same manner as dressings, etc. Placed in the towel with the gloves is a small
envelope of gauze about 2 inches square containing a dram or two of talcum
powder. The gloves come out of the sterilizer perfectly dry and are kept in
the original package, unopened, of course, until needed;
A more troublesome method of preparing gloves, where a steam sterilizer is
not available, is by boiling and then drying them. The procedure is as follows :
An ordinary box of talcum powder with a perforated top, several towels, and the
little envelopes of gauze filled with talcum are sterilized in an ordinary kitchen
oven with dry heat. (This is by no means a certain method, but serves fairly
well in an emergency.)
The gloves are then turned wrong side out, placed in a wire cage, and
submerged in clean water in the ordinary instrument boiler. Care should be
taken that all of the glove is filled with water and the air driven out. Two
pairs of long dressing forceps or sponge-holders should be put into the boiler
PREPARATION OF HANDS 19
with the gloves. The gloves are allowed to boil for from five to ten minutes.
They are then taken from the cage and allowed to drain hastily. With the
sterile forceps the gloves are placed on one of the sterile towels spread out flat
and another sterile towel laid over them. If all the free water has been allowed
to drain from the gloves, a little stroking and patting of the upper towel will
thoroughly dry the outer surface (really the inside, for the gloves were turned
wrong side out) in a few minutes. The upper towel is then turned back and
the gloves, both back and palm, thoroughly dusted with the sterile powder from
the box.
We are now ready to turn the gloves right side out. With one pair of
forceps the «dge of the wristband is lifted and the other pair of forceps intro-
duced into t'he glove until the blades can grasp the web between the middle and
ring fingers; by drawing on the interior pair of forceps and turning the cuff
over with the other pair it takes but a moment to completely reverse the palm
or hand portion of the glove. The neatest way to reverse the fingers is to grasp
owo diametrically opposed points of the edge of the wristband with the two pair
of forceps and then twirl the glove two or three times about its transverse axis ;
in so doing one closes the orifice of the glove and imprisons some air in the palm.
Lay the glove with the orifice still sealed on a sterile towel, and, pressing on the
balloon part of the glove with another sterile towel, the compressed air causes
the fingers to be everted with a rush. The gloves are next dried on their outer
surface by again stroking and patting with a sterile towel until they are per-
fectly dry. With the forceps the cuffs are turned back, the gloves together with
the envelope of talcum powder put in a sterile towel, folded over, and pinned.
By this method of preparation the gloves have only come in contact with sterile
towels, sterile forceps, and sterile powder. The inside is well lubricated, the
outside is free from powder, and the gloves are perfectly dry.
The proper way to put on gloves is very simple ; it is as follows : The hands
are thoroughly cleansed by any method the surgeon elects and then thoroughly
dried on a sterile towel. The package of gloves is opened by an attendant, and
the surgeon carefully picks up the gauze envelope of powder; by rolling the
gauze between and over his hands he thoroughly dusts his hands and fingers
with the powder. He then grasps with one hand one glove by the turned-back
cuff, only touching the inside of the glove (that part which eventually will lie in
contact with his skin), and draws the glove onto the other hand. Then with the
gloved hand he seizes the other glove, putting his gloved fingers into the recess
of the folded cuff, thus only touching the glove on its outside, and draws, or,
rather, pushes, the glove on the second hand. Not until both hands are gloved
should the fingers be stroked into place nor the cuffs straightened out. In this
manner the skin of the hands has at no time come in contact with the outside of
the glove.
It seems fitting in this place to point out some gross errors in technic in
the use of rubber gloves, because it is possible to witness many surgical opera-
tions where several people are employed arid see gross errors of technic in the
20 ASEPTIC SURGICAL TECKNTO
manner of using gloves; errors not so much of carelessness, but of lack of in-
struction and thought on the subject. This applies particularly to the internes
on our hospital staffs and nurses. We assume that the surgeons-in-chief have
studio! the subject and errors on their part we ascribe to carelessness, but the
juniors are receiving their training, and the details of instruction should not be
nedected. Their thought and power of logic should be awakened so that a
correct routine becomes a matter of subconscious habit.
The first armiment in favor of the use of gloves is the one which the writer
believes is most frequently set at naught by the careless manner in which the
-loves are drawn on the hand. For example, the surgeon washes his hands in
the most thorough manner, rinses them in various powerful antiseptics, accord-
ing to his fancy, dries his hands on a sterile towel, and is now ready for his
gloves. Are his hands sterile ? Does he know it for a fact ? If so, he is foolish
to go to the trouble of wearing gloves. On the other hand, does he doubt the
asepsis of his hands ? Is he credulous ? If so, note how he vitiates his technic
by his manner of putting on the gloves. Over and over again, by those who
should know better, one may see it done as follows : The gauntlet or wristband
of the left glove is seized in a generous grasp by the right hand, and the left
hand pushed into the glove as far as possible ; then with the naked right hand
the finger-tips of the left glove are stroked into place and the glove nicely ad-
justed. The right glove is now grasped by the left hand, already clothed, and
the naked right hand introduced and the glove drawn into place, usually at the
expense of dragging the left gloved thumb over the naked right hand and wrist.
The surgeon now feels ready to begin his work, or possibly deems it wise to
rinse off his gloved hands in some sterile solution.
Another favorite method of putting on gloves is to throw several pairs of
freshly boiled gloves into a bowl of bichlorid of mercury solution or some simi-
lar antiseptic liquid. The surgeon, after thoroughly washing his hands as
before, proceeds to draw, or, rather, to float, onto his hands the gloves lying in
the bowl. During these manipulations he splashes the- solution over the naked
forearms and hands, the solution in turn bathes the gloves, and smears over
their outer surface epithelium, etc., washed from the skin. The foregoing
errors in technic are perfectly apparent when they are brought to our notice,
and tli at they are errors in fact and not hair splittings must be conceded by all
who admit the truth of the first and most important reason for wearing gloves,
namely, the uncertainty of being able to sterilize all hands every time for all
operations.
If one accepts the above as a fact, and nearly all up-to-date surgeons do,
what possible excuse can there be for allowing the discredited and suspected
hand to touch and rub up against the outside of the gloves so carefully pre-
pared '. I f the surgeon adopts gloves, he places himself in the ranks of those who
believe that the hand cannot, infallibly be sterilized. If he then puts on his
gloves as has been described, he must be a traitor to his beliefs. Successful
operative results in spite of these errors do not nullify the argument. We see
SKIN OF PATIENT 21
many perfect healings after operations where gloves were not worn, but the
element of possibility of wound infection in the case of the naked hand has
been proved by laboratory tests to be high, and practically nil with the sterile
glove. Why, then, place on the face of the glove the very material we so eagerly
strive to imprison within the glove ?
Another objection to putting on gloves that are immersed in some liquid is
the constant dripping from the wrist of the water imperfectly confined by the
fingers in the interior of the glove. This water may have been lodged at the
finger-tips for some time, and after having macerated and bathed the skin a
thoughtless change of level of the hand allows this impure liquid to escape at the
wrist and in all probability to fall into the wound or in its immediate vicinity.
The same is true where a torn finger-tip is used. The whole glove acts as a
funnel, the torn or tipless finger serving as the small end to lead with unerring
aim the sweat, detritus, etc., of the whole hand into the wound.
Let us then properly prepare our gloves, properly put them on and use only such
as are perfectly water-tight. The gloves are sterile only so long as we keep them so;
they have no inherent virtue, no antiseptic power. One would think on seeing the
carelessness with which gloves are handled that they had properties similar to radium,
emitting powerful bactericidal rays, and were capable of neutralizing the grossest
negligence on the part of those who abuse them.
SKIN OF PATIENT
The remarks on the difficulty of sterilization of the skin of the surgeon's
hands apply equally well, though to a lesser degree, to the skin of the patient.
It has already been pointed out that the more usual sites of operation on the
patient are where the skin is less exposed to contamination and roughening,
and furthermore we have as a rule more time at our disposal.
A well-established rule for skin preparation is as follows: About twelve
hours before operation a generous area about the operative site is thoroughly
shaved and then freely lathered with soap suds and well scrubbed with a piece of
gauze ; a scrubbing brush is too harsh and is liable to set up a dermatitis. The
suds are then rinsed off and the parts again rubbed with gauze and ether, to be
followed by a third rubbing with alcohol. After the alcohol has evaporated a
soft soap poultice is applied, the whole covered with sterile gauze and a ban-
dage, which is left on until the patient is on the operating table. On the
operating table the soap poultice is removed, the parts are again washed in soap
and water, to be followed by ether and alcohol rubbings as already described.
Skin so prepared is very nearly always sterile from a surgical point of view.
Another equally efficacious way is to carry out the procedure already giver
up to the point of applying the soap poultice ; this latter is omitted and plain
dry sterile gauze applied instead. On the table the sterile dry dressing is
removed and the operative field painted with a single coat of tincture of iodiu
22 ASEPTIC SUEGICAL TECHOTG
(officinal strength) applied with a sterile brush (soft) or pledget of cotton. If
this method be followed it is highly important to see to it that no water has been
applied to the skin for several hours (the writer has put in his practice a mini-
mum of eight hours) before the iodin is applied. The reason for this is that the
cells of the skin absorb the water and swell up, thus preventing the penetration
of the iodin.
Some surgeons apply two coats of iodin at intervals of several hours. This
is hardly necessary, for if the first coat closely follows the soap-and-water scrub-
In ni: it is of no avail, and if the coats be put on at proper intervals the whole
time of skin preparation is unduly prolonged.
In emergency work where no proper time for skin preparation is permitted
one may have reasonable confidence in a good heavy coat of iodin applied at the
last moment, provided the abstinence of water to the skin has been, observed.
The use of iodin has in some cases resulted in a dermatitis of more or less
severity — two fatal cases have come to my knowledge. Removal of the iodin
with alcohol at the close of the operation largely diminishes the risk of subse-
quent skin irritation. [A liberal coat of iodin applied on the table and allowed
to dry, then wiped off with alcohol, is efficacious. — EDITOR.]
Iodin applied to very sensitive skin areas, as the scrotum, etc., increases the
risk of dermatitis, and these parts should invariably be washed with alcohol
after operation and lightly smeared over with sterile oil or vaselin.
If the surgical field be the hand or foot, where the skin is more or less
horny, the preparation should be started two or three days before operation.
The preparation should consist of several scrubbings with soap, ether, and
alcohol, and applications of soap poultices at 12-hour intervals with the final
preparation as already described.
AUTOCLAVE OR STEAM STERILIZER
Mention has been made so frequently in the foregoing pages of sterilizing
dressings and surgical materials by steam under pressure that it may not be
inappropriate to describe briefly the apparatus for producing this result, al-
though -so familiar an object as the steam sterilizer must be well known to all.
Different manufacturers have devised various styles of autoclave, but the
main principles are the same. The following description and illustration are
quoted from the catalogue of the Kny-Scheerer Company :
1. Fill the steam jacket with clear water by opening valve on metal funnel C
turning lever No. 1 to the right. The quantity of water required for sterilization
depend! on the length of time for which the apparatus shall be operated. It is not
desirable to have the jacket filled more than half full of water. (See sectional view,
The glass water gauge on side indicates exactly the height of water in jacket
A permanent connection with the hydrant water supply can be made through
,the clean-out valve) by connecting a Tee back of valve G and using a
AUTOCLAVE OR STEAM STEK1LIZEE
23
gate valve on the Tee, to which you connect your hydrant water. This method of
filling the water into the jackets works rapidly, and in addition offers the advantage to
be able to inject water at any time, even though the apparatus may be under pressure
and in operation. The pressure of the water supply at point of entrance at valve G
CHAMBER OF STERILIZATION
Jb
FIG. 4. — AUTOCLAVE.
FIG. 5. — SECTIONAL VIEW OF FIGURE 4.
Gradually as the temperature of the water in jacket increases, the air in the sterilizer chamber
becomes rarefied and finds an escape through cup valve F. The sterilizer chamber therefore, in the
first stage of the process, serves the purpose of a hot air oven, gradually warming the dressings pre-
paratory to letting pressure steam into the chamber.
must, of course, exceed that of the steam pressure in the jacket; the latter being 15
pounds to the square inch, it follows that the water pressure should at- least be 25
pounds or more.
3. The steam jacket having been filled with a sufficient quantity of water, throw
lever handle No. 1 back to the left and light the burner (gas, petroleum or alcohol)
leaving valve on funnel C open until steam issues, then close it tightly. The combina-
tion steam pressure and vacuum gauges E will register the conditions prevailing in
24 ASEPTIC SUEGICAL TECHOTC
the jacket and the steam pressure safety valve D will blow off steam as soon as the
latter exceeds the normal pressure of 15 pounds (= 1 atmosphere).
Whenever live steam, exceeding 35 pounds per square inch derived from a boiler
plant, installed in the building, is available, we strongly recommend the use of the
latter as heating medium. For this purpose we place in all of our sterilizers (with
the exceptions of No. O and No. 1) a set of steam-heating coils between the two cop-
per cylinders forming the jacket, consisting of heavy wall copper pipe, which is
connected to nipples AA, one of these serving as steam inlet, the other as steam
outlet.
Through these heating coils the high pressure steam circulates, and its tempera-
ture, in proportion to the respective amount of pressure, rapidly raises the tempera-
ture of the water in jacket to boiling-point and over, until it reaches the temperature
of 250° F. (121° C.), which is the equivalent degree of steam or of water boiling under
a pressure of 15 pounds to the square inch. The safety valve D keeps pressure in
jacket under perfect control at 15 pounds.
4. The dressing material should be placed in the sterilizer chamber -before tHe
heaters are lit, or as in the case of steam-heated jackets, before the boiler steam is
turned into the heating coils. Door of sterilizer is locked securely and air-filtering
cup valve F, which is filled with a wad of absorbent cotton, is left open, handle being
in vertical position as shown in drawing Fl.
Gradually as the temperature of the water increases the air in the sterilizer
chamber becomes rarefied and finds an escape through cup valve F. The sterilizer
chamber therefore in the first stage of the process serves the purpose of a hot air oven,
gradually warming the dressings preparatory to letting pressure steam into the cham-
ber.
5. As soon as the steam pressure gauge indicates a pressure of 15 pounds, the
safety valve will begin to operate by blowing off steam in excess of the required pres-
sure, then close the air filtering cup valve F by thrusting handle into a horizontal
position.
The moment has now arrived for exhausting the already rarefied air in the ster-
ilizer chamber by creating a partial vacuum. This is done by throwing lever No. 1 to
vacuum. The combination gauge E will soon register a vacuum in the chamber, five
inches being sufficient to insure absolute result.
When this degree of vacuum has been reached, move lever 1 to chamber whereupon
the pressure steam will rush into the chamber. The dressing material contained in
the latter, having thus been carefully prepared by the air exhaust process for an eager
absorption of live steam, will instantaneously and thoroughly be penetrated by the
same. Furthermore since the inrushing steam which is of a temperature of 250° F.
(121° 0.) will meet with material which has for some time been subjected to dry, hot
air of nearly the same degree of temperature as that of the pressure steam, the latter
will not condense and therefore not wet the dressings. The process of steam steriliza-
tion shall last for from 20 to 30 minutes.
6. The dressing material can now be considered absolutely sterile and may be
taken out at once, if desired. It is advisable, however, to let it remain in the sterilizer
chamber for from 10 to 20 minutes longer in order to remove every trace of dampness.
For this purpose move lever No. 1 to vacuum and again start the exhausting process
drM-Hhed under X... 5, for the time above specified. After this, extinguish flame or
shut off steam supply and throw lever No. 1 to the left.
7. To remove sterilized dressings from the chambers it is necessary to destroy
the vacuum from the latter in order to be able to open the door. This is done by
letting air enter the chamber through the air-filtering cup valve F, which is filled
with absorbent cotton.
AUTOCLAVE OE STEAM STEKILIZER
25
Dressings thus prepared can be absolutely depended upon as to their sterility.
They may be left in the apparatus for an indefinite time before being used without
becoming infected.
Water. — The surgeon has no need for chemically pure water, but germ-free
water is constantly needed for all surgical work. Plain water boiled for a short
time is perfectly reliable for all solutions, etc. The objection to boiling water
FIG. 6. — DOUBLE TANK WATER STERILIZER.
in an ordinary vessel is that it must be used at once and not left exposed to the
air. For extensive hospital work water is boiled under pressure in tanks espe-
cially designed, in which the water may be stored without fear of air con-
tamination.
The illustration shows a Kny-Scheerer double tank water sterilizer. The
water from the city main flows through the filter (between the tanks) and enters
both chambers. When tanks are nearly full the water is shut off and the burn-
ers lighted. A pressure gauge is at the top of each tank and set at 15 pounds.
The water is heated until the pressure overcomes the gauge, which is equivalent
26 ASEPTIC SUKGICAL TECHNTC
to 121° C. This is continued for twenty minutes. The water is now thor-
oughly sterilized and may be drawn from the faucets at the bottom. One tank
(marked "Cold") has coiled within it a number of feet of copper pipe, through
which cold hydrant water may be allowed to circulate, thus cooling the sterile
water in that tank (not by mixing, but by contact through the wall of the copper
pipe) . In this manner we have a liberal supply of hot and cold sterile water at
hand.
BIBLIOGKAPHY
1. COLLINS. Medical News, Aug. 20, 1904.
2. GROSS. Medizinische Blatter, 1905, 37, 38, 39.
CHAPTEE II
GENERAL OPERATIVE TECHNIC
HOWARD D. COLLINS
The practitioner of surgery should constantly use the details of his art so
that the various steps of his technic may become a second nature to him,
enabling him to perform these acts without thought on his part, leaving his
mind clear for the higher faculties of judgment. In order to facilitate this
training it is wise to limit our technic as much as possible to the essentials,
eliminating all needless embellishments. In our discussion on antiseptics an
effort has been made to show how small a part they should play in true aseptic
surgery. In a properly conducted surgical operation it is assumed that all the
materials furnished are in a sterile condition, and the surgeon should see to it
that they are kept so, and not permit breaks in his technic, calling for the
doubtful effects of antiseptics to set all straight again.
An endless list of solutions, an immense array of instruments, and countless
other paraphernalia all tend to confuse and upset our aseptic plans. A skilled
workman does his work best when provided with the proper tools, without being
hampered by too great a variety of appliances.
The element of time is one that has advocates on both sides of the question,
and, as in most other subjects, a happy medium is the wise course to pursue.
An operator who is constantly trying to lower by a minute or two his operative
record is very apt to be led away from the real purpose of the operation, namely,
complete and speedy recovery of the patient. He will slur over little details —
not essentials, it is true, but of great importance to the postoperative comfort
of his patient — because he has one eye on the clock. On the other hand,
dilatory action is not to be recommended. The longer an operation, by so much
longer is a patient under an anesthetic, the more opportunity is given to handle
the parts, and the longer is the pressure of retraction kept up. All of these
factors are exhausting and tend to diminish the chances of smooth recovery.
One of the greatest masters of the art of operating, Charles McBurney, gave
the impression of being a slow operator because all of his movements were com-
paratively deliberate; but when put to the test of the clock he was found to
equal, and in most instances to exceed, the speed of well-recognized rapid
operators. The secret of this lay in the fact that all of McBurney's operative
27
28 GENERAL OPERATIVE TECHKCC
surroundings were of the simplest, and in doing the work itself he never had
to take a backward step or go over the field a second time. One should cultivate
the habit of passing through the steps of an operation in a logical manner, tak-
ing up each feature in turn and completing it as far as may be possible before
passing on to the next. Clean-cut incisions, complete hemostasis, and the
accurate replacing of the parts, together with as little trauma as possible, are
the fundamental underlying principles leading to the best results.
INCISIONS
The incisions vary, of course, for different operations, and the special forms
of incisions will be dealt with in discussing special operations. Where a choice
is left to the operator he should choose as far as possible to make his skin in-
cision correspond to the natural folds or creases of the skin; this is evidently
nf more importance where a cosmetic result is desired, but even where a well-
concealed scar is not sought for it is wise if possible to choose the "run of the
grain," for if this be followed subsequent suture of the skin is more accurate,
and more prompt healing results. A long skin cut, if subsequently closed, will
heal as promptly as a short cut ; hence it is good surgery to make our skin in-
cision as long as necessary to give a satisfactory view of the deeper parts,
except, of course, where cosmetic effect plays a prominent part. No instrument
is so good for making the skin incision as a scalpel. Some operators pinch up a
fold of skin and cut through with a pair of scissors ; this is rapid but at the
expense of bruising the tissues. The scalpel should be "full-bellied/' that is, the
cutting edge should have a generous convex curve and the middle or most promi-
nent part of the blade should be employed for the cutting. Do not scratch
through the skin with the point of the knife. The handle of the scalpel should
be large enough to give a firm hold, and should be grasped by the whole hand,
and not by the fingers alone. The skin cut is best if made with one stroke of the
knife, and should, of course, be at right angles to the surface. Both ends of the
incision should be plumb and not gutter-shaped.
Wherever practical, the underlying tissues should be divided in the line of
their cleavage. For very large wounds this is of course impracticable, but it is
surprising how satisfactory an exposition of the deepest parts is permitted by
following the natural lines of separation. Following this method, even at the
expense of a little more time and some limiting of the field of exposure, one is
well repaid by the diminution of trauma and the prompter and firmer healing
of muscle tissue.
HEMOSTASIS
Too great stress cannot be laid on the value of stopping all bleeding before
wound closure, save in those operations where a blood clot is purposely left
HEMOSTASIS 29
«
with the hope of its becoming organized. The more fully the point of a bleeding
vessel can be isolated from the surrounding tissue, then grasped with a hemostat,
and tied with as fine a ligature as the diameter arid elasticity of the vessel will
warrant, the nearer wo approach the ideal. It would be folly to waste time in
freeing the end of a small bleeding artery from its surrounding fat or muscle
by a process of dissection before we attempt to clamp the vessel, but it is good
practice to train ourselves to catch the bleeding point with as little other tissue
as possible. A somewhat blunt-pointed hemostat, such as is shown in the ac-
company ing illustration (Fig. 2), is the best for all around purposes. The
comparatively big, blunt point prevents the instrument from puncturing into
the tissues and seizing too large a grasp. The large blades, with their curved
surfaces, aid the ligature while being tied to slip down and off the instrument
at its very tip, and not pass on to the tissues for a greater distance than neces-
sary. With a capable assistant, who understands the art of sponging, it is
nearly always possible to see the bleeding point, when it may be caught as
nearly isolated as possible by the hemostat without having to resort to the repre-
hensible practice of making a bold grasp in the direction of the bleeding, and
by catching as much tissue as the forceps will hold, trust to having clamped the
vessel. Finer pointed hemostats have their place and are very valuable for
more delicate work, but should be used with increased care and circumspection.
Where a vessel has retracted into the tissues and cannot be clamped, it is good
practice to surround the vessel with a fine suture and then tie.
Bone bleeding can usually be stopped by very hot, wet compresses and
pressure, or by breaking down the bony wall of the channel in which the vessel
courses, or plugging the canal with a strand of catgut.
Pedicles. — Large pedicles, containing a number of vessels, should never be
tied en masse, but should be separated into as many divisions as can be done
conveniently and each part tied off individually.
For the nicest results in extensive dissections, say of the axilla, for carcino-
matous lymph-nodes, it is far better practice to tie off each small vein as soon
as exposed, by means of an aneurysm needle and double ligatures, rather than
depend on clamping and subsequent ligation, thus avoiding the drag of many
clamps.
Many surgeons after clamping bleeding points twist them instead of tying
off. For small vessels this is a matter of choice, but it should never be done on
large vessels.
One should never depend on chemicals to check bleeding other than surface
hemorrhage. It is proper enough to apply adrenalin or similar substances to
bleeding skin or mucous membrane, but not to the deep parts of a wound which
is to be closed,, for the action of the hemostatic cannot be depended upon to last
long enough to permit firm clotting in the divided vessels, and so hidden hemor-
rhage may occur after the wound is closed.
There is no step in operative technic that pays a higher reward than is
received from a complete stoppage of all hemorrhage. With a dry wound, with
30 GENEEAL OPEEATIVE TECHKEC
carefully tied so that large masses of strangulated tissue are avoided,
the healing should be prompt and satisfactory. Where subsequent bleeding
occurs the tissues are forced apart and a most suitable nidus is formed for the
development of pathogenic bacteria.
Excessive loss of blood is a most serious factor in producing shock and post-
operative fatalities. The surgeon has already been cautioned to carefully clamp
and tie the bleeding vessels as soon as possible, and thus avoid hemorrhage of
magnitude. If hemorrhage of serious degree has already occurred the loss of
blood may be compensated for to a fairly successful extent by the exhibition
of normal salt solution. This may be administered in one of three ways: (1)
the saline, at a temperature slightly higher than body heat, say 40° to 42° C.,
may be injected directly into a superficial vein; or, (2) introduced into the sub-
cutaneous tissues; or, (3) injected into the rectum. Saline so administered is
rapidly picked up by the blood, and being of the same density as blood serum,
is perfectly incorporated into the blood current. The added watery bulk gives
the heart something to work on, and also furnishes a vehicle for the rapidly
forming red cells thrown out by bone marrow. A direct blood transfusion is a
more ideal procedure, but does not permit of emergency application.
Better than repairing the damage done by hemorrhage is to conserve the
blood as much as possible beforehand. In cases where hemorrhage is antici-
pated, or where the patient is much enfeebled, the principle of sequestration
anemia, as advocated by Dawbarn, is to be highly recommended. Its applica-
tion is as follows : At the time of, and just prior to, operating, such of the four
limbs as may not be the site of the operation are elevated and stroked toward
the trunk so as to empty them as much as may be of blood. An elastic bandage,
preferably the pure gum bandage of Esmarch, is then wound on the limb, be-
ginning at the extremity and passing up to the trunk and there fastened. This
has forced most of the blood out of the limb and prevents any more blood
entering the limb as long as the bandage is in place. The quantity of blood that
would have entered the sequestrated limbs is now stored up in the trunk and
brain, where it will do the most good. The bandages may be removed at the
close of the operation or subsequently, but care must be taken not to leave them
on too long, or the limbs may suffer.
In amputations or other operations on the extremities, where a bloodless
field is desired, the limb to be operated upon may be rendered bloodless by the
use of the Esmarch bandage, but the operator should invariably remove the
bandage before closing the wound and be sure to clamp and tie all bleeding
vessels. It is often possible to see an Esmarch bandage wrongly applied, and
then it is worse than no bandage at all. To make proper application of this
method the writer prefers two Esmarch bandages. They are used as follows:
The limb is raised and stroked toward the trunk. The bandage is wound on
spirally, quite tightly, beginning at the extremity and extending up to Searpa's
triangle, or the insertion of the deltoid, as the case may be. A pad of gauze,
or simple roll of gauze bandage, is placed over the femoral or brachial artery!
BONE OPERATIONS 31
This roll of bandage should have its long axis form an acute angle with the long
axis of the vessel, so as to overlie, and be nearly but not quite parallel to, the
vessel. The second Esmarch bandage is now passed circularly about the limb,
covering the gauze plug or bandage, compressing the artery between the gauze
and the bone. Three or four turns of the second Esmarch bandage is sufficient ;
it is then clamped or tied in place. The first Esmarch bandage is now removed,
and the limb will be found completely anemic. Care must be taken that the
pressure on the artery is not excessive, so as to bruise it and its accompanying
nerves.
An Esmarch bandage applied about a limb which is filled with blood, or
where the bandage only serves to retard the venous flow without checking the
arterial supply, is a nuisance; the limb continues to ooze venous blood from
every little vessel and no satisfactory view can be obtained.
Eor high amputation of the thigh, where an Esmarch bandage is of no avail,
McBurney hit upon the clever plan of making a small intermuscular incision
through the abdominal wall in the iliac region. Through this an assistant can
compress the common iliac artery against the brim of the pelvis, completely
controlling all hemorrhage. A similar procedure can be done for the sub-
clavian, but requires a more discriminating touch on the part of the assistant
doing the compression, owing to the proximity of the brachial plexus. (The
writer recalls a case of paralysis of the arm lasting six months from too wide a
field subjected to pressure.)
TRAUMA TO TISSUES
It is surprising what a lot of abuse the tissues will stand in the absence of
sepsis, but it is far wiser to show the body structures proper respect and not
subject them to needless injury. Parts should never be torn where they can be
cut; needless pinching with clamps, forceps, etc., is harmful, and prolonged
severe retraction bruises and temporarily paralyzes muscles and nerves. Pro-
longed handling of intestines, and especially dragging on their mesentery, is a
very potent factor in producing postoperative shock. Much subsequent pain
may be avoided by seeing to it that cut nerves are not included in the ligation
of vessels. If cut nerves can be identified the operator should invariably pull
the nerves as far out of the surrounding parts as possible, and cut away the
loose end in order that the cut nerve may not be involved in the subsequent
scar.
BONE OPERATIONS
The secret of success in bone operations is the preservation of the perios-
teum. A bone largely deprived of periosteum will usually necrose, but where the
periosteum is peeled off during the operative work and then allowed to fall
32 GENERAL OPERATIVE TECHNIC
back on the bone it will promptly adhere to the bone, and the vitality of the
latter will be preserved. Small areas of bone may be deprived of periosteum
without subsequent necrosis; for the periosteum will bridge across from the
edges of periosteum left intact, and if this bridging over occurs before the vital-
ity of the bone is exhausted all goes well. If large areas completely or in great
part encircling the bone be denuded, the subsequent necrosis will probably en-
tirely vitiate the operative procedure. The beginner in operative practice should
bear in mind that the periosteum is more easily stripped from the bone than the
surrounding tissues can be freed from the periosteum, with the result that when
the bone is thoroughly exposed it is denuded of periosteum, but on closing the
wound the periosteum falls back into place and necrosis is avoided. All cuts
into bone should be as clean and smooth as possible, and all splintered and
bruised fragments removed. In cases where the bone is divided with the inten-
tion of replacing the ends in apposition the ends should be so shaped as to make
as good a fit as possible.
CLOSURE OF WOUNDS
Too much stress cannot be laid on the importance of accurate apposition of
the parts in the closure of wounds. The small amount of additional time spent
in accomplishing this is well repaid by the increased rapidity of healing and
the greater strength of the scar. It is not good, or at least refined, surgery to
close an abdominal wound with a generous retention suture passed through the
whole thickness of the abdominal wall, trusting that the cut edges of the divided
parts will be brought into accurate contact when the suture is tied. Such a plan
is all well enough when great haste is called for, because the resultant scar
serves in most instances sufficiently well, but there can be no assurance that one
wall of the wound does not lie on a slightly different plane from the other, and
while the skin may fit accurately, the chances are that the underlying tissues
do not.
In the previous chapter we have discussed the advisability of using ab-
sorbable sutures and also the value of bringing the parts together without undue
tension. It is my practice to use as fine a suture of plain catgut as will as-
suredly last until tissue agglutination has occurred. In the case of endothelial
tissue, such as peritoneum, serous membrane, pia mater, etc., this occurs in 24:
to 48 hours or less, and the finer numbers of catgut suffice. For split muscle
fibers where the replacement is almost spontaneous fine catgut lasts long
enough. Where a muscle has been divided across its fibers, or where muscle is
transposed as in a hernia, treated by the Bassini method, the union is much
slower, and here it is necessary to employ a suture that lasts at least two weeks,
for which purpose a so-called 20-day chromic gut is best. The time for ab-
sorption of different strands of catgut of the same size, or similar degree to
which they have been chromicized, depends on the greater or lesser amount of
blood bathing the parts where the gut is buried. Thus a 20-day chromic gut
CLOSURE OF WOTTXDS
33
employed to suture muscles, as in a Bassini operation, may not last more than
the required 2 weeks, whereas, if employed to suture fascia, it might last the full
20 days. Fat is slow to heal and at the same time shows considerable objection
to the presence of coarse suture material, which peculiarity of the fat may be
met by using a fine non-absorbable suture such as silk or celluloid linen thread
(Pagenstecher), which serves to
close both the skin and subcu-
taneous fat. To do this a fairly
long curved needle is used. The
needle pierces the skin at a point
away from the line of incision,
equal in distance to the depth of
the subcutaneous fat; the needle
now penetrates the skin and the
full thickness of the fat, crosses
to the opposite side, and passes
through the opposite fat and skin
in the reverse direction, appearing
at the skin at a corresponding
point to its spot of entrance; the
suture is of course drawn through
with the needle. Several such su-
tures are passed at intervals, but
are not tied until all have been
placed. When tied, these sutures
bring the cut wall of fat and skin
in close contact, and it is surpris-
ing how few are needed to close
a wound of considerable length,
four or five sufficing for a six-inch wound. It is a more rapid method
than closing the fat by buried catgut suture and then sewing the skin
separately. In six or eight days at most the sutures have served their
purpose, are then removed, and firm healing without dead spaces is the
result.
In curved incisions the sutures should be passed so that they correspond to
the radii of the circle or curve on which the incision was made.
FIG. 1. — SHOWING SUTURE or SKIN AND SUBCUTANEOUS
TISSUES DOWN TO THE DEEP FASCIA IN ONE
LAYER.
At one time Michel's clips and subcutaneous skin closure enjoyed considerable
popularity, but one sees them much less practiced now than formerly. Michel's
clamps are small strips of metal with sharp prongs at the ends; by means of a special
holder and applicator these clips are placed across the skin wound with its edges
approximated, then pressed into place and held by being slightly bent on themselves.
The advantage in their use is speed, but they only serve to hold the skin and provide
no support for the underlying fat. The resultant scar is not as perfect as may be
obtained by careful interrupted suturing.
4
34 GENERAL OPERATIVE TECHOTO
Subcuticular Suture.— The subcuticular suture is placed by introducing the
needle with its suture into the edges of the wound just below the surface, and
passing the needle back and forth from one side of the wound to the other.
Thus we form a continuous suture without the objection of the numerous needle
punctures on the surface. The removal of the suture may be somewhat trouble-
some and the apposition is not very perfect.
DRAINAGE
When to drain and when not to drain is a problem that taxes the experience
or guessing powers of the surgeon to an annoying degree. In the presence of
infection there is no question ; there is but one rule — and that is to drain. But
for the borderline cases, or where there has been uncontrolled slight oozing, it
may be worth while to close the wound, trusting to complete operative asepsis
to avoid trouble. Rather than take the chance in doubtful cases, I prefer to
drain, using, however, only a very small drain of gauze or folded gutta-percha
tissue led down to the suspected point; in two or three days this may be re-
moved, inspected, and replaced if conditions warrant. Its presence for a few
days retards ultimate healing very little, and may save much distress.
Where frank drainage has to be employed one should respect the laws of
gravity and physics. Wherever possible the point of exit of a drained wound
should be at its lowest point, so that the discharges may escape by gravity;
where this is impracticable we must depend on the capillarity of the drainage
material. If gauze be the material employed, as soon as the gauze is saturated
it should be replaced, be it 8 or 48 hours, for the gauze will only hold so much,
and when soaked it fails of its purpose.
The only other point to be mentioned here in the drainage of wounds is to
see that the orifice of the drained tract is larger than any of the underlying
parts, and that the channel is as straight as possible. It is folly to attempt to
drain and heal up a large buried area through a small skin orifice. Laying the
superficial tissues wide open will save much time, distress, and risk to the
patient.
DRESSINGS
The application of gauze to a wound, open or closed, serves a threefold
purpose: (1) to absorb moisture and discharges of the wound; (2) to prevent
objectionable material from coming in contact with the wound; (3) to serve as
a splint for keeping the parts at rest. Plain, dry sterile gauze is the most
efficient agent to accomplish the first purpose. The same material serves ad-
mirably for the second, and if helped out with cotton is very satisfactory for the
third, unless absolute absence of motion is desired; as in cases of fracture where
some rigid material must be employed on the outside, as plaster-of-Paris.
USE OF INSTRUMENTS 35
Too little stress is laid on the value of rest of the parts after operation, and one
may frequently see the dressing of a post-operative wound left to one of the junior
house staff, who has never received proper instruction on the subject. Take for exam-
ple a simple closed appendectomy wound. The usual procedure is something as fol-
lows : The surgeon and his principal assistants have closed the wound and turn away,
a junior places a square of gauze on the wound and over that presses a couple of strips
of adhesive plaster; a binder may be then put over all. Now, if the patient have a
fairly full- rounded belly, the adhesive, if properly put on (and it seldom is), or the
binder, may serve well enough for a splint and keep the abdominal wall at rest. If, on
the other hand, the patient be thin, or with a contracted belly, or prominent anterior
iliac spines, no proper support has been given. Those who apply the dressings and
who value the comfort of their patients should study each case and mark its needs.
Personally, I make it a practice to use shaken out fluffs or handkerchiefs of gauze, and
with these build up a dressing which will smooth out the inequalities of the region
about the wound, so that when the bandage, adhesive, or binder is applied, a uniformly
firm but light pressure is evenly distributed over the parts, serving to keep the muscles
at rest.
This is well illustrated in operations for hemorrhoids, where the anus has been
stretched. One of the great discomforts following these operations is from the sag-
ging of the entire perineal floor due to the relaxed levator ani muscle. This may be
very largely relieved by building up a pyramid of gauze, the apex of which impinges
on the anus and the plane of the base is on a level with the tuber ischii. The T-binder
holds this wedge in place and the perineum is given proper support, which it does not
receive from flat sheets of gauze, no matter how many in number.
USE OF INSTRUMENTS
The illustration shows a few of the ordinary instruments, and an ex-
planation of them may aid the beginner in laying the foundation of his arma-
mentarium. A great variety of instruments is needed for special work, and
such instruments will be discussed under the description of the special opera-
tions.
The knife shown is of the "full-bellied" type already referred to, and the
operator should again be cautioned to do the cutting with the prominent part of
the blade, and not depend on the point to "scratch" through the tissues.
Two artery clamps are shown. The one with the blunt, thick tips is to be
recommended for general work, as the conical blades aid the ligature to slip
off on to the tip of the vessel during the act of tying, and this blunt instrument
is less liable to puncture into surrounding tissues while clamping the bleeding
point. The finer nosed forceps should be used with increased care.
It will be noted that the scissors shown are quite heavy, blunt-tipped, and
the blades quite short, with relatively long handles. It is very seldom that the
surgeon is called on to make a cut over an inch or two in length with his scis-
sors, and consequently it is needless to have the blades longer than two inches.
The longer the handles are in proportion to the blades (within reason, of course)
the more easily the cuts are made, and with less fatigue to the hand. Sharp-
pointed scissors are very liable to puncture surrounding structures unless great
36 GENERAL OPEEATIVE TECHNIC
care be used, and present no value for delicacy of work over blunt-pointed ones,
and consequently are not to be recommended save to the most experienced oper-
ate Scissors with blades curved on the flat are of great assistance because,
while iisiiiir tli.-in. the vision is less obstructed by the instrument itself, thus
assuring our ih;,r he is cutting only the structures desired and nothing more.
1. ,
1 1
1
In
r<
stZzi
'W^*7aru<
9? '/
t '
FIG. 2. — ASSORTMENT or INSTRUMENTS.
Thumb forceps are of two varieties: those with flat, corrugated blade tips
and those whose tips terminate in sharp interlocking teeth. The flat-bladed
ones, or dissecting forceps, as they are called, depend on the pressure exerted
in pressing the blades together to maintain their hold on the structures grasped.
I f the tissue be resistant or under tension, considerable force must bo used to
prevent the forceps from slipping. The result is that the tissues are badly
bruised between the blades, and the operator is fatigued if the tension has to
be loiiif maintained.
The other variety, the mouse-toothed, depends on the sharp teeth puncturing
the tissues for maintaining the grasp. They are much superior to the dissecting
Foivcps except in situations where the puncture of the sharp teeth may cause
damage, as, for example, grasping a blood-vessel or thin-walled loop of intestine.
I n ordinary work where the tissues are not injured by the puncture of the teeth,
as for example the skin, muscle, fascia, etc., the mouse-toothed forceps maintain
a firmer and less fatiguing grip and do less damage. The very long pair of
nioii>c tonthcd forceps shown in the picture has slender blades of uniform,
diameter for a large portion of their length. They are particularly valuable
OPERATING THEATER 37
in doing deep dissections, as they do not interfere with the field of vision. The
very delicate small pair of forceps is constructed just like those described
except for the size. They are particularly useful in inverting small hollow
stumps like the stump of an amputated appendix or the divided cystic duct after
cholecystectomy.
The tension or spring of a pair of forceps depends on individual choice, but
I find that the forceps that require the least pressure to close them and yet have
sufficient resiliency to relax their hold on the tissues are pleasantest to use.
There is quite a little muscular effort expended to keep a firm grasp on the
tissues, and if the spring is strong and the operation lengthy the fatigue to the
fingers is very marked.
Two probes are shown. The one is the usual fine silver probe, and the
other much larger in diameter and longer. Both have bulbous tips. It is
almost impossible to guide the small probe along a crooked sinus, the diameter
of the orifice of which is the size of, or but little larger than, that of the probe,
without having the probe puncture into the surrounding tissues and make a new
tract for itself, thus obscuring the information sought. Nearly all sinuses that
the surgeon seeks to explore with a probe are of sufficient size to admit the larger
instrument, provided the orifice be enlarged by a slight cut or stretching. The
larger probe with its heavier end is less prone to force its way out of the sinus,
and with a little manipulation and bending of the probe a fairly crooked sinus
can be safely explored for some distance.
Retractors, except the very coarsest, are with difficulty held in place unless
the retractor has its toe turned backward for a short distance, or else terminates
in sharp prongs. Sharp-pronged retractors are to be used circumspectly, for
they easily may cause damage by puncture. The smaller retractors shown in
the picture are very practical varieties for general use, and others of various
sizes, built on the same plan, are suitable for larger and deeper work. The
large pair shown is the so-called "trowel retractor" of Child. They are de-
signed and especially adapted for pelvic work through the abdomen. They aid
in keeping the surrounding structures from slipping into the pelvis, and serve
as excellent light reflectors.
OPERATING THEATER
It would be a very difficult matter to prescribe the arrangement of an op-
erating theater and its accessory rooms which would meet the approval of a
majority of surgeons. Every operator has his own individual preferences based
on custom and experience, and if called on to build an operating-room would
incorporate his personal views. Likewise architects should not build a surgical
equipment without consulting those who will have to use it.
There are certain general principles agreed on by all that it may be proper
to mention. Foremost of these are suitable light and ventilation, accessibility
38 GEKEKAL OPERATIVE TECHNTC
of the various parts of the plant, and a construction that permits of a high
degree of cleanliness.
Light. — The best of all lights is bright daylight (but should not include
direct sun-rays), and to accomplish this an overhead skylight either flat or
slightly sloping toward the north (in the northern hemisphere) furnishes the
most satisfactory natural light. The skylight should not be placed so high
above the floor that a large amount of light is lost, and the skylight should be
sufficiently large to amply cover the space occupied by the operating-table and
its surroundings. Ordinary wall windows are well enough for lighting if the
operative field can be brought close to the window, but such light entering the
room horizontally, or at an acute angle, is of little use for illuminating a deep
wound. For perineal work a side window light is of the greatest convenience
and satisfaction.
Electric lighting is the best of all artificial light, as it is safe and clean.
For ordinary purposes an electric fixture with half a dozen bulbs placed so as
to throw their light directly downward onto the table is a very satisfactory
arrangement. This may be further supplemented by one or two portable
electric lamps equipped with reflectors, to be held by an assistant or fixed to
an adjustable stand so as to throw the light at any angle desired.
For thoroughly equipped operating theaters the plan of using reflected
electric light has recently been, adopted. The principle is as follows : A pow-
erful arc light is placed in a room adjacent to the operating-room and through
a hole in the wall the light from the lamp, gathered by a lens into a beam of
parallel rays, is projected into the operating-room and cast upon a mirror
fastened on the opposite wall. The lamp, hole in the wall, and mirror are
all several feet higher than the heads of the operators. The mirror is
swiveled and can be adjusted to cast the reflected light directly, or by other
mirrors, on the operative field. The advantages of this method are a stronger
concentrated light cast directly on the desired field, and a very large dim-
inution of heat, as the arc lamp is placed some distance away and in another
room.
A much more expensive equipment consists of a group of mirrors on which
the beam is first received. The surfaces of these mirrors are not in the same
plane, but are placed at slightly different angles one to another. From this
battery there will be reflected as many rays of light as there are mirrors in the
battery, and each ray will diverge from the others. These various secondary
beams are each caught on other mirrors, which in turn reflect the light so as to
concentrate all the rays onto the desired field. The advantage of this plan is
the absence of shadows. Where the light comes from but one reflected beam it
is very probable that some object, say the surgeon's hand, will get into the path
of light and thus cast a shadow ; whereas, with a "battery" of seven mirrors or
so, we have seven rays from different angles concentrated on the field. This
would require seven objects, each placed in a separate path of light, before we
would get more than the faintest shadow. An equipment of this sort has been
OPERATING THEATER
39
in use at the Presbyterian Hospital of New York and has given great satisfac-
tion.
No matter how well equipped with electric light an operating theater is,
there should be some accessory system which may be put in commission
on the shortest notice. The best for this is gas, burning in inverted
mantles. The light is powerful, steady, and clean, but of course throws
out much heat and presents the danger of a naked flame for ignition of ether
vapor, etc.
Ventilation. — A very high temperature is not essential in an operating-
room, but the patient should be protected from all drafts and the air of the
FIQ. 3. — MAHKOE OPERATING TABLE.
room should be as fresh as possible. I believe a temperature of 70° F. (21° C.)
is quite warm enough, provided there are no drafts, and the drafts can be avoided
by keeping doors and windows shut if some form of artificial ventilating sys-
tem has been installed. Engineers and architects who may be engaged in
equipping a ventilating system for operating-rooms should be instructed to
make the entrances and egresses for air larger for operating theaters than for
ordinary rooms, to insure rapid removal of the anesthetic vapors, and to guar-
antee very perfect ventilation without resorting to opening the windows. The
air entering the room should pass through some sort of screen or sieve to remove
palpable particles and dust.
Accessible Secondary Rooms. — In addition to the operating-room proper
there should be in close communication with it a room in which the staff may
dress and wash, a sterilizing room for preparing surgical materials, and suit-
able storage rooms, together with a room devoted exclusively to anesthetizing
FIG. 4. — PATIENT IN CELIOTOMY POSITION.
FIG. 5. — TRENDELENBURG POSITION.
FIG. 6. — ROSE POSITION.
JTIG< 7, NEPHBOTOMY POSITION, SHOWING USE OF CUNNINGHAM BRIDGE.
42
GENERAL OPERATIVE TECHNIC
the patients. The perfect sealing of waste traps, with which modern plumbing
is provided, offers but very little risk of contamination from that source ; and
so basins and sinks may be placed directly in the operating-room, but they add
to the labor of keeping the operating-room as dustless and clean as possible, and
hence it is far better that all plumbing and fixtures be placed in one of the
adjoining chambers.
Cleanliness. — The material and construction of the operating-room and its
accessory chambers should permit all parts to be flushed out with a hose, play-
ing a generous stream of hot water, without in any way injuring the surfaces.
Marble or tiles set in Portland cement have been the favorite materials for this
purpose and are ideal on account of their durability, smooth surfaces, and
beauty. Such an equipment is expensive, and for all practical purposes Port-
land cement well troweled furnishes an equally good surface, but lacks the at-
tractive appearance. Corners, wherever possible, are rounded, and all wood-
FIG. 8. — KELLY INSTRUMENT TABLE.
work should be free from grooves and mouldings and painted with hard enamel
paint. A number of patent floorings have been used, but none are so good and
lasting as the marble mosaics set in Portland cement, or the plain cement itself.
Furniture. — The prime requisite of an operating-table is that its height is
such as to permit the surgeon to do his work without unduly stooping over. In
addition, the table should be adjustable, allowing the patient to be placed and
firmly held in various postures adapted to the work at hand. I know of no
better table than the one that bears the name Francis Markoe, or the Hartley-
Murray table. This table is of tubular metal frame, metal edges and braces,
and may be equipped with a glass or sheet iron or copper, nickel-plated top!
It permits of being adjusted for the Trendelenburg, lithotomy, Hartley, Rose,
and other positions. The Cunningham bridge is also furnished, elevating the
waist of the patient while lying on the side, a most valuable feature in kidney
operations. The drainage is provided for in a very satisfactory manner, and a
hoop of iron to be draped with a curtain shuts off the anesthetist from the field
of operation.
In connection with operating-tables it is proper to mention the Bentlev-
POSITION AND ARKANGEMENT OF PATIENT
43
Squier's portable table. While not designed as a feature of permanent operat-
ing-room equipment, the table is a most useful adjunct to the surgeon's kit.
The table can be folded into a small space
and is of light weight so that it may be easily
transported from house to house for work in
private. When in position the table is very
rigid and capable of several adjustments.
Beside the operating-table, the operating-
room should be equipped with several tables
and stands for instruments, dressings, and
gloves. A very serviceable type for instru-
ments is that of Kelly. This is usually fur-
nished with a glass top, but one of sheet iron
is just as useful, lasts longer, and is cheaper.
Hand bowls and irrigating stands shown in
the cuts explain themselves.
When in use the tables should be draped FlG> Q.—HAND BOWLS.
with sterile sheets, and on these the sterile in-
struments, dressings, etc., are placed and covered over with sterile towels.
POSITION AND ARRANGEMENT OF PATIENT
Before being anesthetized the patient should be clothed in a canton flannel
gown, with the opening in the back, permitting its removal and replacement
while in the recumbent position. There should also be pro-
vided a pair of loose stocking-like garments of canton flannel,
reaching up to the knee. The hair is covered with a rubber
bathing-cap. Thus clad, and covered with a light but warm
blanket, the patient is well protected while taking the anes-
thetic, lying either on a stretcher or in bed.
On the operating-table the patient should lie on a soft pad
to serve as a protection against the glass or metal top of the
table. Care is taken to see that the patient's arms or legs do
not hang over the edge of the table, producing a pressure that
may result in a very annoying paralysis.
The site of operation is now exposed, the final sterilization
given, and the whole body covered with a sterile sheet ree'n-
forced by sterile towels, leaving the operative area free. If
the field be a small one a hole of suitable size in the sheet
makes a very practical arrangement. If a whole limb is to be
in view, the rest of the body is covered as described and the
limb in question rests on sterile towels or a second smaller
sheet.
GATING STAND.1 If the operation be about the face or neck, the rubber cap
44 GENERAL OPERATIVE TECIDxTC
is covered l)v sterile towels, nml towels arc so placed as to leave the desired parts
exposed.
For operations on the back the patient lies on the abdomen; but care must
be taken that one shoulder is supported on a sandbag so that the breathing is
not restricted, and that the arm of the unsupported shoulder be alongside of,
and not doubled under, the body. For perinea! work the foot of the table is
lowered and the thighs strongly flexed on the body and abducted with bent
knees ; the buttocks are raised slightly on a sand-bag. To maintain this position
the rods and stirnips with which most tables are equipped serve fairly well, but
.nallv I prefer the Clover crutch. This appliance consists of a telescoping
rod of metal capable of being adjusted and clamped at varying lengths, each
en.l of the rod terminating in a leather strap to be buckled below the patient's
knee. A long strap is passed behind the patient's neck; one side passing in
front of the shoulder, the other passing through the opposite axilla ; the ends of
this strap are buckled to either end of the extension rod. With this device the
thighs can be flexed and the knees abducted as much as may be desired.
The accompanying cuts show the patient in position for several types of
operation. In the Trendelenburg position the hinge between the body of the
table and the footpiece should correspond with the knee-joint, and the braces
against which the shoulders rest should be so adjusted that a good part of the
patient's weight is supported by the shoulders rather than let the patient hang
by the knees.
In the "Rose" position the head hangs over the edge of the table. This is a
most useful position for operation in the mouth, as, for example, resection of
the superior maxilla, the blood necessarily accumulating in the back of the
pharynx being less prone to enter the trachea. It is also the correct position for
introducing the tube when intratracheal insufflation is to be employed for anes-
thesia. In operations on the kidney through the lateral route the patient lies
on the side with the waist line resting on the "Cunningham bridge." The
bridge is then elevated, which widens the costo-iliac space and crowds the kid-
ney nearer the surface — a great comfort to the surgeon.
SURGEON'S DRESS
Operating dress is subject to the dictates of fashion and individual taste, as
are other articles of clothing, and one can but mention one's personal choice.
The writer prefers a simple cotton pyjama suit with short sleeves. This suit
is put on when preparing for the operation, and while furnished sterile, as a
matter of routine, no attempt is made to keep the garments aseptic. After pre-
paring the hands the rubber gloves are put on and then a sterile linen gown is
donned. This gown reaches from the neck to well below the knees, is buttoned
at the back, and has long sleeves. The sleeves are gathered at the wrist with
elastic bands placed in the puckering hem, or tapes may be used. As the gown
SUKGKOX'S DKKSS
45
is put on after the gloves, the sleeves at the wrist lie superficial to the gauntlet
of the glove. This I believe to be a better and neater arrangement than draw-
ing the gauntlet of the glove over the lower end of the sleeve. The sleeve of the
gown should be made sufficiently long so that no movement of the arm drags
on the cuff, allowing a gap to exist between the sleeve and glove, exposing an
area of naked wrist.
A cap and a mask, if desired, are then adjusted by the attendant nurse.
The surgeon, enjoying good health, who observes the niceties of the toilet as
FIG. 11. — FACE MASK AND GOWN.
FIG. 12. — ANOTHER TYPE OF
FACE MASK.
regards the hygiene of the mouth and scalp need fear but little from them as
sources of wound infection. If. however, the surgeon suffers from a coryza he
should invariably wear some form of mouth and nose covering; likewise the
victim of dandruff should wear a cap. A variety of these coverings has been
adopted. The commonest form of cap used is a simple cap of cotton cloth,
which covers about as much of the surgeon's scalp as the ordinary hat, and is
well enough as far as it goes ; but the temples are left exposed and no assurance
46 GENERAL OPERATIVE TECHNTC
given that perspiration from the forehead may not drop into the wound. The
masks are simple squares of folded gauze with a tape sewn at each corner. The
upper pair of tapes pass around the head above the ears and are tied behind;
the lower pair pass around the neck and are there tied. Such a mask covers
the nose and mouth. The combined mask and head covering in the illustration
is the one that appeals to me. It resembles the "casque" of a medieval armor.
It covers the entire head and face, leaving only a generous space for the eyes.
Being in one piece, and having no strings to tie, simplify its application.
CHAPTER III
SURGICAL ANESTHESIA
KARL CONNELL
INTRODUCTION
The abolition of the sensation of pain, together with surgical asepsis, has
made possible modern surgery.
Pain is abolished by any physical or chemical agent which suspends for the
moment function of the sensory nerve terminals, the conducting paths, or the
receiving neurons of pain perception.
Local Anesthesia. — (See Kesume, p. Yl. — EDITOR.) The nerve terminals
and conducting paths are acted upon physically by cold and pressure, and by
other physical agents. They are acted upon chemically by a group of alkaloid-
like bodies, which are so administered as to act locally as transitory poisons on a
group of nerve terminals or on a selected nerve trunk. The administration and
dosage of the poison are so adjusted as to cause the minimal systemic effect.
General Anesthesia. — The receiving neurons, on the other hand, are an-
esthetized only by agents whose diffusion is general. For the most part these
agents are volatile and gaseous drugs, administered usually by the pulmonary
route. They abolish first the function of the cerebral cortex, followed by that
of the basal and spinal nuclei, until finally in overdosage the great vital centers
cease to act.
For completeness there may be mentioned certain forms of anesthesia inci-
dental to toxic overdosage of alkaloidal and other narcotics. Anesthesia is also
present in trauma to the central nervous system, in the state of hypnosis, in that
of catalepsy and hysteria, in profound shock, and in the intense intoxication of
various diseases. Anesthesia so induced or accidentally present is occasionally
used wholly or in part for painless surgical procedure.
LOCAL ANESTHESIA
Local anesthesia is secured by temporary inhibition of the conductivity of
the nerve ends or the nerve trunks distributed to a given area, through physical
or chemical agents.
47
48 SURGICAL ANESTHESIA
LOCAL ANESTHESIA BY PHYSICAL AGENTS
Certain forms of electricity, of light, and radio-activity are anesthetic, yet
the only really useful physical agents available for surgical purposes are pres-
sure and refrigeration.
Pressure.— Inhibiting the function of a nerve trunk by local pressure or by
a tightly constricting band is of historical interest only, since it causes pain, is
uncertain, and may result in long-continued or permanent motor palsy. The
cnly common example of useful pressure anesthesia is that of pinching up a
spot of skin for the painless insertion of the hypodermic needle.
Refrigeration. INDICATIONS AND LIMITATIONS.— Numbing by cold is use-
ful for superficial anesthesia and for the psychic effect, in anticipation of
puncturing through the skin by needle or trocar or of a superficial incision.
The anesthesia is superficial, incomplete, and transitory, and the discomfort of
chilling often exceeds that of the surgical procedure in hand. Eor deep in-
cisions chilling is at best an emergency makeshift.
TECHNIC. — The traditional method is to pack against the area pulverized
ice and salt, equal parts, inclosed in a rubber bag for from 3 to 5 minutes, or
until the surface is numb. The operation in hand is speedily carried to termina-
tion. In olden days this chilling was repeated as successive planes of tissue
were met. Sodium sulphate as the refrigerant salt is more effective than sodium
chlorid.
A more rapidly effective method is the vaporization of the volatile liquids
upon the surface. For example, a fine spray of ether may be directed against
the part, vaporization being hastened by blowing. This results in superficial
chilling of the tissue. As soon as the tissue begins to blanch and stiffen the
spray is discontinued, since superficial anesthesia is now present. Hard freez-
ing is not desirable, for the tissue cuts with more difficulty, the after-pain is
considerable, and necrosis may follow.
The standard method of to-day is to direct at the part from a distance of 5
to 10 in. a spray of ethyl chlorid held as a liquid in a commercial container
i Kiir. 1). The tissue is superficially frozen by the rapidly volatilizing liquid
within half a minute, resulting in transitory anesthesia.
LOCAL ANESTHESIA BY CHEMICAL AGENTS
Introduction. — Chemical agents are more generally useful than physical
agents. They are for the most part alkaloid-like, loosely combining nerve
poisons of the cocain type, and act on the nerve terminals or the nerve trunks.
Anesthesia by Action on Nerve Terminals. — Sensory nerve terminals may be
reached: first, by osmosis through mucous membrane and other absorbent
surface; second, by hypodermic injection into and diffusion through the lymph
spaces — infiltration anesthesia ; third, by local injection into the sequestrated
venous system of a given area — intravenous anesthesia ; and, fourth, by inject-
LOCAL ANESTHESIA
40
ing the anesthetic into the arterial system supplying the desired area — end-
arterial anesthesia. A method which may be dismissed with a word consists in
driving the anesthetic chemical into the tissue by electric current — cataphoresis.
Anesthesia by Action on Nerve Trunks. — Kn tire regions ,mly be anesthetized
by blocking the nerve trunks, either by injecting directly into the trunk
— intraneural anesthesia, or by infiltration in the neighborhood — perineural
anesthesia.
By injecting the agent into the spinal fluid extensive segments of the body
FIG. 1.— REFRIGERATION BY ETHYL CHLORID. The ethyl-chlorid container is adjusted to spray a
fine stream from a distance of about 6 inches. Evaporation is hastened by blowing on the spot
from a distance of about 10 inches. When the area for operation has become frosted and stiffened,
superficial anesthesia is present.
may be anesthetized by there blocking the nerve roots in the spinal canal-
spinal or intramedullary anesthesia.
Agents. — COCAIN.— Cocain is the most rapid and effective of local anes-
thetics. It has a marked local vasoconstriction action, tending to render drv
the operative field and to prolong the local anesthesia. The vasoconstriction
inhibits the re-absorption by the blood plasma of the drug from the nerve tissue
with which it has loosely combined. By the addition of adrenalin the vaso-
constriction is rendered more efficient, the union of the anesthetic in the local
area is more complete, anesthesia is increased in depth and in duration, absorp-
tion is delayed, and the liability to systemic intoxication much diminished.
Cocain has three drawbacks : first, it is unstable when in solution, hence for
full anesthetic value it must be freshly dissolved ; second, it is largely destroyed
by boiling, hence difficult to sterilize; third, it is an excitant to the central
nervous system of high toxicity. It should not be used in quantities exceeding
0.05 gram actually to be absorbed. Even less quantities than this frequently
cause excitation of speech and motion and cardiac palpitation. Sudden deaths
from cardiac failure have been ascribed to minute doses of the drug.
Preparation of the Solution of Cocain. — The solutions of cocain are as a rule
5
50 SURGICAL ANESTHESIA
from V4 up to 2 per cent. One-half .per cent, is the routine strength for
minor operations. This solution may be safely used up to 10 c. c. for anes-
thetizing the skin and deeper structures in minor operations, or for cutaneous
anesthesia in major procedure. Two per cent, is the preferred strength where
intense effect with little distention of tissue is desired, as in acutely inflamed
areas.
Where the sterility of the solution must be unquestioned only the sterile
crystals in sealed ampules from the manufacturer should be used. These
should be dissolved at the time of use, preferably in sterile normal saline
solution.
For routine work it suffices to drop the commercial crystals or tablets into
water, or preferably into freshly boiled normal saline solution just as boiling
ceases. The crystalline drug is permitted to sink quietly to the bottom. Thus
contaminating pyogenic or other surface organisms, if present, are washed off
and killed in the hot upper stratum of water while the cocain dissolves in the
cool bottom stratum.
A method more surely effective but rarely used on account of deterioration
of the cocain is fractional sterilization, i. e., exposure of the solution on 3
successive days to a temperature of 67° C. for % hour. A method for large
quantities is nitration through a Berkefeld filter.
Plain water is frequently used as the solvent, but it is in itself a cell irritant,
produces pain, waterlogs the tissue and may injure the cells. These are
negligible factors with small injections, but for use of considerable quantities
the solution should be made isotonic by salt. The weight of the required cocain
salt may be disregarded in calculating toiiicity, since cocain must be present in
large quantities (5.8 per cent.) to in itself render the solution isotonic. When
epinephrin (adrenalin) is added such quantity is used as to make a strength
of 1 : 20,000 solution.
NOVOCAIN. — Of the many substitutes for cocain, this synthetic alkaloid is
the best. It has the advantage over cocain of being 7 times less toxic. The
solution keeps many weeks without change, and it may be sterilized by heat,
since the drug does not perceptibly decompose on boiling. Only after prolonged
or repeated boiling is evidence of deterioration noticeable. It lacks the vaso-
constriction action of cocain and is not so rapidly nor so persistently anesthetic.
Under favorable conditions anesthesia appears in about 2 minutes and persists
about 15 minutes. Eor more lasting anesthetic effect it must be combined, as
must weak cocain solution, with epinephrin (adrenalin) 1 :10,000 to 1 :40,000.
It is non-irritating to tissue.
Novocain is used in solution of the same percentage as cocain, and because
of less toxicity in quantity 7 to 10 times as great, i. e., up to gm. 0.5 (grains 7.5).
It is the routine agent for use after the skin has been anesthetized by cocain
and is the anesthetic of choice in all extensive infiltration and endovascular
injection procedures.
STOVAIN.— The usage of this drug is largely confined to the induction of
LOCAL ANESTHESIA 51
spinal nerve root anesthesia. Although only about half as toxic as cocain, it is
mildly irritating, lowers the vitality of tissue, is a mild vasodilator, and causes
after-pain. It inhibits the motor as well as the sensory nerves.
The solution may be sterilized by gentle boiling for 3 minutes. It is more
powerful, more toxic, and less stable than novocain. It is precipitated by
alkalies and for spinal injection the solution must be acidified with lactic acid,
and sterilized by Pasteurization at 67° C.
QUININ AND UEEA HYDROCHLORATE. — This drug is used where prolonged
local anesthesia is desired. Anesthesia appears slowly, i. e., in from 15 minutes
to % hour. It persists for 1 or 2 days or longer. Solutions are sterilized with-
out deterioration by boiling. It is used in the same strength as cocain, i. e., %
to 2 per cent.
Locally quinin and urea hydrochlorate is a cell irritant. It causes edema
and lowers the vitality of the tissue. Wounds heal less promptly and the estab-
lishment and spread of infection is promoted. Even dilute solutions may cause
sloughing of the tissue and strong solutions must be used with caution. It
should not be used in infected areas, or those liable to become infected, nor in
tissue of low vitality. It has very little general toxicity.
OTHEE DRUGS WHICH ARE LOCALLY ANESTHETIC. — The foregoing agents
are generally recognized as the best available, although even they are not com-
pletely satisfactory. Many other drugs have been tried and found wanting,
among these tropococain, which, although only half as toxic as cocain, is much
less anesthetic and is a vasodilator; alypin, which in toxicity almost equals
cocain, causes pain and vasodilatation, also marked after-pain and irrigation.
To these may be added eucain, beta-eucain, holocain, and many other drugs.
Adjuvants to Local Anesthetic Agents. — EPINEPHRIN — This agent is a
powerful vasoconstrictor, thereby it delays the absorption of an anesthetic,
diminishes the systemic intoxication, and prolongs the regional effect. The
vasoconstriction effect may be so marked and prolonged as to devitalize the
tissues. Epinephrin should not be applied to mucous membrane stronger than
1 : 2,000, or injected subcutaneously stronger than 1 : 10,000. Epinephrin
has a general toxic effect in overdosage. It should not be used in intravascular
methods of anesthesia. Although subcutaneously the systemic effect is only
1/40 as powerful as by intravenous dosage, yet even for infiltration anesthesia
solutions should contain in total not more than 5 c. c. (75 minims) of the
1 : 1,000 stock solution.
The alkaloidal narcotics, hydrocarbon and other general anesthetics as ad-
juvants to local agent are considered later.
1. LOCAL ANESTHESIA BY OSMOSIS
Mucous and other moist membranes may be rendered superficially anesthetic
by local application of the selected agent. Through normal skin anesthetics
are not absorbed in sufficient quantity for surgical anesthesia.
52 SURGICAL ANESTHESIA
The only efficient agent on absorptive surfaces is cocain hydrochlorate, in
strength of from 1 to 10 per cent, solution in sterile water. Two per cent,
blunts sensation within 2 minutes. Ten per cent, accomplishes complete anal-
gesia within 5 minutes. Occasionally on very restricted areas the pure cocain
crystals are applied. To anesthetize periosteum beneath mucous membrane 10
per cent, of cocain must be held in contact for 15 to 20 minutes.
For nose and throat operations the usual procedure is to spray sparingly
with weak solutions, securing thereby sufficient anesthesia so that stronger solu-
tion may be applied directly to the desired area by a cotton swab without irrita-
tion, or for deep and prolonged anesthetic action held in contact by packing
the part.
On structures with poor circulation, such as the cornea, the action of cocain
as a protoplasmic poison contra-indicates the use of solutions stronger than 2
per cent.
The general toxic effect of cocain must be ever borne in mind by the surgeon
and a total of cocain which could be absorbed in excess of 0.05 gm. (% grain)
should never be used. Fatal results have followed the local application of much
smaller amounts than the above, notably in the urethra. Larger amounts, even
up to 10 grains, are used locally in the expectation that a toxic dose will not be
absorbed. It should be used with great caution. None should be swallowed.
As an osmotic agent novocain is a feeble anesthetic and lacks altogether the
highly desirable quality of cocain in blanching the field of mucous operations.
2. LOCAL ANESTHESIA BY INFILTEATION
General Considerations. — The agent is injected into or beneath the skin.
By diffusion throughout the neighboring intercellular spaces it inhibits the
nerve terminals of pain perception. By the usual agents, i. e., cocain and
novocain, touch perception is not so fully inhibited as is pain sense. Volun-
tary motion is inhibited very little.
Diffusion of the anesthetic may be interfered with by dense planes of tissue,
or by the brawny edema of acutely inflamed area ; or, again, the anesthetic may
be rapidly absorbed by blood or lymph flow before it can combine with nerve
tissue. These adverse factors are met by grading the strength of the anesthetic ;
by proper distribution of the solution in the various planes of tissue, and by
there delaying absorption of the drug into the circulation, either by mechan-
ically stopping the circulation or by adding to the solution a vasoconstrictor.
Apparatus for Infiltration Anesthesia.— The best syringe for infiltrating
dense structures, such as skin and acutely inflamed area, is one of small
capacity, 1 to 2 c. c., with slender piston so that the solution may be injected
economically, accurately, and with little pressure on the piston. For infiltrat-
ing loose tissue with very dilute solution larger syringes, 5 to 10 c. c., are more
convenient.
Steel needles are the best, holding a sharper edge, are more rigid, and
LOCAL ANESTHESIA 53
much cheaper than those of iridioplatinum. These latter, however, should be
used for deep puncture, where motion of the patient may snap the needle. The
best needle points are those ground on a short bevel with a rounded cutting edge.
The apparatus should be sterilized by boiling in plain water. Syringes of
metal and glass are fragile to heat ; those of the Luer all-glass type and those of
the all-metal type are most practicable.
General Technic of Infiltration Anesthesia. — The needle is inserted into the
skin obliquely at an angle of 30°. As soon as the lumen of the needle is
buried, from about 2 to 4 minims is gradually injected until a whitened wheal is
raised and spreads in the substance of the skin. Into this the needle may be
thrust further and the wheal rapidly elongated. When further thrust ceases
to raise a wheal effectively the needle is withdrawn and inserted at the edge of
the elongated wheal and a second injection made, so progressing until the line
of incision is infiltrated. A very effective means to prolong the cutaneous anes-
thesia is to widely block off by circumferential infiltration the entire area of
operation, after the manner of Braun. Effective anesthesia is induced, not by
massive edematous infiltration, but by complete diffusion of proper strength
of anesthetic.
If immediate anesthesia is not desired the skin may be liberally infiltrated
through deep layers by weak solution. An extensive skin area may thus be
more rapidly infiltrated than by the wheal method, yet anesthesia is not so
rapidly established nor so persistent. The anesthetization of the zone of in-
cision being completed, the needle is plunged into the deeper structures and
injection made into those layers of the field of operation which carry pain
sense. Many tissues such as fat, muscle, areolar tissue, and fascia give no
sense of pain to sharp dissection, and require no infiltration.
Those tissues to which special care must be given are skin and mucous sur-
face, nerve trunks, vascular trunks, periosteum, parietal pleura, parietal perito-
neum, and joint structures. All these tissues must be independently infiltrated
when reached.
Traction and excessive pressure on tissue should not be used. These give
rise to sensation, against the blockage of which local anesthesia is not effective.
Some of these sensations, while not those of conscious pain, impair the function
of great vital systems such as the circulatory, respiratory, and sympathetic.
An especially gentle, clean, sharp-cutting technic must be developed for suc-
cess with local anesthesia.
Preferred Technic for Special Groups of Operations. — MINOE OPERATIONS
ON NON-INFLAMED AEEAS. — The skin is anesthetized by % per cent, cocain or
novocain with epinephrin 1 : 20,000, by line of wheals. Incision is made and
the deeper parts injected as need arises.
MINOR OPERATIONS ON INFLAMED AREAS. — When in a condition of acute
inflammation all tissues become more or less sensitized. If the area of opera-
tion be small, as, for example, in a furuncle, the area is blocked by slowly sur-
rounding it with wheals of injected anesthetic, preferably i/2 per cent, solution
54 SURGICAL ANESTHESIA
of freshly dissolved cocain. The deeper subcutaneous tissue must be more
liberally infiltrated than when dealing with non-inflamed tissue. Eor more
rapid and certain anesthesia and to decrease the pain caused by distention of
tissue already tense the percentage of cocain may be advantageously increased
to 1 or 2 per cent, solution. The toxic limit, i. e., % grain, must not be ex-
ceeded in the total amount of cocain used.
MAJOR OPERATIONS ON NON-INFLAMED AREAS.— For extensive and pro-
longed operation under local anesthesia it is desirable to induce by morphin or
Fio. 2. — INFILTRATION ANESTHESIA: FURUNCLE. A line of wheals encircles the septic area. The
needle is reinserted only so often as further infiltration ceases to raise a wheal. It is reinserted
in an area already anesthetized. The desensitized area within the circle of wheals is infiltrated
by four or more separate punctures, infiltrating the skin and the underlying tissue. Line of crucial
incision diagrammed.
other alkaloid light preliminary narcosis. Thus the harmful psychic dread of
operation and the acute cognizance of the unaccustomed surroundings and
procedures in the operating room are blunted, the dosage of local anesthetic may
be lessened and the duration of effect increased. At any stage of the operation
this narcotic state may be deepened and the effect of the local anesthetic mark-
edly increased by administering by inhalation about 1 drop of ether per second
for a few minutes.
The usual narcotic is morphin, grain %, with atropin, grain 1/150, given
hypodermically !/2 bour before the operation; a more active combination is
morphin, grain %> and scopolamin, grain 1/100.
The line of incision is anesthetized by widely surrounding it by wheals,
preferably of % per cent, novocain in normal saline with epinephrin freshly
added 1 : 20,000.
Through this blocked-off area deeper tissue is infiltrated, preferably with
^4 novocain-adrenalin solution; the skin is then incised, Next each sue-
I
LOCAL ANESTHESIA 55
cessive layer is infiltrated with novocain in the degree which its sensitiveness
requires, infiltrating with special care parietal peritoneum, pleura, and peri-
osteum. Solution of % per cent, novocain, combined with epinephrin 1 : 40,-
000, is the most generally useful for extensive infiltration.
Where the need of a considerable quantity of anesthetic is anticipated it is
well to measure out prior to the operation the maximum total dose which may
be safely used. One measures out for a stock solution 50 c. c. of novocain, 1
per cent, solution in normal saline, to which is added epinephrin sufficient to
make 1 : 10,000. This contains 0.5 gram or 7% grains of novocain, the limit
of safety. From this stock is withdrawn for the first cutaneous injection, full
strength solution; for subsequent infiltration the stock solution is diluted with
3 parts of saline solution (0.8 per cent.) to yield a ^ per cent, novocain solu-
tion with strength of epinephrin 1 : 40,000. Weaker solutions are ineffective.
When sensory nerve trunks are encountered, as, for example, in herniotomy,
these are separately infiltrated. Thus a wide area becomes anesthetic and
requires no further infiltration.
The novice in local anesthesia must beware of pressure by blunt instru-
ments, of the spreading of the muscle fibers, and of traction on the viscera.
Such manipulations, while not painful to the patient, give rise to undesirable
stimuli, which may result in vomiting, syncope, shock, postoperative neuras-
thenia, and other nervous derangement.
EXTENSIVE OPERATION ON ACUTELY INFLAMED AREAS.— Infiltration an-
esthesia is inadvisable for extensive incision of inflamed areas, or for deep-
seated tendon and joint lesions. The pain of injection, the unsatisfactory
anesthesia, and the toxic dosage necessary to secure any reasonable degree of
anesthesia render general anesthesia much preferable.
Types of Operation Performed Under Infiltration Anesthesia — OPERATIONS
ABOUT THE HEAD AND FACE. — For the dissection of small superficial tumors
and plastic operations on the head and elsewhere the line of incision may be in-
filtrated, or the entire tumor may be blocked by a circle of wheals as described
under Minor Operations on Uninnamed Areas. Dissection proceeds with
the usual gentle manipulation necessitated by local anesthesia. The deeper
planes of tissue are anesthetized only as need arises. On the face and other
highly vascular parts the proportion of epinephrin must be as high
as 1:10,000 to secure the vasoconstriction needful for the maintenance of
anesthesia.
Wounds of the scalp and elsewhere are best treated without local anes-
thesia, since the pain of infiltration equals that of cleansing and suture.
In fractures of the skull small fragments of bone may be elevated or re-
moved by a trephine under infiltration anesthesia, particular care being used
to forcibly inject the anesthetic circumferentially under the pericranium. The
meninges and brain are insensitive. Large operations are preferably done
under general anesthesia.
Any section of the face may be readily anesthetized by infiltration .for the
56 SUEGICAL ANESTHESIA
excision of small tumors and basal cell epitheliomata. However, absorption
is rapid and anesthesia transitory, even when the usual strength of epmephrm
is doubled. For larger procedures infiltration is of little service.
Operations, such as prolonged plastic work on the eyelids, nose and mouth,
the excision of epitheliomata involving glandular dissection, operation on the
maxilla and mandible, are feasible only by blocking the various sensory branches
of the trigeminus at strategic points. The elaborate and precise technic is
best described in the monographs of Braun and of Hirshel. For the smaller
procedures see Intraneural Infiltration.
The ear drum may be anesthetized for puncture by infiltrating deeply into
the superior wall of the external auditory canal.
Individual teeth may be anesthetized by forcibly injecting the anesthetic
with a small, strong syringe into the gum at the margin and beneath the peri-
osteum of the alveolar border, both on the buccal and lingual aspect.
For operations on the mandible see Intraneural Infiltration.
For operation within the nose see Local Anesthesia by Osmosis.
MINOR OPERATIONS ON THE NECK AND THROAT. — The tonsil region
nuiv be anesthetized by swabbing the pillar with 10 per cent, cocain and then
infiltrating the peritonsillar tissue with % per cent, cocain or novocain so-
lution.
Superficial lesions and encapsulated tumors may be removed and abscesses
opened under infiltration anesthesia. For extension dissection of glands and
lymph nodes local anesthesia is inadequate.
For furuncles, carbuncles, etc., the area is surrounded by a circle of cocain
infiltration in a line of wheals as described under Minor Operations on In-
flamed Areas. The line of incision within this circle is infiltrated, care being
taken that the needle once fouled in the septic area is not inserted in the sur-
rounding healthy tissue. Finally several deeper punctures in the septic area
are made and the underlying base infiltrated.
TRACHEOTOMY.- — For tracheotomy local anesthesia by infiltration is par-
ticularly satisfactory.
THYROIDECTOMY. — An oval area embracing the line of collar incision is
injected with anesthetic, first infiltrating the skin circumferentially by line of
wheals, then the subcutaneous tissue and platysma with weak anesthetic solu-
tion (see page 54). Incision is then made, exposing the deep cervical fascia,
through which the deep muscle plane is infiltrated in a wide band. After a mo-
ment this plane may be divided gently by sharp incision. The lobes and the
isthmus of the thyroid are now exposed. With great caution to avoid intra-
vascular injection of the anesthetic, the areolar tissue outside the thyroid is
scantily infiltrated as need arises, particular care being given to the superior
pole and to the space between the trachea and thyroid. Each lateral lobe may
now be carefully dislocated and resected or otherwise dealt with. Thyroid
tissue proper is not sensitive.
THORACOTOMY. — The area of incision is widely blocked as in the foregoing
LOCAL ANESTHESIA 57
procedure. The periosteum of the rib is infiltrated and then the needle is
directed up beneath the overhanging lower edge of the rib and the region of the
intercostal nerve is infiltrated. The rib is now resected and the parietal pleura
separately infiltrated before being incised.
CELIOTOMY. — The area of incision is widely blocked by infiltrating the skin
FIG. 3. — INFILTRATION ANESTHESIA FOR REPAIR OF SMALL INGUINAL HERNIA. Indication of area
blocked by line of superficial wheals and by deeper infiltration.
and subcutaneous tissue down to the muscles, as in major operations (see page
54). Incision is made and the muscle planes are scantily infiltrated as one
proceeds. These are now divided by clean dissection with little traction, ex-
posing the fascia transversalis. Through this layer the subperitoneal areolar
tissue is infiltrated as widely as is feasible. The peritoneal sac is now opened. '
The manipulation of the abdominal viscera induces no immediate sensation-
58
SURGICAL ANESTHESIA
of pain, and they may be operated on without anesthetization so long as pres-
sure and traction are avoided. For closure and suture of the abdominal wall
after prolonged operations the parietal peritoneum and skin may have to be
reanesthetized. If reenforcement of the local analgesic be needed the best
agent is a few drops of ether (see the Zone of Confusion in Ether Anesthesia,
Fio. 4. — INFILTRATION ANESTHESIA FOR REPAIR OF SCROTAL, HERNIA. Groin and entire scrotum blocked
by line of wheals. Deeper tissues infiltrated and nerve trunks blocked.
page 82). One has recourse to the prolonged anesthetic action of quinin and
urea as a supplementary procedure, but the drug interferes with wound healing
and has been largely abandoned.
OPEBATION FOR SMALL INGUINAL AND FEMORAL HERNIA, HYDROCELE
OF THE CORD, AND GLAND OF THE GROIN. — The area is blocked as in Figure
3. If the operation be for scrotal hernia the field is infiltrated by more
extensively surrounding the scrotum as in Figure 4. In about 3 minutes the
skin and the external oblique muscle may be incised and the internal ring ex-
FIG. 5. — INFILTRATION ANESTHESIA FOR HEMORRHOIDS. Anus surrounded by line of wheals; sphincter
relaxed by deep infiltration; polyp delivered and mucous membrane anesthetized by infiltration
across line of excision.
FIG. 6. — INFILTRATION ANESTHESIA: REGION OF KNEE. For excision of prepatellar bursa, or repair
of fractured patella, showing area blocked by line of wheals and direction of deeper infiltration.
60
SURGICAL ANESTHESIA
posed. The ileohypogastric nerve is now identified lying upon the internal
oblique muscle above the upper margin of the internal ring. The ileo-inguinal
nerve is identified with more difficulty, running with the cord through the
inguinal canal and lying on the under surface of the cord facing Poupart's
ligament. Each nerve is blocked as it is exposed by
intraneural injection (see page 61). Further sur-
gical manipulation thereupon becomes painless, save
the tying off of the sac. This must be blocked sepa-
rately by local infiltration of the subperitoneal tissue.
The skin may have regained sensation before the close
of the operation and then must again be scantily infil-
trated to be sutured.
OPEEATIONS FOR HYDROCELE, OPERATIONS ON
THE TESTICLE, ETC. — The area of incision is
blocked by infiltration. The sac is exposed and each
line of dissection infiltrated before incision.
CIRCUMCISION. — The penis is constricted by a liga-
ture of rubber tubing. The sheath of the penis is in-
filtrated through the superficial layer proximal to the
line of circular incision, and the reflected portion
separately infiltrated near the corona, infiltrating with
special care the frenum. A collar section of the
prepuce may then be excised, preferably by sharp dis-
section.
HEMORRHOIDS. — See Figure 5.
OPERATIONS ON THE UPPER AND LOWER EX-
TREMITIES.— For excision of patellar bursa or adjust-
ment of patellar fracture the area is blocked as in Fig-
ure 6. The periosteal layer beneath the bursa must be
separately infiltrated by deep puncture.
For amputation of the smaller toes and the fingers
the proper line of infiltration is shown in Figure 7.
For amputation of the great toe or arthroplasty, as for hallux valgus, the
procedure is indicated by the same diagram.
For operations on the distal phalanges of the toes and fingers the nerve
trunks may be blocked by perineural infiltration at the first phalanx (see page
27), or the site of operation may be locally infiltrated as by the general tech-
nic of infiltration on uninflamed areas.
Fractures of the long bones such as Colles' fracture may be reduced under
infiltration anesthesia.
Fio. 7. — INFILTRATION AN-
ESTHESIA OF THE TOES.
Line of infiltration for
nerve terminal and nerve
trunk conduction anes-
thesia: for amputation,
plastic arthrotomy, or
other local minor pro-
cedures.
LOCAL ANESTHESIA 61
REGIONAL ANESTHESIA
Introduction. — When it is desirable to anesthetize entire regions with
minimal manipulation and small dosage of local anesthetic one has recourse to
the following method : The most effectual method, where it can be applied, is
infiltration into a nerve trunk — intraneural infiltration. A nerve trunk may
also be blocked by infiltrating into the surrounding tissue — perineural infiltra-
tion. Or the nerve trunk may be bathed in the proper anesthetic solution, as by
injecting the agent into the spinal canal — spinal or medullary anesthesia.
An entire segment of an extremity may be anesthetized by injecting the
agent into the vascular channels of that part — intravenous and intra-arterial
local anesthesia.
REGIONAL ANESTHESIA BY INTKANEUKAL INFILTRATION
For the infiltration of an exposed nerve trunk the nerve is held steady by
gauze or grasped in special forceps which do not pinch or bruise. Into the
nerve is injected through a fine hypodermic needle sufficient solution to make a
bulbous swelling on the nerve. The best agents are a solution of % per cent,
cocain or of 1 per cent, novocain.
The puncture and injection cause momentary tingling and other pares-
thesise over the distribution of the nerve. Within 2 minutes anesthesia appears
and gradually deepens for the next 10 minutes. This anesthesia is absolute
only at the center of the nerve distribution, indeed there may be hyperesthesia
at the periphery of the area of distribution where the nerve is overlapped
by neighboring supply. Anesthesia lasts 30 to 90 minutes, occasionally
longer.
For intraneural injection of unexposed nerve trunks only those trunks which
have a definite course and landmarks are available. The entrance of the inject-
ing needle into these trunks is signaled by a sensation like an electric shock
along the nerve. Thus the proper trunk from a plexus may be identified and
injected. For this blind method the solution should be twice as strong as when
the nerve is exposed.
The following are the areas commonly anesthetized by these methods: (1)
the frontal region, by injection of the supra-orbital nerve at its foramen; (2)
the side of the nose and cheek and the upper lip, by injection of the infra-orbital
nerve in the canal; (3) the lower jaw and the region of the chin, by injection
of the inferior maxillary nerve at the inferior maxillary foramen; (4) the
upper extremity, by injection of the brachial plexus in the supraclavicular
triangle, or in the axilla; (5) the little finger, by injection of the ulnar nerve
behind the internal condyle of the humerus; (6) the groin and scrotum, by
injection of the ileo-inguinal and ileohypogastric nerves during herniotomy;
(T) the leg below the knee, by injection of the great sciatic at the sacrosciatic
notch; (8) the outer side of the leg and dorsum of the foot, by injection of the
62 SURGICAL ANESTHESIA
external popliteal nerve in the popliteal space lying parallel to the tendon of
the biceps. . . , .
The less common procedures of cranial, spinal nerve, and plexus injection
are heyond the scope of this article. (See Braun's monograph ) llustrative
of these procedures is Figure 8 and the following description of brachial plexus
anesthesia.
Brachial Plexus Anesthesia.— The subclavian artery is palpated above it
clavicle. External to and above the artery a hypodermic needle is inserted into
PJO> g. — BRACHIAL PLEXUS ANESTHESIA. The illustration shows the position of the cords of the bra-
chial plexus as they emerge from between the scaleni muscles where they are punctured in the
posterior cervical triangle and rendered anesthetic and non-conductive by intraneural infiltration.
the brachial plexus as the nerve trunk emerges from between the scaleni
muscles. Puncture and injection of each nerve trunk give immediate pares-
thesia over the area supplied by that trunk. Anesthesia develops in about 2
minutes and gradually deepens. If the nerve trunks be definitely entered a
solution of % Per cent, cocain or 1 per cent, novocain suffices as an anesthetic
agent. If the injection be perineural the strength should be doubled.
As accidents of this method the pleura may be punctured with subsequent
pleurisy, or the dose may be injected intravascularly with general intoxication,
or a long-continued neuritis may be caused. A similar procedure is used in
anesthetizing various branches of the brachial plexus in the axilla as they sur-
round the axillary artery.
Nearly all nerve trunks have such ill-defined surface landmarks that direct
injection of the non-isolated trunk is not feasible. In such case one has
recourse to perineural infiltration, next to be considered.
LOCAL ANESTHESIA
63
REGIONAL ANESTHESIA BY PEKINEUEAL INFILTRATION
A nerve trunk traversing an infiltrated area absorbs anesthetic from the
surrounding lymph and becomes blocked. When the blood flow is active the
anesthetic may be washed away before affecting the nerve trunk, hence blockage
by perineural infiltration is limited preferably to the nerves of the digits and
larger extremities which can be
isolated by hemostatic tourni-
quet. The procedure elsewhere
is uncertain, requiring a dosage
of anesthetic double that of the
preceding method in strength.
When possible the part is
exsanguinated by gravity and
by bandage, and sequestrated by
elastic ligature as for intra-
venous anesthesia (see page
TO). An area of tissue about
% in. wide is infiltrated across
the path of the nerve at proper
depth to bathe the nerve trunk.
If the anesthetic be successfully
distributed anesthesia appears
over the area of nerve distribu-
tion in about 10 or 15 minutes
and persists while the circula-
tion of the blood is CUt Off and
j? i er • f,
lor 15 minutes Or more alter
circulation is reestablished.
Special Technic. — The finger is the area most commonly anesthetized by
perineural infiltration. The special and anatomical features and technic are
considered in diagram and legend (Figs. 9, 10, 11). The operator should
proceed only with a clear conception of the course and anastomosis of the 2
N. DIGITALIS DOR5ALIS
N. RADIALIS
FIG. 9. — PERINEURAL CONDUCTIVE ANESTHESIA OF THE
FINGER. Showing method of hemostasis and location
(A) of ring of infiltration. (See also Figs. 10 and 11.)
N. DIGITALIS VOLARIS PROPRIUS'
N. MEDIAN
FIG. 10. — NERVES OF THE RIGHT INDEX FINGER. Showing the course of nerves and the placement
of the solution to obtain, by perineural infiltration, conductive anesthesia of the distal portion
of the finger.
64
SURGICAL ANESTHESIA
dorsal and palmar nerve trunks (see Fig. 10). Then by following the general
teehnic given above, infiltrating in the manner illustrated m Figure 11 a satis-
factory anesthesia of the distal phalanx may usually be obtained m ab
minutes.
The entire liand may be similarly anesthetized. The hand is exsanguinated
by elevation, and rendered ischemic by elastic ligature m the middle of the
forearm. The nerves are
blocked by infiltrating round
about at the wrist, except for
a space over the dorsum,
where no trunks exist. The
bracelet or band of infiltra-
tion is about % in. wide and
is placed 1 in. above the
wrist. First the skin and
subcutaneous tissue are anes-
thetized, then the deeper tis-
sues, special care being taken
to infiltrate: first, the region
traversed by the median
nerve where it lies at the in-
ner side of the tendon of the
palmaris longus ; second, that
of the ulnar nerve external
to the flexor carpi ulnaris,
lying between this muscle and the ulnar artery ; and, third, that of the radial
nerve as it winds external to the shaft of the radius about l1/^ in. above the
styloid process.
The arm is anesthetized preferably by other methods, such as brachial
plexus infiltration, or better yet by intravenous anesthesia.
The foot may be anesthetized in a manner similar to the hand by a band of
superficial and deep infiltration above the malleoli.
Perineural anesthesia of the less common areas of operation on the upper
and lower extremity requires a special knowledge of cutaneous nerve distribu-
tion and surgical approach of the various sensory nerve trunks too voluminous
for this work.
FIG. 11. — CROSS-SECTION OF FINGER THROUGH FIRST PHA-
LANX. Showing in black a cross-section of the nerves, illus-
trated in Fig. 10, and showing the relative position of infil-
trated tissue, indicated by elliptical wheals. a, The volar
tendon; b, the bone; c, the dorsal tendon.
REGIONAL ANESTHESIA BY INJECTION INTO THE MEDULLARY CANAL: SPINAL
OR MEDULLARY ANESTHESIA
Introduction. — Spinal nerve roots when bathed in proper anesthetic solution
cease to functionate. Pain impressions from the lower segments of the body.
may thus be blocked by intrameningeal injection of a proper dose of an anes-
thetic agent. This fact was first demonstrated by Corning with cocain, and its
LOCAL ANESTHESIA 65
practical application made by Bier. With the recent discovery of agents less
toxic than cocain the margin of safety in the method has increased until it now
has become a routine method in certain clinics for operations below the
diaphragm.
Physiology. — Following intramedullary injections into the spinal cavity the
anesthetic agent diffuses itself through the cerebrospinal fluid and rapidly com-
bines with all exposed nerve tissue, which it deprives of conductivity. The
spinal nerve roots are most affected, the cord proper less so. Within a few
seconds sensations of paresthesia appear. In about 2 minutes pain sense is
abolished and touch sense is much impaired over the distribution of the nerve
roots affected. Motor and sympathic paralysis follow, reaching their height in
about 15 minutes. The sense of position of any limb affected is lost. The cord
proper, being protected by the pia mater, is only superficially influenced by the
anesthetic and continues to carry nerve impulse to and from distal segments.
Control by the operator as to the area to be anesthetized and the degree and
duration of anesthesia is secured by proper selection of drug and dosage, by
the site of injection, and by the predetermined course of distribution of the
agent injected. The distribution is controlled by having the agent in solution
of a specific gravity either distinctly lighter, so as to rise, or distinctly heavier,
so as to fall in the cerebrospinal fluid surrounding the cord. The specific
gravity of cerebrospinal fluid being uniformly between 1.0055 and 1.0065, the
solution is made heavier than this by lactose, or lighter by alcohol. The sacral,
lumbar, and lower dorsal segments are those usually blocked, securing anesthesia
below the level of the nipple. Following such blocking the following physical
signs are to be noted in addition to the anesthesia :
The abdominal walls become completely relaxed and abdominal breathing
is largely abolished. The anal sphincter relaxes and the contents of the large
intestine escape aided by active peristalsis of the entire intestinal tube, which
is now released from the inhibitory control of sympathic nerves.
CIKCULATIONV — The vasomotor control of the area affected is lost. The
pulse is slow, and the blood pressure falls, proportionately to the upward ex-
tension and intensity of the anesthetic action. With involvement of the upper
dorsal segments the pulse may drop to 40 or 30 per minute and be indistinguish-
able at the wrist.
The fall in blood pressure is due to the combined action of vasomotor
paralysis in the lower segments of the cord, to the limitation of respiratory
movement, and to unopposed inhibitory vagus action on the heart. This fall
begins soon after the motor paralysis, reaches its height in about 15 minutes,
and slowly passes off.
Untoward depression of circulation is combated by adrenalin, administered
intravenously in normal saline. From 2 to 10 minims of the adrenalin solution
is added to each 6 ounces of saline infusion. As -little as 2 minims may be
effective or as much as 70 may be required.
EESPIEATION. — Kespiratory movement is similarly inhibited. Abdominal
66 SUEGICAL ANESTHESIA
respiration is first lost, then thoracic, and finally, with involvement of the
phrenic nerve at the fourth cervical segment, the diaphragm itself becomes
paralyzed. The respiratory motor palsy reaches its height in from 15 to 20
minutes, and may last for several hours.
If the phrenic nerve be involved by untoward upward extension of the anes-
thetic, life may be sustained by artificial respiration until the nerve recovers
its conductivity. But without adequate artificial respiration or with additional
involvement of the floor of the fourth ventricle, death ensues.
UTERUS. — The uterine muscle retains its tone and contractile power but
lacks the aid of voluntary expulsive forces of the abdomen.
SKIN.- — The surface of the body tends toward paleness and is dry. Heat is
lost less rapidly in this method of anesthesia by radiation and evaporation than
in the suffusion of general anesthesia.
Limitations. — The method should not be used in conditions of shock. It is
applicable with safety only to operations below the level of the nipple, pref-
erably below the diaphragm. To extend the field of anesthesia to the upper
thoracic, brachial, and cervical regions may be best characterized as fool-hardy.
The method should be adopted only after a thorough training in the tech-
nic of injection and full knowledge of the physics and physiology involved.
As a casual method by the inexperienced, or without facility for artificial
respiration, the method is much more dangerous than the inexpert administra-
tion of general anesthetics. The method does not promise to replace general
anesthesia.
Utility. — The method seems to some observers to be indicated in operations
below the level of the nipple where general anesthesia is contra-indicated ; also
when peculiar skill in this method is developed, and in prison, military, and
hospital surgery, where for local reasons facility or trained skill is lacking in
methods of general anesthesia.
Apparatus. — The best syringe is of the Luer, glass type, capacity of 2 c. c.
with accurate graduation.
The needle should be a special lumbar needle of iridium platinum 7.5 cm.
long and .1 cm. thick. It should be provided with a. stylet which effectively
closes the lumen, so that it may not become clogged in its introduction. The
needle point should be ground on a short bevel of not over .2 cm. and should be
keenly edged. The syringe and needle should be boiled only in pure water for
15 minutes before using, as any trace of alkali may decompose the anesthetic.
The syringe should be taken from the water still hot, so as to warm the anes-
thetic solution.
Preparation of the Anesthetic Agent.— The agents employed in order of effi-
ciency are stovain, tropacocain, and novocain.
These are dissolved in water and sterilized. The solution is rendered either
distinctly lighter, or much heavier than the cerebrospinal fluid, so that the route
of diffusion, which occurs slowly, may be plotted in advance and the position of
the patient adjusted accordingly.
LOCAL ANESTHESIA 67
The solution is made of lighter specific gravity by alcohol and heavier by
sugar of milk. The stovain solution must be acidified to avoid precipitation by
the alkaline cerebrospinal fluid.
The lighter solutions are the more useful. Even for cervical analgesia these
may be employed, injected in the lumbar region, and allowed to diffuse upward.
SOLUTIONS EMPLOYED IN SPINAL ANESTHESIA (BABCOCK)
Light Solutions:
A. Stovain 0.08 gm.
Lactic acid 0.04 c. c.
Absolute alcohol 0.2 c. c.
Distilled water 1.8 c. c.
B. Tropacocain 0.1 gm.
Absolute alcohol 0.2 c. c.
Distilled water 1.8 c. c.
C. Novocain 0.16 gm.
Absolute alcohol 0.2 c. c.
Distilled water 1.8 c. c.
Heavy Solutions:
D. Stovain 0.08 gm.
Lactic acid 0.04 c. c.
Milk-sugar 0.10 gm.
Distilled water, to make 2. c. c.
These solutions are conveniently kept in ampules, each containing 2 c. c. of
solution. They should be prepared under aseptic precautions and sterilized by
the intermittent method and at temperatures not above 65° C. (149° F.).
Solutions made from tablet or powder carry some risk of infection. There
is no advantage, except to alter the specific gravity, in adding to the solution
adrenalin, strychnin, glucose, gelatin, or similar substances.
The dose for the adult of each solution is from 1 to 1.5 c. c., the larger dose
being employed only for robust adults. Of these solutions that of stovain is the
most powerful anesthetic and motor paralyzant, most toxic, most actively
hemolytic, and the strongest protoplasmic poison. If not acidulated it is pre-
cipitated by the alkaline cerebrospinal fluid. It gives excellent anesthesia.
Tropacocain is somewhat less active as an anesthetic and is considered by
some to have fewer untoward effects. Each anesthetic when in solution may
show variations in analgesic power and in toxic action, possibly due to imperfect
sterilization, to by-products not eliminated in the manufacture, or as a result of
the decomposing effects of heat.
Novocain is much weaker than stovain, but is not precipitated by cerebro-
spinal fluid, and even in a 10 per cent, solution is not actively hemolytic. The
clinical efficiency and clinical toxicity of novocain are about % that of stovain.
The loss of the sense of touch is less under novocain.
68 SUEGICAL ANESTHESIA
Babcock prefers solution A, injected through one of the lower dorsal or
upper lumbar interspaces. This fluid diffuses rather slowly and passes toward
the head or the sacrum, according to the posture of the patient. If, for example,
the injection is made through the twelfth dorsal interspace, and the patient sits
up after the injection, the solution, which ascends with an approximate rapid-
ity of about 10 cm. per minute, will usually reach the lower cervical segments
in about 1 minute. The cervical segments will be involved during the second
minute, and if the patient sits up over 2 minutes some involvement of the
cranial nerves may occur. As the fluid becomes somewhat diluted in its ascent,
a larger dose and, therefore, a more prolonged effect may be obtained, with less
danger of high motor paralysis than when the higher point of injection, advo-
cated by Jonnesco, is employed. Anesthesia involving the higher segments is
not so certain or so safe as that involving the segments below the level of the
diaphragm.
The heavy solution is used only where it is desired to keep the head elevated
during the operation.
Preparation of the Patient. — Preferably, the stomach and colon should be
empty as for general anesthesia.
If the patient be nervous, or partial general narcosis be desired, this is
secured by morphin with atropin or hyoscin. These drugs must be adminis-
tered cautiously, and are best avoided in those patients presenting respiratory
obstruction or depression from grave renal disease, and in conditions of grave
toxemia. The usual dosage of the narcotic for a robust individual is, beginning
one hour before the operation, morphin % with scopolamin 1/100 grain given
hypodermically. Atropin, grain 1/150, may be substituted for the scopolamin.
Scopolamin should not be administered in the young, in fact, is undesirable up
to 25 to 30 years of age. After 20 minutes if no narcotic effect is evident the
dosage is repeated. Occasionally a third dose must be given to secure an
obvious narcotic effect.
The field of spinal puncture is swabbed with tincture of iodin, which is
allowed to dry and is then washed off with alcohol.
Technic. — The following technic of injection is that given by Babcock:
"The injection may be made either with the patient lying on the side or sitting
on the operating table. To avoid undesirable diffusion of the solution, the injection
should be made immediately before the operation and preferably on the operating
table. With the patient on the side, the head should be well flexed on the chest, the
thighs on the abdomen, so as to arch the back and separate the spinous processes,
the patient being so arranged that the spine is not rotated. The interspace is located
by a towel, the edge of which when placed on the iliac crests will cross the fourth
lumbar spine or interspace; or the interspace may be located by selecting the inter-
space opposite the angle formed by the last rib and the erector spinse muscle; this
is the first lumbar.
The injection should be made about opposite the upper level of the field of opera-
tion, that is, through the twelfth dorsal or first lumbar interspace for upper abdominal
work, and the second lumbar interspace for operations on the lower abdomen or legs.
LOCAL ANESTHESIA 69
The needle should be entered close to the midline about the center of the interspace
and at right angles to the surface of the body, and it should be introduced until the
resistance of the ligamentum subflavum is felt. In the athletic this may have an
almost cartilaginous consistency, and the sensation imparted usually indicates that
the proper direction of the needle is being maintained. If the needle encounters
only loose, non-resistant tissue it is probable that it has deviated too far to the side,
and it should be withdrawn and reintroduced with more accurate orientation. The
stylet is now withdrawn, and the needle is cautiously pushed forward with short,
quick strokes a few millimeters at a time. The loss of resistance as the needle enters
the tissue about the dura is noted, and then the slight resistance accompanied by a
perceptible and sometimes audible snap as the tense dura is punctured. The needle
is cautiously rotated to make sure that the point is entirely within the cavity of the
arachnoid. Cerebrospinal fluid should now drop from the needle; if it does not, the
lumen of the needle should be cleared by the use of the stylet, or the needle should
be so adjusted that the fluid will run freely; otherwise satisfactory analgesia need not
be expected. The usual errors are to incline the needle upward or laterally in the intro-
duction. The quantity of cerebrospinal fluid permitted to escape should be about
that of the solution to be injected. If the needle deviates to the side a nerve root may
be touched, producing a lightning-like pain usually radiating down the leg. If this
occurs the needle should be immediately withdrawn and reintroduced. Puncture of
the cord produces no sensation, and, while it is to be avoided, it is relatively harmless.
"The syringe charged with the anesthetic solution is affixed to the needle and free
communication with the arachnoid again proved by gently withdrawing the piston.
The mixture is now cautiously injected and the needle quickly withdrawn. Apart
from placing a sterile towel on the patient, the point of puncture requires no dressing.
If a light anesthetic solution be used the head and shoulders of the patient must be
instantly lowered and maintained below the level of the dorsolumbar region for half
an hour after the injection. If a heavy solution be employed the shoulders and head
must be kept elevated for a corresponding period of time. Improper movement of
the patient and lack of these precautions are responsible for many of the accidents
of spinal anesthesia.
"Nausea, pallor, or marked lowering of the pulse tension usually indicate that
the anesthetic is reaching too high a level, and the position of the patient should be
further modified to keep the anesthetic solution in the lower part of the spinal canal.
"The analgesia should develop within two or three minutes. To avoid suggestion,
the patient should never be asked as to sensations of pain, but the analgesia de-
termined by watching the face as the skin is pinched. If no analgesia is present in
six minutes, the injection should be repeated, using the same dosage, and perhaps
selecting another interspace. Lack of anesthesia may follow from the use of imper-
fect solutions, failure to introduce the needle properly, and leakage of the solution
outside of the arachnoid. The analgesia gradually disappears without unpleasant
sensation, from above downward in from forty-five to ninety minutes. If not contra-
indicated by the operation, sips of water or bits of ice may be administered while
the patient is on the operating table. If the analgesia is inefficient and too transient,
there is no objection to the associated administration of ether."
REGIONAL ANESTHESIA BY INTRAVENOUS INJECTION
This method was introduced by Bier in 1909. It was designed for the pur-
pose of anesthetizing rapidly and completely all structures, even the bones and
joints, of a given segment of an extremity. Anesthesia is induced en bloc by
filling the venous channels of that segment with a considerable bulk of saline in
70 SUKGICAL ANESTHESIA
which the agent is dissolved. The area to be anesthetized must be one from
which the blood can be emptied and shut off, hence this method is applicable
only to the hand and foot, or to any given segment of a limb, such as the region
of elbow or knee.
Technic.— The part is depleted of blood, first, by elevation, second, by
applying with tension a flat rubber bandage spirally from the extremity of the
limb proximally. The ingress of fresh blood is blocked by so adjusting the
bandage as to check the arterial pulse. A good substitute for a flat band to
cut off the pulse is a pneumatic cuff such as is used for determination of blood
pressure. The extremity first being emptied of blood by elevation and bandage,
the cuff is inflated by a small bicycle pump to a pressure about 50 mm. above
the blood pressure, usually to 200 mm. or 4 pounds of pressure.
A vein, the location of which has been previously marked, is now exposed
under infiltration anesthesia and a cannula introduced as for saline infusion.
The best agent in this method of anesthesia is novocain in dosage averaging
0.5 gram for the adult. For injection of the hand or elbow this is dissolved in
50 c. c. of saline, and for the foot and knee in 70 to 100 c. c. of saline. This
amount of fluid insures thorough distribution to the entire part. If an ex-
tremity is to be amputated, then novocain up to 2 grams in 200 c. c. of saline
is employed, since the overdose becomes combined in the amputated part and
cannot reenter the circulation on removal of the hemostatic band. (See also
Centra-indications to Surgical Operations.)
Over the sequestrated area anesthesia appears within 5 minutes, becomes
complete within 15 minutes, and lasts as long as the part is kept ischemic, and
usually continues about 15 minutes after the circulation is reestablished. If
the preliminary evacuation of the blood has been incomplete, this will gather
at remote points, such as the finger tip, and result in non-anesthetized areas.
Formerly the veins were flushed with normal saline before reestablishing the
circulation, but this has been abandoned as of no utility, since the toxic anes-
thetic has already entered into such union with the tissue that it will not re-
dissolve in normal saline. The hemostatic bandage should be removed before
starting suture to flush out the novocain and catch the bleeding points. It is
unsafe to keep the part ischemic for more than 40 minutes, for the life of the
muscle cells and other highly organized structures may otherwise be perma-
nently destroyed.
REGIONAL ANESTHESIA BY INTRA-ARTEBIAL INJECTION
In this method the anesthetic agent is distributed over the area supplied by
a given artery, by injecting the agent from a syringe into the lumen of the
artery.
Technic. — The distal part is exsanguinated by elevation and bandage as
for intravenous anesthesia. The arterial pulse is cut off by proximal constric-
tion. The artery is exposed under infiltration anesthesia and into the lumen is
GENERAL ANESTHESIA
71
injected, by fine hypodermic syringe, from 5 to 10 c. c. of a 1 per cent, solution
of novocain. The proximal constriction is then released, allowing a gentle
trickle of blood to wash the anesthetic saline solution to that region supplied by
FIG. 12. — THE BIER INTRAVENOUS METHOD OF REGIONAL ANESTHESIA. A segment at the elbow
has been exsanguinated and sequestrated. The veins of this segment are filled with the anesthetic
solution injected into any convenient vein.
the artery. The band is then tightened until anesthesia appears. The method,
while using less anesthetic than the intravenous, is not so reliable in anesthetic
effect.
RESUME
Simple local anesthesia and local anesthesia as an adjuvant to light general
narcosis have unquestionably a field of utility in major and minor surgery. Occa-
sionally local anesthesia has decided advantage over methods of general anesthesia.
Yet the enthusiasts in this method, in an endeavor to retain the consciousness of an
operated case, and to avoid the dangers and sequelae of general anesthesia — which
arises largely from improper administration — have overstepped the bounds of
reason, by subjecting the patient to the psychic shock of consciousness of the opera-
tive procedures, to neuroses from nerve strains, to postoperative cardiovascular
strain and insufficiency far beyond that of general anesthetization, and finally in
callously disregarding the protests of the physically and psychically restrained
patient. By these forced methods of local anesthesia the attempt is made to accom-
plish practically without anesthesia, operative procedure in ways current before
the days of modern anesthesia under the guise of safety and efficiency. — SUB-
SCRIBED TO BY THE EDITOR.
GENERAL ANESTHESIA
General anesthesia may be secured by several drugs which suspend for a
time the activity of the neurons of the central nervous system, beginning with
the highest. These drugs inhibit, first, reason, judgment, and will; then con-
sciousness; then the cortical motor and sensory activities; then the reflex
72 SURGICAL ANESTHESIA
activity of the basal and spinal centers. Finally, only the action of the great
medullary and sympathetic centers which maintain the functions of the body
necessary to life is left active. The function of these centers is impaired, as are
in less degree the general cellular function and activity of all the more lowly
organized body tissues.
THEORY OF GENERAL ANESTHESIA
The general anesthetics used in surgery are hydrocarbons, all except nitrous
oxid, having the common property of being active solvents of fat and fat-like
bodies. These hydrocarbons belong to that group of neutral or indifferent sub-
stances which dissolve in living protoplasm without forming fixed union with
the receptors of the cell as do foods and basic and acid poisons. The anes-
thetics enter and leave the cell freely and unchanged; the amount that the
cell holds at any given moment being governed entirely by the laws of diffusion,
of vapor tension, and by the solubility of the given chemical in the watery, fatty,
and other elements of the cell.
Of the many hydrocarbons that are anesthetic only those are adapted to
surgical anesthesia which combine the requisite physical properties of volatiliza-
tion, diffusion, and capacity to dissolve fats, with a toxic action on animal proto-
plasm so slight as to be unimportant.
The Hans Meyers hypothesis of the anesthetic action of these drugs, as
elaborated and established by Overton and Meyers, may be summarized as
follows :
1. All chemically indifferent substances which are solvent of fats and lipoids
are narcotic to animal protoplasm in so far as they can reach it by diffusion.
2. Anesthetization is established more rapidly and in greater degree in those
cells into the structure and functional activity of which the lipoids most extensively
enter, namely, the nerve cells.
3. The efficiency of these different narcotics is dependent on the relative physical
affinity of the narcotic for the lipoids on the one hand, and for the other solvent
media of the living body on the other hand, the bulk of which is water.
4. The efficiency is directly as the partition coefficient of the chemical between
solution in oil and in water. This is obtained by dividing the amount which remains
dissolved in oil by the amount which diffuses to an equal volume of water to estab-
lish a balanced vapor tension.
Of the many thousand chemicals of this group which possess anesthetic
properties, only three are generally recognized as possessing proper physical
qualities of volatilization, diffusion, and solubility of lipoids, combined with a
low or negligible toxicity toward animal protoplasm. These are ether, chloro-
form, and ethyl chlorid.
ETHER
Introduction. —Of the various hydrocarbon series, that radical is found in
actual practice to be the least toxic toward which animal protoplasm has been
GENERAL ANESTHESIA 73
longest adapted. The ethyl radical in the form of alcohol has been a normal
constituent of animal food since the day the first ameba lived in stagnant swamp
water. Animal protoplasm has always had to deal with the lipoid solvent action
of the ethyl group.
Of this group, ethyl oxid (di-ethylic ether) exerts the most clearly defined
and most readily controlled action. It is inherently the safest of all efficient an-
esthetics. Formerly the results of maladministration were confused with the
physiological action of ether, but with the newer methods of administration and
the revision of older methods, and appreciation by the surgeon of the necessity
of gentle manipulation of tissues, ether has become more universally recognized
as the safest and most generally useful anesthetic.
Physical Properties of Ether. — Ether is a clear, volatile liquid of pungent
taste and odor. It is lighter than water (specific gravity, .716) and boils at
below body temperature (at 35.5° C.).
The vapor tension at room temperature is about 460 mm., yielding, when
saturated in air, 60 per cent, by volume of ether vapor, or 80 per cent, by
weight. The vapor is 2% times heavier than air, and until it becomes diffused
it flows downward in air like water. It is highly inflammable.
On prolonged exposure to light or air ether gradually develops aldehyds
and other more irritating decomposition products. The U. S. P. allows a small
percentage of alcohol as a preservative.
PHYSIOLOGICAL ACTION OF ETHER
Local Anesthetic Action. — When exposed to the air, as on the skin, ether is
a refrigerant by rapid volatilization. The caloric loss in vaporization is only
about 1/6 that of water, but the vaporization goes on rapidly at such low tem-
perature ( — 20° C.) that ether is available as a refrigerant local anesthetic.
Ether inhibits by direct action the sensory and motor nerve endings, being a
weak local anesthetic and relaxant of voluntary muscle.
Irritant Action of Ether on Skin, Mucous and Serous Surfaces. — Ether pro-
duces a sense of intense smarting on thin skin, such as that of the scrotum, and
on mucous membranes, but incites no lasting inflammatory reaction. On the
conjunctiva liquid ether causes inflammation only when held long in contact.
The so-called "ether eye" is usually of traumatic or infective origin. In the
gastro-mtestinal tract liquid ether produces a sense of warmth and tenesmus.
Ether, 75 per cent, in oil, produces in the colon slight immediate stimulation,
but exerts no lasting irritation or inflammation. On the peritoneum and other
serous surfaces liquid ether induces neither acute inflammation nor adhesions.
In the respiratory tract ether vapor in therapeutic dosage is a mild stimulant.
At a vapor pressure of 30 mm., i. e., 4 per cent, by volume or 10 per cent, by
weight of ether to air at sea level, ether vapor has so little pungency as to be
scarcely noticed except for odor. Six per cent, by volume exerts slight stimula-
tion on the larynx. (This is the mixture with which full surgical anesthesia
74 SUKGICAL ANESTHESIA
finally becomes established and may be maintained for many hours.) On first
inhaling the vapor mixture 7 per cent, causes coughing, but soon becomes un-
noticed. From this percentage upward the vapor grows more stimulating. At
9 per cent, a cough is scarcely to be restrained on first inhaling the vapor, and
higher percentages cause secretion of mucus, particularly in the light stages of
anesthesia. Fully conscious, man cannot breathe stronger vapor without a sense
of strangulation, except by gradually accustoming the mucous membrane to the
vapor. With the gradual onset of general anesthesia the vapor may be increased
to about 25 per cent, by volume, or a partial vapor pressure of 190 mm., without
evidence of laryngeal or bronchial irritation other than slight excess of mucous
secretion. This is the strongest vapor required for induction of anesthesia.
Vapor above 25 per cent, by volume up to 60 per cent. (i. e., saturation) exerts
an asphyxial effect and may rapidly overpower the respiratory center, yet even
in this strength there is no lasting irritation in the respiratory tract.
Effects of Ether on Body Function. — RESPIEATION. — Ether increases the
depth and frequency of respiratory movement up to the stage of deep surgical
anesthesia. On overdosage gradually the respiratory center succumbs, the
respiration grows more and more shallow, finally its rate decreases, and the
patient may die of respiratory failure.
HEART ACTION. — The heart is stimulated in force and frequency. The rate
is increased 10 to 20 beats per minute. With any respiratory insufficiency the
rate rises and the force is diminished. The heart succumbs to overdosage some
minutes after the respiratory center. But with artificial respiration by insuffla-
tion, the heart beat may continue for an hour or more on dosage which has
caused cessation of respiratory movement.
BLOOD PEESSUEE. — The blood pressure rises about 20 mm. in the initial
stage of anesthesia, then slowly drops, reaching the normal in 1 or 2 hours.
Embarrassment of respiration by blockage of the upper air passage, also the
trauma of an operative procedure improperly correlated to the depth of anes-
thesia, cause a transitory rise, followed by a sharp fall of blood pressure.
Chilling, loss of blood, and overdosage of anesthetic cause a progressive fall of
blood pressure during ether anesthesia. From overdosage of ether the pressure
almost completely regains the original level within 5 to 10 minutes after the
excessive dosage ceases. The fall of pressure from trauma, hemorrhage and
chilling is regained much more slowly. From these depressants, the blood
pressure is sustained far better under ether than under chloroform, though not
so well as under nitrous oxid.
SENSOEIUM.— Ether like alcohol affects first the most highly coordinated
senses. First, reason, judgment and will are suspended, and the patient be-
comes exhilarated and excited. Much of this excitation is due to the local stimu-
lation of ether in the respiratory tract. The pure ether effect, as seen in in-
travenous injection of the dose, is induction of narcosis with very little excite-
ment. A certain degree of general analgesia is induced even before conscious-
ness is lost.
GENERAL ANESTHESIA 75
Next in order, consciousness is suspended and the patient passes into a
subconscious or automatic state, wherein he is amenable to suggestion. The
auditory, tactile and muscular senses continue for a time. Slight to violent
subconscious excitement is passed through, dependent on the resistance of the
individual toward the ethyl radical and the external impressions which the
subconscious patient receives.
Next in order, the lower centers are inhibited so that auditory impressions,
tactile and muscular sense, and all motion except the reflexes are suspended.
The entire cortical function is now abolished and the deepening anesthesia con-
tinues progressively to desensitize the basal and spinal centers down to the great
primitive vital centers in the medulla.
Excretion of Ether. — Ether is chiefly excreted by physical diffusion into the
alveolar air, a small amount is oxidized in the body. Owing to the physical
affinity for fat, the fats and lipoids tenaciously hold a trace of ether so that
excretion continues on the breath for as long as 36 hours.
CLINICAL COURSE OF ETHER ANESTHESIA
First Stage or the Stage of Conscious Excitement : The Period of Cortical Dis-
association. — This stage begins with the first respiratory stimulus of the
pungent rather disagreeable odor of ether. If this odor be masked by oil of
orange and the administration be gradually and cautiously increased, there is
little noticeable respiratory irritation. With rapid administration there is a
sense of suffocation, repeated closure of the glottis, holding of the breath,
cough, and repeated swallowing.
Soon the respiration becomes rhythmical and deeper and quicker than
normal, and the skin is slightly flushed and the pulse accelerated. The patient
becomes mentally confused and verbal response becomes progressively more
incoherent. By proper suggestion on the part of the anesthetist, the patient
remains quiet and reassured. Disturbances of the special senses are common.
All skin reactions are present. The pupil is dilated and mobile. Loss of con-
sciousness takes place abruptly, usually in about 2 minutes.
Second Stage or the Stage of Involuntary Excitement: The Period of Sub-
conscious Disassociation. — Memory and intelligent volition are lost. The pa-
tient responds to the stimulation of external environment. If the ether be
crowded the breath is held and respiration becomes thereafter irregular.
Laughing, shouting, and struggling may be met with, usually in those patients
who from alcoholic or other narcotic habits have acquired such association with
this stage of anesthesia.
This involuntary excitement may be much diminished by proper suggestion
by the anesthetist through the auditory center. If restraint be necessary, this
is first exercised by full-toned verbal suggestion, for example, that the patient
cannot move, later by physically misdirecting any physical effort of the sub-
conscious patient. Rarely is direct force needed to oppose those efforts which
76 SUEGICAL ANESTHESIA
the patient may make to escape from the subconscious hallucinations of this
stage.
The pupil continues mobile, tends to be large and may be irregular. The
voluntary muscles are held stiffly, occasionally in tonic spasm or in clonic
tremor. The secretion of tears, mucus and saliva is stimulated. The skin
grows more flushed and moistened with perspiration. Breathing tends to be-
come irregular from such obstruction as clenching of the jaw, movements of
the tongue and of the pharynx in repeated acts of swallowing, also by stiffen-
ing of the general musculature. Then comes a gradually increasing stertor, the
muscles relax, the breathing becomes regular. Those paths from the subcon-
scious mind which may stimulate or inhibit the medullary and spinal centers
are broken, and the patient passes into the third stage of anesthesia.
Third Stage or Stage of Surgical Anesthesia: The Period of Basal and Spinal
Disassociation. — With the onset of stertor and the simultaneous general muscu-
lar relaxation, the stage for surgical operation has been reached. This requires
usually in the average adult not less than 8 minutes. The more smoothly and
quietly anesthesia has been induced the better the subsequent status of anes-
thesia. Gradually the superficial reflexes have been abolished, the cornea be-
comes insensitive. The pupil is usually moderately dilated, is sluggish or im-
mobile in reaction to light. The respirations are usually about 30 to 40 per
minute and of increased amplitude. Soft stertor of the relaxed pharyngeal
structures is constantly to be heard, unless the upper airway be kept effectively
open by extending the head and carrying the jaw forward. Marked stertor
should never be allowed.
When operative trauma is occasioned on some richly endowed sympathetic
area the respiration grows rapid, forceful and noisy. This is always an indi-
cation that the depth of anesthesia is too light for that particular trauma, and
the trauma should be immediately suspended and the anesthesia should be
deepened.
The circulation is not impaired in this stage by the anesthetic. In fact, for
several hours the pulse is of slightly increased or of normal force. The pulse
grows more rapid and feeble, first and foremost from embarrassed respiration
and partial asphyxia, usually from obstruction in the oral nasopharyngeal por-
tion of the airway ; second, after an initial stage of excitation, by those opera-
tive stimuli which cause the foregoing respiratory increase. These stimuli
may be effectually blocked by proper depth of anesthesia. Therefore, the anes-
thetist must know the tissues and operative procedure which give rise to these
trauma stimuli and gauge the required depth of the anesthesia accordingly.
Another factor in the depression of the circulation is exposure of the body to
refrigeration by surface evaporation. To this the patient under full anesthesia
is particularly liable because of the flushed moist skin. The last factor, and
the one of prime importance, is hemorrhage, the prevention of which is not in
the province of the anesthetist.
Through this stage the one best guide of the depth of anesthesia is the
GENERAL ANESTHESIA 77
breathing. Administration of ether should be continuous but graded accord-
ing to the necessity. If on minimal dosage the breathing becomes shallow with
an occasional deep breath, the patient is dropping into the subconscious zone,
and in a moment will reach the level of the vomiting center.
If on full dosage the breathing is becoming shallow, especially if accom-
panied by slight cyanosis, the patient is being over-anesthetized. Any marked
response of respiration and pulse to the momentary stimulus of operative
trauma indicates too light a degree of anesthesia. Unless asphyxia enters as a
factor, the margin of safety under ether is very wide in this stage.
The entire progress of administration may be governed by the quality of
respiration and the color of the skin and mucous membranes. The pulse, the
corneal reflex and reaction of the pupil are secondary guides. In the deep
stage the cornea is insensitive. For lighter degrees of anesthesia the reflex
coiitracture of the palpebral muscles is elicited on lightly touching the cornea
with the finger tip. In the subconscious zone stroking the edge of the upper lid
suffices to elicit the above tarsal reflex. In the light subconscious zone the
musculature of the other eyelid also reacts and the level of vomiting center has
been unblocked. These reflexes tire out easily and should not be called into
repeated action by the anesthetist.
Fourth Stage or Stage of Overdosage : The Period of Medullary Disassociation.
—In this stage the great vital centers which in the previous stage were par-
tially or completely disassociated from reflex outside stimuli now begin to be
intrinsically desensitized. The first of the 3 great centers affected is the
respiratory. This loses its normal sensitiveness to carbon dioxid and the stimu-
lating influence of asphyxia. The respiration grows shallow and with an in-
effectual quick inspiratory gasp. It may even become of Cheyne-Stokes type.
The skin and mucous membranes grow pale with a cyanotic tinge and the pulse
becomes more rapid. Blood pressure gradually falls.
At the same time or slightly before this stage the pupil becomes dilated
and fixed and the cornea entirely insensitive. The tension of the eyeball lessens.
If the condition be not relieved by suspension of dosage with effective ventila-
tion of the lungs, the patient will die of respiratory failure.
This stage may come on gradually by slight overdosage, i. e., above 90 mm.
of ether vapor pressure, or may come on rather abruptly by profound over-
dosage, i. e., above 210 mm. This sudden overdosage may occur even in the
second stage of anesthesia, by the inhalation, in the period of involuntary ex-
citement, of excessive concentration of ether vapor. From the sudden over-
dosage of the medullary centers during the induction period, the respiratory
center rights itself as soon as venous blood ceases to be overcharged by the pres-
sure of ether in the alveolar air. Usually this recovery is a matter of 30 sec-
onds to 2 minutes. However, from the overdosage wherein the body as a whole
has been gradually brought to overtension over a long period of anesthesia,
the respiratory center may require 5 to 10 minutes of ether excretion, through
artificial ventilation of the lungs, to again resume effective automatic action.
78 SUKGICAL ANESTHESIA
The symptoms of overdosage may be precipitated by asphyxia, usually
from high obstructive blockage in the upper air passage. With asphyxia, par-
ticularly that of gradual onset, the circulatory centers are rapidly depressed.
Ether, itself, is relatively non-toxic to the circulatory mechanism.
Fifth Stage or the Stage of Eecovery: The Period of Inverse Reassociation.
— The various levels of the nervous activity are resumed inversely to the order
in which they are lost. The respiratory and cardiac centers again begin to be
influenced by operative trauma. Kespiration becomes more shallow and quiet,
the pulse becomes slightly less frequent, blood pressure is lowered, reaction by
the pupil to light returns and the cornea regains its sensitiveness. Slight
lacrimation is present and the lid reflex reappears. In about 10 minutes, after
an hour of full even anesthesia the vomiting center is reached and any stimu-
lation to the pharynx or operative irritation of the abdominal contents usually
results in subconscious vomiting. If there be no such stimulation and if the
ether has been evenly administered without repeatedly dropping from full
anesthesia into the subconscious zone, vomiting is less common.
Next the patient responds to auditory and visual stimuli in a dull drunken
way, but after being roused soon relapses into a narcotic sleep. The awakening
of consciousness and memory is usually abrupt. The patient suddenly asso-
ciates himself consciously with his surroundings and if of well-trained mind he
takes command over his confused mentality.
The tendency to somnolence usually continues, but there may be marked
excitement. There is partial analgesia which lasts for 2 to 3 hours. Mental
and physical lassitude may last many hours. There may be headache. Con-
scious vomiting, as a physiological effect of ether, is the exception rather than
the rule. It is present most frequently as a complication of intra-abdominal
manipulation and occurs with irregular dosage of ether, and with that asso-
ciated with partial asphyxia of the rebreathing methods of administration,
and with asphyxia resultant from poorly maintained upper airway during
anesthetization and early in the stage of recovery.
THEORETICAL CONSIDERATION OF THE ADMINISTRATION OF ETHER
Introduction. — To induce ether anesthesia smoothly and carry the patient
safely through, at proper depth for the operation in hand, the theory as well
as the practice of ether administration must be understood. Theoretical con-
siderations must of necessity be first expressed in scientific terms and applied
later to the various empiric methods of administration. By this application,
the art of crude anesthetization becomes standardized, and a definitely formu-
lated, intelligent procedure. The data herein tabulated have been made avail-
able by an accurate mixing and measuring apparatus, the anesthetometer.
Ether is commonly introduced as a vapor with the inspired air into the
respiratory tract. By diffusion throughout the lung and into the blood, thence
into the neuron, a sufficient amount of ether accumulates in the central nervous
GENERAL ANESTHESIA T9
tissue to establish a state of general anesthesia. Ether diffuses to the nerve cells
and is held therein by a driving force known as vapor tension, scientifically ex-
pressed in millimeters of mercury pressure. Thus, to establish and maintain
full surgical anesthesia, the blood flowing past the neuron must contain con-
stantly about 14 per cent, of ether, or, in tension, 50 mm. of ether, resulting
in over 0.6 per cent, of ether accumulating at that tension in the central
nervous system. The nervous system, due to its generous supply of blood,
rises and falls in ether content much more rapidly than the rest of the body
in response to varying ether pressure in the lungs. The general body, particu-
larly the subcutaneous fat, being less freely bathed in ether-charged blood than
is the central nervous system, comes to tension less rapidly and excretes ether
more slowly. Thus the general body acts as a governor on the changes in depth
of anesthesia ; it is a reservoir above which the central nervous system may rise
or below which it may be depleted in ether content, depending on the relative
percentage of ether vapor (expressed as vapor pressure) maintained in the air
of the pulmonary alveoli.
Details of Induction. — The objective in induction is to bring the central
nervous system to full anesthetic tension as rapidly and smoothly as possible.
Forty-eight to 55 mm. is the tension required by all animals to disassociate
entirely the cerebral cortex, including consciousness, motor power and sensory
perception and as well to disassociate completely the reflexes of the spinal cord
that have to do with pain and touch stimuli, and abolish the reflex tonicity of
voluntary muscle.
The ideal curve of ether vapor pressure to be maintained in the tidal air is
shown in Figure 13. To induce full anesthesia this curve must be followed
approximately no matter how crudely and unintelligent^ the anesthetic may
be given. The more evenly and intelligently the curve can be followed, the
better the anesthesia and less undesirable the immediate and after-effects of
ether anesthesia and of operative trauma. The curve differs in various physical
types of man only in the time required to induce anesthesia and arrive at
equilibrium. The depth of anesthesia established at any given level of dosage
is equal for child and adult.
For induction the vapor may be started at about 4 per cent, or 30 mm. of
vapor pressure. Inhalation of a few breaths at this dosage accustoms the
mucous membrane to ether and carries the sensorium so far into anesthesia
that successively stronger vapor may be inhaled without irritation, until within
a few minutes the strongest vapor is reached. High percentages (16 to 24
per cent, by volume) are necessary for induction, since the venous blood in the
early stage of anesthesia returns to the lung with little ether, having been largely
depleted of ether in the capillary network of the body. Only by high percent-
age of vapor in the pulmonary air can the arterial blood be recharged con-
stantly to proper anesthetic tension and the central nervous system reduced
to a state of quiet anesthesia within reasonable time. If the tidal volume in-
haled be relatively large, and the state of consciousness readily subdued, as in
80 SUKGICAL ANESTHESIA
a young child, or if administration be continued for upward of 15 minutes the
vapor pressure need not rise above 120 mm. or 16 per cent. In fact, if the
individual be in preliminary narcosis from nitrous-oxid-oxygen or other light
anesthetic, the ether vapor need not exceed 90 mm. or 12 per cent. If, on the
other hand, the tidal volume be small, due to the subconscious control which
certain individuals hold over the respiratory center through the first 3 zones of
etherization, or if the absorptive capacity of the lung be relatively small, as
460""" - SATURATION 6 22°C __
180""
ISO""1
120 »*•
90m*
75 •••
50mm
3Omm
ASPHYXIAL INDUCTION ZONE
RAPID AND DANGEROUS
ZONE FOR RESISTANT SUBJECTS
RAPID INDUCTION*
RELAXATION
IN 7-10 MIN.
SLOW INDUCTION
RELAXATION
IN 12-15 MIN.
(IRRITATION, MUCOUS
SUBCONSCIOUS EXCITEMENT
INDUCTION
FUI*. SURGICAL
I MANY n CPUR_a_
''ANAESTHESIA
Fio. 13. — VAPOR PRESSURE OF ETHER IN TIDAL AIR FOR INDUCTION AND MAINTENANCE OF FULL ANES-
THESIA. Partial pressure of vapor in millimeters of mercury.
in stout people, the vapor for the prompt establishment of surgical anesthesia
must be carried momentarily to 210 mm. or 28 per cent.
This group of cases is exemplified by athletic subjects and those who
have been so adapted to light habitual narcosis, by alcohol, ether, tobacco,
morphin, cocain, chloral and other narcotics, as to be unusually resistant to
narcotic disassociation of the subconscious centers from that of respiration.
When at last these resistant low association paths are broken, then the most
robust alcoholic remains in the same degree of anesthesia on the 50 mm. level
as the young child.
The surgical operative procedure may be started at the peak of the induc-
tion curve (Fig. 13), but to protect fully the nervous system from reflex
stimuli it is best to wait until relaxation has become complete, and the vapor
pressure in the tidal air has been lowered to 90 mm. This induction period
may total 3 minutes in the young child up to 15 minutes in the robust alcoholic.
Establishment of Anesthetic Tension. — The time and sequence of the various
body tissues in reaching equilibrium are shown in the accompanying chart
GENERA! ANESTHESIA
81
(Fig. 14). After the induction period, the general body tension as averaged by
the venous blood gradually rises, until at the end of the establishment period
the entire body is in equilibrium. This takes about 10 minutes in the young
child up to 40 or even 60 minutes in a large robust individual.
Stage of Recovery. — The excretion time and sequence in loss of ether by the
various tissues after the administration of ether has ceased are shown in Figure
15. When the breathing is full and the excretion of ether is uninterrupted,
the nervous system drops into light anesthesia in about 3 minutes, and into
I2O- 180
5Om
ANAESTHETIC EQUILIBRIUM
gOm m ESTABUSHE D AT 5O m m
Qmm
TIME
AVERAGE ADULT
PERIQD < INDUCTION
ESTABLISHMENT
CONTINUANCE
FIG. 14. — PLOT OF ETHER VAPOR PRESSURE IN PULMONARY TIDAL AIR AND ETHER TENSION IN BODY
IN FIRST HOUR OP IDEAL ANESTHESIA.
the subconscious state in about 8 minutes. Usually in about 12 minutes the
lower level of the subconscious zone (see page 83) is reached and the vomiting
center may recover and subconscious vomiting ensue.
The light subconscious zone is entered in about 15 minutes and the zone
of confusion in about 30 minutes. From the low ether tension of this zone
recovery is gradual, since the fats of the body yield to the blood the last traces
of ether very slowly. If at any time the tidal volume of respiration be ob-
structed, excretion of ether ceases from the venous blood and the patient re-
lapses into deeper anesthesia.
If the administration of ether ceases before the entire body is saturated to
full anesthetic tension, recovery is rapid, since the nervous system, gaining or
losing ether rapidly, soon balances with and then drops below the general ten-
sion of the body. Thus, within 3 minutes after short full anesthesia, the
tension of ether in the nervous system may have dropped low into the zone of
confusion and the patient be fully conscious.
7
82
SUEGICAL ANESTHESIA
Zones of Anesthesia. — The depth of anesthesia is governed by the tension of
ether established in the central nervous system. This tension is dependent on
ether diffusing according to the vapor pressure maintained in the tidal air,
either to or from the nerve tissue through various intermediate media, until
a balance is finally established. The zones of ether dosage at which the various
phenomena of ether intoxication become persistent are given by Figure 16.
These zones have been established and the utility determined by me on about
3,000 cases at the Koosevelt Hospital, and by confirmatory findings on the dog.
omm
TIME
FIG. 15. — PLOT OF ETHER TENSION IN BODY. Recovery stage after full ether anesthesia.
No variation has been observed between adult and child, between strong and
weak, except the time required and difficulty of bringing the subject to equi-
librium in balanced vapor tension.
Phenomena and Utility of the Zones of Ether Anesthesia. — ZONE 1: THE
ZONE OF CONFUSION (0 to 15 mm. of ether vapor tension). — Reason, judg-
ment and will are much clouded, there is mental confusion and a tendency
first to exhilaration, later to somnolence. Moderate analgesia is present. The
mind is open to suggestion.
This zone is useful to produce stimulation, confusion, and analgesia on very
ill cases in which some minor procedure such as thoracotomy for empyema must
be performed, and where it is desirable to retain consciousness and the ability
to move and cough at command of the surgeon. The analgesic action of local
anesthetics is much heightened in this zone. With magnesium sulphate ad-
ministered as a general anesthetic, a dangerous anesthetic action is developed.
ZONE 2: THE LIGHT SUBCONSCIOUS ZONE (15 to 25 mm.). — In this zone,
as in zone 1, the reflexes are active, but the anesthetist is no longer able to con-
trol the mentality of the patient. The patient responds to stimuli by subcon-
scious movements. Sweat, lacrimal, salivary and mucous secretions are exces-
sive. At the top of this zone and at the bottom of zone 3 the vomiting center
is stimulated. Superficial anesthesia is present.
GENEKAL ANESTHESIA
83
This zone is useful to supplement those local anesthetics such as nitrous
oxid which are intrinsically light. For this purpose it is the more desirable,
since the vomiting center is not stimulated.
ZONE 3: THE SUBCONSCIOUS ZONE (25 to 35 mm.).— The reflexes are less
active, complete anesthesia of the lighter grade is present. Severe stimuli such
as trauma to nerve trunks, to peritoneal and visceral surface, cause active stimu-
lation of respiration and circulation followed by depression.
LEVEL OF NERVE
CENTRE DISASSOCIATION
DEPTH OF
ANAESTHESIA
ASPHTXIAL
AND LETWAl
FOR TRACTON ON THE
MESENTERY AND BILE TRACTS
DEPRESSION OFRESPIRATORY CENTER H
OOMlNAL
THORACIC AND
| SPINAL REFLEXES
REFLEX
PKARYN&EAl. REFLEXES
HERNIA
AMPUTATION OP BREAST ETC
JwvSmp - |UD R£FLEX
fesaei^sys!
PLASTIC AND OTHER
SUPERFICIAL OPERATIONS.
SUBCONSCIOUS
ANAESTHESIA
• INCISION OF ABSCESS
REDUCTION OF FRACTURE
SUPPLEMENT Of LOCAL ANA ESTHETIC
AND NITROUS OXIDE
SUBCONSCIOUS
ANALGESIA
| CONSCIOUSNESS
I CO-ORDINATE' THOUGHT
IHIGHLY CO-ORDINATE THOUGHT
CONSCIOUS
ANALGCStA
SUPPLEMENT OF
LOCAL A>; AESTHETIC
FIG. 16. — ZONES OF ETHER ANESTHESIA.
This is the proper zone in which to establish anesthesia for merely super-
ficial plastic work and where it is desired to maintain at the same time complete
loss of consciousness, together with the presence of such reflexes as induce cough.
The top of this zone gives the same degree of anesthesia with greater safety than
is present in full nitrous oxid anesthesia.
ZONE 4: THE ZONE OF LIGHT SURGICAL ANESTHESIA (35 to 48 mm.).—
Superficial reflexes are abolished. The pupillary reflex is sluggish, the anal
reflex is present. Severe operative stimuli are still responded to by reflex
muscular rigidity and other reflex action.
This zone is useful for all superficial operations where full muscular relaxa-
tion is not necessary, such as amputation of the breast, hernia, and intraperi-
toneal work where no visceral traction is made*
ZONE 5: THE ZONE OF FULL ANESTHESIA (48 to 55 mm.). — All super-
ficial reflexes are lost and deep reflexes are much blunted; the pupil is mod-
erately dilated, the muscles are completely relaxed, there is no evidence of
nervous stimulation or shock by such degree of trauma as the stretching of
muscle. The respiratory center begins to be depressed toward the top of this
84 SUEGICAL ANESTHESIA
zone, but is in no danger, unless asphyxia by respiratory obstruction be superim-
posed on the ether anesthesia.
This is the surgically ideal and physiologically advantageous zone for all
operative procedures wherein full muscular relaxation and blockage against
fairly severe traumatic stimuli are required. It is the zone for cranial, thoracic,
abdominal, and joint surgery.
ZONE 6: THE ZONE OF DEEP ANESTHESIA (55 to TO mm.). — All reflexes
are lost, muscular relaxation is complete, the pupil is moderately dilated and
immobile to light, breathing is of lessened frequency and amplitude, blood pres-
sure is slightly lowered, and the heart rate increased. Keaction to severe
trauma such as pulling on the mesentery and the biliary tracts and section of
nerve trunks is very slight.
The anesthetist carries the patient into this zone only at such stage of opera-
tion as induces profound vasomotor stimuli ; stimuli which may ultimately result
in splanchnic paralysis or other form of shock ; such stimuli as traction on the
mesentery and on the biliary tracts, operation on the heart, on nerve trunks, and
on sensitized joint structures. Thus the anesthetist temporarily deepens
anesthesia to the most advantageous degree in correlation with the require-
ments of the operative procedure. The respiratory center may become danger-
ously depressed if any degree of asphyxia be superimposed on the ether
anesthesia.
ZONE 7: THE ZONE OF PBOFOUND ANESTHESIA (70 to 90 mm.). — Ees-
piration becomes shallow and gasping, or Cheyne- Stokes, in type, the skin cold,
pale, and slightly cyanotic; the circulation fails in proportion to the degree of
slow asphyxia ; blood pressure falls 30 to 60 mm., and the pulse becomes rapid.
At the top of this zone the respiratory center fails, but life may be continued
by artificial respiration.
This zone is not useful on account of the danger of respiratory failure and
circulatory depression. When the above noted symptoms present as a result of
overdosage the patient is dropped to a lower zone by decreasing or stopping
momentarily the administration of ether.
The following zones have been deduced from the action on human subjects of
strong ether vapor in variously determining the proper dosage for inducing
anesthesia. The danger symptoms have been only momentary on the human
subject, but the zones have been more definitely established on the dog.
ZONE 8: THE SLOWLY LETHAL ZONE (90 to 210 mm.). — Death occurs
from respiratory failure probably requiring in man on the higher percentage
at least 10 minutes and usually 15 to 30 minutes. If life be continued for a
while by artificial respiration and dosage be continued death is resultant from
circulatory collapse. In the lower levels of this zone life may be carried on for
some hours by intratracheal insufflation, with the respiratory center entirely
paralyzed.
ZONE 9: THE EAPIDLY LETHAL ZONE (210 to 460 mm.).— This zone
may be entered rapidly during light anesthesia by suddenly breathing highly
GENERAL ANESTHESIA 85
concentrated vapors, i. e., above 28 per cent, by volume. Irregular respiration
and slight cyanosis are first noticed. The pupil soon dilates and becomes immo-
bile, the respiration and circulation diminish, cyanosis becomes more marked,
and the patient may die of respiratory failure. Usually when this zone is thus
rapidly entered by the respiratory center the body in general has not yet been
saturated with ether and the circulation of blood and irritability of protoplasm,
except in the nervous system, remain active for many minutes. After such short
overwhelming dosage, on withdrawal of the anesthetic, the respiratory 'center
rapidly balances with the general body tension and respiration is resumed.
Were the tension in this zone fully established death would be inevitable.
GENERAL TECHNIC OF THE ADMINISTRATION OF ETHER
Introduction. — Ether for pulmonary absorption may be delivered by the
open method: First, by a succession of drops onto gauze stretched over an open
mask — drop method; second, by intermittently pouring small quantities into an
open cone — open cone method. The vapor may be trapped on exhalation in a
closed bag and rebreathed wholly or in part — closed method. Or the liquid
ether may be volatilized at a distance and delivered into an open or closed
face mask, blown into the nostrils or mouth, or directly into the pharynx or
trachea — vapor method — nasal, mouth, pharyngeal, and intratracheal insuf-
flation.
For induction, as in all anesthesia, the environment should be quiet and
cheerful. The anesthetist should see that there are no loose foreign bodies in
the mouth. A sympathetic psychic control of the patient should be secured
by the anesthetist. The patient should be chatted with, reassured, and
distracted from the procedure in hand. As induction proceeds helpful sug-
gestions by the anesthetist may be made to the patient as to breathing
and quietude.
Open Methods.— ADMINISTRATION BY SUCCESSIVE DROPS: DROP METHOD.
— APPARATUS. — A large wire mask of the modified Esmarch, Clayton, or Mayo
type is covered with from 10 to 16 layers of gauze. (The object of many layers
of gauze is to multiply the surface from which ether may vaporize. When
gauze becomes cold and moist the proper vapor tension cannot be maintained
from a small surface. Induction of anesthesia is difficult with less than 8 layers
of gauze. )
TECHNIC. — The eyes may be covered by a moist boric pad overlain by a
strip of gutta-percha tissue. The mask is held loosely in front of the patient's
face, and a few drops of ether are added until the patient becomes accustomed
to the odor. Any pleasant odor which will at first overpower that of ether is
advantageous, such as is obtained by adding a few drops of essence of orange,
as suggested by Gwathmey. When the patient has become accustomed to the
local stimulation of ether the rate at which the ether is dropped is increased.
For the first minute about a drop a second suffices ; this establishes in the tidal
86 SURGICAL ANESTHESIA
air of the average adult a pressure of about 20 to 30 mm. The rate is now
increased to about 2 drops per second.
Gradually the mask is securely seated against the patient's face, and is en-
veloped by degrees in the folds of a towel, which forms a tight joint round the
edge of the mask, and dams back the downward flow of the heavy, gradually
increasing ether vapor. The respirations are watched and the ether dosage
governed accordingly. The rate of the ether drop is gradually increased so
long as the respiration keeps smooth and regular up to about 4 drops per second.
At this level a vapor pressure of from 80 to 100 mm. is established in the
average case. Within 3 minutes the patient passes into the stage of subconscious
excitement. The enveloping towel must now be more closely adjusted so as to
also cover the top of the mask. The liquid ether is now added more rapidly in 1
to 2 dram amounts at sufficient intervals to keep the gauze thoroughly impreg-
nated. By thus gradually increasing the vapor at first and then rapidly running
the pressure up to the full vaporizing capacity of the open mask anesthesia may
be induced without disturbing the respiratory rhythm by other than a few halts
and quickenings of the rate, and possibly by a warning cough during over-
stimulation.
Difficulty in inducing anesthesia arises when the early dosage is so irritant
as to cause coughing, light breathing, or holding of the breath. With skilful
administration the peak of the delivery should be reached in 6 minutes and then
slightly decreased until stertor and relaxation appear, whereupon the dose may
be gradually lowered to about 2 or 3 drops per second. On this level administra-
tion must usually be continued for the next 20 minutes.
Finally a level is reached at which a slow succession of drops carries the
patient to full surgical anesthesia for many hours. It is difficult to lay down
a definite formula, since many factors enter, such as the tidal volume, and the
amount of ether wastage on expiration, and by extraneous air currents. Tech-
nically speaking, this level is such as establishes and maintains in the tidal air
a vapor pressure of 50 mm. Without wastage this would require about 11
medium-sized drops of ether per liter of air inspired, or in the average breathing
somewhat in excess of a drop per second (about 2 grams of ether per minute).
The patient should be held continuously on a level that is neither light nor
profound.
DROP METHOD IN CHILDREN. — During induction of anesthesia the young
child exercises no measurable control over mind and body as does the adult.
To gradually induce ether anesthesia prolongs the period of excitement. There-
fore one must start with such dosage as will rapidly overwhelm the conscious-
ness. The mask is immediately saturated and seated. After a moment of hold-
ing the breath the child cries, and within 4 to 6 inspirations has established
such tension in the arterial blood and neurons as to have lost consciousness. The
tension may rapidly become overpowering, hence the dosage must be lessened
within a minute and an occasional breath of air allowed. Full anesthesia is
reached within 4 minutes. The dosage is now lessened. Gradually the entire
GENERAL ANESTHESIA 87
blood stream and body is brought to full anesthetic tension of about 50 mm.
This requires in the very young child about 6 minutes as against 40 to -60
minutes in the adult. Thereafter a continuous level is established, on which
anesthesia may be maintained for hours. This level for the child is the same as
for the adult, but owing to the dissimilar tidal volume of air the amount of
ether used is proportionately less, and finally 10 drops a minute may suffice.
The liability to overdosage is greater in children than in the adult because of
the greater proportional respiratory absorptive surface and smaller reservoir
capacity of blood and fat.
ADMINISTRATION BY POUEING OF SMALL PORTIONS: OPEN CONE
METHOD.- — This differs from the drop method in that the ether is added to the
mask intermittently, and the face is more muffled. Vaporization is governed by
the extent of vaporizing surface, the movement of air over that surface, and the
vapor tension of ether as lowered by refrigeration and by water condensation.
Fortunately refrigeration so lowers the vapor tension of ether that even if an
excess of ether be added an approximately correct percentage of ether for induc-
tion of anesthesia is established automatically. Lower percentages of ether are
obtained in a very irregular manner by increasing the interval and decreasing
the amount at each pouring.
APPARATUS AND TECHNIC. — The cone may be made of folded newspaper,
of a butcher's cuff, or of metal (Allis inhaler). The mask usually selected is a
newspaper cone, enveloped in a folded towel. Into this is packed a half yard of
gauze as an ether reservoir.
Induction is begun by pouring on the gauze, first a few drops as in the drop
method, then a dram, and, finally, toward the peak of the delivery curve at the
end of 3 minutes, an amount of ether 2 to 4 drams at a time, keeping the gauze
continuously moistened. Gradually the amount is lessened, and the interval
between the moistening of the gauze is increased until there may be an interval
of 5 minutes between doses, 2 to 4 drams at each dose. This is a rough proce-
dure, requiring the least skill of all methods, but yielding sufficient anesthesia
for a short operation, such as the reduction of a fracture. The greatest objection
to the method as applied to prolonged operation is the irregularity with which
anesthesia is maintained. Next to the closed or rebreathing method the open
cone has been the most widely used and disadvantageous method of ether admin-
istration.
Closed Method. — Where the exhaled tidal volume is trapped and rebreathed
the method is spoken of as a closed method. Any open cone method traps the
exhalation to some slight extent, but the closed method traps the exhalation in
larger part. Thereby the vapor pressure of ether is kept up by small additions
of fresh ether, also a small amount of heat and moisture is conserved, any de-
sired degree of asphyxia may be induced, and carbon dioxid and other waste
products are retained at will.
The method is the least desirable of any method of ether administration.
To avoid a sinister degree of asphyxia, of exaggerated respiration, and the
88 SUKGICAL ANESTHESIA
aspiration of retained mucus and saliva in refractory subjects the anesthetist
milst be highly skilled.
APPARATUS AND TECHNIC. — The Ormsby and Hewitt apparatus may be
mentioned as early types. The Bennett apparatus is the preferable type. For
induction with this apparatus nitrous oxid is usually employed as an adjuvant
(see page 103). With ether alone the breathing bag is partly inflated, a few
drops of ether are poured into the reservoir, and the mask lightly seated.
Gradually the ether dosage is increased by the intermittent pouring of small por-
tions. After a minute or two an air vent is opened, through which portions
of the respired gases are exhausted and renewed. Thus the air may be re-
freshed and the percentage of ether controlled in a crude measure.
Vapor Methods. — INTRODUCTION. — In all vapor methods the ether is evap-
orated at a distance from the patient by the passage of a current of air or other
respirable gas over or through the anesthetic.
For the induction of anesthesia the vapor must be delivered into a closed or
open-face inhaler. After anesthesia has been secured the vapor may be blown
into the nose or mouth; but preferably it is insufflated into the pharynx or
trachea. The vapor may be concentrated and small in amount and be diluted
in the respiratory tract by the inhaled air; or, preferably, it may be of such
dilution as to furnish, in a volume of air sufficient for respiration, the minimal
concentration of ether vapor necessary to induce and maintain anesthesia.
The special advantages of the vapor method are: first, that with a given
apparatus, no matter how crude, ether dosage is more constant and controllable
than by either the open or closed methods; second, a considerable amount of
body heat may be conserved by moistening the vapor, and a small amount by
warming the vapor, as is sometimes done; third (and most important), by this
method the bulk of air-vapor mixture may be delivered — for example, into the
pharynx — where it will satisfy air needs in the act of inspiration without undue
respiratory strain, thus eliminating the partial asphyxia which so often is asso-
ciated with the crude methods of administration.
This is in theory and practice the most advantageous of all methods. The
only .object ion to it is that apparatus is needed to impel the air and vaporize
the ether, and that this becomes more complex as one approaches the ideal con-
ditions in which the entire tidal volume of vapor both in bulk and percentage is
accurately measured.
THE NEGATIVE PRESSURE METHODS OF VAPOR DELIVERY.— This
method depends on the negative pressure of inspiration (as, in fact, do all the
preceding open methods) to draw the air over the ether for the purpose of va-
porization. For example, in the Vernon Harcourt inhaler a mask is connected
with an ether chamber through which an adjustable proportion of air may be
drawn for the purpose of impregnation with vapor. This is then sometimes
popularly called the "draw over method."
A simpler procedure advocated by Crile is as follows : After the induction
of full anesthesia 2 No. 22 F. catheters are passed one through each nostril well
GEKEKAL ANESTHESIA 89
into the pharynx — a distance of 12 to 14 cm. from the nares. These catheters
are connected with a funnel, which is covered by gauze, onto which the ether is
poured for vaporization. This procedure is especially applicable when the
operation is on the mouth and the pharynx is packed off. The same procedure
may be used for anesthesia through a tracheotomy wound.
The negative pressure method throws extra strain on the respiratory ap-
paratus and exaggerates the negative pressure in the pharynx, thereby tending
to aspirate mucus and blood into the lungs. It has now largely been aban-
doned for the method depending upon positive pressure.
THE POSITIVE PEESSUEE METHOD OF VAPOE DELIVEEY.— More effec-
tive than the preceding methods is the delivery of vapor under pressure, where
it may become available for inspiration without exaggerated suction effort on
the part of the patient. This may be either intermittent or continuous.
In the intermittent method of vapor delivery a strong vapor is blown by
hand bulb, bellows, or other propulsive apparatus into the nose, mouth, or
pharynx as need arises and is here diluted with inhaled air.
The continuous method of vapor delivery is far better. Either a small quan-
tity of concentrated vapor may be continuously delivered to the patient to be
diluted by his inhaled air or, preferably, the entire required volume of diluted
vapor may be prepared and delivered by propulsive apparatus.
APPARATUS FOR POSITIVE PRESSURE METHODS. — Apparatus to Compress
Air. — For the small quantity of air needed to vaporize and deliver a highly
concentrated mixture a large hand bulb such as is used for an atomizer yields
the necessary 1 to 2 liters of air per minute. A small duplex dental foot bellows
yields by easy pedaling from 8 to 12 liters per minute. Oxygen bubbling from
a tank may also be used as the vehicle to convey the vapor.
For the larger quantities of air needed in insufflation methods a glass-blow-
er's foot bellows, known in commerce as size 9, is convenient (see Fig. 19).
This yields about one liter of air at a stroke, requiring for face mask methods
8 strokes per minute, and for insufflation about 25 strokes per minute. Far
more convenient than this is a portable rotary motor-driven air compressor.
Such an air apparatus is illustrated in Figure 20.
For permanent hospital installation air should be supplied to the operating
room from a central plant. The air should be compressed, washed, and stored
by automatic electric-driven rotary compressor or by steam pump, and delivered
from a wall cock in the operating-room at about 1 pound of pressure, thus avoid-
ing the hum and annoyance of portable apparatus.
Apparatus to Vaporize Ether. — Vaporizer for Concentrated Vapor. — In
order that small quantities of air or oxygen absorb sufficient percentage of vapor
to induce and maintain anesthesia, the gases must be bubbled through liquid
ether. The Gwathmey and Lumbar d apparatus effectively secure this result.
The well known Junker apparatus for chloroform has not the capacity for ether
vaporization.
Vaporizer for Dilute Vapor. — The apparatus must be more capacious to
90 SUKGICAL ANESTHESIA
vaporize the larger total quantity of ether needed to impregnate the air for
insufflation methods. For in these methods, since there is no rebreathing of
exhaled vapor, and the mixture is continuously delivered, about half the mix-
ture is wasted, namely, that portion which is insufflated through the period of
expiration. The total ether vaporized must, therefore, be double that used by
the concentrated method to secure the same physiological effect, or. about 9
ounces an hour.
The types of vaporizers are two : in the first the air passes over a surface
of ether and absorbs what it will, depending on the extent of surface, the rate of
the air flow, and the surface temperature of the ether ; in the second and more
accurate type ether is dropped in known quantity into a chamber and im-
mediately and completely vaporized by an air current passing through this
chamber.
For surface vaporization an area of at least 20 sq. in. is necessary to
evaporate the ether with sufficient rapidity for the induction of anesthesia.
Therefore, air is usually bubbled through a smaller container of ether at this
stage of administration. After anesthesia is fully induced a surface of 4 sq. in.
will suffice to impregnate the air, flowing at the usual rate of 18 liters per min-
ute. Liquid ether is chilled by the evaporation and gradually vaporizes with
less rapidity. To obtain more dilute vapor a portion of the air current is
diverted around the vaporizing chamber, only a portion passing over the sur-
face of the ether. To obtain stronger vapor the ether reservoir is kept at or
about room temperature by a water bath. Such an apparatus may be readily
constructed from a Wolff bottle (see Fig. 21). The Elsberg, Janeway, Boothby,
and Robinson apparatus depend on this principle of evaporation.
A more controllable method, providing the rate of flow is known, is to drop
ether into a chamber and there immediately vaporize it into the air, either by
, dropping it onto a broad bottom or, better, by providing artificial heat, as from
an electric stove. The ether is usually contained in an oil cup from which it
is dropped by regulating the feed cock to control the rate of drop. About 46
drops in the average equal a gram of ether. After anesthesia has been induced
by face mask methods, and it is desired to start insufflation, the ether must be
set dropping at the rate of 4 to 5 drops a second to maintain anesthesia, insuf-
flating at the usual rate of 18 liters per minute. Gradually the rate of the drop
is diminished until after 40 minutes full anesthesia may be continuously main-
tained by a rate somewhat less than two drops per second. The Flint ap-
paratus, also my own vaporizer, a prototype of the following anesthetometer,
depends on this principle of evaporation.
The most accurate, safe, and useful vaporizer, one which automatically
measures the air and ether, and mixes them in any desired percentage, is the
anesthetometer (see page 131).
METHOD OF ADMINISTRATION. TECHNIC OF THE VAPOE METHOD. The
administration of the ether is readily controlled by delivering the vapor mix-
ture into the breathing bag of any closed inhaler. (For closed inhalers, see
GENERAL ANESTHESIA 91
page 115, Nitrous Oxid Anesthesia.) The strength at which the vapor should
be maintained through successive minutes is indicated in Figure 13. The
vaporizing capacity of crude apparatus must be learned empirically and the
strength governed by the reaction of the patient. The quantity of the vapor
mixture for the first 2 minutes should be not less than 3 liters; thereafter at
least from 5 to 8 liters should be supplied each minute. That is enough to fill
the ordinary 2-gallon rubber breathing bag in about 60 seconds.
When by this face mask method the pharynx has relaxed, usually within
from 8 to 12 minutes, the delivery may be changed to pharyngeal insufflation
(see page 95), or, for more effective aeration and for positive pressure, an
intratracheal tube may be introduced when general relaxation is obtained,
usually within from 10 to 15 minutes.
ANESTHESIA BY INTRATRACHEAL INSUFFLATION
Introduction. — A form of insufflation has long been practiced for special
emergencies through a tracheotomy wound and through a tube in the larynx.
Recently, however, Meltzer has devised a precise, safe, and widely applicable
method of insufflation anesthesia which takes an important place among the
modern surgical procedures.
In the Meltzer method the trachea is intubated by a loosely fitting endo-
tracheal catheter. Through this tube ether vapor or other anesthetic is deliv-
ered by positive pressure well into the depths of the trachea, mixed with a
proper volume of air or other respirable gas. The ether-air mixture is the
safest and most efficient and will be exclusively considered here, although
chloroform and nitrous oxid have also been employed in this way.
Primarily this method was designed as a differential pressure method, to
keep the lungs in partial distention when the pleura is opened, and to provide
perfect aeration with minimal thoracic movement during intrathoracic surgery.
A wider scope has now been developed for the method: First, when ob-
struction to the upper air passage is to be anticipated, during the operation
either from posture, such as the lateral or prone position, or from lesions which
encroach upon the trachea and larynx ; second, when the aspiration of blood and
mucus or vomitus is impending, as in operations on the tongue and throat, and
in the vomiting of intestinal obstruction; third, in prolonged operations on
feeble subjects because of the even, full anesthesia, perfect aeration, and the
freedom from respiratory insufficiency and from shock which it secures.
The disadvantages of the method are: first, the need of apparatus to gen-
erate pressure and to vaporize the ether in a controllable manner; second, the
depth of anesthesia by other procedures required before intubation becomes
feasible; third, the occasional difficulty and time consumed in intubating;
fourth, the physical and physiological risks from over-pressure.
Physiology. — Meltzer has shown that the tidal movement of air in the
respiratory tract is not needed for aeration nor for the diffusion of an anes-
92 SUKGICAL ANESTHESIA
thctic, provided a proper air circulation be artificially maintained in the
trachea. Effective insufflation secures such a circulation, from which, through
diffusion, the respiratory needs are met.
The anesthetic state in insufflation anesthesia differs from the usual, in that
the respiratory movement is here slower and more shallow than in the face mask
methods, yet oxygenation is more efficiently maintained. No element of
asphyxia enters, the color stays bright, and the pulse remains the physiological
pulse of ether anesthesia when devoid of respiratory strain, namely, a full pulse
of well-sustained pressure, accelerated 10 to 20 beats above normal, usually
running 70 to 90 per minute. Owing to the even flow of vapor the anesthetic
state may be perfectly maintained at any desired level. The patient may be
placed in a zone of deep anesthesia, with complete blockage of the traumatic
stimuli, yet with no danger of respiratory insufficiency.
Postoperative sequelae are reduced to those of a perfectly delivered vapor
anesthesia. "Ether" or inspiratory bronchial "pneumonia" is unknown, except
as a result of preliminary and postoperative inspiratory accidents. The method
in itself carries no more risk of pulmonary irritation than inhalation anesthesia.
Slight pharyngeal and laryngeal mechanical trauma is occasionally caused by
clumsy intubation. Owing to the ease with which inspiratory negative pressure
is satisfied by the rush of intratracheal delivery, and also to the double volume
that must be exhaled through the glottis, this method tends to increase the intra-
thoracic pressure, usually diminishing the negative and raising the positive
pressure about 5 mm. If the delivery be excessive, or the return be choked, a
continuous positive pressure may be maintained.
If the phase of negative pressure be totally obliterated by excessive intra-
thoracic pressure (i. e., in excess of 20 mm.), the patient may be rapidly thrown
into a condition of shock. Therefore, when the delivery is of excessive or un-
known volume, or of deliberately increased pressure, as for intrathoracic sur-
gery, the flow should be interrupted from 2 to 4 times a minute to allow of de-
flation of the lungs and to remove obstruction to the return of venous blood and
lymph to the right auricle from the great venous sinuses and lymphatic chan-
nels.
Technic of Intratracheal Insufflation. — The patient must first be anes-
thetized to full relaxation by the usual face mask methods.
With the patient lying supine, the head is knuckled backward down to the
table, until the shoulders are slightly lifted and the plane of the face forms an
angle of 60° with the table (see Fig. 17). A Jackson direct-vision laryngoscope
is now inserted over the base of the tongue, and the epiglottis is identified. The
upper lip is disengaged from between the instrument and the upper teeth. Care
is taken not to exert leverage with the upper incisor teeth as a fulcrum. The in-
strument is now carried deeper and the beak engages the epiglottis, and this,
with the base of the tongue and the lower jaw, is carried directly upward as if
to raise the patient's head from the table (see axis of arrow, Fig. 17). The
axis of the laryngoscope is now in line with that of the trachea. If the patient
GENERAL ANESTHESIA
93
be well anesthetized the triangular opening of the glottis stands wide open on
each inspiration. Into this opening a stiff catheter is passed by direct vision.
The catheter should pass about 13 cm. into the trachea, or 26 cm. from the
incisor teeth. A clamp loosely incloses the catheter at the teeth, holding it from
slipping and preventing compression. The fact that the catheter is in the
trachea should be established by the ebb and flow of air at the bore of the
catheter by a bit of fluff cotton or by the hand. A cough, as the catheter is
passed, is usually proper evidence that the tube has passed the glottis. If, on
the other hand, no ebb or flow takes place on respiratory movement, it is pre-
sumable that the catheter has been passed into the esophagus.
FIG. 17. — TECHNIC OF INTRATHACHKAL INTUBATION.
If the catheter has been so misdirected it is withdrawn and a fresh catheter
properly inserted. If the mistake be not discovered until the pressure has been
connected, and then discovered by the dilatation of the stomach, or by expulsion
of gulps of air and gastric secretion from alongside the. catheter, then the tube
is disconnected, but not withdrawn until all the air has been expelled from the
stomach.
Some few deft operators with long fingers can tuck in a soft rubber catheter
by feel, also the catheter may occasionally be introduced blindly through a
curved hollow instrument shaped like a sound, the Boothby-Cotton introducer.
Such technic is not recommended. The Janeway introducer is a refinement
of the Jackson instrument.
When it is evident in a breath or two that the catheter is properly placed,
it is connected to the air-ether supply. The tubing should be strapped in place
by adhesive plaster. A clamp may be attached to the tube at the line of the
teeth to prevent compression by the bite.
94 SUKGICAL ANESTHESIA
The quantity insufflated should be such that on inspiration no air is inhaled
from outside. Eighteen to 20 liters is the average quantity for the adult. This
may be blown by 20 mm. of pressure through a 22 F. catheter. Allowing for
the resistance of the connecting tube, 26 mm. is the average pressure desired at
the ether vaporizer.
The quantity should suffice entirely to supply the tidal volume during in-
spiration. If any air can be heard sucked in alongside the catheter the quantity
must be increased by raising the pressure.
When the depth of anesthesia is such that it is feasible to intubate then the
patient has already passed the induction period of ether anesthesia (see Fig.
13). If anesthesia has become light from the breaths of air during intubation
insufflation of strong vapor quickly deepens it again. Usually for 20 seconds
the strength of the vapor should be 6 per cent, by volume, i. e., 50 mm. of vapor
saturation, so as not to induce violent coughing. It is rapidly strengthened
to 90 mm., i. e., 11 per cent., then gradually decreased as anesthetic tension be-
comes fully established until after 40 minutes in the vigorous adult, or in less
time, according to the reactions of the patient, the vapor pressure may be main-
tained at the 50 mm. level.
On this strength of vapor anesthesia stays uniform through the succeeding
hours of anesthesia. Ten to 12 minutes before the close of the operation air
alone should be insufflated, which results in rapid elimination of the ether, so
that the patient is in the light subconscious stage as the operation terminates.
Maintenance of Positive Pressure. — In those infrequent procedures of intra-
thoracic surgery where positive pressure is desired this pressure is maintained
in one of three ways.
First, the tracheal return may be choked by a tube, disproportionately large
to the bore of the trachea, i. e., 26 to 28 F. catheter. This is a blind method,
since the return flow cannot be regulated.
Second, the volume delivered may be doubled by increasing the delivery
pressure to 60 to TO mm. This is the usual method, but undesirable in that the
lungs may be subjected to possible over-pressure, i. e., constantly in excess of 20
mm.
Third, the best method is to choke the return by placing a hand over the nose
and mouth until the cheeks remain in moderate distention. This yields the
necessary 5 mm. of plus pressure. At 8 mm. air may be forced into the esoph-
agus ; if this happens a stomach tube should be inserted and left in situ.
From 2 to 4 times a minute the inflow of air must be momentarily inter-
rupted. Positive pressure is maintained only for so long a period and to such
degree as is absolutely indicated by the operative procedure. Persistent efforts
to keep a lung in full distention tend toward the production of shock (see
Physiology of Intratracheal Insufflation).
GENERAL ANESTHESIA 95
ANESTHESIA BY PHARYNGEAL INSUFFLATION
Introduction. — Small quantities of concentrated anesthetic vapor may be
blown into the pharynx, to be here diluted with air inspired by the patient.
However, a highly advantageous delivery is not attained until the anesthetic is
already properly diluted, and the mixture is of such bulk as will entirely fulfil
the needs of inspiratory effort and of anesthesia without further dilution. This
method is far more efficient than face mask delivery and ranks almost equal to
endotracheal insufflation. Indeed, as a routine method, where high efficiency
of insufflation method is demanded, it is preferable to endotracheal delivery,
since it is mechanically much more simple in its application.
Pharyngeal insufflation shares with endotracheal delivery the following ad-
vantages : First, the common obstructive difficulties of the upper air passages
are largely overcome by delivering a sufficient tidal bulk behind and below the
base of the tongue. Second, the mucus, saliva, and blood from operative pro-
cedure is blown outward by positively impelled air stream. (Since no puddle
forms in the pharynx to be aspirated into the bronchi, and as no negative pres-
sure exists in the pharynx to aspirate the saliva and mucus of the mouth and
the mucus of the nose, the so-called "ether pneumonia" is rarely met with under
this method.) Third, the method shares the even, full anesthesia common to all
vapor delivery.
Technic. — The same air pressure and vapor apparatus are employed as
those used in endotracheal insufflation. The most convenient delivery device is
a metallic Y-forked tube, bent to fit the nose and forehead, each fork carrying
FIG. 18. — CONNELL NASOPHARYNGEAL TUBE. (For pharyngeal insufflation.)
an 18 F. soft rubber catheter with double eyelet. Each catheter is about
13 cm. long.
Before pharyngeal delivery can be instituted the patient must be anesthetized
to the stage of surgical relaxation by the usual face mask methods. If anes-
thesia be too light when insufflation is instituted the patient will swallow air,
halt in breathing, and may vomit. With ether as the agent, insufflation should
not be started before 9 to 12 minutes as a rule.
To lubricate the catheters they may be moistened in the saliva of the pa-
tient's mouth. . The nose is tilted upward and the catheters are passed directly
back, one through each nostril along the inferior strait of the nasal chamber.
96 SURGICAL ANESTHESIA
If the catheters be directed upward instead of backward they may become
jammed and kinked. If the septum be found deflected then both catheters must
be passed through the free side. If the nose be doubly obstructed the catheters
must be introduced per ora. They are passed a distance measured by laying the
catheters on the face of the patient from an ala of the nostril to the external
auditory meatus of the same side. The eyelet of the catheter then lies at a level
of the epiglottis, usually a distance of about 12 cm. from the nostril. Insuffla-
tion may also be practiced through a bent tube, introduced through the mouth
into the lower pharynx. The nasal route is preferred, as the tubes are more
accurately introduced and lie in place more securely.
The quantity of anesthetic delivered should be of such bulk as to satisfy
totally each inspiration without extraneous dilution. To satisfy the negative
pressure of inspiration at the glottis a total of 18 liters per minute must be
insufflated in the average adult. When the patient is breathing rapidly this
must be raised to 20 liters or may be dropped to 15 liters at quiet periods. A
positive pressure of 26 mm. at the vaporizer supplies about the correct average
quantity through two unobstructed, 18 F. catheters. An instantaneous gas flow
gauge in circuit is highly desirable to read at all times the actual gas flow.
The percentage or vapor pressure of anesthetic to be maintained is the same
as by face mask and intratracheal delivery (see Figs. 14, 15). Usually the
mouth and jaw do not have to be held by the anesthetist. If the jaw tends to
drop back so that the epiglottis obstructs breathing, then the head must be
adjusted to one side. If the mouth tends to open widely, allowing the vapor
delivered to become so dilute that anesthesia is not well maintained, then the
chin should be held toward the head of the table by an adhesive strap.
The same even, quiet anesthesia, with the luxury of easy respiratory move-
ment results as in the endotracheal delivery. The patient shows in general
good condition, the absence of such respiratory strain as is often occasioned
by face mask methods. The pulse and respiration tend to be but little accel-
erated ; the depth of anesthesia may be accurately controlled and the undesirable
sequelae of crude methods of anesthesia are largely eliminated.
Maintenance of Positive Pressure. — Positive pressure within the lung for
intrathoracic surgery may be easily maintained by obstructing the return flow
with the hand over the nose and mouth until the cheeks bulge under moderate
distention. While this serves for emergency, yet the following is a better
method (see Fig. 25). The return flow is blocked at the nostrils by a collar of
large rubber tubing slipped on over the delivery catheters, a collar of such size
as to plug the nostril. The mouth is then blocked by a stiff rubber sheet or
cofferdam, oval-shaped and slipped in between the lips and gums. This is
perforated at its center for a pharyngeal breathing tube. To the breathing tube
is attached outside the mouth a common 2-gallon rubber rebreathing bag. On
insufflating a vapor mixture it is exhaled into this bag. The bag gradually dis-
tends and maintains an elastic pressure against the pharyngeal air, and in fact
against the lung itself. The distention of the bag and exhalation therefrom are
GENERAL ANESTHESIA
97
regulated by a cock at the distal end. The bag must be fairly firmly distended
to yield 5 mm. of pressure against the lung. Occasionally the bag is deflated
for a moment.
This method of maintaining positive pressure is much more controllable
than face mask methods. It is not so efficient in aerating the lung as is the endo-
tracheal method. This latter method (the endotracheal) should decidedly be
chosen when both pleural cavities are to be open simultaneously.
Should the stomach become distended by this method, as it may do if a
pressure of more than 10 mm. be maintained, then a small gavage tube may be
passed and left in situ. Not less than 8 liters, preferably 15 to 18 liters, of
fresh mixture should be insufflated in this positive pressure method.
THE VARIOUS UNITS OF APPARATUS USED IN INSUFFLATION ANESTHESIA
First Unit : Air Compressor — As a source of air pressure, a small-sized glass-
blower's foot bellows 7 by 12 in. is sufficient. This is obtainable at small cost from
any hardware store. A pressure of 25 mm. and air flow of 18 liters per minute is
maintained by about 25 strokes a minute. (Fig. 19.)
FIG. 19. — FOOT BELLOWS OF AIR COMPRESSOR FOR VAPOR ANESTHESIA. Size 9 yields somewhat
less than one liter per full stroke, about 10 strokes a minute for face-mask methods, about 25
strokes for insufflation methods.
Motor-driven blowers are more convenient, of which the best is a rotary com-
pressor of the "Hypress" type. Small reciprocating pumps are noisy and not capacious.
Modern hospital equipment should include a supply of compressed air to the
operating room from the engine room, obviating attention to this detail on the part
of the anesthetist. The Connell portable air compressor is shown in Figure 20.
Second II nit: Filter and Humidor. — It is customary to blow air through moist
gauze for purpose of filtration and water vapor saturation. Any receptacle for the
8
98
SUEGICAL ANESTHESIA
gauze, such as a bottle with 2-way opening, suffices. This is not an essential, but a
desirable unit.
Third Unit: Ether Vaporizer.— Ether is vaporized either by blowing air over
the surface or by dropping liquid ether in measured amounts into the air stream.
The simplest apparatus is a 3-mouth Wolff bottle of a diameter not less than 6 in. The
air enters one mouth, circulates over the ether, and leaves by a second mouth. The
FIQ. 20. — GENERATOR FOR COMPRESSED AIR: CONNELL PORTABLE MODEL. 1, Electric motor; 2, gears,
oil-housed; 3, rotary compressor; 4, muffler; 5, oil tank and separator; 6, humidor and air filter; 7,
instantaneous air flow gauge; 8, safety valve; 9, hollow bottom with control rheostat.
third is used for renewing the liquid ether. The tube and stop cocks are so arranged
(Fig. 21) that any portion of the air may be shunted around the bottles, thereby
weakening the total vapor mixture. Other types of vaporizers are discussed under
vapor methods, page 89.
A convenient form of this vaporizing unit is the Robinson, where the essential
tubing and stop cocks are combined in a lid which fits any common fruit jar. If
sufficient ether is not taken up by the air in passage over the ether, then the vaporizer
is immersed in a water bath at a heat between 75° and 80° F.
A more controllable ether feed is the dropping, from an ordinary oil cup, of liquid
ether onto a warm surface. When this is done by mechanical correlation of the
movement of ether to that of air, a scientifically accurate proportion may be obtained.
The anesthetometer is the latest 'and most effective development in this method (see
page 131.
Fourth Unit : Safety Valve. — To avoid overpressure, a safety blow-off valve must
be provided near the patient; this should be set at not more than 20 mm., so that
excessive pressure on the lungs is impossible. The valves are of 2 types, the sub-
merged and the pop valve. The submerged valve consists of a glass tube buried 20
mm. into a bath of mercury held in a wide bottle, such as an Ehrlymer flask. The
blow-off point may be varied by adjusting the depth of the tube. The disadvantage
of this type is the weight and cost of the mercury and loss by spillage and spattering.
The pop type of safety valve is more convenient. The pressures may be adjusted by
increasing the weight carried on the piston by spring or by weight on a lever arm,
as in the ordinary steam engine safety valves. This valve should be set at 15 to 20
mm., and should be in circuit near the patient, so that any cough is responded to by
lifting the safety valve, and excessive pressure cannot accumulate.
Fifth Unit : Intubating Catheter.— The preferred catheter is the straight cylin-
GEKEKAL ANESTHESIA
99
drical silk-woven, shellac-covered, urethral catheter with single lateral eye, size 20
to 26 F. The patency of each catheter should be determined by blowing through it,
as some catheters have an im-
perfect bore. Size 20 will carry
sufficient air on usual pressure
for the adolescent, 22 F. is
chosen for the small adult, and
24 F. for the larger adult. Size
26 F. is used to block the air
return alongside the tube in in-
trathoracic surgery.
When the catheter is to be
introduced by other than the
direct vision method, then a
soft red rubber catheter is
preferable.
Accessories. — Connecting
tubing should be at least 5/16
in. bore. As an introducer, the
Jackson direct-vision laryngo-
scope is preferable (see Fig.
17). The Janeway introducer
FIG. 21. — SURFACE VAPORIZER. A, Wolff bottle, containing
ether; B, filling funnel; C, C', C", control clamps; D, basin
of water.
is an excellent instrument. In-
struments for the blind intro-
duction of the tubing by sense
of feel, such as the Cotton-Boothby hollow sound-shaped introducer, are to be decried.
INTRAVENOUS ADMINISTRATION OF ETHER
Introduction. — The object in the intravenous administration of ether is to
saturate the blood to proper anesthetic tension, obtaining the physiological effect
on the neuron in pure form, without those side effects which are dependent on
the stimulation of high percentage of ether in the respiratory tract. By this
method the blood may be brought to solution of about % per cent, ether or an
ether tension of 50 mm. without the vapor pressure in the respiratory tract
ever reaching an irritating degree. Buckhardt first adapted the method to man.
The ether is dissolved 5 to 7.5 per cent, by volume in normal saline and is
introduced by intravenous infusion.
Special Physiology. — On establishing an intravenous flow of about 50 c. c.
per minute of 5 per cent, ether in normal saline, the patient becomes drowsy
within 2 or 3 minutes, and there is slight excitation of respiration and of pulse
rate. The pulse grows full and slightly increased in tension. The skin becomes
flushed and moist.
Usually with very little or no mental excitement, the patient drops off into
a state of quiet narcosis. Shortly the breathing becomes roughened or even
stertorous and the muscular system perfectly relaxed. The stage of full surgi-
cal anesthesia has now been attained. This requires about 5 minutes, adminis-
tering about 250 c. c. of 5 to 7 per .cent, solution to the average individual.
100 SUKGICAL ANESTHESIA
After arriving at the stage of full anesthesia this is maintained by such dosage as
will balance that ether which is being excreted by the respiratory tract, plus
that which by diffusion is bringing about an equilibrium over the entire body.
The stage of recovery is attended by the usual phenomena of a smoothly
induced and maintained ether anesthesia. The vomiting is much reduced over
the rougher methods of pulmonary administration. Occasionally with robust
alcoholics the excitement is as troublesome as by other methods.
With the onset of stertor the upper airway of the respiratory tract must
be adjusted and held open and the depth of anesthesia gauged by a competent
anesthetist.
The advantages of this method are those of a rapidly and smoothly induced
pure ether anesthesia, without pulmonary stimulation. Also the region of the
face is rid of inhalation apparatus. The disadvantages are those incident to
ordinary infusion of saline in excessive bulk when no saline is physiologically
needed, plus the destructive solvent action of ether in high percentage on the
blood at the point where it first commingles and before it has been diluted by the
general blood stream. The solvent effect of ether on the red blood cells in such
solution in the plasma as is needed for anesthesia (i. e., % per cent.) is negli-
gible, but the lipoid solvent and laking effect of ether in a far larger percentage
(i. e., 5 to 10 per cent.) necessary in the infusion is a menace. Hematuria,
excretion of lipoids, and postoperative anemia are seen. This effect, together
with the accidents of air embolism, thrombosis, pulmonary embolism, and
edema of the lungs, which are dependent on the infusion procedure, will no
doubt relegate this method to the realm of physiological experimentation and
not that of a useful surgical method. Approximately equal smoothness of anes-
thesia is attainable by proper pulmonary and rectal dosage. The danger of
overdosage does not exceed that of other methods, if reasonable care and de-
liberation be exercised during the infusion and the physiological effect be
closely watched by a competent anesthetist.
Technic of Administration. — Apparatus such as is commonly used for
saline infusion suffices. The solution is prepared by dissolving 75 c. c. pure,
clean ether in 925 c. c. of cool normal saline, or Einger's, solution. If the
solution must be prepared in advance it should be kept cold and tightly corked
to prevent loss of ether. For use the solution may be poured into a graduated
glass irrigation jar covered by a flat glass dish to inhibit the diffusion of ether
into the air. The jar is elevated about 3 feet. The delivery tubing should be
guarded by a small screw pinch clamp and should have in continuity below
the irrigator a glass drip tube, so that each drop of solution may be seen as it
feeds as for rectal drip. Near the patient the tube may be coiled through a
water bath or placed beneath a hot-water bag to take the chill off the solution.
Very hot water is objectionable, as it distills out the ether.
With the patient under light alkaloidal narcosis (see page 102), any con-
venient vein, preferably a large vein in the forearm, is exposed by dissection
under infiltration anesthesia. A cannula is inserted and tied in place as for
GENEEAL ANESTHESIA 101
saline infusion. With all air ejected except that residual at the sight feed, the
tube is connected to the cannula and the infusion allowed to run into the vein,
about 50 c. c. per minute. When light anesthesia is induced the amount de-
livered is cut to about 20 and then to 10 c. c. per minute, i. e., 2 or 3 drops per
second. Gradually a level is found on which an even grade of anesthesia con-
tinues by a slow, even drop. The depth of anesthesia may be controlled by the
rate of the drop. If anesthesia deepens unduly administration is checked for a
few minutes and the cannula and vein kept free meanwhile by a very low stream
of normal saline from a second jar. Anesthesia may also be lightened by in-
creasing the tidal volume of breathing by means of a breathing tube, or it may
be deepened by muffling the face with toweling. Administration is checked
about 10 minutes before the termination of the operation, and the wound
sutured as the surgical operation terminates.
RECTAL ADMINISTRATION OF ETHER
Introduction. — Ether is administered by the colon for the purpose of elim-
inating the undesirable effects of the drug on the respiratory tract, such as
cough, disturbance of respiration, and reflex excitement. Pure liquid ether
cannot be used for injection into the intestine, since at body temperature it
boils and may distend and rupture this viscus. Nor can ether vapor mixed with
air be delivered into the intestine in sufficient strength to saturate the blood to
anesthetic tension, since the absorptive surface is here so much smaller than
that of the lung. The nearest approach to success was that of Sutton, who, by
substituting for the inert nitrogen of the air, oxygen passed through warm liquid
ether, increased the absorption. The various previous attempts have recently
given way to what gives promise to be a successful method — the oil-ether method
of Gwathmey.
Oil-Ether Anesthesia. — When ether is mixed with olive oil in a percentage of
75 the boiling point is above the body temperature and the danger of rupturing
the intestine is eliminated. The vapor tension remains high (almost boiling)
and the ether rapidly diffuses throughout the content and through the walls of
the intestine into the blood stream. Gradually in the course of 20 to 30 min-
utes the blood and nervous system of the body may be brought to proper anes-
thetic tension. A certain amount of ether volatilizes into the gases of the in-
testine, increasing their bulk and moderately distending the intestine. Gradu-
ally the tension of the mixture first introduced falls, as the oil loses its ether,
until the rate of absorption into the blood from the gut no longer balances ex-
cretion from the lungs, whereupon the patient emerges from anesthesia.
The depth of anesthesia must be gauged and the upper respiratory tract
kept open by a competent anesthetist.
TECHNIC. — The colon is first thoroughly cleansed by catharsis and enemata.
One hour before operation % to % grain of morphin with atropin, grain
1/100, is given hypodermically. Fifteen minutes later 10 grains of chlore-
102 SUKGICAL ANESTHESIA
tone in ^ ounce each of ether and oil is administered by rectum. Eifteen
minutes later through a small rectal tube, with the patient in the Sims' posi-
tion, the following dose is administered : a solution of ether 75 per cent, by vol-
ume in olive oil, the amount being 1 ounce of the mixture to each 20 pounds of
body weight, in total not to exceed 8 ounces.
Almost immediately ether may be detected on the breath ; in about 10 min-
utes the patient becomes drowsy and somewhat incoherent. In about 20 minutes
unconsciousness supervenes, soon passing into the stage of light anesthesia. If
the patient becomes excited and breathes deeply elimination of ether is so rapid
that anesthesia may not appear. By this slow induction the specific relaxant
action of ether on the voluntary muscle and other desirable anesthetic effects
are satisfactorily obtained.
To lighten the anesthesia the tidal volume of respiration is increased and
elimination of ether is hastened by inserting a Connell breathing-tube (see
Fig. 28). To deepen anesthesia diffusion of ether is checked by muffling the
face in loose layers of toweling. Should anesthesia grow too deep the oil mix-
ture may be in part withdrawn by a rectal tube, and the diffusion of the re-
mainder checked by cold saline irrigation.
Anesthesia usually lasts about 60 minutes, after which, if required, 2 ounces
of fresh mixture should be given, or this method supplemented by inhalation.
Ten minutes before the termination of the operation the residual mixture should
be withdrawn by insertion of rectal tube, and replaced by 4 ounces of olive oil.
The objections to the method are the occasional discomfort and tenesmus
before anesthesia appears ; evacuation of the mixture ; the impossibility of anes-
thetizing deeply breathing patients; occasionally an uncontrollable depth of
anesthesia; distention of the intestine; gas pains; and, rarely, paresis of the
anal sphincter following operation.
MISCELLANEOUS METHODS OF ETHER ADMINISTRATION
Ether has been injected into the muscle of the buttocks and thigh and subcu-
ianeously. Also it is rapidly absorbed from serous surface such as the peri-
toneum, as proved by deepened anesthesia where ether is used to cleanse a
tuberculous peritoneum. None of these methods promise to be widely used.
AGENTS USED AS ADJUNCTS TO ETHER IN ANESTHESIA
The Alkaloidal Narcotics. — Morphin and scopolamin used as preliminaries
to ether permit the initiation of the ascending stages of ether anesthesia with
markedly diminished excitement. The patient may be carried through an
operation under lighter anesthesia than is possible without supplemental nar-
cosis, and may be more readily carried repeatedly from the light subconscious
into deeper zones of ether anesthesia without cough or respiratory difficulty.
However, for the abolition of muscular rigidity and for the protection of nerve
GEKEKAL ANESTHESIA 103
centers from the harmful stimulus of severe operative trauma the same tension
of ether is required as without the adjunct of such narcotics.
These narcotics smooth the course of irregular, inexpert administration of
ether, but by combination with nerve tissue more stable than that of ether and
by prolonged depression of the respiratory center, they desensitize the res-
piratory center in the higher zones of ether anesthesia. These drugs are par-
ticularly badly borne in the partial asphyxia which usually accompanies the in-
expert administration of ether. The more efficiently ether is administered the
less advantage can be derived from these narcotics. They are rarely employed
by the skilled anesthetist.
Atropin, while not a narcotic, is of distinct advantage in inhibiting the
mucous secretion when increased by the stimulus of concentrated ether vapor.
However, with the expert and continuous administration of ether, stimulating
concentration need be maintained only for a short period in the preliminary
stage of ether anesthesia. The greatest utility of atropin, therefore, is to nullify
the vicious effect of unevenly administered ether.
DOSAGE. — The usual dosage of preliminary narcotic is % grain of morphin
with 1/100 grain of atropin, administered hypodermically 1 hour before anes-
thesia.
THE USE OF NAKCOTIC ALKALOIDS FOLLOWING ANESTHESIA. — There
can be no question of the value and advisability of alkaloidal narcosis to supple-
ment and continue ether analgesia, i. e., that partial analgesia which lasts into
the third hour of recovery from the ether zone of confusion. For this purpose
morphin is the customary analgesic, administered hypodermically in 1/6 to %
grain dose, as ether analgesia wears off and the patient becomes cognizant of
pain.
Nitrous Oxid. — Nitrous oxid as a preliminary anesthetic to ether is the most
rapid, pleasant, and effective means of inducing ether narcosis. It is the safest
method barring one risk, namely, that of asphyxia. Asphyxia frequently arises
in the inexpert management of the transition from one anesthetic to the other.
TECHNIC. — The Bennett inhaler is a popular type of apparatus for this
sequence. It is a modification of the Clover type of inhaler. In this apparatus
the gas bag is filled with nitrous oxid, the gauze in the ether chamber is charged
with about 1 ounce of liquid ether. With the ether and the nitrous oxid closed
off, the mask is adjusted to the face. After a few breaths of air with the ex-
piratory valve open the air supply is cut off and nitrous oxid substituted. After
3 breaths of this gas the expiratory valve is closed and to and fro breathing
into the bag is instituted. At the first quickening of respiratory rhythm the
ether chamber is very gradually opened, so that the gas becomes charged with
ether.
This is the stage which marks the skilled anesthetist from the bungler.
After a few of the rapid breaths which indicate the onset of nitrous oxid anes-
thesia a small whiff of air must be allowed, or the patient will become cyanosed
and respiratory rhythm will be upset. This small proportion of air is added by
104 SUKGICAL ANESTHESIA
momentarily opening the air valve during inspiration. Leaking apparatus or
defective face adjustment of the mask may allow too great dilution of the gas
and upset the smoothness of the transition. The stage of asphyxia should be
held in abeyance and nitrous oxid breathing continued until the percentage of
ether vapor mounts to such height that the arterial blood goes to the nervous
system constantly charged to proper anesthetic tension.
Thus 90 seconds suffices to put a patient to the peak of the induction curve
without consciousness of the odor or irritation of ether vapor and without ex-
citement or halt in breathing.
The ether chamber must be recharged after a minute, else the vapor pres-
sure will fall. When the ether vapor is on to the full capacity of the apparatus
the gas bag is removed and the air rebreathing bag is substituted. The dosage
of ether must be maintained until the onset of surgical relaxation, otherwise the
arterial blood and nervous system drop into the zone of confusion. If the per-
centage of ether be diminished excitement and irregular breathing and poorly
achieved induction of anesthesia result.
A method by which nitrous oxid anesthesia is merged into ether narcosis
with less risk of asphyxial symptoms even in inexperienced hands is that of
Gwathmey. The essential feature is that ether is added to the nitrous oxid by
the vapor method. For this method the mask is adjusted and nitrous oxid
anesthesia instituted. By a hand bulb or foot pump air is forced through an
ether bottle and, becoming laden with strong vapor, is delivered by tubing into
the gas bag. Ether is thus added more gradually and is under better control
than with the Bennett apparatus, and at the same time air is introduced in any
desired quantity, thus avoiding asphyxia. Not less than 3 liters of
fresh air per minute should be supplied, and after the first few minutes 5 to
8 liters.
Nitrous Oxid-Oxygen. — Best Method. — Nitrous oxid-oxygen anesthesia is
fully established, then gradually full ether anesthesia is substituted. Thus the
advantages of both anesthetics are secured and the disadvantages of each are
eliminated. If the substitution be gradual, over 15 minutes, the vapor pressure
of ether need not exceed 90 mm. ; a toxic zone of ether is at no time entered ; the
oxygen percentage may be kept high, i. e., 12 to 16 per cent., and there is no
stimulation of mucous secretion by high levels of ether vapor. When anes-
thesia reaches that stage where 20 per cent, of oxygen causes no return of
sensibility then air may be substituted for the nitrous oxid-oxygen gases, and
ether anesthesia continued by any method, preferably vapor delivery by pharyn-
geal insufflation.
Chloroform. — Since anesthesia can be secured more rapidly, quietly, and
with less discomfort by chloroform than by ether, chloroform is occasionally
chosen to institute primary anesthesia, and this is gradually merged into full
ether anesthesia.
Such dangers as attend this method are those incident to the early stage of
pure chloroform anesthesia, but these may be in some measure obviated by an
GENERAL ANESTHESIA 105
early substitution of the stimulative action of ether for the depressing effects
of chloroform on the heart muscle.
This method is simpler but is much less agreeable, less rapidly effective, and
not so safe as the nitrous oxid-ether sequence. (However, the statistics of
Gwathmey show a lower mortality than for nitrous oxid-ether.)
TECHNIC. — The administration of chloroform is begun by the drop method
on an open mask. After the first few drops ether is added; gradually the pro-
portion of ether is increased and that of chloroform diminished, until by the
end of 6 to 8 minutes full anesthesia has been achieved with expenditure in
total of not more than 2 drams of chloroform and of 1 to 2 ounces of ether.
A more effective method is by vapor delivery into a closed inhaler. This,
however, requires great care in controlling the chloroform vapor from over-
concentration, i. e., in excess of 3 per cent.
Ethyl Chlorid. — To carry the patient rapidly and quietly over the period of
cortical disassociation this very effective lipoid solvent may be employed. Be-
fore the dangers of ethyl chlorid were fully appreciated this sequence was car-
ried on in a closed inhaler by rebreathing. The only relatively safe method in
the average hands is the open method.
TECHNIC. — An open inhaler of the Esmarch type is seated on the face
and well enveloped at the periphery in toweling. On the gauze 1 or 2 c. c. of
ethyl chlorid is sprayed over the first five inspirations. A few drops of ether are
now added. Gradually the ether is increased with an occasional momentary
spray of ethyl chlorid. After 2 minutes the ethyl chlorid is discontinued and
ether anesthesia progresses into the higher zones as by the drop method. A total
of 4 c. c. of ethyl chlorid usually suffices.
CHLOROFORM
Introduction. — Chloroform in physical properties is a most effective agent
for inducing complete, controllable general anesthesia. It volatilizes well, dif-
fuses rapidly from pulmonary air to blood, and from blood to nerve tissue, and
is so active a solvent in the neuron that a low vapor content in the pulmonary air
establishes and maintains a proper state of anesthesia. Were it not for certain
limitations in chemical stability and toxic action, chloroform would be the an-
esthetic of universal choice. Thus, in chemical structure, chloroform is
unstable, being decomposed by light, heat, and age into highly toxic products ; in
physiological action it is an early and cumulative paralyzant of heart muscle
and a primary depressant of blood pressure ; and in remote toxic effect on the
parenchyma of important organs, such as the liver and kidney, it results, after
prolonged or repeated dosage, in late destructive degeneration of the cells of
these organs. Therefore, despite the ideal physical qualities in vaporization,
diffusion, and solvent action, because of inherent vicious properties chloro-
form has been largely supplanted for full general anesthesia by ether, and for
transitory and for shallow general anesthesia by nitrous oxid,
106 SUKGICAL ANESTHESIA
According to the best substantiated theory, chloroform acts by a solvent action on
the lipoid content of the neurons, similar to the action of ether. In this solvent
action it is much more powerful than ether, having a partition coefficient between
oil and water of about 33, as against ether, 4.5. Chloroform is, therefore, 7 1/3 times
more powerful than ether. For full anesthesia in man it must be present in the
plasma of the arterial blood to the extent of 1/40 to 1/60 per cent. The lipoids of
the red cells hold a much higher percentage at the same vapor tension.
The- amount of chloroform that must be present in the tidal air, to establish and
maintain this percentage in the blood, rises during the induction stage from 2 to 3
per cent, by volume in the air, or a vapor pressure of about 20 mm. The amount
necessary after anesthesia is established gradually falls, as the anesthetic tension of
the body is established, to about 1V2 per cent., or 11 mm., gradually scaling down
through prolonged anesthesia to slightly less than 1 per cent., or about 7 mm. of
vapor pressure.
PHYSIOLOGICAL ACTION or CHLOROFORM
Chloroform as an Irritant Compared with Ether. — Chloroform is locally a
marked irritant to epithelium. If liquid chloroform or the concentrated vapor
be held in contact with normal skin, blistering and continued inflammation re-
sult. In this lasting irritant action chloroform differs markedly from ether.
In the maximum vapor concentrations (i. e., 3 per cent, by volume) needed
to institute anesthesia chloroform does not stimulate the secretion of mucus so
much as do those percentages of ether which are necessary to induce anesthesia
(i. e.y 15 to 24 per cent, by volume). Chloroform in amounts required for
anesthesia probably causes no lasting damage to the epithelium of the respira-
tory tract. As with ether, those pulmonary sequelae occasionally observed are
resultant not so much from direct irritation as from .various aspiration acci-
dents and from the exposure and depression of general anesthesia and of
operative trauma.
When the parenchyma of other vital organs, prominently the liver and kid-
neys, is considered, chloroform in anesthetic dosage is found after long-con-
tinued or repeated administration to be a drastic cell poison inducing excessive
degeneration. On the other hand, ether at its worst causes only a transitory
parenchymatous degeneration.
The Effects of Chloroform on Body Function. — RESPIRATION. — Chloroform,
like other volatile irritants, in the respiratory tract causes depth and frequency
of respiration continuing into the stage of full surgical anesthesia. The respira-
tory center then becomes gradually depressed and the respiratory movement
grows more shallow. This stimulation and subsequent depression are not so
marked as with ether.
CIRCULATION.- — On first inhalation chloroform induces an increase in the
force and frequency of the heart beat and a slight rise of blood pressure, largely
because of the volatile irritant action of the drug. Soon the characteristic effect
of chloroform is manifested, namely, that of a primary paralyzant of heart
muscle. The pulse becomes full and soft, the blood pressure falls about 20 mm.,
GENERAL ANESTHESIA ICtt
the heart remains slightly accelerated or drops back to normal rate, and the beat
of the heart is less forcible. The heart in light chloroform anesthesia is more
readily inhibited by vagus stimulation than the normal.
In toxic gradual overdosage the pulse becomes weak and small. The rate
may be increased or fall below normal. The blood collects in the splanchnic
area, the heart becomes slow and feeble, the jactitation marking tissue asphyxia
may appear. Then the pulse becomes imperceptible, respirations become shal-
low and cease. Finally the automaticity of the heart muscle is at an end.
Death is primarily one of circulatory failure.
In sudden overdosage caused by breathing concentrated vapor the heart may
be arrested within a few breaths, the color blanches, the patient gasps and dies
(see Accidents: Heart Failure).
SENSOEIUM. — Nerve activity is suspended in the various levels in the same
order as in ether anesthesia. Consciousness is abolished with less excitement
and slightly more rapidly than with ether. In chloroform dosage the same
zones of anesthesia exist as with ether, but the low zones, i. e., the subconscious
zones, are more dangerous on account of sudden cardiac inhibition by vagus
stimulation, and the high zones, the deep and profound, are more dangerous
than those equally anesthetic in ether dosage on account of low blood pressure,
circulatory insufficiency, and cardiac failure. The medium zone yields a quiet
relaxed anesthetic state with protection from harmful traumatic stimuli of
operative procedure, but without the sustaining stimulation of ether and
nitrous oxid.
Excretion of Chloroform. — Chloroform is excreted largely by diffusion into
the air of the pulmonary alveoli. A small amount is broken up in the body.
CLINICAL COURSE OF CHLOROFORM ANESTHESIA
First Stage or Stage of Conscious Excitement: Period of Cortical Disassocia-
tion. — The mild sweetish taste and agreeable odor of dilute chloroform vapor
cause no unpleasant sensation as do the taste and odor of ether. The breathing
grows more full, the skin is flushed and moist, and articulation becomes slightly
incoherent. Usually with very little excitement the patient becomes uncon-
scious within 3 to 5 minutes from the first inhalation. Athletic subjects and
those accustomed to the various narcotics may, however, show marked excite-
ment.
Second Stage or Stage of Involuntary Excitement : Period of Subconscious Dis-
association. — The skin may become less or more flushed, it remains moist.
There is slight acceleration of pulse and of breathing. The pupil is apt to be
dilated and reacts actively to light. Spasm of the muscles of the jaw or glottis
and fixation of the chest and abdomen may be noted in resistant subjects. This
irregularity of breathing must be met by free allowance of air, as the patient
under chloroform bears asphyxia badly and about half the fatalities occur at
this stage. It is imperative for safe chloroform induction that the anesthetist
108 SUKGICAL ANESTHESIA
should know the theory and practice of relieving obstruction in the upper air-
way.
A period of false anesthesia is occasionally noted, i. e., the patient becomes
quiet, the muscles relax, the color becomes pale, and the pulse small. Vomiting
usually follows, after which the color returns and induction of anesthesia may
proceed.
Soon the breathing grows roughened or slightly stertorous, the muscles
relax, and the patient passes into the third stage of anesthesia.
Third Stage or Stage of Surgical Anesthesia : Period of Spinal and Basal Dis-
association. — This differs in no wise from the stage of full surgical anesthesia
with ether, except that the skin is less flushed and less moist, the breathing is
more quiet, and respiratory obstruction in the upper airway less in evidence.
The pupil uniformly remains moderately contracted, the pulse is slower, and
blood pressure 20 to 40 mm. lower than with ether.
Fourth Stage or Stage of Overdosage: Period of Medullary Disassociation.
—The pupil dilates and becomes insensitive to light, the tension of the eyeball
diminishes, the color of the skin and mucous membranes grows pallid, with slight
cyanosis, blood pressure drops and the pulse becomes imperceptible. Finally
the circulation becomes insufficient to maintain life, breathing ceases and
in a few minutes the automatic action of the heart is at an end. This stage
may rapidly follow slight overdosage, namely, a half minute of concen-
trated vapor.
Fifth Stage or Stage of Recovery: Period of Inverse Reassociation. — The
various levels are passed through in the same order, though more rapidly than
after ether administration. After full chloroform anesthesia the light zone is
entered in about 3 minutes, the subconscious zone in about 6 minutes, the light
subconscious zone in about 15 minutes, and the zone of confusion in 20 to 30
minutes. Somnolence and analgesia are less marked than with ether.
TECHNIC OF ADMINISTRATION OF CHLOROFORM
Chloroform should be administered only by the open drop and by the
vapor methods. Closed rebreathing methods in chloroform are dangerous and
have been largely abandoned, since toxic concentration by the closed methods
quickly occurs, and the asphyxia from rebreathing is ill borne by the circulatory
mechanism.
Open Drop Method. — The simplest inhaler is in the form of a wire mask of
the Esmarch type covered by several layers of gauze.
The eyes are protected by a pad of gauze, the face and lips are greased with
petrolatum, the mask is adjusted loosely. Administration is begun by the
drop, at first a drop every few seconds, increasing as soon as the patient
becomes used to the pleasant sweetish odor, first to 1 and finally to 2 or 3 drops
per second. The rate depends on the volume of tidal air of the individual
respirations, and on the loss by diffusion, which is determined by whether the
GENERAL ANESTHESIA 109
mask is loosely or tightly seated, and whether it is free or enveloped in a layer
of gauze or toweling.
The delivery must be even in rate and by the drop. Chloroform should
never be douched onto the mask. It is imperative that the dosage be not in-
creased in periods of excitement. With ether the anesthetic may be safely
crowded at such periods, but with chloroform the margin of safety is small. A
toxic percentage suddenly overcoming the circulatory mechanism may result in
its abrupt cessation. With the onset of slight inspiratory roughening the dosage
is gradually diminished, until a level is reached on which the state of anesthesia
remains unchanged. With the average respiratory capacity and by the Esmarch
mask this level is usually about 1 drop of chloroform every 2 to 4 seconds. With
children or others of small tidal capacity the dosage is proportionate. The de-
livery should not be entirely suspended until recovery is desired, as the patient
finally reaches a tension of anesthetic equilibrium, as with ether, on which even
anesthesia proceeds for many hours.
Vapor Methods. — In this method the chloroform is vaporized at a distance
from the patient by a current of air and is conveyed to closed or open face mask.
After anesthesia has been established, the vapor may be insufflated directly into
the pharynx or trachea of the patient. This delivery has the advantage over the
drop method of being more controllable, particularly if the delivery be con-
tinuous and the chloroform vapor be diluted with a bulk of air sufficient for
the tidal volume.
The methods of vapor delivery are two, the interrupted and the continuous.
INTERRUPTED METHOD OF VAPOR DELIVERY. — In the interrupted method
of vapor delivery a small quantity of air is blown over or through liquid chloro-
form. The air is impelled by a hand bulb or small foot pump. The impreg-
nated air is then delivered to and accumulates in an open mask over the pa-
tient's face. The small volume of concentrated vapor is here diluted by the
tidal volumes of respiration. The anesthetist governs the quantity and con-
centration delivered by the reaction of the patient to the dosage. After anes-
thesia is established, the delivery may be made, for head cases, into the nose,
or into the pharynx by nasal or by mouth tube and the vapor here diluted and
mixed with the tidal air. Except for the convenience of ridding the operative
field of the cumbersome face mask in head cases, this delivery has no advantage
over the drop method.
The usual vaporizer is patterned after that of Junker, i. e., for the air
supply a double atomizer bulb ; for the vaporizer a graduated bottle with two-
way stopper through which the air passes either over or through chloroform,
and, third, the delivery tubing. The vaporizing capacity of each apparatus
must be learned by experience.
For induction in the first 5 minutes usually 1% drams of chloroform is
vaporized, in the second 5 minutes % dram, through the second 10 minutes
about 1 dram and through the next % hour about 1 dram. This amount is
modified to fit various exigencies of changing tidal volumes.
110 SUKGICAL ANESTHESIA
CONTINUOUS METHOD OF VAPOB DELIVEKY, — The continuous method em-
ploys a constant stream of air or other gas, such as oxygen, flowing over chloro-
form. Any portion of the air stream may be shunted around the chloroform,
securing thereby any desired modification in the percentage of vapor borne by
the air.
The method becomes more efficient the larger the volume of air delivered
and the greater the dilution of the chloroform vapor. At the point where all air
needed for tidal volume is charged with the minimal amount of chloroform
needed to induce and maintain full anesthesia this delivery becomes the most
even and efficient method of chloroform delivery.
APPARATUS. — As a source of air supply, a foot bellows, or preferably a
mechanically driven small air compressor, is the most efficient portable ap-
paratus. As a vaporizer, the Gwathmey bottle is useful since with this any
portion of the air may be blown across or be shunted around the chloroform.
Compressed oxygen may be used as the vehicle. The smoothness of anesthesia
seems to depend upon an even flow of oxygen to deliver an even percentage of
chloroform, rather than upon any effect of the gas itself.
TECHNIC. — For induction, any type of closed face mask may be connected
to the delivery apparatus. The breathing bag is filled with dilute vapor, i. e.,
less than 1 per cent. A flow of fresh vapor and air at the rate of 5 liters per
minute is established and the percentage soon raised to between 2 and 3 per
cent. The volume of delivery is increased to at least 8 liters or a volume suffi-
cient to fill a 2-gallon bag within 60 seconds. This quantity of fresh air should
flow continuously, otherwise an element of asphyxia enters into the chloroform
anesthesia. Exact strengths of chloroform vapor may be automatically pre-
pared and measured by the anesthetometer. With the onset of anesthesia the
vapor strength is lessened until a line of equilibrium is reached. With chloro-
form this is not so well established as with ether, but is somewhere between
5 and 11 mm. of vapor pressure.
After induction, if desired, the delivery may be changed, as with ether, to
the pharyngeal or intratracheal type, delivering a volume of 18 liters per
minute of the same strength of vapor as by face mask methods.
NITEOUS OXID
The anesthetic value of nitrous oxid gas was discovered by Wells in 1843.
Since that time it has become the anesthetic of choice for short operations, when
safe, light, transitory anesthesia is desired. In the last 2 decades the use of
nitrous oxid has been extended to anesthesia for prolonged operations, by
adding to the respired gas a proper percentage of pure oxygen.
Nitrous oxid (N20) is a stable, non-irritating, non-toxic gas, of sweetish
taste and odor. It is formed in the decomposition, of ammonium nitrate by
heat. Small plants for the manufacture of the gas are on the market. The gas
so obtained is somewhat cheaper and less liable to contain toxic by-products
GENERAL ANESTHESIA 111
than the gas of commerce. The commercial product is obtainable as a liquid,
stored in portable steel cylinders under vapor tension of about 760 pounds.
PHYSIOLOGICAL ACTION OF NITROUS OXID
Introduction. — Nitrous oxid is supposed to act as an anesthetic chiefly by
decreasing the oxygenation of the nerve tissue. It accomplishes this both by
displacing oxygen from the respiratory tract and possibly by loose combination
with the hemoglobin of the blood. Additionally there is a direct anesthetic
interference of unknown nature with the functional activity of the neuron.
The objective in the administration of nitrous oxid is that the highest ten-
sion of the gas possible be maintained in the body. Of necessity, at the same
time so much oxygen must be allowed to reach the blood and neuron as will
keep the flame of subconscious existence alight, and such a fresh tidal volume
must be supplied as will adequately wash from the respiratory tract gaseous
excrement such as carbon dioxid.
Physiological and Toxicological Action of Nitrous Oxid Undiluted. — On in-
haling the pure gas, one experiences within 2 full breaths a general sense of ex-
pansion and a desire to inflate the lungs. Then come a peculiar, pleasurable
"thrill" and a ringing in the ears. Within 4 to 6 breaths, consciousness is lost.
A transitory period of subconscious excitement is now passed through, which
gives way, within from 10 to 15 inspirations, or usually within 1 minute, to
rapid, full breathing, followed in the second minute by deepening cyanosis,
partial relaxation, and complete general anesthesia.
Full anesthesia is usually established by the thirtieth breath or within 2
minutes, although no rule as to time can be laid down, since many variable
factors enter, such as the depth and frequency of respiration and the reserve
oxygen capacity of the blood. The most reliable indication of anesthesia is the
quickened, irregular rhythm and deepening of respiratipn together with the
onset of stertorous inbreathing. Deep snoring occasionally occurs, or the breath-
ing may become slow and shallow with labored expiration. In this stage the
pulse is quickened about 20 to 40 beats per minute, and the blood pressure
increased 30 to 60 mm.
At the first sign of anesthesia, a short surgical operation may be proceeded
with. For dental operations the subject is allowed to proceed about 4 breaths
into the stertorous and asphyxial stage.
If atmospheric air or oxygen be now breathed, the color rapidly becomes
normal. The state of anesthesia persists for about 40 seconds after discon-
tinuing the anesthetic. This is followed by a period of confusion and excite-
ment (the "laughing gas" stage), which may last 20 seconds to 2 minutes.
Nausea, vertigo and headache may now follow, usually being of transitory
character.
OVERDOSAGE OF NITROUS OXID.- — If the undiluted anesthetic be con-
tinued, the color becomes livid, the muscles stiffen, jactitation of asphyxia ap-
112 SUKGICAL ANESTHESIA
pears respiration .grows more labored and stertorous. The pupil dilates widely,
the rapid pulse becomes slow and the heart action irregular and labored
blood rises 60 to 100 mm., then begins to fall, the color turns a dark bluish
gray, the jaws and thoracic muscle become fixed in tonic spasm, the epiglotti
is aspirated tightly over the glottis aperture, and the thoracic muscle becomes
fixed in tonic spasm. The heart becomes dilated, but continues forceful work for
a few minutes, during which time resuscitation may be accomplished if the
asphyxia be relieved, otherwise death rapidly ensues. Even in the first stage of
overdosage, cardiovascular strain may result in permanent lesions to heart and
arteries.
If air or oxygen be allowed before the heart action ceases, resuscitation
takes place spontaneously, since the respiratory mechanism usually makes the
last gasp which relieves the asphyxia, and results in return of the respiratory
rhythm. However, the epiglottis may be sucked tightly by violent inspiratory
effort into the chink of the glottis. Death from asphyxia follows if the condi-
tion be not relieved. The relief is afforded mechanically by raising the epi-
glottis, preferably by grasping the linguo-epiglottic ligament between 2 fingers
and carrying the entire base of the tongue forward. But this maneuver, as
well as artificial respiration, is difficult on account of the tonic spasm of the
jaw and thorax muscles. This respiratory spasm is less marked in asphyxia
of gradual onset.
By proper admixture of air and anesthetic the asphyxial stage is held in
abeyance. This requires 30 per cent, of air. However, by this large dilution,
chiefly with inert nitrogen, the tension of nitrous oxid in the blood is so lowered
that irregular and unsatisfactory anesthesia results. If, however, pure oxygen
gas be the diluent in place of air, the tension of the nitrous oxid may be kept
much higher and at the same time oxygenation is more perfectly controlled.
For continuance of life only 6 or 7 per cent, of oxygen is required by normal
man in the tidal gases, against 30 per cent, of air.
Physiological Action of Nitrous Oxid-Oxygen Mixture. — On inhaling nitrous
oxid mixed with 6 to 8 per cent, by volume of oxygen, the normal man ex-
periences less sense of general expansion than on inhaling pure nitrous oxid.
All the symptoms of anesthesia come on less rapidly, and the anesthetic 'stage
is reached without the symptoms of asphyxia which mark the inhalation of
pure nitrous oxid. Memory is lost in about 12 inspirations. Analgesia is now
present even before the subconsciousness zone is entered. Next a slight stage
of subconscious excitement is passed through, which gives way in about 4 to 6
minutes to light surgical anesthesia. Superficial reflexes may be present for 15
minutes or persist through prolonged operation. The deep reflexes are never
abolished, and muscular relaxation does not become complete. Suspension of
function in the lower reflex motor and sensory centers is not to be achieved in
normal man by nitrous oxid, unless supplemented by a basic narcotic, by a
hydrocarbon anesthetic, or by an undesirable degree of asphyxia.
The breathing under nitrous oxid oxygen is full, regular, and of moderately
GENERAL ANESTHESIA 113
increased rate, with slight inspiratory roughening. It. becomes exaggerated
under stimulation of the trauma of operative procedure, or by carbon dioxid
accumulation resultant from repeatedly rebreathing expired gases. The breath-
ing may also become of excited character in very light anesthesia.
The pulse is of moderately increased rate, of full quality and usually of 5
to 20 mm. increased pressure. The pressure is increased, not by the action of
nitrous oxid itself, but by slight asphyxia and retention of carbon dioxid so com-
monly present. With full oxygenation and with a sufficiency of fresh gases,
there is little or no rise in blood pressure. Under this anesthetic the pressure
remains well sustained despite hemorrhage, trauma, and other depressants of
blood pressure, so long as the anesthetic be continued. The blood vessels are
engorged and bleed excessively in the operative field. The blood is dark. The
skin is usually moist and slightly cyanotic to pink, depending on the degree of
oxygenation. The suffusion of the skin and heat loss by the evaporation are not
so great as with ether.
Anesthesia deepens through the first half hour. Usually the oxygen may
be gradually increased up to 11 per cent, in the tidal volume (about 13 per
cent, in a delivery of 10 liters per minute) without altering the physiological
state of light surgical anesthesia.
On withdrawal of the anesthetic, after full anesthesia for an hour or more,
complete consciousness is usually regained within 5 minutes, and with very
little nausea, headache, or the other sequels of the hydrocarbon anesthetics.
The more prolonged and intense the anesthesia, the longer the stage of recovery.
The stage of recovery occasionally lasts for an hour or more, and is some-
times accompanied by vomiting of a nature more acutely distressing than that
of hydrocarbon anesthetics. The patient occasionally continues cyanotic or
of greenish or reddish hue for several days. This has been ascribed to impuri-
ties in the gases, notably nitrogen dioxid.
Pulmonary complications, such as bronchopneumonia from aspiration, or
lobar pneumonia from exposure and lowered vitality, are less common than
after ether or chloroform anesthesia. Circulatory complications — hemiplegia,
cardiac dilatation and cardiac decompensation — have been noted after skilled
administration, although not with frequency as after the asphyxial anesthesia
of undiluted nitrous oxid. These cardiovascular complications, together with
the light degree of true anesthesia and the ever imminent asphyxia, constitute
the physiological objections to this anesthetic.
Zones of Nitrous Oxid Anesthesia. — Zones of anesthesia may be differen-
tiated, each with a definite symptom-complex according to the percentage of
oxygen in a given mixture. The percentage of mixture inspired in each zone
is in the average constant and basic for the animal kingdom. In man it re-
quires about 5 minutes to establish an anesthetic equilibrium in any given
zone. Individual requirement toward higher percentage of oxygen is common
when there is present any abnormal condition of tidal volume or of quality or
rate of blood flow. For example, diminution of tidal volume from obstruction
9
114
SURGICAL ANESTHESIA
or breath holding, diminished oxygen-carrying capacity of the blood by low
hemoglobin, and diminished rate of blood flow, all require higher percentage
of oxygen than the average for that zone of anesthesia. The carrying capacity
of the blood for oxygen is much diminished by anemia and by septic conditions ;
second, the capacity seems to be lessened and the necessity for higher per cent.
of oxvocii is evident in rapidly growing children and in patients of rapidly
increasing weight; third, the carrying capacity, being in direct ratio to the
rate and volume of the blood flow, is lessened in asthenic states, such as old
DEPTH OF
ANAESTHESIA
DEGREE OF
ASPHYXIA
DEGREE OF
RELAXATION
PERCENTAGE IN
TIDAL GASES
EXTRACTION or TEETH
INCISION OF ABSCESS
(USE CONDEMNED)
TONIC &CLOWC
SPASM
CONSIDERABLE
(DANGEROUS)
ASPHYXIAL
RIGIDITY
PARTIAL
(DANGEROUS)
MODERATE
CYANOSIS
ABDOMINAL
SURGERY
SURFACE SURGERY
OR ABDOMINAL SURGERY
WITH SUPPLEMENTAL NARCOSIS)
PARTIAL
COMPLETE
K.H ANALOE8.A
EQUAL PARTS OF AIR ALLOWED
FIG. 22. — ZONES OF NITROUS OXID-OXYGEN ANESTHESIA IN NORMAL MAN WITHOUT SUPPLEMENTAL
NARCOSIS.
age, cardiac decompensation and conditions of disease. Any of these factors
which decrease the oxygen intake by a lessened tidal volume, or decrease the
oxygen-carrying capacity of the blood by lessened hemoglobin or rate of blood
flow, must be compensated for by increase of oxygen in the mixture adminis-
tered to that patient.
The zones charted in Figure 22 were determined in routine anesthesia at
the Roosevelt Hospital, except the most dangerous zones which were determined
by insufflation on the dog. For the analgesia zones I am indebted to Dr.
0. K. Teter.
The percentage of the lethal zone is used for short operations such as ex-
traction of teeth. The asphyxial mixtures of this zone «»hould be abandoned
for those which induce anesthesia more slowly and safely. Anesthesia induced
in the lethal zone subjects the patient to severe cardiovascular strain, and car-
ries him to within a minute or two of death from asphyxia. The profound
and deep zones are frequently invaded by error during the routine administra-
GENERAL ANESTHESIA 115
tion and are rapidly retreated from, by raising the percentage of oxygen when
oncoming asphyxia is observed. By intratracheal insufflation a dog may be kept
alive in the profound zone for half an hour. Man may be carried in the deep
zone if the tidal volume is large and no asphyxial obstruction or thoracic fixa-
tion presents, yet the margin of safety is small. The medium zone is useful only
for the first few minutes of induction, as an undesirable degree of asphyxia is
soon induced. Some anesthetists utilize the physiologically disadvantageous as-
phyxia of this zone for an additional degree of anesthesia on resistant subjects. It
is much safer to utilize the lighter zones and supplement the narcosis by ether.
The light zone is the one desirable for abdominal surgery. The perfect
relaxation of the hydrocarbon anesthetics is never present, but if relaxation is
desired, it may be secured in part by supplemental narcosis or local anesthesia.
The very light zone is the desirable one for surface surgery, such as amputa-
tion of the breast. Both this and the subconscious zone may serve for all de-
grees of operative work when supplemented by ether. In fact, these are the
ideal zones, since in these zones the blood pressure is not raised, the color is
normal, the breathing is not exaggerated and there is no asphyxia.
On the usual volume of delivery of 8 to 10 liters of gases per minute, the
percentages in the gases delivered must be about 2 per cent, higher than those
charted above on account of dilution with expired gases from which the oxygen
has been in part absorbed. In patients who are anemic or toxic from disease
or whose respiratory volume is small or who have diminished blood flow, a higher
percentage of oxygen is required to maintain the same oxygenation of the tis-
sues. The percentage of oxygen needed in the inspired gases is approximately
in direct ratio to the degree of anemia or intoxication. For example, a patient
with 50 per cent, hemoglobin or half the normal oxygen-carrying capacity re-
quires for the zone of light anesthesia 20 per cent, of oxygen in the tidal volume
of respiration, instead of 10 per cent, mixture, as does normal man.
The stimulus of operative trauma elevates the blood pressure 10 to 30 mm.
in all zones, even in the zone of profound anesthetic asphyxia. Nitrous oxid
has not the ether effect in blocking efferent sensations by direct action on the
nerve ends. Therefore, it provides no zone which protects against harmful
stimuli, as do the hydrocarbon fat-solvent anesthetics.
APPARATUS FOR NITROUS OXID-OXYGEN ANESTHESIA
Inhaler. — As it is essential to exclude dilution by air the face mask should
fit snugly. To the mask should be connected in close proximity a light rubber
reservoir bag of 1 or 2 gallon capacity for the gas. The inhalers supplied by
dental houses for pure gas administration are ineffective for surgical anes-
thesia. For surgical work the Gatch, Boothby, Gwathmey, Coburn and Teter
inhalers may be mentioned as excellent types. A proper mask should have the
following features : A metallic or celluloid mask enclosing the area of the nose
and mouth, the edge of the mask being properly shaped to the average con-
116
SUKGICAL ANESTHESIA
tour and rendered gas-tight on slight pressure by an inflating rubber ring; a
series of valves, so that the gases on exhalation may be wasted into the outer
air, or be returned into the original reservoir bag for rebreathmg.
may provide for inhalation of atmospheric air as desired.
Gas Supply.— The most convenient supply of gases is that compres
commercial cylinders.
Apparatus for Control of Gases. —CRUDE APPARATUS WHICH DOES NO'
MEASURE.— In the simplest form of apparatus both cylinders are connected by
a Y tube to the inhaler bag, and the flow of each is controlled by a valve at the
cylinder head. An efficient apparatus may be improvised by strapping 2 tanks
together so that they sit
securely and leading the
outflow by Y connection
into a common tube which
runs to an inhaler. As
each gas is required, the
cylinder cock is opened;
the oxygen, being in gase-
ous form, flows smoothly,
but the nitrous oxid, being
liquefied, boils and sput-
ters. The flow becomes
more even and controllable
when a reducing valve is
attached to the tank.
These reducing valves with
proper pressure gauges are
common articles of com-
m e r c e supplied by the
manufacturers of nitrous
oxid and oxygen gas. A
good form of stand for
holding and controlling the
raw cylinders is the Gatch
apparatus.
An extensively com-
mercialized type of deliv-
ery apparatus, mentioned
to be condemned on ac-
count of the misinforma-
tion which it yields, is that which depends on the simultaneous opening of valves
or ports of different sizes, as a means of measuring the relative volume of the
two gases delivered. Dependence on this inaccurate type of measurement may
lead to distressing misjudgment and asphyxial death, especially in inexperienced
Fio. 23. — THE BOOTHBY APPARATUS FOR NITROUS OXID-OXYGEN,
AIR AND ETHER MIXTURES. A, Water chamber, a sight feed
for the different gases, bubbled through the water; B, ether
vaporizer; C, reducing valves and pressure gauges; D, face
mask; E, air-pressure generator.
GENERAL ANESTHESIA
117
hands. Simple apparatus, with alternate manual opening and closing of valves
and visual or auditory estimation of the proportion of gases delivered, is much
to be preferred to these inaccurate instruments.
APPAKATUS WHICH MEASURES.— The Teter apparatus measures the gas
FIG. 24. — CONNELL NITROUS OXID, OXYGEN, ETHER FLOW CONTROL. A, Nitrous oxid instantaneous
gas-flow gauge (piston type); B, oxygen gauge (piston type); C, parachute gauge, combined
gases; D, ether tank; E, ether dropper; F, gas-control cocks; G, outlet.
flow by gradual opening of a graduated valve. It is approximately correct so
long as the valves remain unworn and true, and if the pressure is accurately
controlled.
The Boothby apparatus (see Fig. 23) depends for measurement on the
bubbling of gases through water as a means of estimating the rate of flow. It
is much more elastic and accurately adjustable than the foregoing, since the
parts do not wear nor does the pressure need to be constant.
The McKesson apparatus depends on the suction effort of inspiration,
open adjustable parts and the aspiration of oxygen and nitrous oxid from 2 bags
118 StJRGICAL ANESTHESIA
of balanced pressure. The apparatus is accurate in measurement kit has the
fault of requiring for its operation aspiration effort on the part of the patient.
The Connell apparatus (see Fig. 24) is a measuring unit of the instan-
taneous gas flow gauge type. It is designed for use between the gas supply and
the inhaler and permits of accurate constant measurement of each gas. It
consists of two Connell instantaneous gas flow gauges of the piston type. Each
gauge may be connected, one to nitrous oxid, the other to the oxygen supply
under any pressure from 1 up to 150 pounds. By opening a pin valve the pis-
ton rises and accurately reads the volume of gas flowing each instant. The
oxygen gauge reads in quarter liters of gas per minute up to 6 liters. The
nitrous oxid gauge reads in 2 liter steps up to 16 liters per minute. These
gauges are mounted on an aluminum base containing a small electric stove.
Ether may be fed by the drop into the gases from a 2-ounce tank through a
sight feed. The combined gases find exit through a third gauge, the Connell
parachute gauge, reading from 6 to 24 liters per minute. The entire apparatus
weighs about a pound.
TECHNIC OF ADMINISTRATION
Nitrous Oxid. — Eor short operations such as incision of abscess, the inhaling
bag is filled with 8 liters or 2 gallons of pure gas. The face mask is securely
fitted and the valves so adjusted that the first 4 exhalations of the gas are dis-
carded together with the nitrogen and oxygen that were present in the respira-
tory tract as tidal and residual air. The exhalation valve is then closed and
the gas is rebreathed to and fro until sudden increase of the depth and fre-
quency of respiration marks the onset of the stage of anesthesia. The mask
may now be removed and the anesthesia will persist for about 40 seconds. If
a longer operation be contemplated, a proportion of atmospheric air must be
allowed by occasionally opening an air inlet, or by raising the mask for an
instant during inspiration. Eresh nitrous oxid must be supplied as this is lost
or becomes too diluted with air.
To and fro rebreathing of the gases, for anesthesia of short duration, is of
advantage because in this way anesthesia is secured with less muscle twitching,
thoracic fixation, and cardiac strain than when each tidal volume is of fresh
nitrous oxid.
The usual anesthesia quickly achieved with pure nitrous oxid depends in
large measure on the state of partial asphyxia induced. While for small dental
procedures this short asphyxia is attended with little danger other than that
incident to the cardiac strain, yet for the more prolonged anesthesia required
in surgery, even for procedures of 1 minute's duration, the asphyxial anes-
thesia of undiluted nitrous oxid should be abandoned for the true, non-asphyxial
anesthesia secured by nitrous oxid-oxygen mixture.
Nitrous Oxid-Oxygen Mixture.— General Consideration. — The preferred mix-
ture for induction is 6 to 8 per cent, of oxygen in nitrous oxid administered
GEKEKAL ANESTHESIA 119
in quantity of about 6 to 10 liters a minute. The first few exhalations are dis-
carded. Thereafter the exhalation may be mixed with the fresh gases and to
and fro breathing is permitted. The rebreathing bag may be emptied of old
gases and filled with fresh every 1 or 2 minutes or preferably a slow even de-
livery and discharge are established. Within 2 minutes the percentage may
be raised to 9 per cent. If no reliable measuring apparatus is available, these
percentages are approximated by guess work, using the patient as an index.
Any respiratory embarrassment or deepening cyanosis calls for higher per-
centages of oxygen. The stage of slight excitement lasts usually about 3 min-
utes. Light surgical anesthesia comes on in about 5 minutes and gradually
deepens. The color, the respiration and the pulse must be carefully watched,
and signs of asphyxia quickly noted and relieved by higher percentages of oxy-
gen or air. The color should never show more than the slightest tinge of blue-
ness and preferably no cyanosis whatsoever. The pulse should be of moderately
increased frequency and of increased force and volume. A slow, asthenic pulse
or a rapid one of weakened quality shows danger to the circulation and immi-
nent asphyxia, as do shallow, jerky respiration, muscular twitching, or an ashy-
gray cyanosis. Much exaggerated breathing may mean too superficial anes-
thesia, or, on the other hand, carbon dioxid retention. This latter is met by
more freely washing out the lungs with a larger supply of fresh gases. The
upper respiratory tract must be efficiently open. If there is any obstruction to
the ebb and flow of tidal volume, the intrapulmonary gases become so rapidly
depleted of oxygen that asphyxia shortly appears. Nasal obstruction demands
that the mouth be kept open by gag or by breathing tube.
When relaxation is unsatisfactory it cannot be secured by deepening the
asphyxia ; to the contrary, relaxation is accomplished by increasing the oxygen
percentage and the total gas flow, or by supplemental ether anesthesia.
Occasionally the percentage of oxygen may be increased as high as 12 per
cent., or under conditions of shallow respiration and asthenic states even
higher. When the gases are excessively rebreathed and the total supply is
small, as high as 15 to 20 per cent, of oxygen is required in the fresh supply
to yield in the tidal gases the proper anesthetic mixture of from 8 to 11 per
cent, of oxygen. Percentages lower than these may be used in short procedures
of 5 minutes' duration, since the blood carries for some minutes of anesthesia
a reserve supply of loosely combined oxygen. However, when the reserve sup-
ply becomes depleted after 3 or 4 minutes, any depression of the oxygen below
6 per cent, is fraught with danger of sudden collapse of the respiratory center
from asphyxia. Percentages of oxygen higher than 11 are useful only for very
light anesthesia or when nitrous oxid is supplemented by other anesthetics or
alkaloidal narcotics. The operatoi must work in harmony with the anesthetist,
and not expect the complete and continuous anesthesia and relaxation of the
other general anesthetics.
Methods of Delivery in Detail. — The two basic types of delivery are the in-
terrupted flow and the continuous flow method of administration.
12o SURGICAL ANESTHESIA
THE 1NTEEEUPTED FLOW OR EEBREATHING METHOD (GATCH METHOD).
—This method requires the least apparatus and is the most effective of crude
methods. It is economical of gases and in the hands of the inexpert anesthetist
working with crude apparatus it is the method of choice.
The rebreathing bag is filled loosely with nitrous oxid and 1/12 part of
oxygen is added. The first 4 breaths are exhaled, washing out the residual air.
The exhaling bag is then closed, and the patient rebreathes the remainder of
the gases. Fresh nitrous oxid is now added and is slightly diluted with oxy-
gen (1/10 part). The patient is allowed to rebreathe these gases so long as the
color shows only a tinge of blueness. After a minute a small amount of oxygen
is added to replenish that which has been absorbed into the blood. The breath-
ing soon shows marked stimulation in frequency and in tidal volume because
of excitement and carbon dioxid accumulation. After 2 to 4 minutes the ex-
piratory valves are opened and the rebreathing bag almost emptied, to be filled
again with fresh gases. As little as 40 gallons of gas and 12 gallons of oxygen
may be consumed in 1 hour, yet better anesthesia is achieved by 120 gallons of
nitrous oxid and 15 to 20 gallons of oxygen per hour.
The anesthetist is constantly on guard against asphyxia. The patient may
rapidly turn blue and begin to twitch. More to be dreaded than this acute
asphyxia is the asphyxia of the asthenic type. In this type the pulse loses its
force, the respiration grows shallow with labored inspiration followed by a short
expiratory jerk, and the skin turns a dirty gray. When either of these types
of asphyxia appears the percentage of oxygen is immediately increased or pure
oxygen is substituted. For the asthenic type of asphyxia, showing as it does
circulatory danger, the effort to induce anesthesia by nitrous oxid alone is
abandoned and, with a liberal allowance of oxygen, ether narcosis is gradually
superimposed, or substituted entirely for that of nitrous oxid.
THE CONTINUOUS FLOW METHOD (BOOTHBY METHOD), — This is a more
rational method and yields a safer and more even grade of anesthesia. The
same outfit of face mask, rebreathing bag and valves is utilized, but the de-
livery apparatus is of such nature that a continuous flow of adjustable volumes
of the 2 gases may be established. To yield the best results the gases should
flow uninterruptedly at the rate of at least 8 liters per minute (120 gallons
per hour). Smaller volumes and intermittent flow result in carbon dioxid
accumulation, rapid breathing, cyanosis and poorly maintained degree of anes-
thesia.
The gases may be set flowing by guesswork from tank pressure preferably
reduced to at least 4 pounds, but some method of approximately accurate esti-
mation is far more satisfactory. As previously noted, the common commercial
cocks and ports, alleged to be minutely graduated in percentage and quantity,
are grossly inaccurate. The best crude determination is that of Boothby,
namely, bubbling each gas through water from graduated holes. With the
Boothby apparatus and its more portable modification, the Gwathmey-Woolsey
apparatus, the anesthetist soon learns at what rate each gas should bubble. The
GENERAL ANESTHESIA 121
total flow should fill a 2-gallon bag in 60 seconds. Thus a constant fresh delivery
of 8 liters per minute is established. Escapement of breathed gases is permitted
best by an automatic pressure release valve at the mask. One or 2 mm. or more
of positive pressure at the face mask ensures against aspiration of air into the
mask, and yields, therefore, a more even grade of anesthesia than if no pressure
is maintained. After the first 10 minutes it becomes practicable to strike such
an even rate of flow that the apparatus need scarcely be further adjusted
through subsequent hours of anesthesia.
Only in case of respiratory obstruction or other accidents of anesthesia need
the nitrous oxid be cut off and the oxygen flow increased. Cyanosis should at
no time be present. If deeper anesthesia or muscular relaxation for abdominal
surgery is desired, this is best obtained by a slow continuous dropping of ether,
beginning at 2 or 3 drops per second and gradually decreasing to 1 drop every
3 seconds (see Nitrous Oxid Adjuvants).
With the Connell instantaneous gas-flow gauge apparatus, the gases may be
measured with accuracy and the ether added in definite proportion. The ap-
paratus is connected to any pressure of gas from 1 to 450 pounds, but most con-
veniently to a flow reduced from tank pressure to about 4 pounds.
CONNELL TECHNIG OF NITROUS OXID ADMINISTRATION. — For all
cases, children and adults, nitrous oxid is set flowing at 8 liters per minute,
with the single exception of large muscular men of active metabolism, who re-
ceive 10 liters per minute. The oxygen is adjusted to % liter per minute.
This volume is fed into any proper type of face mask and breathing bag, where
it mixes with the expired gases. As soon as faint cyanosis appears, usually
within 2 minutes, the oxygen flow is raised to 1 liter and shortly thereafter
to 1% liters per minute. This results in a mixture of about 13 per cent, oxy-
gen, which, when mixed with expired gases, yields about 11 per cent, of oxygen
constantly present in the breathing bag. On this mixture nearly all patients
come to anesthetic equilibrium in light anesthesia. If sufficient anesthesia
cannot be secured by nitrous oxid, ether is added as indicated (see Nitrous
Oxid Adjuvants). After 20 minutes the oxygen may usually be increased to
1% liters per minute. For anemic and septic cases the oxygen must be rapidly
increased as need arises, until the level of the patient is found. Rarely are more
than 2 liters of oxygen per minute required, unless the tidal volume of respira-
tion be very small.
OTHER METHODS.- — INSUFFLATION. — Nitrous oxid-oxygen mixture may be
administered by pharyngeal and intratracheal insufflation by the technic already
described under these methods. This administration is wasteful, requiring 20
to 26 liters of fresh gas per minute, and is less advantageous than ether-air mix-
ture.
PARTIAL INSUFFLATION, FOR AUTOMATIC OR POSITIVE PRESSURE ANES-
THESIA.— After anesthesia has been induced by face mask, a flow is established
into the pharynx by the nasal route, delivering 8 to 10 liters per minute. The
gases are expired through a pharyngeal breathing tube (see Fig. 25). The
122
SUKGICAL ANESTHESIA
patient receives a constant supply of fresh gas into the pharynx, and breathes
back and forth through this mouth tube. The expired gases are trapped in and
spill from a rubber breathing bag attached to this tube. This establishes an
automatic delivery, keeps the upper airway open, and relieves the anesthetist
FIG. 25. — PHARYNGEAL INSUFFLATION WITH REBREATHING. Connell method for differential pressure
in ether anesthesia, or for automatic delivery and economy of gases in nitrous oxid-oxygen anes-
thesia. (For the usual method of pharyngeal insufflation without rebreathing, the nasopharyngeal
catheters alone are inserted. See pages 95 and 96.)
from holding a face mask in place. If positive pressure is desired, the spill
cock from the breathing bag is partially closed until the bag is distended to the
desired pressure.
ADVANTAGES AND LIMITATIONS OF NITROUS OXID-OXYGEN ANESTHESIA
Nitrous oxid-oxygen mixture is the safest of all anesthetics for short opera-
tions. For long operations it is as safe as ether only when skillfully admin-
istered. Death from asphyxia may rapidly occur, and since the extensive
introduction of this gas into general surgery the reported and unreported
deaths have probably far exceeded those from ether. The anesthetic should be
given only by anesthetists thoroughly familiar with the required apparatus and
quick to recognize the symptoms of asphyxia in all its phases.
Anesthesia is induced rapidly and pleasantly and without irritation or
excessive secretion of mucus. Bronchopneumonia, which follows the inspira-
tory accidents of ether, is rarely seen, and the "exposure" lobar pneumonia
occurs less commonly than after ether and chloroform.
GENEKAL ANESTHESIA 123
Nitrous oxid has no known immediate nor remote toxicology other than
from asphyxia. It is the anesthetic of choice in acute pulmonary and renal in-
flammation.
The after-complications of general anesthesia are minimized, nausea and
vomiting are somewhat less common than after ether and chloroform anesthesia
of equal duration, and are usually transitory in character. The stage of re-
covery of sensibility is shortened. This rapid recovery of pain sensibility
may be classified as a disadvantage in major surgery.
Nitrous oxid is unsatisfactory to the surgeon who has been trained to work
unhampered because of the physiological limitations of this anesthetic, namely,
light anesthesia, incomplete relaxation, changed color value and excessive con-
gestion of tissue. Nitrous oxid often fails to hold in proper anesthesia vigorous
young adults, vigorous fat subjects, and those accustomed to narcotics, such as
alcohol, tobacco, morphin and cocain. To yield an anesthetic state approaching
in depth that of full ether and chloroform anesthesia, nitrous oxid must be
supplemented in action by preliminary narcosis of such undesirable narcotics
as morphin and scopolamin, or must be reinforced during the administration
by light ether anesthesia, or by efficient local analgesia.
Nitrous oxid is unsafe when respiration is restricted or obstructed in any
way. The narrow and collapsible gas way of the upper respiratory tract in
infancy and childhood renders nitrous oxid an unsafe anesthetic for children
under 8. It is unsafe where strain on the heart or high pressure may result
in decompensation, or arterial strain may result in apoplexy.
The increased cost of nitrous oxid-oxygen over ether anesthesia is a question
of hospital economics, the cost averaging not less than 2 dollars per hour of
anesthesia.
NITKOUS OXID ANESTHESIA ADJUVANTS
Introduction. — Owing to the intrinsically light character of nitrous oxid-
oxygen anesthesia, as said above, it must frequently be supplemented for gen-
eral surgery by alkaloidal narcosis or by light ether anesthesia, or both.
Morphin with atropin or with scopolamin is the recognized alkaloidal adjuvant.
Without these adjuvants it is impossible to hold in surgical anesthesia robust
athletic individuals and those of alcoholic, tobacco, and other narcotic habits
without dangerous degrees of asphyxia.
Ether Anesthesia Supplemental to Nitrous Oxid. — By proper combination,
the best points of both of these anesthetics may be secured. By combining the
very light zone of nitrous oxid anesthesia, i. e., 11 to 14 per cent, of oxygen,
with the light subconscious zone of ether anesthesia, i. e., a vapor pressure of
15 to 25 mm., a physiologically ideal state of general anesthesia may be in-
duced, for the light transitory anesthesia of nitrous oxid is secured together
with the relaxation, sensory nerve-end paralysis and postoperative analgesia of
ether. The asphyxial zones of nitrous oxid may be avoided, also such concen-
124 SURGICAL ANESTHESIA
tration of ether vapor as actively stimulates mucus secretion in the bronchi.
Nor do the after-effects exceed those of unsupplemented nitrous oxid adminis-
tration.
TECHNIC 1. — The patient is primarily anesthetized by nitrous oxid oxy-
gen. Ether is now slowly added, increasing the vapor pressure to approximately
86 mm. by adding 65 drops of ether for each gallon of gas, usually 2 drops
per second. At the same time the oxygen percentage may be increased to 12
per cent. When anesthesia is complete and general relaxation has been estab-
lished, usually within 6 minutes, the anesthetic state may be readily continued
by nitrous oxid-oxygen alone, usually without further recourse to ether.
TECHNIC 2. — At any time during the course of nitrous oxid-oxygen anes-
thesia, when it becomes necessary to secure efficient anesthesia or to establish
relaxation, the administration of ether is desirable. This is a far safer pro-
cedure than to persist in attempting to get complete anesthesia in unsupple-
mented nitrous oxid anesthesia by reducing the oxygen supply.
About 86 mm. of ether vapor pressure (i. e., 65 drops of ether per gallon
of gas) is necessary to establish an efficient state of anesthesia within reasonable
time, i. e., 3 to 5 minutes. When relaxation is secured, the ether is discon-
tinued or reduced to minimal dosage, i. e., 20 mm. of vapor pressure or 15
drops of ether per gallon of gas.
TECHNIC 3: THE BEST METHOD. — By starting the administration of
ether immediately in nitrous oxid administration, adding less than 22 drops of
ether per gallon of gas, the dosage of ether vapor may be kept constantly below
30 mm. of ether vapor pressure. The oxygen content in the gas may be gradu-
ally increased to 15 per cent. Thus the safest, most satisfactory state resultant
from any general anesthetic is obtained, a state combining the light subcon-
scious zone of both ether and nitrous oxid into one of deeper yet controllable
anesthesia. A proper ether now is a drop every 2 seconds for the first half
hour, thereafter a drop every 3 seconds. The gases are best delivered continu-
ously, 10 liters per minute. Thirty grams of ether per hour and 150 gallons
of gases are used.
Alkaloidal Narcosis Supplemental to Nitrous-Oxid. — Preliminary alkaloidal
narcosis renders the course of nitrous oxid anesthesia smoother, increases the
depth of anesthesia, allows an increase of 1 to 3 per cent, in the oxygen per-
centage, and renders the necessity for ether less frequent. However, these nar-
cotics desensitize the respiratory center and increase the danger of respiratory
collapse from asphyxia. Scopolamin or hyoscin also occasionally exercises
rapid powerful depression on the circulatory mechanism.
TECHNIC l. — The usual procedure is to administer, 1 hour before anes-
thesia, % grain of morphin with atropin, grain 1/150. Or the dose of morphin
may be % grain given 1 hour before anesthesia, and if no narcotic effect is
manifest the dose may be repeated % hour later. With athletic, robust indi-
viduals the dosage may be doubled. In total not more than y2 grain of morphin
nor. 1/75 grain of atropin should be administered.
GENEKAL ANESTHESIA 125
TECIINIC 2. — Morphin, 14 grain, with scopolamin, 1/100 grain, is ad-
ministered 1 hour before operation. If no narcotic effect is evident, the dose is
repeated in y2 hour.
With these narcotic adjuvants a susceptible patient may easily be carried
in satisfactory light surgical anesthesia on a 10 to 12 per cent, oxygen delivery,
but the physiological state is not so safe or satisfactory as with ether as an
adjuvant.
Postoperative Narcosis. — Unless a preliminary narcotic has been given, post-
operative alkaloidal narcosis is a necessity following nitrous oxid anesthesia, as
no merciful after-period of somnolence and analgesia is present as with ether.
The usual technic is to administer hypodermically morphin, i/4 grain, 5
minutes before discontinuing nitrous oxid anesthesia.
ETHYL CHLORID
Introduction. — Ethyl chlorid is a rapidly acting, intense yet transitory
anesthetic. For practical purposes it may be considered as a very rapidly acting
chloroform. It has such properties of rapid volatilization and diffusion, and
such intense action as a lipoid solvent as to be controlled with difficulty in its
anesthetic effect.
For a time it was vaunted in England as possessing the quick action and
safety of nitrous oxid, but a series of fatalities brought disillusion to its advo-
cates. As a prolonged anesthetic it has had extensive trial and been found so
uncontrollable as to be dangerous in the deeper stages of full surgical anes-
thesia, and to induce in exaggerated form the evil after-effects of the hydro-
carbon anesthetics.
At present it is used, with the same indications as nitrous oxid, for transi-
tory anesthesia where the gas is not available. It is occasionally employed to
hasten the induction of ether anesthesia. Its use for the maintenance of anes-
thesia beyond 5 minutes has been largely abandoned. In the light stages of
primary anesthesia it is less dangerous than chloroform, but in the stage of
recovery death from cardiac collapse is more frequent. It is not a safe anes-
thetic to use in a sitting posture as is nitrous oxid.
Physiological Action. — Ethyl chlorid is locally a refrigerant by rapid vapori-
zation. It has very little odor and in the required percentage is not an irritant
to the respiratory tract. On the circulation it has the same effect as chloroform,
being a primary paralyzant of heart muscle and depressant of blood pressure.
EESPIEATION.- — After a few inhalations respiratory movement grows full
and more rapid. Within 15 breaths slight stertor marks the onset of anesthesia.
In the stage of light anesthesia with excitement there may be respiratory em-
barrassment, cyanosis, and asphyxia from spasm of the jaw or the glottis, or
from thoracic fixation. With this anesthetic asphyxia is badly borne and must
be promptly relieved.
SENSOEIUM. — Consciousness is lost with remarkable rapidity. By closed
126 SUKGICAL ANESTHESIA
methods and with rapid admission of the vapor, consciousness may be abolished
within 4 breaths, and as a rule without noticeable discomfort or resistance. By
the open methods and in resistant subjects a stage of excitement may be present,
with some respiratory halting and slight general muscular rigidity.
ZONES OF ANESTHESIA. — Without doubt the same zones of anesthesia exist
as with ether and chloroform, but it is impracticable to maintain continuously
any desired level of anesthesia, since the changes are so rapid with this vola-
tile drug.
Period of Recovery. — The period of recovery is brief. After a short admin-
istration the patient may regain consciousness within a few breaths, after longer
administration recovery may take 5 minutes. At times when sudden over-
anesthetization occurs, the degree of anesthesia may dangerously increase for
an instant by absorption of the anesthetic residual in the alveolar air. The
period of recovery largely depends on the duration of anesthesia and the rela-
tive tidal volume of respiration.
Recovery of consciousness is not infrequently followed by severe headache,
nausea, repeated vomiting and severe prostration. Late in this period even
several hours after the administration, a delayed collapse has added a number
of fatalities to the score of this anesthetic. This late collapse is more liable to
occur after prolonged administration, also when, for purpose of economy and
to deepen the anesthesia, a state of chronic asphyxia has been occasioned by
excessive rebreathing.
Technic of Administration. — There are two methods, the closed and the
semi-open.
CLOSED METHOD.— Into the inflated 2-gallon air bag of any closed face
inhaler, such as the Ormsby or the Bennett, liquid ethyl chlorid is sprayed
through any convenient vent, in dosage of about 1 to 2 c. c. for the child, up to
3 to 5 c. c. for the adult. Rebreathing is judiciously allowed for about 15
breaths, when a period of available anesthesia ensues, lasting a minute or more
after removing the mask. For more prolonged anesthesia fresh air must be al-
lowed by partially opening the air vents of the inhaler and adding fresh anes-
thetic as indicated, in dosage of % to 2 c. c. per minute.
SEMI-OPEN METHOD.— Either an Esmarch inhaler, well swathed in gauze
and moist toweling, is employed, or a special ethyl chlorid inhaler consisting of
rubber face mask with a 1 in. gauze-covered opening is selected. Onto the
mask is sprayed a continuous stream of ethyl chlorid, 4 to 5 c. c. per minute
until anesthesia ensues, when the dosage is decreased to y2 up to 2 c. c. per
minute.
The Esmarch inhaler is the simplest and safest mask, but involves the
largest wastage of the drug. Unless it is well swathed over the face with moist
toweling, proper anesthetic pressure of ethyl chlorid in the tidal air is secured
with difficulty.
For prolonged anesthesia it is far safer to superimpose light ether anesthesia
than to continue the ethyl chlorid alone. On the whole, ethyl chlorid meets no
GENEEAL ANESTHESIA 127
necessity in anesthesia which cannot be better supplied by ether, nitrous oxid
or chloroform.
THE ETHYL CHLORID GROUP OF DRUGS
A series of drugs has at various times been tried with the high fat-solvent power
and rapid action of ethyl chlorid. These have been found more objectionable than
ethyl chlorid, because either less stable, less controllable, or intrinsically more danger-
ous. Among these are ethyl bromid, ethidene dichlorid, amylene and pental, and
many recent proprietary mixtures and compounds, for the most part dilute ethyl
chlorid and bromid mixtures put forth with somniferous names and unsubstantiated
claims. The anesthetist should not be lured into the use of these mixtures, but use
only the 4 standard anesthetics of the highest purity obtainable, either singly or in
deliberately planned combination or sequence as the exigencies of anesthesia demand.
ANOCI-ASSOCIATION
Introduction. — Systematic effort has been made by Crile to exclude from
the central nervous system of a patient, the various afferent stimuli of fear and
pain. Crile believes that these stimuli exhaust the cell through the rapid dis-
charge of nervous energy and thereby predispose to shock during and after the
operation, and to postoperative neurasthenia. A series of measures to disasso-
ciate "the nerve cell from these noxious stimuli has been termed by Crile anoci-
asso elation.
The method deserves mention in detail despite its complexity and the toxic agents
employed, because of the widespread beneficial influence which the accumulated facts,
systematized procedures, and engaging hypotheses of anoci-association have had on
modern surgical technic; particularly toward increasing the efficiency with which
general anesthetics are now administered and toward emphasizing the necessity for
gentle, considerate, surgical manipulation even under ether and chloroform anesthesia.
Technic. — The first measures deal with the preoperative stage. Appre-
hension on the part of the patient is lessened by the reassuring attitude and
the efficiency of the surgical attendants throughout this period. Acute fear and
excitement at the time of operation are lessened by a small dose of morphin
(grain %) and scopolamin (grain 1/120). With especially nervous cases,
such as those suffering from exophthalmic goiter, even the time of operation is
unknown to the patient, and the anesthetic (nitrous oxid) is administered under
the guise of inhalation therapeusis.
For anoci-association during the second or operative period, Crile employs
nitrous oxid as the anesthetic agent, believing that the anesthetic effect of
nitrous oxid more efficiently protects the nervous system than even the fullest
action of ether. (This is not supported by general opinion and is in direct
divergence from more recent and carefully controlled observation.) In addi-
tion he employs a method of terminal nerve block by local anesthesia (see
Novocain and Local Infiltration Anesthesia for Major Operations, believing
128 SUEGICAL ANESTHESIA
that centripetal stimuli constantly bombard the nervous system, even during
efficient general anesthesia.
In the third or postoperative period, the after-pain of operation is blocked
by the long-continued local anesthetic effect of weak alcohol (50 per cent.),
or quinin and urea injected into the most sensitive tissues when the wound
is about to be closed and before general anesthesia has ceased. Thus, in
celiotomy the peritoneal suture line is widely blocked by subperitoneal infil-
tration, also the field of fascial and cutaneous suture.
The technic of the "shockless" operation by anoci-association is largely
based on the assumption that centripetal stimuli of operative trauma continued
under general anesthesia; that merely the consciousness of pain is removed.
This is true only for the lightest grade of general anesthesia, whereas the
deeper grades slowly induced and fully maintained block all except the most
vital stimuli, such as have to do primarily with blood flow, aeration and splanch-
nic control. (For order of disassociation by efficient general anesthetic, i. e.,
ether and chloroform, see Figure 16.)
DIFFERENTIAL PRESSURE METHODS IN ANESTHESIA
Introduction. — For certain intrathoracic operations it is desirable to estab-
lish an atmospheric pressure within the lung greater on the average than that
which exists on the chest wall. Such a differential pressure may be maintained
either by decreasing the pressure outside the lung (negative pressure or suction
method), or it may be maintained by increasing the atmospheric pressure
within the lung (positive pressure method). The purpose in establishing
differential pressure is to overcome the tendency of the lung to collapse and
become immobile when the pleural sac is opened. To overcome this tendency,
it is necessary to maintain a differential pressure within the alveoli at least 5
mm. (mercury column) greater than that which exists in the opened pleural
sac. By this pressure the elasticity of the lung is balanced and the lung re-
mains in partial or full distention and follows more or less completely in a
normal manner the movements of the thorax. Thereby, even if both pleural
sacs be opened, the normal ebb and flow of tidal air and aeration of blood con-
tinue. The differential pressure maintained must not be too great, for a
pressure continually in excess of 20 mm. retards the return of blood and lymph
to the thorax, and within 3 to 5 minutes a condition of shock is induced.
So long as the tidal volume is adequate to ventilate the lungs it matters
little in the physiological effect whether the necessary differential pressure of
5 to 20 mm. of pressure be maintained by gentle suction from without (nega-
tive pressure method) or by moderate pressure from within (positive pressure
method). Mechanically, however, the positive pressure methods have proved
so much more simple and generally applicable, and in addition the insufflation
methods have provided such an effective artificial ventilation of the lungs, that
these methods alone are in general use.
GENEEAL ANESTHESIA 129
Negative Pressure Method in the Sauerbnich Chamber. — APPARATUS. — The
chamber is an air-tight room built to withstand a negative pressure of a pound
or more. This room is of sufficient size to accommodate the operating table,
the operating staff and the equipment. The atmosphere of the room may be
exhausted, under control of the anesthetist, by a large rotary air pump. The
air exhausted is continuously replaced by the inflow of fresh air through valves,
which are released automatically at a given pressure. The patient's head pro-
jects from the chamber through a hole, the margin of which is adjustable by a
membrane and a collar snugly fitting the patient's neck.
TECHNIC. — The patient is anesthetized by the usual routine methods. At
that stage of the operation when differential pressure is desired all ingress
into the room is closed off except the inflow valves, and the room is exhausted
by the air pump. By adjusting the inflow valves the interior pressure of the
chamber may be kept at any desired degree of exhaustion, usually about 10 to
20 mm. of negative pressure. Anesthetization may be carried on by the usual
face mask methods by the anesthetist outside the room.
The only advantage of this method over the face mask method of positive
pressure is that the anesthetist can more freely adjust the mouth and upper air
tract than when the face is covered by a tight pressure mask. The mechanical
disadvantages of the method are obvious, in extensive and complicated equip-
ment. It has been almost entirely superseded by positive pressure methods.
Positive Pressure by Face Mask. — By delivering the anesthetic mixture un-
der pressure into a snugly fitting face mask, the rubber breathing bag becomes
gradually distended and maintains by its elasticity a constant pressure against
the alveolar air. Thus when the pleura is opened the lung does not collapse,
but tends to follow the movements of respiration in a normal manner.
APPARATUS AND TECHNIC. — As suitable masks the Gwathmey, Booth-
by, and Teter masks may be mentioned, although any snugly fitting face
mask will suffice. Masks fitted with an adjustable escape valve, which opens
and discharges when the pressure becomes excessive, are preferable; or to con-
trol the escapement, a tube may be led from a face mask and discharged into
water at a depth from 5 to 10 in. beneath the surface. This maintains the
necessary 10 to 20 mm. of pressure within the face mask.
For apparatus to generate and deliver the anesthetic mixture under pres-
sure, see page 97. A quantity not less than 8 liters per minute of fresh
mixture should be delivered, and preferably 15 to 20 liters. Usually 10 to 20
mm. of pressure at the face mask results in the necessary average increase of
5 mm. or more of pressure within the lungs. The lungs are kept only in gentle
distention, and this is maintained only for such period of the operation as is
necessary. The degree of positive pressure is lowered every few minutes, since
long-continued high pressure tends to produce shock.
To ensure an open upper air tract and avoid accident, a pharyngeal breath-
ing tube (see Fig. 28) should be placed and the depth of anesthesia should be
full and continuous, well beyond the vomiting stage.
10
13o SURGICAL ANESTHESIA
Positive Pressure by Pharyngeal Insufflation.— Pharyngeal insufflation is
much more effectual than face mask methods, since the mixture is delivered not
only where it can be more freely inspired and pressure more dirctly applied,
but also the upper airway may be kept widely opened. The anesthetist is
relieved from holding a face mask in place. (See Fig. 25.)
Positive Pressure by Intratracheal Insufflation. — The most effectual method
is the Meltzer method of intratracheal insufflation. 'Not only is positive pres-
sure easily maintained, but also an effectual artificial ventilation of the lungs
(see page 91). This is the only method whereby life can be continued with
both pleural sacs opened, and both lungs immobile or partially collapsed.
THE NEWER MECHANICAL METHODS OF ARTIFICIAL RESPIRATION
Intratracheal Insufflation. — The efficiency and technic of this method of
artificial respiration have already been considered (pages 91, 92). The objec-
tion to the method lies in the fact that, with absolute suspension of respira-
tory movement, a phase of negative pressure is at no time created to assist by
aspiration the return of blood and lymph to the thorax. To render insufflation
as thoroughly effective on venous flow as it is on aeration, the air current should
be interrupted about 4 times a minute and an inspiratory movement carried
out by extending the arms and lifting the short ribs, as in the Sylvester and
other standard methods of artificial respiration.
Pharyngeal Insufflation. — Air blown into the pharynx will be carried into
the lungs if the mouth and nose be held shut and the epiglottis be raised by
carrying the tongue and jaw forward. The best instrument for this method
of artificial respiration is the pharyngeal tube of Meltzer. This tube is a cylin-
der about 1 in. in diameter, flattened on the under side and presenting a large
fenestrum at its proximal end. This tube is thrust against the posterior pharyn-
geal wall and obturates the nose and mouth. The tongue is pulled out to raise
the epiglottis, and air is insufflated by a foot bellows or other apparatus. The
current of air is interrupted about 15 times a minute by alternately opening an
inflow and an exhaust valve. The air flows into the lungs under pressure and
is expired by the elastic recoil of the thorax. If the stomach becomes distended,
this is deflated by a small stomach tube passed through a space provided in the
Meltzer cylinder.
Pulmotor. — The pulmotor is an apparatus operated by compressed oxygen
which alternately exhausts and increases pressure in a face mask for purpose of
artificial respiration. The apparatus is started by opening the valve of an oxy-
gen cylinder. A face mask is attached to the apparatus and is securely adjusted
to the face, the patient's tongue having been drawn well forward.
The motive power — namely, the compressed oxygen — flows from a cylinder
through a Sprengel pump. This pump first sucks air from the face mask, then
blows air into the mask, the current being changed automatically by certain
mechanical devices, when a set degree of suction or of pressure is created in the
GENEKAL ANESTHESIA 131
face mask. A full tank of oxygen usually furnishes motive power for about
40 minutes of respiration.
The objections to the apparatus are : First, the limited motive power in the
compressed oxygen ; second, the complexity of the automatic mechanism ; third,
the excessive degree of pressure and of suction to which the mechanism may be
adjusted; fourth — not however inherent in the apparatus — the average ineffi-
ciency with which the upper respiratory tract is held open in the novice's at-
tempts at resuscitation. Properly used it is a very valuable apparatus for artifi-
cial respiration as well as an aid to venous circulation.
Lung-Motor. — The "Lung-motor" substitutes for the above, as the motive
mechanism in creating positive and negative pressures in the face mask, a
double acting piston pump operated by hand. Thus, motive power is more re-
liable and the degree of suction and of pressure is less severe than with the
pulmotor. Otherwise the general utility and mode of use are the same. In
neither apparatus is the small amount of oxygen which may be added to the
sufficiency in normal atmosphere of any material advantage.
THE CONNELL ANESTHETOMETER
Introduction. — The anesthetometer is an apparatus to vaporize exact
amounts of liquid ether and chloroform, and to accurately mix and measure
anesthetic vapors and gases. It is developed from a commercial gas meter.
The apparatus as originally designed is the most accurate and practical working
instrument yet devised for exact dosage by pulmonary diffusion of the various vapor
and gas mixtures. It has made possible the standardization of ether vapor adminis-
tration and of nitrous oxid-oxygen dosage (see tables under these subjects. The
construction plan of the original instrument is shown in Figure 26. This origi-
nal model has been supplanted for nitrous oxid-oxygen administration by a very
small and flexible, although somewhat less accurate, instrument, the Connell in-
stantaneous gas flow gauge (see Fig. 24). For ether-air administration, the original
instrument, for use outside of large hospitals and experimental laboratories, has been
modified into a smaller, more cheaply constructed, and less complex design, eliminating
all unessential or complex parts. Since the latter model is more generally acceptable,
it is described herein.
Description. — The simplified anesthetometer (Fig. 27) consists of three
assembled units : an air meter, an ether measuring unit, and a vaporizer. The
first unit, the air meter (A, Fig. 27) is a small commercial "dry gas-meter."
This is a necessary unit. In fact, by no other mechanism than an accurate
meter can air be sensitively measured and a liquid, such as ether or chloroform,
be simultaneously and automatically fed into the air current, and thus ac-
curately correlated to the bulk of air passed by the apparatus.
Air under light pressure from any generator, such as a foot bellows or
preferably a motor blower, is driven through the meter. This moves not only
the measuring and recording mechanism, but also a mechanism which feeds
132 SUKGICAL ANESTHESIA
into each 3 1/3 liters of air any desired amount of liquid ether from zero to
5.8 c. c. Thus the air may be impregnated by any vapor percentage from zero
to 28 per cent, by volume, or better expressed as partial pressure of ether vapor
ranging from 0 to 210 mm.
Fia. 26. — THE ANESTHETOMETER, ORIGINAL HOSPITAL AND LABORATORY MODEL. 1, Inflow; 2, safety
valve; 3, cock; 4, meter; 5, dial; 6, outlet of meter; 7, glass vaporizing chamber; 8, absorption disc;
9, electric heater; 10, manometer; 11, instantaneous gas-flow gauge; 12, outlet; 13, thermometer;
14, loose piston of gas-flow gauge; 15, ether feed pipes; 16, function clutch; 17, ether cock; 18, 19,
gas-oxygen mixing unit (abandoned); 20, revolving disc; 21, piston crank; 22, ether chamber;
23, displacement piston; 24, screw spindle; 25, filling cup; 26, window; 27, 28, 29, 30, 31, ratchet
mechanism.
The second unit of the apparatus (B, Fig. 27) measures out the ether
into the third unit, the vaporizer (C). This second unit consists of sev-
eral parts; first a small glass ether cup (4, Fig. 27), on which a can of ether
may be inverted. The ether drips out from the can as needed into the cup
when the level of the ether in the cup becomes lower than the mouth of the
GENERAL ANESTHESIA
133
can. This eliminates the necessity for a large reservoir. The second part
of this unit is a compound three-way cock. By movement of this cock, ether
flows from the cup into a horizontal hypodermic syringe. By a return move-
ment of the cock, the ether thus measured into the chamber is emptied into
the vaporizer. The cock is moved by the meter through a simple connect-
ing mechanism at each revolution of the meter and thus a definite quantity
FIG. 27. — THE CONNELL ANESTHETOMETER. Simplified model for ether vapor. A, Gas meter; B,
ether-measuring apparatus; C, vaporizer. 1, Air inflow; 2, pop safety valve; 3, outlet from meter
to vaporizer; 4, ether cup; 5, U pressure gauge; 6, instantaneous gas-flow gauge; 7, outlet of
vapor mixture.
of ether is measured into a definite amount of air. The capacity of the syringe
is modified by moving the piston in or out by a screw, diminishing or increas-
ing the amount of liquid ether measured off at each revolution of the meter.
A scale of measurement is attached to the glass barrel of the syringe with
graduations, expressed in millimeters of ether vapor pressure. The available
134 SUEGICAL ANESTHESIA
percentage or pressure of ether vapor ranges from zero to 210 mm. Thus the
piston may be set to the 50 mm. graduation, and by charging the ether cup
and supplying compressed air to the meter the apparatus automatically meas-
ures 1.14 c. c. of liquid ether into each 3.39 liters of air. The resultant output
of vapor mixture from the apparatus contains 50 parts of ether vapor in each
760 parts of mixture, physiologically a strength of mixture on which the entire
animal kingdom may be safely held in full surgical anesthesia for many hours.
The third unit (C) is the vaporizer, a thin metal double bottom on which
is set the foregoing unit. The liquid ether from the measuring unit and the
air measured from the meter flow through this bottom in a tortuous course.
The surface of this channel is so devised that the metal acts as a radiator and
supplies in total from the atmosphere of the room the heat necessary to evapo-
rate and warm the mixture to room temperature. This obviates the necessity
for artificial electric heat. The resultant mixture finally emerges from the
vaporizer without material loss of heat or moisture. The mixture flows out
through an instantaneous gas flow gauge, an aluminum piston moving in a
vertical glass tube calibrated so that the operator may observe at any moment
at what rate the mixture is being delivered. The apparatus also embodies a
pressure gauge (No. 5) and an adjustable safety valve (No. 2).
Advantages. — The desirability and utility of such an instrument as will
automatically deliver any quantity and strength of anesthetic mixture, under
full control of the anesthetist, have been sufficiently set forth.
By the use of such an accurate instrument and with the theoretical knowl-
edge of the underlying facts of ether administration, the average novice anes-
thetist rapidly acquires facility in properly inducing and maintaining a perfec-
tion of anesthesia by these accurate vapor methods, which is attained in an
empiric way only by exceptionally adept individuals and after years of training
in the cruder methods.
ACCIDENTS OF ANESTHESIA
Accidents from Decomposition and Ignition of the Anesthetic Agent— Chloro-
form should not be administered in a closed room in the presence of a naked
flame, since the free vapor is decomposed into highly irritating fumes (phos-
phagon and hydrochloric acid), which are detrimental to the patient and may
be overpowering to the surgical attendants.
Ether should be used with precaution against ignition particularly from
the thermocautery and from sparking electric apparatus. When the cautery
is used in the region of the head or neck, the ether should be withdrawn for a
minute or two prior to the use of the cautery. The expired breath highly
charged with ether may ignite with a blue flame and burn at the lips. Fortu-
nately this does not flash back into the respiratory tract, but becomes extin-
guished by the cooling effect of the mucous membrane. When the cautery must
be used in the region of the mouth, chloroform is the anesthetic of choice.
When the cautery is used elsewhere, care must be taken that it is not held be-
GENEKAL ANESTHESIA 135
low the level of the table (since the heavy ether vapor sinks) and that the cur-
rent of ether exhalation from the patient is deflected away from the cautery
by a moist towel over the patient's face.
Obstruction to Respiration. — Of the various factors contributing to irregu-
lar anesthesia and often leading to respiratory and cardiovascular disaster, the
most common is respiratory obstruction. This obstruction is usually at the
base of the tongue and in the deep pharynx and is due to relaxation of muscular
support, but may be at any of the following sites :
A. NASAL OBSTRUCTION. — The alae of the nose may collapse on inspira-
tion. For this the nostril may be held open by a bent hairpin or probe.
Obstruction may be occasioned by insufficiency of the nasal passage. As a
remedy, mouth breathing must be instituted. If in the preliminary examina-
tion any nasal obstruction is evident, it is well to impress on the patient the
necessity of breathing through the mouth during induction. With pure nitrous
oxid asphyxial anesthesia, it is best to have a rubber mouth gag between the
teeth as a preliminary measure to/ induction.
B. MOUTH OBSTEUCTION. — Occasionally the relaxed lips of elderly people
and of those from whom false teeth have been removed act as a double flapper
valve obstructing inspiration. To hold the lips open and gums apart a small
wad of gauze may be tucked into an angle of the mouth.
Close set teeth clenched from excitement or from asphyxia may obstruct
respiration. It is difficult to unlock these jaws by a mouth gag. The best
remedy lies in the prevention of such manifestations of asphyxia. The quickest
relief is afforded by passing a size 22 F. soft rubber catheter with multiple
lateral eyelets a distance of 14 cm. through each nostril. When the condition
of acute asphyxia has been relieved, and the jaws relax sufficiently to be easily
pried open, a pharyngeal breathing tube should be inserted.
C. PHAEYNGEAL OBSTRUCTION. — The base of the tongue may drop into
the pharynx from the relaxation of muscular support. This is tiie most common
of all obstructions. It can usually be met by adjusting the head and jaw of the
patient. The head must usually be extended and thrown slightly to one side
and the lower jaw thrust forward until absence of stertor and full movement
of the chest wall and abdomen indicate an unobstructed airway. Occasionally
the jaw must be held forward continuously by the anesthetist through a gen-
tle pressure with his fingers beneath the body of the jaw at about the
bicuspid teeth. Occasionally a rather forceful forward thrust must be
exercised by well-distributed pressure behind the angle of the jaw,
throwing the lower jaw into an "undershot" position. Prolonged and
forceful pressure on one spot may incite a subsequent painful traumatic
parotitis.
If the obstruction can be cleared in no other way, the tongue must be pulled
forward directly by the thumb and forefinger or by a tongue clamp or traction
suture passed through the tongue. The tongue may be seized by opening the
mouth and depressing the chin. On the next attempt at expiration the tongue
136 SUKGICAL ANESTHESIA
will be found to protrude and may be seized in a piece of gauze between the
thumb and forefinger.
These barbarous methods pf tongue traction and the forceful holding tor-
ward of the jaw may be obviated by the introduction of an artificial airway
reaching from the lips into the lower pharynx. A convenient improvised form
is a % in. rubber tube, 5 in. long with two lateral eyelets at the pharyngeal end.
The Coburn breathing tube is of this pattern. A useful procedure of Bennett
to hold the. tongue forward is to wrap the shaft of this breathing tube with
fluff gauze so that it will ad-
here to the rugse of the palate
and to the tongue. By draw-
ing out the tongue it will be
held forward and leave free
the pharyngeal airway. The
best device is the Connell
breathing tube, a flattened cop-
FIG. 28.— THE CONNELL PHARYNGEAL BREATHING TUBE. £
A flattened metallic tube, easily inserted, fitting the per tube, accurately ntting the
curve of the palate and pharynx, not compressible by f ^ palate and
the bite of the teeth, and providing an abundantly free
airway into the lower pharynx pharynx, incompressible by
the bite of the teeth and pro-
viding an abundant airway with mineral displacement of oral structures (see
Fig. 28). This may be easily inserted at the first indication of obstruction
and guarantees against many of the embarrassments of faulty airway and faulty
administration of the anesthetic.
D. OBSTKUCTION OF THE GLOTTIS. — The epiglottis may fall over the aper-
ture of the glottis by the same muscle relaxation which allows the tongue to fall
back. It is raised by the same maneuvers which carry forward the tongue.
Occasionally, as the result of powerful inspiratory efforts in the course of
asphyxial obstruction, the epiglottis will be sucked tight as a cork into the
aperture of the glottis. Pulling forward the tip of the tongue does not relieve
this obstruction. For relief, the base of the tongue as a whole must be car-
ried forward by 2 fingers in the pharynx or by forceps which grasp the linguo-
epiglottic fold and carry forward the whole base of the tongue.
During light anesthesia the glottis may be thrown into tonic spasm by over-
concentrated vapors. This passes off spontaneously, but may render the subse-
quent course of etherization more stormy.
The glottis may be obstructed by a foreign body, such as false teeth, chew-
ing gum and tobacco. This should be prevented by preliminary search for
loose foreign bodies in the mouth. The treatment is by digital removal, or by
tracheotomy in the face of impending dissolution.
E. TEACHEAL OBSTRUCTION. — The usual cause of tracheal obstruction is
collapse of diseased tracheal walls during inspiration, or pressure of a tumor in
the region of the thyroid or of the thymus gland. If pathological conditions
are known to exist which may cause such sudden obstruction in the course of
GENERAL ANESTHESIA 137
anesthesia, this disaster may be forestalled by the intratracheal insufflation
method of anesthesia. Obstruction once developed must be promptly relieved
by passing a large urethral catheter, size 26 F., or other tube by way of the
larynx or through a tracheotomy wound, well past the obstruction. Suddenly
developed obstructive asphyxia from an enlarged thymus and from thoracic
goiter may be thus relieved. Diagnosis is difficult unless the pathological con-
dition be suspected before anesthesia. The above measure for relief of obstruc-
tion should be employed when acute obstructive asphyxia has not yielded to the
opening of the upper airway, and death is impending.
F. BEONCHIAL OBSTRUCTION.— The finer bronchi become obstructed by
mucus and vomitus. Oversecretion of mucus is the more common and results
from concentrated and irritating vapors, particularly from rapid and irregular
induction and irregular maintenance of very light anesthesia. The condition
is indicated by rattling and moist rales and slight cyanosis.
TREATMENT. — Bronchial obstruction should be avoided by smooth induc-
tion and full, continuous anesthesia. Excess of mucus may be relieved by low-
ering the head of the table and by allowing the patient to emerge from anesthesia
until coughing clears the obstruction. Recurrence is prevented by full anes-
thesia or by hypodermic administration of atropin, grain 1/100.
Inspiration of vomitus is another factor in obstruction. It may be obviated,
first, by anesthetizing only when the stomach is empty; second, by full con-
tinuous anesthesia ; third, by the proper management of the head when vomit-
ing occurs, i. e., turning the head to one side and allowing the propulsive
mechanism of vomiting and coughing to evacuate the mouth and pharynx
before the anesthetic is again resumed. The obstinate vomiting- of intestinal
obstruction is to be relieved during the operation by repeated lavage.
Vomiting. — Irritability of the vomiting center is physiological at a certain
level in the subconscious zone of general anesthesia. At this level the vomiting
center is undergoing disassociation or reassociation. If the induction of an-
esthesia is smooth and continuous the vomiting center usually becomes anes-
thetized without excitation. If the anesthetic is irregularly administered or the
intake of the anesthetic is delayed by breath holding or by small tidal volume,
as when abdomen is rigid, then vomiting more commonly ensues. Vomiting
does not occur in the stage of full surgical anesthesia.
In the stage of recovery subconscious vomiting to the extent of slight retch-
ing frequently occurs in all general anesthesias. After this the patient lapses
again into sleep.
Vomiting in the progress of anesthesia is judged to be impending when
on light dosage of the agent anesthesia seems suddenly to deepen, the pulse
diminishes in volume, the skin grows pale, and increased lacrimation appears.
The most reliable sign is a long inspiration followed by a pause, a moment
after which, if the anesthetic be not immediately increased, vomiting may be
expected.
TREATMENT. — Vomiting may frequently be inhibited when threatening, by
138 SUEGICAL ANESTHESIA
rapidly and repeatedly stimulating the pupillary light reflex by opening and
closing the eyelid a dozen times or more. It may also be inhibited by chafing
the face, by rubbing the lips, by administering a strong whiff of fresh cold ether
vapor, or by a light tap over the epigastrium.
When vomiting occurs the face mask should be removed, the head turned to
one side, and the mouth allowed to open. The anesthetic should not be resumed
until the act has been completed and the pharynx sponged out, or emptied by
coughing. The first subsequent deep inhalations are assisted by dragging the
jaw forward. Kepeated vomiting, as during anesthesia for operation on in-
testinal obstruction, should be relieved by gastric lavage.
Pulmonary Edema. — Pulmonary edema may result from cardiac decom-
pensation occasioned by anesthesia and the shock of the surgical procedure. It
has also been occasioned during anesthesia by flooding the cardiovascular sys-
tem with an excessive quantity of saline infusion.
The symptoms are those of circulatory depression, a pale cyanotic color, the
exhalation of watery and frothy material from the mouth in large quantity,
and an abundance of moist rales.
TREATMENT. — Aside from the usual intravenous epinephrin and strychnin
stimulation and the depletion of venous engorgement by phlebotomy when indi-
cated, the most effectual treatment is that of Bennett. Bennett injects into the
rectum 2 ounces of concentrated solution of magnesium sulphate. This is fol-
lowed in favorable cases, within 10 minutes, by marked diminution or relief of
the pulmonary edema.
Respiratory Failure. — ETIOLOGY. — The most common cause of respiratory
failure is acute or chronic asphyxia of the respiratory center with consequent
suspension of its automaticity. Acute asphyxia as a cause is commonly re-
sultant from complete obstruction in the upper airway during the stage of in-
duction. Chronic asphyxia as a cause is resultant from partial obstruction pro-
longed over the course of anesthesia, or from persistent rebreathing and oxygen
starvation. Both forms are most commonly seen in nitrous oxid and in ether
anesthesia and are usually due to blunders of an incompetent anesthetist.
A less common cause of respiratory failure is overdosage of anesthetic.
This may be a sudden large dose or prolonged gradual overdosage.
To the third group of etiological factors belongs the toxemia of disease.
This is rarely a primary, but usually an accessory, factor to the depression of
asphyxia and overdosage of anesthetic.
SYMPTOMS. — In acute respiratory failure usually after a period of violent
muscular effort at respiratory movement these efforts suddenly cease. The
patient meanwhile turns bluish and then livid, jactitation of asphyxia appears,
the eyes open and bulge, the pupil dilates, the blood pressure first rises and the
pulse slows, then becomes rapid and irregular with sharp fall of blood pressure.
This form is seen several times a year in any large hospital training novice an-
esthetists and usually results from obstruction, less commonly from spasm,
and least commonly from acute overdosage of anesthetic.
GEKEKAL ANESTHESIA 139
In the chronic form of desensitization of the respiratory center the respira-
tion grows more shallow and irregular, tending toward the Cheyne-Stokes type
of rhythm. The color becomes pale with pronounced cyanotic tinge, the heart
action becomes more rapid, the blood pressure falls, and finally the respiration
stops. This is far more serious from the standpoint of resuscitation than an
acute form of failure.
TEEATMENT OF FAILURE FEOM ACUTE OBSTRUCTION. — If obstruction be
relieved or the anesthetic be withdrawn the condition usually rights itself
automatically, probably from cumulative carbon dioxid stimulation of the res-
piratory center. A size 22 F. catheter is passed through each nostril a distance
of 12 to 14 cm. If this does not relieve the asphyxia the mouth must be pried
open and the base of the tongue and epiglottis carried forward by 2 fingers
down the throat, and artificial respiration instituted. The crisis arising from
such obstruction is usually passed within 60 seconds.
TREATMENT OF FAILURE FROM ACUTE OVERDOSAGE. — From acute OVer-
dosage of anesthetic recovery is more gradual and the respiration must be car-
ried on by artificial means sometimes for a period of 10 or 15 minutes before
automaticity of respiration is reestablished. If in addition the circulatory
center has been asphyxiated or intoxicated, measures directed as in cardiac fail-
ure must be instituted.
TREATMENT OF FAILURE FROM CHRONIC OBSTRUCTION. — For the slow
and chronic type of respiratory failure the best measure, as with the acute type,
is preventive, in keeping the airway open and relieving the respiratory center
from overwork in the early stages of anesthesia. The same treatment must be
instituted as with acute asphyxia, namely, opening of the upper airway, with-
drawal of anesthetic, and institution of artificial respiration. The most effec-
tive means of artificial respiration is by intratracheal insufflation of air or
oxygen mixture, using about 20 liters of air per minute and interrupting the
current about 15 times a minute.
The presence of carbon dioxid up to 10 per cent, in the air acts as a marked
stimulus in starting the respiratory center.
Cardiac Failure. — ETIOLOGY. — Predisposition to cardiac failure may be due
to fatty and other degenerative myocardial changes. The intoxication of dis-
ease, such as sepsis and uremia, and pathological states, prominently status
lymphaticus, are contributing factors.
The exciting causes are : first, nervous inhibition ; and, second, intoxication
of the muscle by the anesthetic agent. From nervous inhibition, even before
the anesthetic is inhaled, the patient may die from psychic shock. Similarly
sudden arrest of the heart from nervous inhibition may be induced early in
chloroform and in ethyl chlorid anesthesia by the irritation of too strong anes-
thetic vapors and by the psychic influence of trauma, such as the movement of
a painful joint, when the patient is not sufficiently anesthetized. The heart
may also be stopped early in chloroform and in ethyl chlorid anesthesia by
actual overdosage of anesthetic. This commonly occurs by inhaling concen-
140 SURGICAL ANESTHESIA
trated vapors during a period of excited breathing. Thus a wave of toxic
blood passes to the left heart and overwhelms the heart muscle, even before the
nervous system is affected. Ether, being less toxic to heart muscle and requiring
much higher concentration, practically never causes this sudden cardiac death.
Cardiac failure from gradual overdosage is rarely seen, even in chloroform
anesthesia, since the signs of gradually deepening anesthesia and falling blood
pressure serve as a warning. In ether anesthesia the respiratory center fails
so long before the heart that arrest follows respiratory failure only when the
resultant asphyxia is unrelieved.
PROPHYLAXIS. — Chloroform and ethyl chlorid should especially be avoided
in the lymphoid conditions of childhood, also where adult status lymphaticus is
"suspected, or degenerative or toxic changes of the heart are present.
TREATMENT. — After sudden stoppage by nervous inhibition the heart beat
may again become active, either spontaneously or by external .stimulation, as
by pressing with a hot towel about 60 times per minute over the precordia.
From cessation of heart beat by acute chloroform intoxication the heart is only
to be resuscitated by massaging the toxic blood out of the heart muscle and
cavities. Thus in intra-abdominal operations the heart has been resuscitated
by transdiaphragmatic massage several minutes after rhythmical motion had
ceased. This method, as well as transpleural pericardotomy for purpose of
cardiac massage, may be practiced with some slight hope of resuscitation up to
12 minutes after death. The usual drug stimulants are of no avail in cardiac
failure, since circulation has ceased. As shown by Meltzer, electric stim-
ulation by weak faradic current at the auriculoventricular sinus is the most
effective stimulus in resuscitating the heart.
A method of retrograde arterial dosage with epinephrin has been suggested
by Lieb. The radical artery is exposed and divided and the proximal end can-
nulized, as for intravenous infusion. Normal saline, 500 to 1,000 c. c., is in-
jected into the artery under a head of 4 feet of gravity. When tEe flow is well
established 10 minims of epinephrin solution 1 :1,000 is administered by slowly
injecting it by hypodermic syringe through the wall of the infusion tubing.
This dose is repeated 4 or 5 times during the infusion in the hope that
the epinephrin saline solution may back up and out into the coronary
artery, and thus stimulate the heart muscle to again resume rhythmical con-
traction.
For failure of gradual onset the anesthetic, if excessive in dosage, must be
diminished and an abundance of air supplied and the usual cardiovascular
stimulants employed.
Surgical Shock. — The obscure condition known as surgical shock, char-
acterized by a persistent fall in blood pressure, by accumulation of blood in the
splanchnic area, and by lowering of all body functional activity, may arise as
one of the complications of anesthesia.
ETIOLOGY. — Predisposing to this condition is any depletion of body activity
such as exhaustion from pain or from disease. The exciting causes from the
GENEKAL ANESTHESIA 141
surgeon's side are : first, inadequate preparation of the patient physically and
nervously for the operation in hand ; second, excessive blood letting ; third, ex-
cessive surgical trauma, particularly by rough manipulation of great joints,
of periosteum, of peritoneum, and of pleura, and by traction on viscera, espe-
cially in the splanchnic area. From the anesthetist's side the exciting causes
are : first, too light a degree of anesthesia during the foregoing severe surgical
manipulations; second, long-continued strain on the respiratory apparatus by
partial respiratory obstruction; third, chilling; fourth, a bad position of the
patient during anesthesia, such as the high inverted (or Trendelenburg) posi-
tion, or the sitting posture; fifth, continuously maintained intrathoracic pres-
sure in excess of 15 to 20 mm.
TEEATMENT. — Measures to be effective must lie not so much in treatment
as in prevention of shock, since when the shock is fully developed active treat-
ment is of little avail. External heat should be applied by hot blankets and
hot-water bags. The various adverse or etiological factors should be so modified
as to be no longer operative. The body should lie horizontally, the head slightly
lowered.
The only drugs of proved value are strychnin and epinephrin administered
intravenously, strychnin in dosage up to 1/20 grain, and epinephrin solution
in dosage of 10 to 70 minims. Epinephrin is best administered with 500 to
1,000 c. c. of saline by intravenous infusion, injecting the drug gradually as it
Vis needed by hypodermic syringe into the rubber tube which carries the saline
infusion. When hemorrhage has been the principal factor in the causation of
shock a large infusion of normal saline up to 1,500 c. c. should be administered,
or 500 to 1,000 c. c. of heterologous blood may be transfused. Artificial respira-
tion by the Sylvester method, so as to obtain a pumping effect on the blood
sinuses, may be employed where respiration is much depressed. When the state
of anesthesia begins to lighten, the nervous system should be blunted to psychic
impressions and sensations of pain by a moderate dose of morphin. However,
this drug must be used with caution, since it is an undesirable depressant of
respiration when shock is acute. An effective respiratory stimulant is carbon
dioxid administered by inhalation, 1 volume to 10 of air or oxygen. This also
tends to relieve the venous congestion present in surgical shock.
Nerve Lesions. — During anesthesia various nerves may be compressed or
stretched, with subsequent anesthesia or paralysis. The most common lesion is
wrist drop. This occurs from compression of the musculospiral nerve in the
middle third of the arm by allowing the middle third of the humerus to hang
against the edge of the table. A less common paralysis is the flexor palsy of
the forearm from continuous stretching of the median and ulnar nerve in the
axilla by hyperextending the arm above the head during anesthesia.
PEOPHYLAXIS. — The anesthetist should be ever watchful lest the arm hang
over or be dropped sharply against the edge of the table. The hyperextended
position of the arms should never be induced. The arms preferably are ad-
ducted at the sides, forearm extended parallel to the axis of the body, and are
142 SUKGICAL ANESTHESIA
folded into a sheet or other band passing beneath the patient. A common posi-
tion, less desirable because of restriction to respiratory movement, is with the
forearms folded across the chest, the sleeves pinned together at the wrists.
With a patient in the lateral posture the arm should not lie directly be-
neath him. In this position care should also be taken that no edge of furniture
or apparatus presses against the external popliteal nerve where it lies super-
ficially below the head of the fibula.
CHAPTER IV
PEEPAEATION OF PATIENTS FOB OPERATION
CHARLES E. EARK
To prepare a patient for operation various factors must be considered, such
as the age, sex, mental condition, the physical state of the various organs, and,
lastly, the part to be operated upon. The preparation itself has two sides, a
mental and a physical, and its object is to bring the patient to the operating
table in as nearly a normal condition in each respect as may be possible.
Erom a superficial point of view the less mental preparation we have the
better, but a certain amount of it is a necessary evil except in the mentally
incompetent, such as children, idiots, and the unconscious. Worry and fear
unquestionably sap the vital powers of resistance to shock and infection, while
the smooth convalescence of the emergency case is proverbial. However, it must
be kept in mind that here, as in children, we are dealing with a local lesion in
tissues otherwise presumably sound. When conditions are not so favorable
unpleasant sequels are only too common.
A frank discussion of the case can do no harm and, indeed, is necessary in
order to obtain a legal consent, based upon a reasonable degree of knowledge.
Fearful descriptions of operative details must be avoided, but there should be a
clear, though brief, statement of what is to be done, giving the advantages and
the disadvantages of the operation and comparing its dangers with the dangers
or discomforts of the diseased condition. The statement that an operation is
without danger should never be made, as it is not true. Even the pulling of a
tooth has resulted fatally more than once. However, one may honestly say that
the danger is very slight, or remote in the average case, and is far outweighed
by the benefits to be attained.
Aside from this one necessary discussion all reference to operation should be
studiously avoided and the atmosphere and environment of the patient should
be kept as cheerful, diverting, and encouraging as possible. In particular, dole-
ful friends and relatives, with gruesome tales of other operations of a similar
kind and always with an unfavorable or fatal ending, must be excluded.
Once an operation has been determined upon nothing is to be gained by
delay unless the physical or mental state of the patient can surely be improved
thereby. In many conditions, however, operations which are not urgently indi-
143
144 PEEPAEATION OF PATIENTS FOE OPEEATION
cated would best be postponed until every resource of medical treatment has
been exhausted to bring impaired tissues or organs back to normal or as near
normal as may be possible in the given conditions. Obesity, arteriosclerosis,
and high blood pressure, cardiac and renal disease, intestinal toxemia, acidosis,
tuberculosis, syphilis, etc., are strong contra-indications to all but the most im-
perative operations. Much may be accomplished, however, by intelligent medi-
cal supervision toward rendering a bad operative risk a relatively good one.
Carefully regulated massage, bathing, graduated exercises, dieting, and, above
all, copious water drinking, will accomplish wonders in properly selected cases.
Of drugs, the tonics, cathartics, and the arterial dilators are the most useful.
Specific treatment for such diseases as syphilis and malaria must not be for-
gotten, nor iron for anemia. All of these measures not only render the opera-
tion safer, but make the convalescence smoother and far pleasanter for the
patient.
If an operation must be done in a region or in tissues partially devitalized
by trauma or disease, and is not urgently indicated, it is the part of wisdom to
wait for reaction to set in, if such may reasonably be expected to occur. Simi-
larly, if the skin of the operative field is abnormal, particularly if eczema or
any inflammatory condition is present, every effort must be made to cure the
disease before operation. No amount of preparation can possibly obviate the
danger of an established infectious process.
The preliminary preparation of the patient consists in making every effort
to render him in mind and' body as nearly normal as may be under the circum-
stances. It is only by such efforts that occasional disasters may be avoided and
the final, as well as the immediate, operative result be made the best attainable.
The days preceding an operation should, so far as possible, be ones of rest,
relaxation, and diversion, and the latter should be of the simplest nature. Ex-
ercise must be moderate, and nothing should be allowed to fatigue the body or
mind. Business worries and household cares are especially to be avoided.
The immediate physical preparation of the patient consists in the care of
the alimentary tract, the respiratory tract, the genito-urinary tract, and the
skin. Cleanliness, simplicity, and safety are the main indications to be met.
To begin with the alimentary tract, the first part to require attention is the
mouth, including those ever-ready sources of infection, the teeth, the tonsils,
and the pharynx. When time permits, too much attention cannot be given to
these structures, especially if the operation is to be upon any part of the ali-
mentary or respiratory tracts. Carious teeth should be filled or removed, de-
posits of tartar cleaned out, and any pyorrhea treated as effectually as possible.
Next in importance to the teeth, the tonsils ought to be examined, the crypts
cleaned of any plugs, chronic abscesses opened, and, if infection still persists,
the tonsils should be enucleated a-s a preliminary to the main operation. The
pharynx also is to be inspected and any acute or chronic affection must receive
appropriate treatment, consisting of mild gargles, douches, or applications of
astringents, such as 10 per cent, silver nitrate solution. An excellent wash for
PREPARATION OF PATIENTS FOK OPERATION 145
the mouth and throat is the peroxid of hydrogen, one-half strength, with the
addition of a little lime water. If this is followed by a one per cent, watery
solution of thymol, or a saturated solution of boric acid, surgical cleanliness
will be approximated as nearly as may be.
The nose and its accessory sinuses, the nasopharynx, the larynx, trachea,
and bronchi, are prolific sources of postoperative trouble, especially when in-
halation anesthesia is used. The thorough use of an oil spray, such as albolene,
containing 1 per cent, thymol or menthol, will render the discharges somewhat
less infectious. Any of the more serious lesions should be put in charge of
a specialist.
The preparation of the alimentary tract proper is comparatively simple.
The diet up to the day of operation should be light, nutritious, and easily
digested, leaving slight residue. If the operation is to be upon the stomach or
bowel the food and drink may well be sterilized, with the addition of buttermilk
or some one of the lactic acid bacilli preparations. None of the numerous
intestinal antiseptics is of any value, unfortunately. Aside from this simple
regulation of the diet, the only precaution necessary is against intestinal stasis.
For this a simple laxative is all that is required, or, at most, a mild purge, such
as an ounce of castor oil. This should be administered on the night preceding
operation and in the morning a low enema of a quart of soapsuds is given, fol-
lowed, if needed, by an irrigation of plain warm water. The latter is especially
indicated in operations on the rectum and vagina. These simple measures are
enough. The days of prolonged fasting, violent purging, and repeated exhaust-
ing enemas are, happily, over. The patient should have at least two hours' rest
before the anesthetic is administered. In emergency cases it is better to omit
the enema than to bring an exhausted patient with a half emptied bowel upon
the table. The process is only too sure to be completed on the table, to the dis-
comfiture of everyone concerned.
The evening meal on the day preceding operation should consist of a mod-
erate allowance of toast, cocoa, a chop or poached egg, or any other similar food
of an easily digested nature. In the morning, if the operation is to be during
the forenoon, nothing but a cup of coffee without milk or sugar is allowed. For
an afternoon operation coffee, a roll .or toast, and a soft-boiled egg may be given,
but no food is to be taken within six hours of operation. The drinking of water
in small quantities frequently repeated up to within a half hour of the admin-
istration of the anesthetic is an excellent thing. It allays nervous excitement,
flushes the kidneys, and tends to prevent operative shock.
No hypnotic or sedative drugs, such as chloral, the bromids or morphin,
should be given without the consent or expressed wish of the anesthetist. Cer-
tain conditions, great restlessness and nervous excitability, for example, require
their exhibition, but in general they are much better omitted.
The preparation of the genito-urinary tract is in general very simple. The
kidneys should be flushed by copious water drinking and the bladder emptied
just before operation. Catheterization is needed only if retention exists. If
11
146 PREPARATION OF PATIENTS FOR OPERATION
any part of the urinary tract is infected, or if the operative attack is to be upon
or near it, urinary antiseptics should be administered. The best are salol and
urotropin, either of which may be given in 0.3 gm. (5 gr.) doses every four
hours, or in much larger doses if deemed necessary. It must be remembered,
however, that urotropin is of no value in alkaline urine. In addition to the
above, the bladder and urethra, and, in the female, the vagina, should be irri-
gated at least every four hours with warm saline or saturated boric acid solution.
In emergency cases if food has been eaten within six hours, in vomiting cases
especially if the vomitus be of a fecal nature, and in cases of suspected gastric
stasis or dilatation, the stomach should be washed out until the return is absolutely
clear. The omission of this simple precaution has cost many lives. Warm water
or a weak solution of the bicarbonate of soda should be used.
Preparation of the skin has been the great stumbling block o'f surgical
technic ever since the early days of Listerism. Practically every other detail
in the aseptic technic can be absolutely relied upon, as instruments, gloves,
sutures, and gauze can be boiled or sterilized by live steam under pressure, but
as yet no way has been found to render the skin aseptic. Beginning with phenol,
there has been a constant search for more and more powerful antiseptics and
germicides, each new discovery being seized upon and exploited as the perfect
antiseptic, only to be discarded in a few years at the most as too irritating to
living tissues or as lacking in germicidal properties. The latest of these is
iodin, now in almost universal use, and considered the acme of perfection of the
antiseptic technic. Only a few of the more conservative surgeons have held
aloof or, having given the iodin technic a more or less extensive trial, have
returned to one of the older forms of preparation. Here and there, also, are
met signs of dissatisfaction and the reaching out after something newer and
better.
It is an obvious fact that skin sterilization must depend upon two factors,
mechanical cleansing and chemical disinfection, as thermal sterilization is out
of the question. Moreover, the amount of mechanical cleansing which the skin
can bear without injury is decidedly limited. This, however, is no excuse for
its omission, because undoubtedly, within its limitations, it is of great value. It
is one of the great faults of the iodin technic that this important factor can-
not be efficiently used.
Since, then, thermal disinfection of the skin is impossible and mechanical
cleansing, although important and useful, is limited in its applicability, our
main resource must be chemical disinfection. Unfortunately, our knowledge
of the action of the various antiseptic and germicidal drugs on living tissues is
very limited. The inhibition of the growth of the ordinary pathogenic bacteria
in test tube media is a very simple thing, as the innumerable present-day anti-
septics prove. The killing of these same bacteria, however, is a very different
matter and is not so easy, even in fluid media. Many of -the most highly
vaunted antiseptics have little or no germicidal power and a number of patho-
genic bacteria are highly resistant to the strongest of the germicides. It is self-
GENERAL DIRECTIONS 147
evident, then, that in living tissues which are themselves extremely susceptible
to the irritant action of all the chemical germicides and whose vital resistance
must be preserved at any cost, the action of any antiseptic or germicide in a
concentration compatible with the life and function of the tissues is very
problematical. Undoubtedly, the pyogenic organisms on the surface of the
skin can be killed by the more powerful germicides, such as iodin, alcohol, and
the bichlorid of mercury, while those in the upper layers of the epidermis can
be temporarily inhibited, during the time in which the chemical is still present,
but the deeper layers of the skin, to say nothing of the underlying tissues, are
entirely unaffected.
An aseptic skin is unattainable by any means at present known, and what
is true of the skin is even more true of mucous membranes with their infection-
harboring folds and crypts. It may be taken for granted that all wounds are
infected and that the only reason so-called aseptic wound healing occurs is that
the tissues are able to overcome a certain amount of infection and that healing
takes place in spite of this infection. Unquestionably the great majority of
surgical wounds would heal without gross infection if the skin received no
preparation at all except simple cleanliness, provided the tissues were reason-
ably sound, that only aseptic materials were introduced, the wound was dry
and free from devitalized tissue, and that the sutures were not drawn too
tightly. The skin technic is only one, and not the most important one, of the
many factors entering into wound healing. This alone makes the relative value
of the various skin technics extremely hard to judge. The best clinics in
this country report from 1 to 5 per cent, of infections in the so-called clean
cases, regardless of the technic employed, and, although most of these are
of minor consequence, their occurrence is not thereby justified.
A number of more common methods of preparing the skin will be enumer-
ated below, but the following precaution applies to them all: Do not place
implicit reliance on any skin technic, but protect the underlying tissues and
the viscera from any contact with the skin or anything which has touched it.
GENERAL DIRECTIONS
Unless special centra-indications exist, a prolonged warm bath should be
taken the evening before operation, using plenty of soap and scrubbing the
operative field with a coarse wash-cloth or piece of gauze. Lather and shave if
necessary. This latter cannot be done with too great care, as careless shaving,
abrading and cutting the surface of the skin, is a prolific source of infection.
The inhumanity of the average nurse or orderly in this respect, due, of course,
to ignorance or carelessness, is one of the chief minor ills of the patient's
operative ordeal. After wiping the field dry with a soft mop of gauze any one
of the following methods may be employed :
The Iodin Method. — Cleanse the skin with alcohol (95 per cent.) and apply
148 PREPARATION OF PATIENTS FOR OPERATION
a dry sterile dressing. After anesthesia is induced remove the dressing, dry the
field, if necessary, with 95 per cent, alcohol, and apply one coat of tincture of
iodin (U. S. P.). Allow to dry three minutes and cover all but the line of
incision with dry sterile sheets or towels. After the incision in the skin is
made fasten the towels to its edges with sutures or suitable clips.
PRECAUTIONS.— Use only freshly prepared tincture of iodin. The alcohol
evaporates rapidly, increasing the irritating properties of the solution.
Apply only one smooth coat, without pressure or friction.
Avoid excess of iodin. It may collect in a pool or run into a crease in the
skin and cause a burn.
Avoid soap on the field. It will prevent the efficient penetration of the
iodin.
Do not use wet towels or solution of bichlorid of mercury on the skin. They
increase the irritant effect of the iodin.
DANGERS. — Burns or dermatitis, due to the iodin, may result from idiosyn-
crasy or from careless use of the solution. They are generally of no serious
importance, but are very annoying and at times quite painful. No preventive
treatment seems of any great value, although it is claimed by some that by
removing the excess of iodin with alcohol, either three minutes after its ap-
plication or at the end of the operation, the probability of burns is nearly
obviated. The alcohol must be carefully mopped on, as brisk rubbing will only
increase the irritation. The treatment of an established iodin dermatitis is
like that of any other similar lesion, a bland sterile dusting powder, such as
zinc oxid, or aristol, usually sufficing.
One other danger noted by some surgeons is the production of extensive
peritoneal adhesions by the iodin which unavoidably reaches the peritoneal
cavity to a greater or less degree. This is strongly denied by others, who even
go so far as to use iodin freely to prevent adhesions. The question is still
undecided, but it would seem wiser to avoid unnecessary contamination.
DRAWBACKS. — Aside from the dangers noted above and from its probable
inefficiency, two minor drawbacks may be noted, that it cannot be used in cer-
tain situations safely and that it obscures the landmarks of the skin. As to the
former, certain parts of the anatomy, such as the eyes, are too sensitive for the
efficient use of any antiseptic, and on others, such as the scrotum or perineum,
a half strength solution of the iodin, using alcohol as a diluent, may be used.
As to the second, the skin markings, if they are of any importance, may be
preserved by tracing them on the day preceding operation with a 10 per cent,
solution of silver nitrate.
Modifications of the Iodin Technic. — There are many variations from the
above preparation, of which the most important are as follows: (1) Omit all
preliminary treatment of the skin, dry shave on the table, one coat of full
strength iodin. This is almost universally used as an emergency preparation,
is simple, and apparently fairly safe. With many it is the method of choice.
(2) Dry shave and one coat of iodin on the day preceding operation with the
OEHERAL DIRECTIONS 149
usual teclmic on the table. (3) As in (2), using one half strength iodin.
(4) Like the preceding, with a preliminary treatment of a weak solution of
iodin in benzin.
The Alcohol-Ether-Bichlorid Technic.— After the preliminary washing
with soap and water and the shaving the field is cleansed with alcohol, ether,
arid a watery solution of bichlorid of mercury, 1 :1,000. A soap poultice is
then applied for a half hour or more, the field again cleaned with alcohol and
ether, and a moist dressing applied of 1 :10,000 bichlorid. On the table the
dressing is removed and the field again vigorously scrubbed with soap and
water followed by alcohol, ether, and one in one thousand bichlorid.
PRECAUTIONS. — Use only cotton, soft gauze, or a very soft brush, as the
skin is very easily irritated by too much scrubbing. The soap must be very
bland. A solution of castile soap is better than the tincture of green soap. The
action of the soap poultice on the skin must be watched, as it may be very irri-
tating. The bichlorid solution must not be too strong, for it may set up a
severe dermatitis.
DANGEKS. — The only danger is that of causing a dermatitis by too vigorous
scrubbing or too strong bichlorid.
MODIFICATIONS. — There are many variations of this technic, consisting
of changes in the strength of the bichlorid solution, the number of times the
dressings are changed, and the scrubbing performed. A strong alcoholic solu-
tion of bichlorid may be used in the final preparation, if the skin is not too
irritated.
DRAWBACKS. — This method is probably as efficient as the iodin preparation,
but is far more tedious and exhausting to both the patient and the nurse. It is
sloppy, uncomfortable, and irritating.
The Lime and Soda Technic. — This is used for the most part as a step in
the preceding and consists of the application of a freshly prepared and moist-
ened mixture of chlorinated lime and sodium carbonate. The nascent chlorin
formed is a very powerful germicide, while the alkali of the mixture dissolves
the superficial epithelium and allows a deeper penetration of the antiseptic.
The main drawback to its use is its irritant action on the skin. It is a very
useful adjuvant to other forms of preparation, especially on thick, tough, or
very dirty skins.
The Benzin Technic. — Benzin, gasoline, and naphtha, although rather
weak in germicidal power, are excellent cleansers of the skin and have been
extensively used for the entire preparation of the skin. The method is very
simple, consisting of a single application on the day preceding operation, dry
dressing, and another application on the table. The results in a fairly large
number of cases observed by the writer were excellent. Care must be taken
that the agent does not collect in pools or run into creases in the skin, and that
the latter is perfectly dry before it is covered, or severe burns will ensue.
Many other chemicals, notably carbon tetrachlorid, thymol, and picric acid,
have been enthusiastically advocated for the preparation of the skin, but are as
150 PREPARATION OF PATIENTS FOR OPERATION
yet in the experimental stage. Carbon tetrachlorid has one decided advantage
over benzin in that it is not inflammable. Inhalation of its fumes is very
dangerous. Thymol, 5 per cent, in 80 per cent, alcohol, is a powerful anti-
septic and germicide, not very irritating, and is a splendid deodorant. It does
not obliterate the natural or artificial markings of the skin. Picric acid in 1
per cent, watery or alcoholic solution has about the same advantages, and the
added one that it can be applied to irritated and inflamed surfaces, on which
it has a decidedly soothing and anesthetic action. As applied by the writer in
quite a large number of minor surgical cases it has proved exceedingly useful
and reliable.
Alcohol, which forms the menstruum of many of the best germicides, is
itself a powerful antiseptic and germicide and it is an open question whether
or not alcohol is not the principal ingredient in some of them. A few operators
have relied upon it alone, using from 50 to 95 per cent, solutions. The ques-
tion of germicidal power in the various strengths is not yet settled.
Many attempts have been made to apply an impervious aseptic or antiseptic
coating to the operative field, through which the incision is to be made. No
great success has as yet been attained, but it may well be that the next step in
advance will be in this direction. Certainly if a sheet of rubber dam or other
similar substance could be firmly and evenly cemented to the skin and the in-
cision made through it, contamination of the wound by the skin would be
nearly impossible. We now use sheets of gutta-percha to protect clean wounds
from infected areas, cementing them to the skin with chloroform, but we cannot
be sure of the sterility of the tissue itself.
Certain regions require special methods of preparation. Thus in the eye
only saline, boric acid solution (watery), or argyrol is permissible. In the
external ear alcohol or an alcoholic solution of boric acid may be used. In the
mouth and nose solutions of menthol or thymol in water or liquid vaselin, of
about 1 per cent, strength may be of some value. The rectum will tolerate only
saline irrigations, while in the bladder, saline, boric acid, or weak permanganate
solutions may be used. lodin can be safely used in the vagina if it is wiped dry
afterward, but it is very questionable if irrigations of weak bichlorid or iodin
solutions are not more efficacious.
In conclusion, one other most important subject remains to be touched upon,
namely, the attempt to increase the resistance of the tissues to infection. If
by serum, by vaccine, or by drugs we could confer even a fleeting immunity to
infection by the various pathogenic organisms, all our elaborate technic of
preparation, not only of the patient, but of the surgeon's hands, dressings, and
instruments could be entirely discarded. In this direction lies the real path of
progress, not in attempting the impossible task of destroying the innumerable
infective organisms themselves. The three great sources of danger from opera-
tions are hemorrhage, shock, and infection. Of these hemorrhage is practically
overcome by modern operative technic, shock bids fair soon to become so, and
infection remains, conquered only in part by diligent efforts at asepsis.
CHAPTEK V
EELATIONS OF MEDICAL DISEASE TO SURGERY
ALEXANDER BRYAN JOHNSON AND JAMES H. KENYOW
PART I
ALEXANDER BRYAN JOHNSON
Commonly, surgical operations are grouped under two heads : operations of
necessity and operations of choice, expediency, or election. There can be no
two decisions in regard to the wisdom of opening an acute abscess whenever
practicable and as soon as may be ; nor of evacuating a full bladder, somehow ;
whereas a man with Dupuytren's contraction of the palmar fascia may well
think twice or even several times before submitting himself to a surgical
operation.
Our task in this chapter will, however, be to try to help those who are per-
haps less experienced than ourselves, and to jog the memory of others who
desire this sort of aid in deciding in a given case and under a variety of local
and general pathological conditions whether to operate or not, and also to tell
in what way the preparation and after-care of an operative case may be modified
to advantage in the presence of acute and chronic diseases and other local and
general changes that give the surgeon pause. The task is no light one, and per-
haps the title of the chapter might better have been "Surgical Judgment Made
Easy or Everyman a Good Surgeon."
ANEMIA
A profound degree of anemia from any cause adds a serious risk to any
considerable surgical operation. In simple anemias, such as we see from acute
hemorrhage or from repeated small bleedings — uterine bleedings, for example
—the more acute the condition the more serious the effect upon the prognosis
of a surgical procedure. In the most acute cases where shock and hemorrhage
are combined the shock element is an absolute contra-indication to any serious
operation.
Shock.— Active external bleeding may and should be controlled at once.
This can usually be done in a few moments without anesthesia. But any
151
152 KELATIONS OF MEDICAL DISEASE TO SUKGEKY
formal operation, such as amputation or an abdominal operation, should be
postponed until the shock has passed. Every young surgeon left to his own de-
vices learns this from sad experience. Until this lesson has been brought home
to him more than once he fails to realize that a muscular man of 30 whose
shoulder has been amputated by the wheels of a locomotive, who has lost but
little blood, whose pulse is slow, though not full, who says cheerfully that he
has no pain and "is quite comfortable/' and who is pale and bathed in a clammy
sweat, is the worst possible surgical risk. Some 24 or 48 hours later he may
be able to endure a formal amputation or disarticulation at the shoulder joint
with but little risk. Now, while in shock, the same operation is murder pure
and simple.
Chronic Simple Anemia. — Chronic simple anemia uncomplicated is, on the
other hand, by no means so serious an added risk. The common rule has been
that less than 30 per cent, hemoglobin contra-indicated a serious operation.
One of the most common types of this sort is seen in women reduced to
severe anemia by uterine bleeding from causes other than cancer. In these
cases it is astonishing that hysterectomy may be done successfully with a per-
centage of hemoglobin of 20 per cent., and even, as in one case that came under
my observation, of 12 per cent. To be sure, the reparative power of the tissues
is much reduced, and in these cases the operative wound takes much longer to
form a solid scar. There is, I think, also more danger of infection, slight or
severe, than in persons in ordinary health.
When similar grades of anemia are caused by or accompanied with a can-
cerous cachexia or a septicopyemia death follows any serious operation with
great regularity.
In some anemic cases, more especially when uncomplicated, transfusion
from a suitable donor may be a very valuable preparatory measure indeed.
In some cases of chronic sepsis combined with anemia repeated transfusions
have rendered successful operations possible.
TYPHOID FEVER
Typhoid fever during the active course of the disease is a contra-indication
to surgical operations, except those of necessity.
The complications often call for surgical interference, either immediate,
as in cases of perforation and of acute suppurative processes, wherever situated,
or, later, after the fever has run its course and the patient is suffering from one
or more of the numerous sequela?, such as a typhoid joint, osteomyelitis, chole-
cystitis, abscess in the skin and deeper soft parts, middle ear disease, or some
other of the lesions left after the intestinal ulcers have healed.
It may be understood that, since in a large proportion of cases, 85 to 90 per
cent., the typhoid bacillus is circulating in the blood and often causes purulent
inflammations wherever it may lodge, the list of surgical complications of
TYPHOID FEVER 153
the disease is a long one. The more common ones are here enumerated ; their
'treatment will be found in other sections of this work under appropriate head-
ings.
1. Perforation of the bowel.
2. Hemorrhage from the bowel.
3. Typhoid appendicitis.
4. Typhoid infection of the biliary passages and of the liver.
5. Typhoid cholecystitis with perforation.
6. Typhoid rupture of the spleen and typhoid abscess of the spleen.
7. Stricture of the esophagus following typhoid.
8. Typhoid inflammation of the bones and periosteum.
9. Typhoid arthritis.
10. Typhoid spine.
11. Typhoid larynx.
12. Bed sores.
13. Typhoid gangrene of the extremities.
14. Typhoid abscesses, subcutaneous or in special organs other than those
mentioned.
15. Typhoid inflammation of any mucous membrane.
During the early days of the disease it has happened that a diagnosis of
appendicitis has been made, and the appendix removed. As a rule, these
patients have done well, the operative wound has healed, and the disease has
run its course without apparent modification.
Perforation. — In regard to operation for typhoid perforation. Success de-
pends upon: (1) Early diagnosis; (2) early operation; (3) rapid operation;
(4) simple procedures; (5) the general condition of the patient as affected by
the typhoid, and by the added effects of the septic peritoneal absorption.
Within the past few years the results have been much improved. Thus, in the
Montreal General Hospital during the year 1909 and up to May, 1910, Arm-
strong reported 22 typhoid perforations, 19 of which were operated upon and
9 of whom, or 47 per cent., recovered.
Other Acute Abdominal Conditions. — Other acute abdominal conditions may
simulate perforation during typhoid; among them may be mentioned acute
appendicitis, typhoid perforation of the appendix, intussusception, mesenteric
thrombosis, volvulus, acute obstruction by bands, and strangulation or perfora-
tion of MeckeFs diverticulum, also spontaneous rupture of the spleen and
rupture of the gall bladder. All these conditions are indications for immediate
operation since in all delay is fatal.
Intestinal hemorrhage may be an indication for operation in exceptional
cases. Transfusion of blood may be indicated.
Typhoid Gangrene. — Typhoid gangrene of an extremity is not a very fre-
quent complication. The mortality is high, amputation of the lower extremity
having been fatal in nearly half of the cases. An effort on the part of the
tissues to form a line of demarcation should be encouraged in every way — by
154 RELATIONS OF MEDICAL DISEASE TO SURGERY
dry heat, dry antiseptic dressings, elevation of the limb, etc. — in the hope of
improving the general vitality before amputation is done.
TYPHUS FEVER
The depression of vitality in this disease is extreme. Operation for its
surgical complications are, therefore, attended by a high mortality. These are
by no means so frequent and varied as in typhoid. The most common are
gangrene, usually of a lower extremity ; ulceration of the fauces with possible
edema and mechanical dyspnea ; and empyema.
Gangrene, when it occurs, is due to the lowered vitality of the tissues, fol-
lowed by arterial or venous thrombosis, or both, less often by embolism. Pre-
existent diabetes or arteriosclerosis or both are believed to be predisposing
causes. The popliteal is the artery most often involved, next the femoral, the
aorta, and the iliacs. In the lower extremities a line of demarcation may form,
or none. In the latter group amputation must be done early and well above
the advancing area of necrosis to be effective. The mortality is very high,
probably nearly 75 per cent. Edema of the larynx demands tracheotomy and
empyema drainage of the pleura.
SMALL-POX
The relations of small-pox to surgery consist merely in the treatment of the
suppurative complications and of the sequelae of the disease.
The most frequent are furuncles, deeper abscesses, erysipelas, and ulcera-
tion of the larynx and fauces ; less frequent are bed sores, progressive and fatal
gangrene of the skin and subcutaneous tissues, noma, and suppurative or gan-
grenous parotitis. Empyema is not common. Cicatricial deformities of the
eyelids may require plastic operations. In certain epidemics diphtheria is a
complication. These several conditions demand appropriate treatment de-
scribed elsewhere in this work.
CHICKEN-POX
(Varicella)
Surgical complications are rare in this disease. As in all conditions fur-
nishing open atria for infection through the skin, local and general septic
processes are possible, and may be severe or fatal. Thus, in rare instances,
streptococcus septicemia, erysipelas, localized gangrene of the skin, and joint
lesions have been noted. Death resulted in a few instances. The treatment is
that of similar lesions whatever their origin.
SCARLET FEVER 155
SCARLET FEVER
(Scarlatina)
Surgical complications during or after an attack of scarlet fever are by no
means rare. They demand watchfulness on the part of the medical attendant
lest they escape notice until far advanced, and when recognized may require
immediate surgical treatment. Some of them are of grave import and some
only annoying.
The disease itself is a septicemia of a specific sort, and seems to invite a
secondary invasion, local or general, of the common pyogenic microbes. In-
deed, streptococcus septicemia complicating the disease is the cause of death in
not a few cases.
Scarlet fever as a complication after surgical operations, other wounds,
burns, and during the puerperium is of occasional occurrence and may render
the prognosis grave. The infection may precede or follow the trauma. In the
latter group both the lowered vitality and the raw surfaces may favor infec-
tion. These conditions were formerly spoken of as "surgical scarlet fever." In
earlier days septic rashes, after surgical operations, were more common than at
the present, and were doubtless mistaken for scarlet fever in some cases. At
present the above term is rarely used.
The list of pyogenic processes complicating or following scarlet fever is long.
The most frequent is otitis media. Deafness and chronic middle ear disease only
too often mark the individual for life. In the statistics of various observers infec-
tion of the middle ear occurs in from 10 to 50 per cent, of the cases. It is usually
bilateral with a purulent or mucopurulent exudate. Mastoiditis is not very
common. The antrum of Highmore and the sphenoidal sinuses are rarely
involved.
Otitis Media. — Otitis media may occur as early as the third day of the dis-
ease, or at any time until complete convalescence. It occurs more often and is
of a more severe type when the throat symptoms are marked. When it occurs
early it is more apt to be masked by other symptoms and to pass unrecog-
nized until the ear drum bursts and a discharge appears at the meatus;
when it occurs later severe pain in the ear and a rise of temperature are
present.
Early incision of the drum head is indicated in all cases, followed by frequent
irrigations with warm boric acid solution, in order to wash out the sticky dis-
charge and keep the drainage free. Cessation of this discharge, with return
of pain and fever, demands examination of the ear and reopening the drum if
the former incision is closed. Mastoiditis demands operation.
Affections of the Lymph Nodes. — The lymph nodes of the neck are regularly
enlarged in scarlet fever, the increase in size may be slight or marked, in the
latter group the swollen glands may gradually subside or suppurate.
156 RELATIONS OF MEDICAL DISEASE TO SURGERY
Suppuration may occur early or be delayed for weeks. It is indicated by
the usual signs : Pain, tenderness, fever, and leukocytosis. Suitable and liberal
incisions for drainage are indicated.
Paronychia.— Pyogenic infection at the root of the nails is frequent during
desquamation. Scratching and picking with infected finger nails is the cause.
In some cases small incisions and suitable dressings may be required. Painting
the finger tips with iodin may prevent infection of the other fingers.
Albuminuria and Nephritis.— Albuminuria is almost regularly present dur-
ing scarlet fever. It is not necessarily accompanied by marked organic changes
in the kidney and usually ceases during convalescence. Nephritis is not a rare
complication and may terminate fatally from uremia. Chronic nephritis fol-
lowing scarlet fever occurs once in 250 cases.
In selecting the anesthetic to be given to an individual who has re-
cently had scarlet fever, examine the urine. If nephritis is present local
anesthesia or gas and oxygen in suitable cases may be safer than ether or
chloroform.
Arthritis. — Arthritis is a complication of scarlet fever: the joints rarely
suppurate, but if they do they must be drained. The streptococcus is the most
frequent organism found in the pus.
ACUTE POLYARTICULAR ARTHRITIS (ACUTE ARTICULAR RHEUMATISM).
—Acute poly articular arthritis may occur and demands suitable treatment:
rest, local applications of methylsalicylate, and internal medications.
Peritonitis. — In bad cases of scarlet fever diffuse peritonitis may occur,
apparently without discoverable localized origin. The patients are septic and
the outlook is grave.
MEASLES
Much the most common medical complication of measles is bronchopneu-
monia. Lobar pneumonia may occur and be followed by empyema demanding
operation. Among the other pyogenic complications are boils and noma.
Osteomyelitis and arthritis are rare, as is also otitis media.
DIPHTHERIA
Laryngeal diphtheria demands intubation or, if this cannot be done,
tracheotomy. The general use of antitoxin has diminished the frequency and
severity of this complication.
Otitis occurs in about 4 per cent, of the cases and demands incision of the
drum head. Cervical adenitis is a regular concomitant of diphtheria, the
swelling may be moderate or excessive, and may end in resolution or in sup-
puration. Incision for drainage is indicated in the latter group.
EPIDEMIC CEKEBKOSPINAL MENINGITIS 157
WHOOPING-COUGH
The presence of a spasmodic cough from any source is a contra-indication
to operations of expediency, notably on the abdomen — for example, hernia —
since, during violent coughing, the suture line may be weakened or even broken
open.
If an abdominal operation becomes necessary especial care should be used
in suturing the aponeurotic structures of the abdominal wall. A continuous
suture of chromic gut may be reinforced by a series of interrupted stitches of
the same material. It is never wise to use buried sutures of non-absorbable ma-
terial under these conditions. In addition, the wound edges and the entire
belly wall should be supported by carefully placed masses of gauze so applied
that the zinc oxid plaster strips placed over all shall really support and keep
quiet the abdominal muscles.
MUMPS
The surgical complications of mumps are chiefly two: otitis media and
edema of the glottis. The complication orchitis does not proceed to suppura-
tion, though it may lead to atrophy of the testis. Otitis is treated by early
incision of the drum head. Edema of the glottis by inhalation of medicated
steam from a croup kettle. For this purpose compound tincture of benzoin, one
dram to a pint of water, answers well. Preparations for instant tracheotomy
should be made and a cannula placed in the wind pipe when asphyxia threatens.
INFLUENZA
In epidemics of influenza accompanied by pneumonia as a frequent compli-
cation, abscess and gangrene of the lung as well as empyema are observed.
They demand operative treatment when the local and general conditions permit.
(See Vol. II.)
EPIDEMIC CEREBROSPINAL MENINGITIS
The surgical complications of this disease are otitis media, very common,
and purulent arthritis, very rare. Panophthalmitis has been observed. The
otitis may readily be overlooked ; so common has been this complication in cer-
tain epidemics that puncture of the drum head has been recommended as a
routine measure.
Lumbar Puncture. — Lumbar puncture has been used both as a diagnostic
and therapeutic measure. As a means of treatment it has not given encourag-
158 EELATIONS OF MEDICAL DISEASE TO SUKGEEY
ing results. It may, however, be tried, 30 c. c. to 50 c. c. of cerebrospinal fluid
being withdrawn in the usual manner. It can scarcely be considered an efficient
method of drainage in these cases.
ERYSIPELAS
Erysipelas is caused by a particularly active form of the streptococcus
pyogenes.
During recent years the number of cases seen in our surgical wards, or,
more properly, developing in patients who are recovering from operations in
such wards, has greatly diminished. This is partly owing to better wound
treatment and partly because, when a case of erysipelas comes to, or develops
in, the ward of a general hospital, it is either isolated or transferred to a special
hospital at once. No ordinary isolation will suffice. The patient should be
placed in another building or in some specially arranged part of a building
with a separate entrance. Medical attendants, nurses, and orderlies should be
detailed for the care of the case and should not come in contact with other cases.
During all handling of the patient special clothing and rubber gloves should be
worn.
The patient himself should be bathed frequently, and should have frequent
changes of body and* bed clothing. The baths may well be of 3 per cent, boric
acid solution after the use of soap and water. Upon recovery he should receive
several thorough baths. The hands and hair should be thoroughly disinfected.
All fomites should be disinfected either by steam or formalin solution, and the
apartment disinfected with formaldehyd gas.
Not only are persons with wounds likely to contract erysipelas, but also per-
sons with medical diseases or healthy persons who may have some slight abrasion
of the face or a fissure within the nostrils. In cases of facial erysipelas this last
is a very common portal of entry, the contagion being conveyed by the fingers.
The surgical complications of erysipelas are numerous: Abscesses,
gangrene of the skin, lymphadenitis, phlebitis, pneumonia, empyema,
septicemia, pyemia, otitis, edema of the glottis, arthritis, and delirium
tremens.
James M. Anders, in Osier's "Modern Medicine" (Vol. II, Chap. XX),
gives analyses of 1,674 cases with especial reference to complications, with
results as follows: Abscesses, 105; arthritis, 20; delirium tremens, 10; lobar
pneumonia, active delirium, phlebitis, pleurisy, each Y; acute nephritis, 6;
synovitis and diarrhea, each 5 ; tonsillitis, 3 ; catarrhal pneumonia, otitis media,
edema of the larynx, acute bronchitis, each 2. The most fatal complications are
lobar pneumonia and delirium tremens.
Abscesses. — The most frequent site of abscess is the face (eyelids) and
scalp. They give the usual signs of subcutaneous abscess and should be opened
early. They may be single or multiple, and are usually of moderate size, but in
EKYSIPELAS 159
bad cases they may attain large proportions and be followed by extensive
sloughing of the skin and subcutaneous tissues.
When on duty in the erysipelas pavilion of Bellevue Hospital many years
ago I saw a number of cases in which these abscesses were very large, took
long to heal, in spite of free incisions, and left ugly scars. The most extensive
were in the neck and scalp.
Several epidemics of erysipelas occurred in the surgical wards during the
time I was surgical interne at Bellevue, and I saw others later in Roosevelt
Hospital. The speed of transmission from patient to patient was striking.
Thus, in a male surgical ward of 18 beds, a man was admitted with a severe
scald of the genitals and abdominal wall produced by a bursting steam pipe.
Within a day after admission the characteristic intensely red blush of the skin
had appeared at the margin of the scald of the scrotum, the man had a chill and
a high temperature, was removed to the erysipelas pavilion, became delirious,
and died comatose in less than 48 hours thereafter. A man in the next bed
had been operated upon for a fracture of the patella, he developed facial erysip-
elas, but survived. Across the ward lay a man with a simple fracture of tibia
and fibula, and on the same day he developed erysipelas of the face. Three beds
removed from the first case was a man with inoperable cancer of the neck,
whose common carotid artery had been tied. Three days after the first case he
had erysipelas in his wounds and then erysipelas of the pharynx, with edema
of the larynx, and died in spite of early tracheotomy. Another patient near by
had a perineal section for stricture of the urethra. Within a few days he had
erysipelas and died. There were 8 deaths in this ward as the result of this
epidemic, and the lesson has never been forgotten.
The disease is infectious and contagious. In those early days we knew noth-
ing of proper precautions and the hands of orderlies and surgeons infallibly
carried the infection from one patient to the other. I have heard eminent sur-
geons say that erysipelas in a ward caused them no anxiety. To them it was
no more than any other infected wound. Such a view does not agree with my
experiences. I have seen the disease recur after months of exemption and
believe that the germ is a peculiarly resistant and enduring form, not to be re-
garded lightly, and that it should receive most careful attention from the be-
ginning. Only in this manner can a hospital be protected from such infection.
The use of rubber gloves for all examinations and dressings is the best means at
our disposal to avoid this particularly unfortunate and disastrous type of wound
infection. Infection with erysipelas may have a beneficial effect on sluggish
wounds and on sarcomata — more rarely on carcinomata.
In the extremities the abscesses and necrotic processes may be localized,
or diffuse. When circumscribed they resemble subcutaneous abscesses else-
where, are easily discovered, and demand early incision. WTien diffuse, ex-
tending, for example, from the ankle to the knee, or from the wrist to the
clavicle, they require, for the relief of tension and evacuation of pus, cuts of
unusual length from the ankle to the knee or thigh, from the wrist to the
160 RELATIONS OF MEDICAL DISEASE TO SURGEKY
clavicle. All tension must be relieved, all pockets drained. The operator must
remember that a cut in the skin two feet long is as nothing compared to the life
of the patient, and that such cuts are of no great consequence since they do not
as a rule impair the usefulness of a limb and heal quite rapidly.
Gangrene of the Skin. — A peculiarly deadly form of streptococcus infection
combined with putrefactive microbes may complicate cutaneous erysipelas or
occur alone. This disease has been called "erysipelas alba." It results in a
progressive necrosis followed by putrid decomposition of the subcutaneous tis-
sues and connective tissue planes. The skin may show no redness, but only a
boggy edema. The most fatal forms occur in the neck, and death from septic
absorption or edema of the larynx may occur in two or three days.
The widest incisions and the use of antiseptics in the wounds and all
pockets may stay the process. Tincture of iodin or Chlumpsky's solution may
be used.
9
Camphor 60
Carbolic acid 30
Alcohol 10
An excess of this solution must be carefully wiped away with gauze swabs
gently applied. The wound cavities may be lightly packed with gauze saturated
in the above solutions. Frequent changes of dressings are required, daily or
twice or three times daily. Pocketing should be sought for, and all pockets
laid open as soon as found. Most of these cases die in spite of every effort for
their relief.
Stimulants in every form should be given in large doses ; in young subjects
alcohol in large quantities may be used with advantage, such as brandy,
whiskey, or rum.
lymphadenitis. — Lymphadenitis is seen most often in the neck and groin.
If it ends in suppuration, incisions will be required, not enucleation of the
glands. This is a conclusion arrived at after a long experience in the surgery
of infected wounds.
Phlebitis. — Phlebitis is observed in the veins of the lower extremity. Eest,
cotton, and bandaging, with slight elevation of the limb and absolute immobil-
ity, are indicated.
To avoid the danger of embolism the quieter the patient is kept the better.
Pneumonia and Empyema. — Pneumonia is, as stated, one of the most fatal
complications of erysipelas. It may be a streptococcus pneumonia or a pneu-
monia due to the pneumococcus. It is followed in a small proportion of cases
by empyema, giving the usual signs, and demanding the resection of a rib and
drainage. The pneumonia in these cases is often a terminal phenomenon last-
ing only a short time and ending in death, and in most instances little can be
done. Several portions of the lungs may be involved in succession — "wander-
ing pneumonia."
STATUS LYMPHATICUS 1C1
Delirium Tremens. — The chronic alcoholic is peculiarly susceptible to infec-
tion with erysipelas. If the alcoholism has resulted in serious organic changes
in the liver, kidneys, alimentary tract, heart, and blood vessels the prognosis is
grave.
It is better not to withhold alcohol in these cases, but to give it in moderate
quantities, to force the ingestion of milk, eggs, and broths at frequent intervals.
(This is contrary to the opinion of good observers of large experience, notably
Alexander Lambert. In delirium tremens uncomplicated with infection I
agree with him.) (For the use of drugs and other measures, see Delirium
Tremens, page 166.) Other stimulants, strychnin, digitalis, and camphor, may
be given and an effort made to induce sleep. Paraldehyd seems to be as effi-
cient as any drug for this purpose. When asleep these patients should on no
account be disturbed.
These patients may require restraint, by a sheet passed across the body and
by suitably arranged rolls of gauze or muslin tied to the wrists and ankles. A
method in use for many years at Bellevue Hospital is efficient, easy to apply,
and much easier to bear than a straight jacket. It is described as follows by
Lambert.
"There is no question that these patients should be confined to bed during the
entire delirium stage, as in the wilder delirium it is often necessary to restrain them
by a sheet tied around their ankles and then tied to the foot of the bed, and by another
sheet which goes from the bed up over one shoulder, down through the axilla, across the
back to the opposite axilla, out across the shoulder, up to the bed; the wrists, when
necessary, can be restrained by a muslin bandage wrapped around over cotton wool,
which thus prevents abrasions and holds them firmly; sometimes a folded sheet
stretched across is sufficient to hold them in bed."
The other surgical complications of erysipelas will receive due attention
elsewhere since they possess no distinctive peculiarities.
STATUS LYMPHATICUS
Persons with status lymphaticus should not be operated upon if it is pos-
sible to avoid it. They are very bad surgical risks and often die merely from
the administration of a general anesthetic. Unfortunately the condition may
not be recognized until it is too late. These individuals are peculiarly suscep-
tible to poisons of all kinds, notably to ether and chloroform, and to acute infec-
tions, and they succumb to slight injuries and operations. If occasion arises where
operation must be done it might be safer to use a local anesthetic, novocain, not
cocain.
So important is the recognition of this condition in order to avoid a fatal
result from some relatively slight operative procedure that I quote from John-
son's "Surgical Diagnosis" (Vol. Ill, pages 705, 706, 708) :
12
162 RELATIONS OF MEDICAL DISEASE TO SURGERY
EXTERNAL APPEARANCES
The body is graceful in its proportions, except in disease, well nourished, and
rarely obese.
The conformation of the limbs is most characteristic, especially that of the thighs.
These are well rounded, arched anteriorly and laterally, the latter being the most
noteworthy feature. The lateral and anterior arching exists both in male and female,
and in both sexes the pelvis may be small. The upper arms are rounded, the shape
being graceful; the forearms are not rounded, except in marked cases. The muscular
development, even when excessive, does not cloak these appearances, some of the
most marked cases having occurred in muscular male cadavers. This configuration
cannot be considered as a female type of build, but rather a persistence of the juvenile
contour.
The skin most frequently has a glossy, less often a pasty, appearance, as was first
brought out by Escherich and Daut.
Hair. — The hair upon the pubis is distinctly feminine in distribution, confined to
the suprapubic fat pad, the superior edges being sharply marked off. The hair may
be abundant, but it is never absent, except in the young. A few hairs may extend up
the line toward the umbilicus.
AXILLARY HAIR in adults is usually scanty, although the individual hairs may be
long. Hair on head may be abundant even in less marked cases. It is coarse, straight
and lusterless.
HAIR ON LIMBS. — Even in subjects having the usual amount of hair, the thighs
are, except for lanugo, free of hair, even when the legs and forearms are hairy. The
same is true for the upper arms.
The head is brachycephalic in type.
The neck is implanted squarely upon the upper thoracic opening. It may be
either long, thin, and columnar, or short and thick.
Genital Organs. — A few of the marked cases present evidences of infantilism, the
external genitals being small. This infantile type of the genital organs is, however,
exceptional, even in those cases associated with a hypoplastic condition of the aorta
and arterial system. The glans penis is frequently pointed like an acorn.
Many of the above characteristics may be absent, the most constant being the
peculiarity of the thighs.
Thus, the pubic hair may be normal or excessive, running up to the linea in
normal adult males. This is, however, exceptional.
Our experience at the morgue teaches us that the external appearances are of
considerable importance in diagnosing the presence of the status cases, especially
those which are recessive in type. It is certainly a striking fact that time after time,
without clinical history, the diagnosis has been made before autopsy.
1. Status lymphaticus is characterized by hyperplasias of the lymphatic structures
associated with persistence or enlargement of the thymus gland beyond the age of
puberty, with arterial hypoplasia and possibly with hypoplasia of the chromaffin sys-
tem.
2. Cases of this state have characteristic external appearances, especially in
respect to general conformation of the body and distribution of the hair.
3. This constitution represents a constitutional anomaly, and not a mere per-
sistence of the infantile type or an arrest of development. Infantilism is, however,
not infrequently associated with it.
4. Individuals with this constitution have a special predisposition to disease, and
increased susceptibility to various insults.
I
LOBAK PNEUMONIA 163
5. The frequency of the lymphatic constitution has not been sufficiently empha-
sized, nor has sufficient account been taken of it in its wide medical, surgical, and
insurance aspects, especially its relation to prognosis and duration of life. We have
found this condition in about 2 per cent, of over 2,000 autopsies.
6. Not all the individuals with the lymphatic constitution succumb to disease.
Many survive to adult age. The various lymphatic structures thereupon tend to
undergo recessive changes.
7. The lymphatic constitution is noted with especial frequency in diseases of the
ductless glands (Basedow's, acromegaly, Addison's, and in tumors and diseases of the
pineal gland) and in diseases such as epilepsy, which are probably due to disorders of
internal secretion.
8. The thymus is an epithelial organ, and not a lymphoid structure.
9. More exact knowledge of the thymus, in its relation to general lymphoid
hyperplasia, to the onset of spermatogenesis, and the development of the secondary
sexual characters is vital to any further progress in the elucidation of important
physiologic and pathologic consideration of health and of disease.
LOBAR PNEUMONIA
Lobar pneumonia is a centra-indication to all operations except such as are
rendered necessary by the complications of the disease itself. It is worthy of
note that in earlier stages of pneumonia, before the physical signs are well
marked, or in cases where the diaphragmatic pleura is first involved, errors in
diagnosis are not very rare.
Pain may be referred to the abdomen, and abdominal rigidity may be well
marked. Highly competent surgeons have opened the abdomen in search of an
inflammatory focus and found nothing abnormal, and the signs of pneumonia
have appeared the following day or later.
I came near doing this myself a short time ago in a case where a few days before
I had removed a tuberculous testis associated with inguinal hernia. The patient
developed a temperature with very severe pain referred to the left upper quadrant of
the belly and back. A probable diagnosis of a tuberculous kidney was made. Within
two days signs of pneumonia in the lower lobe of the left lung were recognized, and
no operation was done. The patient survived and left the hospital apparently quite
well.
The surgical complications of pneumonia are few but very serious. The
most important are empyema, abscess of the lung, gangrene of the lung, pneu-
mococcus arthritis, pulmonary embolism, and peripheral venous thrombosis.
Empyema. — In from 2 to 5 per cent, of the recorded cases pneumonia is
followed by empyema. The exciting germ may be the pneumococcus, or the
streptococcus. The percentage varies in children and adults. Ewart found
that in children 75 per cent, of all the empyemata were caused by the pneu-
mococcus, 25 per cent, by streptococcus pyogenes. In adults the percentages
were reversed.
164 RELATIONS OF MEDICAL DISEASE TO SURGERY
The treatment of empyema, as soon as the presence of pus in the pleural
sac is verified by the aspirating needle, is drainage of the pleura by resecting an
overlying rib and introducing one or more large rubber tubes. N. B. The
tubes should have large safety pins thrust through their outer ends lest they
slip in and be lost in the cavity, a most annoying accident. (See Vol. I, Chap.
VII, "Aspirating Devices in Surgery.'7)
It is not wise to irrigate the pleura. If the patient is weak, is breathing
badly, and is cyanotic, a rib may be resected under local anesthesia. The pro-
cedure is very painful and distressing. I seek to avoid it whenever possible.
Abscess of the Lung. — The treatment of abscess of the lung is drainage
when practicable. (For technic see Vol. II.)
The other complications of pneumonia are rare, nor does their treatment
require special mention here.
ALCOHOLISM
The habitual use of excessive amounts of alcohol greatly increases the risk
of surgical operations, and renders prognosis after an injury or in cases of any
infection much more serious. The longer the individual has had the habit
and the larger the quantity of alcohol he takes daily so much the worse, and yet,
here, careful discrimination is necessary. Alcohol is a poison to all, but it
acts differently on different individuals. There are men who have taken more
than a quart of whiskey every day for many years, who yet recover from a
serious injury or a serious infection requiring operation without much trouble,
even though all alcohol be withdrawn at once. They are, indeed, the better
for the withdrawal. They are, as a rule, men who have led active lives out of
doors.
In other cases even a moderate alcoholic habit may cause the patient to be-
come delirious after a surgical operation or to develop pneumonia and die.
Among alcoholics in general, it is to be remarked that pneumonia is very fatal.
In some cases when alcohol is withdrawn, the patients, for a few days at
least, are greatly depressed. If in this group an operation is believed to be
necessary and there is no indication for immediate action, the best treatment
I know of is as follows : Keep the patient in bed. Feed him with milk, eggs
and broths at frequent intervals, keeping his stomach full of these things, given
preferably hot. Keep his bowels open with, first, a large dose of calomel
(I£ Calomel grs. ii, iii or iv with Sodium Bicarb., grs. x) followed by %
to 1 ounce of magnesium sulphate, the following morning. Give him Tinct.
Nux Vomica m. x, t. i. d. in water a. c. and every morning for two weeks.
Carlsbad salts gss in hot water before breakfast. Iron and other tonics may be
given if indicated.
One of the best drugs I know of as a tonic and sedative is asafetida in
doses of 3 grains four times a day; it is well combined with extract of nux
ALCOHOLISM 165
vomica, % grain, or % grain of powdered mix vomica. It is astonishing to
see how these patients will improve under this treatment. In a fortnight they
may be so much better that any ordinary operation— for hernia, for example,
or a stricture of the urethra — may be performed with good convalescence. The
three cardinal points are :
(1) Eestinbed.
(2) The bowels open.
(3) Plenty of easily digested food.
When a man long dependent upon alcohol is put in bed and kept these with
no necessity for physical or mental effort, when he is fully fed with simple
food, and his bowels kept freely open, he loses quickly the craving for drink.
He may lie more or less quietly, or for a day or two may be a little- restless,
but after a very few days, if not obliged to exert himself, the craving passes
off and soon he becomes almost if not quite normal. These remarks apply to
the average young or even middle-aged drunkard whom we see in the hospitals.
He should be protected from the necessity of worry and mental or physical
effort.
It is rarely necessary to give a sedative for more than two or three nights
to induce sleep. Such sedatives as veronal, trional or paraldehyd may be em-
ployed. An old formula which agrees with most people is useful when these
patients are very nervous. It may be varied to suit the individual case. It is
as follows :
Bromid of sodium .................................... gr. xxx
Chloral hydrate ..................................... gr. x
Tr. of nux vomica .................................... m. x
Tr. of capsicum ...................................... m. v
Water up to a drachm.
M. Signa, a teaspoonful every 4 hours in water.
This dose may be given well diluted with water every three hours until the
patient is quieted, when the intervals may be increased. If the heart is dilated
or weak, digitalis may be added.
In some cases, chloral in doses of this size seems to make the patients more
excited. In these cases the dose of chloral may be doubled and caffein added
or some other drug must be chosen. In my experience, much larger doses of
chloral may be given to induce sleep if the heart is in good condition. After
a few days these sedatives can be omitted; they tend to produce a certain de-
gree of mental and physical depression.
In the treatment of alcoholism, A. Lambert places a high value on the
hypodermic use of ergot, combined with strychnin. He warns against giving
these drugs by the stomach, more particularly in delirium tremens, lest they
accumulate in the stomach and later be absorbed suddenly and in dangerous
quantity.
166 KELATIONS OF MEDICAL DISEASE TO SUKGERY
In deciding for or against a serious operation in the given case, the follow-
ing conditions — one or all — will render the prognosis more serious or very seri-
ous: Marked arteriosclerosis, a rapid, feeble and dilated heart, i. e. a degen-
erated heart muscle, marked chronic gastritis, chronic nephritis, obesity, pre-
mature senility, well-marked cirrhosis of the liver.
No sane man would think of operating on a patient with delirium tremens,
but, as the result of accidental trauma or infection, the surgeon is often called
upon to treat these conditions, more especially in hospitals. When a patient
who has an alcoholic habit is received in a hospital suffering from an accidental
trauma, it is wise in my opinion to give alcohol in moderate and diminishing quan-
tities for about a week, together with the sedatives just mentioned.
When delirium occurs it appears on the second or third day or may rarely
be delayed until the sixth. When active delirium develops, the treatment al-
ready outlined in the preceding pages may be used.
The treatment used by Lambert in Bellevue Hospital is as follows :
Alcohol should be absolutely withdrawn in all cases.
First and foremost, all these patients must be treated from the standpoint of those
having a degenerated heart muscle, and they therefore should be stimulated with
strychnin (gr. 1/60-1/30, gm. 0.001-0.002) every four hours or oftener, or by caffein
or camphor, and these are best given hypodermically. Strong coffee or tea can be
given in mild cases instead of the pure caffein. The patient should be given a purga-
tive such as compound cathartic pills, compound licorice powder, or calomel. In
young, vigorous adults, without any appreciable change in their arteries, who have
recently been drinking, an emetic such as copper or zinc sulphate is often an advan-
tage. These should never be given to elderly persons or to those who appear old for
their age.
In mild and abortive attacks a dose of a dram of paraldehyd, repeated if neces-
sary in an hour, is all that is necessary to cause sleep, from which the patients fre-
quently awake either clear-headed or with their delirium lessened. In the severer
cases the paraldehyd may be given in dram doses, at hour intervals, even up to three
doses. Other hypnotics, such as sulphonal, trional, etc., have in the hands of the
writer usually failed utterly except in the mildest cases. Opium should be resorted
to only as a last resort, and is especially contra-indicated with pronounced arterio-
sclerosis. Hyoscin (gr. 1/125, gm. 0.0005) and morphin (gr. 1/6-^4, gm. 0.01-0.015),
hypodermically, should only be given to young and vigorous individuals in whom the
motor symptoms are especially marked. Hyoscin alone tends to increase the delirium,
especially in women. Often in the severest cases a mixture of hyoscin, gr. 1/100
(gm. 0.0006) with apomorphin, gr. 1/10 (gm. 0.006) and strychnin, gr. 1/30 (gm.
0.002), will quiet them and give at least a few hours' rest. Bromids are insufficient,
and in the hands of the writer have been practically useless.
Chloral is one of the best drugs when properly administered ; small doses are use-
less, and Lancereaux claims that they even tend to excite these patients. When the
heart is properly stimulated chloral hydrate does not have any deleterious effects.
Lancereaux recommends thirty to sixty grain doses (gm. 2-4) ; the combination of
chloral and morphin is especially advantageous in that smaller doses of each can be
given and the mixture be more effective than either singly. The mixture of morphin,
gr. % (gm. 0.008), chloral, gr. 15-30 (gm. 1-2), with tincture of hyoscyamus, 3ss
(2 c. c.), tincture of ginger, m. x (c. c. 0.6), and tincture of capsicum, m. iii (c. c. 0.2),
and water to Jss. (c. c. 15) is very effective, and can be repeated at the end of an hour.
ALCOHOLISM 167
These hypnotics, while causing sleep, do not necessarily cut short the delirium, but
after a sleep of some hours the delirium is often quieter and there is the further
advantage of rest for the heart from cessation of motor excitement. Of late years
the writer has used ergot hypodermically in Livingston's solution, which is as follows :
One dram of the solid extract of ergot is dissolved in an ounce of sterile water and
three drops of chloroform and three grains of chloretone are added, and the solution
filtered; this is sterile and should be given straight into the muscles in the gluteal
region or in the deltoid. It should never be given subcutaneously ; if carelessly given,
it will produce painful spots. The administration of thirty drops of this solution,
hypodermically, every two to four hours, reduces the dilated blood vessels, lessens
the various congestions, and brings about a better equilibrium of the circulation.
After it there is a distinct tendency to a quieter delirium and less need of restraint;
it reduces the tremor, less hypnotic is required, and it diminishes the tendency to
"wet brain." The writer has. never seen symptoms of ergotism, although thirty
minims of this solution were given every two hours for ten days or longer. As soon
as patients awake they must be given food, best in the form of milk or milk and eggs.
This should be given regularly every two or three hours during the delirium, but if
asleep they should not be awakened for any reason.
The treatment for the "wet brain" condition should be begun as soon as it is
suspected. Strychnin, gr. 1/60 to 1/30, and ergot, 30 minims, both hypodermically,
should be given every two hours, and caffein and camphor are also of use. The patient
should be carefully fed every two hours with milk, broth, and eggs, and thorough
purging is advisable. Alcohol seems to increase the effusion, and should not be given.
During convalescence, however, a little alcohol in the form of eggnog, two or three
times a day for a few days is often of benefit.
A treatment has been published by McBride of Toronto, which has proved very
successful in his hands. The writer has tried it in a few patients, and so far the
results have been all that could be desired. It is as follows: As soon as the patient
is over the severe effects of his debauch, or if he is steadily drinking without any
drunken outbreak, he should be given, hypodermically, three times a day, atropin and
strychnin, of each gr. 1/100 (gm. 0.0006) ; these drugs should be gradually increased
until the full physiological effect of the atropin is obtained and the patient is taking
a thirtieth or even a twentieth of a grain of strychnin three times a day; when the
mouth is continually dry and the pupils dilated, the atropin should be reduced slightly
and held at this dosage for four or five days; then both the strychnin and atropin
should be gradually reduced, and finally the patient should be given the drug twice
daily, then once daily, and then cut off entirely; the length of time required for this
treatment is about a month or six weeks. Often the compound tincture of cinchona
is added, especially in the morning, when the craving for alcohol is greatest. It is a
noticeable fact that after a few days, usually in less than a week, the desire for alcohol
has ceased, and the thirst from the dryness of the mouth is easily satisfied with water.
McBride reports that he has tried this for a number of years, and the patients whom
he thus treated ten or twelve years ago have remained abstinent; this has not
been universally successful, but in his hands it has succeeded in such a large
majority of cases that it is worthy of the most extensive trial, and it has the special
advantage that the patients need not be confined or absent from their homes or even
daily work.
This treatment has now been in rather extensive use in New York City for
some years and has furnished satisfactory results.
168 RELATIONS OF MEDICAL DISEASE TO SURGERY
USE OF OPIUM AND MORPHIN
Before the use of opium and morphin has produced marked deterioration
of health and while the heart muscle is still in fair condition, the habit is not
in my experience a serious contra-indication to a surgical operation. The pa-
tient must by no means be deprived of his accustomed doses or disaster is sure to
follow. If the total quantity taken in 24 hours is large, it may be diminished
somewhat and the bowels should be thoroughly emptied by purgatives and kept
active.
If the patient has long been habituated to the drug and it be suddenly and
totally withdrawn he will wilt like a wet rag and pass into a condition of mental
and bodily wretchedness which may speedily end in fatal collapse. If to this is
added the shock of a surgical operation, it is easy to understand that a fatal
result is very probable. If, on the other hand, he gets his stimulant at stated
intervals, even though somewhat less in quantity, his convalescence may be and
often is as smooth as could be desired.
The difficulty in these cases often is that the patient does not confess his
habit, perhaps does not realize how dependent he is upon the drug, or fears to
suffer the shame which a knowledge of his slavery will entail among his friends,
or in other cases the family will unwisely withhold their knowledge of the con-
dition and permit the surgeon to operate in ignorance. Therefore, the symp-
toms of chronic morphinism, and more especially the symptoms of deprivation
from the drug, should be well understood by every surgeon. In my experience
those who take morphin habitually do not realize what abstinence means. They
never abstain long enough to know more than the premonitory symptoms of
deprivation. When any slight additional call is made upon their energies, they
naturally think that it can better be met with just a little of the customary
stimulant. The little must be increased to more, and that to still more, until a
grain or two becomes just a small stimulating dose which scarcely counts in
the day's allowance.
It is, therefore, important for the surgeon to seek the confidence of his
patient in any suspected case of drug addiction in order that a proper under-
standing of the conditions may be known and proper measures may be taken.
This can best be done by placing the patient in a hospital, taking away every-
thing in which the drug could be concealed and having him constantly watched
for a day or two. If he is addicted to opium or morphin, certain symptoms will
certainly develop within twenty-four hours. They will vary in intensity, ac-
cording to the duration of the habit and the quantity taken. They are yawning,
violent and repeated sneezing, a profuse discharge of tears from the eyes and of
mucus from the nose, cramps in the legs and back, profuse sweating. The skin
is at first flushed, later cold and clammy, arid the sweating is often most marked
upon the forehead and at the back of the neck. The sweating may be preceded
by chills alternating with flushes of heat up and down the spine. The yearning
USE OF OPIUM AND MOKPHLN" 169
and craving for the source of peace, ease and comfort are such that the individ-
ual regards it as his right as though when thirsty he were deprived of water. As
the hours pass, after the time of the habitual dose, the patient becomes pale, the
face has an anxious drawn expression, extreme restlessness appears, he thrashes
about in bed, and there may be violent jactitation of the limbs and an utter
inability to lie still. A feeling of constriction about the chest is complained
of, and the respiration is sighing. The patient becomes very weak, with a
rapid, thready pulse. He can hardly stand or walk, nausea and vomiting are
common, and within a day or two a profuse diarrhea. This last may still
further weaken the patient and in bad cases the vomiting and purging may con-
tinue until he passes into a fatal collapse. He may become hysterical or even
maniacal and attempt suicide, or murder; collapse with heart failure may sud-
denly follow and the patient may die, unless morphin be given, when the symp-
toms disappear like magic and he is himself again. If such symptoms occur
and then suddenly cease without treatment, it is certain that the patient has
obtained his drug somehow.
The suffering from abstinence is so great that patients will resort to any
expedient to obtain the drug, and use great cunning and skill in hiding it,
secreting it in the toe of a bedroom slipper, the inside of a sock on the foot, a
cigarette case, between the leaves of a book, etc.
One of the most common results of the prolonged use of opium and morphin
is emaciation, leading in the end to profound cachexia. Patients in this con-
dition should not be operated upon if it be possible to avoid it. The condition
of the heart and of the kidneys should be looked into carefully in such cases,
since the heart muscle is often degenerated and the kidneys faulty. Loss of
hair and teeth occurs during the advanced stages of chronic morphin poisoning,
usually with extreme physical weakness and emaciation, and are signs of ill
omen. In such cases the processes of repair and resistance of the tissues to
infection are greatly diminished.
If operation be decided upon and delay is permissible, an attempt should at
first be made to improve the general condition. Most important is it to get
the alimentary tract, in a state to absorb food. To this end, repeated doses of
castor oil are useful, given daily for a week or longer, in 1-ounce doses, or
%-ounce twice or 3 times daily.
As a tonic, strychnin may be given subcutaneously in doses of gr. 1/30-1/60
several times a day. For patients in better general condition, tincture of mix
vomica, citrate of iron and quinin and tincture of capsicum are useful. The
subcutaneous use of ergot as in alcoholism is highly spoken of by A. Lambert.
Tea and coffee, and for a time alcohol, in moderate doses may be given. Egg-
nog made with milk, egg, and brandy, sherry or rum, given 3 or 4 times daily,
helps greatly to make these patients more comfortable and to improve nutrition.
If the patient does well after operation and is anxious to be rid of his habit,
an attempt may be made to cure him by the rather rapid method of withdrawal
i. e., the dose is reduced one-half each day until in a few days the drug is
170 KELATIONS OF MEDICAL DISEASE TO SUKGEKY
entirely withdrawn. ' The suffering is severe, but the very gradual withdrawal
is tedious and trying in the extreme for both patient and his attendants.
He will require constant watchfulness day and night and is best placed in
a hospital or special institution. The suffering for the first few days is severe,
and the patient requires every possible aid and encouragement.
USE OF COCAIN
The use of cocain as a local anesthetic, either subcutaneously or locally
upon mucous surfaces, while still general, has been supplanted to a great extent
by novocain usually combined with adrenalin. The latter combination pos-
sesses two advantages, i. e., it can be sterilized in solution without destroying
its effects and is much less poisonous.
We are here concerned with the habitual use of cocain as a stimulant and
what effect, if any, such use may have upon the individual considered as a
surgical risk. Of the three intoxicants in most common use — alcohol, morphin
and cocain — the last named is the most rapid in its destructive effects upon the
body and mind of its victims. It is taken either by snuffing, by mouth, or
subcutaneously. The doses vary, and may reach a maximum of gr. 30-60 daily.
In those not habituated to its use %-l grain may be a dangerous subcutaneous
dose in the adult and a much smaller quantity in children. Many persons take
morphin and alcohol and to combat the depressing after-effects take cocain.
Others take cocain as their principal stimulant and alcohol or morphin or other
hypnotics to put them to sleep.
The primary effects of a moderate (non-poisonous) dose of cocain are an
intense mental and bodily exhilaration, said to be more agreeable than any
other form of intoxication. These effects are brief in duration, and are accom-
panied by an increased pulse rate, by an irrepressible mental and motor
activity, and, if the drug is taken at night, are followed by insomnia. Sweating
is also a symptom of cocain intoxication.
When taken habitually, cocain produces insanity. These patients early
lose self-respect and all sense of responsibility. They become careless of their
affairs and lie without compunction, later delusions of grandeur are present,
the individual believes himself capable of wonderful feats of physical and
mental strength. He may be furiously industrious in his profession, but his
actual accomplishment is inferior to normal work. He often believes that he
has discovered new methods or new principles and has developed new theories
of great importance. When critically considered, his methods, principles and
theories are found to be borrowed from well-considered ideas of sane men,
already well known, or else they are mere eidolons, without substance and of
no practical value. He may talk or write incessantly, but what he says or
writes is confused, wandering and useless.
Soon, hallucinations of the various senses occur, and delusions of persecu-
USE OF COCADsT 171
tion are added. The patient is nervous and irritable, and sleeps but little,
unless, as is common, he takes morphin, alcohol, chloral or any hypnotic he can
get. Motor excitement and motor ataxia soon become so marked that in walk-
ing he wanders all over the sidewalk. If he takes up a glass of water to drink
he may drop or throw the glass across the table or upon the floor at the far
side of the room. Emaciation is rapid . and marked in these cases. If the
cocain and other drugs be stopped the patient recovers after weeks or
months.
It is said to be easier to stop the use of cocain than morphin or alcohol.
But while addicted to the first, the individual is a bad surgical risk. In order
to be cured he must be put under restraint for a long time.
A truthful man has told me that soon after cocain became available, he took it
as a stimulant and found it most agreeable. He used it much as the average drinker
takes alcohol, as a pleasant means of escape from care and the daily annoyances of
life, and used to sit and read pleasant books and enjoy himself. He was a man of
middle age, in good health and with a physique unimpaired by dissipation. His maxi-
mum dose was 40 grains of cocain. He decided that the drug might be dangerous,
stopped at once, and has never taken another dose for more than 25 years.
The nervous and physical degeneration exhibited by the cocain habitue
in a short time are much more marked than is to be observed in morphin cases,
except those very far gone in chronic morphin poisoning; and yet the former
can, when under restraint, be more readily brought back to a comparatively
normal condition if taken in time.
The main difficulty about curing the cocain habit is that this drug is rarely
used alone. Its effects, though delightful, are evanescent, and the after-depres-
sion follows quickly, and is of a most damnable description. A man whom I
knew many years ago, and who was one of the first cocain habitues, told me
that the dose had to be repeated every hour in order to keep comfortable. Sleep
without some hypnotic was impossible. He used whiskey and morphin and,
being a sensible man, later had himself locked up for a year and a half. He
still survives after nearly 30 years, is a distinguished and useful man, and
never went back to his slavery.
I am not one of those who prefer local anesthesia for surgical cases.
My objections are that with local anesthesia many operations are very pain-
ful, even with the most skillful use of the anesthetic, and entail unneces-
sary suffering. The fact that the patient suffers is apt to cause the operator
to hurry and may well impair his technic. At least, his attention cannot
be given so completely to the operation, and this may cause some serious error
of omission or commission. The wound healing is also sometimes less perfect
in my experience than when a general anesthetic is used, due probably to tech-
nical errors in sterilization of the solution injected.
There is in my opinion an unwarranted fear of general anesthesia in certain
groups of cases. I refer particularly to operations for exophthalmic goiter. If
172 RELATIONS OF MEDICAL DISEASE TO SURGERY
skillfully given, general anesthesia by gas and ether does not materially in-
crease the operative risk in these cases.
Where sequestration of the part is possible, as in the extremities, local
anesthesia offers advantages in certain cases, notably in diabetes, arterio-
sclerosis, nephritis and where the heart muscle is degenerated. In these cases
a general anesthetic may increase the operative risk, and with care even ampu-
tation of the thigh may be done with relatively little pain. In diabetic cases
of gangrene of the foot and leg I have amputated in the middle third of the
thigh with sequestration anesthesia of novocain and adrenalin, with only the
slightest pain in cutting the sciatic nerve and none at all in sawing the femur.
SYPHILIS
Speaking broadly, syphilis, even in its earlier and more active stages, is
not a contra-indication to surgical operations. These patients, more especially
if put on active treatment before and after operation, do about as well as others.
The surgeon runs some risk of infecting himself, and yet, if gloves be worn,
such risk, as shown by experience, is slight though real.
There are, however, many cases where the surgeon does not know that his
patie'nt is syphilitic. The wound may heal in a sluggish way. There is no
active infection, and yet the healing is not ideal. The wound edges normally
united in a week or less do not agglutinate. A drainage orifice does not close
as it should. There is little or no discharge, and yet, somehow, the wound does
not heal and close as it should. Enquiry, or the Wassermann test, may reveal
a history of former infection. IsTeosalvarsan and mercury by inunction and
iodid of potassium internally, in moderate doses, will work a magical cure.
Since we now have a Wassermann test made almost as a rule, many errors are
avoided. In many of these cases a spirit of kindly humanity will cause the
surgeon to allege to friends that a suitable tonic was all that was needed to
cause the wound to heal.
There are, however, many cases of active and late syphilis where the ques-
tion of a surgical operation and the decision of this question are a very serious
matter. In cases of severe syphilitic cachexia owing to want of treatment or
in cases severely poisoned by mercury, operations are strongly contra-indicated.
I have seen cases of early malignant syphilis where in spite of the most
active and careful treatment the lesions were severe and recurrent. If not
improved by neosalvarsan, these patients should be sent to the "Hot Springs
of Arkansas" and after a sojourn of six weeks or two months they will usually
return well, all active manifestations gone and in good general health. They
are then good surgical risks, and any operation of expediency may be done with
nearly the same prognosis as in a normal individual. The operator must, how-
ever, bear in mind that his own risk of infection may be the same, and that a
slight abrasion or a needle prick may make him also a syphilitic.
TETANUS 173
Cases of late syphilis (tabetics) bear operations quite well. Ordinary
fractures usually unite, but one caution may not be out of place. Resection
of a Charcot's knee joint is followed by non-union so far as my experience goes.
Another observation worth recording is that, in tabetics, perforative appendi-
citis may not present the characteristic signs and symptoms. Pain, rigidity and
tenderness may be slight, and yet there may be an extensive purulent exudate in
the abdomen.
The relation of syphilis to aneurysm is well known, probably more than
fifty per cent, of true aneurysms occurring in syphilitic subjects. Indeed, since
syphilis may attack any tissue or organ in the body, its relations to surgery are
very extensive. Most important it is that the surgeon should be able to recog-
nize syphilitic lesions when he sees them, and that every student of medicine
should receive thorough clinical training in the diagnosis of syphilitic lesions.
Since the several blood tests for syphilis have, as stated, come to be a routine in
any doubtful case, it is astonishing to find how large a percentage of the popu-
lation is syphilitic.
TETANUS
Of the complications following surgical operations there is none more ter-
rible than tetanus. Fortunately it is very rare. And yet it may occur even
though every possible aseptic precaution has been observed. When it develops
in this way, the attack is as a rule acute and rapidly fatal in spite of treatment.
Accidental wounds are followed by tetanus in a small proportion of cases in this
vicinity. The disease is common in the tropics.
Contused or lacerated wounds with embedded foreign bodies, punctured
wounds, wounds of the extremities — notably of the hands and feet — are those
most likely to be infected. The sources of infection are, garden soil and street
dirt, manure, other feces, toy pistol wadding and the like, impure cow pock
vaccine, and imperfectly sterilized catgut in surgical operations. The treat-
ment of the disease receives attention elsewhere. I shall mention here briefly
the prophylatic measures in common use.
All wounds in which tetanus infection may be suspected should be most
carefully disinfected by the thorough application of tincture of iodin, Chlump-
sky's solution,
9
Carbolic acid 2
Camphor 60
Alcohol 10
M.
or pure carbolic acid (wash with alcohol). The wound may need to belaid
open for the purpose. Careful search and removal of foreign bodies is indi-
cated. The patient then receives an injection of at least 500 units of anti-
174 RELATIONS OF MEDICAL DISEASE TO SURGERY
tetanic serum, at once. When the symptoms of lockjaw, etc., have developed
the serum is of little use, and other measures (see Volume IV) must be
added.
DIABETES MELLITUS
The presence of sugar in the urine is a contra-indication to all surgical
operations except those which are absolutely necessary.
If in addition the urine contains acetone and diacetic acid the risk is greatly
increased. If also Beta oxybutyric acid is present the patient is in a dangerous
condition and is likely to go into coma at' any time. Persons in this condition
who receive a general anesthetic and undergo a serious surgical procedure are
very apt to pass into diabetic coma and die in a few days. If, as in cases of
diabetic gangrene, it becomes necessary to operate, the patient should be put
upon diabetic diet, and if acidosis is present should receive large doses of
sodium bicarbonate.
An attempt should be made to determine the quantity necessary to render
the blood alkaline, this being a fair measure of the patient's resistance, accord-
ing to Blum. In mild cases this quantity will be about 20 gm. daily ; in more
severe cases 20-30 gm., in bad cases 50 gm. In cases of coma no amount of
sodium bicarbonate taken internally will make the blood alkaline. Wiener con-
siders that when the daily excretion of ammonia exceeds 1 gm. serious surgical
procedures are contra-indicated.
A local measure of benefit when moist diabetic gangrene is present is the
application of dry heat in the form of a blast of hot air. This is accomplished
by a special electrical apparatus. This application should be made for a
half or three-quarters of an hour daily and should be applied to living as
well as dead parts, since an active hyperemia is produced, thereby improving
nutrition. To the living parts the temperature of the air may be 80° to 100°
C. To the dead tissues 200° to 300° C. or higher. By this means the dead
tissues are rapidly desiccated, bacterial growth and septic absorption are dimin-
ished, the pain and evil odor are lessened, and the general condition improved,
so that with a proper diet the patient may be changed from a hopeless to com-
paratively good surgical risk, and an amputation be done with a successful
result.
In a large proportion of these cases a marked degree of arteriosclerosis is
present. This may be treated with the vasodilators. The best of these is
iodid of potassium, which may be given in 5/10 grain doses well diluted in
water, t. i. d.
The surgical complications of diabetes depend largely upon a diminished
resistance of the tissues to pyogenic infections. The most common are boils,
carbuncles, and gangrene of the toes and foot. In addition, acute progressive
necrotic infection of the toes and sole of the foot and chronic perforating ulcer
of the sole of the foot are not uncommon.
DIABETES MELLITUS 175
The gangrenous processes are associated with arteriosclerotic changes in
the arteries supplying the part, with complete or partial obliteration of their
calibers, sometimes with thrombosis.
In treating these processes surgically by incision of boils, excision of car-
buncles, and amputation of gangrenous members, we are sometimes able, by
diet and other measures, to improve the patient's general condition and bring
him to the operating room a better surgical risk. Moreover, with improved
resistance, a less radical operation may suffice; for example, removal of one
or more toes instead of amputation through the thigh. One caution is here in
order, namely, if the infection is spreading rapidly or is acute, as in moist
gangrene of the foot with septic absorption, which resists the measures already
described, or in carbuncle of the back, the risk of a radical operation is less
than that of delay.
Diet. — In cases where the delay is permissible we prepare the patient as
stated, by diet and other agents. This diet treatment has been studied and
formulated with great care. To be effective, it must be carried out with skill
and watchfulness. The details are so important that I here quote in some detail
from an article by Thomas B. Euteher in Osier's "Modern Medicine" (Vol. I,
Chapter XXIX) :
"We have seen that the symptoms of diabetes are directly or indirectly de-
pendent upon the hyperglycemia, the grade of which is pretty accurately
indicated by the amount of glucose excreted. Our object, therefore, should
be to eliminate the hyperglycemia if possible. This will be most quickly
effected by cutting out of the dietary those constituents that are most readily
converted by the digestive processes into grape-sugar — namely, the carbo-
hydrates.
"When a diabetic patient comes under observation, it should be the physi-
cian's first duty to ascertain the patient's capacity to warehouse carbohydrates,
or, in other words, to determine his tolerance for carbohydrates. This is done
by placing the individual for at least five days on a diet absolutely free from
starches and sugar ; that is, on a proteid-f at diet. In so doing his weight must
be taken into consideration and the diet so arranged that it will provide approxi-
mately forty calories for each kilo body-weight. This can, as a rule, be fairly
readily done — and in a hospital work should always be done — as the proteid
and fat percentage of the various foods is given in some of the standard works
on dietetics. Knowing that 1 gram each of proteid and carbohydrates yields
4.1, and 1 gram of fat, 9.3 heat units, the caloric equivalent of the diet can be
readily calculated. As the carbohydrates, which ordinarily provide the largest
number of calories in our diet are cut off, it will be seen that the proteids and
fats must be largely increased to make up for this deficit. Before arranging
the non-carbohydrate diet, the individual likes and dislikes of the patient should
be ascertained, so as to secure one that will be most palatable and one that will
likely be entirely eaten each day during the test. The following may be used
as a 'standard' diet for tolerance test, subject, to be sure, to variations accord-
176 RELATIONS OF MEDICAL DISEASE TO SURGERY
ing to the patient's age, weight, and likes or dislikes for certain forms of
meats :
"Breakfast.— 1.30 A. M. 120 grams (g iv) beefsteak or mutton chops with-
out bone; two boiled or poached eggs; 200 c. c. (g vi) of tea or coffee.
"Lunch.— 12.30 P. M. 200 grams (g vi) cold roast beef, mutton, or
chicken; 60 grams (g ii) celery, fresh cucumbers, or tomatoes, with 5 c. c.
(3 i) vinegar, 10 c. c. (3 ii) oil, pepper and salt to taste ; 20 c. c. (3 v) whiskey
(if desired) ; 400 c. c. (g xiii) of water or Apollinaris water; 60 c. c. (g ii)
coffee.
"Dinner. — 6 p. M. 200 c. c. (g vi) clear bouillon; 200 grams (g vi) roast
beef; 60 grams (g ii) lettuce with 10 c. c. (3 ii) vinegar; 20 c. c. (3 iv) olive
oil, or three tablespoonsful of some well-cooked green vegetable, as spinach;
three sardines a Thuile; 20 c. c. (3 iv) cognac or whiskey (if desired), with 400
c. c. Apollinaris water.
"Supper. — 9 p. M. 2 eggs, raw or cooked ; 400 c. c. Apollinaris or seltzer
water.
"With the four meals at least fifteen grams (about 3 iv) of butter should be
used in making the gravies and with the eggs. ISTo milk or sugar is permitted
with the tea or coffee. Saccharin may be used to sweeten them. The time of
taking lunch and dinner, of course, may be reversed. This daily diet should
provide a person of 60 kilos (132 pounds) with a little over the requisite 2,400
calories for an individual of that weight. One precaution must be emphasized
here. If the patient has been eating freely of starches, these must be cut down
slowly for two or three days before he is placed on the standard diet. Any
sudden and radical change from one diet to another is liable to induce coma.
As it has been found that a dog must fast five days before the glycogen of his
liver has been all used up, it is well to keep the diabetic on the above diet for
at least five days; by so doing it practically eliminates the possibility that any
sugar excretion at the end of that time is derived from the stored-up glycogen
of the liver.
"While on this diet, the total amount of urine should be collected for each
twenty-four hours, mixed, measured, and the sugar determinations made from
a specimen of the twenty-four-hour amount. The reduction in the sugar excre-
tion is often very striking in the first twenty-four hours. If the patient be-
comes aglycosuric within the first five days the case may then be considered a
mild form of the disease, and it is then desirable to ascertain how much starch
can then be added to his diet without sugar appearing in the urine; in other
words, to determine his tolerance for carbohydrates. This is probably best
done by allowing the patient a weighed quantity of plain white bread, which
contains approximately about 55 per cent, of starch. For the first day 25
grams of bread may be allowed. If sugar fails to appear in the urine
another 25 grams (a little less than g i) may be added to the next day and
so on until glycosuria does develop. The formula for the tolerance is as
follows: Tolerance = Standard diet + x grams starch, x representing the
DIABETES MELLITUS 177
number of grams of starch the patient can take without sugar appearing in
the urine.
"If the patient continues to excrete sugar after being on the standard diet
for five days, it indicates that he is suffering from a severe form of the disease.
It further means that the tolerance for carbohydrates is entirely destroyed, and
that the sugar eliminated in the urine is manufactured from his tissue-albumins.
In the cases in which glycosuria persists after the patient has been on the non-
carbohydrate diet for five days, Naunyn recommends that a 'Hunger Tag/ or
hunger day, be instituted, during which time no food whatever is taken for
twenty-four hours. In a certain percentage of these cases the patients will be-
come aglycosuric as a result of the starvation-day. Naunyn's reason for estab-
lishing a hunger-day is to remove the hyperglycemia even though it be for
only twenty-four hours. By so doing he claims that the tolerance for starches
is increased, and that it is then possible to give small quantities of starch with-
out glycosuria occurring, which, without the hunger-day, would not be ware-
housed. The increased tolerance is believed to be due to the tissues securing
a temporary rest from sugar formation. The writer's experience with the
hunger-day is that it is useless to advise it if the percentage of sugar is 0.5
or over, as when it is that high the sugar rarely entirely disappears. In the
treatment of diabetics it is most advisable to put them on such a standard diet
at least every three months in order that their tolerance for carbohydrates may
be increased.
"The foods the diabetic should be warned against taking, excepting, with
the permission of the physician, are as follows: Bread of all sorts, wheaten,
rye, and brown ; all farinaceous preparations such as rice, sago, tapioca, hominy,
semolina, arrow-root, and vermicelli.
"Thick soups are to be avoided. Among meats, liver is about the only form
to be prohibited, owing to the glycogen it contains. For the same reason, oys-
ters are sometimes prohibited.
"All starchy vegetables: Potatoes, turnips, parsnips, squashes, vegetable
marrow, beets, corn, peas, and artichokes.
"Beverages: Beer, the sweet wines and sweet aerated drinks. These are
excluded owing to the sugar, and not to the alcohol, they contain.
"Fruits : Grapes, dates, figs, currants, raisins, dried prunes and plums, and
other dried fruits rich in sugar, should be forbidden. Certain fruits such as
peaches, apricots, stewed green gooseberries may be permitted in mild cases.
Some authorities on this disease are inclined to be rather more lenient in regard
to fruits. It is well to remember that levulose (fruit-sugar) has been shown
to be tolerated better by the diabetic patient than any other form of sugar.
"Sugar for sweetening purposes must be omitted. Without the physician's
permission, milk must not be taken.
"The following foods the diabetic may take unconditionally: Soups:
Bouillon, ox-tail, and turtle; broths, soups with marrow and eggs permitted.
Fresh meats : All the muscular part of the ox, calf, sheep, pig, deer, wild and
13
178 RELATIONS OF MEDICAL DISEASE TO SUKGEKY
domestic birds— roast or boiled— warm or cold, in their own gravy or in a
mayonnaise sauce.
"Internal parts of the animals: Tongue, heart, brain, sweetbreads, kid-
neys, marrow-bones, served with non-farinaceous sauces.
"Preserved meats : Dried or smoked meat, smoked or salt tongue, corned
beef, American canned meats.
"Fresh fish: All kinds of fresh fish, boiled or broiled, prepared without
bread crusts or cracker-meal and served with any kind of non-farinaceous
sauce, preferably melted butter.
"Preserved fish: Dried fish, salt or smoked fish such as codfish, haddock,
herring, mackerel, flounders, salmon, sprats, eels, etc. ; tinned fish, such as sar-
dines in oil, anchovies, etc. ; caviar.
"Eggs : Eaw or cooked in any way, but without any mixture of flour.
"Fresh vegetables: Green lettuce, cress, spinach, cucumbers, onions, as-
paragus, cauliflower, red and white cabbage, French beans. The vegetables,
as far as they are suited to this method of preparation, are best cooked with
meat or a solution of Liebig's Extract and salt, with plenty of butter. The
addition of flour is not permissible.
"Preserved vegetables: Tinned asparagus, French beans, pickled cucum-
bers, mixed pickles, sauerkraut, and olives.
"Spices: Salt, white and black pepper, Cayenne. pepper, curry, cinnamon,
cloves, nutmeg, English mustard, and capers.
"Cheese: Neufchatel, Edam, Stracchino, old Camembert, Gorgonzola, and
other fat and so-called cream cheeses.
"Beverages: All kinds of natural and carbonated waters, either clear or
with lemon juice, or with rum, whiskey, cognac, and cherry brandy. Light
Moselle or Rhine wines, claret, dry sherry, or Burgundy, in amounts pre-
scribed by the physician. Coffee, black or with cream, without sugar but
sweetened with saccharin if desired. Tea, clear or with cream or rum.
"From this list it will be seen that the number of articles not containing
starch the diabetic may choose from is quite extensive, and permits him to
vary his diet from time to time. In making up the standard diet certain
articles in the above list may be substituted for some of those in the diet
outlined.
"Bread is the article of diet the cutting off of which the diabetic tolerates
least well. Sooner or later a craving for it is inevitable. Various substitutes
have from time to time been put on the market. The oldest of these and the
one in most extensive use is gluten bread or biscuits made from gluten flour,
first introduced by Bouchardat, in 1841. It is prepared by washing away the
starch from wheat flour. The text-books on cooking give recipes for making
bread and biscuits from this flour. Many firms claim to make pure gluten
flour. Others are more conscientious, and state the percentage of starch their
various preparations contain. It is easy to demonstrate that these gluten flours
almost without exception contain starch, by adding a few drops of LugoPs soln-
DIABETES MELLITUS 179
tion. A blue, or even black, reaction is obtained, according to the amount
of starch present.
"Another substitute is bread or biscuit made from aleuronat flour, advo-
cated by Ebstein and prepared by Dr. Hundhausen of Hamm, Westphalia,
Germany. It is a vegetable albumin prepared by a special process from wheat.
It contains from 80 to 90 per cent, of albumin in dry substance and only 7
per cent, of carbohydrates. In making bread from it, a considerable percentage
of starch had to be added.
"Flours prepared from soya bean, almonds, cocoanuts, and Iceland moss
have had their advocates as substitutes for wheat flour. The writer's experi-
ence has been limited to the use of gluten and aleuronat bread, and it has taught
him that patients eventually tire of them and they still crave white wheat
bread. Owing to the expense and the unreliability of most gluten flours, the
writer has given up their use. It is much better to allow a diabetic to have
daily a definite weighed quantity of white bread, the starch percentage of which
we know to be about 55 per cent. It is well to have the bread thoroughly
toasted. Well-toasted graham bread may be used as a substitute with advan-
tage.
"Starch, in the form of potato, is thought to be more easily assimilated
than wheat starch, and the comparatively recent work of Mosse seems to bear
this out. The observations at the Johns Hopkins Hospital tend to confirm this
view. Mosse allowed his cases 1 to 1.5 kilos (2 to 3 pounds) of potatoes daily.
He says that there is a marked amelioration of all the distressing symptoms
under the potato treatment. It is best to bake the potatoes. Naunyn does not
speak very enthusiastically of this special cure in his last edition. He thinks
that, when benefits result, it is mainly due to the fact that .the diet in the case
heretofore has not been properly arranged so far as the allowance of carbo-
hydrates is concerned. Von Noorden recently has advocated very strongly a
specially prepared oatmeal, and has claimed remarkable results in eliminating
glycosuria.
"In mild cases of diabetes (those who have become aglycosuric on the
standard diet) , the best course to pursue is to add to this standard diet weighed
quantities of well-toasted white bread, the amount to vary with the tolerance
of the individual. Occasionally, a roast potato may be substituted for the
bread. In these cases milk is especially useful, as it contains only between 4
and 5 per cent, of lactose, which is very well assimilated by diabetics. A pint
or a pint and a half, accordingly, may be permitted daily. The monotony of
the standard diet may be from time to time relieved by making substitutes from
the list of unconditionally allowable foods given above.
"In the severe cases (those who fail to become aglycosuric on the standard
diet) it, at first thought, would appear that the addition of carbohydrates
would be contra-indicated, as they would tend to increase the glycosuria, con-
sidering that the tolerance is nil Experience, however, shows that these do
better, and are more likely to hold their weight, if given very moderate quanti-
180 KELATIONS OF MEDICAL DISEASE TO SUEGEKY
ties of starchy food. The danger of coma is increased by any long continuation
of an exclusive proteid-fat diet.
aln both forms, a return to the strict diet, in order to increase the toler-
ance, should be made at least every three months for a period of ten days. It
is desirable at shorter intervals in the severe forms.
"No attempt should be made to restrict the water taken by the diabetic. No
good will follow by doing so, as the thirst and polyuria are dependent on the
hyperglycemia. Harm, on the other hand, is likely to ensue, as the increased
thirst causes increased mental and physical distress. Apollinaris and seltzer
water may be allowed, and the thirst may be quenched by drinking lemonade
sweetened with saccharin instead of sugar. A drink made by dissolving a
dram of cream of tartar in a pint of boiling water and flavoring with lemon
peel and saccharin, and then cooling, may be given freely for the same purpose.
"Alcohol, in the form of whiskey, cognac, or rum, is to be recommended, as
it aids fat digestion, and tends to make up for the loss in heat units resulting
from the cutting off of carbohydrates. One gram of alcohol by its combustion
yields 7.0 calories.
"Sawyer, of Cleveland, claims to have obtained marked benefit in diabetes
by systematic gastric lavage."
These cases of pyogenic infection or of necrotic processes in diabetics try the
soul of the surgeon; let alone, they die; operated upon, many die also, and yet by
skillful management many can be saved and live perhaps in comparative comfort for
many years.
To state a paradox, the older they are the better the prognosis. Young persons
who have diabetes and surgical complications die almost invariably. Persons of middle
life or older, diabetics, have, as a rule, a small or moderate amount of sugar in the
urine. They may live for many years and even have serious surgical complications
requiring surgical interference and operative care, yet survive. Such individuals
have been known to live for many years.
A man who has been a diabetic patient of mine since 1885, and whose brothers,
four in number, all had diabetes, and whose father died of this disease at the age of
82 years, is now alive at the age of 80 years, in fairly good health. He has no serious
discomforts of any sort. During these years he had suffered two serious fractures, one
an intracapsular fracture of the hip joint, one a fracture of the shaft of the humerus.
Both fractures healed quickly and without complications.
The question of where to amputate in cases of diabetic gangrene of the foot
is one not always easy to answer. If the process is a spreading moist gan-
grene without line of demarcation and is associated with cellulitis and suppura-
tion of pyogenic origin, amputation should be done through the lower third of
the thigh. The same rule applies to spreading cases of septic necrotic cellulitis
of the deep structures of the foot not associated with putrid decomposition. If
one or more toes alone are involved and there is little or no tendency to spread
into the sole or dorsum of the foot, and if the process is dry, amputation may
be done at any level where free bleeding occurs in cutting into the limb. This is
a fairly safe rule, but reamputation will be found necessary in some cases. An
DIABETES MELLITUS 181
Esmarch bandage or a large soft rubber tube an incb or more in diameter may
be loosely applied over the femoral artery and quickly tightened if necessary.
Unless free bleeding occurs a higher level must be chosen.
Another method for determining the level for amputation is to apply an
Esmarch bandage to the limb from below upward, tight enough to render the
limb bloodless. A second bandage or constrictor is then wound about the limb
at its junction with the trunk, compressing the main artery. The first bandage
is removed and a few minutes later the second. As the circulation returns, the
skin becomes suffused with a deep red blush, which extends from above down-
ward, but stops where the limb is not properly nourished. Amputation should
be done well above this level.
Ether is the general anesthetic of choice, though gas and oxygen may be
used. It is less likely to be followed by coma. Sequestration anesthesia, novo-
cain and adrenalin; may also be used to great advantage in these cases.
I have amputated the thigh by this method, even in a large stout man, with almost
no pain and no shock. The technic is as follows: The patient may properly re-
ceive a hypodermic injection of morphin one-half hour before the operation — in a
large adult 1/3 of a grain. The limb to be amputated is held vertically for several
minutes (but in case of gangrene not stroked) in order to free it from blood, as far
as possible. An Esmarch bandage or large soft rubber tube is then applied as a
tourniquet at least 6 inches above the proposed point of amputation. It must be
applied, quickly, tightly and accurately and must occlude all the vessels in the first
turn, thus closing instantly both arterial and venous circulation. A second ligature
is similarly applied 6 or more inches below the first one. A section of the limb 6
or more inches in length is thus rendered bloodless and removed from vascular com-
munication with the remainder of the limb. The internal saphenous vein is then
sought for and freed. It is opened or divided. With a large glass syringe 50-100-150
c. c. of a 1 per cent, solution of novocain and adrenalin is injected into the vein under
pressure, slowly and with some force. The tip of the syringe in the vein must, of
course, be surrounded by ligature to accomplish this. The section of the limb takes
on a peculiar blanched appearance. After waiting a few minutes, an amputation is
done in any way the surgeon prefers.
This procedure is quite different from ordinary local anesthesia and more
efficient. Amputation of the thigh may be done with scarcely any pain. I
have amputated the thigh in several cases of diabetic gangrene in this way,
without any complaint of pain except a single exclamation of "Ouch" when the
sciatic nerve was cut, and without any notable signs or symptoms of shock, and
the results were in each instance good.
It might be well to record my experience with gangrene of the toes and
foot in cases of presenile gangrene and diabetic gangrene of the lower extremi-
ties. Imprimis amputation of the lower third of the thigh is followed by
good wound healing and by no recurrence. Amputations at a lower level,
though theoretically good, are in many cases not followed by cure, good wound
healing or satisfactory results. In the less favorable cases, gangrene of the
stump occurs and reamputation is necessary; in the more favorable ones the
flaps either slough or heal very slowly. In some cases the patient returns with
182 RELATIONS OF MEDICAL DISEASE TO SURGEEY
a poorly nourished stump, which is ulcerated and painful; he is unable to
wear an artificial limb, and intolerable pain may drive him to seek a higher
amputation.
OBESITY
Persons who are abnormally fat are not good surgical risks. Their tissues
do not resist infection as well as those of normally nourished individuals. In
order to do a given operation, the cut, as a rule, must be longer and deeper.
The soft, friable tissues are more easily bruised and torn by retractors and
other instruments, sutures cut through readily, etc., and wound healing is often
less perfect.
Fat necrosis in the subcutaneous tissues is not a rare accident. These
difficulties obtain when operating on all inordinately fat people. But much
more serious dangers may exist than these. Among the obese of middle life
or advanced age, a number of serious organic weaknesses are prone to develop,
anemia, bronchitis, mechanical interference with action of the heart, fat infiltra-
tion and weakness of the heart muscles, arteriosclerosis, often of the coronary
arteries. These changes in their advanced- stages produce cardiac asthma,
anginal attacks, cerebral hemorrhage. Among other conditions often observed
in these cases are hernia, glycosuria, albuminuria, edema and general muscular
weakness.
Therefore, only necessary operations are to be done on the very stout. If
the patient is plethoric, i. e. full-blooded, with the normal number of red cells
and hemoglobin, the prognosis is better than in the anemic type of obesity.
There is one common group of cases, however, where it is better and safer to
operate than not. I refer to the large irreducible hernise of fat women, where
the viscera cannot be permanently retained within the abdomen by belts,
binders, corsets, and trusses. In deciding for or against operation in these cases
the surgeon must study the general and local conditions with care. In neglected
cases the tumor may be so large that replacement may be impossible. In these,
if the contents of the sac consist largely of intestine, it is wiser to forbear. If,
on the other hand, large masses of omentum are recognized, they may be
resected, thus making more room for the bowel. Such resections of large masses
of omentum are not devoid of risk and must be made with great care. (See
chapters on Hernia. )
When wisely selected these cases do well. Unoperated, the danger of
strangulation is great, and the mortality following operations for strangula-
tion is very high.
RICKETS
Inasmuch as the disease is rarely seen in its active stages after the age of
three years, the surgeon is interested in treating the resulting deformities rather
than the disease itself.
SCUKVY 183
The causes of death during the active stages of the disease are, most com-
monly, bronchitis, bronchopneumonia, convulsions and laryngismus stridulus.
The disease is very amenable to treatment by diet, i. e., by cutting down carbo-
hydrates and increasing the fats. If cream is not obtainable, cod liver oil may
be given. During the treatment the child must not be allowed on its feet until
marked improvement occurs, usually for several months. Phosphorus is be-
lieved to be useful if well borne, and bathing and general massage help the
general health.
SCURVY
Scurvy occurs when, under unfavorable hygienic conditions, chiefly cold
and wet, persons are obliged to live on a dietary wanting in fresh vegetables,
or their equivalent, and fresh meat. The alkalinity of the blood is diminished.
Whether the disease is caused by this alone, or whether an added infection
through the mouth is necessary, is not definitely determined.
As is generally known, one of the most notable characters of the disease is
a marked tendency to hemorrhages into tissues and organs and from mucous
surfaces.
When death occurs in scurvy, it may occur from bleeding — either external from
an ulcer, or internal from the mouth or nose — from heart failure, gangrene of the
lung, or a putrid bronchitis associated with a bloody effusion into the pleural sac.
It is to be borne in mind that the subcutaneous and subperiosteal hemorrhages
may occur without trauma. This fact may be of medico-legal importance, more espe-
cially when we recall that the crews of merchant ships, even to-day, sometimes develop
scurvy.
This alone would render a scorbutic individual a bad surgical risk ; but to
this must be added a general depression of all the vital forces and marked
anemia, so that, if it is possible to avoid it, no surgical operation should be
attempted until the individual has been improved by a suitable diet and warm
dry surroundings. Even under favorable conditions it will be weeks and
months before the patient regains his normal health and strength.
Most important in the treatment of scurvy is a diet containing abundance
of fresh vegetable food. In addition, among the articles believed to be most
useful are fresh lime and lemon juice. Among preserved vegetables sauer-
kraut is excellent. Infusion of malt is of value. Fresh meat and meat juice
and fresh milk in liberal doses are all anti-scorbutic.
Drugs are of less value. Iron may be given for the anemia and a bitter
tonic, such as quinin, for the appetite. Diarrhea may require treatment.
Astringent and antiseptic mouth washes should be given at frequent inter-
vals : Potassium permanganate solution, chlorate of potassium, Dobell's mouth
wash, etc. Ulcers, if they exist, demand antiseptic and stimulating treatment,
such as balsam of Peru, etc., with protection and support. Intravenous injec-
tions of horse serum may be given, if available, for hemorrhages.
184 RELATIONS OF MEDICAL DISEASE TO SURGERY
ACUTE POLYARTICULAR RHEUMATISM
Although a form of streptococcus has been demonstrated in the joint exu-
dates of acute articular rheumatism, yet, as a matter of experience, such joints
rarely require surgical interference. Complete restoration of function is the
rule upon recovery.
If the joint inflammation is very severe and resists the ordinary means of
treatment, a needle may be introduced, and if the exudate is found to be puru-
lent, containing pyogenic cocci, the joint should be opened, washed out with a
mild antiseptic — e. g., carbolic acid 1-60 or a weak solution of formaldehyd
solution — drained for a few days and immobilized until the joint cavity re-
mains dry.
GOUT
The relations of gout to surgery are of two kinds :
1. If a gouty tophus breaks down .and suppurates, it should be incised
and curetted, or excised, thus sparing the patient the formation of a chronic
sinus. If a tophus becomes unsightly or from its size and situation interferes
with motion or causes pressure symptoms, or is itself pressed upon by the shoe,
it may be removed.
2. Persons with chronic gout are often obese, they often develop chronic
interstitial nephritis, with arteriosclerosis, they may develop a dilated heart
muscle or coronary disease, and they sometimes have glycosuria. They are,
therefore, to be regarded in many instances as extra-hazardous surgical risks.
Accordingly, patients who have gout should be carefully examined with the
above facts in mind before they are subjected to an operation of expediency.
POISONING BY BICHLORID OF MERCURY
Acute poisoning by mercurial bichlorid has within the past year acquired
a fleeting interest for surgeons on account of certain accidental fatal poison-
ings and, later, attempts at suicide, owing to the publicity afforded these acci-
dents by the press. Bichlorid of mercury tablets are easily purchased, and they
are to be found in almost every household, for the treatment of wounds, for
bed bugs, or for less obvious reasons.
Some years ago, Edebohls proposed and carried out a procedure in cases
of chronic interstitial nephritis, based upon the assumption that the kidney
underwent degeneration and loss of function on account of undue tension of its
fibrous capsule. He cut down upon the kidney, split and stripped the capsule
from the organ, and alleged that such cases were improved by the operation.
We are not here concerned with this contention whether justified by results
or not.
PHOSPHOKUS POISONING 185
In acute poisoning by mercuric bichlorid the patient immediately suffers
from abdominal pain, nausea, vomiting and diarrhea. The passages from the
bowel are often bloody. The history of these patients is, however, peculiar.
After two or three days the acute symptoms of gastro-intestinal irritation sub-
side to some extent and they become quite comfortable. They may look well,
but they pass no urine. The kidneys have ceased to functionate. The catheter
withdraws merely a dram or two of turbid or bloody fluid from the bladder.
Patients may live for a number of days, and, until they become comatose from
uremic poisoning, suffer but little. They are rational and look so well that it
is hard to realize that they are doomed to speedy death.
On January 2, 1914, I saw one of these cases — a man, aged 60. On account of
business troubles, threatening bankruptcy, he became desperate. He took into his
mouth, chewed up, and swallowed 5 of the ordinary T1/^ grain bichlorid of mercury
tablets. Some acute symptoms followed; acute abdominal pain, nausea, vomiting and
general distress. I was called to see him 3 days after he had swallowed the poison. He
had in the meantime changed his mind. The presence of his wife and children, and
of numerous sympathetic friends, and the attention he received in the hospital changed
his point of view. He was just as anxious to live as he had been to die. He appeared
quite normal. He was a large, plethoric, healthy-looking man, a temperate, sane,
intelligent Hebrew. His face was flushed, his eyes bright, and he had a rapid high-
tension pulse. It was hard to realize that this man so normal in appearance was to
die in a short time. I was induced against my judgment to operate.
I exposed his kidneys and split and stripped their fibrous capsules. Neither kid-
ney was enlarged, nor did the parenchyma appear to be under any tension. The left
kidney was dark red in color and the cortex bled freely, the capsule was adherent.
The right kidney was of normal size and softer than normal. The capsule stripped
easily. The whole kidney was pale in color. Scattered over the surface of the cortex
were numerous areas, large and small, of a yellowish white color. These appeared to
be areas of necrosis. The wounds were closed. The patient passed no more urine
and died comatose the following day. The operation was quite futile, and I shall
never repeat it. I believe operation is contra-indicated in these cases. The micro-
scopic examination of these kidneys showed total necrosis of the entire parenchyma.
PHOSPHORUS POISONING
Acute poisoning by phosphorus has no surgical interest. Chronic poison-
ing by this element possesses only an historical interest in America, and is a
purely occupational accident.
In former years while white phosphorus was used extensively in the manu-
facture of matches, such poisoning was common among those who were daily
exposed to the fumes of this element. The lesions produced were inflammation
of the gums followed by progressive necrosis of the jaw, usually the lower jaw.
One tooth was first involved ; toothache of a severe character was followed by
the extraction of the tooth and the escape of fetid pus from the tooth socket
unless upon the first sign of irritation the individual was removed from danger ;
then followed progressive and rapid necrosis of the jaw. In some cases the
186 KELATIONS OF MEDICAL DISEASE TO SUKGEEY
process involved total necrosis of the lower jaw, and these unfortunates became
hideously disfigured and on account of the horrible fetor. were disgusting ob-
jects. The condition is rare in this vicinity. I have never seen a case of this
kind.
TUBERCULOSIS
Although almost every structure in the body the seat of tuberculosis has
been the object of surgical attack and although a large percentage of surgical
operations are for the cure of this disease, there is one aspect of the subject
which always demands serious consideration on the part of the surgeon, namely,
the question of a surgical operation in the presence of tuberculosis of the lungs.
The condition may demand operation upon the pleura or the lung itself, as
in tuberculous empyema and pyopneumothorax. Operations have also been
done on the chest wall to put the diseased lung at rest and to obliterate dead
spaces, and upon the lung itself. All these conditions receive due consideration
in other parts of this work. We are here concerned with modifications in treat-
ment when we are obliged to do any serious operation upon a subject of lung
tuberculosis.
These patients are poorer surgical risks, the more acute and extensive the
process. If the operation can be delayed, it may be well to precede it by a
sojourn in a suitable locality, a strictly out-of-door life, good food and the best
of hygienic surroundings. The local processes may thus be improved and the
resistance of the patients increased.
A very important point is the selection of the anesthetic. A local anes-
thetic should be used when possible. Novocain and adrenalin is the best com-
bination. If a general anesthetic must be given, nitrous oxid gas arid oxygen
is the safest. It must be given by one skilled in its use, since it is at best
troublesome for both surgeon and anesthetist; but it is safer than ether or
chloroform, and does not leave behind irritating effects upon the respiratory
tract, noted after the two latter. Cyanosis and absence of muscular relaxation
are the trying features. It cannot be too forcibly impressed upon the practi-
tioner of medicine and surgery that nitrous oxid and oxygen anesthesia, al-
though useful, can only be undertaken with propriety by a man of large experi-
ence and training. Here a few remarks may perhaps be made in regard to
anesthesia in general.
The editor speaks from an experience of 30 years, having given and seen given all
the local and general anesthetics in use at the present time. When in doubt give ether;
it is less dangerous than chloroform, and its administration requires less skill and
judgment than that of any other anesthetic, local or general. It may be given by a fool
or a totally inexperienced person with less danger than any other anesthetic. Local
anesthesia may well be used when the operation takes but a short time for its per-
formance or when general anesthesia would be very dangerous.
Patients operated upon under local anesthesia, where the operation is prolonged,
DISEASES OF THE DIGESTIVE SYSTEM 187
suffer very much when the operation involves a rather deep dissection and when the
anesthetic is injected into the skin and superficial parts only. See, however, the dis-
cussion of sequestration anesthesia, under Diabetic Gangrene, page 174; also Chapter
on Anesthesia, Vol. I.
PART II
JAMES H. KENYON
DISEASES OF THE DIGESTIVE SYSTEM
Diseases of the Mouth. — All the various forms of stomatitis increase the
danger of inhalation pneumonia if a general anesthetic is given, and if the
operation is in the region of the mouth or pharynx the danger of a wound in-
fection is increased. Thrush absolutely contra-indicates operation for harelip
or cleft palate, as it prevents union of the flaps.
The local condition should be cured by local and constitutional treatment,
if possible, before operating. If time is not available for this, employ a general
anesthetic with special attention to thorough disinfection of the local condition,
both at the time of operation and subsequently.
Diseases of the Pharynx.
(a) ACUTE AND CHEONIC PHAEYNGITIS.
(b) ULCEEATION OF THE PHAEYNX. — The same precautions as detailed
under diseases of the mouth should be applied here.
(c) ACUTE INFECTIOUS PHLEGMON.
(d) EETEOPHAEYNGEAL ABSCESS. — This condition requires only local or
nitrous oxid anesthesia, never sufficiently deep to abolish the coughing reflex,
the chief aim being to prevent aspiration of the infectious material into the
larynx.
In children no anesthetic is necessary. As soon as the opening is made in
the abscess cavity, the patient should be quickly turned face downward to facili-
tate the escape of the pus and to prevent its entrance into the larynx. In many
cases the Kose position with the head lowered is useful.
(e) ANGINA LUDOVICI. — As these cases often develop intense dyspnea,
preparations for intubation or tracheotomy should always be made, not only
previous to the operation, but the tracheotomy set should always be at hand for
some days during the postoperative treatment.
Diseases of the Tonsils. — Any obstruction to respiration from enlarged ton-
sils may be overcome by the use of a nasal tube to the posterior pharynx, the
ether vapor being blown through this tube. Or the regular mask or inhaler may
be employed if a free airway is provided by passing a fenestrated rubber tube
through one or both nostrils, or a somewhat larger tube through the mouth to
the level of the epiglottis. A flat metal tube with a curve to fit the roof of the
mouth, the inner end extending to just below the base of the tongue, the
188 KELATIONS OF MEDICAL DISEASE TO SUEGEEY
outer end provided with a flange which rests against the lips, has been con-
structed for the purpose.
All the above-mentioned diseases centra-indicate operation on any other part
of the body, except that of an emergency, as the patient's reparative powers are
lowered and the danger of complications increased.
Diseases of the Esophagus. — Diseases of the esophagus result in such an im-
pairment of nutrition that the patient is not a good subject for operative pro-
cedure. The local condition should be dealt with first and some means insti-
tuted to improve the general condition. If the patient is suffering from malnu-
trition directly attributable to the inability to obtain sufficient nourishment, a
preliminary gastrostomy with subsequent feeding through the tube will do much
to improve the general condition if time permits.
Any retained secretions or material in the dilated esophagus or its diver-
ticula should be carefully washed out before giving any general anesthetic, in
order that this material may not escape into the pharynx and add to the risks
of an inhalation pneumonia. For this reason intratracheal anesthesia should
be chosen.
Diseases of the Stomach. — Each of these diseases will demand individual
treatment both before and after any operation that is undertaken.
In all cases except those of a suspected perforation of the stomach or duode-
num, or hemorrhage, the stomach should be thoroughly washed before adminis-
tering the anesthetic. One should shorten as much as possible the time of
operation and the amount of ether used.
The postoperative position of a semi-sitting posture favors gastric drainage
and lessens vomiting. Absolute failure of gastric digestion or assimilation,
or persistent vomiting, may necessitate feeding through a jejunostomy.
Diseases of the Intestine. — Diseases of the intestine associated with diar-
rhea, from their general weakening effect on the patient, make it necessary to
shorten, as much as possible, any operation which is required. Light ether
anesthesia and as little manipulation of the tissue as possible are indicated.
Enteroptosis. — While this condition does not in any way centra-indicate
operation upon any part of the body for other disease, attempted operative re-
lief of the relaxed structures themselves is seldom attended with great success.
Diseases of the Liver. — Jaundice from any cause, particularly with fever,
renders the patient less able to stand the shock of an operation and more liable
to bleed. The coagulation time is retarded from 8 to 10 minutes. For this
reason, when it can be done, some preliminary treatment to increase the clotting
power of the blood should be employed before operating.
In all diseases of the liver the duration of the operation should be as short
as possible, and particular care taken to control all bleeding points and sur-
faces, either with ligature, suture or firm packing. Local anesthesia, if possible,
or nitrous oxid and oxygen or a very light ether anesthesia is most desirable.
Diseases of the Pancreas. — Acute hemorrhagic pancreatitis does not present
a favorable condition for any anesthetic, but an operation is always indicated.
DISEASES OF THE EESPIRATORY SYSTEM 189
The rapid, feeble heart should be steadied with the proper medication or a
hypodermoclysis. The stomach, which is very apt to dilate quickly, should be
washed out before starting the anesthetic. It is often advisable to leave the
stomach tube in place throughout the operation.
Light ether or gas oxygen anesthesia should be chosen, if possible. In some
cases local injections of novocain may be sufficient.
Diseases of the Peritoneum. — Acute general peritonitis demands the short-
.est possible operation and the least possible manipulation. The anesthetic may
be local, gas oxygen or light ether.
DISEASES OF THE RESPIRATORY SYSTEM
Coryza and Chronic Catarrh. — The conditions should have, if possible, some
preliminary treatment before a general anesthetic is given. If this cannot be
done the excessive secretion may be controlled by morphin and atropin. One
should use a local anesthetic if possible, or ether and oil by rectum may be
used. Theoretically, any of the anesthetics commonly used would be better
than ether in that they produce less inflammatory reaction of the mucous mem-
brane and less secretion, but, practically, ether may be safely used in many
cases.
Diseases of the Larynx. — Diseases of the larynx render the administration
of a general anesthetic inadvisable, in that they are apt to be complicated by
acute edema of the larynx and obstruction, or are followed by a postoperative
pneumonia. Intratracheal insufflation, ether and oil by rectum, or perhaps
tracheotomy would be indicated.
Diseases of the Bronchi. — Diseases of the bronchi render anesthesia by any
inhalation method undesirable. Either gas-oxygen, ethyl chlorid or chloroform
should be chosen if the need of a general anesthetic is imperative. Otherwise
a local anesthetic is better.
Diseases of the Lung.
A. PNEUMONIA. — Pneumonia contra-indicates all operations, except some-
thing of a very urgent nature, in which case nothing but local anesthesia should
be used.
B. EMPHYSEMA. — Local anesthesia or the inhalation of ethyl chlor^d is
taken very well by these patients. The latter should be chosen in preference to
ether or gas.
C. GANGRENE OF THE LUNG.
D; ABSCESS OF THE LUNG. — In these cases local anesthetics or ethyl
chlorid may be used. Chloroform is theoretically better in some respects, but it
has many drawbacks and added dangers. Ordinary ether anesthesia may be
used. To prevent too much pulmonary embarrassment when the pleural cavity
is opened, intratracheal insufflation should be employed.
Diseases of the Pleura. — The presence of any considerable amount of fluid
190 EELATIONS OF MEDICAL DISEASE TO SUKGEKY
in the pleural cavity embarrasses respiration, particularly if the patient lies on
the sound side. As an anesthetic, ethyl chlorid inhalation, nitrous oxid, or a
light ether may be employed. Local anesthesia with novocain will be sufficient
in many cases, even for resection of a rib. If a large amount of- fluid
is present and the patient's general condition is poor, . a large dressing should
be quickly applied; or, better, a rubber tube which snugly fits the opening
in the chest wall and extends below the level of sterile fluid in a bottle
placed on the floor may be used. The object is to prevent a sudden change of
intrathoracic pressure from too rapid an escape of the pleural contents, and
also, in the latter case, to prevent a pneumothorax. For a detailed description
of this method see chapter on "Aspiration and Aspirating Devices in Operative
Surgery."
When operating upon any other structure, in cases with much dyspnea
from a considerable amount of fluid in the pleural cavity, great relief may
be obtained by a preliminary aspiration of the fluid. After this has been
done, if the dyspnea is less or has disappeared, a general anesthetic could
be given, but in those cases in which a local anesthetic is possible it should be
chosen.
Pneumothorax, hydropneumothorax, and pyopneumothorax are best oper-
ated upon with local anesthesia or with ethyl chlorid inhalation or nitrous
oxid-oxygen. The use of the above-mentioned long tube which makes an air-
tight fit with the opening in the chest wall and terminates below the level of
sterile fluid in a bottle furnishes a water trap check valve which permits the
escape of air and fluid, but prevents the entrance of air into the pleural cavity.
The preliminary treatment in these conditions should be directed toward reliev-
ing the embarrassed respiration.
Affections of the Mediastinum. — Affections of the mediastinum require in-
tratracheal anesthesia or a cabinet for differential pressure.
DISEASES OP THE CIRCULATORY SYSTEM
Plastic Pericarditis. — Plastic pericarditis generally contra-indicates opera-
tion only in so far as the disease to which it is secondary contra-indicates or
modifies the surgical procedure, as, for example, rheumatism, gout, tubercu-
losis, septic processes, chronic nephritis, etc.
Pericarditis with Effusion. — This is a much more serious condition and
contra-indicates operation, except that required for its own treatment. The
anesthetic should be local, light ether, gas-oxygen, or ethyl chlorid.
Diseases of the Heart.
ACUTE ENDOCAEDITIS. — Acute endocarditis contra-indicates operation.
CHEONIC ENDOCARDITIS.
CHEONIC VALVULAE DISEASE.— Cases of the last two mentioned diseases
generally stand operation with a general anesthetic very well, provided there is
DISEASES OF THE BLOOD AND DUCTLESS GLANDS 191
good compensation. Light ether anesthesia with particular regard to the vary-
ing degrees of cyanosis, pulse rate, and blood pressure is very satisfactory.
HYPERTROPHY AND DILATATION with poor compensation render any oper-
ation very dangerous. Cardiac stimulants and, in some cases, withdrawal of
blood may steady the cardiac action so that an emergency operation may be
performed. Local anesthesia, if possible, otherwise light ether should be Used.
Wounds of the Heart. — Intratracheal insufflation of air and ether is Very
desirable, as the pleural cavity on one or both sides may be opened and cause
embarrassed respiration.
Neuroses of the Heart. — These do not contra-indicate operation, but re-
quire a little more care on the part of the anesthetist. General anesthesia is
satisfactory.
Congenital Affections of the Heart. — These affections do not absolutely
contra-indicate operation. A light ether anesthesia combined with oxygen
should be used. Special attention must be paid to the blood pressure and to
the patient's color.
Diseases of the Arteries. — DEGENERATION, ARTERIOSCLEROSIS, ANEURISM..
— Cases with the above-mentioned diseases demand special care in making
the operation as short as possible with gentle handling of the tissues. Many
advise against any operation if the blood pressure is high. In these cases
ether or chloroform can be used, although it is better to use a local anesthetic
if possible. But the high blood pressure in itself does not contra-indicate opera-
tion.
DISEASES OF THE BLOOD AND DUCTLESS GLANDS
Anemia. — Although an operation is not contra-indicated in this disease, the
risk from shock or possible infection is doubtless increased, and even a moderate
hemorrhage rendered more serious. Healing is usually slow and convalescence
prolonged.
If time permits, the general condition of the patient should be improved
by the use of diet, food, drugs, general hygienic treatment, or transfusion.
Often, however, the anemia is secondary to some surgical condition which de-
mands immediate operative treatment. Before and after the operation every
precaution should be taken to lessen its severity, making it as short as possible,
with special attention to control of hemorrhage. Gas-oxygen with more or
less rebreathing with the closed ether apparatus, or light ether anesthesia is to
be preferred. All the precautions employed in cases of shock should be used
if indicated, such as external heat, fluids in the vein, under the skin, or in the
rectum, position with the head lowered, bandaging of the extremities, etc.
Leukemia. — The resistive power of the patient is lowered and the healing of
the wound prolonged. What has been said with regard to the severe anemias
applies to this condition.
Hodgkin's Disease.— This does not contra-indicate operation.
192 EELATIONS OF MEDICAL DISEASE TO SUKGERY
Purpura and Hemophilia.— These diseases lower the resistive power of the
patient and render any operation dangerous because of the profuse bleeding
which follows. Every attempt must be made to make the blood coagulate more
quickly.
Status Lymphaticus. — Status lymphaticus would always contra-indicate
operation if this condition could be recognized with certainty, although those
cases in which an enlarged thyrnus alone is apparently responsible for the symp-
toms respond very well to an operation for its partial removal.
Diseases of the Thymus. — In diseases of the thymus, on account of the
tracheal obstruction to breathing, an intratracheal anesthesia may be required,
although ether by the drop method is very satisfactory. The operative pro-
cedure should be made as short and simple as possible.
Diseases of the Spleen and Suprarenal Bodies. — These do not contra-indi-
cate operation.
Diseases of the Thyroid. — Goiter and tumors of the thyroid do not un-
favorably influence an operation. Wherever an operation is indicated, gentle-
ness in handling the tissues, with special care to have a clean, dry operative
field, should be observed. This is especially true if the thyroid itself is being
operated upon.
If there is any obstruction to breathing from pressure on the trachea, intra-
tracheal anesthesia should be employed.
EXOPHTHALMIC GOITEE. — Patients suffering from this condition should
have a preliminary rest in bed, and, in certain severe cases, ligation of two or
more arteries before any operation is undertaken. If a general anesthetic is to
be used, it is well to accustom the patient to the inhalation of it for a short time
for several days. This tends to relieve him of the mental strain accompanying
the knowledge that an operation is about to be performed. Local anesthesia
should be used whenever possible. Light ether, or gas-oxygen, are the general
anesthetics most easily taken. Too much emphasis cannot be placed upon ex-
treme gentleness in handling the tissues and careful control of bleeding. Enough
gland tissue and as much of the posterior capsule as possible should be left
undisturbed in order to insure the presence of sufficient parathyroid tissue after
the operation. Operations elsewhere are not generally considered unless abso-
lutely necessary, but when indicated the precautions mentioned above should be
carried out as far as possible.
DISEASES OF THE KIDNEY
Anuria. — If not due to a surgical condition demanding immediate opera-
tion, anuria should be relieved before operations elsewhere are considered.
"Uremia. — Operations should not be undertaken in patients suffering from
uremia.
Acute Nephritis. — This condition does not absolutely contra-indicate an
TROPICAL DISEASES 193
operation, but renders the outcome more serious and should, if possible, first re-
ceive its appropriate treatment. If the urgency of the condition demands sur-
gical interference, local or gas-oxygen anesthesia should be used.
Chronic Nephritis. — This condition, even with a high blood pressure, does
not centra-indicate an operation, but does demand special precautions with re-
gard to the anesthetic used, the duration of operation, and the postoperative
treatment.
Local, gas oxygen or ether anesthesia may be used. The operation should
be short and as simple as possible. In the postoperative treatment one should
make a special point of filling the system with plenty of fluids and aiding the
skin elimination as much as possible by employing hot packs, hot air baths,
etc. In short, the regular treatment for the nephritis should be continued.
Any condition requiring the removal of one kidney should not be under-
taken until the functionating power of the other kidney has been ascertained.
DISEASES OF THE BLADDER
Diseases of the bladder do not contra-indicate operations elsewhere. Blad-
der conditions in which there are retention of urine and impairment of kidney
functions demand an appropriate treatment before other surgical procedures
are instituted. Acute gonorrheal urethritis is a centra-indication to operations
for hernia near the genitals.
DISEASES OF THE CENTRAL NERVOUS SYSTEM
These diseases, both central and peripheral, do not contra-indicate opera-
tions except in cases of edema, cerebral hemorrhage, tumors and cysts, and
abscess of the brain. In these cases operation other than that indicated for
the actual condition is contra-indicated except in extreme urgency. Then a
local anesthetic is to be chosen if possible, though a general anesthetic may be
used.
In certain of these cases emergency operations may be performed without
any anesthetic.
TROPICAL DISEASES
The tropical diseases contra-indicate operation only in so far as they weaken
the patient and lower his vitality and render him less able to withstand any
surgical procedure. Furthermore, there is a local contra-indication ^in those
cases which have a lesion in the skin or subcutaneous tissue, rendering infection
more probable and delaying or preventing the healing of the wound.
If the operation is not absolutely demanded both the local and general con-
dition should first have its appropriate treatment.
14
194 KELATIONS OF MEDICAL DISEASE TO SUKGERY
SKIN LESIONS
Centra-indications to operations and conditions modifying operative pro-
cedures are found in the following skin lesions :
A. Lesions of the skin which might cause wound infection.
B. Lesions of the skin which might cause wound infection and also gen-
eral infection.
C. Lesions of the skin which might cause delayed healing of the wound.
D. Lesions of the skin which might cause a recurrence of the condition in
the wound, or in some other part of the body, or in both places.
E. Lesions of the skin which can be better treated in some non-operative
manner.
A. Lesions of the Skin Which Might Cause Wound Infection. — Under this
heading might be grouped such diseases as acne, carbuncle, dermatitis, eczema,
erysipelas, furunculosis, parasitic diseases, scabies, impetigo contagiosa, derma-
titis venenata, pemphigus, vaccinia, burns, and destructive traumata of the skin.
In certain cases in these conditions the" patient's general vitality may have
been so lowered that only a very urgent operation would be advised. If the
operative field or the adjoining region is involved the danger of subsequent
wound infection is greatly increased and, unless operative intervention is abso-
lutely necessary, it is better to treat the skin lesion first.
In cases of eczema caused by an irritating discharge from a wound or sinus
which escapes and spreads over the skin the most efficient method of treatment
is the application of continuous suction by means of an appropriate double tube
introduced into the sinus or wound a short distance to remove all the discharge
before it reaches the surface. After this removal of the irritating factor is ob-
tained, the ordinary applications are sufficient. See Chapter on "Aspiration."
B. lesions of the Skin Which Might Cause Both Local and General Infection.
— The conditions mentioned under A in their more severe forms might cause
a general as well as a local infection.
C. Skin Lesions Which Cause Delayed Healing of Wounds and Render Any
Operation, Other than That of Emergency or Simple Incision and Drainage, Unde-
sirable.— Examples of this are such conditions as elephantiasis, leprosy, myx-
edema, and scleroderma.
D. Lesions of the Skin Which, After Their Operative Removal, Tend to Recur
Locally or by Metastasis. — Such are keloid, melanotic sarcomata, and pig-
mented mole. In the last two serious conditions the removal of a considerable
area outside the diseased region, with the minimum amount of handling and
traurnatism to the pathological tissue, will give the best result and afford the
least danger of metastasis.
E. Lesions of the Skin Which Can Be Treated in Some Non-operative Way.
—Examples of this are syphilitic conditions, lupus, and some cases of super-
ficial epithelioma.
CHAPTEK VI
THE PEOPHYLACTIC AND THERAPEUTIC ADMINISTRATION OF VACCINES
AND SERA
JOSEPH C. EOPER
The administration of vaccines and sera of various kinds in an effort to
develop an immunity against a particular organism or to supplement the
natural immunity of the body has come to be a well-recognized therapeutic
procedure. To avoid confusion if possible, and to have a definite view of the
indications for and limitations of this method of treatment, a short discus-
sion of the essential features of immunity is presented.
IMMUNITY
Immunity in its broadest sense is the power of living organisms to resist
successfully any harmful influence. The type of immunity which we shall
consider is usually divided into that due to inherited characteristics, "natural"
immunity to certain diseases of bacterial origin, and that developed through
infection or treatment, "acquired" immunity. This type of immunity is
absolutely essential for the perpetuation of organic life. Without it the bac-
teria would quickly overcome all animal life. The cessation of life and the
consequent cessation of immunity production are followed by complete bac-
terial invasion and destruction. This is a necessary part of the scheme of
animal existence, releasing as it does the combined body nitrogen for the use
of plant life, thus permitting its subsequent elaboration by the plants into a
form available for later re-utilization by animal life.
Natural Immunity. — Natural immunity, that is, the property of immunity
to ordinary saprophytic bacteria, is inherent in man. The bacteria against
which natural immunity is complete are non-pathogenic. The bacteria against
which there is no natural immunity or against which there is only a relative
natural immunity are or may be pathogenic. In other words, the question
of pathogenicity is dependent on immunity rather than on any inherent
properties of the bacteria.
Natural immunity varies with the species, the lower animals being im-
mune, for example, to the gonococcus and spirochseta pallida, while man is
195
196 ADMINISTRATION OF VACCINES AND SEKA
immune to many animal diseases. Relatively it varies, also, with age, with
body conditions which influence the activities of the leukocytes, as exposure
to cold and wet, with fatigue, with the state of nutrition, as when the food
is improper or of poor quality, and with chronic diseases, such as nephritis,
diabetes, cirrhosis, etc. It is diminished, also, by alcohol and by general
anesthetics, particularly by prolonged anesthesia. On the other hand, it may
be augmented by favorable conditions and surroundings.
It has been clearly shown that the blood of many persons in normal health
contains measurable amounts of diphtheria antitoxin. Several units to the
c. c. have been demonstrated in the blood of children apparently immune to
diphtheria. This form of immunity would perhaps more properly come under
the head of acquired immunity, as it probably results from mild infections
with attenuated organisms.
Acquired Immunity. — Acquired immunity, as the term is generally used,
expresses the immunity resulting from an attack of a particular disease or
that developed by special treatment, and differs from the augmentation of
natural immunity, which may be brought about by improved hygiene, etc.
The ability of an individual to develop immunity varies with the individual
and with the exciting organism. The duration of the immunity also varies,
many diseases conferring a lifelong immunity against a second attack, as, for
example, small-pox, while others, such as pneumonia, develop but a transient
immunity. (Recent work on pneumonia suggests the possibility that the re-
current attacks may be due to different strains of the pneumococcus, it having
been shown that immunity against one strain does not protect against some
of the others.)
In the development of immunity, the virulence of the invading organism
is an important factor. This virulence is known to vary greatly under dif-
ferent conditions. Many attempts have been made to produce avirulent cul-
tures of pathogenic organisms which might be safely used in the living state
to produce immunity.
Acquired immunity exists in 2 forms: active immunity and passive im-
munity. Active immunity may result (1) from a natural attack of a disease,
(2) from an artificially induced attack, (3) from the use of living cultures
of diminished virulence, and (4) from the injection of killed organisms. The
second method is used to some extent in animals. The best examples of
the third method are vaccination against small-pox and inoculation against
rabies. The small-pox vaccine probably consists of an organism modified by
passage through calves. The material for the vaccine against rabies is ob-
tained from the cords of rabbits killed by the virus, which is then modified
by drying the cords for varying lengths of time. The fourth method is the
one in which we are interested in this chapter, and the principles on which the
production of immunity by this means depends will be considered later.
Passive immunity is the immunity conferred by injecting an animal with
the serum of another in which active immunity has been induced, and pro-
THEORIES OF IMMTXITY 197
tects only against the organism against which the original animal has been
immunized.
Time Required for Production of Immunity. — The difference in the time in-
volved in the production of the 2 types of immunity is marked. Active im-
munity develops slowly, requiring at least a week under favorable circum-
stances, while passive immunity is conferred almost at once by the injection
of the serum. Unfortunately most of the attempts to produce potent sera
which would confer a passive immunity have been unsuccessful.
Duration of Immunity. — Passive immunity is much more transient than
active immunity. It begins to diminish almost at once, because of the elimina-
tion of the antibodies, and usually endures but 3 to 6 weeks, while active
immunity may persist for from 1 to several years.
Theories of Immunity. — Various theories have been advanced to explain
immunity. Among them may be mentioned the exhaustion theory of Pasteur,
who argued that the immunity was due to the lack of suitable food for the
bacteria, and the theory of Metchnikoff, who considered that the immunity
was due entirely to the phagocytic properties of the leukocytes. The leukocytes,
according to him, had fixing and digesting properties for bacteria, the former
corresponding in a measure to Wright and Douglas' opsonins, as at times
they might be liberated by the phagocytes. He considered also that the leuko-
cytes had the property of absorbing toxin.
Experiments which showed that the blood of persons recovered from in-
fections or of animals immunized against certain organisms had a protective
power gave rise to the humeral theory.
EHKMCH'S SIDE-CHAIN THEORY. — Ehrlich's side-chain theory, which
graphically permits of an explanation of many of the phenomena, was ad-
vanced in 1897 and is still most highly regarded.
In 1896 Weigert proposed the following hypothesis to explain hyperplasia
resulting from irritation or injury : The maintenance of normal structure and
function of tissues depends on the equilibrium produced by a series of mutual
restraints exercised by neighboring cells on each other. The functions of
the cell itself depend on similar restraints exercised by its component units
on each other. Injury or irritation of one of these cells or component units
changes the relation of all the other cells or units to each other and unre-
strained development or growth takes place. This growth, Weigert points
out, always goes on to excess, more new material being produced than is neces-
sary to replace that lost.
This hypothetical reasoning will explain the occurrence of free antibodies
and will enable us to comprehend the equally hypothetical side-chain theory of
Ehrlich. Ehrlich points out that a cell has 2 functions, one which has to do
with a physiological process, such as gland secretion or nerve conduction, and
the other with nutrition. That portion of the cell which discharges the physio-
logical function must be nourished. The property of providing nourishment
must be regarded as due to a series of activities separate from those that have
198 ADMINISTRATION OF VACCINES AND SERA
to do with the physiological activity. The former is the more important func-
tion in relation to immunity. It enables the cell to appropriate food from
the circulating fluids and to elaborate it into molecules
of protoplasm to replace waste. This property is proba-
bly at bottom a chemical process, the food molecule be-
coming attached to some portions of the cell or groups of
atoms for which it has a chemical affinity. These
groups he calls side chains, haptines or receptors (Fig.
1). While their principal function is to convert the
FIG. i.— CELL WITH RE- particles of food into a condition suitable for assimila-
CEPTORS OR HAPTINES.
tion by the main portion of the cell, they also have a
variety of other functions. These enable them to combine with substances
which are not food. One of these substances is the toxin molecule. The toxin
molecule may be represented as containing 2 groups, a haptophore or com-
bining group and a toxophore group (Fig. 2). The hapto- ^^^ r
phore group permits the toxin molecule to attach itself to
the haptine or receptor of a body cell and thus enables the J\
toxophore or poison group to exert its enzyme-like action on \ O H
the cell (Fig. 3). Depending on the number of toxin mole- FlG- 2. — TOXIN
. . MOLECULE WITH
cules anchored by a cell, the cell may be injured or destroyed. HAPTOPHORE
If the insult to the cell has not been enough to destroy it, GROUCH* TND
there takes place a great change in cell tension and there is an TOXOPHORE (EN-
immediate regeneration of fresh receptors to replace those GRO^TPE.L
lost. If this phenomenon is reproduced several times by doses
of toxin insufficient to destroy the cell, the cell eventually develops the faculty of
manufacturing more receptors than it can accommodate and these are thrust off
into the circulation, thus forming toxin receptors or antitoxin (Fig. 4). It will
be readily seen that, if these free receptors combine with the toxin molecule, the
latter cannot attach itself to the cell and its toxophore group is rendered inert.
Many experimental facts have been brought forward in support of this
theory, and its simplicity permits of the
presentation of the principles of immunity
in a concrete form.
Receptors or antibodies, according to
Ehrlich, are not all of the same composition
or structure, and individual receptors may
exercise entirely different functions. Each
cell is supplied with a multitude of these
receptors, which, when thrust off, constitute
FIG. 3. — CELL WITH TOXIN MOLECULES cm+ilx/~v/li^c, "171. V t, i, j' «j j j_i
ATTACHED BY COMBINATION or HAP- antlbodl6S. Ehrlich has divided the re-
TOPHORE GROUP AND RECEPTOR. ceptors into 3 orders. The first order, the
simplest of these antibodies, is represented
by the antitoxin molecule, which has only a single group, a haptophore or com-
bining group (Fig. 5). The second or more complicated order is represented
THEORIES OF IMMUNITY
199
FIG. 4. — RECEPTORS CAST OFF CONSTI-
TUTING FREE RECEPTORS OR ANTI-
TOXIN.
by the agglutinins, which contain an agglutinaphore group in addition to
the combining or haptophore group (Fig. 6). The third or most complicated
order contains 2 combining groups and may
be typified by the amboceptor (Fig. 7).
This group requires for the completion
of its activity the presence of comple-
ment.
According to Ehrlich, amboceptor is
formed for the anchoring of molecules too
large for the simple receptors which anchor
the toxin molecule. The amboceptor pos-
sesses 2 haptophore or combining groups, one
to combine with the molecule of food ma-
'terial and the other to combine with the digestive enzyme or complement which
breaks down the large molecule and prepares it for utilization. In the same way
the amboceptor combines, on the one hand, with antigen and, on the other hand,
with complement, a principle made use of in the Wasser-
mann reaction. Complement, therefore, must have 2 groups,
a combining or haptophore group and a zymophore or di-
gestive group, and must belong to the second order of anti-
bodies. Its resemblance to the toxin molecule will be evi-
dent. This resemblance has been further established by
the production of anticomplement. Complement is present
normally in the blood and is easily destroyed by heat, acids,
etc. Only in combination with complement is the ambo-
ceptor able to dissolve bacteria, cells, etc. Sera containing
receptors of the third order are bacteriolytic or bactericidal
only when combined with complement.
IMMUNITY TO TOXINS. — In the development of the resistance of the body
there are 2 factors involved, the immunity to toxins and that to bacteria. It
is possible by the injection of suitable small quantities of bacterial
toxins at suitable intervals to render an otherwise susceptible ani-
mal immune. Immunization against a toxin confers also some de-
gree of immunity against the pathogenic action of the organism
that produced the toxin. An animal immunized against the toxin of
one bacterium, however, is not protected against the toxin of another.
The toxins are of 2 varieties : the extracellular or soluble toxins
produced and liberated during the growth of an organism and the
intracellular or insoluble toxins which are liberated only on the
death and disintegration of the organism. The former may be
separated from the organisms by filtration. All pathogenic bacteria
do not form them. Two organisms which form them freely and
which have been extensively studied are B. diphtherias and B. tetani. The
intracellular toxins or endotoxins constitute a property inherent in the bod-
FIG. 5.— FIRST OR-
DER OF ANTIBOD-
IES FREE RECEP-
TORS OR ANTITOX-
IN HAVING ONLY
A SINGLE GROUP,
THE HAPTOPHORE
OR COMBINING
GROUP.
H
FIG. 6. — SEC-
OND ORDER
OF ANTI-
BODIES
HAVING A
COMBINING
GROUP H
AND AN AG-
GLUTINA-
P H O R E
GROUP A.
200 ADMINISTRATION OF VACCINES AND SERA
ies of the bacteria and not liberated during growth. The subject is not en-
tirely clear, some investigators claiming to have isolated endotoxins and to
have produced antitoxins against them with killed organisms and others de-
nying the possibility of producing such antitoxin. Organisms such as the
pneumococcus, which are not known to produce an extracellular or soluble
toxin, are supposed to exercise their harmful influence when endotoxin is
liberated by the death and solution of the bacteria.
It is now generally accepted that toxin and antitoxin form compounds
which are devoid of toxic action on animal cells. Various
proofs that this union is chemical have been brought forward ;
the most striking of which, by Martin and Cherry, showed that
toxin would pass through a filter impregnated with gelatin,
BODIES HAVING while antitoxin, apparently having a larger molecular struc-
GKOUPMAMBO^ ture, would not. They also demonstrated that, when a freshly
CEPTOB). made mixture of toxin and antitoxin was placed on a filter,
the first portion of the filtrate was toxic but that this toxicity
diminished in later portions and was absent a few minutes after the mixture
had been made. The inference was that the toxin and antitoxin had combined
to make a molecule too large to pass through the filter. When freshly made mix-
tures of toxin and antitoxin are exposed to a temperature of 70° C., the toxicity
is restored, the antibody having been destroyed and the toxin resisting this tem-
perature. When this mixture has been allowed to stand for some time, however,
the toxicity is not restored by a temperature of 70° C. It is apparent that the
molecule formed by the union of toxin and antitoxin, being less thermostable
than free toxin, has been destroyed. Ehrlich showed that toxin and antitoxin
combined in definite proportions.
Toxins against which antitoxins may be produced possess 2 groups: a
haptophore or combining group and a toxophore group. The latter may be
destroyed without injuring the former. This has been observed in old prepara-
tion of toxins. The resulting molecule is called a toxoid. It is still capable
of combining and of exciting antitoxin formation, but is not toxic.
BACTEKIAL IMMUNITY.— The main factors in bacterial immunity are
bacteriolysis and phagocytosis, operating either independently or in combina-
tion. Phagocytosis constitutes the main defense and is so effectual that or-
ganisms very rarely find a foothold in the circulation. It is highly probable
that in most infections bacteria gain entrance to the circulation but in the
great majority of instances they are very quickly destroyed. Normally the
blood contains substances which render the bacteria susceptible of ingestion
and destruction by the phagocytes. These bodies, called opsonins by Wright,
are supposed by him to exist in the circulating blood. Other observers have
claimed that they are developed during manipulation of the blood and are the
result of clotting or of phagolysis. In support of this, it has been pointed out
that in those portions of the body where the circulation is slowest and leucocyte
destruction — and therefore, opsonins — most abundant, as the spleen and bone
VACCINES 201
marrow, phagocytosis is most marked, and that it does not occur experimentally
to any degree when bacteria are mixed with blood in situ, as in a normal
ventricle cut off from the circulation. The opsonins resemble complement in
being thermolabile, although some substances which act as opsonins are ther-
mostabile. Similar bodies were discovered by Neufeld in 1904 in the blood of
pneumonia patients and called by him bacteriotropins. They play an important
part in recovery in that disease and are regarded by some as identical with
opsonins. Their action, however, is specific, as normal opsonin is wholly with-
out effect on virulent pneumococci while bacteriotropins permit or cause their
ready ingestion by the phagocytes.
The phenomena of destruction by phagocytosis differ materially from the
phenomena of bacteriolysis or extracellular solution, the latter necessitating as
it does both amboceptor or immune body and complement. The results, also,
are different, as in destruction by phagocytosis it is probable that the endo-
toxins are destroyed or neutralized, while in direct bacteriolysis they are
liberated. *
Summary. — To recapitulate, for the development of immunity there must
result from the injection of antigen the formation of antibodies. These anti-
bodies may be of several kinds: antitoxins, agglutinins, opsonins or bacterio-
tropins, bacteriolysins, etc. The antibodies, whether bacteriolytic or cytolytic,
are specific in nature. It is conceivable that we may, through the indiscrim-
inate use of vaccines (antigens), by lowering the antibody-producing power
of the cells, interfere with the normal development of protective antibodies.
VACCINES
Preparation of Vaccine. — Vaccines are usually prepared from cultures
grown on suitable solid media. Some, however, such as the tubercle bacillus,
are grown on liquid media. With the intention of keeping the organisms
as little changed as possible, various ways of attenuating their virulence and so
permitting the use of live organisms have been tried. Organisms in the
living state are very rarely used, however, in the vaccination of human beings.
They are killed either by heat, exposure or chemicals. Each method has its
adherents, almost all admitting, however, that the ideal vaccine would be
composed of living 'organisms attenuated just to the point where they would
not harm the host yet were active enough to excite continuous antibody for-
mation.
As this end has not been attained and the organisms must usually be
killed, the method most generally adopted is exposure to as low a temperature
as will do this (60° C..for 1 hour).
The routine method at the New York Hospital is as follows : The material
supplied, if suitable, is used for streaking plates without any previous manipu-
lation. By this method the purity of the culture is assured. If unsuited for
202 ADMINISTKATION OF VACCINES AND SEKA
direct use, a tube of broth is inoculated with one or several loopfuls of material,
thorough distribution of the organisms is attained by shaking and plates of suit-
able media are streaked. In this way information is obtained as to the variety
and relative number of bacteria involved.
To decide which bacteria are directly responsible complement deviation
tests of those isolated are sometimes necessary. In some cases it is possible to
determine from their pathogenicity which are the causative organisms, as, for
example, in the isolation of a typhoid organism from a gall-bladder sinus.
However, the organism must be of definite pathogenicity to justify such a
procedure.
FIG. 8. — APPARATUS FOB "FRACTIONAL" STERILIZATION OF VACCINES.
After the cultures have been grown for 24 hours, they are washed into a
sterile test-tube with 5 to 10 c. c. of sterile salt solution. The clumps are
broken up as far as possible by vigorous and prolonged shaking, the tube is
centrifugated a moment to remove the larger particles, and the number of
organisms per c. c. determined by the method devised by Wright and Douglas
or by counting directly in a counting chamber. The methods for the estima-
tion of the number of bacteria are only relatively accurate. The bacterial
suspension is now diluted to the proper strength for injection and is divided
among 4 test tubes. The organisms are killed by heating at 4 different tem-
peratures— 65° , TO0, 75°, and 80° C.— 1/2 hour. The apparatus used (Fig.
8) consists of a series of constant level water-baths equipped with automatic
gas controls and thermometers. In each is a perforated diaphragm for sup-
porting test-tubes containing vaccine. The baths have covers, thus insuring a
VACCINES 203
fairly uniform temperature for all parts of the tube. In this way the ob-
jection made to the open bath, that organisms spilled on the sides of test tubes
may not be killed, is overcome.
After heating, cultures are made to insure sterility, the different sus-
pensions are combined, and the vaccine is put up in sterile hypodermic vials
closed with rubber caps. Through these caps, after immersion in alcohol or
application of a drop of carbolic, a hypodermic needle may be thrust and
the vaccine withdrawn as needed. The strength of the vaccines varies from
100 to 1,000 millions to the c. c., depending on the organisms involved.
FIG. 9. — CAPILLARY PIPET.
Standardization of Vaccines. — Of the various methods proposed for the
standardization of vaccines, the method devised by Wright is probably most
widely used. By it the ratio of organisms in a given suspension to red blood
cells is determined in a stained smear. The bacterial suspension is made as
directed under preparation of vaccine. A capillary pipet (Fig. 9) is marked
about 1/2 in. from the end. Blood from a fresh puncture is drawn up to this
point, a small bubble of air is drawn in, and then the bacterial suspension is
drawn up to mark. The equal quantities of blood and suspension obtained in
this way are blown out on a glass slide, mixed thoroughly by drawing in and
out of the pipet several times, and a smear is made from a drop of this
mixture. The slide is stained with a polychrome blood stain and the relative
number of red cells and bacteria counted in a number of fields. At least 500
red cells should be counted. A ruled ocular diaphragm aids greatly in the
counting. If this is not available, the slide may be divided into squares.
Taking 5,000,000 as the average number of red cells per c. mm., the number
of bacteria per c. c. may be estimated. There are very many sources of error
in the method.
The organisms may be counted directly in a Helber-Zeiss counting cham-
ber, using a red or white cell pipet for diluting. This method is more ac-
curate than Wright's but takes longer.
A special centrifuge tube has been devised by Hopkins, in which the suspen-
sion, filtered through cotton, is centrifugalized for a definite time at a constant
speed. This gives a uniform sediment, which is made up to a 1 per cent, sus-
pension. The value of this suspension for the different organisms has been esti-
mated. The method is accurate for organisms of a constant size.
It will be seen that only a relative accuracy is achieved in standardizing
vaccines. This is sufficient, however, for practical purposes, as — because of
the variation in the organisms themselves — the dose, after the first one, must
be determined by the effect.
Dosage of Vaccines. — The first dose of vaccine must be decided arbitrarily;
204 ADMINISTRATION OF VACCINES AND SERA
the subsequent doses are dependent on the reactions resulting from the first.
Clinical data are usually relied upon for determining the size and time of all
doses but the first. The opsonic method for controlling the dose, etc., has fallen
into disuse because of inconstant results. The initial doses recommended by
Wright for the various organisms are as follows :
Gonococcus, 5,000,000 to 50,000,000.
Colon bacillus, 5,000,000 to 50,000,000.
Pneumococcus, 10,000,000 to 50,000,000.
Typhoid bacillus, 5,000,000 to 50,000,000.
Streptococcus, 10,000,000 to 25,000,000.
Staphylococcus, 50,000,000 to 1,000,000,000.
These figures serve as a rough guide for the initial dose only. If following the
initial dose there is a marked local or constitutional reaction, no subsequent dose
should be given until after this has subsided. Local redness, tenderness, or induration
to any considerable extent, with constitutional disturbance and increase in special
symptoms, are indicative of overdosage.
Interval Between Doses. — The usual custom is to allow an interval of 5 to 10
days to intervene between doses, so as to avoid the so-called negative phase. With the
object of developing the immune bodies as rapidly as possible, it has been the custom
for several years at the New York Hospital to start the treatment with daily doses
for the first 5 days, unless contra-indicated by reactions, and then to give injections
at 5-day intervals. There is experimental evidence to prove that agglutinins may be
raised more rapidly by this method, and there is a possibility that other antibodies are
similarly influenced. The results by this method have been satisfactory.
Prophylactic Vaccination — The injection of vaccines of staphylococci or strep-
tococci before operation in the hope of avoiding infection by developing immunity
against these organisms must be regarded as an unsound procedure. In the present
state of our knowledge, we can be none too sure that no harm will result.
Following the administration of a dose of vaccine, animals are prone to become
ill and while in this condition certainly are less resistant to infection. It hardly
seems wise to subject a patient to possible injury and so reduce his resistance.
Sensitized Vaccines. — Sensitized vaccines have been prepared for a number
of diseases. Living cultures are submitted to the action of specific sera, the or-
ganisms are separated from the sera and used as a vaccine. This vaccine will
contain the organisms plus the antibodies which have become attached to them
while in contact with the serum. This method has been used by Besredka for
immunization against typhoid, in which he claims excellent results and no
drawbacks. The method is also used by the Pasteur Institute of Paris for the
preparation of antirabic vaccine. The dangers of using living cultures have
limited the employment of sensitized vaccines. The advantages do not seem to
offset these dangers. All organisms cannot be sensitized, so that at best the ap-
plication will be limited.
Stock Vaccines. — In every case autogenous vaccines, where available, are
to be preferred. Where a vaccine seems indicated, however, and an autogenous
one cannot be prepared, a stock vaccine is permissible if the connection between
'APPLICATION OF VACCINE AND SEKUM THEKAPY 205
the disease and a particular organism is undoubted. Because of the number
of strains and the variation in the different strains of the same organism, even
when the causative agent is known, an autogenous vaccine is vastly to be pre-
ferred. The number of strains of gonococci with qualitative differences, iso-
lated by Torrey, illustrates this point. Where an autogenous cannot be pro-
cured, a polyvalent vaccine made from a number of strains of the same -organ-
ism should be used. Many factors, including uncertain source, age and
strength, argue against the stock vaccine.
In no case should a stock vaccine be used without definite information as^ to the
causative agent involved. The infections in which most benefit has been derived from
the use of stock vaccines are those in which the staphylococci are concerned.
Stock vaccines must, of course, be used for antityphoid inoculation.
Mixed Vaccines. — This term is used to identify vaccines consisting of 2 or
more different bacteria. They must be differentiated from polyvalent vac-
cines, which contain several different strains of the same bacterium. There
can scarcely be any scientific method for the application of a mixed vaccine.
While we may be able to determine by the plate method of culture the variety
and relative numbers of organisms in the particular material supplied, this is
far from being a safe guide to the actual numbers and relative importance
of the organisms involved in the process. In mixed infections the complement
deviation test may prove to be a practical help.
APPLICATION OF VACCINE AND SERUM THERAPY TO VARIOUS
DISEASES
Acne. — Staphylococci of all varieties are found in this condition some-
times associated with the "acne" bacillus, an organism of the diphtheroid
type. Vaccines of the former are readily prepared, but the latter grows with
difficulty. Where improvement is not obtained with the staphylococcus vac-
cines, the "acne" vaccine may be tried. The local and general treatment
should be continued while the vaccines are being used, but even under those
conditions the results are not always satisfactory.
Chronic Furunculosis. — The most brilliant achievements of vaccine therapy have
been attained in chronic furunculosis. Any variety of the staphylococcus may be
present. Autogenous vaccines are easily prepared. If an autogenous vaccine is not
available, however, a stock vaccine prepared from several strains of staphylococci may
be used, but if prompt improvement does not follow it should be abandoned. The
first dose should be large, about 500,000,000; subsequent doses may have to be larger
or smaller, depending on the reaction. Daily doses are given for 5 days unless the
reactions are severe, subsequent doses should be given at 5-day intervals.
Carbuncle. — The staphylococcus aureus seems uniformly to be the or-
ganism involved in this condition. Autogenous vaccine should be used, how-
206 ADMINISTRATION OF VACCINES AND SEKA
ever, wherever practicable and the dosage should be large. Attention to the
general health and diet of the patient is very important in conjunction with
proper surgical measures.
Anthrax. — Although the manifestations of this disease suggest the pres-
ence of a toxin, there is no experimental proof of its existence. Attenuated
living vaccines are used in developing immunity in animals. For the condi-
tion known as malignant pustule in man, serum has been used with success.
It may be obtained in the open market. It should be given also in pulmonary
anthrax. If the serum is not available, killed vaccines may be tried.
Arthritis. — The type of arthritis following definite localized infections
should be amenable to treatment with organisms isolated from the site of the
original infection if their relation can be established by complement deviation
tests. Unfortunately this relation cannot always be traced, and frequently
in cases of long standing no definite focus of infection can be found. Re-
cently several organisms have been isolated by Rosenow from the glands in
the neighborhood of the affected joints in chronic arthritis, and vaccines
made from these organisms are being used. Vaccines made from organisms
whose relation to the disease has been established by complement deviation tests
alone have been used with some degree of improvement. The results, while
encouraging, have not been brilliant, however.
In these conditions all possible accessible sources of infection must be
kept in mind, as the accessory sinuses, antrum of Highmore, teeth, tonsils,
ears, urethra, uterus, prostate, bladder, etc. The source of the infection, how-
ever, if it is an infection, may be in an organ not readily accessible, such as
the gall-bladder or appendix.
Bacillus Aerogenes Capsulatus Infection. — In conjunction with efficient sur-
gical treatment, the use of vaccines in this comparatively rare and relatively
fatal infection may be of assistance. The initial dose should be small.
Cholera (Vibrion Cholerse). — Sera have been prepared which have a pro-
tective value in animals but no curative value. The serum of recovered pa-
tients is very strongly bacteriolytic. Haffkine, using attenuated living or-
ganisms, has used preventive vaccination in India with considerable success.
Infections with Colon Bacillus. — Organisms of the colon group have been
isolated from a variety of conditions. They are prone to locate in the gall-
bladder and pelvis of the kidney. The variations in the members of this group
and the marked differences in the biological characteristics of the different
varieties make the value of stock vaccines of the type usually used (the bacil-
lus coli communis) highly problematical. The members of the group extend
from the coli communis, through the paracoli and enteritides, to the paraty-
phoid group. Autogenous vaccines are the only ones whose use is justified.
Even with autogenous vaccines the results in cases of pyelitis, etc., are fre-
quently disappointing, possibly because the places where the organism thrives
are not accessible to the immune bodies. The usual initial dose is about
50,000,000.
APPLICATION OF VACCINE AND SEBUM THERAPY
Diphtheria. — The production of diphtheria antitoxin furnishes a practical
example of the development of an active immunity. This organism furnishes
a soluble toxin and this toxin is available for immunization.
As marketed, diphtheria antitoxin contains from 300 to 2,000 units to the
c. c. The usual sites for injection are the loose subcutaneous tissues of the
abdominal wall and between the shoulder blades. In urgent cases the injection
should be made intravenously. Park has shown that where, after subcutaneous
injection, the blood will show 2 units per c. c. after 6 hours, it will show 20
units per c. c. after same period if a similar injection has been given intra-
venously.
The same authority strongly recommends one large dose instead of several
small ones and has supported his recommendation by showing experimentally
that, of 2 animals injected subcutaneously, one with 1 dose of 15,000 units
and the other with 4 doses of 5,000 units each at 8-hour intervals, the blood
of the former after a short time contained over 3 times as many antitoxin units
to the c. c. It was not until after 3 days that the strength of the latter in units
of antitoxin to the c. c. of blood equaled that of the former.
The doses recommended for children are as follows: when seen on first
day, 5,000 'to 10,000 units subcutaneously; on second day, 10,000 to 15,000
units subcutaneously; on third day, 10,000 to 15,000 units intravenously.
Even when seen early, if the membrane is extensive, involving the pharynx
or larynx, intravenous injections are advised. In very severe or late cases
doses of 20,000 to 100,000 units may be given intravenously. There is some
evidence to suggest that large doses may separate the toxins from their com-
binations with the cells.
If there is no distinct improvement in the general and local condition after
twelve hours, it is customary to repeat the dose or to give a larger dose. Park
claims that if the initial dose is of sufficient size this will be unnecessary.
All children exposed should be immunized, the immunizing dose varying
between 300 and 1,000 units, depending 011 the age and size of the child. The
protection persists only for from 4 to 6 weeks.
Active immunization has been used with some success for the treatment of
"carriers" of diphtheria bacilli. An autogenous vaccine should be prepared.
Dysentery. — The bacteria which are regarded as causative factors in dysen-
tery have been divided into 2 classes, those not fermenting mannite and pro-
ducing a soluble toxin — the Shiga type — and those fermenting mannite and
not producing a soluble toxin — the Flexner-Harris type. Organisms belonging
to the latter type are the ones most prevalent in the United States.
No satisfactory results have been obtained in active immunization against
both types.
In Japan passive immunization with antidysenteric serum prepared against
the Shiga type has reduced the mortality from 22 to 26 per cent, to 9 to 12
per cent. As this organism produces a free toxin, the serum is antitoxic in
nature. Sera prepared against the variety of organism prevalent in the United
208 ADMINISTRATION OF VACCINES AND SERA
States, however, must depend on bacteriolytic properties, as these organisms
do not produce soluble toxins. Therefore, the serum will be antibacterial and
not antitoxic. No definite beneficial results have been obtained from these
sera. More recently a polyvalent serum has been used with some success,
possibly due to antitoxins produced against the Shiga bacillus.
Shiga's serum is given in 10 c. c. doses repeated in 6 to 10 hours if neces-
sary. The same doses are given on the second and third days in severe cases,
but not over 20 c. c. are given in one day. The sera against the Flexner-
Harris type have been given in larger doses, up to 100 c. c.
Erysipelas. — Erysipelas appears to be a self -limited disease in which vaccines,
leukocyte extracts, sera and proprietary preparations are apparently without any influ-
ence. In a number of cases (95) observed by Erdman at Bellevue Hospital treated by
vaccines prepared from stock cultures, by trade stock vaccines, and by other proprietary
bacterial remedies, the duration of the disease was not lessened; the mortality remained
at the same level; there was no immunity against recurrence, spreading or complica-
tions and no change in the subjective symptoms as compared with the control cases.
Graves' Disease (Exophthalmic Goiter) — The hopes that were raised with the
introduction of antithyroid serum have not been fully realized. The serum appears
to have no influence in many cases. Its specificity has been questioned, it having
been argued that the precipitate obtained when the antigen is prepared as directed by
Beebe contains salts of protein and nucleic acid instead of nucleoproteid, and that the
antibodies produced are due to the protein introduced. If tried and found to have no
effect on a given case, the use of the serum should not be persevered in.
Glanders. — The disease is recognized under 2 conditions, one known as
glanders, in which it involves chiefly the mucous membranes, and the other
known as farcy, in which the principal lesions are located in the skin. The
causative organism is known as the bacterium mallei. The diagnosis is made
by agglutination tests and by inoculating male guinea pigs subcutaneously
or intraperitoneally with purulent material or blood. In positive cases
enlargement of the testicles follows.
Mallein, prepared along the lines of Koch's old tuberculin, is used for
diagnostic purposes in animals. It has no curative value. Attempts at active
and passive immunization have resulted only in failures.
GonoCQCCUS Infections COMPLEMENT-FIXATION TEST (SCHWAKTZ AND
McNElL). — A polyvalent antigen is prepared from various strains of gonococci
grown on salt-free veal agar, neutral to phenolphthalein. Twenty-four-hour-old
cultures are washed off the agar slants with distilled water, and the resulting sus-
pension is heated for 2 hours on the water-bath at 56° C. It is then centrifu-
gated and passed through a Berkefeld filter. When desired for use, this antigen
is made up to 0.9 per cent, salt solution by mixing 9 parts of antigen with 1 part
of 9 per cent, salt solution. The antigen is preserved in small quantities in
sealed tubes heated to 56° C. for % hour on 3 successive days. Prepared in
this way, it will keep almost indefinitely. It is standardized, if possible, with
a known positive serum from a clinical case. If this is not possible, immune
rabbit serum may be used, provided the minimum amount of serum which will
APPLICATION OF VACCINE AND SERUM THERAPY 209
completely fix complement is used. The anti-sheep hemolytic system is used.
Immune rabbit serum may be obtained in the market. The technic and
controls are much the same as in the Wassermann reaction, but the reagents are
used in 1/10 the quantity.
Schwartz and McNeil regard the complement-fixation test for gonococcus
infection as clinically absolutely specific for the gonococcus. The one positive
result obtained aside from cases with gonococcus infection was with a highly
immune animal antimeningococcus serum. Sera from patients suffering from
meningococcic cerebrospinal meningitis have been uniformly negative.
A positive reaction is not to be expected earlier than the fourth week, and then
only when such complications as prostatitis, gonococcus arthritis, etc., have super-
vened. A positive reaction is not obtained when the disease remains confined to the
anterior urethra. A weakly positive reaction may appear in the third week when
the posterior urethra has become involved. In uncomplicated cases a reaction is
obtained only after 8 weeks. A complicated case gives a -\ — \- or -| — | — \- reaction in
4 weeks. The fact that the early weeks of the infection do not give a positive reac-
tion may be of value in differentiating a fresh infection from the recurrence of an old
one apparently cured.
In females a positive reaction will not be obtained unless the cervix is in-
volved. This is usually the case in women but is an unusual condition in
children, hence the latter rarely give a positive complement-fixation test.
A negative reaction should be obtained, as a rule, Y or 8 weeks after cure. In
other words, if a positive reaction is obtained 7 or 8 weeks after a clinical cure the
patient should be regarded as harboring gonococci.
The test is of great value when a bacteriological examination fails. This is espe-
cially true in the female. If the complement-fixation test is negative and the bac-
teriological test positive, the latter should be accepted only when the proof is abso-
lute, i. e., the isolation of the gonococcus culturally.
VACCINE AND SEEUM TREATMENT OF GONOEEHEA. — For treatment of
gonorrhea, both vaccines and sera have been employed. A polyvalent stock
vaccine is usually used in an initial dose of 50,000,000 in the chronic cases
with gonorrheal involvement of joints and other structures. Many observers
claim some help from the vaccines. There is general agreement that they
are of little or no benefit in the acute processes. Cases treated with anti-
gonococcus vaccine give a strongly positive complement-fixation test, showing
that antibodies specific for the gonococcus are readily produced in the human
system.
Improvement has been reported in cases of localized infection, such as
vulvovaginitis of children and epididymitis. In the former condition, however,
relapses occur just as in the unvaccinated cases. A shortening of the course is
the most definite result, but this can be demonstrated only when a large series is
considered and even then it is open to doubt. The organisms, as in the infec*
15
210 ADMINISTKATION OF VACCINES AND SEEA
tions of the pelvis of the kidney, are in a position not readily influenced, if
reached at all, by immune bodies.
In epididymitis and chronic infections of other adjacent parts, such as the
seminal vesicles and prostate, cultures form the urethra after massage of the
prostate and vesicles may reveal secondary infecting organisms against which
a vaccine may be used. It is well, however, to control their pathogenicity by
a complement-deviation test. This vaccine should always be an autogenous one.
Antigonococcus serum has been prepared, along the lines suggested by
Torrey, by vaccinating rams with various strains of gonococci. The serum, like
the vaccine, gives no definite results in acute cases, but some observers claim
benefit in the chronic cases and in complications due to the gonococcus. The
usual dose is 2 to 6 c. c., but larger doses up to 12 to 15 c. c. have been used.
The serum has not been standardized, and its action may be due to contained
antigen, as the animals, probably deficient in their ability to form antibodies,
may lack the power to combine the injected antigen. No antitoxic power
has been demonstrated. Serum sickness is prone to follow its use and more
than 5 to 7 days should never elapse between injections. The serum may be
purchased in the open market.
Hodgkin's Disease. — Diphtheroid organisms (called corynebacterium hodg-
kini) have been isolated from the glands in this condition and vaccines made
from them have been used and improvement reported in some cases. The
history of the so-called diphtheroid organisms shows that at one time or an-
other they have been regarded as the causative factor in almost all diseases
of obscure origin. For this reason many refuse to accept their association
with Hodgkin's disease as anything more than an incident. In judging the
value of treatment one must not lose sight of the many unexplained periods
of improvement which may occur in the course of an untreated case of this
disease.
Localized Infections. — In angina, otitis media, adenitis, osteomyelitis, etc.,
the causative organism should be isolated and an autogenous vaccine pre-
pared.
In conditions such as these, in which the causative organism is not constant,
every effort should be made to identify the bacteria involved. In otitis media
usually several varieties are associated. The results of vaccine treatment
in this condition are not very encouraging, but vaccines may be of help in
conjunction with efficient local treatment.
Infections with Bacillus of Influenza. — In chronic processes following an
acute influenza vaccines of the influenza bacillus should be of value if the
relation of the organism to the process can be established. Other micro-
organisms may play a part. Their identity should always be determined before
using a stock vaccine.
Meningitis. — In all cases lumbar puncture should be performed to determine
the character of the infection. For lumbar puncture the space between the
third and fourth lumbar vertebrae is the site usually chosen. This is on a level
APPLICATION OF VACCINE AND SERUM THERAPY 211
with the highest point of the iliac crests. The patient should be lying on his
side with thighs and neck strongly flexed. Occasionally the sitting position
is chosen. In some cases a slight degree of general anesthesia is necessary,
but usually a moderate degree of local anesthesia by freezing or cocain is suffi-
cient. The spinal canal is reached at a depth of 1 to IVk in- (in children % in.).
The gross characteristics of the fluid are a help toward diagnosis. With
well-marked symptoms of meningitis, a clear fluid under pressure suggests a
tuberculous process. When an epidemic prevails, a turbid fluid, in the absence
of any focus pointing to a different cause, suggests the diplococcus intracellu-
laris, and Flexner-Jobling serum should be injected at once. Smears and
cultures should be made from the fluid, but often a positive bacteriological
diagnosis cannot be established without some delay. The earlier the serum is
administered, the better are the results. In the presence of a focus of in-
fection, such as a fracture of the skull or an otitis media, smears and cultures
should be carefully examined for the infecting organism, usually a streptococ-
cus, pneumococcus or staphylococcus.
In treatment by serum the usual procedure is to draw off as much spinal
fluid as will run easily and to inject slowly from 30 to 60 c. c. of anti-
meningococcus serum. In severe cases a second injection may be made in about
12 hours, but usually 24 hours elapse between treatments. Subsequent in-
jections depend on the symptoms, the appearance of the fluid, and the pres-
ence of organisms. It is customary to continue treatment for a day or two
after organisms have disappeared, even if the temperature has become normal.
A recurrence of the organisms in the fluid naturally calls for more treatment.
The serum is bacteriolytic, bacteriotropic, and anti-endotoxic in action.
Vaccination with diplococcus intracellularis for curative purposes has been
ineffectual, but prophylactic vaccination has met with some success.
In cases of meningitis due to streptococci antistreptococcic serum has
seemed to have a curative influence in some cases. The procedure is the
same as that outlined above for the meningococcus.
No satisfactory sera exist at present for treatment of staphylococcic or
pneumococcic infections of the meninges.
Pyorrhea Alveolaris. — Cultures may be made from the root canal if the
nerve is dead, from the tip of the root reached alongside the tooth or if an
abscess at the root has been demonstrated by X-ray by incising the gum and
boring through the bone of the alveolar process. The use of a suitable autogen-
ous vaccine in connection with local treatment seems to be of benefit in obstinate
cases. It is in this field that complement deviation work should prove especially
helpful.
The streptococcus viridans has been isolated from a number of cases.
Pyorrhea alveolaris may furnish a portal of entry for this organism into the
general circulation, at times with disastrous results.
Considerable work has been done in establishing the relation of this condi-
tion, and the organisms isolated from it, to cases of arthritis of obscure origin.
212 ADMINISTKATKOT OF VACCINES AND SEKA
Bacillus Pestis (Bubonic Plague) . — The organism may be isolated from the
buboes or from the blood. Vaccines have been used for protection and treat-
ment and sera have been prepared and used. The reported results show wide
variations. The prophylactic use of the vaccine seems to have reduced the
morbidity.
Infections with Pneumococci. — The pneumococci may be divided into sev-
eral groups differing entirely in their immune reactions. Immune serum
prepared against one group will not protect against or agglutinate the mem-
bers of another. Antipneumococcus sera and vaccines have been tried exten-
sively in pneumonia, but their routine use cannot be advised, as their value
has not been clearly established.
Localized infections due to the pneumococcus may be benefited by an autog-
enous vaccine. That it should be an autogenous vaccine there is no question.
The initial dose may vary between 20,000,000 and 100,000,000.
Many of the so-called postoperative pneumonias are really not true pneumonias
but inflammatory processes due to emboli. Their course differs from that of a true
pneumonia, and the organisms involved may not be pneumococci. The use of an anti-
pneumococcus vaccine in this condition therefore is not rational.
Puerperal Infection. — The organisms isolated from this condition include
the streptococcus, pneumococcus, colon bacillus, gonococcus, and bacillus
aerogenes capsulatus.
In every case a blood culture should be made, as in this way if successful we may
be sure that we are finding and dealing with the causative organism. Failing in this, a
culture from the uterus may demonstrate an organism with pathogenic properties, but
this latter method is always open to doubt. In a prolonged local infection, however, the
use of a vaccine from this source might be justified. The indiscriminate use of stock
streptococcus vaccines, however, cannot be commended.
Cases have been reported which have been benefited by antistreptococcus
serum. The mechanism of the action of such a serum must be bacteriotropic
and, as in the case of the pneumococcus, the serum probably must be prepared
against the special strain involved. The indiscriminate use of antistreptococcus
serum, therefore, is irrational.
Rabies. — By vaccination against rabies, immunity is established after in-
fection, that is, during the incubation period of the disease. The diagnosis of
hydrophobia in a suspected animal is made from Negri bodies in the brain
tissue or by inoculating an emulsion of the brain cord or medulla into the
subdural space of a rabbit through a trephine opening. The organism causing
the disease has not been identified. The virus as administered in all prob-
ability contains the living organisms in an attenuated form.
According to the method originally devised by Pasteur, cords of rabbits
dead of the disease were used in preparing the virus. These cords were dried
over caustic potash for varying lengths of time. For the first injection Pasteur
APPLICATION OF VACCINE AND SERUM THERAPY 21S
used a cord dried for 15 days. Cords kept as long as this are now regarded as
practically innocuous. Various modifications of the original procedure have
been made.
The scheme of treatment advised by the U. S. Hygienic Laboratory at
Washington, known as the intensive method, is the one followed by the Depart-
ment of Health of New York City.
The treatment may be administered by the physicians of the department or it
may be administered by the patient's private physician, to whom the department will
mail each day the dose appropriate for that day. To physicians outside of the city
who are desirous of treating their cases personally the dose for each day is mailed on
the preceding day or earlier if necessary because of the distance. The preparation is
always administered subcutaneously into the abdominal wall.
The routine treatment covers 21 days. On the first day a mixture of cords dried
8, 7, and 6 days is given; on the second day a mixture of 4- and 3-day cords; on the
third day a mixture of 5- and 4-day cords; on each succeeding day a dose is given
derived from a cord dried from 5 to 2 days. Only in rare cases are 1-day cords used
on eighth and twenty-first days.
Very rarely an attack of paralysis has developed during the administra-
tion of the virus. These have usually been mild, but some severe cases have
been reported. Many modifications in the preparation of the virus have been
devised to avoid the possibility of paralysis, but their use cannot be advised at
present, as their value, like that of antirabic serum, has not been definitely
established.
Acute Rheumatic Fever. — Although definite progress seems to have been
made regarding the causative organism or organisms in this condition, it is
not one at present amenable to either vaccine or serum treatment.
Scarlet Fever. — As the relation of the streptococcus to this disease is not
clear, there is hardly any justification for the use of streptococcus vaccines.
The same may be said of antistreptococcus serum, although good results
have been claimed for the latter by some.
Tetanus. — As is well known, infection with the bacterium tetani may occur
after gunshot wounds or any lacerating or penetrating wound which has been
contaminated with garden, street or barnyard soil. As the results of the
preventive use of tetanus antitoxin are so much more satisfactory than its
use as a curative agent, it is the duty of every physician to administer a
prophylactic dose in all such cases.
Tetanus antitoxin is prepared in the same way as diphtheria antitoxin.
The dose for prophylactic purposes is from 1,500 to 3,000 units given sub-
cutaneously as soon as possible after the injury. Depending on the richness of
the nerve supply at the site of injury the period of incubation varies from 2 to
14 days, the usual period being 10 days. Once symptoms of tetanus have devel-
oped, the disease must be treated vigorously by intravenous and intraspinous
injections, as advised by Park and Nicoll. The antitoxin has also been injected
214 ADMINISTRATION OF VACCINES AND SERA
intracerebrally into the lateral ventricles through a small needle introduced
through a trephine opening.
While theoretically only the free toxin will be neutralized by the antitoxin,
there is some evidence that even that which has entered into combination with
the nerve cells may be affected. This has been explained on the theory of
"mass" action causing dissociation. There is clinical justification for its use
after active symptoms have developed in the fact that the mortality in untreated
cases is from 80 to 90 per cent., while in treated cases it is about 20 per cent,
lower. Recent results from early intraspinous treatment promise to reduce
this percentage much lower.
In this condition, as in diphtheria, Park claims that 24 hours after a single
large dose there is a large amount of free antitoxin in the circulating blood.
While this obtains, subsequent doses are unnecessary.
The possibility of tetanus developing in any given condition must be
judged from the nature of the injury. The bacteriological diagnosis after
symptoms have developed may be impossible.
Park and Nicoll make the following recommendations:
"Iu every case strongly suspected of being tetanus, from three to five thousand
units of tetanus antitoxin should be given at the first possible moment intraspinally,
slowly, by gravity, and always, if possible, under an anesthetic. In order to insure its
thorough dissemination throughout the spinal meninges the antitoxin should be
diluted, if necessary, to a volume of from 3 to 10 c. c. or more, according to the pa-
tient's age. When fluid is drawn off previously to the giving of the antitoxin, an
amount of the latter somewhat less than that of the fluid withdrawn should be given.
A number of cases of 'dry tap' have been observed in the disease by those so expert
in spinal puncture as to leave no room for doubt that the canal was properly entered.
In such cases only a small amount of tetanus antitoxin should be injected (from 3
to 5 c. c.).
"It must be remembered that in the human type of the disease there is frequently
a focus constantly pouring out more and more toxin, for which reason it is probably
advisable to repeat the intraspinal injection in twenty-four hours. While unques-
tionably the blood will soon become antitoxic through the intraspinal use of antitoxin,
in order to insure the quickest possible neutralization of all toxins in the tissue fluids,
it would seem advisable to give, at the same time as the first intraspinal dose, a dose
of 10,000 to 15,000 units intravenously. A similar dose given subcutaneously three
or four days later will insure a highly antitoxic condition during the next five days.
We do not believe there is any advantage in giving larger amounts of antitoxin than
those indicated."
Typhoid Fever. — Antityphoid vaccination as a preventive measure is es-
tablished on a firm basis. It was first used extensively in India with but
indifferent success. The results in South Africa during the Boer War were
more satisfactory. In the United States army the published results have been
most striking and have fully established the value of the procedure.
The vaccines used are from cultures on slant agar, 24 hours' growth, the
organisms being killed at 60° C. This is one of the few conditions in which
the use of stock vaccines is permissible. In adults the first immunizing dose is
TUBERCULIN THERAPY 215
500,000,000, given subcutaneously. For the site of the injection the upper
arm or loose tissue of the abdomen, back, or subclavicular region may be chosen.
This first dose is usually followed by 2 other doses of 1,000,000,000 each,
given at intervals of 5 to 7 days. Depending on the weight, age, and condition
of the patient, it may be necessary to vary these doses somewhat. In children
Russell advises that the dose should bear the proportion to the average adult
dose that the child's weight bears to the average adult's weight (150 Ibs.).
The reaction to the vaccine varies. Sometimes there is none. Usually,
however, there are headache and malaise; occasionally temperature of 103°,
chills, vomiting and diarrhea. The local reaction may be marked, and the
glands in the neighborhood may be enlarged and tender. The reactions usually
come on in 6 or 8 hours and may last 2 or 3 days.
The duration of the immunity conferred is uncertain, but it is believed to vary
between 1 and 3 years.
In the vaccine treatment of typhoid fever much smaller doses are used
than those advised above. Reaction must be avoided. Some observers report
satisfactory results, but there is no sound scientific basis for the use of vaccine
during the course of the disease. Post-typhoid involvements of gall-bladder,
bones, joints, etc., are, however, appropriately treated with vaccines in con-
junction with suitable surgical procedures.
TUBERCULIN THERAPY
Varieties of Tuberculin. — Under the term tuberculin is included a great
number of preparations differing from each other in their physical condition
or manner of manufacture but all derived from cultures of the tubercle
bacillus. Some of these are made from the media in which the organisms
have been grown, while others are made from the organisms themselves. No
tuberculin is derived from serum.
Hamman and Wolman have conveniently divided the various tuberculins
into groups.
GEOUP l. — Group 1 comprises the tuberculins which contain the bodies
of the tubercle bacilli, dead or alive, subjected to only physical changes. This
group contains B. E. Behring's Vaccines, Tebeau, and Tuberculo-Sero- Vaccine.
B. E. is the lacillen-emulsion of Koch (1901). For its preparation the
organisms are grown at body temperature for 6 or 8 weeks in flat-bottomed
flasks in a thin layer of slightly alkaline bouillon medium plus 5 per cent, of
glycerin. The bacilli are filtered off, dried, and pulverized by grinding. When
examination has proven that all the organisms have been destroyed, 1 part of
the powder is diluted with 100 parts of distilled water and 100 parts of glycerin.
Thus, 1 c. c. contains 0.005 gm. of tubercle bacilli unchanged, as they have
not been washed or submitted to heat.
GROUP 2. Group 2 comprises those tuberculins which are made by ex-
216 ADMINISTRATION OF VACCINES AND SERA
trading the tubercle bacilli without any attempt whatever at the isolation of
the ultimate principles. In this group are T. R., Beraneck's tuberculin,
von Ruck's tuberculin, the aliphatic tuberculins derived from fatty substances,
Krehl and Mathes' tuberculin, Vasilescu's oxytuberculin, Sciallero's, Mare-
char s, Jacob's, Benario's, Contani's, Turmann's, and Rosenbach's tuberculins,
tuberculoplasmin, frozen bacilli, prosperol, tuberculin liquid, and Ishigami's
tuberculin.
T. R., tuberculin residue or new tuberculin (Koch, 1897), is derived from
young virulent cultures 4 to 6 weeks old grown as for B. E. The bacilli are
filtered off and dried in a vacuum, and 1 gm. of the dried bacilli is ground in a
mortar until there are no intact bacilli. One hundred c. c. of distilled water
are now added, and the mixture is centrifugated. The clear fluid is decanted
and is known as T. O. (tuberculin oberes). The sediment is again dried,
powdered, and again taken up with a small quantity of water. It is again
centrifugated and the fluid preserved. This process is repeated until the sedi-
ment consists only of large particles. The fluids, with the exception of the first,
are united and 20 per cent, of glycerin is added for preservation — the volume
not to exceed 100 c. c. Each cubic centimeter should contain 0.002 gm. of
solids, representing 0.01 gm. of dried tubercle bacilli.
Beraneck's tuberculin consists of equal parts of the filtrate of a culture of
tubercle bacilli and a 1 per cent, orthophosphoric extract of the residue.
Von Ruck's tuberculin is prepared from a culture concentrated in vacuo
to 1/10 volume. After several precipitations and filtrations, the preparation
represents a 1 per cent, aqueous solution.
GEOUP 3. — Group 3 comprises preparations derived from culture fluids.
In it are O. T., B. F., Jochmann's tuberculin, iron-tuberculin, tuberculin
purum or endotin, Jesseu's, and Leber and Steinharter's. Some of these
belong, also, in Group 2.
O. T. is the original tuberculin, alt tuberculin or old tuberculin (Koch,
1891). It was Koch's first tuberculin and was prepared by concentrating
6 or 8-weeks-old cultures to one-tenth of their original volume by a current of
steam. The concentration of glycerin having been 5 per cent, in the original
culture medium, is 50 per cent, after evaporation. The bacteria are removed
by filtration through a Chamberland filter. The result is the familiar brown
fluid ready for use.
B. F., or bouillon filtrate, was first prepared by Denys in 1905. The
culture is grown as for O. T. Without having been heated or concentrated in
any way, the mixture of bacteria and culture medium is passed through a
bacteria-proof porcelain filter. This filtrate is used without further prepara-
tion.
Jochmann's tuberculins are made from organisms grown on a protein-
free medium. They are no more efficient than O. T., but are claimed to be
less toxic.
GEOUP 4.- — Group 4 includes modifications which aim at the isolation of a
TUBERCULm THERAPY 217
pure principle, as tuberculol, tuberculocidin, Haent Jen's filtrase, and tuberculo-
nastin.
Tuberculol was made by Landmann in the hope of conserving all the im-
portant factors. The fragmented bacilli are extracted with glycerin-normal salt
solution at increasing temperatures from 40° to 100° C. These extracts are
combined and concentrated. The original culture medium is concentrated,
combined with the concentrated extracts, and sterilized by passing through
porcelain.
GEOUP 5. — Group 5 consists of tuberculins in which emphasis has been
placed upon the type of bacillus to be employed: as Spengler's tuberculins
from bovine and human strains; the tuberculins made from avian or other
acid-fast bacilli ; Calmette's Cl and autogenous tuberculins.
The tuberculins most used are those of Koch — 0. T., T. R., and B. E. —
Denys' B. F., and Beraneck's tuberculin. Clinically there seems to be no
reason for a preference. These various tuberculins are used as vaccines in
attempts to develop immunity. None of them have been shown to have any
direct bactericidal effects. The development of the immunity must be judged
by clinical symptoms.
Experimental Observations. — The original observations on which Koch
founded his tuberculin therapy were as follows: Following inoculation of a
healthy guinea pig with turbercle bacilli there is no reaction until 10 to 14
days later, when a small nodule appears at the site of inoculation. This
nodule breaks down and ulcerates, and the ulcer persists until the death of
the animal. If, however, the pig inoculated is tuberculous (has been suc-
cessfully infected with tubercle bacilli 4 to 6 weeks previously) a necrotic area
develops at the site of inoculation 1 or 2 days after the injection. This area
sloughs off, leaving a shallow ulceration which heals rapidly without involve-
ment of the neighboring glands.
He also showed that killed tubercle bacilli could be injected under the
skin of a healthy pig in considerable quantity with the production of local
suppuration as the only result. Tuberculous pigs, on the contrary, were
killed in 6 to 48 hours by similar injections. By using smaller doses, how-
ever, he was able not only to avoid death but to obtain improvement in the
tuberculous animals. He regarded the killed organisms as unsuitable for
use in human beings and devised his extract known as O. T., arguing
that the virtue lay not in the organisms themselves but in their
products.
The Reaction. — In using tuberculin therapeutically it is generally agreed
that strong reactions are to be avoided, lest, being uncontrollable, they may be
so severe as to do harm. The agreement is not universal, however, and it is
possible to divide the users of tuberculin into 2 schools, one of which seeks
to avoid all reactions and another which gives tuberculin more freely, paying
but slight heed to slight reactions. Trudeau and Sahli represent the former
218 ADMINISTRATION OF VACCINES AND SERA
group and Petruschsky represents the latter. Sahli claims that patients treated
cautiously attain a tolerance as soon as or sooner than those who have shown
reactions. Petruschsky claims that time is wasted by this method and enough
local reaction for healing is not excited. Hamman and Wolman favor the
slower method, but do not confine themselves absolutely to it. They are
inclined to group the patients into classes of slow, intolerant or sensitive and
rapid, tolerant or insensitive. Attention is centered on the patient and not on
the dose, careful watch being kept for local, focal, and general signs of a
reaction. These signs include pain, tenderness, or swelling at the site of in-
jection, cough, expectoration, dyspnea, hemoptysis, etc., as focal symptoms
in pulmonary cases, and fever, rapid pulse, loss of weight, headache, etc., as
indicating constitutional disturbance. Fever, loss of weight, and symptoms of
general depression are regarded as most important guides for dosage. The
dose following one giving rise to a vague feeling of not being well has so often
been followed by a reaction, that stress is laid on the general feelings of the
patient. "The smallest fraction of a degree rise in temperature above the
usual maximum is looked at askance," and close watch is kept for additional
signs. Slight changes in temperature alone may sometimes be disregarded,
but any associated signs call for a repetition only or even a diminution of
the dose unless a definite, intercurrent, independent non-tuberculous cause
can be discovered.
Denys refuses to consider any temperature which does not appear within
48 hours as due to tuberculin. Hamman and Wolman have been so impressed
by the occurrence of a local reaction preceding the dose which liberates the
general reaction that they are inclined to discredit an elevation of temperature
coming suddenly in the midst of an otherwise smooth course, i. e. without a
preceding local reaction. This local reaction must be watched for with care
as it occurs alone more often than any other sign. It may consist of tender-
ness and redness only, or there may be infiltration and gland involvement.
The dose should not be increased if there is any local reaction. Indeed, even
the repetition of the dose which called forth the local reaction may cause
an undesired systemic reaction. The safer proceeding is to give a smaller
dose. Strict watch must be kept for other symptoms, as fever, increase of
pulse-rate, loss of weight, dyspnea, headache, chilliness, loss of appetite, sleep-
lessness, gastro-intestinal disturbance, etc.
Dosage. — To avoid reactions, the initial dose should be small and the tol-
erance of the patient rather than any arbitrary scheme must determine the
size of subsequent doses. In determining the initial dose, Hamman and Wol-
man divide the patients into 3 classes: (a) children, (b) patients with slight
pyrexia or not in good general condition, (c) patients with no fever and in
good general condition.
A and B receive the smaller initial doses and C the larger in the following
table. Only very rarely is there a reaction to the initial dose if this scheme
is followed.
TUBERCULIN THERAPY 219
TUBERCULIN
INITIAL DOSE
MAXIMAL DOSE
O. T
0 0000001 to 0 000001 c c
1 C C
T. R. . .
0 000001 " 0 0001
2 "
B. E
0 000001 " 0 0001 "
2 "
B. F
0 00000001 " 0 0000001 "
1 "
Beraneck's
of A/32 0 05
of H 1 "
Preparation of Tuberculins for Use. — Tuberculins are prepared for thera-
peutic and diagnostic use by dilution with 0.8 per cent, sodium chlorid solution
to which has been added 0.25 per cent, carbolic acid. The solution should be
made with pure sodium chlorid and distilled water to avoid the flocculent
precipitate which may otherwise form. Eight grams of NaCI and 2.5 c. c. of
carbolic acid are mixed with 1,100 c. c. of distilled water. This may be
distributed in 10 small flasks, 110 c. c. to each, and sterilized by boiling for
15 minutes on 2 successive days. The extra 10 c. c. allow for evaporation. For
holding the diluted tuberculin 7 small bottles or vials such as are used for vac-
cines are sterilized and numbered from 2 to 8. In each is placed 9 c. c. of salt
solution. To No. 2, 1 c. c. of tuberculin is added ; to No. 3, 1 c. c. from No. 2 ;
to No. 4, 1 c. c. from 3 and so on through the 8 bottles. The result will be :
No. 2 — 9 c. c. salt solution 1 c. c. tuberculin 10 c. c. of which 1 c. c. 0.1
3 « « « " No. 2 " " 0.01
4 « « « « 3 " " " " 0.001
5 « « « « 4 " " " " 0.0001
6 " « " " 5 " " " " 0.00001
7 « « ' « « 6 " " " " 0.000001
g « « « " 7 " " " " 0.0000001
For the sake of economy dilutions may be started with 3, using 9.9 c. c.
salt solution and 0.1 c. c. tuberculin. The result will be the same as 3 in
the table, and the succeeding dilutions may be made as before.
Method of Treatment. — Treatment is begun with the initial dose given
above. At first the interval between injections is 3 to 4 days. This period
gives ample time for the development of reactions. The interval is increased
to 1 week when the dose reaches a certain size : for O. T. at about 0.1 c. c. ; for
T. R. and B. E. at about 0.2 c. c., and for B. F. at about 0.05 c. c. If a re-
action does occur in spite of all precautions, tuberculin must be stopped until
it has completely disappeared. If reactions continue to appear with diminished
dosage, tuberculin treatment may have to be interrupted for several months.
If no symptoms of reaction develop, the dose is increased regularly. This
increase may be conveniently made with the dilutions described in the table
on this page. Beginning with dilution 8 the patient will receive 0.1 c. c.
or 0.00000001 gm. (1/100,000 mg.) for the first dose, 0.2 c. c. for the
second dose, 0.3 c. c. for the third dose, and so on until the tenth dose has
220 ADMINISTRATION OF VACCINES AND SEKA
been reached. This dose being equivalent to the first dose of dilution 7 the
latter is given instead.
It must be borne in mind that each dilution is 10 times as strong as the one imme-
diately below it. Thus 0.1 c. c. of 7 is equal to 1 c. c. of 8 and 0.2 c. c. of 7 is equal
to 2 c. c. of 8 ; therefore, the second dose of dilution 7 represents an increase 10 times
as great as has been the rule when using dilution 8.
When passing from one dilution to the next, it is wise in most cases to
repeat the first dose of the new dilution and on the next dose to give but %
the stronger dose. • If, however, the patient has been found to be possessed of
considerable tolerance, it may have been possible to increase the dosage by more
than 0.1 c. c. each time. If the patient has tolerated an increase of 0.3 or
0.5 c. c. in the weaker dilution, one may go on with the stronger dilution
without repeating the first dose.
The limit of dosage is arbitrary, the usual maximum for O. T. or B. F.
being 1 c. c. and that for B. E. or T. R. 2 c. c. There is no definite reason
why this dose should not be exceeded if indications seem to warrant it. It
has been claimed, however, by some observers that a higher limit is harmful,
and it must be admitted that the above figures express the average maximum
dose. The procedure varies when the maximum dose has been reached. Some
continue with the maximum dose at intervals of 8 to 14 days, as long as it
seems beneficial. Others interrupt the treatment for periods of 4 to 8 weeks
or even more. Again the patient is the most satisfactory guide, the chief
tendency being to continue the maximum dose as long as he seems to be bene-
fited by it. In some individuals the maximum dose may be much lower than
the figures quoted.
When the patient is being benefited by tuberculin severe reactions are absent, the
fever is favorably influenced, cough and sputum diminish, pains are lessened or dis-
appear and digestion improves.
Cutaneous reactions have been used in attempts to determine what is
the maximum optimum dose with no reliable results.
SITE OF INJECTION. — The subcutaneous tissue of the back below the angle
of the scapula is advised as the site of injection. Fewer local reactions occur
in this situation than in the arm. The subcutaneous method is recommended.
When the injection is given intramuscularly or intravenously, the impossi-
bility of observing the local effect is a handicap. The oral route is unsatis-
factory.
Results of Tuberculin Treatment.— The results obtained in adenitis, laryngi-
tis, eye affections, bone and joint involvement — operative and nonoperative —
and many other conditions have been encouraging and at times striking. The
usual hygienic therapy must be combined with the tuberculin, and all surgical
indications must be promptly met. It must always be borne in mind that
tuberculin is only an aid, although often a valuable one.
FIXATION OF COMPLEMENT 221
Diagnostic Use of Tuberculin.— For subcutaneous use for purposes of diag-
nosis, dilutions 3 and 4 of the table on page 219 are used. The generally ac-
cepted routine is to give 0.0002 c. c. (1/5 mg.) as the first dose. If no re-
action has occurred within 48 hours, 0.001 c. c. (1 mg.) is given. If after
another 48 hours no reaction has developed, 0.005 c. c. (5 mg.) are given.
Failure to react to the last dose reasonably excludes tuberculosis, but if physical
signs or local symptoms render the presence of a tuberculous lesion very
probable, a dose of 0.01 c. c. (10 mg.) may be given after another 48 hours.
Failure to react to this dose gives "added assurance" that the lesions are not
tuberculous. It is desirable that the series of injections be given as outlined
above in order to avoid the hypersensitiveness to tuberculin, which reaches its
maximum in 10 to 14 days. In average children from 8 to 14 years of age,
0.0001 c. c. may be given as the first dose, and 0.001 c. c. as the last dose, with
2 intervening graded doses. For poorly nourished children half these amounts
or less may be sufficient.
The principal phenomena of the reaction are possibly some inflammatory
reaction at site of injection, a sharp rise in temperature of varying degree,
and a fall almost equally abrupt, general malaise, chilliness, etc.
Of the other diagnostic tests for tuberculosis, von Pirquet's reaction is
produced by placing a drop of O. T. on the skin of the forearm or arm and
scarifying through it, as in vaccinating against small-pox. One or two similar
scratches without tuberculin are made in the neighborhood to act as controls.
When the reaction is positive, an area of hyperemia or infiltration of varying
extent develops at the site of inoculation within 24 to 48 hours.
The test is chiefly useful in the diagnosis of tuberculosis in children under 4 years
of age. Up to the age of 8 a positive reaction has some value, but in older children
and in adults the possibility that an old healed lesion is responsible for the reaction
renders it unreliable.
The Moro test is performed by rubbing into the skin below the clavicle on
one side about 0.1 gin. of an ointment consisting of equal parts of O. T. and
lanolin. Plain lanolin is rubbed into the opposite side as a control. In a posi-
tive reaction an area of redness, with some papular elevations, develops within
24 to 48 hours. The test is less satisfactory than von Pirquet's.
Calmette's conjunctival reaction is elicited by dropping into the eye 2
drops of a solution made by precipitating tuberculin with alcohol and dis-
solving the precipitate in water. Usually when positive it gives rise to a
mild conjunctivitis, but at times the reaction or secondary infection has been so
severe that the test has lost favor.
FIXATION OF COMPLEMENT
For the complement-fixation test the following substances are necessary.
Antigen : In testing for syphilis, antigen is prepared from either a syphi-
222 ADMIOTSTKATIOIsr OF VACCINES AND SEKA
litic liver or from- a normal heart or liver. In testing for bacterial diseases an
extract of the bacteria against which the serum is to be tested is used.
Suspected fluid: Serum from blood drawn from vein or obtained in other
way, spinal fluid, etc. Blood serum should be inactivated by exposing it to a
temperature of 56° for 30 minutes.
Serum Containing
Syphilitic Antigen Syphilitic Antibody Complement Complement Combined
I
FIG. 10.— DIAGRAM TO ILLUSTRATE THE BINDING OF COMPLEMENT WHICH TAKES PLACE ON MIXING
COMPLEMENT WITH HOMOLOGOUS ANTIGEN AND ANTIBODY. (For example, syphilitic antigen and
syphilitic serum.) No free complement present.
Complement: Usually fresh guinea pig serum.
Red blood-cells: Human or sheep cells, washed and diluted.
Hemolytic serum: Containing amboceptor against the red blood-cells em-
ployed. Usually rabbit serum.
In addition to the suspected serum there must be, where possible, as in
syphilis, sera from positive and negative cases to be used as controls.
Syphilitic Antigen Normal Serum Comp. Complement Not Combined
o zz .<a - a ns D
FIG. 11. — DIAGRAM TO ILLUSTRATE THE LACK OF COMPLEMENT BINDING WHEN COMPLEMENT is
MIXED WITH HETEROLOGOUS ANTIGEN AND ANTIBODY. (For example, syphilitic antigen and
normal serum.) Free complement present.
The fixation or deviation of complement (Bordet-Gengou phenomenon) is
dependent on the ability of a mixture of antigen, antibody (amboceptor) and
complement so to combine that when red blood-cells and serum capable of
causing hemolysis of those cells, because of its hemolytic amboceptor, are
added, the cells will not be dissolved. This is because there is no free com-
plement to combine with the hemolytic amboceptor and so activate it. The
Syph. Ant. Amb. Comp. Red Cells Hemolytic Serum
^ « NO Hemolysis
FIG. 12. — DIAGRAM TO ILLUSTRATE LACK OF HEMOLYSIS WHEN RED CELLS AND HEMOLYTIC SERUM
ARE ADDED TO MIXTURE ILLUSTRATED IN FIGURE. No free complement = no hemolysis; i. e., a
positive reaction.
complement has been fixed or deviated by the original mixture. This devia-
tion of complement in the original mixture occurs only when the antigen and
amboceptor are homologous. This may be illustrated by the Wassermann
reaction. If a mixture of syphilitic antigen, serum containing syphilitic anti-
body (amboceptor), and complement are incubated at 37° for 1 hour, the
result will be as represented in Figure 10. If the serum employed contains no
SEKUM SICKNESS 223
syphilitic antibody (is not homologous), the result will be as shown graphically
in Figure 11. If now to the mixture depicted in Figure 10 hemolytic am-
boceptor and susceptible red blood-cells are added, the result may be illus-
trated by Figure 12. Complement is necessary for the completion of hemolysis
but, there being no free complement, the hemolytic amboceptor cannot act,
there is no hemolysis, hence a positive Wassermann reaction. If red cells and
hemolytic serum are added to the mixture depicted in Figure 11, containing
Syphilitic Hemolytic
Ant. Normal Serum Comp. Red Cells Hemolytic Serum Comp. Red Cells Scrum
D
H,.moly,L~
FIG. 13. — DIAGRAM TO ILLUSTRATE OCCURRENCE OF HEMOLYSIS WHEN RED BLOOD CELLS AND HEMO-
LYTIC SERUM ARE ADDED TO MIXTURE REPRESENTED BY FIGURE. Free complement permits hem-
olysis = a negative reaction.
normal serum, not homologous, they will find free complement, and hemolysis
will occur as shown in Figure 13.
In all complement deviation tests, all reagents must undergo a preliminary
titration shortly before using to determine their strength, and the test must
be carefully controlled. Actual laboratory experience is necessary for the
proper performance of the test and for the interpretation of results. Wide
application is being made of this reaction, it being used to determine the
presence or absence of antibodies against various organisms in obscure con-
ditions.
SERUM SICKNESS
Occasionally following or even during the course of the injection of
serum, symptoms more or less alarming may develop. These include chills,
fever, sweating, cyanosis, collapse, asthmatic attacks and skin rashes. While
the above symptoms may appear shortly after the injection, serum sickness
usually develops 8 to 12 days later.
The chief symptoms which characterize the late appearing reactions are
fever and urticarial eruptions, sometimes accompanied by joint pains, rarely
by an actual arthritis.
While the above alarming phenomena may occur on the occasion of the first
injection of serum they are more prone to develop when following a first injec-
tion an interval of 12 to 40 days is allowed to elapse before a subsequent injec-
tion. This condition of sensitization has been termed anaphylaxis.
The generally accepted theory of serum sickness is that a foreign proteid,
when first introduced parenterally, is broken down very slowly. Following the
first injection of the foreign proteid, there develop a large number of free
antibodies capable of rapidly breaking down the proteid molecule. On the sec-
ond injection, these antibodies immediately attack the foreign proteid and break
it up so rapidly that toxic substances are liberated in poisonous doses. In the
224 ADMINISTRATION OF VACCINES AND SERA
unsensitized individual the process is slower and the toxic substances are pres-
ent only in small quantities. To avoid as far as possible the dangers of sensiti-
zation, injections should be made at 6-day intervals and special care must be
exercised where it is necessary to immunize persons subject to asthmatic attacks,
as they are prone to have a degree of
I sensitization. To such patients, if
time warrants, the intraderinic injec-
tion of 0.01 c. c. of serum has been
advised. If they are sensitized, a lo-
cal inflammatory zone should develop
within 24 hours.
In using sera intravenously par-
ticular care must be exercised to note
the development of any symptoms
suggesting an anaphylactic reaction.
SERUM THERAPY
Since the development of potent
sera against the toxins of diphtheria
and tetanus, numerous attempts have
been made to produce sera active
against other organisms. No defi-
nitely active sera, however, have been
produced against many of the com-
mon pathogenic organisms, as, for ex-
ample, the pneumococci and strepto-
cocci. These organisms belong to the
class producing no extracellular toxin
and sera active against, them must
have properties other than antitoxic.
It is true that sera with definite pro-
tective properties have been pro-
duced by immunizing with these organisms, but their curative value is not
great, or they may have none, particularly when directed against cases of
septicemia. Where, however, the serum may be brought in direct contact
with the organisms, as in meningitis, more definite results have been seen. The
activity of these sera seems to be due to bacteriolytic, bacteriotropic and anti-
endotoxic antibodies. A rather serious objection to their use is the absence of
any accurate method for their standardization. The method applicable to
the. standardization of antitoxins cannot be applied to the antibacterial sera.
To some extent they are standardized by the estimation of their opsonic
power.
FIG. 14. — VEINS FROM WHICH BLOOD MAY BE MOST
ADVANTAGEOUSLY DRAWN AND INTO WHICH
VACCINES AND SERA MAY BE INTRODUCED.
Where these veins are not accessible as when
covered by thick layer of fat, the veins in the
back of the hand may be entered, using a very
fine needle.
DEFENSIVE FERMENTS (ABDKIMIALDEN) 225
The dose varies from 10 to 100 c. c.
Sera are usually administered subcutaneously into the loose tissue of the
ahdominal wall or of the back between the scapulae.
At times intravenous administration may be advisable. The technic of
this proceeding is the same as that for blood-cultures. The usual site is the
median cephalic or basilic vein (Fig. 14). A tourniquet having been applied
to the upper arm, the skin is sterilized and the needle plunged into the vein
parallel to its course. The tourniquet is removed as soon as the blood entering
the syringe shows that the vein has been entered, and the serum is injected
slowly. Severe cases of undoubted streptococcus septicemia should have the
possible benefit of 1 or 2 doses of a polyvalent antistreptococcus serum. The
second dose may be given in from 4 to 8 hours. If no beneficial effect has been
apparent in 24 hours, the serum is probably not potent against the infection. If
further serum treatment is attempted, a different product should be used.
When used intraspinally for streptococcic meningitis, the technic is the same
as for meningitis due to the meningococcus, which see.
TRANSFUSION OF BLOOD
Direct transfusion of blood has been used in the hope of conferring pas-
sive immunity.
In chronic infections good results have been reported following the re-
peated transfusion of small amounts of blood at 3 to 7 day intervals. In
this condition, as in pernicious anemia, more benefit seems to be derived from
repeated small doses than from single large doses. Indeed, the latter may do
harm if very large. The amounts transfused vary from 200 to 400 c. c. at a
time. A possible field of usefulness is the transfusion of blood of a normal
person who has been vaccinated against the organism infecting the recipient.
Such a proceeding could be rationally used in cases of chronic endocarditis
with septicemia due to the Streptococcus viridans, in which condition vaccines
so far have failed.
In all conditions involving transfusion, hemolysis and agglutination tests
should be made on the blood of donor and recipient. In cases of extreme
urgency, as in hemorrhagic disease of the new born, where an immediate rela-
tive is available as donor, this may be omitted, but the effect of the transfusion
must be watched with extreme care.
DEFENSIVE FERMENTS (ABDERHALDEN)
The ability of the cells of the body to develop defenses against foreign
("disharmonious") substances has been made the subject of special investiga-
tion by Abderhalden and his co-workers. According to Abderhalden's views
these defenses are of the nature of ferments.
16
226 ADMINISTRATION OF VACCINES AND SERA
"According "to our observations there is not the slightest doubt that the animal
organism is not left without means of defense against disharmonious substances. If
such products make their way into the body, the latter sends out defensive ferments
that are directed against special kinds of substrates. Not only do they effect the
destruction of the specific character of the parenterally introduced substance by means
of an extensive decomposition, but they render possible the utilization of the products
of the decomposition in the general metabolism. The reaction we have demonstrated
enables us at any time to decide whether a certain substance is in harmony with the
body cells or not. We must distinguish not only substances that are in, or out of,
harmony with the body, but also those which are in, or out of, harmony with the blood
or its plasma, or again with the cells. The intestine, with its ferments and those of
its accessory glands, decomposes all disharmonious substances until an indifferent
mixture of only the simplest units is left; the cells of the gut walls and of the liver
carefully test the absorbed products for all substances that are out of harmony with
the body and blood. Moreover, all the cells of the body take care that nothing shall
pass from them into the circulation which has not attained a certain grade of de-
composition. For further protection, the lymph with all its complicated arrangements
is interposed between the cells of the body and the circulation. Here everything is
tested afresh and nothing is let loose into the circulation that has not been rendered
harmonious with the blood and its plasma. . . . The lymph is to be considered as
a sort of buffer between the cells of the body and those of the blood ; as a neutral zone
in which everything is assimilated as far as possible."
"If these views are correct, it should be possible to trace such substances as are in
harmony with the body, but not, with the blood and its plasma, by demonstrating defi-
nite ferments. It is quite conceivable that, in certain diseases, the cells only partially
effect the decomposition of the nutritive material and the constituents of the body,
and that to a certain extent, materials that are harmonious only with the cells are
handed on to the lymph. The lymph would do its best to correct this failure by means
of its leukocytes and lymphatic glands and would attempt to decompose some of the
disharmonious substances before they reached the blood. In many cases, however,
disharmonious material will get into the blood and produce all kinds of disturbances.
We know of at least two conditions in which disharmonious substances undoubtedly
circulate in the blood, namely, Bence-Jones's albuminuria and pregnancy."
The fact that chorionic villi had been demonstrated in the circulation
suggested the possibility that there might be present in the circulation during
pregnancy substances that were in harmony with the species but not with the
plasma. The presence of such disharmonious substances should result in
the setting free of special ferments. Experiments showed that such ferments
were constantly present and that they bore no relation to the occasional pres-
ence of chorionic villi in the circulation. Abderhalden's view is:
"The organism of the mother has at its disposal, up to the appearance of preg-
nancy, a certain amount of cells of a certain kind which all harmonize in their metabo-
lism with each other. With conception, appears an entirely new kind of tissue with
particular duties. Although the impregnated ovum and the developing placenta, with
its various cells, are in harmony with the species, the metabolism of these cells appears
as something quite new and strange to the complex of cells composing the organism of
the mother. The blood probably receives substances — perhaps also secretions — which
are out of harmony with the plasma, and remain so ; and the time is too short for the
blood to accustom itself entirely to these new kinds of substances."
DEFENSIVE FEKMENTS (ABDERHALDEN) 227
The placenta and fetus, according to this point of view, never settle down
completely within the organism of the mother. During the whole period of
pregnancy defensive ferments, which are able to reduce placenta albumin,
circulate in the blood. These ferments may be demonstrated within 8 days
after impregnation. With the expulsion of the placenta the ferments dis-
appear fairly quickly, 14 to 21 days.
Abderhalden is inclined to attribute the power of producing these fer-
ments to all the cellular elements of the blood, leukocytes, erythrocytes, and
blood platelets.
So convinced is he from his own experience of the specificity of the test
in pregnancy that he lays down the following rule to govern workers :
"No one should deal with pathological cases by means of the dialysation method
or the optical method who has not given evidence of having been able to produce 100
per cent, of correct diagnoses from pregnant and particularly non-pregnant individuals,
using placenta as his substrate. Should the technic of the student be found wanting
in this branch he has not mastered the method."
Experimental Observations. — The first experiments in support of the theory
that the organism reacted against foreign substances by the formation of
specific ferments were made with dogs and rabbits. White of egg or horse
serum was introduced either subcutaneously, intra-abdominally, or intra-
venously. Abderhalden regarded the following experiment as proving with
exceptional clearness that the plasma of an animal specially treated actually
reduces proteins. The plasma of prepared animals was mixed with white of
egg and the mixture placed in a dialysation tube. Very shortly the presence
of peptones could be demonstrated in the outer fluid by means of the biuret
reaction. When the plasma of normal animals was placed in the dialysation
tube, no substances giving the biuret reaction could be demonstrated in the
outer tube, even after several days. When the serum of specially treated
animals is mixed with albumen the nitrogenous content of the outer fluid is
considerably greater than .when the serum of normal animals and albumen
are mixed. The latter contains only nitrogen diffused from the plasma.
Methods. — In their studies Abderhalden and his co-workers used 2 meth-
ods, one a dialysation and the other an optical method.
The technic is so complicated and a strict adherence to the technic so essen-
tial to success that only an outline will be given here. For details the original
works should be consulted.
The dialysation method depends on the fact that albumen, being a colloid,
will not diffuse through animal membranes, while peptones, the first product of
the decomposition of albumen, are diffusible.
If albumen is placed in a dialysing tube and the tube placed in water, no
albumen will appear in the surrounding fluid. If peptone and hydrochloric
acid are added to the albumen in the tube, it will be digested or broken down
and the products of its digestion will appear in the surrounding fluid. These
228 ADMINISTKATION OF VACCINES AND SEKA
products consist of peptones and other simpler compounds. Similarly, if a
fluid is to be tested for proteolytic (albumen decomposing) ferments, it is
placed in a tube with albumen and the surrounding fluid investigated for
products of decomposition.
The fluid to be tested in this case is blood serum. It is obtained during
fasting by puncture of a vein in the usual manner, and the blood is allowed
to clot; the serum is separated and is then completely freed from form ele-
ments by centrifugation. It must also be free from hemoglobin, as its pres-
ence shows the destruction of red cells and possible liberation of substances
reacting with ninhydrin.
The material to be tested is either an albuminous body or a mixture of
these bodies, i. e. an organ. It is called a substrate. On its preparation de-
pends the success of the process. It must be absolutely free from blood and
must be submitted to a number of boilings to free it from substances that
react with ninhydrin.
A freshly prepared 1 per cent, solution of ninhydrin is used.
The dialysing tubes must have undergone a preliminary testing for their
impermeability to albumen and uniform permeability to the decomposites of
albumen.
In the optical method peptones are used instead of albumen; The substrates
are prepared as before but require less boiling, as substances which react with
ninhydrin do not influence rotation. Peptones are formed by hydrolysis with
H2SO4, which is later removed by barium hydroxid.
The peptones are mixed with the serum (absolutely free from hemoglobin
and cells) and any ferment action is observed in a polar iscope.
The test has been employed in various conditions with considerable diagnos-
tic success. Abderhalden urges the necessity of exhaustive investigations of
diseased conditions to support the experimentally established facts. Among
those on which work has already been done are cancer, Graves' disease, demen-
tia prsecox, and general paralysis. Eeferences to the important literature are
given in the last edition of Abderhalden's work on the subject.
CHAPTEE VII
ASPIRATION AND ASPIEATING DEVICES IN OPERATIVE SURGERY
JAMES H. KENYON
The surgical application of suction, though of very ancient origin, has been
vastly improved and widely extended during the last few years. History of
savage tribes relates the treatment of wounds from bites of poisonous snakes or
insects by suction produced by the direct application of the mouth, or through
the medium of a hollow bamboo reed. Cups, wet and dry, and the various forms
of aspirating syringes, are familiar to all.
In July, 1903, Karl Connell (5) published the description of an aspirating
bottle which he had been using for some time at the New York Hospital. A
small amount of alcohol is placed in a strong gallon bottle, shaken, ignited, and
after a few moments the stopper is quickly inserted. A clamped rubber tube
is fastened to a glass tube which projects through the stopper. To the other
end of the rubber tube is attached the aspirating needle. Of course, the amount
of suction is limited to the capacity of the bottle.
The chief advance in the surgical application of suction has been due to the
employment of an efficient, economical, and steady method of obtaining con-
tinuous suction, for hours or days if necessary, at the operative field or at the
patient's bedside. Further, to the development of safe and suitable tips or
nozzles which quickly remove the fluid material, be it thick or thin, from the
wound or sinus, without clogging the tube, sucking the tissues or producing an
injurious cupping effect.
METHODS OF PRODUCING SUCTION
Pumps. — The required suction may be produced in various ways, as by the
use of mechanical pumps — piston or rotary, operated by power, preferably a
small electric motor ; a falling column of water, or some form of the jet pump
operating on water, steam, or air, with a pressure of 20 pounds or over, may be
employed.
MECHANICAL PUMPS. — Mechanical pumps of the to-and-fro or piston type
were first made in 1654 and are very efficient. The more modern form consists
229
230
ASPIRATING DEVICES
FIG. 1. — A, FILTER PUMP; B, FILTER
PUMP IN SECTION.
of several pumps placed close together with a common shaft for their pistons,
thus giving a steady suction. Another mechanical type is the circular or rotary
pump, made on the turhine principle, a wheel with numerous blades or forms,
rapidly turning in a tight casing. All of these are driven by power, preferably
an electric motor, either with a direct shaft
connection or through the medium of a belt,
chain, or gear. Practically all of the numerous
vacuum cleaners on the market employ, effi-
ciently, one or the other of these types.
PUMPS OPERATED BY FLUIDS OR VAPOR.
— Working on the principle of the barometer,
Toricelli, Geissler, Sprengel, and Bunsen de-
vised pumps composed of tubes through which
fluid, water, or mercury was allowed to fall.
Each particle of falling fluid acted as a piston,
forcing the air out ahead of it, and producing a
negative pressure behind.
Jet pumps are so constructed that water,
air, or steam, with a pressure of 20 pounds or
over, rushes at high velocity through a narrow tube across an open space and
into another tube, slightly larger than the inlet. These two openings and the
space between them are so inclosed that the resulting negative pressure may be
utilized.
FILTER PUMP. — The filter pump (Fig. 1), so-called from its employment in
the chemical laboratory to hasten the filtering of chemicals, is made in different
styles and sizes, of which the medium size,
Chapman, is the best. This has two fittings,
one, threaded, that may be screwed on to
the hydrant or faucet similar to the attach-
ment of a garden hose, the other, a rubber-
lined ring that will slip on a faucet. These
are made and sold by the large chemical
supply houses.
EJECTOR. — Another jet pump, known
as an ejector (Fig. 2), is of similar con-
struction to the injector which is employed
to force water into a boiler. Of these the
best type is the Hayden Derby or H. D.
Model C., No. 1 or No. 2. These operate
very well with water or steam having a
pressure of 20 pounds or over.
For use in the operating-room the full
strength of the suction is desirable, but this may be controlled by regulating the
amount or pressure of water or steam, flowing through the apparatus. Or it
FIG. 2. — A, STEAM EJECTOR; B, STEAM
EJECTOR IN SECTION; a, inlet; b, out-
let; c, suction.
METHODS OF PKODUCING SUCTION
231
may be controlled by having an opening in the tube very near the nozzle. Air
rushes into this opening and prevents any suction at the tip until the operator
closes it with his finger. This is better than a valve, but neither is necessary.
The II. D. Ejector Model C. ~No. 1 has been used continuously at the Xew
York Hospital since 1906 and has been found to be most efficient. It may be
permanently connected with the high pressure steam-pipe in the operating-
room, one valve on the inlet being all that is necessary. The outlet, or exhaust,
may be carried to some convenient flue or chimney or out of the window, the
essential point being to have no back pressure. The ejector may be connected
with the water pipe, with the outlet running into the sink. For simplicity,
FIG. 3.— METHOD OF CONNECTING THE EJECTOB WITH THE WATER PIPE AND THE SUCTION BOTTLE AND
TUBE WITH THE OPERATIVE FIELD.
with no moving parts to get out of order, for heavy continuous service every day,
and for efficiency, the preference is to be given to the ejector and the filter
pump.
Methods of Obtaining Suction in Private Houses. — For operations in hos-
pitals or private houses not equipped with the suction outfit one of the filter
pumps can be readily and quickly attached to some near-by faucet over wash
basin or bath tub, from which a generous length of stiff tubing — 10 to 60 feet
or even more — will bring the suction to the place desired.
A small electric motor and pump, or an improvised fitting on a vacuum
cleaner, may be employed.
If the water pressure is too low and the room happens to be one or more
stories up, the filter pump is connected to the faucet in the usual manner, but
on the outlet a rubber tube 30 feet long is fastened, the other end of this tube
232 ASPIRATING DEVICES
hanging out of the window or down the staircase to the sink on the floor below.
This falling column of water, 30 feet or more, produces the required suction.
Connections Between Suction Pump and the Wound. — The suction pipe is
connected with a gallon bottle (Fig. 3) under or near the operating-table by a
stiff non-collapsible rubber tube or, what is better, a tube composed of rubber
and fabric known to the trade as pressure hose. From a connecting tube in the
stopper of this bottle a tube 5 or 6 feet in length is led to the operative field.
This tube may be smaller than the other but should be fairly stiff and not easily
collapsed. This short tube, with the appropriate nozzle, is boiled with the in-
struments whenever its use is anticipated. The large bottle is emptied and
thoroughly cleansed between operations, but not necessarily sterilized, as noth-
ing passes from it toward the wound. The tube from the suction pipe to the
bottle is never contaminated unless the bottle upsets, or becomes too full, and
its contents are sucked over.
For the special use of the anesthetist to remove secretions from the pharynx
another smaller tube is led from the bottle to his end of the table. There is
generally enough excess negative pressure in the bottle to permit these 2 tubes
to be used at the same time, but if for any reason there is not, one or the other
must be temporarily clamped off.
Care and Cleaning of Apparatus. — During the operation the nozzle should
be occasionally immersed in a basin of cold sterile water to remove from its
interior blood and pus that might otherwise dry, clot, and occlude its lumen.
At the conclusion of the operation the tube is cleaned by permitting it to suck
up soap suds followed by hot water and bichlorid, after which the tube is soaked
in bichlorid, boiled, or sterilized in the steam sterilizer.
When and Where the Method Was Introduced.— This method was first intro-
duced by tlje author during the service of the late Dr. Frank Hartley at the New York
Hospital in April, 1906. About the same time George Laurens (15) published the
description of a mastoid operation, during which suction was obtained by a filter
pump, employed to keep the operative field clear of blood and pus. The first cases on
which it was used were operations for the removal of the Gasserian ganglion for
trifacial neuralgia, the chief object being to give a clear operative field by removing
the excess of blood and cerebrospinal fluid, thereby greatly diminishing the amount
of sponging necessary and facilitating and shortening the operation. The conditions
arising in this operation, namely, a deep opening with a bony wall on one side and
the firm dura, partially covered by a broad brain retractor on the other, were such
that the simplest type of nozzle was the best.
Tips or Nozzles. — Specially constructed tips or nozzles have been devised
to meet the requirements of the various operative conditions, dependent upon
the region and the lesion.
TIPS MADE OF A SINGLE TUBE. — Figure 4 shows one of this kind, merely
a small metal tube about 3 to 5 mm. (i/8 to 1/5 inch) in diameter; 15 to 20
cm. (6 to 8 inches) long; made of soft malleable copper or aluminum, which
may readily be bent to suit the depth of the wound. This is held by the as-
METHODS OF PRODUCING SUCTION
233
sistant so that the tip is near the bottom of the wound, either in the anterior or
posterior corner, so as not to obstruct the operative field. From time to time, as
occasion requires, the tip is lightly and quickly brushed over the part obscured
by blood or cerebrospinal fluid.
The principle of this simple, single, soft metal tube, open on the end, can be
applied wherever the soft parts can be protected from the cupping action.
TIPS OB NOZZLES COMPOSED OF A DOUBLE TUBE. — For general use, and
particularly in the abdomen, Figure 5 shows the appropriate form of a double
tube designed by E. H. Pool
(11). This consists of an.
inner suction tube open on
the end or provided with 2
side openings very near the
end, the other end of which
has a coarse screw thread
conical in shape for the rub-
ber tubing. The outer pro-
tecting tube is slightly larger
than the inner and is pro-
vided with many perfora-
tions in its lower half and
several larger openings near
its outer end. This screws
into a collar fastened to the
smaller tube. This sievelike
outer tube forms a well into
which the fluid settles to be
sucked out by the inner tube.
The holes near the outer end,
so placed that the operator's
hand cannot occlude them,
of
FIG. 4. — SUCTION TUBES. No. 1. — Double tube for abdom-
inal work with extra irrigating tube. No. 2. — Double tube
for abdominal work. No. 3. — Double tube for abdominal
work. No. 4. — Small single tube of soft metal. No. 5. —
Double tube for mouth and pharynx.
permit an inrush o ar
which passes down in the
space between the 2 tubes to
the end of the inner one, and
thus prevents the formation
of a vacuum or any cupping action on the surrounding tissues. This tube may
be inserted anywhere in the abdomen regardless of the omentum or intestines and
without danger of damaging them. Figure 4, No. 1, shows the earlier form of
this tube which was provided with an irrigating tube so that irrigation and
aspiration could be employed simultaneously. When irrigation is desired it is
probably better to introduce the ordinary glass irrigating tip, either by the side
of the suction tube or at some more distant point, in which case the irrigating
fluid has a more extended action.
234
ASPIRATING DEVICES
Sfoooooooooooooooooooooooo
3)3
FIG. 5. — DOUBLE SUCTION TUBES. Same as those in Figure 4 taken apart to show construction.
Figure 4, No. 3, shows improvised double tubes of glass. The outer tube is
a perforated glass drainage tube and the inner a small glass tube open only on
the end.
Figure 6, No. 1, shows a simple method of constructing a double tube suit-
FIG. 6. — DOUBLE TUBES FOR CONTINUOUS SUCTION IN POSTOPERATIVE TREATMENT. Nos. 1 and 2. —
Double rubber tubes. Nos. 3 and 4. — Double metal tubes: a, the inner tube which by turning
half way round may be removed from the outer tube; b, thin, flexible metal strip which may be
bent to fit the curve of the body.
USES AND ADVANTAGES OF CONTINUOUS SUCTION 235
able for removing pus, blood, or other fluid from the abdomen or any cavity
with surrounding soft parts." The outer tube of rubber, about 15 mm. (3/5
inch) in diameter, and 15 cm. to 20 cm. (6 to 8 inches) long, is fenestrated
on every side with numerous small openings. Another rubber tube about 8
mm. (% inch) in diameter arid 23 to 25 cm. (9 to 10 inches) long, with
only the end opening, is fitted with a snug rubber cuff which has a
projecting side. The small tube is inserted in the larger and the cuff fast-
ened to the larger by a safety pin. By firmly holding the cuff the inner
tube may be slipped through it inward or outward so that its open end is
about 1.5 to 2 cm. (3/5 to 4/5 inch) distant from the end of the outer
tube.
TIP FOE MOUTH AND PHARYNX. — Figures 4 and 5, Nos. 5 and 6, show
a tip designed by Dr. George M. Creevey for use in the mouth and pharynx to
remove mucus, saliva, and blood during anesthesia or operations around the
nasopharynx. It consists of a small, short tube, open on the end, near the other
end of which is a threaded collar, and beyond this a flange for attaching a rub-
ber tube. A slightly larger metal cap with many perforations slips over this
tip and screws on to the collar.
TIP TO BE USED AS A RETRACTOR, — Any of the single tubes that are not
too small, as from 1 to 3 cm. (2/5 to 1 1/5 inches) in diameter, may be used
as a retractor on soft friable tissue to facilitate its removal. The strength of
vacuum is sufficient to hold small masses of tissue or foreign bodies so that the
cupping action of these various tips may be utilized. Fedor Krause has de-
vised cupping tips of various sizes and shapes to be used only as retractors,
applied directly to the soft friable tumor mass or to a cyst wall. He has used
them in this manner in the removal of brain tumors. They may also be used
to remove such bodies as renal, vesical, and biliary calculi, and foreign bodies
from nose or ear.
USES AND ADVANTAGES OP CONTINUOUS SUCTION
The advantages of continuous suction during an operation may be enu-
merated as follows :
(1) Infectious material is removed quickly with little or no soiling of the
surrounding tissues, thereby lessening the danger of spreading the infection.
(2) Less trauma, less sponging, therefore less hemorrhage.
(3) Shortens the time of operation.
(4) It gives a clear, clean operative field by removing saliva, mucus,
blood, pus, bile, urine, cystic fluid, or irrigating fluid.
(5) It furnishes a retractor on soft friable tissue in which a volsellum or
tumor forceps would tear out, or on a deep inaccessible structure where a
clamp or forceps would darken and obscure the operative field.
(6) It furnishes a ready means of removing foreign bodies from any of
236 ASPIRATING DEVICES
the tracts communicating with the exterior of the body or from deep wounds or
cavities.
(7) It aids the anesthetist in removing mucus, saliva, blood, pus, etc.,
from the nasopharynx, thus doing away with the irritative throat sponging
which oftentimes increases the material one is trying to remove. This rapid
removal of such material lessens the danger of inhalation pneumonia.
(8) It decreases the amount of gauze required for sponging and the num-
ber of pads and towels that have to be laundered, and at the end of a year will
be found to have been an economical feature in hospital management.
(9) It lessens the soiling of the operating-table and the operating-room.
(10) Its application to the sterilizer removes the steam and prevents its
escape into the room.
APPLICATION TO VARIOUS PARTS OF THE BODY
Head. — During operations on the scalp there is no particular need for suc-
tion, but in intracranial procedures it is most useful. For exploring the brain,
either before or after opening the dura, or for tapping the ventricle, the blunt-
pointed hollow needle of 1 or 2 mm. (1/25 to 2/25 inch) in diameter, with two
side openings near the end, is inserted to the desired depth. Its outer end is
connected to the suction bottle with a small rubber tube, which is cut across
about 4 to 8 cm. (1 3/5 to 3 1/5 inches) from the needle and a short glass con-
necting tube inserted to render visible the material aspirated. To control the
amount of suction accurately this tubing should have a hole in it, which re-
mains open and sidetracks the suction until the operator closes it with his
thumb or finger. If it is desired to save the material aspirated a small steri-
lized suction bottle of 1 to 2-ounce capacity may be connected with the tube
near the needle. The advantage of this method is that any degree of suction
may be maintained steadily or intermittently both during the insertion and
removal of the needle, without the irregular jerk or slip that so often accom-
panies the pulling out of the piston of an aspirating syringe. As an adjunct to
sponging, to produce a clean operative field, the plain tip of soft malleable
metal 3 to 5 mm. in diameter (3/25 to 5/25 inch), bent to the suitable curve,
may be used.
This is particularly valuable when a cortical or subcortical lesion is being
exposed by the aid of the brain retractors, or where the brain is being retracted
and a clear field at the bottom of one of the cranial fossa? is desired.
Examples of these conditions are cortical or subcortical tumors, cysts or
abscesses, intracranial neurectomies, as division of the second or third branch
of the fifth nerve, or the sensory part of the seventh nerve. It is of very great
aid in the removal of the Gasserian ganglion or the division of its sensory root,
as it quickly and easily removes, without trauma to the surrounding structures,
the cerebrospinal fluid and blood which obscure the operator's view.
USES AND ADVANTAGES OF CONTINUOUS SUCTION 237
Spinal Cord. — Aspirating is extremely valuable as an aid to sponging in all
operations on the spinal cord. The soft metal tube which can be bent is the
appropriate tip. This is placed in the lower corner of the wound toward which
the cerebrospinal fluid gravitates. The tip is held parallel to the cord and a
slight distance from it, so that there is no danger of injuring the cord.
By this means the field is kept constantly clear with the minimum amount
of manipulation and sponging of the delicate cord tissues. If a tumor or cyst
is found in the cord or in the surrounding structures, its contents may be
emptied. The cyst wall or the tumor can then be drawn up with the cup-
ping tip and its removal hastened. Much less sponging is necessary, the time of
operation is shortened, and the ease and accuracy of the dissection favored.
Mastoid Region. — A small malleable tip 3 mm. (3/25 inch) in diameter is
of service in mastoid operations and also in operations on any of the accessory
sinuses. With an assistant manipulating the suction tube, the operator can
work more steadily with fewer intermissions than ace necessitated by frequent
sponging. It has the same advantages in operations on the accessory sinuses
as in any deep cavity.
Mouth and Pharynx. — The dissection of the tonsil is facilitated by this
method of removing blood and mouth secretions. All the operations on the
tongue, nasopharynx, and larynx are made easier and the danger of inhalation
pneumonia lessened by the rapid removal of blood, mucus, and saliva. Even if
the intratracheal method of anesthesia is employed the addition of the suction
renders a cleaner and clearer field possible. For cleft-palate and harelip opera-
tions a small catheter makes a very useful tip. It may be used intermittently to
clear out the pharynx or it may be inserted in one nostril with the eye of the
catheter just below the uvula, and the suction attached continuously or at in-
tervals. In the former case care should be taken that the opening in the
catheter does not become occluded with tissue or blood.
During esophagoscopy and broiichoscopy a long tube, either metal or rubber,
smaller in diameter than the bronchoscope, may be inserted down it to remove
secretions. With a suitable tip certain foreign bodies may be cupped, and
drawn up through the instrument or drawn against its end and everything re-
moved at once. Foreign bodies in the nares, pharynx, or in the external audi-
tory canal may be thus cupped and removed.
Thorax. — Operations on the heart or pericardium, where speed, minimum
trauma, and a clear operative field are most important, may be facilitated by
the employment of suction. Suction is also of considerable aid in operations on
the pleura or lung, either with the cabinet or the intratracheal method, where
the work is being done in a deep cavity which renders sponging difficult and
slow. It is especially useful in sacculated empyema, interlobular abscess, or
abscess in the lung. A subdiaphragmatic abscess that has been approached by
going through the pleural cavity may be aspirated absolutely dry — thus lessen-
ing the danger of infecting the thorax.
Abdomen. — Liver abscess or ecchinococcus cysts are quickly emptied with
238 ASPIRATING DEVICES
diminished danger of spreading the process. The daughter cysts are sucked out
intact, the cyst wall is drawn up into an appropriate cupping tip, and its sub-
sequent removal made easier.
Gall-bladder and Ducts.— The distended gall-bladder may be quickly emptied
without any soiling of the surrounding parts, and after it is widely opened for
the removal of calculi it may be kept free from bile, thus favoring a thorough
inspection of its interior for other calculi and for evidence of its condition
which will decide the question of its being left or removed. Incision in the
common duct is made in a good visual field, free from blood and bile, and
exploration of the ducts is more easily performed. Small calculi in the common
duct or, perhaps, some distance up in the hepatic duct, may be cupped and
pulled out. Cases of ruptured gall-bladder are quickly relieved of the extrava-
sated fluid.
Stomach. — Extravasated stomach contents from ruptured stomach or per-
forated ulcer are easily removed with less shock and irritation than would
follow sponging or washing. Suction forms a very valuable aid to inspection
of the interior of the stomach through an incision in its anterior wall, as by this
means mucus and gastric contents may be removed, preventing their escape
and subsequent soiling of the peritoneum, and also giving a clearer field.
Intra-abdominal Conditions. — In intra-abdominal hemorrhage from any
cause, as a ruptured ectopic pregnancy, ruptured spleen, liver, or vessels from
penetrating wounds, etc., a rapid mopping out of the larger clots with aspira-
tion of the fluid blood greatly hastens the search for and the control of the
bleeding structure.
When the contents of any hollow viscus have escaped into the abdomen their
removal and the search for the rent are greatly facilitated. Inflammatory exu-
dates in the peritoneal cavity are easily and quickly removed with less peritoneal
trauma than accompanies sponging. Suction has been particularly valuable in
removing the pus of an appendix abscess, and furnishes a clearer field for the sub-
sequent removal of the appendix. It has a similar function in the operative treat-
ment of pyosalpinx.
In general peritonitis and tuberculous peritonitis the exudates are quickly
removed and ascitic fluids quickly aspirated without trauma.
Cysts of every description are quickly emptied of all their contents, thus
favoring their removal through a much smaller incision than would otherwise
be required.
G-enito-urinary Tract. — Operations on the bladder, particularly the removal
of tumors by the transperitoneal method, are performed in a clearer field with
more exactness and less soiling of the abdominal contents with urine. With the
suction tip the urine and blood are removed as fast as they appear. This
facilitates the removal of the growth or the transplantation of the ureter, should
these procedures be necessary. In prostatectomy the suction aids in removing
urine, blood clots, and the fluid used in irrigating. The patient is kept far
drier than by the older methods of treatment. Realizing the age of these pa-
CONTINUOUS SUCTION 239
tients and the risks of pneumonia from exposure, damp garments, and unneces-
sary manipulation, any procedure which aims to minimize these risks assumes
the utmost importance. In operations on the kidney aspiration is useful in
removing collections of pus or urine around the kidney, as, for example, a
perinephritic abscess, hydronephrosis, and pyonephrosis. A tuberculous kid-
ney, in which the parenchyma has been replaced by caseous material and the
capsule only is left, may be completely emptied through an aspirating needle.
Or, better still, a small incision in the capsule may be made through which the
suitable suction tip may be passed. This procedure so reduces the size of the
structure which is being operated upon that a comparatively small skin incision
will suffice for the subsequent steps of the operation, drainage, or nephrectomy.
The use of suction renders operations on cysts or abscesses in any part of
the body much easier for the operator, of shorter duration, and therefore easier
for the patient. There is also far less soiling of the operating-table and room.
CONTINUOUS SUCTION AND ITS POSTOPERATIVE APPLICATION
For this purpose the suction may be obtained by employing any of the
methods already mentioned, although it is more economical to use water in-
stead of steam.
For use in the wards the suction is obtained from the most convenient water
supply, generally in the adjoining wash-room. A small quarter-inch iron pipe
is laid from the source of the suction along the baseboard behind 3 or 4 beds,
as required, with a stop cock and hose connection opposite each bed. A few feet
of stiff rubber tubing lead from this hose connection to the suction bottle under
the bed. The tubing from the bottle to the wound may be smaller in diameter
but fairly stiff and long enough to permit the patient to turn without disturbing
its attachment to the tip in the wound. For this reason it is well to have this
extra length resting in the bed. This tubing should be sterilized before using it.
The bottle may be of any convenient size, pint, quart, or gallon, fitted with
a tight rubber or cork stopper, through which pass 2 metal or glass tubes, 5 to 8
mm. (1/5 to 1/3 inch) in diameter, with a right angle bend, so that the rubber
tubes, dropping down, will not kink. These tubes project a short distance
through the stopper into the bottle, 2.5 cm. (1 inch) for one, and 5 cm. (2
inches) for the other. The shorter is connected with the suction, the longer one
with the tube from the wound. By this arrangement the wound secretions are
prevented from fouling the suction pipe. The bottle should be empty when
first used, so that a record may be kept from time to time of the amount ob-
tained.
The application of the suction tube to the region to be drained must be such
that no vacuum will be formed in the wound and no cupping action exerted on
the surrounding soft parts. This result is obtained by using a double tube.
The outer one is fenestrated and of such a diameter and length as to fit the
240 ASPIRATING DEVICES
sinus or wound to be drained ; the inner one, with only an end opening or two
small side openings very near the end, must be smaller in diameter so as to
permit free circulation of air between the tubes, and thus prevent a vacuum.
The inner tube must not extend into the wound as far as the outer by 1 to 2 cm.
(2/5 to 4/5 inch). (Fig. 6, Nos. 1 and 2.)
These two tubes may be held in their proper relative position by transfixing
both of them with a large safety pin. This pin, with a split gauze pad under it
and a couple of long, narrow adhesive straps over it, serves to anchor the tubes
in the wound. The objection to this arrangement is that it may be undesirable
to change the outer tube for some time, whereas the inner tube may require
frequent removal for cleansing. This would necessitate the removal and rein-
sertion of the safety pin with probable leakage at the punctures. A further
objection is that the pin obstructs, more or less, the lumen of the suction tube
and predisposes to its subsequent blockage. To obviate these objections a better
method is to slip on the inner tube a snugly fitting rubber cuff about 1 cm. (2/5
inch) wide with a prolongation on one side about 2 cm. (4/5 inch) long. This
tongue extends down on the outer side of the larger tube and is fastened to it by
the safety pin. This double tube arrangement is sterilized before being in-
serted in the wound.
Utilizing the same principle, I have devised double metal tubes (Eig. 6,
~Nos. 3 and 4) of various lengths and diameters which are more easy of applica-
tion and more readily removed for cleansing.
The varied conditions for which this method of continuous suction is de-
sirable readily suggest themselves. Eor example, any deep wound with difficult
uphill drainage, where the patient is constantly suffering from wound absorp-
tion ; all cases where the discharge is irritating to the surrounding skin, as fecal
fistulse, pancreatic wounds, etc. ; cases in which the discharge is very profuse
and the patient is made uncomfortable by being continually wet or is annoyed
by frequent dressings.
There are many cases in which the suction is most valuable during the
dressing of the wound to remove thoroughly the infectious material from the
depth of the wound. If irrigation is being employed, the fluid may be sucked
up and carried into the bottle before it runs over and soils the patient's skin
and bedding.
APPLICATIONS TO THE VARIOUS REGIONS OF THE BODY
Head. — Infections of the scalp can generally be drained sufficiently by mak-
ing good generous incisions in the most dependent part, but in a similar condi-
tion on the face where the resulting scar would be objectionable, a small incision,
if supplied with the double suction tubes, suction being applied continuously
or intermittently, will be sufficient.
In infection in the accessory sinuses of the nose, frontal, sphenoidal, and
maxillary antrum, otitis media with discharge, suppurating wound following
CONTINUOUS SUCTION
mastoid operation the secretions may be removed without much discomfort to
the patient by employing a single rubber or metal tube of suitable size and
length to which the suction is applied intermittently. Here again the combina-
tion with syringing and irrigation is very effective.
Abscess in the brain has been treated with rather poor results because of the
difficulty of securing good drainage. The proper application of the suction will
be of great value by keeping the drainage tract open and at the same time com-
pletely removing the broken down material from the depth of the abscess with-
out trauma to the brain.
Mouth and Pharynx. — All operative procedures around the mouth, pharynx,
and larynx, as removal of tumors of the tongue, cheek, tonsil, or larynx, and in-
cisions for quinsy or retropharyngeal abscess are attended with considerable
risk of inhalation pneumonia. The employment of suction during the operation
and, more or less continuously, during the convalescence has greatly lessened
this danger. It has added much to the patient's comfort by relieving him of
the painful and frequent swallowing efforts which follow these operations. The
injurious mouth and wound secretions are, therefore, not swallowed and do not
accumulate in the stomach with the subsequent bad effects from absorption.
The short double tip shown in Figure 4, No. 5, is very serviceable for this
purpose. It may be left in the mouth the greater part of the time, or removed
and inserted as required. It is particularly useful in removing the fluid used
as a mouth wash or gargle, saving the patient the effort of expectorating it.
Thorax. — Suction obtained in the above mentioned manner is most valuable
for aspirating fluid from the pleural cavity or from the pericardium. Its advan-
tage over the more commonly used methods is that the suction is steady, may be
continued for any length of time, and is easily controlled without the jerky char-
acter peculiar to the small aspirating syringe. The .drainage of the pleural
cavity is markedly favored by a moderate degree of negative pressure. Too
much suction is bad and may cause bleeding and cupping of the tissues.
By the use of a double tube one can completely remove the pus without cup-
ping the tissues and convert a very disagreeable foul-smelling dressing into a
simple clean one, as most of the discharge is collected in the bottle instead of in
the gauze over the wound.
This form of drainage, though excellent and many times better than the
ordinary short tubes opening into the dressing, has the same objection as the
tubes, in that the lung is not relieved of the atmospheric pressure and, as a
result, cannot expand as it should.
Dr. George E. Brewer has devised a short rubber tube with a flange which
makes an air-tight fit in the chest opening. This tube is firmly held in place
by strips of zinc oxid adhesive plaster. The opening in this tube has a slight
taper from without inward. Into this tapering tube another similarly shaped
tube fits snugly so that there is no leakage. This tube is long enough to extend
down to a bottle tinder the bed. From this bottle another tube leads to the suc-
tion apparatus, the suction of which must be very weak.
17
242
ASPIRATING DEVICES
For this particular purpose Karl Connell has made a very ingenious appli-
cation of the Sprengel pump, in which a small amount of water (a few drops
at a time) drips from a reservoir and flows through a long, narrow tube bent
in a circle in its upper portion. The length of the vertical fall below the circle,
together with the amount of water flowing through it, governs the amount of
suction.
KENYON'S METHOD.— In order to establish thorough drainage of the pleural
cavity without disturbing the normal pressure relations on the lung surface and in
the air vesicles, I (10) devised a simple method which was first used at the Babies' Hos-
pital in 1910. (Fig. Y.)
The drainage tube consists of fairly stiff rubber, 5 mm. (1/5 inch inside
diameter), the wall about 2 mm. (2/25 inch) thick, and about 1 m. (1 yard)
FIG. 7.— METHOD OF CONNECTING LONG TUBE FROM PLEURAL CAVITY TO BOTTLE CONTAINING
STERILE WATER. This method may be used in empyema and pneumothorax.
long. Near one end of the tube a small window is cut, and over this end a
tightly fitting cuff of a slightly larger tube, about 8 mm. (8/25 inch) inside
diameter, is slipped, leaving about 2.5 to 4 cm. (1 to 1 3/5 inches) protruding-
just enough to penetrate the chest wall. A piece of tape 10 cm. to 15 cm. (4
to 6 inches) long with a hole, preferably buttonhole stitched, in its center,
CONTINUOUS SUCTION 243
is threaded over the tube down to the cuff, which prevents it from
slipping.
This rubber tube is connected with a glass tube, which passes through
a stopper down to the bottom of a bottle of about 500 c. c. capacity.
Through the stopper there is another short tube, making a device similar
to the "wash bottle" used in the chemical laboratory. A notch in the side
of the stopper will serve the purpose of admitting air as well as this second
tube.
The bottle, stopper, tube, and tape are sterilized either by boiling or in the
steam sterilizer. This sterile bottle is then filled to one-quarter or one-third of
its capacity with warm sterile salt solution or sterile water, and the stopper
inserted.
The method of inserting this tube into the pleural cavity is as follows:
After the operative field has been painted with tincture of iodin, the aspirating
needle is inserted to locate the pus. Novocain anesthesia in the skin surround-
ing the aspirating needle, which is left in position, or a light ether anesthesia
may be employed before anything further is done.
A narrow bladed knife is inserted along the side of the needle, between it
and the upper margin of the rib below, until it penetrates the pleural cavity.
With the knife in this position, a short incision parallel to the rib is made, the
knife is then withdrawn and an artery clamp inserted. The needle, which up
to this time has acted as a guide, is now withdrawn, and the artery clainp opened
to stretch the opening just enough to admit of the tube being crowded in. The
tube makes an air-tight fit with this opening and cannot slip further in because
of the rubber cuff, and cannot slip out because the buttonholed tape, which is
fastened to the chest wall with adhesive plaster, firmly holds the outer edge of
the cuff. A small split gauze pad surrounds the tube and completes the
dressing.
The other end of this tube, as mentioned before, is connected with the
bottle which is placed on the floor or suspended under the bed. The fluid in
the bottle moves up and down in the tube with the respiratory movements. The
pus from the pleural cavity runs down the tube and mixes with the fluid in the
bottle.
If the discharge is very thick and it is desirable to thin it or to irrigate the
pleural cavity, the bottle is elevated to the level of the chest or slightly higher
and tilted over somewhat. This causes the warm sterile water or salt solution
to run from the bottle into the chest, and when the bottle is lowered the fluid,
mixed with the pleural exudate, runs back again into it. When the fluid does
not move up and down in the tube during respiration or when the small dressing
becomes soiled it means usually that the tube is blocked. It is well to have a
duplicate set of tubes and bottle sterilized so that a complete change may be
quickly made.
The fluid in the bottle is renewed as often as necessary, perhaps every 2 or
3 hours, or possibly only two or three times a day. Before changing the fluid it
244 ASPIRATING DEVICES
is well to put a clamp on the tube and also to avoid touching or contaminating
the stopper and that portion of the tube which is within the bottle.
When for several days there has been little if any discharge in the bottle,
with a normal temperature and pulse, the tube is completely removed and the
opening in the chest wall closed with adhesive plaster. In a few cases there
may be after this a return of fever, increased pulse rate, and physical signs
of fluid in the chest, necessitating a reintroduction of the tube for a time. The
above method has been most satisfactory for very young children — from a few
months to 2 years old.
For older children, for adults, or for cases with large masses of fibrin or
dense adhesions that should be removed or broken up, the ordinary method of
rib resection must be employed, but even in these cases the same principle may
be used. Here, of course, the opening must be sutured down so as tightly to
surround the tube, and a somewhat larger tube used after completing the intra-
thoracic manipulations.
The advantages of this method are:
(1) A simple operation, easy to perform.
(2) No shock, due to the simple, quick operative procedure, to the slow escape of
pus and subsequent gradual change of intrathoracic pressure, and to the absence of
pneumothorax.
(3) The single gauze dressing which does not require frequent changing, as there
is practically no leakage around the tube. This greatly lessens the danger of serious
and often fatal mixed infection of the pleura.
(4) Convalescence is much shorter.
(5) Patients are far more comfortable.
(6) This method is particularly applicable to young children, where with the
older methods, as is well known, the mortality is alarmingly high.
(7) Drainage is very efficient, as the discharge is continually thinned and diluted
by mixing with the warm sterile salt solution.
This method seems to be ideal for the treatment of pneumothorax, whether patho-
logical or traumatic. The steps of the operation are just as described. The respiratory
movements force the air from the pleural cavity down through the tube to escape at its
lower end and bubble up through the sterile water. A column of water now ascends
in the tube a varying distance, thus preventing any air entering through the tube.
The intense dyspnea and cyanosis which accompany these traumatic cases are in-
stantly relieved and the lung is enabled to work under nearly normal conditions until
nature or some operative intervention repairs the damage. This method is very satis-
factory for use in any operation in the thorax performed with the aid of the intra-
tracheal insufflation or the cabinet, where it is desired to drain for a short time. If
both pleural cavities have been opened, they may both be drained in this manner
without any danger of the lung collapsing.
Abdomen. — Continuous suction may be applied to various conditions in the
abdomen, as has been demonstrated in cases of the following conditions : abscess
under the diaphragm or in the liver ; echinococcus cysts ; gall-bladder drainage
or sinus leading down to the biliary ducts ; wounds following operations on the
pancreas ; intra-abdominal abscess from any cause ; appendicitis ; diverticulitis ;
CONTINUOUS SUCTION 245
or salpingitis. A deep-seated abscess in the pelvis from an appendix, fallopian
tube, ruptured bladder, or fractured pelvic bone is particularly amenable to
suction. The double tubes with the continuous suction keep the wound clear
down to the very bottom, lessen absorption, and favor the healing. The dis-
charge is in this way prevented from coming in contact with the skin — which
condition usually gives rise to a troublesome dermatitis. This is particularly
important in fecal fistulse and in sinuses discharging bile, pancreatic secretion,
or urine.
Some quite remarkable results have been obtained in the treatment of fecal
fistula?, where the irritating discharge has produced a most acute eczematous
condition over a large area of the abdominal skin which did not respond to any
treatment and, from its intense irritation, kept the patient in a wretched con-
dition. The application of the short double tubes which penetrated the wound
only a few centimeters or really rested in the depression of the wound served
to collect all the discharge as soon as it appeared and to convey it to the bottle.
The skin condition rapidly cleared up in a few days, the general health im-
proved correspondingly, and, with strapping, the fistula healed.
When one desires to heal an opening in a hollow viscus, as the gall-bladder,
urinary bladder, or the intestines, the short double tube which merely pene-
trates the skin and subcutaneous tissue should be employed. This in no way
hinders nature's attempts at repair. The patient's comfort is greatly increased
and his rest undisturbed by eliminating the frequent dressings which are
generally required in the cases in which the discharge is profuse or offen-
sive.
In suprapubic prostatectomy the bladder is often drained by means of a
good-sized rubber tube tightly sutured in the wound by 2 or 3 purse string
sutures or 2 or 3 rows of linear sutures. This tube is carried over the side of
the bed into a bottle. This method is quite satisfactory and does not require
suction, but it is necessary that the sutures be water-tight, and great care must
be taken that the tube does not become occluded with blood clots. When, after
some days, this tube is removed, there is for some time considerable leakage of
urine. This makes the patient most uncomfortable, particularly at night, as the
frequent changing of the pads disturbs his rest. All this may be avoided by
inserting a small, short, double tube as soon as the original one is removed,
strapping the wound around it and applying the suction. This does not neces-
sarily confine the patient to the bed, as, with a sufficient length of tubing, he
may be up and around the room — yet absolutely dry. The double tube with
the suction may be employed from the first. In this case the larger outer tube,
either rubber or metal, should have only the end opening without any side
windows. It should extend some distance into the bladder, about half-way down
to the region from which the prostate was removed. This tube is sutured in
place as described above, and within it is placed the smaller suction tube. This
inner one should be large enough, however, to remove the clots.
By means of this suction the bladder never becomes more than half full,
246 ASPIRATING DEVICES
with the result that there is no pressure on the suture line, and consequently a
more rapid and firmer union.
This is especially important where there has been an extensive suturing of
the bladder after the removal of a tumor or from a rupture of the vesical wall
or where the ureter has been transplanted. In all these cases a comparatively
empty bladder favors a more rapid and stronger healing.
USE IN PRODUCTION OF HYPEREMIA
Another use for suction obtained in this manner is its application to the
various cups and apparatus designed by Bier for the production of hyperemia.
These may be exhausted to any degree of vacuum desired and, if provided with
a stop cock, several may be employed at the same time.
BIBLIOGEAPHY
1. BIER. Hyperemic Treatment.
2. BREWER. Surgery of the Thorax, Keen's Surgery, vi.
3. BRYANT. Treatment of .Empyema, American Practice of Surgery.
4. BULAU. " Fur die Heber Drainage bei ,Behandlung des Empyems. Ztschr.
klin. Med., 1891.
5. CONNELL. The Ignition Vacuum Bottle, Med. Rec., July, 1903.
6. DIEULAFOY. Traite de Inspiration des liquides morbides.
7. HARDY ATI. De T aspiration en chirurgie et en particulier de Themato-
aspiration en oto-rhino-laryngologie, Paris Thesis, 1906-07.
8. HOLT. The Siphon Treatment of Empyema in Infants and Young Chil-
dren Compared with Other Measures, Amer. Med., June, 1913.
9. KENYON. Continuous Suction and Its Application in Post-operative
Treatment, Surg., Gynec. and Obst., July, 1913.
10. — . A Preliminary Report of a Method of Treatment of Empyema in
Young Children, Med. Rec.? Oct., 1911.
11. KENYON and POOL. An Apparatus for Aspiration, Surg., Gynec. and
Obst., Dec., 1909.
12. KLAPP. Die Saugbehandlung, In. Berl. Klin., 1906.
13. KRAUSE. Chirurgie des Gehirns und Riickenmarks, Band II, 505.
14. LANGENBECKS. Die Verwendung der Ansaugung in der operativen Chir-
urgie, Arch. f. klinische Chir., Band XC.
15. LAURENS. Chirurgie oto-rhino-laryngologie, 1906.
16. PERTHES. Ueber ein neues Verfahren zur ISTachbehandlung der Opera-
tion des Empyems, Beitr. z. klin. Chir., Tubingen, 1898.
17. POTAIN. Pleuresie purulente, Gaz. d. hop., Paris, 1886.
18. ROBINSON. Acute Thoracic Empyema; Avoidance of Chronic Empyema;
BIBLIOGRAPHY
247
Rib Trephining for Suction Drainage, Bost. Med. and Surg. Jour.,
Oct., 1910.
19. SCHLEY. Aspiration Drainage in the Treatment of Empyema, Am. Jour.
Med. Sciences, Jan., 1908.
20. SEWALL. A New and Simple Device for Exploratory Aspiration, Jour.
Am. Med. Assn., Jan., 1909.
THE PKINCIPLES AND TECHNIC OF OPEKATIONS UPON
BLOOD VESSELS
CHAPTEK VIII
THE PEINCIPLES AND TECHNIC OF OPEEATIONS UPON BLOOD VESSELS
FREDERICK T. VAN BEUKEN, JB.
GENERAL CONSIDERATIONS
There are two principles common to all vascular surgery which, important
as they are in general work, are here preeminent. Cleanliness and gentleness
are, you may say, the foundation upon which rests success in operations of this
sort; and blood transfusion, transplantation, and anastomosis of vessels are
dangerous possibilities in the hands of one not thoroughly trained in the prac-
tice of aseptic surgery. Even the clean and capable operator finds plenty of
technical difficulties to be overcome, handling the narrow tubes, with their
delicate lining and thin, flaccid, or thick contractile walls ; and the manipula-
tion of tiny needles and fine sutures, such as are generally employed, requires
skill as well as good intentions. So it seems fair to say that no one ought to
attempt the more difficult operations upon human blood vessels without previous
practice upon animals. And in this respect it is interesting to remember that
many of those operations now usefully employed in human surgery were
originated by experimenters on animals ; while it is entirely possible that many
others which are being worked out in the laboratory to-day will, within a short
time, become established procedures in the operating-room.
For the sake of simplicity (I) operations upon arteries; (II) operations
upon veins ; and (III) operations upon capillaries are here considered in sepa-
rate series. But operations upon blood vessels are, in the main, intended to
accomplish one or more of the following ends : to check bleeding or interrupt the
circulation ; to obliterate the vessels ; to alter the blood or circulation for pur-
poses of depression or stimulation ; to remove the cause of circulatory disturb-
ances due to varicose veins ; to restore or reestablish the circulation ; for drain-
age of tissues or cavities ; to prevent the dissemination of infection. And thus
I have, for the sake of a logical arrangement, grouped the various surgical
procedures under these sub-headings.
249
250 OPEKATIONS UPON BLOOD VESSELS
SURGICAL PROCEDURES
Arteries. — The surgical procedures directed against arteries are:
(A) OPERATIONS TO CHECK BLEEDING. — The application of :
1. Postural compression.
2. Bandages and compresses.
3. Digital pressure.
4. Tourniquet.
5. Forcipressure.
6. Torsion.
m -IT,, fa. temporary.
7. Terminal ligation^ ,
[b. permanent.
(B) OPERATIONS TO OBLITERATE THE VESSELS. — (See Chapter on
Aneurysms. )
(C) OPERATIONS TO RESTORE OR REESTABLISH THE CIRCULATION
~ fa. longitudinal wound.
1. Sutured ,
[b. transverse wound.
2. Arterial anastomosis, end-to-end.
a. end-to-end.
3. Arteriovenous anastomosis-
b. end-to-side.
4.1 , . i a. embolus.
. Arterial section
c. side-to-side.
i.
thrombus.
5. Transplantation.
II
Veins, — The surgical procedures directed against veins are:
(A) OPERATIONS TO CHECK BLEEDING OR INTERRUPT THE CIRCULA-
TION
1. Posture.
2. Bandage, compresses, and packing.
3. Digital pressure.
4. Torsion, forcipressure, and terminal ligation, ligation en masse.
5. Cautery.
(B) OPERATIONS TO ALTER THE BLOOD OR CIRCULATION FOR PUR-
POSES OF STIMULATION OR DEPRESSION
1. Intravenous injection (blood serum, etc.).
2. Intravenous infusion.
3. Intravenous transfusion-
c. intermediate.
a. artery-to-veinl ..
i . . ^direct.
b. vem-to-vem J
GENERAL CONSIDERATIONS 251
4. Intravenous injection (anesthesia, etc.).
5. Venesection (blood-letting).
(C) OPERATIONS TO EEMOVE THE CAUSE OF CIRCULATORY DISTURB-
ANCES DUE TO VARICOSE VEINS
1. Injection.
2. Ligation.
3. Excision.
4. Incision.
5. Suture.
(D) OPERATIONS TO RESTORE OR REESTABLISH THE CIRCULATION
1. Lateral ligation.
2. Suture.
fa. end-to-end.
3. Venous anastomosis^ *>. end-to-side.
|^c. side-to-side.
4. Transplantation.
(E) OPERATIONS FOR DRAINAGE OF TISSUES OR CAVITIES
Transplantation.
(F) OPERATIONS TO PREVENT THE DISSEMINATION OF INFECTION
Removal of septic thrombi.
ni
Capillaries. — The surgical procedures directed against capillaries are :
(A) OPERATIONS TO CHECK BLEEDING
1. Styptics.
2. Packing.
3. Cautery.
4. Ligation en masse.
(B) OPERATIONS TO OBLITERATE THE VASCULAR CHANNELS
1. Acupuncture.
2. Galvanopuncture.
3. Injection.
4. Freezing.
5. Excision en masse.
6. Desiccation, Kromayer light.
7. Ligation.
IV
Lymphatics. — Handley's operation is here introduced for the sake of its
relation to blood vascular operations.
ANATOMICAL POINTS TO BE NOTED
It is, of course, essential for the surgeon operating to have very definitely
in mind those muscular and bony prominences which serve to indicate upon the
252
OPERATIONS UPON BLOOD VESSELS
FIG. 2. — SERREFINES WITH SMOOTH
BLADES.
FIG. 1. — THREADED NEEDLE MOUNTED ON
SLIP OF PAPER FOR CONVENIENT HAND-
LING. Dotted lines show where paper may
be folded.
FIG. 3. — CHILE'S CLAMPS.
FIG. 4. — DORRANCE CLAMP.
surface of the skin an imaginary projection of the particular vessel toward
which his attentions are directed ; and it is almost as necessary that he be thor-
oughly familiar with the relations borne toward this structure by the veins,
nerves, muscles, tendons, and fascial planes which accompany or surround it.
The neat and careful exposure of a blood vessel at a predetermined point in its
course is quite a different procedure from the often somewhat headlong opening
GENERAL CONSIDERATIONS
253
FIG. 5. — SEBREFINE WITH TAPE OB
GAUZE STRIP.
of the peritoneal cavity, in which the exploring hand may palpate, if the in-
cision be long enough, almost every structure from the xiphoid to the cul-de-sac
of Douglas. Skin and fascial planes should be cleanly and sufficiently divided
for proper retraction without undue tension of the parts. Muscles should be
separated, when that is possible, at their in-
termuscular fascial planes, or split, if it be
necessary, in the direction of their fibers. In
a word, it is imperative to avoid any unneces-
sary trauma whose resultant bleeding may
obscure the vessel sought, or whose tissue de-
struction may endanger the success of the
operation by inviting to subsequent blood
clotting and infection. To accomplish this an accurate knowledge of the site
and relations of the vessel to be attacked must be obtained before any operation
is attempted. Moreover, there should be a clear understanding of the structure
of a vessel wall and the way in which a vessel will behave if bruised, wounded,
or divided.
INSTRUMENTS USED
Besides the ordinary outfit of scalpels, dissecting forceps, scissors, retractors,
hemostatic forceps, etc., certain instruments and apparatus of a special nature
are required: (A) to control the flow of blood temporarily; (B) to facilitate
the approximation and adjustment of the vessel segments, or potentially con-
FIG. 6.— JEGER'S CLAMPS, STRAIGHT AND CURVED.
254 OPEKATIONS UPON BLOOD VESSELS
nect them; (C) to maintain the apposition of the vessel ends or edges until
cellular repair has established itself; (D) special instruments for excision of
veins.
The first group (A) includes:
(1) Elastic constrictors, linen tapes, or strips, or heavy twisted silk, fast-
ened by forceps or serrefines.
Q
FIG. 7. — FINE SCISSORS AND FORCEPS, STRAIGHT AND CURVED.
(2) Broad-bladed, delicate Billroth forceps; miniature Doyen hysterectomy
clamps (Dorrance) (Fig. 4); Herrick's clamps; Crile's clamps (Fig. 3);
serrefines with smooth blades (Fig. 2) ; Jeger's clamps, straight and curved
(Fig. 6).
Among the second group (B) are:
(1) Fine thumb forceps (Fig. T).
(2) Fine scissors (Fig. 7").
(3) Various individual implements such as Payr's magnesium rings;
Murphy's forceps ; Crile's and Elsberg's cannula ; Brewer's tubes ; Lindemann's
syringes; Curtis and David's container, etc., which will be described each in
connection with its appropriate operation.
The third group (C) comprises:
(1) Fine needles, curved and straight (No. 12 to ~No. 16).
(2) Fine sutures of catgut, Pagenstecker linen or very fine silk (first
choice) (Fig. 1). Carrel uses special Lyons silk; Lilienthal uses ~No. 000 silk;
Dorrance uses No. 1 Pagenstecker linen; Guthrie uses No. 12 to 16 needle from
Kirby, Beard & Co., Eavenhurst Works, Bradford St., Birmingham, and silk
from James Pearsall & Co., 71 Little Britain, London, or "Bead silk," whole
for large, and untwisted for small vessels.
OPERATIONS UPON ARTERIES 255
The last group (D) includes such individual instruments as Mayo's dis-
sector, Mamourian's probe, etc., which will be mentioned more fully later.
METHODS AND CHOICE OF METHODS
There have been published so many methods of undertaking the various
surgical procedures upon the blood vessels, and comparatively so few statistics
have been gathered during the short time in which this class of work has been
at all extensively practiced, that only those ways of proven value will be fully
described, others being mentioned (with reference) for the convenience of the
reader.
The choice of a method naturally depends somewhat upon the chooser's
individuality, if not peculiarities ; but, generally speaking, that method should
be the choice which promises to fulfil for the procedure in question the greatest
number of the following desiderata: (1) safety, (2) speed, (3) ease, (4)
simplicity.
DANGERS AND DIFFICULTIES: CAUSES OF FAILURE: COMPLICATIONS:
RESULTS
The dangers and difficulties, the causes of failure, the complications and
results of operations upon the blood vessels can best be detailed in connection
with each operation, but it may be said in passing that escape from the first
and excellence in the last depend largely upon the avoidance of dirt and
roughness.
I. OPERATIONS UPON ARTERIES
OPERATIONS TO CHECK BLEEDING
POSTURAL COMPRESSION
Postural compression is hardly an operating-room procedure, but I have
seen its value in at least one case on its way to the table. A man with popliteal
aneurysm was wheeled into the City Hospital at Blackwell's Island. As he was
being transferred from chair to stretcher the aneurysm ruptured through the
overlying skin and he would probably have bled to death then and there had
not an unusually intelligent assistant flexed the leg sharply upon the thigh
with a folded towel at the bend of the knee. This checked the bleeding suffi-
ciently to allow time to find and apply a tourniquet and get the patient to the
operating-room, which was at some distance. In a similar fashion, with a pad
between, complete flexion of the hip or elbow joints, and adduction of the
shoulder joint will exert obliterative pressure upon the adjacent vessels.
256 OPEKATIONS UPON BLOOD VESSELS
BANDAGES AND COMPRESSES
A stout rubber bandage, with a gauze compress beneath it, may be used to
control arterial circulation or to check arterial bleeding, but it is far inferior to
the regular elastic or pneumatic tourniquet and the compress has to be ac-
curately placed over the vessel to make it properly effective.
DIGITAL PRESSURE
Digital compression is little used now, except for the temporary closure of a
divided vessel until a clamp can be applied, or to control the circulation in an
emergency, or for special operations, as in MacEwen's method of aortic com-
pression.
THE TOURNIQUET
The tourniquet is used, in the operating-room, chiefly to control the cir-
culation; 1, preceded by the application of an Esmarch or Martin bandage,
to secure a bloodless field for difficult and careful dissection of complicated
structures, such as tendons, etc., at wrist or ankle ; 2, to prevent loss of blood
in preparing for, or performing, the amputation of an extremity.
There are two satisfactory forms of tourniquet: (a) the solid rod or tube of
elastic rubber, about 2 feet long and ^ inch in diameter, and (b) the pneumatic
tourniquet [Perthes] with metal reenforcement, a smaller form of which has
been much used in connection with blood pressure testing. A description of
the instrument will be found in the chapter on Amputations.
Trendelenburg's pin, Yarick's modification of it, Thomas's forceps, Wyeth's
pins, Jordan-Lloyd's tourniquet, Momberg's tube, etc., are special implements
best described in connection with the operations (amputation of hip and shoul-
der) they were designed for.
The Esmarch method of applying the tourniquet consists in applying
tightly, from below upward, in an even spiral, without reversing, an elastic
rubber bandage which is carried as high on the limb as necessary. Immediately
above it an elastic rod or tube is then wound around the limb sufficiently tight
to arrest all arterial circulation below. Thus the limb is emptied of blood and
kept so. The tourniquet is then fastened by clamp or tying and the bandage
removed from above downward. Instead of the preliminary bandaging the
limb may be emptied of blood by elevation for 3 minutes, while massage to-
ward the trunk of the body is practiced.
Matas utters the following warnings anent the use of the tourniquet and
the elastic bandage :
Always apply the elastic tourniquet over the femoral or humeral shaft, or at such
points that no vessel can escape a circumferential compression.
Begin by compressing the vascular or adductor side, leaving the outer or extensor
OPERATIONS UPON ARTERIES 257
surface of the limb free from pressure, so that venous choking of the limb may be
avoided.
Separate each turn of the constrictor by an intervening space to distribute the
pressure.
Do not allow the constricted member to be suddenly flexed or extended after the
constrictor is in place for fear of tearing subcutaneously the underlying muscles and
nerves.
Do not keep the constrictor in place much longer than an hour, or an hour and
a half.
It has been objected with good reasons that the ischemia of a limb obtained by
forcible elastic compression is likely to be followed by : (1) Excessive capillary oozing;
(2) it increases the risk of septic embolism and of cancerous metastases; (3) it greatly
favors the absorption of toxic chemical antiseptics; (4) it increases the liability to
ischemic necrosis.
For this reason Matas thinks elevation and massage preferable to the elastic
compression bandage as a preliminary to the application of the tourniquet.
The pneumatic constrictor is made to encircle the limb at a convenient
point proximal to the intended field of operation after preliminary elevation
and massage, unless this is contra-indicated. It is then fastened snugly, but
not tightly, by its metallic ring, and the pneumatic circlet, which surrounds
the limb inside the metal reenforcemerit, inflated by means of its pump until
the pulse, palpated at some point distal to the constrictor, is completely oblit-
erated. This usually requires a pressure of 150 to 200 mm. of mercury.
The only bad results to be feared from the application of the tourniquet
are temporary pressure paralysis and injury of diseased vessels at the point of
application. This should be kept in mind and the tourniquet must be applied
only with sufficient force to obliterate the pulse, which should be under the
finger of an assistant during the application. In cases where the arteries are
stiff and presumably fragile digital pressure control of the circulation is prob-
ably safer. The pneumatic constrictor has this advantage over the elastic
tourniquet, that its pressure can be very carefully and easily graduated, but the
simplicity of the elastic band has so far brought it into common use. Either
one properly applied is safe and of great convenience.
FORCIPRESSUKE
Practically the only method now used in operation wounds of checking ar-
terial hemorrhage is forcipressure, with or without subsequent ligation, and
this is true of accidental wounds when instruments are at hand. In deep
wounds where ligation is dangerous on account of the fragility of the tissues, or
impossible because of the narrow space, the forceps may be left on the vessel
for from 24 to 48 hours until the formation of a firm clot and the contraction
of the crushed inner coats provides for sealing of the vessel. Wherever pos-
sible, ligation should follow the application of the hemostatic clamp, unless the
vessel is of very small caliber, when many operators crush or twist it (and trust
18
258 OPERATIONS UPON BLOOD VESSELS
to luck that the retraction and torsion of the inner coat will suffice). Ligation
is safer, however, if you are sure that your ligatures are sterile.
It is important that no extraneous tissue be seized in the clamp with the
artery, lest nerve fibers be accidentally crushed or included in the ligature and
so give rise to subsequent pain or possibly paralysis.
Hemostatic forceps, or artery clamps, as they are usually called, are made
in various sizes, weights, and patterns, but the crushing principle is the same in
all of those designed for permanent hemostasis. They consist essentially of a
pair of jaws whose opposed surfaces are serrated, attached to handles with rings
at the end for a thumb and finger. They are provided with a ratchet lock to
hold them in adjustment at the desired tension. The jaws may be long or
short, broad or narrow, and blunt or narrow-ended, and some have tiny inter-
digitating teeth at the tip.
The forceps is held by the thumb and index, or thumb and middle finger
(usually of the right hand), the wound edges separated and the tissues around
the bleeding vessel steadied by the opposite hand, and the end of the divided
vessel is caught, as cleanly as possible, in the tip of the jaws of the forceps,
which is thereupon closed and locked with sufficient force to hold the vessel
securely. The handle of the clamp is held vertical until the ligature has been
passed around it and then depressed to raise the tip so that the ligature may be
tied beneath it. After the first knot of the ligature has been tied the handles
of the forceps are pinched slightly together and separated laterally to unlock
the catch, and the jaws are carefully opened and withdrawn from the wound.
The end of the vessel may be cut through and pulled away before the
ligature is properly applied if too much force is used in pinching the vessel
and pulling upon it. Nerves may be included and injured if the artery is not
grasped free from its surrounding tissues.
TORSION
Some operators draw the vessel a short distance from its sheath, steady it in
thumb forceps beyond the hemostat, and twist the end by rotating it three or
four times on its own long axis to rupture and cause retraction of the inner
coat. This is permissible only with very small arteries.
LIGATION
Terminal ligation is far the best means of permanently arresting arterial
bleeding. It may be used in a modified form to control the circulation tempo-
rarily, and will be described in connection with suture of arteries. No. 2
catgut is the most commonly used material for tying superficial vessels in soft
tissue. In firmer tissue, like those of the scalp, a stronger gut may be required.
For ligating large arteries No. 3 or No. 4 chromic catgut is often used and silk
and linen occasionally also.
OPERATIONS UPON ARTERIES 259
The artery to be ligated is caught by a hemostat as described in the pre-
ceding section. The ligature is so handed by the nurse that it may be grasped
near the middle by the surgeon's right hand. He passes it round the vessels
from right to left, catching the free end in his left hand, ties a single knot,
setting it down firmly upon the vessels beyond the tip of the clamp. The as-
sistant then removes the clamp and the surgeon ties a secure knot in such
fashion as to form what is generally known as a "square" or "reef" knot, which
is less bulky than the "surgeon's" knot, and safer than the "granny." Care
must be taken to set the second knot down tightly upon the first and not to
"upset" the knot. If too much force is used in tying the first knot the vessel
may be cut too deeply and the closure be made less secure. It is not uncommon
to see a surgeon in a hurry pull too hard on his ligature while tying a delicate
vessel, and tear the end of the vessel off, necessitating a repetition of the pro-
cedure.
OPERATIONS TO EESTOEE OR REESTABLISH THE CIRCULATION
LATERAL SUTUEE
Lateral suture of an artery may be required to repair an accidental wound or
rupture, either longitudinal or transverse, or an incision that has been made by
the surgeon to remove an embolus. It should not be used in wounds of such
size that their closure will occlude the artery, nor in cases of extensive crushing
of the artery and perivascular tissues. The presence of infection also contra-
indicates it. The essential conditions for the operation are: the best possible
asepsis, a non-injurious means of temporary hemostasis, gentleness in handling
the vessels, accurate approximation of the intimas without unnecessary trauma,
means of maintaining this approximation until cellular repair has been estab-
lished.
The part should be shaved and wrapped in a soap poultice for 24 hours if
possible; then scrubbed with a gauze compress with green soap and sterile
water; then with alcohol and ether and a gauze compress; then flushed with
mercuric chlorid, 1 : 5,000, and, finally, sterile normal saline. The surface
landmarks that indicate the line of the vessel to be attacked must be noted and
the line marked upon the skin by a light stroke of the scalpel.
Equipment. — Beside the usual equipment of scalpels, dissecting scissors
and forceps, hemostats and retractors, ligatures and sutures and needles, there
are required: several serrefines with rubber-covered or smooth blades (Fig.
2) ; 1 pair of fine, straight scissors; 1 pair of fine, curved scissors; 1 pair of
fine, straight forceps; 1 pair of fine, curved forceps (Fig. 7); several fine
hemostats (mosquito clamps) ; a jar of sterile albolin with eye-dropper; and
several fine needles, No. 12 to No. 16, threaded with fine silk (Fig. 1), which
should be boiled in albolin.
Operative Steps. — The operative steps are as follows: (1) Control the flow
260
OPERATIONS UPON BLOOD VESSELS
of blood through the artery by tourniquet, if possible. (2) Expose the artery
by sharp and blunt dissection, using every effort to avoid unnecessary tissue
injury and bleeding, and fasten towels to the edge of the skin. (3) If the
FIG. 8. — SUTUEE OF LONGITUDINAL WOUND IN BLOOD VESSEL: GUTHKIE'S POSITION OF HANDS.
artery is bleeding when exposed, an assistant should exert pressure upon it
above and below the wound, or, if necessary, with a finger upon the wound
until it can be sufficiently isolated from its bed to occlude it temporarily by
tape or clamps (Fig. 5) about 1 inch above and below the wound. (4) Re-
move all blood and blood clots from the wound by sponging with sponges damp-
ened in warm normal sa-
line; and from the vessel
lumen, by very gently
stripping it toward the
wound from both ends, the
expressed blood being ab-
sorbed by a dry sponge
held against the wound.
(5) Handle the vessel
with the fingers (see Figs.
8 and 9) rather than with
the forceps, and as gently
as possible. (6) Pick up,
in fine forceps, the deli-
cate outer coat of the vessel and trim it away from the margins of the wound
for 1 or 2 mm. (1/25 to 1/12 inch) with fine scissors. (7) If the wound edges
in the vessel are lacerated or contused, trim them smooth with fine, sharp
scissors. (8) Take a few drops of sterile liquid albolene, on the tip of a pair
of forceps or in a hypodermic syringe and gently moisten the wound edge
with it. If the sutures have not been boiled in albolene, lower them carefully
in the jar until they are completely saturated with it. (9) A continuous over-
FIG. 9. — SUTURE OF TRANSVERSE WOUND IN BLOOD VESSEL:
HOLDING VESSEL ON FINGER.
OPERATIONS UPON ARTERIES
261
hand (Fig. 14) or interrupted suture may be done, or a lock stitch (Fig. 11),
and should pass through all coats, taking care not to touch the intima with the
needle, except at the point of puncture. The edges of the wound should be
brought into close apposition without inverting,
wrinkling, or puckering, and the suture must
not be so tight as to cut through the tissue. The
needle should be introduced about ^ to 1 mm.
from wound edge and stitches should be placed
about y2 to 1 mm. (1/50 to 1/25 inch) apart
and the ends tied with a square knot and cut off
short.
(10) A continuous mattress suture (Fig.
12) is recommended by Dorrance and inter-
rupted mattress sutures (Briau and Jaboulay)
have been used (Fig. 13) by Archibald Smith
with satisfactory results. Stewart's clamp may
be employed if it is thought unwise to interrupt
the circulation (Fig. 10). When the suture is
completed, remove the distal clamp or tape and
look for leakage at the suture line. If any oc-
curs, press lightly upon the vessel with an ab-
sorbent gauze sponge for a minute. Otherwise,
loosen the proximal clamp or tape and allow the full blood stream to pass the
suture line. If slight leakage occurs, press lightly with a sponge, as before,
until it ceases. If it cannot be so controlled, within 3 or 4 minutes, or if a
spurting point is seen, replace the tape or clamps to control the bleeding, care-
fully sponge away the blood and introduce as many extra sutures as necessary to
FIG. 10. — STEWART'S CLAMP FOR
ISOLATING PORTION OF LUMEN
OF VESSEL.
FIG. 11. — LATERAL SUTURE OF LONGITUDINAL WOUND WITH LOCK STITCH, USING TENSION
SUTURES.
close the defect in the original suture line. Then remove clamps as before. If
the suturing has been carefully done there will be very little leakage and this
will cease within a few minutes as soon as fibrin blocks the hole around the
punctures. Then close the wound of exposure in the usual manner.
The dangers of this operation are not great, if you can be sure of aseptic
262
OPERATIONS UPON BLOOD VESSELS
FIG. 12. — DOBRANCE SUTURE OF TRANS-
VERSE WOUND.
conditions, gentle handling and proper instruments. But the difficulties are
considerable ; for it is not easy to get a good exposure of the vessel and collateral
branches are apt to complicate the control
of the blood current. If they are small,
they may be ligated; but, if large, it is
better to isolate them sufficiently to close
them temporarily with tapes or serrefines.
Again, the fine needles are not easy to hold
and manipulate and the sutures break very
easily, if they are not tied with the utmost
care.
The chief cause of failure is occlusion
of the artery by thrombus formation.
Secondary hemorrhage may occur from
tearing out sutures, or following infection,
if the sutures are not properly placed or
asepsis is imperfect, but it is not likely to happen and only occurred once among
the cases reported up to 1912.
The results are generally good in the reported cases as to function, but doubt
remains as to permanent patency of lumen.
ARTERIAL ANASTOMOSIS
Circular suture of arteries may be called
for where a (1) transverse wound divides
more than one-half of the lumen of an artery ;
(2) where the lateral suture of a gaping de-
fect in the wall would occlude the vessel, or
where crushing of the artery necessitates considerable resection of the wound
edges; (3) where the artery has been completely divided by knife, bullet, or
other injury; (4) after excision of a segment for aneurysm, new growth, or for
extensive crushing of an artery.
/ Arterial circular suture is
contra-indicated (1) in all
smaller arteries whose col-
lateral circulation is normally
sufficient to maintain nutrition
of limb, etc., after ligation; (2)
in all crushed and lacerated
wounds when all the perivascu-
lar tissues are badly or irreparably injured; (3) in all suppurating, or other-
wise infected wounds on account of thrombosis and secondary hemorrhage;
(4) in all cases where approximation cannot be obtained without overstretching
of vessels and where venous grafting or substitution is impossible. (Matas.)
FIG. 13. — BRIAU-JABOULAY INTERRUPTED
SUTURE.
FIG. 14. — LATERAL SUTURE WITH CONTINUOUS OVER-
HAND STITCH.
OPEKATIONS UPON ARTERIES
263
Instruments. — The instruments required are: Usual dissecting set; elastic
constrictors ; Langenbeck's serrefines (or serreplats) ; miniature Doyen clamps
with elastic covering; selection of Payr's magnesium rings (Fig. 20); fine
forceps, straight or curved; fine scissors, straight or curved; finest silk or
Alsace thread (No. 500) with Kirby No. 16 straight needle (for small ves-
sels) ; fine cambric needles, or floss needles, No. 6 to No. 10, with No. 0 or
No. 1 oculist's silk (for larger vessels) ; sterile albolin ; black, lint-free field
sheet, or a white field sheet, if black sutures are used ; skin clips to fasten it
to wound edges.
Methods. — A considerable number of methods of end-to-end anastomosis of
arteries have been reported, but up to the present time only three have been ex-
tensively used: (1) The invagination method (Murphy, Payr, etc.) ; (2) broad
marginal apposition (Salomoni, Briau, Jaboulay, Lespinasse and Eisenstaedt) ;
(3) direct marginal approximation (Carrel, Guthrie. etc.). In all of them the
chief points of technic are: Complete asepsis, exposure of vessels with least
possible injury, temporary interruption of blood current, control of vessel while
applying suture, accurate approximation of the walls, perfect hemostasis by
pressure after removing clamps, careful toilet of the wound.
INVAGINATION METHOD.— The invagination method is said to be "ap-
plicable to all vessels of large caliber, including popliteal and femoral, in which
not more than three-quarters of an inch have been removed by injury or ex-
cision." If position of limb can be made to relieve tension possibly a greater
loss than three-quarters of an inch can be permitted without grafting.
MURPHY'S METHOD. — The steps of Murphy's original invagination method
are:
(1) Expose by a generous incision and isolate the artery from its sheath for
a distance of at least 1
inch above and 1 inch be-
low injury. If collateral
branches interfere, ligate
or temporarily clamp
them. (2) Apply serre-
fines or rubber-covered,
flexible-bladed clamps at
upper and lower ends of
isolated portion with just
enough pressure to stop
bleeding. (3) Excise
crushed portion of vessel
(up to % inch), or trim
edges with sharp scissors, if lacerated or uneven. Pull adventitia over end of
stumps and cut off with sharp scissors (Fig. 15), and remove all blood and clots.
(4) Incise distal stump longitudinally a short distance with sharp knife (Fig.
1G). (5) Place three U-shaped traction sutures, at equidistant points, through
Fio. 15.— CUTTING OFF THE ADVJENTITIA.
264
OPEKATIONS UPON BLOOD VESSELS
FIG. 16. — MURPHY'S EARLIER METHOD
TRACTION SUTURES INTRODUCED.
all coats but intima, of the proximal stump, a short distance (about % inch)
from its cut end. ( 6 ) Thread the free ends of these sutures in separate needles
and pass them from within outward,
through all coats of distal stump about
% inch from its cut edge at points cor-
responding to those on proximal stump
(Fig. 16). (7) By the aid of these as
tractors, and, if necessary, with an as-
sistant manipulating the stumps, the
proximal is invaginated into the distal end and the traction sutures tied on the
surface of the distal stump. (8) The joint is then reinforced by several inter-
rupted non-penetrating sutures on outer surface of
junction of the stumps or by a continuous suture
(Fig. 17).
Murphy's more recent technic includes the use
of a specially devised instrument, a sort of split, hol-
low, open-ended cylinder, with separable halves, car-
ried on a handle. The distal stump is cuffed back-
ward over this, the cut end of the proximal stump
sutured to the reflection and the cuff then turned forward over the prox-
imal stump and sutured in place (Fig. 18). This was devised for end-
FIG. 17. — MURPHY'S EARLIER
METHOD; INVAGINATION
COMPLETED BY CIRCULAR
SUTURE.
FIG. 18. — MURPHY'S RECENT METHOD OP END-TO-END ANASTOMOSIS BY INVAGINATION.
to-end arterio-venous anastomosis. Modifications of this method have been
proposed by Bougie, Jensen, O'Day and others.
PAYR'S METHOD. — Payr's method of in-
vagination utilized a magnesium ring to
maintain the lumen size of the invaginated
portion (Fig. 20). Hoepfner's modification
of Payr's method (1) exposes and isolates the
artery sufficiently to apply clamps well be-
yond the wound or the portion that must be
excised; (2) special curved handle clamps,
with flat or rubber-covered blades (Fig. 19), are then applied with only suffi-
cient force to shut off the blood current; (3) the adventitia and the bruised
FIG. 19. — HOEPFNER-STICH CLAMP.
OPERATIONS UPON AkTKRIKS
265
FIG. 21. — JEOER'S HOLDER FOR PATH'S RING.
FIG. 20. — PAYR'S END-TO-END ANASTOMOSIS WITH MAGNESIUM RING.
ends of the artery are next trimmed carefully off and the blood washed away
with normal saline solution; (4) the distal end of the vessel is then covered
with a sponge damp with saline, while
three fine silk sutures are introduced at
the margin of the proximal stump, 120°
apart through all coats and tied; (5)
the ends held together are passed
through a thin, grooved ring of mag-
nesium (same size as vessel), which is
held in a special forceps and slipped,
like a collar, over the proximal stump;
(6) by traction on the threads, the pro-
truding end of the artery is everted,
rolled back over the ring, tied in place
by a fine silk circular ligature, fitting snugly into the groove, and the traction
sutures removed; (7) three similar traction sutures are now placed in the distal
stump to stretch its margin and gently draw its lumen over the everted cuff of
the proximal stump where it is tied in place by a fine
silk circular ligature. This completes the anastomosis,
which brings intima to intima, but slightly narrows the
lumen. Jeger has devised an ingenious holder for
Payr's rings, which considerably simplifies the technic
(Fig. 21). He has also produced a modified ring or
cylinder which he recommends for use in uniting deeply
placed vessels (Fig. 22).
METHOD OF BROAD MARGINAL APPOSITION. — With a similar end in
view, of bringing intima to intima, Salomoni (Fig. 23), and also Briau and
Jaboulay (Fig. 24), placed their sutures at a little distance from the cut edges
of the vessel in such manner as to evert these edges and draw comparatively
broad intimal surfaces of both stumps into contact. Salomoni used a simple
interrupted suture, while Briau and Jaboulay employed an interrupted mat-
FIG. 22. — JEGER'S MOD-
IFICATION OF PAYR'S
MAGNESIUM CYLIN-
DER FOR DEEPLY
PLACED VESSELS.
266
OPERATIONS UPON BLOOD VESSELS
tress suture. Dorrance, using Pagenstecher No. 1 thread, on the finest needle
that would hold it, and employing special flexible bladed forceps (Fig. 4), for
hemostasis devised a continuous mattress suture (Fig. 25) locked at every
third stitch and reinforced by a continuous overhand suture of the everted
wound margins (Fig. 26).
FIG. 23. — SALOMONI'S METHOD OF END-TO-END
SUTURE.
FIG. 24. — BRIAU-JABOULAY METHOD OF
END-TO-END SUTURE.
FIG. 25. — DORRANCE'S METHOD OF END-
TO-END SUTURE.
Lespinasse and Eisenstaedt have reported a method of anastomosis of blood
vessels, based on the same principle of broad marginal confrontation of intima.
They use chemically pure magnesium rings to facilitate coaptation and com-
paratively coarse suture material. These rings are "flat, washer-like pieces of
"\ metal, with a thickness of one millimeter,
1 — ^s -p and a wall of from one to two millimeters
VAC \ If ll *n width. On the wall, eight suture holes
are located, equidistantly, which have been
countersunk, or beveled to prevent cut-
ting of the sutures when traction is made
in tying them. Likewise the circumferen-
tial and luminal edges are beveled to pre-
vent injury to the coats of the vessels."
These are applied in such a way that
when the final sutures are tied the approxi-
mated ends of the vessel are practically clamped between them (Fig. 27). They
do not state results, but conclude that this "method is superior because 1st, the
suturing is not fine ; it is quite coarse ; 2nd, the sutures and rings are extravascu-
lar and do not come in contact with the blood
stream. The normal intima alone comes in con-
tact with the blood stream at the completion of the
operation."
METHOD OF DIRECT MARGINAL APPROXIMA-
TION.— The method of direct marginal approxima-
tion by continuous through-and-through sutures of
the vessels has been very completely developed by
Carrel and Guthrie, whose methods are practically
the same. Guthrie has recently published a verv
full account of his technic and results and the following description of Carrel's
technic is abbreviated from one of his recent communications.
FIG. 26. — DORRANCE'S METHOD.
MATTRESS SUTURE REINFORCED
BY CONTINUOUS OVERHAND SU-
TURE.
OPERATION'S UPON ARTERIES
267
CAKREL'S METHOD.— Genera? Rules.— To avoid complications of stenosis,
hemorrhages, and thrombosis: (1) A rigid asepsis is absolutely essential; an
infection not sufficient to prevent primary union of a wound may yet cause
thrombosis. (2) Blood vessels may be freely handled in the fingers, but not
with forceps ; the latter, if used, must take only the outer sheath in its grasp,
and when employed for hemostasis must have smooth jaws with carefully regu-
FIG. 27. — LESPINASSE AND EISENSTAEDT METHOD OF END-TO-END ANASTOMOSIS, METHOD III.
lated pressure. (3) Drying of the endothelium or the presence of coagulated
blood, fibrin ferment or foreign tissue, or tissue juices on the interior of a ves-
sel may lead to thrombosis ; therefore, the external sheath must be resected and
the lumen of the vessels and the surrounding parts must be washed with
FIG. 28. — GENTILE'S SYRINGE (Carrel).
Ringer's solution and coated with vaselin. (4) To minimize trauma of the
endothelium by the perforating sutures, the needles and suture material must
be of the smallest size, sterilized in vaselin, and kept coated with it during the
suturing. (5) To avoid stenosis, keep the arterial walls under lateral tension
by traction sutures while putting in the continuous stitch.
268
OPERATIONS UPON BLOOD VESSELS
Instruments.— Crile clamps (Fig. 3) or elastic forceps (Fig. 4), for tem-
porary hemostasis in large vessels, as femoral artery; small Crile clamps or
smooth-jawed serrefines (Fig. 2) without rubber covers, for small vessels, or
narrow rubber strips held round the artery by serrefine or forceps; Gentile
FIG. 29. — ARTERY ISOLATED ON BLACK FIELD SHEET.
syringe and Ringer's solution for washing out the vessels (Fig. 28) ; round,
straight needles, Kirby No. 16, for small vessels, No. 12 to No. 16, can be used
for large vessels; they are threaded with very fine silk (Fig. 1) and sterilized
in vaselin ; Gentile forceps to hold the traction sutures ; a black towel to lay the
sutures on and a black Japanese
field sheet to surround the wound.
Temporary Hemostasis and
Preparation of Vessels. — (1) Ex-
pose the vessels by a large incision
and dissect them free, securing a
large operating field. (2) Catch
all bleeding points and make the
wound as "dry" as possible. (3)
Cause temporary hemostasis of the
artery by clamps, forceps, or rub-
ber bands placed a few centimeters
from the site of the future anastomosis ; clamping or ligating all collaterals that
interfere. (4) Resect the sheath, and trim the ends of the vessels as may be
necessary. (5) Introduce the ends of the syringe into the vessels and wash out
the blood from them and from the operating field, and remove the fluid with dry
FIG. 30. — CARREL'S METHOD OF END-TO-END ANAS-
TOMOSIS: APPLICATION OF THE Two POSTERIOR
RETAINING STITCHES.
OPERATIONS UPON ARTERIES 269
gauze and forceps. (6) Coat the vessels and surrounding parts with warm
vaselm. (7) Place the black silk field sheet around the vessel ends i Ki- 29 ,
Suture.— Place and tie the first posterior retaining stitch on .1,,. ,,,,-if.rior
aspect of the vessels' ends near the edges. Fix the short end i,, a small forceps
and lay the long end in the needle upon the black towel to use for the continuous
FIG. 31. — CARREL'S METHOD: APPLICATION OP
ANTERIOR RETAINING STITCH. '
FIG. 32. — CARREL'S METHOD: CIRCUM-
FERENCE OF ARTERY TRANSFORMED
INTO A TRIANGLE BY TRACTION ON THE
RETAINING STITCHES.
suture. Place the second posterior retaining stitch 120° from the first, cut a
convenient length, and fix both ends in a small forceps (Fig. 30). Make a
slight traction on both posterior stitches and introduce an anterior traction
thread equidistant from them (Fig. 31).
The ends of the artery must come to-
gether without strong traction.
Convert the circumference of the ap-
proximated ends into a triangle by draw-
ing upon the traction threads (Fig. 32),
and unite them by a continuous over-
hand suture (Fig. 33) with the original
needle and silk, beginning near the first
posterior traction stitch and carrying it
around the vessel to the same point,
squeezing out vaselin before closure is
completed. Only a few stitches between
traction threads are necessary; three, for example, in an artery the size of a
dog's carotid. Take great care to approximate the divided surfaces exactly.
They must not come into contact with the blood stream. Carefully examine
the line of suture and close any gaps by an additional stitch.
Reestablishment of the Circulation. — Place gauze sponges on the suture line
and make gentle pressure while the clamps are removed. Expect some leakage
during the first minute, but, if some bleeding persists when the sponges are
removed, after two or three minutes, complementary stitches may be added.
FIG. 33. — CARREL'S METHOD: CONTINUOUS
SUTURE ALMOST COMPLETED.
270
OPERATIONS UPON BLOOD VESSELS
Then wash the vessels and the wound with Ringer's solution, and close the
wound without drainage.
OTHER METHODS. — Guthrie's technic, as recently published, differs
somewhat from CarrePs in minor points. He uses Kirby's needles, No. 12 to
No. 16, and "bead silk," whole for larger vessels, and untwisted for small. He
prefers to occlude the vessel by narrow tapes, held
in forceps (Fig. 5), and he removes the blood from
the divided ends on to a gauze sponge, by gently
stripping them between the fingers instead of wash-
ing with a syringe, and wipes out his wound with
a gauze sponge. After removing the blood, he ap-
plies a little oil to the cut ends instead of coating
with vaselin. He uses one posterior and two an-
terior traction threads instead of the reverse, and
lightly oils his fingers before affixing them. He
places the stitches of his continuous suture about
!/2 mm. from the cut edges, and the same distance
apart, and interrupts the circular suture twice by
tying it at 120° intervals to the traction threads.
Guthrie says suitable silk can be procured from
James Pearsall & Co., 71 Little Britain, London ;
needles from Kirby, Beard and Co., Ravenhurst Works, Bradford St., Bir-
mingham.
Jeger, in describing Carrel's method, emphasizes a practical point illustrated
FIG. 34. — CORRECT DIRECTION
or NEEDLE INTRODUCING STAY
SUTURE. Dotted line shows
incorrect direction.
FIG. 35. — TYING THE STAY SUTURE.
in Figure 34. The vertical introduction, rather than the oblique, of the needle
through the vessel wall has the effect of slightly everting the cut edges of the
vessel segment when the sutures are tied, as shown in Figure 35. He strongly
OPERATIONS UPON ARTERIES
27?.
FIG. 36. — ANOULATION OF THE VESSEL TO FACIL-
ITATE INSERTION OF CONTINUOUS SUTURE.
advises against the use of forceps and
says if they are absolutely necessary
that they should grasp the vessel only
between its cut edges and the suture
line, not beyond this, so that the portion
thus injured shall not touch the blood
stream. He recommends angulating the
vessel at the line of junction, as shown
in Figure 36, to facilitate the insertion
of the continuous suture. Like Guthrie,
he ties the continuous suture to the ten-
sion suture. He places his stitches
slightly closer together than Carrel in
the continuous suture. If comple-
mentary sutures for a spurting point
are necessary, he says that they should
embrace all the coats of the vessel
(Guthrie to the contrary), lest intima
be not brought to intima. If further sutures are needed to stop oozing only,
these he does not make through and through. And if they fail to control the
bleeding he applies a bit of muscle to the place
or wraps a strip of fascia or peritoneum around
the anastomosis, as in Figure 37. He calls
suture of the adventitia superfluous. For deep
vessels he advises that the tension, sutures be
"U" sutures and of heavier silk, if intended for
unusual tension. He recommends the use of
Horsley's tension suture holder (Fig. 38), or Jeger's instrument (Fig. 39), for
the same purpose.
Horsley has devised an ingenious instrument
for holding the stay sutures, in end-to-end anas-
tomosis (Fig. 38) — "a steel shaft, 1/16 inch
thick, curving at one extremity into a shorter
shaft and flattened at the angle to make it
springy. There are five buttons to fasten the
thread to." He employs a continuous mattress
suture and everts the edges of the vessels.
Dobrowolskaja has recently experimented
with complicated incisions, in the effort to pre-
vent narrowing of lumen in end-to-end suture of
vessels of small caliber. The indented incision is
the simplest. This is made triangular to the
middle of the vessel (Fig. 40), one segment rotated 90°, and the long point
brought together with stay sutures, leaving wide diamond-shaped defects.
3B5
FIG. 37. — REINFORCEMENT OF THE
ANASTOMOSIS WITH A STRIP OF
FASCIA OR PERITONEUM.
FIG. 38. — HORSLET'S TENSION
SUTURE HOLDER.
272
OPEKATIONS UPON BLOOD VESSELS
The edges of these are approximated by lateral traction on the stay suture and
then united by a continuous suture. This results in a widening of the lumen
at the line of suture which, it is said, shows a tendency to disappear after ^ a
while. Human hair or silk No. 00 on straight needle were used and it is said
that these complicated incisions and sutures apparently do not endanger the
vessels. They may also be used to accommodate
an artery to a larger vein, in end-to-end suture.
O'Day has recently reported a successful
modification of Payr's invagination in which
he used a circular ligature instead of a ring, to
turn back a cuff on the proximal segment, and
fastened the cuff by quadrant sutures tied to the
ligature. He then invaginated the proximal
into the distal stump and sutured the latter to
the cuff by a running stitch. He draws the
previously retracted adventitia toward the line
of union before removing the temporary hemo-
statics, and, if complementary sutures are neces-
sary, he advises that they should include only
the outer coats.
Choice of Methods. — T h e invagination
method of Murphy is objectionable in that it
narrows the lumen and shortens the vessel itself
and is liable to be followed by thrombosis because it leaves a raw surface in con-
tact with the blood stream. With the exception of the last, Payr's method has
the same drawbacks and, moreover, it requires a special implement, the ring,
which may not be at hand, and may cause thrombosis by pressure necrosis of
the ring on the vessel wall. Broad marginal confrontation, whether by suture
or metal flanges, also somewhat reduces the vessel's length. The direct mar-
FIG. 39. — JEGER'S TENSION
SUTURE HOLDER.
V
FIG. 40. — DOBROWOLSKAJA'S FLAP INCISION FOR WIDENING SMALL VESSELS AT THE LINE OF UNION.
ginal approximation, on the other hand, neither shortens the artery nor appre-
ciably narrows its lumen. Moreover, it can be done without any special equip-
ment other than well-lubricated suture material and needles of requisite fine-
OPERATIONS UPON ARTERIES 273
ness. But above all in its favor is the excellence of its published results, as ob-
tained in experimental work. It requires, perhaps, a higher degree of dexterity
to accomplish than a union by imagination, or with metal flanges; but this
need deter no one who is willing to spend some time in practicing its technic.
Matas says : "The Carrel technique has become the method of election at the
present time."
Jeger calls Carrel's the best technic for the surgeon skilled in blood ves-
sel work, but points out that it is difficult and takes considerable time in the
unpracticed hand, although Carrel can do a circular suture in five minutes.
Further he says that Payr's method, while not offering the same safety (as
regards thrombosis) as Carrel's, is far simpler, more rapid, and is especially
applicable in accidents, in war time, etc. This method, with modifications as
practiced by him, has given good results.
In regard to the restoration of vascular channels in general, Guthrie believes
it is safe to say that, when patency of lumen can be preserved, it is better to
repair the defect by suturing than to ligate the vessel. He adds that in the
event of much vessel wall being destroyed, or if it has to be removed, then
preservation becomes doubtful ; and one of four things can be done :
(1) Ligate on both sides of the defect,
(2) Restore defect by a patch,
(3) Transverse excision with circular suture,
(4) Transverse excision with transplant by circular suture.
The first is safe on secondary arteries, like ulnar; less so on intermediate
arteries, like brachial; unsafe on primary arteries, like renal.
The second is more complicated, difficult and liable to thrombosis than cir-
cular suture.
The third is preferable, if it does not cause too much tension.
If there is too much tension, use the fourth procedure.
With asepsis and careful suturing an arterial anastomosis involves no
greater dangers than are encountered in any other class of operations upon
important anatomical structures; and the difficulties, while considerable, are
such only as can be overcome by patience and perseverance. The imagination
methods would probably be found the easiest in the majority of hands; but
this is not sufficient to prefer them over the direct marginal suture. The intro-
duction of the least infection into the wound; any but the gentlest handling
of the vessels; carelessness in allowing them to dry out or to be invaded by
foreign tissue, or tissue juices ; failure to remove blood and blood clots ; these
are the causes that may act to invalidate the operator's efforts by inducing
thrombosis. An ill-placed, insecurely tied suture, or too great tension on the
sutures, may permit of secondary hemorrhage, though this is rare ; and a cer-
tain degree of stenosis may be produced by too small a ring or by a continuous
suture too tightly drawn.
Carrel says of his method : "If the technique here described is followed, no
complications occur." And his results bear out this bold statement.
19
274 OPERATIONS UPON BLOOD VESSELS
Eesults of Circular Suture of Arteries. — Buchanan collected from the liter-
ature 29 cases (besides his own) up to Nov. 1, 1911. From an analysis of
these cases it appears that the mortality was 6 2/3 per cent. ; and complete
recoveries with good circulation of the parts 83 1/3 per cent. ; while the partial
recoveries, in which gangrene requiring amputation gave incontrovertible evi-
dence of failure to reestablish a normal circulatory condition, were 10 per cent.
It is not apparent that either of the two deaths was directly attributable to
the operation. One was reported as due to delirium tremens; and the other
patient was said to be moribund from hemorrhage when operated upon. A bet-
ter selection of cases would perhaps have resulted in lower mortality.
The only autopsy reported showed "artery pervious (after 5 days) with
thrombus in part of its lumen. "
Now, as to the recoveries, it is reasonable to suppose, if the pulse below the
injury has been feeble or imperceptible before operation and becomes stronger
soon after the anastomosis has been accomplished, that blood is reaching the
distal portion of the vessel via the anastomosed segment ; and, if the pulse re-
mains strong without intermission, it is fair to believe that the patency of the
lumen has been maintained. But if the pulse does not very rapidly return after
anastomosis, or if, having rapidly returned, it later disappears or becomes very
much feebler, it would appear probable that the lumen of the vessel has been
narrowed or obliterated at the anastomotic site, and that collateral circulation
was responsible for the healthy condition of the part distal to it. Naturally, if
gangrene appears in the part distal to the suture, one supposes a failure due to
complete or nearly complete occlusion of the vessel operated upon, as well,
probably, as to a serious amount of damage in the collateral vessels, such as may
have occurred in crushing injuries. Arguing on this basis, it is not clear that
more than 11 of the above reported cases were successful in reestablishing and
maintaining the circulation through the injured segment, since in only 11 is
the pulse stated to have returned within 24 hours ; and Thoma says that return
of pulse (due to collateral circulation) below the ligated main trunk of a ves-
sel can occur as early as 24 hours postoperative, in young subjects, and pro-
portionately later in older persons. This would be 36 2/3 per cent, of operative
successes in a strict sense ; but, since there were over 80 per cent, of recoveries
with good circulation, it is just to say that the anastomosis had perhaps served
its purpose by permitting a partial but sufficient flow of blood to reach the
distal parts during the time required for development of the collateral
supply.
The results of arterial circular suture in animals are more brilliant. An
analysis of the results of Borst and Enderlen, Yamanouchi, Ward, Stich, Glass-
tein, and Carrel, as quoted by Jeger, shows 71.2 per cent, successes in a total
of 148 cases done by the Carrel method.
Jeger quotes an interesting compilation by Sofoteroff which compares the
relative percentage of successes in end-to-end anastomosis of vessels by Mur-
phy's, Payr's and Carrel's methods :
OPEEATIONS UPON AUTKIMKS 275
90 cases of end*to-end anastomosis, Murphy method, 15.5 per cent.
96 " " « Payr 17.6 " "
352 " « Carrel " 49.8 " «
ARTERIOVENOUS ANASTOMOSIS
Arteriovenous anastomosis is the procedure of forming a communication
between an artery and a vein in such manner that the arterial blood is admitted
to the vein for the purpose of displacing its contents and causing reversal of
the circulation.
Thus far, this procedure has been used only in cases of expected or actual
gangrene of the limbs due to (1) Raynaud's disease; (2) obstruction of the
main artery from endarteritis, thrombo-arteritis, embolus, or trauma. The
instruments required are the same as for suture of arteries. The anastomosis
may be made end-to-end, side-to-side, or end-to-side.
End-to-End Arteriovenous Anastomosis. — MURPHY 'S METHOD. — The steps in
the invagination method are as follows: (1) Expose artery and vein; isolate
both and provide temporary hemostasis. (2) Divide both vessels, the vein
y2 inch to % inch higher than the artery, if possible. (3) Ligate permanently
the distal stump of the artery and proximal stump of vein. (4) Apply forceps
(Fig. 18) around distal segment of vein near its end ; evert and roll back open
end of vein like a cuff upon it. (5) Suture cut end of artery to reflected border
of venous cuff by interrupted stitches. (6) Pull reflected vein cuff forward
over line of suture and stitch its cut edge to outer surface of artery. (7) Re-
move forceps and close wound without drainage. Murphy now uses this method
in arterial suture also.
CARREL'S METHOD. — The procedure in end-to-end suture of artery to
vein is the same as in his method of uniting artery to artery except that the cut
edge of the vein is somewhat everted, so
that its endothelial surface lies against
the cut edge of the artery (Fig. 41).
As the vein is usually larger than the
artery, sufficient pull is exerted upon
the three traction sutures to stretch the
artery nearer to the size of the vein and FIG 41>_END_TO_END ARTERIOVENODS ANAS-
each stitch of the continuous suture TOMOSIS: APPROXIMATION OF THE ENDS (Carrel).
is made larger on the vein and at a
slightly greater distance from its cut edge than the corresponding stitch on the
artery. This has the effect of slightly puckering the vein and thus reduces its
lumen to correspond with that of the artery. (Fig. 42.)
End-to-Side Arteriovenous Anastomosis. — End-to-side (Carrel and Guthrie)
anastomosis (for arterial or arteriovenous anastomosis) may be made by:
(1) Preparing the proximal stump of the artery as for an end-to-end anas-
tomosis and ligating the distal end. (2) Temporary hemostasis is then applied
to the corresponding segment of the vein, after being isolated, and an elliptical
276
OPEKATIONS UPON BLOOD VESSELS
opening made into it a trifle larger than the size of the arterial lumen by lift-
ing up a bit of its wall in forceps and cutting it out with sharp scissors. (Fig.
43.) (3) The blood is then pressed out and the edges of the opening vaselined
FIG. 42. — END-TO-END ARTERIOVENOUS ANAS-
TOMOSIS: APPLICATION OF CONTINUOUS
SUTURE (Carrel).
FIG. 43. — END-TO-SIDE ANASTOMOSIS: OVAL
OPENING INTO VEIN (Carrel).
FIG. 44. — END-TO-SIDE ANASTOMOSIS: FIXA-
TION SUTURES INTRODUCED (Carrel).
FIG. 45. — END-TO-SIDE ANASTOMOSIS: COM-
PLETED (Carrel).
and three or four traction sutures tied on the outside of the vessels are made
to approximate the end of the artery to the side of the vein (Fig. 44). (4)
Traction on these sutures triangulates or squares the junction of the vessels
and a continuous suture is made to unite their edges (Fig. 45). (5) The vein
is permanently ligated above the point of anastomosis, and the
temporary hemostats on vein and artery removed.
They also describe a "patching" method: If one of the
vessels is too small to handle conveniently, it may be excised
with a part of the wall of its parent trunk (Fig. 46) and the
latter attached to the oval opening in the other vessel (Fig.
47) and united with it by continuous suture (Fig. 48).
WIETING'S METHOD.— Wieting's method of end-to-side
anastomosis, practically similar to Van Hook's terminolateral
ureteroureteral anastomosis, is open to the theoretical objec-
tion, at least, of leaving a raw edge in contact with the blood
stream. The proximal cut end of the artery is introduced
through a slit in the side of the vein and anchored there by one retaining suture
that is tied on the outside of the vein, and a continuous suture unites the cut
edges of the vein to the outer surface of the artery. The vein is then ligated
closely proximal to the anastomosis.
FIG. 46. — CAR-
REL'S PATCH-
ING METHOD:
SMALL VESSEL
EXCISED WITH
PART OF LARGE
(Carrel).
OPERATIONS UPON ARTER1 KS
277
JEGEE'S METHOD. — Jeger has devised a method for end-to-side anas-
tomosis far superior to Wieting's. It is described under operations on veins,
but it might be applied to arteriovenous
anastomosis.
Side-to-Side Arteriovenous Anastomo-
sis CAKBEL'S METHOD. — (1) After
proper exposure, isolation and hemo-
stasis, both vessels are opened longi-
tudinally, at corresponding points, for
a distance a little greater than the di-
ameter of the artery, by incision with a
scalpel or excision of an elliptical flap
with scissors, and the adventitia
trimmed away. (2) Traction sutures
are then placed, uniting the distal and proximal ends of these openings (or
points close to them on the adjacent cut margins) and tied on the outside of
\\
FIG. 47. — CARREL'S PATCHING METHOD: STAY
SUTURES INSERTED.
FIG. 48. — CARREL'S PATCHING
METHOD: SUTURE COM-
PLETED.
FIG. 49. — SIDE-TO-SIDE ANAS-
TOMOSIS: END TENSION SU-
TURES TIED, ADJACENT
MARGINS UNITED BY CON-
TINUOUS SUTURE, ANTE-
RIOR TENSION SUTURE IN-
SERTED BUT NOT TIED
(Carrel).
FIG. 50. — SIDE-TO-SIDE
ANASTOMOSIS: ANTE-
RIOR TENSION SUTURE
TIED; CONTINUOUS SU-
TURE NEARINO COM-
PLETION (Carrel).
the vessels. (3) While traction is made on these sutures, the needle on the long
end of the distal one is made to penetrate the wall of the vessel from without
inward and a continuous suture is
carried by means of it along the
adjacent margins of the openings,
on their endothelial surface, and
after piercing the wall at the prox-
imal end of the opening is tied,
on the outside of the vessels, to
the proximal traction suture (Fig.
49). (4) A third, or anterior,
traction suture is then made to
approximate the distal margins
of the two openings in the ves-
sels at their middle and tied on their outer surface. (5) Traction on this, and
upon the posterior proximal and distal traction sutures, angulates and approxi-
FIG. 51. — SIDE-TO-SIDE ANASTOMOSIS COMPLETED,
SHOWING EXTRA END SUTURES OF GUTHRIE.
OPERATIONS UPON BLOOD VESSELS
mates the anterior margins of the wounds, which are then united by a continua-
tion of the suture, working upon the adventitial surface of the vessels, which has
already been used to unite the posterior (or
adjacent) margins of the vessel openings.
This is tied, at its completion, to the distal
traction suture (Fig. 50).
GUTHKIE 'S METHOD. Guthrie's
method differs from Carrel's in the follow-
ing respects :
Guthrie makes the openings, in width,
about % and, in length, about 1% the
diameter of the vessel, if the entire circula-
tion of one vessel is to be diverted through
the anastomosis. He places a temporary
posterior traction loop midway between the
proximal and distal traction sutures to aid
in approximating the adj acent margins
while they are being united with the con-
tinuous suture. This is placed on the in-
ternal surface, is not tied, and is cut and
withdrawn before the anterior traction su-
ture is introduced. He ties the continuous
suture with the anterior traction suture as
well as with the proximal and distal. If
much strain is likely to be exerted upon the
suture line, he reinforces it, at proximal and distal ends (Fig. 51), by a some-
what coarser single suture.
FIG. 52. — BERNHEIM'S ANASTOMOSIS:
DIVIDING VESSEL FOR LATERAL
ANASTOMOSIS AND RESULTANT
GAPING OF INCISION.
FIG. 53. — BERNHEIM'S ANASTO-
MOSIS: STARTING THE SUTURE.
The knot is tied on the outside
of the vessels.
FIG. 54. — BERNHEIM'S ANAS-
TOMOSIS: POSTERIOR Row
OF SUTURES BEING PLACED.
LESPINASSE AND EISENSTAEDT METHOD. — They have used oval mag-
nesium plates, similar to those used for end-to-end anastomosis, but the method
is less promising than that by simple suture.
OPERATIONS UPON ARTERIES
279
BEENHEIM AND STONE METHOD.— (1) After dissection and clamping of
the vessels with bull-dogs or Crile clamps (rubber-shod), "a sharp cataract
FIG. 55. — BEBNHEIM'S ANASTOMOSIS: POSTERIOR Row OF SUTURES COMPLETED, ANTERIOR Row
BEING PLACED.
knife, held transverse to the long axis of the vessel, is plunged through the
artery in a direction oblique to the horizontal plane in which the vessel lies,
so as to form a sector of the lumen with its arc equal
to about % of the circumference. The knife is
thrust in with its cutting edge up and toward the
adjacent vein. The overlying 1/3 of the artery is
then divided." (Fig. 52.) (2) Wash out all blood
with saline and moisten lumen and other surfaces
with liquid vaselin. (3) Protect the artery with
vaselin-soaked gauze and make a similar incision in
vein so that it looks toward the artery. (4) The
suture is then (Fig. 53) started at the lower
end of the two incisions, tied on the outside of
the vessels, and made continuous (Fig. 54) back
to the starting point, where it finishes by tying
with the first end (Fig. 55). (5) Ligate vein
on proximal side and loosen distal venous clamps
(Fig. 56). (6) Loosen distal and then prox-
imal artery clamps. (7) Reinforce, if necessary,
for leakage.
Bernheim thinks lateral arteriovenous anasto-
mosis better than end-to-end because it allows some
blood to continue down the artery and does not en-
tirely cut off the circulation if the vein becomes
occluded by thrombosis.
Choice of Methods. — If one judges by results,
the choice of methods is difficult. In the series of
cases collected by Halstead and Vaughan the technic used was specifically
mentioned in 17 cases:
FIG. 56. — BERNHEIM'S ANAS-
TOMOSIS: SUTURE COM-
PLETED, TIED AND Cur.
Clamps removed. Proxi-
mal ligation of vein.
280
OPEKATIONS UPON BLOOD VESSELS
PARTIAL
COMPLETE
CASES
DEATHS
RECOVERY
RECOVERY
6
Wieting : lateral implantation artery into vein.
3
2
1
6
Carrel: end-to-end suture of artery into vein.
3
2
1
5
Invagination : end-to-end, of artery into vein.
3
2
••
In Bernheim's collection of cases there were 46 in which the technic used
was specified:
No. OP
CASES
SUCCESSFUL
23
Carrel : end-to-end sutures
34 78%
12
Lateral anastomosis
33.33%
9
Wieting's intubation .
22 22%
2
End-to-end invagination
50 00%
So far Bernheim seems to have had the best results of any one operator,
but his method has not been used by others sufficiently to judge its efficiency in
general hands.
This is an operation by no means devoid of danger in the class of cases for
which it has been employed. Halstead and Vaughan have collected 41 cases,
with 42 operations, up to January, 1911, and of these 21 died, 11 after the
primary operation, 9 after a secondary amputation, and 1 after opening a
secondary abscess. Three of these 21 deaths were apparently directly attrib-
utable to the anastomosis operation.
The same causes of failure act here as in arterial anastomosis, thrombosis
being by far the commonest. Hesse performed thrombectomy for a thrombus
that formed while he was doing an arteriovenous anastomosis between the
femoral artery and long saphenous vein. The thrombus at once reformed,
however, and he had to make his anastomosis end-to-end with the femoral vein.
In the series of 41 cases reported by Halstead and Vaughan there were 28 in
which pathological findings at amputation or autopsy were included. Among
these were :
Thrombus in all vessels 5 cases
Thrombus in femoral artery above and popliteal artery be-
low 5 cases
Thrombus in femoral vein alone below 5 cases
Short circuiting by collaterals of vein 1 case
Occlusion of central end of artery 2 cases
. This shows thrombosis to be a fertile cause of failure.
OPERATIONS UPON ARTERIES 281
Results. — In many cases the immediate result is good, but, more ana more,
the men who have had experience with this operation are coming to feel that
little permanent benefit can be expected from it.
Oppel says that arteriovenous anastomosis is successful only in cases of
slowly progressing ischemic gangrene, not complicated by thrombophlebitis or
phlegmon ; and he believes that the improvement is due to delayed venous re-
turn and suggests ligation of popliteal vein as a palliative measure (instead of
arteriovenous anastomosis). Hesse, also, believes that Wieting's operation is
inefficient and that the improvement following it is due not to reestablishment
of circulation, but to stasis, which follows stoppage of venous return. After
iy2 months improvement, his patient came to amputation when it was noted
that there was no pulsation in the femoral vein and that venous appearing blood
flowed from the veins.
Perimow advises anastomosis of the artery with superficial veins because the
latter have few or no valves, on the ground that the valves prevent reversal of
circulation in arteriovenous anastomosis. This appears fallacious.
Bernheim says that he has successfully reversed the circulation in all four
limbs of a young woman, as evidenced by cessation of gangrene of toes and
fingers and presence of a palpable thrill below anastomosis ; a bruit audible to
the popliteal space, in legs, and to wrist, in arms ; and pulsation of veins, felt,
in lower, and seen in upper, extremities.
Halsted and Vaughan, of Chicago, in a splendid paper on arteriovenous
anastomosis, have collected 42 operations, 11 for "threatened," and 31 for
actual gangrene. They state that local changes, indicating an immediate im-
provement, were noted in 23 cases, in order of frequency: (1) Increased
warmth in the affected parts; (2) improvement in color (often the only sign
noted) ; (3) relief from pain; (4) improvement in sensation; (5) filling of
superficial veins; (6) pulsation in veins of extremities below site of anastomosis
(14 cases) ; (7) return of the part threatened by gangrene or the actual seat
of gangrene, to the normal.
The case of Ballance is said to be the only one found where circulation was
so far improved by anastomosis as to control an actually existing gangrene and
bring about restoration of the part not actually gangrenous. In Wieting's case.
there was no sign of return of threatened" gangrene for at least two months.
In all the remainder of the cases the favorable signs were of short duration.
after primary operations, 11
There were 21 deaths: \ after secondary amputation, 9
after opening abscess,
1
a mortality of
50 per cent.
Death was directly traceable to arteriovenous anastomosis operation in 3
cases, — 7.1 per cent.
Their conclusions serve very well to exhibit the dark side of the picture.
282 OPEKATIONS UPON BLOOD VESSELS
"There is experimental evidence to show that in animals the circulation through
the large veins of the extremities may be reversed, and that it is possible for the
normal pressure in the arteries to overcome the resistance of the valves in the veins.
"Experimental and clinical evidence show that the anastomotic opening is not
permanent, but that gradual obliteration by intimal overgrowth takes place in event
of the failure of early occlusion by a thrombus.
"There is not sufficient clinical evidence in the reported cases to show that the
pressure of blood in the arteries in the cases operated upon was sufficient to force the
valves in the veins.
"It is also shown by the cases reported that early occlusion of the vessels about
the anastomotic opening by a thrombus was the rule, and in many the opening never
at any time functionated.
"In event of the arterial blood forcing the valves in close proximity to the anas-
tomotic opening, it returns through the larger communicating veins in many, if not
most, instances, and does not transverse the capillaries.
"A study of traumatic arteriovenous aneurysm shows that with a normal arterial
pressure it requires weeks or months for the valves in the communicating vein to be
overcome, as is evidenced by the gradual development of varicosities and the long
delayed pulsation in veins remote from the seat of the aneurysm. Under these condi-
tions, the arterial blood supply is maintained partly through the usual collateral chan-
nels which are unobstructed. In cases of gangrene from obliterating disease of the
arteries, the collateral vessels are already occluded. In such a case, immediate re-
versal of the circulation is imperative. This cannot be accomplished at present : (a)
because of the obstruction offered by the valves ; (b) because in many cases the circu-
lating blood must also overcome the resistance offered by a thrombosed vein; (c) be-
cause the blood returns through the nearest communicating vein and does not reach
the peripheral capillaries.
"Our final conclusion is that there is but one indication for the application of
arteriovenous anastomosis in surgery; i. e., in traumatic destruction of a principal
artery, where end-to-end union of the torn vessel is impossible. In such a case, arterio-
venous anastomosis might be attempted, and through it we might maintain a sufficient
blood supply to preserve the integrity of the limb until an adequate collateral circula-
tion was established."
This is a gloomy picture, indeed, and Coenen adds nothing cheerful to it ;
but all of the cases chosen for this procedure were bad surgical risks, and none
of the operators had previously done more than 4 similar operations.
A criticism of their mistakes and a brighter view of the possibilities of
the operation are given by Bernheim. He says "animal experimentation, and
lots of it, is an absolute necessity to the surgeon who wishes to do clinical work
in the field of vascular surgery." In a paper on arteriovenous anastomosis
he collected 52 cases from the literature, up to 1912, not including 15 of the
cases collected by Halstead and Vaughan, but including 25 cases not men-
tioned in their table. Of these 52 cases, he calls 15 successful. Of these
"successes," 4 required amputation within 4 months. Another "success" died
of erysipelas on the fifteenth day after operation. Another had been followed
only 2 months. Another had pulsation in vein noted only for 8 days. In
another there was only improvement in the pain. Halstead and Vaughan re-
port two complete recoveries in their series of 42 collected cases, or 5 per cent.,
OPERATIONS UPON ARTERIES 283
and 6 partial recoveries, or 14 per cent. While Bernheim reports 15 "suc-
cesses/' or 28 per cent.
It would seem from a review of these statistics that success means one
thing to one operator, another to another. One is satisfied it' the vein pulsates
for a few moments, while another demands that there be arrest of the actual
gangrene present, or a disappearance of signs pointing to the onset of an ex-
pected gangrene, with return of the part to normal. Between these extremes
lie many possible chances for controversy that can never be settled until sur-
geons agree upon a definition of success in this procedure.
A middle ground seems safest as pointed out by Lilienthal, who makes
no extravagant claims. He believes that there is a field for the operation in a
certain few selected cases and that its attempt is justified in a considerable
number as a palliative measure to delay amputation or make possible amputa-
tion at a lower level than could otherwise be done.
In a personal communication Lilienthal states that he has recently done
4 cases of ligation of femoral vein (as suggested by Coenen, Hesse, and
Oppel) for expected gangrene in thrombo-angeitis obliterans, with absolute
relief of pain in 3 cases. He says there is no swelling of the leg as a result
of the ligation, but that, on the contrary, what swelling may be present is re-
lieved.
ARTERIAL SECTION
Arterial section is the procedure of incising an artery for the removal of
a blood clot and restoring the integrity of its wall by suture.
Binnie, pointing out the difference between an embolus lodged in an other-
wise more or less healthy artery and a thrombus formed in a segment of
injured or diseased vessel, wisely says in regard to the latter, "removal of
the blood clot alone is valueless, as another clot will form immediately." But,
"when the closure of the artery is due to the lodgment of an embolus, it is
logical to open the vessel by a longitudinal incision after providing for tem-
porary hemostasis, extract the clot, wash the interior of the vessel segregated
by the hemostatic tapes or slips with salt solution, smear it with sterile vase-
lin and close the wound with sutures."
For arterial section on vessels of the extremities the same instruments are
used as in arterial suture, including a sharp, small, thin-bladed scalpel.
Technic of Operation.— The operation is performed as follows: (1) The
artery is cut down upon in the location of the embolus and palpated care-
fully. If it is pulseless and feels solid it is carefully and gently isolated
from its sheath, temporary hemostasis applied, if necessary, a longitudinal
incision made through its superficial surface and the embolus extracted by
finder or forceps (which must not touch the intiraa), or by means of milk-
ing the vessel toward the wound. (2) When blood flows freely from peripheral
and central ends, temporary hemostasis is applied above and below 1
ment that contained the clot, the lumen washed out with warm saline
284 OPEKATIONS UPON BLOOD VESSELS
Einger's solution, and all the blood washed and sponged carefully out of the
surrounding wound. (3) The interior and cut edges of the vessel are then
moistened with liquid albolene and the incision closed in the same manner
as described for lateral suture of arteries. (4) The wound is then closed with-
out drainage. (5) If the circulation has been restored by the operation the
pulse should be felt at once in the artery or its branches below the point of
incision. (6) In case another embolus lodges, or a thrombus forms at the orig-
inal site, it is perhaps better to perform arteriovenous anastomosis at a point
below the embolus, if this is possible, than to repeat embolectomy.
The dangers and difficulties are no greater than in lateral arterial suture,
but the operation is very likely to be unsuccessful on account of thrombus
formation at the site of the embolus and the published results are therefore
bad.
Results. — Mat as mentions 1 cases that were reported previous to 1908. In
four of these the embolism occurred in the lower extremity. In all 7 another
clot promptly re-formed after removal. Later amputation had to be per-
formed in all the cases.
The pulmonary artery has been sectioned for embolus 12 times (up to
February, 1913) at Trendelenburg's Clinic. There were no permanent re-
coveries, but one patient lived 5 days after operation, dying of pneumonia.
For such operations upon the pulmonary artery Trendelenburg has devised
special instruments which are described with this operation.
I have been able to find but few recent cases of arterial section for embolus.
One is reported by Key. Twenty days after an attack diagnosed as probable
embolism or thrombosis of the mesenteric artery, with recovery after palliative
treatment, a man 43 years old, with mitral stenosis of several years' duration,
was suddenly seized with severe pain in left popliteal space, coldness and loss
of sensation in leg. Seven hours after onset operation was performed. In-
cisions over dorsum of foot and in popliteal space revealed empty vessels. The
common, deep and superficial femoral arteries were then exposed and resist-
ance was felt in the common femoral from its bifurcation 2.5 cm. upward,
which proved on incision of the artery to be an embolus completely filling its
lumen. Clamps were placed upon the common and deep femoral arteries and
the embolus removed with a consequent hemorrhage from collateral vessels
through external pudic and from the tissue incisions which had not bled
before. The limb was elevated after operation and during convalescence
there were noted temporary paralysis of the femoral muscles and thrombosis
of the external peroneal veins, with stricture of the gastrocnemius muscle,
probably caused by slight ischemic contracture. He found three cases of
operation for embolus in the literature, one success arid two failures. He
does not state whether the pulse became or remained palpable in the post-
tibial artery, but his case seems to have been successful in avoiding
gangrene.
Murad Bey did an arterial section for embolus of left brachial artery,
OPEKATIONS UPON VEINS
removed the clot and did a side-to-side anastomosis of artery and vein, central
to the point of embolism. A new thrombus rapidly formed.
Mosuy and Dumont were able to remove an embolus from the left femoral
artery 6 hours after its lodgment, through a 1 cm. incision in the vessel. The
circulation returned and continued.
Lejars removed a soft, dark thrombus from the femoral artery after gan-
grene had set in following thrombosis. The gangrene, however, was not
stopped.
Trendelenburg suggests the intravenous injection of hirudin to prevent
the re-formation of thrombi in the vessels. Jeger says Bodong and Jacobi
have shown that in animals the injection of considerable amounts of hirudin
gave rise to no noticeable interference with respiration, circulation or general
condition, and that the injection in the proportion of approximately 1 mg.
hirudin to 5 c. c. blood delayed clotting for 4Vi> hours.
TRANSPLANTATION OF AKTEBIES
So far, for the reason that venous transplants are satisfactory in function-
ing and require no serious circulatory disturbance to procure, transplanta-
tion of arteries is not at present being done in human patients. In animal
work, however, the following results are encouraging.
ARTERIAL TRANSPLANTS
SUCCESSES
Stich
2 autoplastic
2
8 autoplastic . .
5
Stich
5 home-plastic
3
Borst and Enderlen
7
Yamanouclii
5 homoplastic
3
Yamanouclii
6 hctcroplastic
2
Stich
4
Ward
1
H. OPERATIONS UPON VEINS
ANATOMICAL CONSIDERATIONS
In planning or undertaking any operative procedure upon veins it must be
remembered that we are dealing with collapsible tubes, generally larger in size
than the arteries they accompany, with much thinner walls, and with lumina
larger in proportion and guarded at intervals by valves ; nor should it be for-
286 OPEKATIONS UPON BLOOD . VESSELS
gotten that, in superficial veins, the anastomosing plexus is larger and denser
than in arterial vessels. Moreover, it should be understood that, due to the
very different internal pressures under which they exist in the living organ-
isms, veins are normally not distended anywhere near to their elastic limit,
while arteries frequently are so. Besides this, their walls, although primarily
divisible into the same number of layers as those of arteries, contain much less
muscular and comparatively far more elastic and fibrous tissue. Directly de-
pendent upon these structural and functional differences we find that a vein,
emptied of blood, collapses and its lumen becomes obliterated; that it can be
stretched, transversely and longitudinally, to a comparatively greater degree
than an artery; that, when its wall is partially divided by a transverse (or
more especially by a longitudinal) wound, the edges of this tend to fall to-
gether or, at any rate, gape much less than in a similar arterial injury; and
that, when transversely divided completely, their stumps do not retract nearly
to the extent of those in a divided artery, nor does the periphery of the vessel
contract, nor does its lumen remain patent^
OPERATIONS TO CHECK BLEEDING
Posture. — Elevation of the part above the level of the rest of the body will,
by facilitating venous return, help to check oozing.
Bandages and Compresses. — Bandages and compresses applied closely to
the bleeding point will readily check venous bleeding by pressure obliteration
of the lumen.
Gauze Packing. — Gauze packing inserted fairly tightly into a deep wound
will control venous bleeding in most cases by partial obliteration of the lumen
and mechanically favoring clotting.
Digital Pressure. — Digital pressure may be used in the same manner as to
control arterial bleeding, except that it must be applied directly over the
bleeding point or distal to it.
Torsion, Forcipressure, Terminal Ligation and Ligation en Masse. — These
methods of treatment are used in the same manner as for arterial bleeding.
Actual Cautery. — The actual cautery at a red heat is useful, at times,
where ligation is difficult on account of multiple bleeding points.
OPERATIONS TO RESTORE OR REESTABLISH THE CIRCULATION
LATERAL LIGATION
Lateral ligation is the lateral application of a ligature to close a wound in
the wall of a vein. It is permissible only in small wounds of large veins where
the resulting plication of the wall will not considerably encroach upon the size
of the lumen.
The margins of the wound are carefully grasped in a hemostat and drawn
OPERATIONS UPON VEINS 287
gently in a lateral direction while a ligature is tied around the base of the cone
formed by that part of the wall drawn out in the grasp of the forceps. If the
ligature includes the entire wound periphery and is properly tied, the result is
satisfactory, as the low blood pressure in the veins will not force the ligature
off..
SUTURE OF VEINS
In considering the suture of veins certain anatomical points regarding their
structure must be kept in mind. The wall is thinner, less elastic and more
flaccid than in arteries and they are more easily torn. They require more
stitches in anastomosis than do arteries to prevent leakage and their edges
must be everted. They are more liable to thrombus formation on account of
slower blood current and less liable on account of the constituency of the blood.
It is interesting to note the different opinions voiced regarding the rela-
tive ease of accomplishment of a vein suture as compared with the same pro-
cedure in arteries. Matas says, for example : "The suture may be applied to
veins in continuity (lateral phleborrhaphy) in longitudinal, oblique and
transverse wounds. The rules which govern the technic of arterial suture
apply here with the same force and with greater advantage. The thinness,
softness and suppleness of the venous walls make them more amenable to the
suture than the arteries. The low tension of the venous current also favors
the maintenance of accurate apposition without tension and favors the work
of repair. The suture of veins is, therefore, not only a much easier procedure
than the suture of arteries, but the healing of the line of suture takes place
with regularity, provided sepsis has been rigorously excluded." Jeger, on the
other hand, says : " . . . suture of veins presents various difficulties not
present in arterial suture.
"With the latter, the lumen remains wide open on account of the thick-
ness of the wall ; it is plainly visible even in very small arteries, and one may
accomplish all the procedures (suture, adaptation of the vessel ends to each
other, and so forth) with the fullest exposure of the vessel wall and almost
without the use of a forceps ; and if one has first properly inserted the three
tension sutures, the margins of the vessels automatically rest properly together
throughout the whole circumference. Quite otherwise is the case with veins.
These collapse after being fully divided; the lumen is often only to be dis-
covered after long search; the vein must be held open with instruments, so
there is naturally much handling of the walls with forceps, and consequently
numerous lesions of the endothelium itself are unavoidable. It is indeed true
that the circular suture of veins, in the hands of many experimenters, has
afforded as good or better results than circular arterial suture, but this is
founded on the greater diameter of the veins and perhaps also on the some-
what less active tendency to coagulation in the venous blood. In order to pro-
ceed quite safely, one must absolutely refrain from the above-mentioned
sources of failure."
288 OPERATIONS UPON BLOOD VESSELS
Lateral suture of veins is indicated, to repair, in any important vein, a
wound too extensive for lateral ligature. It is contra-indicated by any
phlebitis, periphlebitis, or infection of wound.
The operative technic is the same as that for similar repair in arteries
except that, instead of direct apposition of cut edges, care is taken to secure
slight eversion of wound margins so as to insure fairly broad intimal approxi-
mation. This can be done with more certainty by mattress suture than by
overhand stitch, either continuous or interrupted. The object is, of course,
to avoid the possibility of inversion of the cut edges, which is much more
likely to occur here than in arterial suture on account of the thinness and
pliability of the vein wall. Such an inversion leads to rapid thrombus
formation.
Results. — The results of lateral suture of veins are excellent.
VENOUS ANASTOMOSIS
Venous anastomosis, like arterial, may be done end-to-end, end-to-side, or
side-to-side, but in human beings the end-to-end is the only method that has
been used with any frequency.
End-to-End. — The indications and contra-indications are the same (as ap-
plied to veins) as those given for end-to-end arterial anastomosis.
The technic of a circular venous suture is exactly similar to that of a
circular suture of arteries, already described, except for the management of
the cut margins of the veins; these should be somewhat everted instead of
being brought edge to edge, so that intimal apposition is assured. To accom-
plish this Jeger recommends the following procedure :
Open the lumen of both segments of veins by grasping the margins of
each in three mosquito clamps placed at equal intervals, and insert 3 traction
FIG. 57. — VEIN ANASTOMOSIS, END-TO-END; APPLICATION OF TENSION SUTURES TO PROVIDE EVER"
SIGN OF CUT EDGES.
sutures, at equal intervals, as shown in diagram (Fig. 57). These are longi-
tudinal "U" sutures whose nearer limb is 3 mm., and whose further is 4 mm.,
from the cut edge. By first drawing tight and then tying these 3 sutures the
lips of the approximated venous segments are slightly cuffed and the usual
continuous suture along the three sides of the triangulated lumen completes
OPERATIONS UPON VEINS 289
the anastomosis. This method avoids including, in the surface that is to be
exposed to the blood stream, any part of the intima that has been handled
by forceps, and Jeger says the results are absolutely faultless.
Carrel, too, mentions the necessity of everting the edges of veins and
says they are "united not by their surface of section, but by their endothelial
surface." Murphy's or Payr's method of invagination may, of course, be
used; but neither of them promises as good results as have already been
achieved by the Carrel suture. The Lespinasse and Eisenstaedt method has
not yet apparently been tried in a human.
Jeger and Janeway have both devised special instruments to facilitate the
approximation of venous segments for end-to-end anastomosis.
EESULTS. — Theoretically, it would appear that the dangers of suturing a
vein were more formidable and the chances of untoward sequela? greater than
in the sutures of arteries. In the first place the veins are apparently more
susceptible to infection than the arteries. In the second place any foreign
matter, as air, tissue, dirt, bacteria, etc., allowed to enter the vein at the anas-
tomotic site, travels toward the central dangerous region instead of going toward
the comparatively safe periphery, as it does when introduced into an artery.
And, lastly, this same condition holds good with regard to possible loose por-
tions of such a clot as unfortunately forms in a certain per cent, of cases at the
anastomotic site. Thus we should expect local infection, thrombo-angitis, pul-
monary embolism, and similar unfortunate results of blood vascular infection
more often in venous than in arterial sutures. Such, however, is not apparently
the case.
Statistics show little difference between the percentage of successful results
in end-to-end anastomosis of veins and of arteries. Glasstein, for example,
reckons 62% per cent, successes for circular suture of veins, in a series of 53
collected cases in humans, and 68 per cent, successes for circular suture of
arteries in a similar series of 37 collected cases. One hates to appear critical
of optimism, but it would seem possible that he has not too high a standard
of success, judging his deductions by those of others.
RESULTS IN VEINS OF ANIMALS. — The results of circular suture of veins
in animals as quoted by Jeger are shown below and may be noted in connec-
tion with Glasstein's statistics :
Stich reports 2 cases, 1 successful = 50 per cent, successes ; Borst and
Enderlen report 14 cases, 7 successful = 50 per cent, successes; Yamanouchi
reports 43 cases, 24 successful — 56 per cent, successes.
It is interesting to find that certain authors claim better results in venous
than in arterial suture. Schiller and Lobstein claim over 40 per cent, success
with arterial suture and 60 per cent, with venous circular suture.
End-to-Side. — The only practical application of an end-to-side venous
anastomosis that has been made in human surgery so far is the re-implantation
of the saphenous into the femoral vein ; and the technic of the suture opera-
tion will be found, further on, among procedures designed to remove the cause
20
290
OPERATIONS UPOH BLOOD VESSELS
of circulatory disturbances due to varicose veins. The technic of Jeger's
method, however, may properly be detailed here.
The anastomosis may be made by suture in precisely the same manner as
described under arteriovenous anastomosis, end-to-side.
Jeger recommends, as simpler and giving absolute assurance of perfect
ilffllf/fflllfff/ffiWW/
I
~\Z7
FIG. 58. — VEIN ANASTOMO-
SIS, END-TO-SIDE. Jeger 's
method: 3-loop suture in-
serted in larger vein and
dotted line showing inci-
sion.
FIG. 59. — VEIN ANASTOMOSIS, END-TO-SIDE.
Jeger' s method: introducing small vein
into side of larger.
endothelial apposition, a method he and Wilhelm Israel devised, using a
Payr's ring and a special Jeger clamp to manipulate it (Fig. 21) as follows:
The smaller vein is sufficiently freed, clamped and prepared and its cut
end is then passed through, cuffed back over and tied upon the ring by a fine
silk ligature. A three-loop suture is then introduced
through the wall of the larger vein as shown in Figure
58 and the needles are cut off, leaving a middle and
two lateral loops. A small incision is then made be-
tween the limbs of the middle loop after isolating this
portion of the vein with a small, special curved clamp
(Fig. 6). The clamped off portion of the vein is then
washed and vaselined, its edges held up by traction
sutures and the smaller vein placed within its aper-
ture (Fig. 59). The middle loop is then carefully
tightened and securely tied upon that part of the cuff
of the smaller vein that contains the ring, the ligature
fitting snugly into its furrow (Fig. 60). Lastly, the
two lateral loops are tied and the ends of these and the traction sutures cut short.
Jeger has done 23 implantations of renal vein into vena cava (on animals)
by this method with only one thrombus.
Side-to-Side. — The only notable application of the lateral venous anas-
tomosis in human surgery so far is the Eck fistula, done for hepatic cirrhosis
FIG. 60. — VEIN ANASTOMO-
SIS, END-TO-SIDE. Jeger's
method: smaller vein in-
troduced, middle loop tied
on ring and ends cut off.
Lateral sutures being
tied.
OPERATIONS UPON VEINS
291
by Eosenstein. The description of the operative steps in performing an Eck
fistula operation comes properly under operations on the liver, etc., but the
technic of the suture itself is exactly
the same as that described under
arteriovenous anastomosis, side-to-
side, by suture.
Jeger has devised a three-bladed
clamp, closely resembling a minia-
ture Roosevelt gastro-enterostomy
clamp (Fig. 61) by the aid of which
he says he can do an Eck fistula on a
dog in 35 minutes. Its mode of appli-
cation is shown in Figure 62 and the
technic of the suture is otherwise the
same as before. Jeger advises oval
pieces to be excised from the vein
walls instead of mere slits being
made, as the latter show a tendency to
close spontaneously, just as in the case of arteriovenous anastomosis.
FIG. 61. — JEGER'S S-BLADE CLAMP FOB ISOLATING
PARTS OF Two VESSELS WITHOUT INTERRUPT-
ING THE CIRCULATION IN THE REMAINDER.
Section of blades.
TRANSPLANTATION OF VEINS
The transplantation of veins, as regards vascular surgery, means the re-
placement of a defect in any vessel by a segment removed from some other
vessel, practically always a vein and practically always of the same individual.
FIG. 62. — VEIN ANASTOMOSIS, SIDE-TO-SIDE: JEGER'S CLAMP SHOWN ISOLATING PARTS OF THE VENA
CAVA AND VENA PORTA WITHOUT INTERRUPTING CIRCULATION THROUGH REMAINDER OF VEINS.
End, middle and lateral traction sutures and posterior layer of continuous suture shown.
This is called autoplastic transplantation as differentiated from homoplastic
and heteroplastic, and has been more successfully used than any other variety
292 OPEKATIONS UPON BLOOD VESSELS
thus far. So many successful homoplastic and heteroplastic transplantations,
however, have been done on animals that it is possible any day may see the
report of some such cases in human patients. Transplantation may be used
to fill a defect caused by excision, crushing, etc., of part of a vessel whose
simple ligation would be dangerous to the life of the part.
Besides simple autoplastic, Guthrie suggests other material that might be
used to fill defects in vessels :
(1) Similar vessels from another human being, — homoplastic;
(2) Vessels from a different species, sheep, etc. — heteroplastic;
(3) Cold storage tissues (not recommended on account of possible putre-
factive autolytic change in them) ;
(4) Formaldehyd fixed tissue (safer than cold storage) ;
(5) Possibly, tissues not of animal origin might be used; tubes of cel-
loidin, glass, etc. ;
(6) Von Hagen, quoted by Jeger, advises calves' arteries fixed in the fol-
lowing manner: 10 per cent, formalin solution; water washing; increased
alcohol strengths; absolute alcohol; xylol till fully cleared; liquid paraffin
over night. Such vessels showed no sign of absorption after six months. They
were encapsulated in connective tissue.
Methods. — The actual union consists of a double end-to-end suture as de-
scribed under end-to-end arteriovenous or venous anastomosis, but several
points are to be mentioned that do not come up for discussion under those
operations.
To supply a defect in femoral, popliteal, brachial, or axillary artery, a
piece of internal saphenous vein may be excised. This must be a little longer
than the defect to be bridged and can be trimmed to suit with sharp scissors.
Before final suture at both ends it should be between % inch to % inch shorter
than the arterial defect when artery ends are naturally retracted. If it is too
short it will put too much strain on the sutures. If too long it will form a
curve in the line of the artery when the blood is allowed to flow through it. If
valves exist in the removed segment of vein it should be reversed, in its new
position, so that the blood current may not be obstructed by the valves.
It is better to -insert the 3 tension sutures at each end of the transplant
before beginning the continuous suture at either end.
If the vein is much larger than the artery Jeger advises that the latter be
cut after Dobrowolskaja's method to meet more nearly the size of the vein.
(Fig. 63.) Guthrie and Carrel advise longer stitches in the vein than in the
artery, all around the circumference, to accommodate its lumen to that of the
artery. Jeger also advised, in excising the vein for a transplant, to cut partly
through it and apply a mosquito clamp to the cut edge, cut further and repeat
this procedure twice, so as to identify front and back or sides of the transplant,
by the 3 or 4 clamps at equal intervals, which also serve to spread the lumen
for application of tension sutures.
linger has small, numbered clamps, 4 of which he attaches in this manner
OPERATIONS UPON VEINS
293
k
to the upper and lower ends of the transplant while excising it, and these serve
to prevent the transplant becoming twisted on its long axis without the opera-
tor noticing it. These clamped portions must not come in contact with the
blood stream when both lines of suture have been completed.
Boothby describes a method for setting stay sutures before the vein is
removed for transplantation: (1) The vein is freed for 2 inches or more and
is ligated at both ends. (2) Grasp vein
with smooth forceps near upper liga-
ture and cut very small aperture. (3)
Insert a suture, from without in, near
the aperture and make it emerge
through this. (4) Repeat this procedure
twice at upper end and three times at
lower end of segment until 3 stay su-
tures are prepared at each end, at equal
distances apart. (5) Then divide the
transplant beyond these sutures and, by
means of them, attach it to the ends of
the defective vessel in its new position.
Operative Steps. — The steps of oper-
ation of free vein transplantation to fill
an arterial defect are: (1) Prepare
ends of resected artery, as described in
end-to-end arterial anastomosis by su-
ture, and cover them with liquid albo-
lene. Pack the tissue wound loosely
with wet gauze sponges after measuring
length of arterial defect. (2) Expose
internal saphenous vein near saphenous opening by a liberal incision. Isolate
it carefully and thoroughly from its bed for a sufficient distance and measure
off on its freed portion a length y2 inc^ greater than the arterial defect. (3)
Apply distal and then proximal temporary hemostasis beyond this portion and
ligate and divide any intervening tributaries. (4) Fix and identify ends of
transplant by Jeger's, Unger's or Boothby's method (previously described) and
excise the included segment of vein. (5) Wash out all blood immediately,
cover it inside and out with liquid albolene and protect it in moist warm
gauze. (6) Uncover artery, reverse transplant, end-for-end (to obviate obstruct-
ing blood current by valves), and lay it in the arterial defect. (7) Connect each
end to the arterial stump by three traction sutures, using care not to twist the
vein on its long axis, and unite by continuous suture, as described in end-to-end
arteriovenous anastomosis (Fig. 64). (8) Remove temporary hemostasis, apply
pressure and add complementary sutures as indicated. (9) Close wound of
exposure for artery and saphenous veins.
Results. — The results are exemplified in the report of these cases.
FIG. 63. — CUTTING ARTERY TO MATCH VEIN
AND PUTTING IN STAY SUTURES.
294 OPERATIONS UPON BLOOD VESSELS
Goyanes, in 1906, excised popliteal aneurysm and filled defect with piece
of vein. Successful result.
Delbet, in 1906, filled an 8 cm. defect due to removal of aneurysm in one
person by a transplant of artery from another individual whose limh was
being amputated at the same time. The operation failed as the transplanted
artery was sclerotic and the sutures tore through. The femoral artery had
to be ligated. Result : amputation.
Lexer, in 1907, transplanted 8 cm. of vein into a defect of axillary artery,
caused by removal of aneu-
rysm. Result : death from
delirium tremens, fifth day.
D°yen> in 1909> in a Pa~
tient with edema of leg fol-
lowing excision of part of
FIG. 64. — ARTERIAL DEFECT FILLED BY DOUBLE END-TO- . e
END SUTURE WITH VENOUS TRANSPLANT. popliteal vein IOr aneurysm,
implanted the external jugu-
lar of a sheep, end-to-side in popliteal vein, above the obliterated area, and
joined it end-to-end with the posterior tibial vein after making a subcutaneous
canal for it. The operation resulted in complete healing, but he does not men-
tion whether the edema was relieved.
Enderlen, in 1909, after resecting part of femoral artery for sarcoma,
transplanted 15 cm. of saphenous vein from another limb. Result: smooth
healing.
Goeckes, in 1912, reported the excision of a right popliteal aneurysm.
An 8 cm. defect was filled by a 10 cm. transplant from left saphenous vein, set
with valves favoring flow of blood. The operation was immediately success-
ful. Pulsation in posterior tibial was felt strongly at once and beginning gan-
grene of foot healed. After 14 days, however, the tibial pulse grew weak and
the wound broke down and a small fistulous tract persisted. The clinical
result, however, was good and the patient was able to go freely about. He
died 5 months later from abscess of knee-joint and endarteritis of coronary
arteries. In the vessel, thrombi occluding it were found at both suture lines,
on autopsy.
Omij in 1912, reported that he had excised a right popliteal aneurysm
leaving a defect of about 8 cm. This he filled with an 8 cm. piece of the left
saphenous vein, by circular suture. He forgot to reverse the vein and the
valves held the blood back. He then divided the vein at valve level, resected
the valves and did a circular suture of the cut vein ends. Good pulsations
appeared in vein and peripheral part of artery, but were not felt in posterior
tibial or dorsalis pedis. Gangrene developed in foot in a few days; patient
refused amputation and died in a short time.
After excision of popliteal aneurysm, in another case, leaving a defect of 7.5
cm., he filled it with an 8 cm. piece of femoral vein, reversed so as to favor
passage of blood through valves, by Carrel circular sutures. Pulse felt after
OPERATIONS UPON" VEINS 295
operation in dorsalis pedis and posterior tibial artery. Excellent result, ap-
parently permanent.
Omi recommends autoplastic vein transplantation in human beings, at
present, as safest.
EESULTS IN ANIMALS. — Venous transplantation in animals shows a
higher percentage of success than in man. According to the reports of Fischer,
Schmieden, Watts, Stich, Yamanouchi, Borst and Enderlen, as collected by
Jeger, we find in autoplastic transplantation 42.8 per cent, and in homo-
plastic transplantation 28.6 per cent, successes, where the transplant was made
into the cervical vessels of dogs.
OPERATIONS FOE DRAINAGE OF CAVITIES, ETC.
The transplantation of veins for purposes other than that of repairing de-
fects in blood vessels may here be mentioned, although the operative details
belong, and will be given, under regional headings.
Hitter has reported the use of free transplanted veins and arteries, as cov-
ering for and connections for divided tendons and nerves, with some success.
linger and Bettmann, in 1910, reported the use of pieces of transplanted
vein (fresh or cold storage) to press upon a defect in the sinus longitudinalis
with resultant closure of wound by adhesion of pieces of vein.
Jeger says that Tietze attempted unsuccessfully to cure a gonorrheal stric-
ture by excising a 6 cm. portion of the urethra and replacing it by a 9 cm.
transplant of saphenous vein ; and that Becker attempted, with partial success,
to construct a urethra in two cases of severe hypospadias by drawing a piece
of saphenous vein through a canal made by a trocar in the penis ; while Stet-
tiner constructed a practicable urethra, in a case of hypospadias, out of a 12
cm. piece of saphenous vein. Taupas of Athens, Von Eiselberg and Muhsam
have done similar operations.
Rouotte, in 1907, and Castle, in 1911, have reported two successful veno-
peritoneostomy operations. Henle and Bakay, Payr, and also McClure used
pieces of saphenous vein (also of artery) to drain ventricles of the brain and
a transplant of the external jugular vein to drain the subdural space.
OPERATIONS TO ALTER BLOOD OR CIRCULATION FOR STIMULATION OR
MEDICATION
INTRAVENOUS INJECTION
By this is meant the injection of a soluble drug or other fluid through a
hollow needle directly into a vein, usually of the arm. It may be used where
the rapid and direct action of any soluble curative agent, as, for example,
injections of salvarsan in syphilis and of blood serum in anemia and hemo-
philia, are required. The preparation of the solution will be described under
296 OPEKATIONS UPON BLOOD VESSELS
the appropriate therapeutic heading, but the technic of the injection is as
follows :
(1) The left arm, preferably, is bared to the shoulder and the antecubital
region either cleansed, as in general operative field preparation, or painted with
tr. iodin, which is washed off with alcohol after being allowed to dry. (2)
A constricting band of rubber, gauze or muslin is placed around the middle
of the arm sufficiently tight to obstruct the venous return and dilate the super-
ficial veins. (3) The vein (median basilic usually selected) is steadied be-
tween thumb and finger of left hand and the needle, which must be very sharp
and smooth, held like a scalpel between the thumb and fingers of the right
hand, is thrust rapidly and carefully through the skin into the dilated vein.
Free bleeding through the lumen announces its entrance, whereupon the con-
strictor is removed. The needle should enter the vein very obliquely so as
to avoid puncturing the opposite wall and must be held steady after entrance
to avoid scratching the intima.1 (4) The shaft of the needle is steadied in the
left hand ; the syringe is held vertical, nozzle upward, in the right hand, and,
after expelling all the air, is inserted carefully into the needle and the injec-
tion made slowly and steadily. (5) The needle is then rapidly and carefully
withdrawn and pressure made with the fingers on a gauze pad over the punc-
ture for two or three minutes. A dry dressing is then strapped on in its place.
(6) Careless or unskillful introduction of the needle may wound the opposite
wall of vein with a resultant hematoma and no free bleeding from needle. It
is possible to wround the brachial artery which lies beneath the median basilic,
separated from it only by deep fascia. If these accidents are avoided and
proper asepsis practiced, there are no bad results.
INTRAVENOUS INFUSION
Intravenous infusion is the direct introduction through a cannula into the
venous system of a considerable amount of solution for the purpose of increas-
ing the fluid contents of the vessels and raising blood pressure.
Solutions. — So-called normal saline is most commonly used. This is pre-
pared by adding 6 to 8 parts of sodium chlorid to 100 of filtered water. It is
sterilized by boiling or by steam under pressure. Other solutions that have
been tried are:
RINGER'S FLUID:
Potassium chlorid 0.2 gm.
Sodium bicarb 0.2 gm.
Sodium chlorid 9.0 gm.
Distilled water q. s. add 1 liter.
1 Steps (1), (2), and (3) of this procedure may be followed to obtain specimen of
blood for Wassermann test, etc.; in such case the constrictor is not removed until the re-
quired amount of blood has been obtained.
OPERATIONS UPON VEINS 297
LOCKE'S FLUID (more satisfactory in its effect) :
Potassium chlorid 0.10 to 0.20 gin.
Sodium bicarb 0.10 to 0.20 gm.
Calcium chlorid 0.20 gm.
Glucose 1.0 gm.
Sodium chlorid 9.0 to 10.0 gm.
Distilled water, 1 liter.
KUTTNER'S SOLUTION :
Decinormal saline solution 1,000 c. c.
Oxygen gas (approximately) .* 20 c. c.
These solutions are sterilized in the same way as simple saline solution.
TEMPERATURE OF FLUID.— Temperature of fluid should be from 105°
to 120° F., in the container, depending on the size and length of tubing
through which it has to flow to the cannula. Temperature of fluid leaving the
latter should be not over 105° F.
PRESSURE OF FLUID. — Eeservoir of fluid should be only about 12 inches
(30 cm.) above vein. Greater height gives unnecessary and even injurious
pressure.
TIME OF INFUSION. — Infusion should not be given faster than 1,000 c. c.
in 10 to 20 minutes.
AMOUNT OF FLUID. — In adults 500 to 1,000 c. c. may be used or more ac-
cording to patient's reaction as expressed in rise of blood pressure.
Much larger amounts of saline than of blood are tolerated. More can be
given with benefit in treatment of hemorrhage than in treatment of shock,
and Locke's solution is perhaps preferable for patients in an exhausted condi-
tion. Adrenalin 1 : 1,000 may be added to the solution in amounts of 10 to
20 minims or may be injected .by a hypodermic syringe (after Crile) into the
rubber tube near the cannula at the rate of 10 or 15 minims in one minute.
Infusion has been used for acute anemia resulting from operative or post-
operative, traumatic, pulmonary, gastric, intestinal, uterine, etc., hemorrhage;
in great loss of body fluid, as in Asiatic cholera ; for flushing the vascular sys-
tem, in acute poisoning, auto-intoxication, such as typhoid, diabetic coma,
puerperal fever, eclampsia gravidarum, bubonic plague, uremia, and blood
poisoning, following venesection; for resuscitation in suspended animation
(Locke's solution injected into carotid artery with reversal of current) ; in
chronic postoperative anemia and for artificial nutrition (Locke's and Len-
naiider's glucose saline solution; or sterile isotonic sea-water, plasma de Quin-
ton).
Binnie says (1912) : "The principal indications for intravenous infusion
of salt solution are shock and hemorrhage. Hypodermoclysis and proctoclysis
have largely taken the place of intravenous infusion."
Certainly saline infusions are less commonly used, and hypodermocly-
sis and proctoclysis are more often employed than they were several years
ago.
298
OPERATIONS UPON BLOOD VESSELS
is
Infusion is contra-indicated, according to Matas, "in all cases where there
already a dilatation with distention of the heart and consequently general
venous stasis." The condition is evidenced hy cyanosis of face and extremities
and overfilling of the superficial veins.
Instruments, etc., required are forceps, scalpel, ligature carrier, ligatures,
cannula, tubing and reservoir, salt solution, skin suture, dressings.
Method.— (1) Select the arm least used by the patient and surround it by
a constrictor midway between elbow and shoulder, sufficiently tight to dilate
superficial veins. Prepare the skin of the antecubital region by washing or by
applying tr. iodin. (2) Select the most prominent vein, usually median basilic
or cephalic; anesthetize locally with 0.5 per cent, novocain and adrenalin, and
incise skin and fascia over it longitudinally or
obliquely for about 1 inch. Expose and isolate
the vein by sharp dissection and free it suffi-
ciently to pass a double catgut ligature around it
in an aneurysm needle. (3) Tie the distal liga-
ture permanently ; set a loose friction knot in the
proximal ligature. Cut a triangular flap in the
superficial surface of the vein, between ligatures,
with its apex pointing distally. Occlude the
opening by finger pressure of left hand. (4)
Grasp the cannula in the right hand ; hold it ver-
tical and allow fluid to flow till all air is got rid
of. Then grasp the tip of vein flap with forceps
in the left hand and introduce the cannula into
the lumen while solution is flowing (Fig. 65).
(5) Tighten the friction knot upon the cannula
and place a finger on the vein, proximal to it, to
regulate rate of flow. Let it be very slow at first,
increasing gradually to the rate of 1,000 c. c. in 20 minutes. Allow the fluid
to flow until observations of the pulse, taken every minute or two, show a return
toward normal tension. In most cases less than 2,000 c. c. are enough to accom-
plish this if it can be done at all. (6) Remove the cannula, solution still flow-
ing ; tighten the friction knot in proximal ligature and reinforce it. Close the
skin wound by sterile adhesive or silk suture, apply gauze dressing and
bandage.
The operation is a very simple one, except in fat people with small veins
or when the superficial veins are empty on account of low blood pressure. In
such cases it may be difficult to find a vein and the brachial artery has occa-
sionally been opened in the search for the median basilic vein.
Too rapid introduction of saline may overwhelm an already weakened
heart and do more harm than good. Too large an infusion may result in
transudation into serous cavities.
Any superficial vein may be used instead of the antecubital.
FIG. 65. — INTRAVENOUS INFU-
SION: CANNULA INTRODUCED
INTO VEIN AT ELBOW.
OPERATIONS UPON VEINS
Slowly and carefully given infusions are undoubtedly of value in cases of
hemorrhage and shock, and bad results, such as every surgeon occasionally sees,
are generally due to haste and carelessness. But, except in urgent cases, the
results in raising blood pressure and replacing lost body fluids are no better
than those from hypodermoclysis and proctoclysis, very much simpler and
easier procedures.
BLOOD TRANSFUSION
Blood transfusion is the transference of blood from the circulation of one
individual to that of another. It may be accomplished by joining the vessels
by suture or tube (direct transfusion) or by withdrawing blood from one indi-
vidual into a syringe or vessel and then injecting it into the other individual
(indirect transfusion). In the recent past the direct method has been more
used, but the indirect method is gaining ground at present on account of its ease,
simplicity, and the ability to measure the amount of blood transfused.
In 1909 Crile wrote: "The question as to what pathologic condition may
be suitably treated by transfusion of blood from one human being to another
has not been definitely settled. The most that can be said at present is that it
is clearly indicated in certain conditions and as clearly contra-indicated in
certain others. With our present knowledge the author feels that it should
be used only when all other resources at command have failed."
Since that time transfusion has been found serviceable in cases of acute
anemia from hemorrhage of traumatic, operative, or other origin, such as
gastric or typhoid ulcers, ruptured extra-uterine pregnancies, etc. It has been
used with some success to raise the blood resistance of anemic patients as a
preliminary to operation.
It has been used a number of times iu pernicious anemia without perma-
nent benefit in most cases. In melena neonatorum it has proved most valuable
and its use in hemophilia in general has been satisfactory. In illuminating
gas and carbon monoxid poisoning, and others where methemoglobin is formed.
Crile has resuscitated a number of cases by transfusion. Cole recommends it
in pellagra. Surgical shock has been treated satisfactorily by transfusion.
Certain toxemias (as of pregnancy) seem to be amenable to it.
Infectious diseases, such as scarlet fever, and septicemias, such as staphy-
lococcus, have been treated, and perhaps improved.
Walter has tried infusing pernicious anemias with blood of polycythemics.
Delbet has suggested infusing typhoid patients with blood of those who have
had, and survived, an attack and show a strong immunity. Lilienthal says:
"In transfusion in typhoid the donor should always be one with acquired im-
munity, to avoid replacing the, at least partially, immune blood of recipient by
non-immunized blood." (Personal communication.) Bevan says there is
evidence of its value in sarcoma. Jeger recommends it also in jaundiced
people, before serious operation, to prevent bleeding.
300 OPERATIONS UPON BLOOD VESSELS
E. II. Pool, in a personal communication in regard to the use of transfusion
in jaundiced patients, says: "The case to which I referred was a woman
about 35. She had extreme jaundice as a result of a stone in the com-
mon duct. She received calcium lactate for some days before operation,
but we did not give her serum because she had received considerable serum, a
few months before for a very severe streptococcus septicemia, and I was afraid
of anaphylaxis. About 48 hours after the operation for stone in the common
duct she began to ooze extensively until she was practically moribund. Her
coagulation time was 15 minutes. A transfusion, using her sister as donor,
was made with marked improvement, but after three days the oozing recurred
and the patient again got into extremely bad condition, so that a transfusion
was again performed and the coagulation time dropped from 15 to 6 minutes;
the oozing stopped and the patient made an uneventful recovery from that
time.
"I am inclined to think that this is the first case in which transfusion has
been performed for postoperative oozing in jaundiced patients. The drop in
the coagulation time from 15 minutes to 6 was striking.
"Subsequently, a patient, an old man with a stone in the common duct, was
markedly jaundiced and I did a preliminary transfusion and operated im-
mediately afterward. He had no postoperative oozing."
Jeger says it is absolutely contra-indicated in the presence of organic heart
disease, because the heart is not equal to any suddenly increased work, and
Dorrance and Ginsberg say that it is contra-indicated in any case where
hemolysis is taking place, as in purpura hemophilia.
For direct transfusion from artery to vein the radial artery of donor and
one of the superficial veins at the elbow of the recipient are generally em-
ployed. Occasionally the internal saphenous, or some other superficial vein,
may have to be employed on account of infection, etc., at elbow. Either left
or right side may be chosen according as donor is right or left-handed.
The instruments required for any direct transfusion are the usual dissect-
ing outfit of scalpel, dissecting forceps, scissors, artery forceps, serrefines,
catgut, and silk ligatures and sutures. Special appliances, such as Crile's
cannula, Brewer's tubes, etc., will be described in connection with the descrip-
tion of their method and use.
Whatever method of transfusion is employed, however, there are certain
common details that should be observed preliminary to and during the opera-
tion. These we may now consider under the term
General Management of Transfusion. — In every case where time is allowed
and facilities are at hand several blood pressure determinations should be
taken and several pulse rate estimations made. A complete red blood cell
count and white blood cell count and hemoglobin estimation should be secured
on both donor and recipient before transfusion is begun ; the last to serve as a
basis for comparison with similar examinations after the operation is over and
during the after care. The two former are to serve as standards for compari-
OPERATIONS UPON VEINS 301
son with similar observations made during the progress of transfusion, obser-
vations upon which, in part, the operator bases his judgment as to the proper
duration (or amount of blood transfused) for the transfusion flow.
Hemolysis and agglutination tests of donor's and recipient's blood should
also be made, if possible ; but the necessary omission of any of these prelimi-
naries and precautions does not centra-indicate the operation by any means.
(Bernheim.) Lilienthal thinks hemolysis and agglutination tests imperative.
A careful examination of the donor should be made to discover any signs
of disease that might make the use of his blood dangerous for the recipient.
This examination ought, if possible, to include serum reactions for syphilis
and gonorrhea, unless the donor is known to be free from any suspicion of
venereal disease.
Each patient should be given % to % grain of morphin (unless contra-
indicated) 30 minutes before operation, and should be reassured as to pain,
danger, etc.
During the transfusion Bernheim recommends controlling the inflow of
blood by finger pressure on the vein throughout the whole operation, and, if
assistants are at hand, taking observations of pulse rate and blood pressure of
recipient every 3 minutes; of donor, every 5 minutes. His routine is "to at-
tempt to bring a pulse of say 150 or 160 down to about 100 and to raise a
blood pressure of 50 or 70 up to 110 or 120, figures well within the zone of
safety.77 But he warns against the danger of raising too much the blood pres-
sure of a patient suifering from the results of internal hemorrhage, as from
typhoid ulcers. He adds that it is most difficult to judge at all exactly of the
amount of blood transfused, but that the pulse and blood pressure observa-
tions, the knowledge gained by the fingers and thumb guarding the entrance to
the vein, the general appearance of the recipient, and the actual time the blood
has been flowing, all serve as guides to the proper time to end the transfusion.
He estimates the duration of actual flow to average in most transfusions 20 to
40 minutes ; the range being 3 to 5 minutes to 1 hour or 1*4 hours, according
to the size of the recipient. He says donor's indications for ending trans-
fusion are a "sudden fall of 20 to 30 points in blood pressure, or, lacking ap-
paratus for blood pressure determination, sudden pallor, accompanied by
nausea and vomiting, continued and increasing thirst, great restlessness, to-
gether with a decrease in blood pressure as shown by the finger of the operator,
in the donor's radial."
Bevan recommends having such operating-tables that the Trendelenburg
position may be used for the donor and the reverse Trendelenburg for the
recipient in order to better manage a possible anemia of the donor or a cardiac
dilatation of the recipient.
Jeger, too, insists upon the gradual beginning of the transfusion flow and
warns one to stop if any sign of cardiac dilatation appears in the recipient,
and wait 10 minutes before continuing the flow. Especially in little children,
he says, are symptoms of cardiac weakness carefully to be watched for.
302 OPEKATIONS UPON BLOOD VESSELS
Lilienthal, who has had a wide experience in transfusion operations, does
not think it necessary to slow the flow with the fingers as Bernheim does. He
watches the recipient carefully for signs of dilated heart, and uses, as signs
for stopping transfusion, dyspnea, cyanosis, rapid irregular pulse of recipient,
and faintness of donor. He prefers the hemoglobin estimations as an indi-
cation of how much blood to transfuse, and has estimations taken every 3 to 5
minutes on recipient during the flow, and endeavors to raise the percentage to
somewhere near double its original point. He does not think it safe to more
than double it, and he has doubled it in 19 minutes in one case (personal com-
munication).
In speaking of the donor, Crile says : "The best way of determining when
to stop the flow is by watching his (donor's) symptoms. At first he will show
loss of color in his mucous membrane, pallor of the skin, slight uneasiness,
slight quickening of pulse and respiration, lowering of blood tension, and be-
ginning shrinkage in the skin of the face. All of the symptoms are progres-
sive, and as soon as they are well marked the flow should be stopped. Often
the condition of the recipient will necessitate this long before the donor shows
any symptoms at all." Concerning the recipient, Crile says that too rapid a
flow may be prevented by partially narrowing the lumen of the artery by
gentle finger pressure, shutting off the flow altogether, if necessary, for short
intervals, to give the heart a chance to assume the added burden gradually.
Crile mentions the possibility of infecting the donor in transfusions performed
for infectious diseases, as typhoid, and advises selecting immune donors. He
thinks there is little risk in cases of chronic infection like tuberculosis, or from
an old septicemia or mixed infection. So far as the recipient is concerned,
Crile says the chief danger is cardiac dilatation. Fortunately a certain amount
of dilatation may occur and pass rapidly away, as shown by his series of cases.
He mentions that preliminary bleeding may be advisable in certain cases.
Not in shock or acute hemorrhage, of course, and rarely in subacute hemor-
rhage; but in all other cases either preliminary bleeding is required or less
blood must be transfused; for blood is retained in the vascular system where
saline infusion, for example, passes rapidly out of it. Bleeding and trans-
fusion may be practiced synchronously in feeble patients with marked reduc-
tion of red corpuscles.
Crile says : "When acute dilatation has once occurred it must be promptly
recognized. Transfusion must be stopped, table tilted to put patient in head
up position, and rhythmic pressure made over heart." If recovery is not
complete in a short time the transfusion should be given up, patient put to
bed in "head up" posture, given carefully graded doses of nitroglycerin to
insure peripheral dilatation of vessels, and digitalin hypodermically in very
small doses to stimulate heart muscles directly. Small doses of morphin also
are advised.
Crile gives no very definite rule as to how much blood should be given the
recipient. "Enough blood must be transfused to accomplish as much good as
OPERATIONS UPON" VEINS 303
possible, and yet too much, must not be given. Sometimes in cases where the
patient does not suffer from the loss of a largo amount of blood it seems to be
as advantageous to transfuse a small as a large amount. The symptoms of the
recipient give the best key to the situation."
AMOUNT OF BLOOD TO BE TRANSFUSED. — In children a small amount
only is needed in most cases. Cooley and Vaughan report a recovery from
melena neonatorum after the transfusion of only 20 c. c. of blood. On the
other hand, Peck has transfused an amount of blood, in the case of an adult,
estimated at 2,000 c. c. In general it would appear that 1,000 c. c. is enough
for most adults, and children require correspondingly less.
The amount of blood passed may be measured :
(a) By bleeding donor's vessel into a test-tube for 30 seconds and multiply-
ing the resulting amount by twice the number of minutes the transfusion flow
lasts (direct method). This is inaccurate on account of variation in pulse
rate and blood pressure and lumen of vessels.
(b) By receiving blood into a receptacle (syringe, pipette) which accurately
measures it (indirect method).
Methods of Direct Transfusion. — ARTERY-TO-VEIN METHOD. — CHILE'S CAN-
NT^ A. — Crile's cannula is one of the earlier and better known instruments for
facilitating transfusion. It is on the principle of Payr's ring, but furnished
with a handle, which may be grasped by a hemostat (Fig. 66). His descrip-
tion of the technic follows:
"Experience has shown that it is best to use a radial artery of the donor and any
superficial arm vein of the recipient near the elbow. Usually the median basilic vein
is the best on account of its size and easily ac-
cessible position. Local anesthesia is obtained
by injecting cocain in 1/10 of 1 per cent, solu-
tion with a few drops of 1 to 1,000 adrenalin.1
Several hypodermic syringes should be ready, so
that there should be no delay on account of hav-
ing to stop and refill a single one. The injec-
tions are first made into the skin and then more
deeply around the vessels. After this, firm pres-
sure is applied by the hand over a gauze sponge FIG. 66.— CHILE'S CANNULA.
to insure spreading the cocain through the tis- (Size greatly exaggerated.)
sues. When carefully performed, there is abso-
lutely no pain in any part of the technique until the sutures are placed in the skin at
the end of the transfusion. By then the effect of the cocain has usually worn away.
"In making the dissection, it is necessary to have good light. Mosquito hemostats
are used to catch every vessel that sheds even a drop of blood. The field should be
kept absolutely clean. The donor's radial artery is isolated for a distance of about
3 cm. at the point of injection in the wrist. Here there are a number of side branches
which must be carefully isolated and tied with No. 1 Chinese twist silk (which has
not been split up into strands) before being cut. The artery is then tied at its distal
end and a 'Crile' clamp is gently screwed in place over the proximal part as near
1 Other operators, Bernheim and Lilienthal, warn against the use of adrenalin chlorid
solution.
304:
OPEKATIONS UPON BLOOD VESSELS
to the place where it comes out of the undissected tissue as convenient. The clamp
should be screwed up with great care.
"Just enough pressure should be used to control the flow of blood without causing
injury to the vessel wall. The artery is severed with sharp scissors a short distance
from where it is tied off, the end cut squarely across, the adventitia pulled down and
cut off. The result should be that the operator has about two and a half cm. exposed
radial artery free from branches. The next step is the dissection of the vein. It is
exposed for the same distance as the artery, the branches tied off in the same way,
and the ligature is also applied to the distal end. The second 'Crile7 clamp is applied
FIG. 67. — CHILE'S METHOD OF ANASTOMOSIS FOR TRANSFUSION WITH CANNULA.
just as before, the vein cut near the ligature and it, in turn, is ready for the comple-
tion of the anastomosis. After selection of a cannula of suitable size (as large a
size should be used as possible without injuring the intima of the artery by stretch-
ing it too much), the end of the vein is either pushed through the handle end of the
cannula with the help of fine-pointed forceps, or pulled through by means of a single
fine suture inserted in its edge, the needle being left on the suture and passed through
the cannula ahead of the vein. The handle of the cannula is then tightly seized by
a pair of hemostats, three mosquito forceps are snapped at equidistant points on the
end of the vein, taking care not to have the tips extend up into the lumen more than
is necessary to get a firm hold. The end of the vein is then cuffed back over the
cannula by gentle traction on the hemostat and tied firmly in place with a fine linen
thread in the groove nearest the handle. The cuffed part is then covered with sterile
vaseline, being careful not to get any in the open end. The three hemostats are then
applied to the edges of the artery, just as with the vein; (it may be necessary to
OPERATIONS UPON VEINS 305
cov-
dilato the end very gently by inserting the closed jaws of a mosquito hemostat _.
ered with vaseline and opening them very gently for a short di>t;.n<-« ) :,n.l the artery
is gently drawn over the cuffed vein on the cannula and tied in place with another
fine linen suture in the remaining groove. All the hemostats are removed. The
venous and then the arterial clamps are removed and the blood allowed to flow. The
exposed vessels should be kept moist with warm saline." (Fig. 67.)
Elsberg's objections to Crile's cannula are:
"Some experience is required before the Crile instrument can be handled
with ease.
"The caliber of the cuffed vessel is decreased by the cannula.
"Sometimes there is difficulty in telescoping the artery over the vein.
"The steps of the operation with Crile's cannula are numerous and the ap-
plication of the guide suture and tying of ligatures complicates the operation."
With the exception perhaps of the last, these objections apply also to
Buerger's, Bernheim's, and Hepburn's modification of Crile's instrument.
ELSBEKG'S CANNULA. — Elsberg's cannula seems, by general consent, to be
the most satisfactory instrument yet devised for the direct method of trans-
fusion. His own description of it and of the technic of transfusion follows:
"The cannula is built, on the principle of a monkey wrench, and can be enlarged
or narrowed to any size desired by means of a screw at its end. (Fig. 68.) The
smallest lumen obtainable is about equal to that of the smallest Crile cannula, and the
largest, greater than the lumen of any radial artery. The instrument is cone-shaped
at its tip, a short distance
from which is a ridge with
four small pin points, which
are directed backward. The
lumen of the cannula at its
base is larger than at the tip.
The construction of the can-
nula can easily be understood
from the following descrip-
tion of the method of using it.
The radial artery of the donor FIG. 68. — ELSBERG'S CANNULA.
is exposed and isolated in the
usual manner. The cannula, screwed wide open, is then slipped under and around the
vessel. It is then screwed shut until the two halves of the instrument slightly com-
press the vessel.
"The artery is then tied off about one centimeter from the tip of the cannula.
Before the vessel is divided, three small eye tenacula are passed through the wall of
the artery at three points of its circumference, a few millimeters from the ligature.
Small mosquito forceps may also be used. These are given to an assistant, who makes
traction on them while the operator cuts the vessel near the ligature. The moment
the artery is cut, the stump is pulled back over the cannula by means of the tenacula
or forceps, and is held in place without ligation by the small pin points. There is
no bleeding from the artery even though no hemostat clamps have been used, be-
cause the cannula itself acts as a hemostatic clamp. The vein of the recipient is then
exposed (but not freed), two ligatures are passed around it; one is tied peripherally
in the usual manner. A small transverse slit is then made in the vein; the cannula
21
306 OPERATIONS UPON BLOOD VESSELS
with the cuffed artery inserted into the vein; a ligature tied around the vein and
cannula; the cannula screwed open, and the blood allowed to flow. The rapidity of
the flow can be varied as much as desired by the size to which the instrument is
screwed or unscrewed, and the lumen of the artery is never diminished.
"It will be noticed that the artery is cuffed instead of the vein. This method I
believe to be more correct. The vein is the larger vessel and can therefore be more
easily telescoped over the artery. The vein is only exposed, not freed, and the artery
is intubated into it. With this cannula I have been able to make the anastomosis
in less than four minutes after the artery has been isolated and have found the entire
procedure a simple one. The advantages of the instrument are the following: (1)
The cannula will fit any vessel; (2) the cannula is applied around the vessel instead
of the vessel being drawn through the cannula; (3) no ligature of the cuffed vessel
is required; (4) the cannula itself acts as a hemostatic clamp; (5) the cuffing of the
artery is easily accomplished without stripping back the adventitia, and therefore
the traumatism to the artery wall is reduced to a minimum; (6) the vein needs only
be exposed, not dissected out and cut; (7) as the cannula is unscrewed, the blood will
flow; the flow can be regulated at will, and the lumen of the artery is not diminished."
Lilienthal and also Elsberg now prefer the direct vein-to-vein over the
artery-to-vein method, and recommend Elsberg's cannula as being the best
means for accomplishing the anastomosis.
BEKNHEIM'S TUBE. — One of the most recently devised appliances for the
direct artery-to-vein method is the transfusion tube of Bernheim.
"It is a two-pieced af-
fair (Fig. 69) consisting
of two hollow tubes, each
4 cm. long, and each
FIG. 69.— BEKNHEIM'S 2-piECE TRANSFUSION TUBE. bulbous at one end in or-
der to form a neck for a
retaining tie, and beveled to facilitate entrance into the vessel ; the other ends
are tubular and fitted for invagination."
He says that it is especially useful in transfusing infants where smallness
of the parts makes actual union of vessels with Crile or Elsberg cannula diffi-
cult; and in emergencies where speed is desirable the separate halves of the
tube can be inserted in the two patients at once by separate operators. This
is his very excellent description of its use:
"The radial artery is dissected out as follows, novocain (0.5 per cent.) being the
anesthetic of choice: (1) Expose the artery with its accompanying veins (just above
the wrist joint) for a distance of about two inches; (2) free the artery from the
veins and tie off all branches doubly with fine silk, cutting between the ties; (3) tie
off the artery doubly at the distal end of the wound and cut between ties, thus allow-
ing about one and one-half inches of the vessel to be free in the wound; (4) tie off
all bleeding points in the wound, and keep a constant stream of warm salt solution
flowing over the artery, all sponging being done with gauze moistened in the same
solution; (5) place a bull-dog clamp on the vessel at the proximal end of the wound.
A small cut is now made in the upper side of the artery with a pair of fine scissors,
the opening being made at right angles to the course of the vessel and about half its
width. Next, every visible trace of blood is immediately washed out in warm salt
OPEKATIONS UPON VEINS
307
solution and liquid vaseline, the latter being injected into the lumen of the vessel
with a medicine dropper at frequent intervals during the washing process. It keeps
the vessel soft and pliable, and prevents too rapid evaporation and consequent drying.
Any little bit of adventitia that may get into the opening should be carefully pushed
away or cut off. (6) The vessel having been carefully prepared, the beveled end of
the male half of the tube is inserted into the artery and held there by a tie thrown
around its neck. (Fig. 70.) Liquid vaseline is again injected into the vessel through
the tube, and the whole thing wrapped in salt solution gauze to await the comple-
FIG. 70. — BERNHEIM'S METHOD OF
TRANSFUSION: MALE HALF OF
TUBE TIED INTO RADIAL ARTERY.
FIG. 71. — BERNHEIM'S METHOD OF
TRANSFUSION: FEMALE HALF OF
TUBE TIED INTO VEIN OF RECIP-
IENT.
tion of a similar preparation of the vein of the recipient. (7) It is hardly necessary
to dissect out more than one inch of the vein, and, as this is always quite superficial,
the time required for the whole procedure of dissection, cleansing and insertion of
the female half of the tube (Fig. 71) amount to hardly more than five minutes.
(8) When both patients have been prepared, their stretchers are brought into apposi-
tion and the two arms are placed on a table about one foot broad. With a little
manipulation the wrist of the .donor is brought into such proximity to the elbow of
the recipient that the tubes can be invaginated to the proper degree. (Fig. 72.)
(9) When this is accomplished, a steady stream of warm, saline solution is started
flowing over the artery, tube and vein, and the bull-dog clamp is removed from the
vein, its place being taken by the thumb and first finger of the operator. With great
care the clamp controlling the arterial flow is now gradually released, coincidently
with which the thumb and finger controlling the vein gradually ease up, thus permit-
ting the blood to go over gradually, so as to prevent any possibility of swamping or
embarrassing the circulation of the recipient by a sudden gush of blood under great
pressure."
308
OPEKATIONS UPON BLOOD VESSELS
If clotting occurs, he removes both tubes, washes out the vessels with
saline and liquid vaselin, and inserts a new set of tubes, the flow being started
in the usual manner. When the transfusion is finished the tubes are re-
moved, the vessel ligated, and the wound sutured.
CARREL'S SUTURE. — Carrel's suture was
used by Crile before he devised his own can-
nula, and has been used by many other oper-
ators with satisfaction. The technic of
the suture itself has been described under
end-to-end arteriovenous anastomosis by su-
ture. Pool reported a series of transfusions
in 1910 by Carrel suture. Lilienthal (per-
sonal communication) says he has used the
suture method successfully in several vein-
to-vein transfusions. He dissects out about
3 inches of the donor's vein at the elbow,
leaving a certain amount of superficial fascia
around it to allow of easy handling, and after
freeing about one inch of the recipient's vein
(usually basilic or cephalic, at the elbow)
he prepares the ends and anastomoses them
by the method of Carrel.
Jeger says that the Carrel method is used
by Enderlen, Hoercken, and Tuffier. Hors-
ley also uses suture, but of mattress type in-
stead of overhand. Jeger continues : "The
use of the direct vessel suture in blood trans-
fusion has, however, the disadvantage of being exceeding difficult. Tuffier in-
forms us that Carrel in his case (at Tuffier's Clinic) completed the vessel suture
in five minutes, but, in the hands of most other surgeons, this operation would
require a very great deal more time."
BREWER'S TUBES. — Brewer's tubes are of glass, lined with paraffin, about
FIG. 72. — BERNHEIM'S METHOD OF
TRANSFUSION: TUBES INVAGINATED
AND ANASTOMOSIS COMPLETE.
FIG. 73. — BREWER'S TRANSFUSION TUBE.
3/16 of an inch in diameter at larger end, tapering to % inch, and slightly
flared at both ends. They are about 2% inches long and have a double bend
(Fig. 73). The artery and vein are exposed in the usual manner, and the
smaller end of the tube is slipped into the artery, the larger into the vein, and
OPERATIONS UPON VEINS
To
Shoulder Tube.
FIG. 74. — FAUNTLEROY'B
MODIFICATION OF BREW-
ER'S TUBES.
tied in with ligature. The flared ends of the tul>e keep the vessels from slip-
ping oft. The objection to these tubes, as stated by Brewer, is that the lumen
is too small to allow of sufficient flow. This objection has apparently been
obviated in the modification brought out by Fauntleroy.
Several years ago Dorrance and Ginsberg advised direct vein to- vein
transfusion ; and later Fauntleroy reported the use of
the Brewer tube in direct vein-to-vein transfusion.
The method would seem an excellent emergency
measure where special cannulse were unobtainable.
VEIN-TO-VEIN METHOD. — Flare the ends of a
piece of thin glass tubing % inch inside diameter by
heating them and pushing a pointed wire nail into
the lumen while hot (Fig. 74). Heat the tube again
and bend into an S- or U-shape with extremities 3
inches apart, as it is designed to have the hands of
the patients pointing in the same or opposite direc-
tions. After boiling the tubes, drop them into
melted paraffin ; lift them out with a sterile forceps,
shake excess paraffin out, lay in sterile gauze to cool,
and wipe paraffin off their outside. They are then ready for use.
Make the superficial veins prominent by applying a constrictor above the
elbow. Expose and free the chosen vein of the recipient for about 1 inch.
Pass 2 ligatures around it at the ends of the freed portion ; tie the distal one
and remove the constrictor. Expose and pass ligatures around the donor's
vein in similar fashion, and tie the proximal one. Temporarily occlude the
distal end by serrefine, tape, and clamp, etc. ; open the donor's vein (or divide
it) far enough above this to slip the prepared tube distally into it, and tie it in
place with the distal liga-
ture. Lay the donor's and
recipient's arm side by
side on a small table with
the elbows at the same
level, and opposite each
other. Open the vein of
the recipient between liga-
tures, remove the tem-
porary hemostatic on the
donor's vein; allow the blood to flow through tube and expel the air, slip the
free end into the recipient's vein, and tie in place with the proximal ligature
(Fig. 75). The donor's constrictor is left in place to keep up his venous pres-
sure. When sufficient blood has passed remove the tube, ligate the veins, and
close the wound. Fauntleroy says it is as easy as a saline infusion: Move-
ment of the patients' arms must be guarded against on account of angulating
veins against ends of tube and causing clotting of blood.
FIG. 75. — VEIN-TO-VEIN TRANSFUSION
(Fauntleroy).
WITH S-SHAPED TUBE
310
OPERATIONS UPON BLOOD VESSELS
Vincent has used similar tubes with satisfaction.
The Indirect Method of Transfusion. — The indirect method of transfusion,
in which the blood is passed from donor to recipient by the medium of some
form of container, depends for its success upon the failure of the blood to clot
in the interval between its withdrawal from the former's and its introduction
into the latter' s veins. Such a coagulation seems to be avoidable in three ways :
(1) By making the transference so rapidly that insufficient time for clot-
ting elapses between the blood's withdrawal from, and its reintroduction into,
normal vascular channels.
(2) By "the employment of an intermediate system, providing no point
of contact with any moistenable surfaces, and at the same time minimizing as
FIG. 76. — CURTIS AND DAVID'S APPARATUS FOR INDIRECT TRANSFUSION.
far as possible the exposure of broken tissue surface to the blood stream."
(Satterlee and Hooker.)
(3) By "the employment of a sufficient amount of some physiologic agent
(antithrombin) to restrain or offset the initiative factors of coagulation during
the time of the conveyance of the blood through a foreign system, such as glass
and metal." (Satterlee and Hooker.)
Upon the first of these principles are based the methods of Moritz and
Lmdemann; upon the second, those of Curtis and David and Satterlee and
Hooker. Experiments are now under way to determine the practical value of
the third principle (by Satterlee and Hooker, and others).
The indirect method of transfusion has recently been taken up by a num-
ber of men, and the work of Moritz, Curtis and David, Risley and Irving,
Lindemann, Satterlee and Hooker has done a great deal toward popularizing
this method.
CUKTIS AND DAVID METHOD.— Curtis and David use a 100 c. c. glass
syringe with rubber tube attached and a double cannula tipped glass bulb of
100 to 400 c. c. capacity (Fig. 76). The glass bulb is sterilized by the dry
method and the inner surface coated with paraffin. The paraffin coat is best
applied by pouring hot paraffin into the open end and then rotating the bulb
to secure a uniform coat. The two cannula tips are then heated and each in
OPERATIONS UPON VEINS
311
turn dipped into melted paraffin, and shaken to make a thorough coating so
as to keep the excess from occluding the lumen. The syringe and rubber tube
are prepared by boiling.
"With the apparatus now ready for use, a one-half inch incision is made over the
most prominent vein of the elbow region in both donor and recipient (using con-
strictors if desired). The donor's vein is then clamped (with a vessel clamp) at the
distal end of the incision, stripped, ligated proximally, cut below the ligature and
washed out with one per cent, solution of sodium citrate.
The recipient's vein is ligated distally, stripped toward the
heart and clamped at the upper end of the incision (with
vessel clamp), cut above the ligature and also washed out.
The cannula tips are moistened by introducing a few drops
of liquid petrolatum through the bulb end, then inserted into
the respective veins of donor and recipient and ligated in
position. Aided by the use of a shoulder constrictor, blood
rapidly enters the bulb when the donor's vein is released. As
the blood rises in the tube, a covering of liquid petrolatum
is added to relieve surface tension. The rubber tube is now
fitted over the top of the glass bulb and the tube and syringe
are used to produce positive and negative pressure, as de-
II
No. 1. No- 2-
FIG. 77. — KIMPTON'S CYLINDER FOB INDIRECT TRANSFUSION, Nos. 1 AND 2.
sired. (The bulb usually fills without resorting to suction.) The donor's vein is
then held by the finger, the recipient's vein released and the blood introduced into the
latter at any desired rate of flow. When the bulb is nearly empty, the recipient's vein
is held and that of the donor released, thus allowing the bulb to again become filled
with blood, after which the process continues as before."
They had done 4 or 5 human transfusions by this method successfully when
they published this report, passing over 1,050 c. c. of blood in one case.
Jeger says that a certain advantage of the Curtis and David apparatus
over others exists in its ability to transfer blood into the arterial (against the
current) as well as into the venous system. Such an ability might possibly be
made use of, he thinks, in a centripetal arterial transfusion by which the
blood would tend to be forced into the aortic bulb and so fill the coronary
arteries and resuscitate an enfeebled heart. This procedure has been men-
tioned by Crile and Dolley.
312 OPEKATIONS UPON BLOOD VESSELS
KIMPTON METHOD.— Kimpton has recently published a method very simi-
lar to Curtis and David's. He uses a 250 c. c. paraffin-lined cylinder of his
own pattern, having a lateral tube and a terminal cannula tip (Fig. 77). He
exposes the antecubital veins of donor and recipient in the usual manner, al-
lows the tube to fill from the former by venous pressure, and then injects the
blood into recipient's vein by pressure from an actual cautery bulb pump
which he attaches to the lateral tube of the cylinder. If more than 250 c. c. of
blood are required he uses a fresh tube for each subsequent injection. He
reports 15 successful transfusions by means of this apparatus, and Turnure, in
a personal communication, tells me of 4 additional successful operations.
COOLEY AND VAUGHAN METHOD. — Cooley and Vaughan injected 120
to 150 c. c. of human blood and saline (about 20 c. c. blood) into the median
basilic vein of a baby exsanguinated by intestinal bleeding of melena neona-
torum. An attempted vein-to-vein anastomosis by Crile cannula having failed
on account of small size of child and lack of blood in father's veins, one of the
operators acted as donor and the other withdrew from his basilic vein about
8 c. c. of blood through a sharp needle into a 10 c. c. glass syringe into which
1 c. c. of saline solution had previously been drawn. One-half c. c. of saline
was then sucked in and the mixture of blood and salt solution injected through
a blunt needle into the baby's already exposed vein, the wound being held
open by two sutures of catgut. About 2 minutes elapsed from the time when
the sharp needle was inserted into the donor's vein until the injection of
blood into the recipient's vein was completed. The injection was repeated in
15 minutes and the child recovered.
LINDEMAN'S METHOD. — Lindeman describes his present technic as fol-
lows:
"The entire apparatus consists of two sets of cannulas, two tourniquets and twelve
syringes. . . .
"Two sets of cannulas are employed, one for the donor, the other for the recipient.
(Figs. 78 and 79.)
"There are three cannulas to each set. Each cannula telescopes within the other,
as shown in Figure 79.
"The innermost cannula is practically a hollow needle. The hollow needle (Fig.
79) is fitted snugly into Cannula 2. Cannula 2 is 5 mm. shorter than the needle and
is fitted snugly into Cannula 3. Cannula 3 is 5 mm. shorter than Cannula 2. The
proximal ends of 1 and 2 are capped with stationary thumbscrew caps.
"The proximal end of 3 is capped with a receiver to fit any Record syringe.
"Cannula 3 is 2 inches long. The caliber of this cannula is the same as the tip
of a Record syringe.
"In very small infants with very small veins, only cannulas 1 and 2 are employed,
2 being capped with the receiver to fit tip of syringe.
"The cannulas I now use are made of platinum.
"The syringes used are Record syringes of new, improved type with a capacity of
20 c. c. and can be sterilized with 95 per cent, alcohol, 20 minutes. . . .
"One operator manages syringe of recipient. Another operator manages syringe
of donor. An assistant stands between operators, who are in position close to the
assistant. Donor and recipient are placed in the recumbent posture.
OPERATIONS UPON VEINS
313
"A table is arranged conveniently between them so that a nurse can wash syringes
as rapidly as they are used. For this purpose two basins of sterile water and one
basin of normal saline solution are used. The normal saline solution is used in the
last rinsing; the syringes are so well cleaned in the first two rinsings that the rinsing
solution remains practically clear.
"In adults and most children over 2 years of age the median basilic vein is easily
accessible. In infants the external jugular or one of its tributaries is entered more
FIG. 78. — LINDEMAN'S CANNULA, ASSEMBLED.
advantageously. In some cases the internal saphenous may prove the vein of prefer*
ence.
"A tourniquet is placed in position, and the skin is sterilized with iodin. The
cannula is then held in a position almost parallel to the vein with the thumb on the:
thumb-screw of the innermost cannula (Fig. 78, 1). The skin is then punctured and
the cannula is forced into the vein. After the first joint (A) has entered vein, Can-
nula 1 is withdrawn a distance of about one-half inch. (This prevents the vessel
wall from being injured or punctured by the needle after the vein is entered.)
"With the thumb now on the thumb-screw cap of 2 the cannula is forced further
in until the second joint (B) (Fig. 78) has entered the vein. Cannula 2 is then
withdrawn a distance of about one-half inch. (Cannula 3 alone can come into con-
tact with the vessel wall.) Cannula 3 is then gently pushed into the vein to a de-
sirable length; usually three-quarters to one inch will suffice.
' "Cannulas 1 and 2 are now withdrawn entirely. If the vein has been successfully
FIG. 79. — LINDEMAN'S CANNULA, SEPARATED.
entered, blood will flow through the cannula. When the first drop appears a syringe
containing warm saline solution is immediately attached and a very slow flow of
saline is maintained through cannula.
"(When the innermost needle, No. 1, has entered the vein, blood is seen to trickle
through the proximal end.)
"There is no need of haste at this stage.
"A cannula is next inserted in vein of donor in a like manner; an empty syringe
is attached to this cannula. Everything is now in readiness for the transfusion, and
blood is withdrawn from donor as rapidly as possible. When the syringe is full the
assistant passes it to the operator on the recipient, who removes the saline syringe,
attaches the syringe containing blood and evacuates the contents gently but speedily
into the vein.
"One syringeful of blood is followed by another in rapid succession until the de-
sired quantity of blood has been transfused.
314 OPEKATIONS UPON BLOOD VESSELS
"A little normal saline is injected through cannula of recipient after every 2, 3, 4,
or 5 syringefuls of blood, depending upon the speed of flow from donor. This keeps
cannula free of blood and precludes the possibility of clotting.
"Some 25 tests have been made to determine the length of time required for blood
to coagulate in a syringe. This was found never less than 6 minutes. The length of
time required for the complete filling and evacuation of a syringe is from 6 to 12
seconds.
"It has been found advisable for the assistant (or third man) to remove the
syringe of the donor as soon as filled. The operator can thus hold the cannula in
place with one hand, while with the other hand he may at once adjust an empty
syringe into the cannula. Loss of blood is thus reduced to a minimum.
"RULES. — (1) Bright polished surfaces of syringe and cannulas are requisite. (2)
A syringe used once should not again be employed until thoroughly cleansed with
sterile water. (3) Air must be avoided. This, however, offers no difficulty. (4)
Tourniquet of recipient must be removed after vein is entered with cannula. (5)
Tourniquet remains on donor throughout operation. (6) Tension of the tourniquet
should not impede the arterial flow, but should be sufficient to block venous return
to a point at which the highest venous pressure is obtainable. If the tension be too
great the first syringe will fill rapidly, the successive ones will fill very slowly. If
the tension be too little, syringes will fill slowly. If the tension be adjusted correctly,
syringes are filled very rapidly. (7) Dexterity and speed are requisite for success.
(8) Before beginning a transfusion syringes are cleaned with hydrogen peroxid and
then washed in a 10 per cent, sodium carbonate solution and rinsed. They are then
ready for a sterilization in alcohol. . . .
"The time elapsing in filling and evacuating the syringe is so brief that blood
does not undergo any alteration from donor to recipient. For this reason larger
receptacles for conveying the blood have been discarded.
"No lubricant is employed. Cannulas are lined with a film coating of albolene.
"Larger syringes with larger calibered carmulas may be used, but the present sizes
have worked satisfactorily and fittings of syringes and cannulas are of universal
gauge.
"Syringes and cannulas may be kept sterile in individual metal containers. They
are thus in readiness for immediate use and no preparation for operation is re-
quired.
"When hemolysis occurs, even when only slight, the symptoms appear imme-
diately, so that in the actual performance of the work I introduce some 20 or 30 c. c.
and then pause to await any symptoms of hemolysis appearing. Should none occur
the. transfusion is completed. Should symptoms appear the cannulas are. withdrawn
and no harm is done to either recipient or donor. In that case another donor is pro-
cured.
"The merits of this method may be summarized as follows: (1) Simplicity for
the recipient. (2) Simplicity for the donor. (3) No pain, other than a skin puncture.
(4) No disturbance of the recipient or change of position is necessary and the work
can be done in the home as conveniently as in a hospital. (5) Any quantity can be
transfused. (6) The quantity is definitely known at the time of transfusion. (7)
The same vein may be used repeatedly. One recipient was transfused 7 times through
the same vein and same skin puncture. One donor was tapped nine times through
the same vein and same skin puncture. (8) No scar remains after operation. No
skin incision is necessary. (9) The danger from hemolysis is practically eliminated by
this method. (10) The facility of application makes possible its application over a
wide therapeutic field. . . .
"Up to date I have performed 137 transfusions by this method. There were no
failures, , , f
OPERATIONS UPON VEINS 315
"The youngest case transfused was 6 weeks old; weight 6 Ibs. 6 oz. The oldest
case transfused was 73 years. In no case was there thrombosis, embolism or sepsis;
in no case was a skin incision made; in no case was anesthesia given; in no case was
death due to any untoward effects of transfusion.
"Post-mortem examinations were made in two cases several weeks after trans-
fusion. Vein punctures were examined by Dr. Charles Norris, Director of Labora-
tories of Bellevue and Allied Hospitals, who could find no evidence of the puncture.
These venous puncture wounds heal by first intention and no thrombosis occurs at
the site of the puncture. . . .
"In the total number of transfusions there were 243 cannula insertions into veins ;
218 into median basilic ; 25 into external jugular. In 208 insertions the median basilic
vein was entered on first puncture.
"In one case six transfusions were performed at different intervals of time, using
the same vein through the same skin puncture in each operation. One donor was
used for eight transfusions at different intervals of time; the cannula was inserted
into the same vein through the same skin puncture on each occasion. . . .
"Judgment of the amount of blood to be transfused will depend upon the size,
weight, age, physical condition of the patient, the type of disease to be treated, the
object to be gained by transfusion, the presence of other complications, and, lastly,
experience. The largest amount I have transfused into one individual in one sitting
is 2,000 c. c. This quantity was taken from two donors. . . .
"The quantity of blood that can be drawn from a donor varies. The largest
quantity I have taken from one individual in one sitting is 1,400 c. c. The largest
was 5 feet 8 inches in height and weighed 170 Ibs. I have frequently taken 900 to
1,000 c. c. in one sitting.
"If the case be not one of infectious disease, two-thirds quantity of the blood drawn
from donor is replaced with normal saline through the cannula with which transfusion
was performed. When infection is present the same cannula is not used.
"If at any time the blood pressure in the donor should fall so that blood is with-
drawn with great difficulty, it is an indication that no more blood can be spared at
that time.
"The reaction — chill, fever, etc. — after transfusion from a blood relative in most
instances is less than from an alien. In three cases of transfusion from aliens, hemoly-
sis occurred from which patients recovered. (It should be borne in mind, however,
that hemolysis can occur with family blood.)
"Providing the same donor be used there is frequently no reaction after the
second and succeeding transfusions. And if any reaction occurs it is usually very
mild.
"A given donor of alien blood will cause a chill and a temperature in one patient
and none in another, though the transfusions be done on the same day and both
patients have the same disease, and the same quantity be given.
"The chill and temperature reactions may be associated with slight degree of
hemolysis incident to serum reaction. I have occasionally observed such hemolysis
in a few cases evident only by a slight jaundice tint disappearing within 24 hours. In
such case in the succeeding transfusion, the same donor being used, this tint is absent
or less.
"In the actual performance of the work I introduce a small quantity of blood and
then pause for a short period of time before continuing transfusion. Opportunity is
thus afforded for observing the compatibility of the blood introduced.
"Should an undesirable reaction ever occur indicative of incompatibility, trans-
fusion is discontinued; no harm is done and another donor is procured. Danger from
hemolysis is thus eliminated."
31G OPERATIONS UPON BLOOD VESSELS
McGRATH'S METHOD. — McGrath has recently described a modification of
Aveling's method, in which he uses a 30 c. c. rubber bulb having two Jong
polar processes, or cannulse, of suitable size to enter the veins. The latter
are exposed in the usual manner and the tips of the processes are inserted into
them, after filling the bulb with salt solution, and held by ligatures. Alternate
filling and emptying of the bulb by compression and release from the donor
into the recipient transfer the desired amount of blood. The apparatus is
made without joints. No anticoagulant is used and the method has proved
successful in experimental work.
SATTEELEE AND HOOKER'S METHOD. — Satterlee and Hooker have re-
cently published an account of a method which appears to be an improvement
on Curtis and David's. See Volume I, Chapter IX.
Choice of Methods. — No absolute decision can at present be made as to
which is the best method of transfusion. Unquestionably the direct method
has received more attention and has been practiced a greater number of times
in the past 10 years than has the indirect method. The possibilities of the
latter, however, are at present being more thoroughly investigated, and it is
probable that the next decade will see a reversal of the proportion of direct to
indirect transfusion.
Curtis and David, in a recent communication, summarize their objections
to the direct method as follows :
"The operation requires delicate technic such as is possessed only by those
who have had experience in blood-vessel surgery. Considerable time is con-
sumed in performing anastomosis of the vessels. The rate of flow and the
amount of blood transfused are not measurable. The flow of blood sometimes
ceases before the desired amount has been transfused, even though the oper-
ative technic is excellent. Movement of either donor or recipient may tear
the vessels apart at their point of union in spite of watchfulness on the part
of the operators. In infectious patients there is always danger of transfer of
infection from the recipient to the donor. This is most liable to occur through
the rubbing of the raw surfaces which are held or bound together during the
entire procedure."
The third objection of this series is the only one that can be held to apply
against the direct method of transfusion by glass tubes as originated by
Brewer and modified by Eauntleroy. The others apply no more to this method
than to Curtis and David's own.
Risley and Irving have (in 1911-12) carefully and critically tested Crile's
cannula, Soresi's cannula, Frank's (dog's carotid), and ITartwell's (simple
invagination of artery into vein) methods, Brewer's tubes and Curtis and
David's syringe and receptacle with a view of settling which is at present the
most generally useful method of transfusion. They say: aln so far as
purely mechanical metal devices go, this admirable little adjustable cannula
(Elsberg's) is still the best." They call the paraffined glass tubes afar ahead
of any of the other more complicated devices proposed, but also by far the
OPERATIONS UPON VEINS 317
most satisfactory for all round transfusion work, artery-to-vein, or vein-to-
vein, adult or infant, and for skilled or unskilled operators."
They also speak favorably of Curtis and David's method.
Just at present, then, it would appear that direct transfusion by the par-
affin-lined glass tube is the most generally available and simplest, but it lacks
the advantage possessed by the indirect methods of accurately measuring the
amount of blood transfused. In as much, however, as the effect upon the re-
cipient, as observed in his general appearance, raised hemoglobin index and
increased blood pressure and in the reduction in rate and the improvement in
quality of his pulse is the real indication of the effect of transfusion, rather
than the accurate measurement of the amount of blood passed, this lack cannot
be considered of the first importance.
If, however, the indirect method with syringe, as practiced by Moritz,
Lindeman, Cooley and Vaughan, and others, or with the paraffin-lined glass
receptacle of Curtis and David and Satterlee and Hooker, proves as safe as
the direct method, it will doubtless become the method of choice; and in this
city it is probably more used now than the direct method. If the direct
method be used there is still some question as between the artery-to-vein and
the vein-to-vein practice of it. Dorrance and Ginsberg state the advantages
of artery-to-vein procedure as: giving sufficient blood pressure to introduce
blood quickly from donor into recipient; that blood from artery is richer in
oxygen than that of vein. They believe, however, that vein-to-vein procedure is
simpler and safer and recommend its use.
Lilienthal states the advantages of the vein-to-vein method as follows:
The dissection does not open the fascial planes of the wrist to possible infec-
tion. The radial pulse is not interfered with. The dissection and manipula-
tion of the vein is easier than that of the artery. The donor's vein generally
used is larger than the radial artery. The vein is less susceptible to. external
influence (for example, contraction of artery and resulting slow, or no, flow).
The flow is rapid and steady.
Elsberg also (personal communication) prefers the vein-to-vein procedure.
Among the difficulties of the operation may be mentioned: refusal of radial
artery to bleed; inability to find sufficiently large vein in arm; clotting of
blood in cannula ; piercing vein.
Peck mentions an instance where the donor's radial artery absolutely re-
fused to bleed.
Peck, Lilienthal, Warren, and others have mentioned the difficulty of find-
ing a suitable vein in the arm of the recipient. In a few cases this resulted in fail-
ure of the operation, as the patient would not allow any other vein to be used.
Peck, Lilienthal, Bernheim, and others mention the occurrence of clotting
in the cannula, or at the point of anastomosis.
Warren and others mention the possibility of thrusting the point of the
needle, or trocar, through the opposite wall of the vein while attempting to
introduce it into the lumen.
318 OPEKATIONS UPON BLOOD VESSELS
Dangers of Transfusion. — Among the possible dangers of the operation
should be mentioned: transmission of disease from donor to recipient; trans-
mission of disease from recipient to donor; hemolysis; agglutination; acute
dilatation of the heart ; air embolism ; blood embolism ; suction changing gas-
eous tension of blood ; laking red cells and setting free toxic substances.
TRANSMISSION OF DISEASE FKOM DONOR TO KECIPIENT (Syphilis, Gon-
orrhea, Malaria, etc.). — This can be entirely avoided by a thorough prelimi-
nary examination of the donor.
TBANSMISSION OF DISEASE FROM RECIPIENT TO DONOR (Typhoid,
Septicemia, etc.). — This can be avoided by using an immune donor, or by
avoiding any actual contact between donor and recipient. (Brewer's tube or
indirect method.)
HEMOLYSIS. — Hemolysis is regarded as a real and ever-present danger by
many surgeons, but Bernheim remarks: "The danger of hemolysis following
transfusion has always been vastly overrated and unwarrantably feared. In a
rather large series of transfusion, done for the relief of many and varied con-
ditions, I have never seen it occur, and I know of but one authentic instance
where it complicated matters.
"It must be remembered that hemolytic tests, even at best, are not en-
tirely conclusive and do not absolutely protect against hemolysis. The blood
of one individual may hemolyze that of another in the test tube, but not in the
body after transfusion; and, vice versa, the laboratory tests may pronounce
an individual a suitable donor, and yet hemolysis may occur after transfusion."
On the other hand, Elsberg, Lilienthal, Peck, Lindeman, and others em-
phasize the extreme importance of it. Elsberg has done 2 successful cases
without preliminary test in emergency cases. Peck mentions a case in which
it was impossible to get a hemolysis test beforehand. The patient was trans-
fused by the Lindeman technic with 33 syringefuls. She died within 48
hours with signs of obscure blood changes.
Lindeman mentions one case where the laboratory reported hemolysis test
negative, but hemolysis was noted after 75 c. c. had been given. Transfusion
was stopped, and another serologist reported hemolysis test: slight hemolysis
of donor's cells with recipient's serum.
Another case: no hemolysis in first transfusion. Second transfusion 5
days later, with same donor. No hemolysis test done. Hemolysis showed at
transfusion, however, and test then made showed hemolysis of donor's cells
with recipient's serum.
Another case : laboratory report negative ; yet hemolysis occurred at trans-
fusion ; no opportunity to check up laboratory report ; all 3 cases recovered.
AGGLUTINATION. — Agglutination of red cells is apparently less to be
feared than hemolysis; but Lilienthal emphasizes the importance of making
the test beforehand. Warren mentions a case of pernicious anemia in which
he failed in an attempt at transfusion by the Lindeman method on account of
the small size of vein in the arm. Two days later Lindeman himself successfully
OPERATIONS UPON VEINS 319
transfused this case through the external jugular. The patient died within 48
hours. In this case there was a very slight positive agglutination reaction
obtained beforehand, although the hemolysis test was negative.
ACUTE DILATATION OF THE HEAET. — Acute dilatation of the heart dur-
ing transfusion is another rare accident. Crile mentions several instances in
his book, none of which were fatal. It has been difficult to find any positive
evidence of fatal cases. Lilienthal and Peck had not observed the accident in
their practice. Elsberg mentions one case who died shortly after the trans-
fusion by the direct artery-to-vein method. He believes that they gave her too
much blood. She was a woman suffering from malignant endocarditis.
AIR EMBOLISM. — I have been unable to discover any deaths thought to be
referable to the entrance of air into the veins at transfusion. Theoretically
one would expect it to be a fairly common accident in the syringe class of
operations. But, as a matter of fact, it is highly probable that small amounts
of air, so introduced, do not give rise to untoward symptoms.
BLOOD EMBOLISM. — No positive evidence is obtainable of any fatalities
due to this cause following transfusion, but Warren speaks of one case of per-
nicious anemia that died of pneumonia within a week following transfusion by
the Lindeman method. Warren thought the pneumonia might be attributable
to pulmonary infarction.
ALTERATION OF THE GASEOUS TENSION OF THE BLOOD. — Alteration of
the gaseous tension of the blood due to suction, and laking of the red cells
with setting free of toxic substances, from contact with syringe or cannula
walls, have been mentioned by Warren and Connell as possible dangers in those
methods that use syringe suction and employ no paraffin to line the cannula.
No definite evidence is obtainable of the reality of such dangers.
INTKAVENOUS INJECTION
Intravenous injection for purposes of local or general anesthesia is de-
scribed in the chapter on Anesthesia.
VENESECTION
Venesection is an operation little used at present except when it is desired
rapidly to lower blood pressure, as in certain cases of cerebral hemorrhage,
uremic coma, etc. ; or where it is desired to remove a certain amount of toxic
or deteriorated blood before replacing it with healthy blood or saline solution,
as in illuminating gas, carbon monoxid poisoning, etc.
The vein selected may be the external jugular, the internal saphenous, or,
more commonly, the median basilic or cephalic. The latter is perhaps pref-
erable on account of its greater distance from the brachial artery and its
freedom from nearby cutaneous nerves. A constrictor is applied at mid arm
tight enough to distend the superficial veins. The skin over the anterior sur-
320 OPERATIONS UPON BLOOD VESSELS
face of the elbow is then painted with iodin, which is allowed to dry and then
washed off with alcohol. The vein is then steadied between the thumb and fore-
finger of the left hand while a sharp scalpel divides it transversely, together
with the overlying skin, to about one-half of its diameter. Local anesthesia
may, of course, be used if desired. The flow of blood may be increased by caus-
ing the patient to grasp a stick tightly. It may be lessened by digital pressure
over the vein. The amount of blood removed usually varies from 8 to 16
ounces. When sufficient blood has been removed the flow of blood is arrested
by removing the constrictor, and strapping a pledget of sterile gauze over the
phlebotomy wound.
OPERATIONS TO REMOVE THE CAUSE OF CIRCULATORY DISTURBANCE
DUE TO VARICOSE VEINS
Binnie says: "The principle of treatment of varicose veins is the trans-
ference of the venous circulation from the superficial to the deep veins, but
before attempting to do this it must be shown that there is neither thrombosis
of the deep veins nor marked obstruction to the return of the blood through
them.
"Mayo, in doubtful cases, applies an elastic support to the limb for a week ;
if this gives comfort it is fairly evident that the deep vessels are capable of
doing their duty."
METHODS OF TREATMENT
The methods usually described are: injection, ligation, excision, incision,
suture.
The treatment of varicose veins by injection, acupressure, and subcutane-
ous ligation is antiquated, and should not be employed. Incision, excision,
and suture are the methods commonest at present.
Treatment by Excision. — Excision is the method most in use. The dilated
veins are marked upon the skin, while the patient is in the standing position,
with tr. iodin, silver nitrate, or some other stain ; or scratches are made in the
skin over them with a sharp scalpel. At the same time a test is made as to the
free communication of the varices with the deeper veins. With the patient
recumbent, the surgeon places his finger upon the saphenous vein just below
its entrance into the femoral and causes the patient to stand up. If, while the
varices are thus relieved of the weight of the superimposed blood, they still
dilate from below - the Trendelenburg operation alone is useless. It may, how-
ever, be used in addition to the excision in continuity.
After a very careful preparation of the operative field an incision is
marked over the dilated vein. If the vein is broadly adherent to the skin it is
often easier to excise a portion of the latter with it. Otherwise, the incision
is deepened carefully just through the skin and flaps are raised on each side
of the incision by thrusting blunt scissors beneath the skin and forcing the
OPERATIONS UPON VEINS 321
blades apart. This, added to a little necessary sharp dissection, will expose a
considerable area of vein which is ligated together with its tributaries, above
and below, and excised for a distance of several inches. All bleeding is then
stopped, the wound carefully cleansed, and its edges united with fine silk, con-
tinuous suture; or, perhaps better, by interrupted sutures alternating with
narrow strips of sterile adhesive. This procedure may be repeated until the
continuity of the dilated venous channel has been interrupted at 3 or 4 levels.
Sometimes the dilated trunk vein and its tributaries arrange themselves in a
sort of nest or plexus 2 or 3 inches in diameter, especially just below the knee,
in front, internal, or behind. It is more satisfactory in such cases to excise a
considerable area of skin, together with the whole mass of dilated tortuous
veins and their surrounding fat, right down to the deep fascia. The defect
may then be closed by loosening superficial fascia around the edges of the
wound from the deep fascia and drawing the wound edges together with sev-
eral deep tension sutures of silk-worm gut. Proper coaptation of the margins
then follows, with silk, as before. Better approximation is secured in this
way, and the tendency of thin, extensive flaps to slough is avoided.
Dry dressings are applied, the limb is elevated and closely bandaged from
toes to groin. A well-padded posterior splint of wood, or a more comfortable
one of moulded plaster, is then added, and the patient kept in bed for at least
ten days, or preferably two weeks, as the experience of the Mayo Clinic has
shown that practically all the cases of embolism complicating this operation
have occurred within 14 days after operation. If the varicosities have been
extensive the patient should be recommended to wear a woven bandage of the
"Ideal" type or a well-fitting elastic stocking for a few weeks after the opera-
tion.
If the varicosities are the result of weight pressure from the superimposed
column of blood, the veins do not distend when the limb is allowed to hang
down while pressure is made upon the upper part of the saphenous vein by the
examiner's finger, which has been previously placed there with the limb in
the horizontal position.
TBENDELENBUKG'S OPEEATION. — In such cases Trendelenburg's opera-
tion may be sufficient. It consists of the excision, between ligatures, of an
inch or two of the saphenous vein at the upper part of the thigh. A rubber
constrictor placed around the limb near the groin may be used to dilate the
vein and make its localization easier, and in fat patients a transverse incision
may discover the vein more readily than a longitudinal one.
MAYO'S OPEKATIOK — Mayo devised a dissector with accompanying for-
ceps to facilitate the excision of the varicose vein through small skin incisions.
It is exceedingly efficient if the vein is thick-walled and not too tortuous, but
is apt to tear thin- walled, tortuous vessels. It is used as follows: expose and
isolate about 1 inch of the saphenous vein near the saphenous opening. Divide
it between double ligatures and thread the distal end through the eye of the
probe dissector (Fig. 80a) and put an artery clamp on it. Hold the clamp
22
322
OPERATIONS UPON BLOOD VESSELS
in one hand and push the dissector downward beneath the skin, guided by the
vein, to a point near the knee. It may be advantageous to have an assistant
press the skin upward against the advancing dissector. If its progress is ob-
structed by adhesions around the vein pass the adhesion forceps (Fig. 80b)
over the vein down to the point of obstruction. Tear the adhesions by gently
opening the blades of the forceps and then proceed with the dissection. When
the eye of the dissector has reached a point near the knee make a small in-
cision over it, push it out through the skin, clamp the vein, and withdraw the
dissector. Rethread the vein in the dissector, reintroduce the latter through
FIG. 80. — a, MAYO'S DISSECTOR FOR VARICOSE VEINS; b, MAYO'S ADHESION FORCEPS FOR VARICOSE
VEINS.
the lower incision, and continue the dissection downward. Remove as many
other veins as is deemed necessary in a similar way. Binnie calls special
attention to the advisability of making the dissection from above downward
to avoid the danger of detaching thrombi and setting them free in the circula-
tion. The bleeding from the tributaries that are torn off can readily be stopped
by pressure with gauze pads. The wounds are closed by suture ; dry dressings
are applied and a snug bandage, applied from below upward (toes to groin),
with a posterior splint, is added.
EXCISION BY INVEKSION". — Mamourian elevates the limb, exposes and di-
vides the internal saphenous vein near the saphenous opening, ligates the
proximal end, and clamps the distal. Traction on the clamp indicates the
position of the vein near the knee, and it is exposed and divided again through
a small incision at this point. The distal end is clamped and a long probe is
passed, eye first, into the proximal end upward and out of the upper incision.
The upper end of the vein segment is fastened to it by a silk suture that
penetrates the vein wall through and through and is tied through the end of
the probe. Strong traction on the lower end of the probe extracts the segment
OPERATIONS UPON VEINS
323
of vein, turning it outside in. Mamourian says a gum elastic catheter may be
used instead of a probe, if the veins are very tortuous. This method is not
applicable to general or cirsoid varicosities.
BABCOCK'S OPERATION. — Babcock devised a long, pliable probe with a
small olivary tip at one end and a larger oval tip at the other, cupped under-
neath so as to catch the cut end of the vein. It is used
as follows: expose and isolate about 1 inch of vein at
the upper end of the segment whose removal is intended.
Grasping it in a hemostat, make a small incision into
the wall and introduce the small end of the probe. Pass
it downward within the vein, as far as possible, and tie
the upper end of the segment tightly around it just
below the large end. Cut the vein between this and the
hemostat and replace the latter by a ligature. Make a
small incision through the skin, fascia, and vein wall
upon the small ends of the probe. Grasp this and make
traction combined with a series of short jerks. The
vein comes away, pleated in a small mass against the
cupped surface of the larger tip; hemostasis; wound
closed ; dressings ; bandage, and splint as usual.
FOSTER'S METHOD. — Foster in a similar way uses 2
feet of No. 4 copper wire, bent at one end into a loop,
or neck, around which the cut end of the vein to be
stripped out is tied.
Treatment toy Incision. — CIRCULAR INCISION.—
Schede has advocated a complete circular incision
dividing all tissues down to the deep fascia in the upper
third of the leg, double ligating each vein as it is cut.
Von Wenzel adds a second similar circular incision at
the junction of the lower and middle third of the thigh.
SPIRAL INCISION. — Keindfleisch and Friedel divide the internal saphenous
vein between ligatures high up in the thigh; mark a spiral with 5 to 8 turns
around the leg; deepen this by incision to the deep fascia, catching and ligating
the divided vessels; pack the wound to hold the edges of the spiral apart and
force it to heal by granulation and epidermization. This leaves a deep spiral
gutter in the leg (Fig. 81). Where ulcers exist they include them, between
turns of the spiral, joining these by vertical incisions on each side of the
ulcer.
Kayser reported 18 cases done by this method, all of the most severe type.
He declared that the size of the leg diminished and remained smaller, existing
ulcers were healed, there were no sensory disturbances of the skin, and his
patients were well satisfied with the results. He makes 6 to 12 spiral turns
according to extent of varicosities, beginning on dorsum of foot, with 3 parallel
incisions on dorsum, which, he says, prevents edema ; and if ulcers are large he
FIG. 81. — FRIEDEL'S. SPI-
RAL OPERATION FOR
VARICOSE VEINS.
324
OPERATIONS UPON BLOOD VESSELS
carries the incisions through them. He keeps the patient in bed 4 weeks after
operation.
Geinitz, reporting the late results of this operation performed for varices
at Garre's Clinic, says they are surprisingly good. The ulcer only recurred in
one case. He recommends it highly for diffuse varices and cases where
simpler methods have failed.
Treatment by Suture. — DELBET'S OPEEATION. — Delbet, in 1906, suggested
and carried out by suture a re-implantation of the saphenous vein into the
femoral 10 or 12 cm. below its original
entrance. His object was to cure varices
by relieving them of the weight of the
superimposed blood column through the
interposition of one or more sets of com-
petent valves. He reported 8 cases, and
Hesse and Schaack collected 48 cases in
all. There was 1 death out of Hesse and
Schaack's 23 own cases, and they called
the other 22 cured.
HESSE AND SCHAACK >S OPERATION.
— Hesse and Schaack operated as fol-
lows : An incision 12 to 15 cm. long was
made through skin and superficial fascia
at Scarpa's triangle in the direction of
the internal saphenous. This vein was
isolated, and all but the largest branches
were ligated. They then exposed and
freed the femoral vein for a sufficient dis-
tance, ligated the saphenous at its en-
trance into the femoral vein, put a tem-
porary hemostat on it a little below, and
divided the vein between ligature and
serrefine. They then reimplanted the
distal cut end of the saphenous into the
femoral vein at least 10 cm. distal to its original entrance, using a traction
suture at the upper and lower ends of the anastomosis, and then completing it
by a continuous suture (Fig. 2). After operation no immediate improvement
was apparent, but soon the Trendelenburg's symptom disappeared. In 21 of
the 23 cases the patency of the anastomosis was established.
JEGEE'S METHOD. — Jeger suggests the advisability of minimizing the dan-
ger of thrombosis by employing for the anastomosis his own method of end-to-
side implantation of veins which approximates the endothelial surfaces very
exactly. ,
COENEN'S METHOD.— Coenen originated an operation similar to Delbet's
for relief of varices of the external saphenous. He ligated and divided the upper
FIG. 82. — DELBET'S OPERATION AFTER
HESSE AND SCHAACK.
OPERATIONS UPON VEINS 325
part of the small saphenous and united its distal end by circular suture to the
central end of the ligated and divided posterior tibial. His end results are not
available, but he saw the tibial vein fill with blood from below upward, indi-
cating that he had accomplished his object of affording another exit for the
blood in the saphenous system.
KATZENSTEIN'S METHOD. — Katzenstein, reasoning that the varicosities of
the saphenous system are due to lack of muscular support, originated a pro-
cedure in which he frees the internal saphenous as widely as possible, lays it
on the sartorious muscle, and builds a muscular canal for it by suturing the
latter around it. His results are said to be good.
CHOICE OF METHOD
The choice of method depends largely upon the extent and type of the
varicosities. Subcutaneous removal by Mayo's dissector, Babcock's probe, or
the inversion method of Mamourian works very well if the veins are thick-
walled and not very tortuous and adherent. But thin-walled veins, tortuous
and adherent, are best removed by open excision. Where the skin is thinned
out and the subcutaneous fat that normally lies between it and the vein has
been replaced by fibrous tissue resulting from chronic periphlebitis it is more
satisfactory to remove the skin and veins en masse down to the deep fascia,
freeing the flaps sufficiently to bring them together without tension. The
high ligation in the thigh may properly be added to any of these procedures
where Trendelenburg's symptom is present ; and, in mild cases, it alone may be
sufficient. The reimplantation of the saphenous is suitable only for cases ex-
hibiting Trendelenburg's symptom ; and, inasmuch as the other simpler opera-
tions are safer and more satisfactory in almost all cases, if properly and thor-
oughly carried out, the saphenofemoral anastomosis by suture seems hardly
justifiable. It has been practiced little, if at all, in this country. The circular
incisions of Schede and Von Wenzel do not appeal to me as being much more
rational than the wearing of one or two tight, circular garters; but the com-
plete spiral of Eindfleisch and Friedel has given good results in properly
selected cases, and should be reserved for those where there are extensive
varicosities with marked periphlebitis, varicose ulcers, and edema.
The operation of excision is simple but tedious and, with the exception of
the suture anastomosis, all the other methods are easily performed. The only
dangers that are to be feared are infection, which, of course, is more liable to
occur in ill-nourished tissue, such as that in the varicotic area ; and embolism,
which is fortunately very rare. A certain amount of necrosis of the edge of
the wound margins is not infrequently seen, due probably to the destruction of
their blood supply in undermining them.
Goerlich reported 2 cases of pulmonary embolism in 147 operations done
by Trendelenburg's method, and collected in all 8 cases, following various
operations for varicose veins.
326 OPERATIONS UPON BLOOD VESSELS
Wilson says that (1) from 1 to 2 per cent, of all cases of blood vessel opera-
tions give more or less distinct clinical evidence of emboli, over TO per cent, of
which are pulmonary; (2) probably about 10 per cent, of cases of postoperative
emboli are fatal; (3) autopsy shows about 80 per cent, of these emboli to rise
from venous thrombosis; (4) in over 12 years at St. Mary's Hospital only 1
fatal case of embolism followed phlebectomy of varicose veins of leg; (5) in
1,372 operations on blood vessels during the same period there were only 2
deaths from embolism. One of these was cerebral, the other pulmonary.
RESULTS OF TREATMENT
Matas quotes Goerlich, who wrote that in 1,425 cases reported by 42
operators he found 65 per cent, to 85 per cent, of cures after ligation of the
internal saphenous.
Miller reports 79 per cent, of cures by Trendelenburg's operation in 41
cases at Halsted's Clinic.
Perthes reported 78 per cent, of cures by Trendelenburg's operation in
Trendelenburg's Clinic.
The Schede operation in Johns Hopkins Clinic gave 33 per cent, of cures
in 19 cases.
"Relapse," says Matas, ais more likely to follow the single linear division
of veins than the more thorough extirpation." Nevertheless, the secondary
dilatation of small superficial tributaries of the extirpated veins, the re-
establishment of direct end-to-end communication through the scar, especially
after ligation, and the regeneration of veins will cause a certain percentage of
relapses even after extensive resection of veins.
Jeannel is quoted by Binnie as taking the high conception of "cured" to
mean the restoration to the patient of a "healthy, vigorous, painless limb." He
says that out of 697 limbs operated on by (1) Trendelenburg's operation, or
its variants, 56 per cent, were cured; (2) out of 23 limbs in which was done
resection of the whole femoral part of the internal saphenous, 52 per cent, were
cured; (3) in 70 limbs excision of isolated varices cured 74 per cent.; (4)
resection of all or most of either the internal or the external saphenous (but
not both) cured 46 per cent, of 57 limbs; (5) Trendelenburg's (or variants)
plus multiple resection and ligation 'cured 60 per cent, of 95 limbs; and (6)
complete saphenectomy cured 95 per cent, of 77 limbs.
OPERATIONS TO PREVENT EMBOLIO INFECTION
It should be well understood that venous thrombi are potentially far more
dangerous than those in arteries. The latter, if we except the pulmonary
artery, can, at worst, lead immediately only to the destruction of the part sup-
plied by its branches; while venous thrombi, by fragmentation, may cause
instant death through embolism of cerebral vessels. Moreover, they may, if
OPERATIONS UPON CAPILLARIES 327
infected, give rise to pyemic abscesses from septic emboli in the most distant
parts and tissues, or furnish the bases of an infective endocarditis.
For these reasons considerable attention has lately been given to the op-
erative treatment of infective phlebitis. Ligation and excision of the internal
jugular to prevent dissemination of infection in cases of sigmoid sinus throm-
bosis is a well established procedure; while similar treatment of the ovarian and
uterine veins, in cases of pelvic thrombosis of septic origin, ha- n-d-ntly been
reported by Jellett. Moreover, Neuhof has done some experimental work in
testing the practicability of ligation of the portal vein with a view to its applica-
tion in the treatment of suppurative pylephlebitis.
Whatever its situation, the principle in the operative treatment of infective
thrombophlebitis is the same: to ligatc the vein on the cardiac side of the
diseased process, and evacuate the clot, or to ligate it both centrally and dis-
tally and excise the segment between. Binnie quotes Trendelenburg as record-
ing a case of "general, chronic puerperal infection which recovered after liga-
tion of the inflamed and thrombosed right internal iliac and spermatic veins."
Faix mentions 20 cases reported operated for pelvic thrombosis from the
clinics of Freund, Trendelenburg, Michel, Bumm, Hackel, Opitz, and Fried-
man, of which 7 recovered — a 65 per cent, mortality. Bumm puts the mor-
tality of non-operated cases at 85 per cent. Bremmer reports 32 cases operated
for mesenteric thrombosis with 5 recoveries — 85 per cent, mortality.
III. OPERATIONS UPON CAPILLARIES
OPERATIONS TO CHECK BLEEDING
Local Coagulants. — Local coagulants may sometimes be used with advan-
tage to check capillary oozing. Of these the most commonly used at present
are hot water, hydrogen pe"roxid, and adrenalin. Gelatin is excellent also, but
not so simple to prepare and use.
ADEENALIN. — Adrenalin is used as a solution in the strength of 1 :1,000
applied on a gauze or cotton sponge, or sprayed from an atomizer. It is par-
ticularly useful in capillary bleeding from the mucous membrane of ear, nose,
and throat, or abraded skin surface.
HYDEOGEN PEROXID. — Hydrogen peroxid is useful in oozing of large
wound surfaces upon which it may be poured or applied by sponges.
HOT WATEE. — Hot water should be used at a temperature not over 140. It
may be sponged or poured on the oozing surface.
GELATIN.— Gelatin in 5 per cent, or 10 per cent, solution, dissolved in
normal saline heated from 40° to 60° C., is applied to the bleeding surface, or
packed into the wound on a saturated gauze compress. The possibility of
tetanus infection from this source necessitates the previous perfect steriliza-
tion of the gelatin. Equal parts of tannin and.antipyrin in a gauze sachet have
been recommended by Park as a local hemostatic in bleeding ulcers of malig-
328 OPEKATIONS UPON BLOOD VESSELS
nant neoplasms. Matas advises gauze compresses wrung out of a 5 per cent,
solution of antipyrin to cover oozing surfaces or pack cavities, and sachets of
compound alum powder (Squibb's surgical powder) to pack bleeding cavities.
Combined with any of these local coagulants, calcium chlorid, 1 to 2 grains in
a neutral solution of 1 : 20 strength injected deeply into the tissues, and in 5-
grain doses by mouth or rectum, will materially aid in reducing coagulation
time of blood.
Gelatin, in the form of Carnot's solution, is said to have the same effect
when injected intravenously (100 to 200 c. c. daily at 37° C.), and thyroid
extract, taken internally, has been recommended for the same purpose by
Taylor.
Packing. — Packing with sterile gauze is undoubtedly one of the most effi-
cient means employed to check oozing from the walls of a wound or cavity. It
should not be too tight, and should be soaked with peroxid or sterile saline
before being removed on the second or third day. The actual cautery, heated
by burning benzin, or by electricity, is a most efficient agent in controlling
capillary hemorrhage. The object of cauterization is to produce a burned
crust sufficiently strong to withstand the pressure of the blood, and for this
purpose it should be used at a cherry red, not white, heat, in order to cook the
tissue slowly and thoroughly, rather than reduce it to an ash. This crust must
not be disturbed until the vessels beneath it have filled up with clot, or bleed-
ing will recommence.
Ligation en Masse. — Ligation en masse may be practiced as described in
ligation of arteries en masse. This for the purpose of checking capillary ooz-
ing in parenchyma of organs such as liver, spleen, and kidney.
OPERATIONS TO OBLITERATE THE VASCULAR CHANNELS IN SMALL
ANGIOMATA AND NEVI
Excision. — Excision of small nevi is easy, the flaps of the wound being
readily brought together with sutures. Larger nevi, when excised, may leave
an area denuded that has to be covered by a plastic operation, or by skin graft.
The incision should pass only through healthy tissue, and hemostasis must be
carefully attended to.
Freezing. — Freezing is the treatment par excellence for ordinary nevi.
The freezing may be done by liquid air or by carbon dioxid snow. The latter
is easier to obtain. If liquid air is to be used make a firm pad of cotton on a
small stick. Dip the pad into the liquid air. Shake off any loose drops of the
liquid. Press the charged pad with moderate firmness on the nevus for a few
seconds. Eepeat the process in every part of the lesion. Apply no dressings.
All scabs must be removed prior to the treatment, and if any raw surfaces are
present they must be covered with thin gauze, otherwise the applicator would
freeze to them.
If carbon dioxid is to be used? a cylinder of the liquid is obtained, a paper
OPERATIONS UPON CAPILLARIES
329
cone constructed and held in front of the outlet while the valve is slightly
opened. The liquid condenses immediately into snow, which is deposited into
the cornucopia, making a cone-shaped mass of snow. It may be whittled to a
sharp point and held in a thick layer of paper with the point protruding.
FIG. 83. — KROGIUS'S SUBCUTANEOUS LIGATURE FOR LARGER ANGIOMATA.
This should be pressed firmly against the growth in several places for a few
seconds at a time. No anesthesia or dressings are necessary. With liquid air
or carbon dioxid the treatment may have to be repeated several times. Too
long application may cause extensive sloughing.
Ligation. — Angiomata of the scalp may be surrounded by a chain of sub-
cutaneous ligatures (using full-curved needle for advance and quarter-curved
for return part of stitch), which cure by cutting off the blood supply in the
main vessel (Fig. 83), or a purse-string
suture with 4 loops may be used to strangu-
late the growth (Fig. 84).
Injection. — Injection of astringents,
cauterization, and scarification, methods
formerly much in use, are not approved
at the present time. Acupuncture, or
needling of the nevus, is a method still
occasionally used. It is painful and gives
rise to a certain amount of scarring, but
it is efficient. The needle is heated to red-
ness by electricity. It should be intro-
duced slowly and cautiously to avoid bend-
ing, and should be removed slowly to avoid
hemorrhage on account of the cooked tis-
sue sticking to the needle and being torn
away with it.
Wyeth has treated arterial, venous, and
capillary angiomata with injections of boiling water, under general anesthesia.
For capillary growths he advises water at about 190° F., throwing in 2 to 0
minims at a puncture, and beginning at the periphery of the growth and work-
ing toward the center. A surgical dressing is then applied and the part kept at
rest. The injection may be repeated in 7 to 10 days.
Desiccation. — Desiccation, the electric desiccation of vascular nevi by high-
frequency currents, is said by W. L. Clark to give very excellent results. He
ANGIOMA
J;
FIG. 84. — PURSE-STRING LIGATURE FOR
SMALL ANGIOMA OF SCALP.
330 OPEBATIONS UPON BLOOD VESSELS
advises that the destruction of the nevi, unless very large, should be completed
at one sitting. In superficial lesions new skin is formed. Deep lesions are
replaced by scar tissue and skin. To avoid cupping, irregularities of the sur-
face, and possibly keloid formation, care must be taken to destroy the tissue
perfectly evenly, and not too deeply. The desiccation action is apparently a
rapid dehydration of the tissue, rupturing the cell capsule and converting the
treated area into a dry mass. Penetration of the tissue is said to be from a
small fraction of an inch to 1 inch or more, depending upon frequency, dis-
tance of electrode from body, time of exposure, and density of tissue. It de-
stroys tissue without opening blood or lymph channels and acts as a styptic
when there is oozing of blood. The dry crust acts as a dressing and separates
in 3 to 7 days and skin regeneration is said to take place beneath it.
The treatment is not very painful if applied with the proper technic, but
local anesthesia may be needed, or, in rare cases, general anesthesia.
A. Schuyler Clark recommends the Kromayer light as being excellent for
"port wine marks."
Choice of Method. — The choice of method will undoubtedly vary with the
individual operator. Liquid air, carbonic snow, desiccation, etc., all give ex-
cellent results in the majority of cases, but all three require some experience
for their proper application. Excision is far less used now than it was formerly,
and should only be employed in those cases that prove refractory to the less radi-
cal forms of treatment. Needling is painful, and hot water injections are too
risky to be recommended.
There is little danger in operating upon these capillary growths, for hemor-
rhage from them is usually moderate in amount, and easily checked by pres-
sure. Oozing may be obstinate, however, after excision, and hemostasis must
be carefully attended to on account of the bad effect of loss of blood in young
children.
Results are excellent, cures being practically always possible, but not
always possible without scarring.
OPERATIONS UPON THE LYMPHATICS
HANDLEY'S OPERATION
For the reestablishment of lymph drainage; intractable edema of the ex-
tremities, due to blocking of lymphatics, following chronic inflammation;
presence of filaria ; Le Dantec's "dermodoccus" (diplodoccus) ; scar forma-
tion after excision of lymph-nodes, etc. The operation consists in establishing
artificial channels for lymph drainage from the edematous parts as substitutes
for the natural vessels which have become obstructed.
Beside the usual dissecting instruments, several long-eyed probes and sev-
eral lengths of No. 12 tubular, woven silk are needed.
OPERATIONS UPON LYMPHATICS
331
Upper Extremity.— (1) Make a 1-inch incision through the skin in the mid
line of front of forearm immediately above wrist (a, Fig. 85). (2) Introduce
a probe through it and pass it upward and outward in the subcutaneous areolar
tissue to the point b (Fig. 85) near the elbow. In-
cise the skin over it there and push the point of probe
out. (3) Take a double line of No. 12 silk twice as
long as the arm ; catch its mid point with hemostat
and wrap one-half up in sterile towel, threading free
end of other half through eye of probe. Pull probe
and silk with it out of incision b (Fig. 85). A double
line of silk now lies in subcutaneous tunnel a-b (Fig.
85) made by probe. (4) Eeintroduce probe through
incision b and bring silk out through incision d made
near insertion of deltoid. (5) Pass a second probe
through incision a upward and inward, and make it
emerge through in-
cision c. The half of
silk line which was
wrapped in towel is
now unwrapped and
threaded through the
eye °^ the probe.
-^u^ probe and silk
out through incision
c (Fig. 85). Re-
move hemostat from
silk so that loop be-
comes buried under
skin at a. (6) In
same fashion pass
silk under skin from c to d. Reintroduce both
probes through d and pass them, under the skin,
round the shoulder to emerge through incision f
at posterior border of deltoid (Fig. 86). (7)
In similar fashion, bury a double line of silk
under skin of back of arm along lines of j, h, f
(Fig. 86), and j, k, f (Fig. 86). There are
now 8 threads emerging through f. (8) Take a
long probe, cut ends of two of emerging threads
so that they are 4 inches shorter than it, and
thread them into the eye. Thrust probe, eye
first, through incision f and make it penetrate under skin of back. The probe,
being longer than silk, unthreads itself. Withdraw probe carefully, leaving
thread to occupy its track. Repeat the maneuver until all the threads emerging
v;
FIG. 85. — HANDLEY'S OPERA-
TION FOR LYMPHATIC DRAIN-
AGE : UPPER EXTREMITY, AN-
TERIOR VIEW.
FIG. 86. — HANDLEY'S OPERATION.
POSTERIOR VIEW.
332 OPERATIONS UPON BLOOD VESSELS
at f are buried in various directions into subcutaneous tissues of back. (9)
Close all incisions with sutures.
Handley states the centra-indications to the operation (after carcinoma of
breast removal) to be :
(1) When general anesthetic cannot be given.
(2) Where threads would have to pass through cancerous tissue.
(3) When there is growth present about the shoulder, and pain in axilla,
or lancinating pain shooting down arm (i. e. nerve plexus pain).
(4) He says that benefit is transient in cases where secondary growths, or
pleural effusion, are present.
(5) It should be reserved for severer cases of lymphostasis.
Lower Extremity (Elephantiasis, Milroy's Disease, Congenital Edema,
etc.). — The techiiic of the operation is similar to that in upper extremity,
but its accomplishment is more difficult on account of the thickened, irregular
nature of the skin; and infection is more liable to follow on account of me-
chanical difficulty of getting a clear operating field.
The Face. — Mitchell did Haiidley's operation on a case of solid edema of
eyelid, following a severe attack of erysipelas that had resisted all ordinary
treatment. The operation was performed as follows :
By means of a small curved incision in upper and lower eyelid, near
mesial part, and another lateral to outer canthus, coarse strands of silk were
carried beneath the skin of both eyelids beyond the outer canthus. From
there they were led subcutaneously downward, by means of an incision lateral
to the angle of the mouth, and finally the buried ends left beneath the skin of
the cheek near the ramus of the lower jaw.
Mitchell performed a similar operation on a patient with solid edema of
the side of the face and the lips, following erysipelas, by burying 2 silk threads
with their upper ends in the masseteric region and their lower ends tucked
into the loose tissue behind the clavicle. Results were good in both cases.
Ascites. — Gerrish says : "In a case of atrophic cirrhosis with ascites Hand-
ley passed a stout needle, threaded with silk such as he used in lymphangio-
plasty, in and out at a number of points through the peritoneum and subjacent
tissues of right iliac region, leaving several series of short loops projecting
into the cavity. The ends of these threads were pushed into the areolar tissue
of the front of the thigh, passing near the anterior superior spine of the ilium,
and behind the inguinal ligament. The immediate result was not satisfactory
and another paracentesis was needed, but ultimately great benefit ensued,
seeming to justify extensive trial of the method."
The operation of lymphangioplasty is simple and easy, and the dangers
are relatively slight. Infection occurred in one of Handley's cases done for
lymphedema of the lower extremity; and in one of Mitchell's cases done for
edema of the eyelid one line of silk had to be removed on account of the "irrita-
tion" it caused.
The results, however, were good in almost every case, and it is unques-
BIBLIOGRAPHY 333
tionably the best treatment now known for the relief of the painful, intractable
lymphedema following operations for carcinoma of the breast
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69. MILLER. Bull. Johns Hopkins Hosp., 1906, xvii, 289.
BIBLIOGEAPHY 335
TO. MITCHELL. Brit. Med. Jour., 1909, 11, 1462.
71. MOBITZ. Munchen. med. Wchnschr., 1911, Iviii, 395.
72. OMI. Deutsch. Ztschr. f. Chir., 1912, 118, s. 172.
73. PAYK. Arch. f. klin. Chir., Ixxxvii, 803.
74. . Munchen. med. Wchnschr., 1912, lix, 793.
75. — . Verhandl. d. deutsch. Gesellsch. f. Chir., 1911, xl, 11 Teil, 515.
76. PECK, CHAS. H. N. Y. City, personal communication.
77. PERTHES. Deutsch. med. Wchnschr., 1895, xxi, 253.
78. POOL and McCLURE. Ann. Surg., Oct., 1910, Hi, 433.
79. RINDFLEISCH and FRIEDEL. Arch. f. klin. Chir., Ixxxvi, 143.
80. RISLEY and IRVING. Boston Med. and Surg. Jour., 1912, clxvi, 956.
81. EITTER. Med. Klin., 1910, Nr. 17, s. 663.
82. ROSENSTEIN. Verhandl. d. deutsch. Gesellsch. f. Chir., 1912, 2 Teil, 232.
83. RUOTTE. Lyon med., 1907, cxix, 574.
84. SATTERLEE and HOOKER. Arch, of Int. Med., 1914, xiii, Nr. 1, 51.
85. TURNURE, P. R. N. Y. City, personal communication.
86. UNGER and BETTMANN. Berlin, klin. Wchnschr., 1910, s. 724.
87. VINCENT. Boston Med. and Surg. Jour., 1912, clxvii, 239.
88. HAGEMANN. Verhandl. deutsch. Naturforscher u. Aerzte, 1910, 2 Teil,
s. 121.
89. WALTER. Med. Klin., 1911, Nr. 19, s. 728.
90. WARREN, MORTIMER. N. Y. City, personal communication.
91. WILSON. Ann. Surg., Dec., 1912, Ivi, 6, 809.
92. WIETING. Deutsch. zeitschr. f. chirurg., 1911, ex, 364.
93. NETJHOFF. Surg., Gynec. and Obst., 1913, xvi, 5, 481.
A SPECIAL METHOD FOE THE TRANSFUSION OF BLOOD
WITH THE USE OF PAR^FIN AND HIRUDIN
CHAPTER IX
A SPECIAL METHOD FOB THE TRANSFUSION OF BLOOD WITH THE USE
OF PAEAFF1N AND HIEUDIN
RANSOM S. HOOKER AND HENRY S. SATTERLEE
For the purpose of the present discussion it will be sufficient, after a short
historical outline, to summarize the main theoretic principles underlying the
authors' methods of transfusion, to briefly indicate the experimental data
which support these principles and which have served as a basis for the devel-
opment of their apparatus and technic, and finally to describe the practical
operation of transfusing blood by these methods. For those who seek general
information on this and correlated subjects, there is appended a classified
bibliography of the references which we believe to be of most interest and
importance.
HISTORY
The idea of transfusing fresh human blood through the agency of an inter-
mediate receptacle, or carrying system, appears to have originated in the
minds of several persons shortly after the discovery of the circulation of the
blood by Harvey. To Francesco Folli, in 1652, is ascribed a plan of trans-
fusion, by means of two cannulas united either by a piece of intestine, or by
part of an artery having a collateral outlet to provide for the escape of air
(Casse). Chereau quotes Robert des Gabets, a Benedictine monk, as propos-
ing, in 1658, the employment of a transfusion apparatus which he had con-
structed 7 years previously. The apparatus was described as 2 silver tubes
united by a small leather purse, the size of a nut, each tube provided with a
valve so that the leather bag would serve as a pump to propel the blood from one
blood vessel to the other; it was also mentioned that the bag would serve the
purpose of measuring the amount of blood transfused. There is, however, no
record that this device was ever actually employed for transfusion.
The first authentic account of the transfusion of blood through a foreign
carrying system was the experiment performed by Richard Lower (37) of
Oxford in 1666 ; and, in the following year, the report of a similar experiment
by Jean Denys (20) in Paris. Lower successfully transfused blood from .the
33 337
33$ THE TBANSFUSION OF BLOOD
carotid artery of one dog into the jugular vein of another dog by means of
several quills fitted together to form a tube. This quill method was later
modified by Lower to a conducting system composed of 2 silver cannulas united
by a section of the carotid artery of a horse or ox, and by this means Dr.
Lower and Sir Edmund King (33), in 1667, transferred blood from the
artery of a sheep into the arm vein of a man. Denys and Emmeretz (21)
reported 3 successful transfusions by a similar method in the same year.
Aveling (2), in reviewing the history of transfusion in the eighteenth cen-
tury, says that the recommendation of vein-to-vein transfusion by Tardy (52)
of Paris and by Harwood (28), Professor of Anatomy at Cambridge, in 1785,
led to the need of a motive power to effect a transfer of blood from donor to re-
cipient; and that Boehm (8) used for this purpose a piece of duck's intestine to
unite the two cannulas, propelling the blood from one vein to the other by strip-
ping this vessel with his fingers from the donor toward the recipient. Coluzzi
(14) used, for the same purpose, 2 glass tubes as cannulas, connected in the mid-
dle by a small bladder holding about an ounce. In operating, he allowed this
bag to fill with the blood and then forced the blood into the recipient's vein by
compressing the bladder while shutting off communication with the donor's
vein. These operations, probably on account of the difficulty of performance,
appear to have been attempted only in great emergency by the bolder spirits
of the time, and gradually fell into disuse.
In 1818, James Blundell (6) revived the subject of transfusion by re-
porting to the Medico-Chirurgical Society of London a series of experiments
upon animals, in which he made use of an entirely new method of transfusion,
the blood being received into a cup from a vein of the donor, and injected
into a vein of the recipient by means of a piston syringe. In the sixth ex-
periment of his series Blundell reported that without causing any harm to
the animal he had transfused 4 pints of blood from the femoral artery into
the femoral vein of a 12-pound dog in 8 minutes, and had repeated this
procedure twice, with intervals of half an hour, making 12 pints of
blood transfused in an aggregate time of 24 minutes. Several years later
Blundell developed a more complicated instrument which he called an
"impeller."
Scott (51) of Newington Causeway invented a transfusion apparatus
about this time which is described in the Lancet of May 13, 1826, as a
"Bead's syringe into the extremity of which slides a hollow flexible tube 14
or 15 inches long, armed with a silver pipe for entering the vein of the emit-
ter. A similar tube is screwed to the lateral branch of the syringe, and has a
silver pipe which is inserted into the vein of the receiver or patient. The
pipes being inserted, and the syringe put in action, the blood is made to pass
freely from one person to another . . . the velocity and- the power of the
current being regulated by the syringe at the discretion of the operator." A
successful case of transfusion with Scott's apparatus was reported in 1826 by
Joseph Ralph (49) ; who says: "However formidable and difficult the opera-
HISTORY 339
tion may have hitherto seemed, it may be performed by this instrument with
the greatest ease."
In 1829, Blundell (7) introduced a further development of his instru-
ment which he called a "gravitator," and which is illustrated and described in
the Lancet of June 13, 1829.
The period from 1830 to 1880 was signalized by the development of many
methods for transfusing both animal arid human blood, fresh and defibrinated.
Numerous ingenious instruments were devised for this purpose, the forms of
apparatus conforming to four general types.
(1) A simple conducting system providing a direct passage from one
blood vessel to the other, usually with some contrivance to allow the escape of
air.
(2) A receiver to collect the blood from the donor and a means of quickly
injecting this blood into the recipient's blood vessel; or, if the blood were
defibrinated, simply the means of injecting defibrinated blood into the circu-
lation of the recipient.
(3) A conducting system in direct communication with a piston or bulb
syringe, or with some other means of pumping the blood from the donor to
the recipient.
(4) Syringe-cannula methods, having cannulas in both donor's and re-
cipient's veins and a syringe or syringes, fitting both cannulas, to draw the
blood from the donor and inject it into the recipient.
Inventions corresponding to these four types were advocated and employed
during this period as follows:
Type 1. — These instruments conform essentially to the original apparatus
of Eichard Lower (1666). Other instruments of this class were those of
Gesellius, Albini, Casselli, Morselli, Luciani and Ore, two varieties.
Type 2. — The apparatus of Blundell (1818) was the forerunner of this
class of instrument. Varieties of this type were developed in the period from
1864 to 1877 by Hamilton, De Belina, Moncoq, MacDonnell, Collin, two varie-
ties, Copello, Hasse, Gendron, Hiiter, Casse, Uterhart and Ore.
Type 3. — The apparatus of Scott in 1826 was the first practical instru-
ment of this type to be developed and was soon followed by an adaptation by
Weiss in London. In the period 1864 to 1874 varieties of this class of instru-
ment were employed by Aveling, Roussel, Grecco, Leblond, LeNoel, Collin,
Ore, Manzini and Rodolfi, Moncoq and Mathieu.
Type 4. — Probably the first instrument of the syringe-cannula class was
that of Moncoq (45) in 1862 ; others were those of Mathieu and Ore both in
1863, and of Graily Hewitt (30) in 1864. Hewitt's apparatus is probably the
best representative of this type and warrants a brief description. It consisted
of a simple piston syringe of 2-ounce capacity used in connection with 2 silver
cannulas. Having exposed the veins of the donor and recipient, Hewitt ex-
tracted with the syringe 2 ounces of blood from the donor as rapidly as pos-
sible, and gently injected 1 to 1% ounces of this blood into the recipient's vein,
340 THE TRANSFUSION OF BLOOD
taking about 1 minute for the injection. Hewitt stated that the transfer of
blood must take place within 3 minutes to escape the danger of coagulation.
SYRINGE METHODS OF RECENT TIMES
In more recent times Cripps (17) improved Aveling's method by uniting
2 silver cannulas with rubber tubing to opposite sides of an oval rubber ball of
2 drams capacity. This conducting system, which was without valves, was
completely filled with warm salt solution before being connected with the
blood vessels, and served as a pump, which, by properly compressing the tubes
and rubber ball, drew the blood from the donor's vein and injected it into the
vein of the recipient. The Cripps-Aveling method has been revived again
very recently by McGrath (88).
In 1892, v. Ziemssen (90) advocated a syringe-cannula method which re-
quired one operator and 3 assistants. A vein of the donor was punctured
without skin incision by means of a hollow cylindrical needle and blood with-
drawn into a 25 c. c. piston syringe. While the syringe was being filled, an-
other needle was likewise introduced into the recipient's vein; when the
syringe was full of blood it was detached from the donor's needle, then con-
nected with the recipient's needle and its contents discharged. Meanwhile a
second syringe was attached to the donor's needle, as soon as disconnected
from the first syringe, and the same procedure was repeated. A third syringe
followed in the same way, the first one being meanwhile washed out with
salt solution by an assistant. V. Ziemssen reported that the transfer of from
250 to 300 c. c. of blood by this method took not longer than 15 to 20 minutes.
In the first series of 7 cases he stated that he observed chills and elevations
of temperature in 3 instances and that in one of these cases he had trouble
with a clot in the recipient's needle which had to.be removed. He, however,
considered the method less liable to the risk of causing dangerous coagulative
changes in the circulating blood, than transfusion by end-to-end anastomosis,
or the use of defibrinated blood.
Moritz (89), in 1911, recommended a method which did not materially
differ from v. Ziemssen's except that the needles were fitted with stop-cocks
and were connected with the syringe by means of an intermediate tube of
glass and rubber which also was provided with a stop-cock. Immediately after
each withdrawal or injection of blood, sterile normal salt solution was forced
through the needles ; the stop-cocks were closed. Strips of adhesive plaster were
used to prevent as far as possible movement of the needles while within the
vein. Hiirter (69) recommends Moritz's method and claims to have had success
with it, although he refers to it as involving a delicate technic.
More recently Freund (86) has devised a somewhat similar syringe method
combining the use of salt solution with an apparatus which is similar to that
of Manzini and Rodolfi. Freund's apparatus consists of a 20 c. c. piston
syringe connected by a two-way stop-cock, with a cylinder of salt solution
HISTORY 341
'and with a piece of rubber tubing leading to another two-way stop-cock
which communicates by short connections with 2 hollow cylindrical needles,
one larger than the other. Donor and recipient are close together and the
apparatus, fastened upon an inclined support, is placed between them. The con-
necting tubes and needles are filled with salt solution and the larger needle
is introduced into the donor's vein. Both needles are held in place with strips
of adhesive plaster. In operation, the blood is pumped from donor to re-
cipient, 16 c. c. of blood mixed with 4 c. c. of salt solution, being withdrawn
and delivered at each stroke of the piston.
Lindeman's (87) method differs from that of v. Ziemssen and of Moritz
in that he has devised a special set of invaginated cylindrical cannulas and that
a dozen or more syringes of 20 c. c. capacity are employed in rapid succes-
sion to convey the blood from one cannula to the other. An improvement over
the v. Ziemssen and Moritz technic is the avoidance of traumatizing the
intima of the veins by the many abrading movements within the blood vessel
of a sharp-pointed instrument, incidental to the frequent connection and dis-
connection of the syringes. This feature is lessened by Lindeman in that the
sharp innermost cannula of his set is withdrawn from the vein as soon as it
has done its work of penetration. It should also be mentioned that the can-
nulas receive a preliminary internal coating of liquid paraffin. Syringe
methods without special apparatus have also been reported in recent years
by Cooley and Vaughan (84) and by Crotti (85).
Except for the admixture of salt solution no attempt is made, in this class
of operation, to prevent the clotting of blood while in the intermediate recep-
tacle and no special measures are taken to prevent or neutralize thrombo-
plastin formation. Success in getting the blood transferred while still in
liquid state depends therefore upon speed in conveying it from the vessel of
the donor to that of the recipient. The element of safety is inversely propor-
tionate to the amount of thromboplastin which is injected with the transfused
blood, and this again depends upon the degree of contact with traumatized
tissue and with moistenable foreign surface during the process of transfusion,
and is probably also influenced by the degree of pressure to which the blood is
subjected by the action of the syringe.
DEFIBRINATED BLOOD
In regard to the transfusion of blood after defibrination a very brief his-
torical note will suffice. Transfusion by this method was proposed as a re-
sult of the researches of Dieffenbach (60), Prevost and Dumas (77), and es-
pecially Bischoff (58), in the early part of the nineteenth century. Various
methods of infusing defibrinated blood were advocated, and the procedure was
from 1830 to 1880 employed to a considerable extent, if, indeed, it was not con-
sidered the method of choice. The intravenous use of defibrinated blood, how-
ever, fell into disrepute after 1880, on account of the researches of some investi-
342 THE TRANSFUSION OF BLOOD
gators of the Dorpat school (notably Kohler) (70) which called attention to
dangerous coagulative changes likely to be induced by the injection of defibrin-
ated blood into the circulation. For a full consideration of the arguments for
and against the use of defibrinated blood see Bibliography, Sec. II.
PARATFIN METHODS
The use of paraffin as an anticoagulant for transfusion apparatus was intro-
duced by Brewer and Leggett (93) in 1909, in their direct conduction method
by means of a paraffin-lined glass cannula. In this variety of operation,
paraffin has also been employed by Vincent (100) and others.
Of the methods of transfusion with paraffin-coated receptacles, that of Cur-
tis and David (94) (95), the Risley and Irving modification of this method
(97), and the method of Kimpton (96) should be mentioned. The first two
methods are very similar; the apparatus comprises a paraffin-lined cylinder
connected by an opening at its upper extremity with a pump for exhausting
or forcing in air, and at its lower extremity by two openings, one leading to
the donor's blood vessel and the other to that of the recipient. Donor and
recipient are placed close together and the apparatus connected by directly
introducing the two tips of the cylinder within their respective blood vessels.
In operation the recipient's vessel is shut off by pressure, and the exhaustion
of air from the cylinder draws the donor's blood into it. When 50 c. c. are
obtained, the donor's vessel is shut off by pressure and the recipient's vessel
released. The forcing of air into the cylinder then drives the blood out of
the cylinder into the blood vessel of the recipient. In a discussion of their
experimental comparison of various methods of transfusion Risley and Irving
report very favorably on this apparatus.
Kimpton's method is by means of a paraffin-lined glass cylinder with an
elongated and twisted neck. He obtains blood from the donor by incising a
clamped artery or vein with a cataract knife. The glass tip of his instru-
ment is inserted directly into this incision. The clamp is then removed and
the cylinder is allowed to fill by the force of the blood current. When the
cylinder is full the clamp is reapplied, the tip is removed from the artery or
vein, and the cylinder is carried to the recipient in the horizontal position, the
twisted neck acting as a trap and preventing the entrance of air through the
tip. The recipient's vein is entered in the same manner as the donor's blood
vessel and the blood is delivered by forcing air into the cylinder with a
cautery bulb.
THEORETICAL CONSIDERATIONS AND PRINCIPLES UNDERLYING
THE AUTHORS' METHOD
It is apparent to anyone who has given it consideration that a large field
of usefulness would be open to the operation of blood transfusion if it could
PRINCIPLES UNDERLYING AUTHOR'S METHOD 343
be performed safely, quickly, and surely by anyone possessing ordinary sur-
gical skill, and, if possible, without expert assistance. The one serious obstacle
in arriving at a safe and simple method of transfusing blood is the element of
coagulation. If this obstacle can be fairly met and overcome all difficulties are
solved.
With these considerations in view, and from a study of the more recent
investigations on the nature and significance of the factors concerned in blood
coagulation, there appear to be two ways of approaching this problem which
offer some promise of success. (139-142, 177-178, 127-1 :)<>. l.M.) The first
way is to preserve the antithrombin-prothrombin balance of the carried blood
by preventing access or formation of thromboplastic substance, which is the
initiating factor in spontaneous coagulation. The second way is to affect the
antithrombin-prothrombin balance of the carried blood by neutralizing the
thromboplastic substance and thus preventing its diverting action upon the
normal antithrombin, or, in other words, to reinforce the antithrombin side of
the balance by addition of the necessary element to offset the anticipated action
of thromboplastin.
The authors of the present methods accordingly planned two lines of ex-
perimentation, based on these premises, to overcome the clotting difficulty, and
at the same time to develop a practical technic of operation.
The first of these alternatives is to employ an intermediate carrying sys-
tem for the blood, lined throughout with paraffin, and thus to provide no point
of contact with any moistenable surface ; and at the same time to minimize as
far as possible the exposure of broken tissue surface to the blood stream in
the process of obtaining blood.
The second alternative is the employment of a sufficient amount of some
physiologic agent, as antithrombin or hirudin, to restrain or offset the initia-
tive factors of coagulation, during the time of the conveyance of the blood
through a foreign system, such as glass and metal.
For a detailed description of the experimental work which has led to the
development of the authors' methods of transfusion, the reader is referred to
previously published work (98, 99, 209). As a result of the earlier part of
this work there appeared to be two main influences which tended to produce
coagulative tendencies in blood transfused through the agency of an inter-
mediate receptacle.
(1) The admixture of thromboplastin derived from wounded tissue, and
more particularly from the wounding of the donor's blood vessel.
(2) The liberation of thromboplastin from the formed elements of the
blood itself, especially the platelets, caused by disintegration or abrasion of these
elements while in process of transfer.
With the present methods and apparatus the first contingency is avoided
by penetrating the donor's vein with a cannula which, by a jet of salt solution,
is immediately washed clear of any contaminating tissue juices which may be
carried into it by the act of removing the obturator or trocar. This cannula
344 THE TKANSFUSION OF BLOOD
serves as a protective sheath through which to introduce the tip of a pipet
directly into the blood stream of the donor without contact with the wounded
wall of the blood vessel. To avoid abrasion of the intima of the donor's vein
by the tip of the pipet while drawing the blood, this tip has a blunt extremity
with its opening in the direction of the blood current.
The second set of factors just mentioned has been met by having the tip of
the pipet of as large caliber and as short a length as practicable, and by ex-
panding its channel as rapidly and as evenly as possible (Fig. 1) ; also, by
having an intact paraffin lining throughout the instrument to provide a non-
Fio. 1. — SECTIONAL VIEW OF LOWER PART OF PIPET. Tip (cylindrical portion) of 14k. gold, seamless
drawn tubing 17.0 mm. (0.67 in.) long; ext. diam. 2.32 mm. (0.091 in.) ; int. diam. 2.03 mm. (0.080
in.) ; soldered into the funnel portion of the tip at an angle of 45°. Tip (funnel portion) of coin silver,
interior tapered from 2.03 mm. (0.080 in.) to 10.20 mm. (0.402 in.), flanged externally at larger
extremity to fit coupling. Coupling of brass nickel-plated, made from a section of 15.875 mm.
(0.625 in.) hexagon rod, drilled and threaded to fit bushing, and flanged *to form swivel union with
tip. Bushing of same material as coupling, tapered internally from 10.20 mm. (0.402 in.) to 12.75
mm. (0.502 in.); ext. diam. 13.71 mm. (0.540 in.), threaded at lower extremity to fit coupling.
Cylinder blown from Jena glass tubing 54.0 mm. (2.126 in.) ext. diam. Neck of cylinder 25.4 mm.
.(1.0 in.) long, with internal diameter tapered from 18.26 mm. (0.7187 in.) to 16.67 mm. (0.656 in.).
Angle of neck with long axis of cylinder is 30°. Asbestos packing made by wrapping around the
metal bushing a piece of asbestos tape 25 mm. (1.0 in.) wide and about 0.4 mm. (£$ in.) thick.
moistenable wall which reduces surface friction in the carrying vessel to a
minimum. As an alternative to the paraffin coating, we have employed a coat-
ing of hirudin solution, to act as a neutralizing agent for thromboplastin de-
rived from the formed elements of the blood at the zone of contact with the
wall of the pipet. To diminish friction, we have also limited the speed and
the force with which the blood can be drawn into and expelled from the
pipet, by employing a method of mouth aspiration by the operator. It may
be stated in this connection that we have tried various mechanical means of
withdrawing and injecting the blood, such as Politzer bags, piston plunger
syringes, etc., and that mouth aspiration is to be preferred to any of these more
forcible methods,
OPERATION WITH PARAFFIN-COATED PI PET 345
METHOD OF OPERATION WITH PARAFFIN-COATED PIPET
INSTRUMENTS
An ordinary scalpel, a small and very sharp knife for incising the
blood vessels, scissors, serrated forceps, mouse-tooth or fixation forceps,
FIG. 2.— DONOR'S CANNULA. 14k. gold seamless tubing, 2.80 mm. (0.110 in.) ext. diam. and 2.34 mm
(0.092 in.) int. diam. Cannula is 15 mm. (0.59 in.) long, bevelled at distal end and flared at prox-
imal end. Lateral arm 20 mm. (0.79 in.) long, joining cannula at angle of 30°, at 5 mm. (0.197
in.) from proximal end. Plug of 10k. gold, diameter to fit proximal end of cannula snugly wire
handle. Obturator of glass rod, 2.25 to 2.30 mm. (0.089 to 0.091 in.) in diameter.
several mosquito clamps; donor's cannula with obturator and plug (Fig.
2) ; recipient's cannula and obturator of appropriate size (or 2 sizes may
FIG. 3. — RECIPIENT'S CANNULA. Proximal part is of 14k. gold seamless tubing, same diameters as
donor's cannula and of similar construction. Into the distal end of this is soldered a platinum-
iridium cannula of smaller caliber which may vary in size and length according to requirements.
The size found most useful is 15 mm. (0.59 in.) long, 2.05 mm. (0.080 in.) ext. diameter and 1.78 mm.
(0.070 in.) int. diameter. Cannulas of smaller diameter may be used for smaller veins and for pene-
trating the skin. Obturator is made of 10k. drawn gold wire of a diameter to fit the platinum can-
nula and of a convenient length for handling. The stop on the obturator is made to fit into the
flared end of the cannula. From a point 5 mm. from the stop to a point near its extremity, a flat
surface is ground upon the obturator 0.5 mm. (0.02 in.) deep. When the obturator is fully seated
in the cannula, this surface provides a channel extending 0.5 mm. (0.02 in.) beyond the shorter lip
of the bevelled end of the cannula when the handle of the obturator is turned in the same direc-
tion (see Fig. 6) . With this arrangement it is apparent that the distal opening of this channel can
be regulated by rotating the obturator within the cannula, and this provides a means of controll-
ing the discharge of salt solution. When fully open, about 60 drops of salt solution will flow per
minute with 5 feet of hydrostatic pressure. Trocar is made of 10k. gold wire of same diameter as
the obturator, and is provided with adjustable stop.
346
THE TKANSFUSION OF BLOOD
be prepared in readiness) (Fig. 3); needles and silk for suturing skin;
hypodermic syringes and needles for local anesthesia. A Michel forceps
is also useful for holding the cannulas.
APPARATUS
One or more pipets, coated with paraffin under sterile precautions and
provided with cotton air niters and aspirating tubes as shown in Figure 4.
An irrigating apparatus for 2 liters of salt solution with a system of rubber
<T>
FIG. 4. — PIPET AND ASPIRATING TUBE
WITH AlR - FILTER CONTAINING
STERILE COTTON.
tubing, having a double distribution
by means of a Y connection and sep-
arate stop-cocks for donor's and re-
cipient's cannulas as shown in Fig-
ure 5 ; or a separate supply of salt
solution may be used for donor and
for recipient if in separate rooms.
An ordinary 2-quart rubber douche-
FIG. 5. — IRRIGATING APPARATUS. Copper vessel,
heavily tinned inside and outside, of three li-
ters capacity, with outlet made from block tin.
Outlet has a larger tubulation above for in-
sertion of glass gauge-tube and thermometer
and a smaller tubulation below for attachment
of rubber tubing. An electric heating plate serves
as a support and is attached by an arm and set-
screw to an iron rod, which latter is fastened
into a cast-iron foot-piece. A sliding sleeve of
celluloid can be moved to any position on the
glass gauge and is graduated in c. c. to meas-
ure the discharge from the vessel at any level
of the fluid.
bag may be sterilized and used for
this purpose. The salt solution should be prepared as for any intravenous saline
infusion and the source of supply should be at a height of from 4 to 5 feet from
the outlet. A pneumatic cuff, similar to that of a blood-pressure apparatus but
about half as wide, with an inflating pump, is useful for constricting the donor's
OPERATION WITH PARAFFIN-COATED PIPET 347
arm ; or a piece of heavy rubber tubing with a large clamp may be used for this
purpose.
OPERATION
The donor's and recipient's vessels are selected for their size and promi-
nence and the close proximity of a valve should be carefully avoided, as this
may interfere with the satisfactory action of the eammhis. The field of opera-
tion is painted with tincture of iodin and then washed off with alcohol. The
veins at the bend of the elbow are usually the most serviceable. If the re-
cipient is a young child the external jugular vein is often the best vessel to
select and this may be entered by a small size trocar and cannula without skin
incision, or through a very small nick in the skin.
FIG. 6. — RECIPIENT'S CANNULA WITH OBTURATOR IN VEIN. Showing drop-instillation of salt solution.
Local anesthesia for the exposure of the veins in recipient and donor is
produced in the usual way with a 2 per cent, novocain solution and about 2
to 3 cm. of both veins are exposed to view and the vessels thoroughly denuded of
their fascial sheaths to facilitate penetration.
The recipient's and donor's cannulas are now connected to their respective
ends of the irrigation apparatus by rubber connecting tubes of small caliber,
all stop-cocks are opened, and salt solution is allowed to flow through the can-
nulas to expel air. The obturators are then inserted in their respective can-
nulas, and the cannulas dipped in sterile liquid paraffin. The recipient's vein
is first entered with the recipient's cannula in the direction of the current. See
Figure 6.
It is important to enter the vein at a point well away from the center of its
exposed portion, so that the position and direction of the cannula when inside
the vein may be seen and controlled.
The most simple and certain way of entering the blood vessels of both
donor and recipient is by means of a small incision through the wall of the
vessel. This incision may be made with the point of a small sharp knife. The
348
THE TRANSFUSION OF BLOOD
size of the incision should be gauged according to the diameter of the can-
nula to be introduced. Another method of entering the blood vessel of the
recipient is to pierce it with a trocar which fits the cannula ; this, however,
requires some force, and therefore is liable to result in more trauma* to the
vessel wall; the trocar method also requires, with small veins and in cramped
situations, some dexterity to enter the lumen of the vessel cleanly on the first
trial.
When entrance of the recipient's vein has been effected with the recipient's
cannula, the two ends of an elastic band, previously passed under the arm distal
FIG. 7. — DONOR'S CANNULA WITH OBTURATOR IN VEIN.
to the incision, are united by a hook over a gauze pad resulting in light com-
pression of the vein just distal to the point of entrance of the cannula. The
obturator is then withdrawn and, by covering the flared opening of the cannula
with the finger, the flowing salt solution is allowed to flush out the recipient's
vein. A moment's flushing will fill the vein with salt solution, and this per-
fusion is maintained by drop instillation, which takes place automatically when
the obturator is replaced in the cannula with the hook turned toward the lateral
arm (see description of recipient cannula and obturator, Fig. 3). This ex-
clusion of blood from the vein is to prevent the possibility of clot formation,
which may be induced by a prolonged presence in the blood current of the metal
cannula.
When the recipient's vein has been prepared with the cannula in situ, the
donor's arm is constricted and the operator, through a small incision as al-
ready described, penetrates the donor's vein with the donor's cannula against
the direction of the blood current (Fig. 7). The mouth-piece of the aspirat-
ing tube is next grasped in the teeth, and the pipet allowed to hang thus for a
moment while the donor's obturator is withdrawn, using both hands for this
purpose. With a clamp or forceps in the left hand steadying the cannula
in the vein, the right hand grasps the pipet and introduces its tip (Fig. 8)
against the outpouring stream of salt solution, through the donor's cannula, into
the blood stream of the donor. The aspiration of blood (Fig. 9) is begun imme-
OPERATION WITH PARAFFIN-COATED PII'I-T
349
diately, and suction should be strong enough to get about the maximum flow
without undue collapse of the vein wall against the cannula. A speed of with-
drawal greater than 100 c. c. per minute should not be attempted. It is well
FIG. 8. — OBTURATOR REMOVED FROM DONOR'S CANNULA AND PIPET ABOUT TO BE INTRODUCED INTO
DONOR'S VEIN.
to mention here that the general precaution should be followed, as in all blood-
vessel surgery, of treating the vessels gently in every manipulation ; and this is
especially true of the donor's vein. A bystander may take the time from the be-
. 9. — ASPIRATION OF BLOOD FROM DONOR'S VEIN.
ginning of the blood flow, so that there may be some guide to the speed of with-
drawal and delivery.
Two hundred c. c. of blood can be obtained from a good donor in 1% to 4
minutes and this amount may be delivered through the large and medium-
350
THE TRANSFUSION OF BLOOD
sized cannulas in from 2 to 4 minutes, making a total of 4 to 8 minutes. We
have considered 12 to 15 minutes a conservative limit of safety for both
paraffin and hirudin methods ; and even with 10 minutes as a limit there is an
ample margin of time, so that there is no need for haste.
FIG. 10. — OBTURATOR REMOVED FROM RECIPIENT'S CANNULA AND PIPET, FULL OF BLOOD, AT THE
MOMENT OF INTRODUCTION.
When the amount required is obtained (200 c. c. or less) the pipet is
withdrawn and the donor's obturator inserted, the tip of the pipet being stop-
pered as soon as withdrawn by a gloved finger of the operator. It is important
to stop suction before withdrawal of the pipet so that no air bubbles may be
FIG. 11. — BLOOD BEING DELIVERED THROUGH RECIPIENT'S CANNULA.
drawn through the blood at the moment of removal from the vein. The pipet
containing the blood is now carried to the recipient, the obturator of the re-
cipient's cannula is withdrawn,1 and the tip of the pipet is inserted against the
*If working without assistance, the recipient's obturator may be extracted by means
of a wire hook attachable to the fourth finger of the operator ;s right hand.
OPERATION WITH' PARAFFIN-COATED PIPET 351
outflowing stream of salt solution into the recipient's cannula. Figure 10
shows the outflowing stream of blood released by the removal of the finger of
the operator from the tip of the pipet just at the moment of introduction into
the recipient's cannula. Figure 11 shows the tip of the pipet within the re-
cipient's cannula while the blood is being delivered. The last 10 or 15 c. c.
of blood are not discharged from the pipet in order to avoid risk of injecting
air. When this point is reached the pipet is withdrawn from the recipient's
cannula and the obturator replaced.
If more blood is needed, another transfusion may be done in precisely the
same way, using another pipet ; or an assistant may collect a second pipetful of
blood from the donor im-
mediately following the
withdrawal of the first
pipet. This rapid se-
quence of withdrawing
blood from the donor is of
course more expeditious,
and is advisable if more
than 400 c. c. (2 pipet-
fuls) of blood are re-
quired. Where the inter-
rupted method is fol-
lowed, care should be
taken to remove the con-
striction of the arm so as to allow a free circulation of blood through the donor's
vein during the intervals when the blood is not being withdrawn.
When the transfer of blood is completed, the recipient's cannula is re-
moved and pressure applied with a compress for a few minutes. Pressure and
suturing the skin will usually suffice to stop oozing from the vein. If desirable
the donor may be given a saline infusion to replace his lost blood, by substi-
tuting a short plug in the donor's cannula for the obturator, which stops the
outlet of the cannula, but does not shut off the passage of the salt solution
through its lateral branch into the vein (Fig. 12).
Hemorrhage from the donor's vein after the cannula is withdrawn can
sometimes be stopped by pressure ; but usually the puncture should be sutured
or tied off laterally with fine catgut. During the course of the operation
neither the donor nor the recipient receives more than an inconsiderable
amount of salt solution, unless more is desired. It will be seen, however, that
with this arrangement any amount of salt solution can be immediately directed
into the circulation of donor or recipient if required. In giving salt solution
to the donor in any considerable amount it is advantageous to reverse the direc-
tion of the cannula within the vein. This may easily be done while the solu-
tion is flowing without removing the cannula from the vein.
FIG. 12. — USE OF PLUG IN DONOR'S CANNULA WHEN GIVING
SALINE INFUSION.
352 THE TKANSFITSION OF BLOOD
PREPARATION OF PIPETS WITH PARAFFIN COATING
The preparation of the pipets and the method of lining them with paraffin
should be carefully followed. The threaded bushings of the cylinders are
first wrapped with thin asbestos tape and securely seated in the cylinders.
The air-filter tubes with cotton filling and the cylinders are then sterilized by
dry heat in an autoclave or ordinary oven. The rubber aspirating tubes,
mouth-pieces, and perforated rubber stoppers are sterilized by boiling. When
sterilized, each cylinder is connected with an air-filter by means of a per-
forated rubber stopper, and the aspirating tube with mouth-piece is attached.
The cylinders are then ready for coating. The rubber stoppers and aspirating
tubes should be thoroughly dry before being connected with the cylinders.
The process of coating the pipets must be conducted with aseptic precau-
tions. The coating is best done from a cylindrical vessel, about S1/^ inches
(8.4 cm.) in diameter and 7 or 8 inches (17.5 to 20 cm.) high, filled to within
an inch (2.5 cm.) of the top with the sterile paraffin mixture. The mixture
which we have found most satisfactory is :
Griibler's filtered paraffin, m. p. 60° to 62° C. (140° to 143.6° F.) . 56 parts by weight
Pure white petrolatum 44 parts by weight
This mixture has a melting point of 49° to 50° C. (120-122° F.) and can
be sterilized by heating to 120° C. (248° F.) for an hour. We have found
that a convenient vessel for melting, sterilizing and holding the paraffin is an
electric warmer for a 10-ounce nursing bottle, with heating coil immersed
directly in the paraffin.
First Coating. — For the first coating the paraffin is heated to from 77°
to 80° C. (171° to 176° F.) ; the neck of the cylinder, with a threaded bush-
ing securely seated in it, is then immersed beneath the surface and the paraffin
sucked up into the cylinder by means of a tube, air filter, and mouth-piece to
within about 1 cm. of the rubber stopper. The paraffin is maintained at this
level until its heat has spread to the cylinder, which is shown by the film over
the glass becoming transparent. As soon as this occurs, the paraffin is allowed
to flow out and the cylinder is placed aside to cool.
The pipet tips and couplings may be sterilized by boiling or by dry heat.
If boiled a short time before coating, they should be freed from moisture before
being attached to the cylinder. This can easily be done by drying over an
alcohol flame. The coated cylinders may be wrapped in sterile towels and kept
in this way until needed, or the pipet tips may be attached and a second
paraffin coating applied at once, the completely coated pipets being then
wrapped in sterile coverings ready for immediate use.
Second Coating. — The second coating, with the tip attached to the cylinder,
is done at 60° to 61° C. (140° to 142° F.) by dipping the tip of the pipet
beneath the surface of the melted paraffin and aspirating sufficient paraffin to
OPERATION WITH ITIRUDIN 353
reach about 2 cm. above tbe neck of the cylinder and immediately expelling
it again. When the excess of paraffin which has been taken into the pipet
is blown out in this manner, bubbles of air will be seen to escape from the sub-
merged tip of the pipet. The pipet is then raised out of the paraffin, its tip is
tilted upward, and air is drawn through it. This latter precaution is to prevent
a narrowing of the lumen of the tip by the congealing at this point of the last
few drops of excess paraffin. The lumen of the tip can easily be inspected by
transmitted light; if it has not a good clear opening it should again be im-
mersed in the paraffin and the operation repeated until satisfactory. It re-
quires very little practice to do this successfully.
METHOD OF OPERATION WITH HIRUDIN
Oxalated and citrated plasmas are well known in the physiological labora-
tories and sodium citrate is reported to have been used as an anticoagulant for
small quantities of transfused blood. Oxalates and citrates act by fixing the
calcium of the blood, which is a necessary factor in spontaneous coagulation.
This decalcification is, of course, a change produced by a chemical reaction
in the blood, and is, theoretically at least, undesirable. The use of hirudin
as an anticoagulant is not open to this objection.
Hirudin is derived from the buccal glands of the pond leech and has been
classed l3y Franz (196) as a secondary albumose. Its physiological properties
are variously regarded by different investigators. Morawitz (204) believes that
it acts by neutralizing thrombin or prothrombin (thrombogen). Mellanby
(203) concludes, from what appears to be substantial experimental evidence,
that hirudin contains an antibody for prothrombin and also a very energetic
antibody for thromboplastin (kmase).
It may be fairly concluded from the available evidence that hirudin has a
decided effect upon the prothrombin-antithrombin balance and that it has a
neutralizing action on thromboplastin.
There is considerable literature on the experimental use of hirudin and there are
some reports upon its therapeutic use by intravenous injection for eclampsia, but no
mention of its use as an anticoagulant for transfusing blood.
From the authors' experimental work it has become evident that hirudin affords
a convenient alternative for the paraffin method of transfusion under most circum-
stances (209). The amount of hirudin necessary with our apparatus is so small that
its uee may not be contra-indicated even in those pathological conditions where there
is already an excess of antithrombin or a deficiency of prothrombin in the circulating
blood of the recipient.
Kaposi (200) has given 40 mg. of hirudin to a 2,000 gm. rabbit. Cowie (189) has
given 35 intravenous injections of hirudin to a rabbit in doses increasing from 10 mg.
to 22 mg. in 26 days and maintained this last dosage until the final injection, the total
period of treatment covering 54 days. At the end of this time the animal had gained
in weight and was in every respect perfectly well. Bodong (186) has given 23 to 73.25
24
354 THE TRANSFUSION OF BLOOD
mg. pro. kilogram of body weight to rabbits, and states that it has no influence on the
circulation or the respiration, and is in no other way harmful to the animal. Von
Hertzen and Ohman (198) have confirmed Bodong's observation in a series of 12 ex-
periments and concluded that hirudin has no disturbing effect upon the heart and blood
vessels. Abel, Kowntree and Turner (182) have used very large quantities of hirudin
in "vividiffusion" experiments on dogs without apparently impairing the health or
normal physiological condition of the surviving animals. Dienst (192) reports that he
has given 200 mg. in 50 c. c. of salt solution by intravenous injection to a patient with
very severe eclampsia with most excellent results; and Engelmann (194, 195) has re-
ported 17 cases of eclampsia treated in this way with doses of 200 to 300 mg.
In making use of hirudin for transfusion we have employed our regular
pipets and cannulas, but have simplified the preparation of the pipets. No coat-
ing of paraffin is applied to the cylinders but only to the tip and neck of the
pipet. This partial coating is done by aspirating a small quantity of the sterile
melted paraffin mixture at a temperature of 70° to 80° C. (158° to 176° F.)
just within the neck of the cylinder and expelling it again, with the same pre-
cautions against blocking the tip with paraffin which have been mentioned
above under second coating. This use of paraffin, from the tip to the neck, is
primarily to insure an air-tight junction of the pipet-tip with the metal bushing,
and of the latter with the neck of the cylinder, but it also has an undoubtedly
valuable effect in lessening thromboplastin formation during aspiration of the
blood, and permits the employment of a minimal quantity of hirudin.
Coating the Pipets with Hirudin. — If the commercial preparation of hiru-
din is employed, one 10-mg. tube is sufficient to coat from 4 to 5 pipets. The
label is soaked off the tube of hirudin, and one end of the tube is well scored
with a file to insure easy breakage. At the time of operation the tube is im-
mersed in a small tray of alcohol- to sterilize its exterior. The solution of
hirudin may be previously prepared or it can be made up conveniently as soon
as the irrigation apparatus has been set up. Under sterile precautions 4.5 c.cm.
of 0.9 per cent, sodium chlorid solution are run off from one of the irrigating
tips into a sterile calibrated cylinder. The hirudin tube is then broken in a
piece of gauze like a tube of catgut, care being taken that the hirudin is shaken
down into the other end before breaking off the end which has been marked by
the file. The hirudin can now be dissolved by adding one or two c.cm. of the
salt solution from the calibrated cylinder, shaking well, and washing back and
forth until all the hirudin is dissolved. This solution, which has a dilution
of 1-450, is transferred to one of the paraffin-sealed pipets, by removing the
rubber stopper and air-filter, and pouring in the hirudin while holding the
pipet in the horizontal position. The rubber stopper is then replaced, and,
while still holding the pipet in the horizontal position with the tip pointing
upward, the hirudin solution is flowed over the inside of the pipet, rotating
and shaking the latter so that the whole interior is completely and thoroughly
wet by the liquid. When this is done the neck portion of the pipet is coated in
a similar manner by tilting up the pipet, and the liquid is then allowed to run
BIBLIOGRAPHY 355
out of the tip, back into the receptacle in which it was mixed, or else directly
into the next pipet which is to be coated. It takes from 1 to 1.5 c. c. of the
hirudin solution to coat a pipet in this manner, and when so coated, the pipets
are ready for immediate use and should be placed in the horizontal position
until required.
With the exception of the preparation of the pipets as noted, the operation
with hirudin is conducted in precisely the same way as with the paraffin-coated
apparatus.
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THE SUKGICAL TEEATMENT OF ANEUKYSM
CHAPTEK X
THE SURGICAL TREATMENT OF ANEURYSM
JAMES M. HITZROT
The treatment of aneurysm is usually divided into medical and surgical
treatment. This chapter has nothing to do with the former, except in so far as
measures spoken of as purely medical may act as adjuncts for the preparation
for strictly surgical methods.
Among the medical methods usually enumerated, rest in the horizontal posi-
tion may be considered as an important adjunct in the preparatory treatment
for a surgical procedure. Kest reduces the pulse rate approximately 10 beats
per minute, or 14,400 beats in the 24 hours. Kest in the horizontal position
furthermore reduces the general blood-pressure about 10 mm. of Hg.
Hence rest not only decreases the force of the arterial impact against the
aneurysmal wall, but likewise decreases the number of these impacts. With the
decrease in the force and number of the impacts, a resulting decrease in the
size of the sac may be obtained, and thus rest is of value both in internal and
in traumatic aneurysm, preparatory to surgical interference.
Bornhaupt, Saigo, Kikuzi, Makins, and others, advise delay from 4 to 6
weeks, in operating on traumatic aneurysm, and during this period, or a large
part of it, rest will materially lessen the discomfort of the patient, and will
tend to limit the size of the aneurysmal sac.
The purely surgical treatment includes all forms of external measures used
directly on the aneurysmal sac, and includes the application of ice (refrigera-
tion), compression, acupuncture, wiring (with or without electrolysis), liga-
tion, the various constricting appliances to produce gradual occlusion of the
artery, Halsted's bands, elastic ligatures, Keen's compressor, Stratton's com-
pressor, etc. ; the radical operations on the sac itself, aneurysmotomy with in-
trasaccular ligation, the operations devised by Matas, endo-aneurysmorrhaphy
and aneurysmoplasty ; and aneurysmectomy with arteriorrhaphy or angioplasty.
REFRIGERATION
The application of an ice-bag is used to inhibit the congestion about the
aneurysmal sac and is chiefly serviceable in traumatic aneurysm and as a pallia-
tive measure in inoperable aneurysms.
363
364 THE SUEGICAL TEEATMENT OF AKEUKYSM
COMPRESSION
Compression may be used as a direct pressure on the aneurysm itself, or in-
direct pressure, i. e. pressure upon the artery above or below the sac or both.
Direct pressure upon the aneurysmal sac should never be used inasmuch as
compression thus produced is likely to cause results more dangerous than the
aneurysm itself.
Indirect pressure is applied as digital pressure, pressure by instruments,
by tourniquet, or by posture (flexion).
Digital pressure is made by a number of assistants working in pairs. Care
should be taken to shift the pressure of the digits to different areas of the skin.
"Ether or morphin should be used when the patient begins to complain of
pain7' (Stimson). The application of digital pressure should be divided into a
number of sittings of 4 hours each, and should be continued from 24 to 36
hours. After 36 hours, the chances for a cure are very slight, and the treat-
ment, if unsuccessful after that time, should be abandoned (Delbet).
The method is difficult to carry out, and gangrene is prone to occur, espe-
cially if the digital pressure is unsteady. "Kecovery may be expected in fifty
per cent. Gangrene occurs in six per cent." (Matas).
Instrumental compression was practiced by many instruments invented for
that purpose for application to the abdominal aorta. It is applicable only in a
few selected cases and of little value because the time limit of compression of
the abdominal aorta is so short.
Elastic Compression — Reid's Method. — This method consists in the firm ap-
plication of an elastic bandage from the periphery of the extremity up to the
sac, then a few light turns of the bandage over the sac, and from the sac con-
tinued in firm, even turns well up the extremity so as to compress the artery
both distally and proximally. The application is quite painful, and requires an
anesthetic (Walsham). The bandage should be kept on for 1 to 2 hours (1 to
1% hours) and then digital compression maintained on the proximal side of
the main artery for from 36 to 48 hours.
Delbet states that it leads to gangrene twice as frequently as digital com-
pression. Stimson states that the method failed to cure in 15 per cent, of the
cases.
The method has been modified by Gersuny and Petit, who apply the bandage
at intermittent intervals of % hour each (intermittent elastic compression).
Compression by Posture (Flexion). — This method was successfully tried in
aneurysms in the groin, the popliteal space, and the elbow.
In applying the method, the flexion must be sufficient to stop pulsation in
the vessels distal to the sac. It is painful, and must be continued from 10 to
14 days to accomplish any result. Delbet states that it leads to rupture of the
sac more often than any other form of compression.
As a whole, compression in any of its forms has little to commend it in com-
LIGATURE
365
parison with the more clearly defined surgical procedures. The results are less
favorable, the dangers greater and the suffering more marked than would seem
justifiable with modern progress along surgical lines.
LIGATURE
The use of the ligature is the oldest form of treatment and was practiced
by Antyllus in the second and third centuries A. D. (see Fig. 1).
The method described by Antyllus has been named
aneurysmotomy by Matas.
It consists in a linear incision over the sac along the
course of the artery carried far enough to expose the
artery at its entrance and exit from the sac'. The vein is
then retracted and the artery tied close to the sac at its
entrance and exit. When these ligatures are tied, a small
incision is made into the sac and its contents evacuated.
With the advent of the Esmarch bandage, that is, in
modern times, this form of constriction is applied before
proceeding to the operation above described. After the
ligation of the main vessel, the bandage is released.
Should any bleeding occur due to entering collateral ves-
sels, the bandage should be tightened, and the collaterals
tied after dissecting them free or by intrasaccular liga-
ture after the method of Annandale, or the obliterative
endo-aneurysmorrhaphy of Matas may be practiced.
Mikulicz modified the Antyllian operation by divid-
ing it into two stages. His first stage consisted in the
ligation of the artery on the proximal side (Anel or
Desault-Hunter type — v. infra). When the circulation
in the sac had decreased and the sac had diminished in
size, the sac was punctured by a small incision and the
clot evacuated (his second stage).
This modification of the older method has little to
commend it, as pointed out by Matas, due to the occur-
rence of hemorrhage during the second stage of the opera-
tion or hemorrhage following that procedure at a later
period.
Philagrius or Purman (1680) further modified the Antyllian operation by
the extirpation of the sac after ligation of the vessels (aneurysmectomy).
The steps in this operation to which attention must be paid are preliminary
control of the circulation, afferent and efferent, and the identification of the
companion vein.
Where possible, the arterial supply above mentioned should be controlled by
FIG. 1. — METHOD OF AN-
TYLLUS. Proximal and
distal ligation, close to
the sac. Incision and
evacuation of contents
of sac.
366 THE SURGICAL TREATMENT OF ANEUKYSM
circular constriction. The vessels are then exposed by dissection and ligated,
or the vessels may be controlled by the various clamps described by Crile,
Matas, Billroth, etc.
Where circular constriction is impossible (in the neck, for example), the
arteries must be exposed by dissection and ligated or clamped, as the case
may be.
This preliminary hemostasis is absolutely essential for the carrying out of the
operation and neglect of it may lead to serious if not fatal hemorrhage.
The identification of the companion vein is often difficult. Koehler has
devised the following expedient to render its identification possible. In pop-
liteal aneurysms, for example, he applies a circular rubber bandage below the
aneurysm at a sufficient distance to permit of easy access to the sac. From the
upper level of this constricting bandage a second rubber bandage is applied in
firm circular turns well up to the middle of the thigh, to squeeze out the blood
and cut off the circulation beyond it. The lower turns are then released up to
the last few upper turns, leaving the region of the sac, and a wide zone
about it, completely anemic. If in exposing the sac it is difficult to deter-
mine the location or permanency of the vein, the lower bandage is released,
and the vein will fill up, thus giving a clew to its location and its per-
meability.
If the vein is so adherent in the wall of the sac that its dissection is difficult
or impossible, Sonnenberg advises leaving behind the piece of the sac to which
the vein is adherent.
Matas lays especial stress upon the preservation of the vein and believes
that the extirpation of the vein must always be regarded as dangerous to the
future vitality of the limb.
Bearing in mind the above cautions, the aneurysmal sac is exposed by free
incision and the afferent and efferent vessels exposed. The sac is then dissected
free by blunt dissection, care being taken to avoid injury to the veins and nerves
which are flattened out on various regions of the sac. If possible the sac should
be dissected free intact, and all collateral vessels entering it ligated or clamped
before division.
When the sac is freed sufficiently, the main vessels are ligated or clamped
and divided and the sac removed.
If any injury to the vein occurs, it should be repaired by suture with very
fine silk, if the vein has given evidence of patency. If obliterated, it may be
tied.
The upper constricting bandage is then removed, and all bleeding points
caught and tied. For success, it is essential that the hemostasis be perfect and
absolute, so that a perfectly dry, clean wound is left.
When this is obtained, the wound is closed in layers without drainage and
dressed with sterile gauze in such a manner as to avoid any compression of the
wound or limb because of the danger of interference with the peripheral circu-
lation.
LIGATURE
367
It is also essential to state that the highest form of aseptic surgical technic
is absolutely essential to success.
The dangers incident to the operation are gangrene of a part or all of the
limb peripheral to the area of the operation, infection
and secondary hemorrhage, and such late effects as edema
of the limb, trophic nerve disturbances, pain and limita-
tion of function in the proximal joint, etc.
The postoperative treatment should comprise all
methods which will tend to aid in the establishment and
maintenance of the collateral circulation.
The limb should be elevated and kept warm. If the
extremity remains cold after the second postoperative
hour, the limb should be placed in a Bier hot-air ap-
paratus, or in a covered tent and
hot air introduced through a pipe,
such as is used in giving the hot-air
bath to uremic patients.
When the wound is healed, hot-
water baths, especially those con-
taining salt, hot sand baths, static
electricity, and gentle massage,
should be used to increase the cir-
culation. The proximal joint
should be baked and massaged and
submitted to gentle passive move-
ments as soon as compatible with
the healing of the wound, iisually
toward the end of the second week.
Active use of the limb, especial-
ly the leg in walking, should be
prohibited until the circulation is so well established that
no marked edema occurs upon standing.
Too early use often leads to irreducible swelling in
the limb distal to the zone of operation, and once estab-
lished, it is not likely to be relieved.
Delbet regards extirpation as the ideal operation, in
that the cure is more complete, and gangrene is less apt
to occur after extirpation than in the other forms of liga-
tion. Matas, however, does not believe that the ideal has
been obtained in extirpation.
Proximal Ligation.— Anel (1710) ligated the artery
on the proximal side close to the sac without opening the sac. (See Fig. 2.)
Desault, in June, 1785, and Hunter, in December of the same year, ligated
the artery on the proximal side at some distance from the sac. Hunter's idea
FIG. 2. — METHOD OF
ANEL. Proximal liga-
tion close to the sac.
FIG. 3. — METHOD OF
DESAULT AND HUN-
TER Proximal liga-
tion at some dis-
tance from the sac.
368
THE SUEGICAL TREATMENT OF ANEURYSM
was to place the ligature at some distance from the sac, so that it tied the artery
at a point in which the vessel wall was more likely to be normal. Scarpa, in
1819, ligated the artery in Scarpa' s triangle for popliteal aneurysm (Scarpa's
operation).
From the impetus thus given many more operations
for aneurysms were done, and it was discovered that total
arrest of the blood stream was unnecessary for a cure.
Later it became evident that such failures as occurred
were due to the development of a collateral circulation
by the way of large branches to the sac. The ligature
close to the sac (Anel) is to be
preferred in proximal ligation in
that it shuts off the circulation at
once and thus decreases the size
of the sac.
Distal Ligation of the Vessel.
—Distal ligation arose as a re-
sult of the treatment for those
cases in which proximal ligation
was too dangerous or impossible.
The distal ligation close to
the sac was suggested by Brasdor
about 1790 (Brasdor's opera-
tion), but was first practiced by
Deschamps in 1798 and Sir Ast-
ley Cooper about the same
period. The earlier cases were
failures. (See Fig. 4.)
In 1825 Wardrop ligated the
vessel on the distal side at some
distance from the sac, and in
Wardrpp's cases the ligature was applied to one of the
main branches after it had been given off from the
parent vessel, i. e. carotid artery in innominate an-
eurysm. (See Fig. 5.)
Results of Ligation, and Objections to This Form of
Treatment. — "Gangrene, however, remains a serious
objection to all methods of ligation" (Matas). The
aneurysm may recur after a number of years, six cases
collected by Delbet, and eight by Matas. The presence
of the sac and its sclerosis, furthermore, may cause pressure on the included
nerves with peripheral motor paralysis or peripheral sensory nerve changes,
neuralgias, paresthesias, trophic ulcers, etc., which remain until relieved by
further operation. -
FIG. 4. — BRASDOR'S OPER-
ATION. Distal ligation
close to the sac.
FIG. 5. — WARDROP'S
OPERATION. Distal li-
gation some distance
from the sac. Wardrop
placed the ligature up-
on a main branch after
it had been given off
from the parent trunk.
WIRING 3G9
Sub-total, or partial, occlusion of the vessel was suggested by Porta about
1850 for treatment of aneurysm of the large vessels in which total occlusion
would be dangerous due to ulceration, gangrene, or secondary hemorrhage.
For this he recommended different forms of partial compression by various
instruments, elastic ligatures, or a series of gradually contracting ligatures.
Halsted in 1906 placed the method on a modern surgical basis by producing
gradual occlusion of the artery by the use of aluminum bands. lie advises the
use of bands of 32 to 36 thickness (sheet metal gauge) and has devised a set of
instruments for the application of the bands to the vessel.
NEEDLING
Needling consists in the introduction of a long needle into the aneurysm so
that it scratches the intima sufficiently to irrigate it and permit the deposition
of a fibrinoplastic exudate upon the injured wall. The needle is left inside the
sac for 24 hours and frequently moved from place to place to increase the zone
of the irritation.
The method has no practical value because of the uncertainty of its action
and the fact that the wall of the sac is usually lined with laminated plastic
exudate, which is disturbed rather than increased in the process.
WIRING
Moore's Method. — Moore introduced fine silver wire into the sac with the
idea of forming a framework for the fibrin to become deposited upon. Later,
iron, steel, and copper wire; catgut (Abbe) ; horse-hair, fine metal watch
springs (Bacelli and Montenovessi) were employed.
The method has certain elements of danger in that the wires, etc., may
migrate even into the left ventricle of the heart (Ballance, Parkam, quoted by
Matas).
Wiring with Electrolysis — Moore-Corradi Method. — Corradi (1879) in addi-
tion to introducing the wire as a framework, passed an electric current through
the wires, to cause electrolysis of the fluid blood in the sac, and to hasten the
deposition of fibrin on the framework formed by the wires. The method is
applicable mainly to thoracic and abdominal aneurysm.
Various types of wires are recommended. Silver wire, silver copper wire
(Finney and Hunner) ; gold wire (Stewart), and gold platinum "Clasp" alloy
wire (Lusk).
Lusk recommends using a piece of No. 11 wire about 11% inches long and
drawing it out to No. 28 (Brown and Sharpe gauge), which will produce a
strand 50 feet long of very resilient wire immune to the solvent action of the
electric current.
25
3TO THE SURGICAL TREATMENT OF ANEURYSM
Lusk furthermore recommends using a gold needle insulated with a cover-
ing of porcelain enamel of a caliber just large enough to admit the 28 wire with-
out friction.
Lusk states, "The wire at its introducer extremity should be spirally shaped.
To prevent snarling during the introduction of the wire, the spiral extremity,
freed from its position of fixation, should first be started through the needle
before the binding wire is removed from the coil, after which the binding wire
should be removed, and then the loops can be kept from crossing one another
by finger pressure over the site of the binding coil, which maintains the orderly
arrangements of the loops so that they will unwind without tangling. The grip
for holding the coil is to hold it in the middle, ring, and little fingers and the
palm of one hand, which leaves the thumb and index finger free for assisting
the other hand with the manipulation of the wire. As the wire, thus held, is
now introduced, it uncoils from off the hand after the manner of uncoiling a
rope. This transmits a twist through the introduced wrire with the passage of
each loop, which, through the resiliency of the wire, enables the loops to reform
within the sac. The technic of passing the wire through the needle should be
practiced in the open previous to operation.
The needle should be boiled in distilled water.
The negative electrode should be placed against the back directly over the
area which corresponds to the situation of the aneurysm, and should be larger
than the aneurysm.
The external portion of the wire should trail over a piece of rubber dam
during the passage of the current.
The current should be started at 100 ma. for 15 minutes, and then the
current should be gradually lowered to 50, 40, and 30 ma. each for 15 minutes.
The positive pole should be attached to the gold wire, and the negative electrode
placed upon the back."
The needle should be inserted through a thick portion of the aneurysmal
wall. Should hemorrhage occur upon its removal, the wire which was sheathed
by the needle should be pulled upon till one of the intrasaccular coils with its
attached fibrin is brought in contact with the site of the puncture, when bleeding
will stop. Should this fail to stop the hemorrhage, Lusk suggests the passage
of a 50 ma. current through the wire for about 3 minutes. (In his experi-
ence, the time required to control the hemorrhage never exceeded nine minutes. )
The projecting wire is then cut off close to the sac and the skin wound closed.
ENDO-ANEURYSMORRHAPHY AND ANEURYSMOPLASTY (THE
MATAS OPERATIONS)
The operations devised by Matas consist in intrasaccular suture of the open-
ing or openings into the sac to cut off from the sac all vascular communications
with it. He divides his operations into three types.
ENDO-AJSTEURYSMORRHAPHY AND ANEURYSMOPLASTY 371
Type 1. — Obliterative endo-aneurysmorrhaphy in which all the openings in
the sac are closed by sutures so placed as to completely close the vascular stomata
which enter the sac. The method is essentially an intrasaccular ligation of the
arteries, which communi-
cate with the sac, and in
this first type the parent
artery is obliterated by the
sutures.
Type 2. — Endo-aneu-
rysmorrhaphy with partial
arterioplasty (restorative
endo-aneurysmorrhaphy) .
This type is suitable
for sacculated aneurysms
with a single vascular
opening into the sac. By
sutures properly placed,
the opening into the sac
wall is closed and the con-
tinuity of the parent vessel
preserved by an arterio-
plasty done within the sac
wall. (Fig. T.)
Type 3. — Endo-aneu-
rysmorrhaphy with recon-
structive arterioplasty (re-
constructive endo-aneurys-
morrhaphy or aneurysmo-
plasty). (Fig. 8.)
This variation is ap-
plicable solely to fusiform
aneurysms in which the
sac walls are firm and resistant, and the two openings leading to the main artery
lie at the same level and are in close proximity and visible in the bottom of the
sac, in a superficial, easily accessible sac.
The essential features of the operation consist in reconstructing a new
artery out of the walls of the sac.
A rubber catheter or a biliary hammer of Halsted is inserted into the two
arterial openings and fine silk or chromic sutures inserted and so placed as to
reconstruct the lumen of the vessel over this guide. Before tying the central
sutures the guide is removed, and the sutures are then tied, effectually closing
and reconstructing the lumen of the main vessel.
The operations of this type are called for only in cases in which the condi-
tion of the sac is favorable for reconstructing the artery, or in cases in which
FIG. 6. — DIAGRAM OF OBLITERATIVE ENDO-ANEURYSMOBRHAPHY.
Note the inclusion of the posterior wall of the artery in the
sutures, and also the collaterals closed by suture. (After
Matas.)
THE SUEGICAL TREATMENT OF ANEURYSM
the collateral circulation is insufficient. In the latter condition, although the
reconstructed vessel, especially in atheromatous vessels, will function only for a
short time, that short period may be sufficient to permit of the establishment of
a sufficient collateral circulation. Should a secondary aneurysmal dilatation
occur at the side of the reconstruction, an obliterative endo-aneurysmorrhaphy
may then be carried out without the previous great danger of gangrene since the
collateral circulation will have become established in the interim.
The method is furthermore especially applicable in traumatic aneurysm in
which the question of atheromatous change does not enter and in these cases
should be as successful as arterioplasty, as carried by the Carrell or other
methods and will probably show a no larger number of failures.
The suture material should be fine silk dipped in vaselin, or number 0 or
00 chromic catgut.
The needle best adapted for endo-aneurysmorrhaphy are the half and full
curved intestinal needles of the Murphy, Fergusson, or Kirby type, conjunctiva!
needles or the staphylorrhaphy needles of Lane (if the opening is small).
In placing the sutures, a firm bite should be taken upon the sac wall. No
attempt should be made to freshen the edges of the sac about to be approxi-
mated. As Matas has stated so frequently this preliminary denudation of the
margin to be sutured is more apt to cause failure of than to aid in the repair
process. The primary layers of sutures should be reinforced if possible by a
secondary tier which should be a continuous running suture wrhich grasps and
approximates the wall of the sac and draws it over the first tier and rein-
forces it.
The treatment of the sac after the closure of the arterial stomata by one of
the above methods is described by Matas under five different headings.
1. — Total Obliteration of the Sac by Suture and Inversion of the Skin Flaps.
— The method consists in closing the sac by a continuous stitch which begins
at one pole and is whipped across the sac wall to the opposite pole until that
portion of the sac wall included in the suture is completely approximated in the
midline. A sufficient number of layers of these sutures are applied to bring the
closure of the sac wall close to the surface. When this step is completed, any
excess of the sac is folded upon itself and stretched together by stitches which
pass through the skin and are tied upon a gauze roll, and the superimposed skin
closed by a suture which includes the linear approximation of the sac wall (see
illustration).
If the dead spaces are carefully obliterated, no drainage is necessary.
2. — Total Obliteration of the Sac by Suture, Leaving the Sac Buried in the
Wound, — This method is applicable to small aneurysms deep in the tissues in
which the skin flaps are not large enough to invert. The closure of the arterial
opening and the superimposed layers of stitches are placed as in the first method
and the skin and other tissues are closed in layers upon the sac.
3.— Lining the Wall of the Sac with Skin Flaps or Grafts. — In this method
the sac is not obliterated but the skin is mobilized and the edges tacked down
ENDO-ANEURYSMORRHAPHY AND ANEURYSMOPLASTY 375
to the bottom of the sac in a manner similar to that used by Neuber in bone
cavities. If the flaps are insufficient, the areas left may be covered by skin
grafts, either at the time of the operation or at a later date when granulations
have formed. Matas suggests using pedunculated flaps as a possible covering
for the sac in certain cases, but the method would seem of doubtful utility in
view of the disturbed circulatory conditions which exist in the skin about the
sac wall. A sloughing flap would, I believe, be more dangerous than open
packing of the wound.
The method is applicable to large aneurysms with rigid walls, and especially
in popliteal sacs which are adherent to the femur and the ligaments about the
knee joint.
4. — Partial Obliteration of the Sac, Excision of the Superfluous Portions of the
Sac and Packing the Space Left by Gauze Saturated with Balsam of Peru. — The
method is adapted to ruptured or infected sacs with irregular diverticulai
which do not permit of obliteration by any of the foregoing methods.
This method was successfully used in a case of the writer's in which there
was a traumatic aneurysm of the profunda femoris in a subtrochanteric frac-
ture of the femur. The circulation was controlled by digital pressure of the
femoral against the pubis, the sac opened, the clots evacuated, and the ragged
lateral tear in the vessel closed by the obliterative suture described under oblit-
erative endo-aneurysmorrhaphy. Since a large part of the sac was formed by
the femur and the callus thrown out about the angulated overriding fragments,
it was not possible to obliterate any except a very small portion of the sac just
adjacent to the suture line in the artery. The wound was packed and healed
by granulation without subsequent trouble.
5. — A Method Used for Intraperitoneal Cases (Iliac Aneurysms). — The
method resembles the third method above described except that the peritoneum
is used to obliterate the sac instead of the skin.
The methods devised by Matas are applicable to all forms of aneurysms in
which primary hemostasis is possible, and have all the advantages of the Antyl-
lian operation without any of that operation's dangers or disadvantages. As an
operative procedure, the technical details are not as difficult as ligation and ex-
tirpation, and the results of the Matas operation are better than those derived
from any form of ligation.
It is essential to emphasize one detail, namely, the preliminary hemostasis.
This may be obtained by elastic constriction on peripheral vessels ; by prelim-
inary exposure of the main vessel and hemostasis by temporary clamping of it
close to the sac in axillary, subclavian, carotid, and other aneurysms close to the
trunk (Matas uses a special clamp but states that the ordinary long, curved
elastic intestinal clamps of the Doyen model are equally satisfactory) ; in
gluteal, sciatic, and obturator aneurysms, by a temporary ligation of the com-
mon iliac.
For statistical reports the reader is referred to Matas' articles. In the
writer's limited experience (3 cases), the method left nothing to be desired, and
FIG. 9. — DIAGRAM OF METHOD OF OBLITERATING THE SAC IN OBLITERATIVE ENDO-ANEURYSMORRHAPHY.
I — Sutures obliterating the opening into the sac and the parent vessel. II — Superimposed layer of
sutures which reinforce the first tier and reduce the size of the cavity. Ill — Row of stitches which
approximate the skin to the enfolded layers which have been previously placed (I and II) . IV—
Stitches passed through the sac from without inward to approximate the portion of the sac not ob-
literated by the previous sutures, and at the same time to approximate the skin to the sac. (After
Matas.)
FIG. 10. — DIAGRAM OF A METHOD OF OBLITERATING THE SAC IN THE RESTORATIVE AND RECONSTRUCTIVE
OPERATIONS. I — Line of sutures which close the opening into the sac and restore the continuity
of the parent vessel. II, III, IV, are similar to those described under method in Figure 9. (After
Matas.)
ANEURYSMECTOMY 377
may be said to do all that Matas has claimed for it. The mortality is stated
by Matas to be 2.3 per cent., and gangrene occurred in 1.1 per cent., in cases in
which the veins were not ligated, and 4.4 per cent, when the vein was ligated.
Relapse occurred only in the reconstructive cases, 28.9 per cent., so that
relapse is much more common in the reconstructive type.
Matas states that the method cannot eliminate the dangers of gangrene from
thrombosis and embolism, but that the method does not show these complica-
tions any more frequently than the method of ligation.
The method furthermore is not applicable to intrathoracic or intra-abdomi-
nal aneurysms, and in these, wiring with electrolysis or the Halsted aluminum
bands would find their greatest field of usefulness.
ANEURYSMECTOMY
IDEAL ANEURYSM OPERATIONS
Under the term ideal aneurysm operations Lexer groups those which re-
move the sac and at the same time restore the continuity of the vessel, artery
or vein or both, by varying forms of suture.
Omi collected 21 cases in which the so-called ideal operations for aneurysm
have been done, which include four cases of his own. He summarizes the types
of the operations under the following headings :
1. Lateral suture of the artery alone (Heller).
2. Lateral suture of the artery with ligation of the vein (Garre, Meissner,
Omi).
3. Lateral suture of the artery and the vein (Korte).
4. Circular suture of the artery alone (Ziembicki, Oppel, Enderlen, Lieb-
lein, Einer Key, Omi, Ribera).
5. Circular suture of the artery and ligation of the vein (Stich).
6. Circular suture of the artery with lateral suture of the vein (Murphy).
7. Circular suture of the artery and vein (Lexer, Auvray).
8. Free transplantation of vessels to repair the deficiency in the artery
(Lexer, Omi, 2 cases).
9. Circular suture of the central end of the artery to the peripheral end
of the vein and the reverse (Goyanes).
10. Circular suture of the vein and running stitch to close the opening in
the artery and vein (Kiittner).
Jeger adds to this list :
1. The end-to-side anastomosis of a piece of vein on the proximal and
distal sides of the involved vessels (artery or vein) so that the circulation might
pass by this method to the periphery until the collateral circulation was estab-
lished (Jeger and Israel).
2. The implantation of a small artery cut longitudinally, folded crosswise
on its long axis, sutured crosswise at the cut end so that the lumen of the trans-
378 THE SUKGICAL TREATMENT OF ANEURYSM
plant is equal to that of the larger vessel and the transplant thus formed may
be then sutured by a circular end-to-end suture to fill in the gap in the larger
vessel (Jeger and II. Joseph).
Tscherniachowski has collected all the cases in which the above procedures
for the treatment of aneurysms have been carried out up to July, 1913, and
gives a fairly successful list of such undertakings.
The literature complete to that date is appended to his article.
His collected cases number 47. The operative procedures are enumerated as :
1. Lateral suture of an artery, 16 cases [Marchant, Peugniez, Le Fort,
Garre, Swiatecki, Ziembicki (2 cases), Morestin, Sencert, Tichow (2 cases),
Heller, Bramann (2 cases), Meissner, Jaboulay].
The result in the 16 cases ( Jaboulay' s case was added after the publication
of Tscherniachowski's paper) was a cure in 13 cases, death in 2 cases, and re-
sult not stated in 1.
2. Lateral suture of a vein, 7 cases (Lissianski, Spisharny, Veauiu, Du
Verger, Pollard, Neck, Palla, Aubert).
One case (Neck) was an aneurysmal dilatation of the femoral vein and the
artery was not involved. The artery in each of the 6 other cases was ligated
and the involved area excised with the sac. A cure resulted in all.
3. Lateral suture of an artery and a vein, 9 cases (Korte, Wiesinger,
Potherat, d'Antona, Abalos, Auvray, Doyen, Zeidler, Kiittner).
A cure resulted in 8 of these cases. In 1 case (d'Antona) infection of the
wound occurred and amputation of the extremity was done.
4. Circular suture of an artery, 8 cases (Dauriac, Stich, Goibet, Lieblein,
Key, Omi, Oppel, Gellert).
In this series 1 case died (Dauriac's), 7 cases were cured. In 1 of the
cured cases there was weakness in the infected limb (Stich's). Necrosis of the
terminal phalanx of the thumb occurred in 1 case (Oppel's).
5. Circular suture of an artery and vein, 4 cases (Murphy, Lexer, Ender-
len, Tscherniachowski).
All the above series were cured.
6. Transplantation of vessels, 3 cases (Goyanes, Lexer, Pirovano).
In this group there were 2 deaths and 1 recovery (Goyanes).
The regional situation in which the above operations were undertaken are:
Axillary artery in 4 cases; brachial in 5 cases; radial in 1 case; external iliac
in 1 case; superficial femoral in 23 cases; popliteal in 13 cases (1 case in
Tscherniachowski's collection, Neck's case, was a venous varix) .
In the cases treated by the above methods death occurred once in the ex-
ternal iliac (100 per cent.) ; once in the 23 superficial femoral cases (4.3 per
cent.) ; twice in the 13 popliteal cases (15.38 per cent.) ; once in the 4 axillary
cases (25 per cent.).
Gangrene occurred in one of the axillary cases, amputation was necessary
in one of the popliteal cases, and there was considerable disability in the limb
in one of the superficial femoral cases.
THE TREATMENT OF SPECIAL ANEURYSMS 379
The above forms of aneurysmectomy with the various types of arterior-
rhaphy, phleborrhaphy, and vessel transplantation are limited in their applica-
tion and in the major number of the above cases were done on readily accessible
vessels. The mortality in the cases of popliteal aneurysms submitted to the
ideal operation (15.38 per cent.) does not compare very favorably with the low
mortality of the Matas operations (1.6 per cent.).
In the other regions there is very grave question as to the essential value of
the proceeding. The chief objection to the performance of any of the above
types of operation lies in the enormous disturbance to the collateral circulation
necessary to the performance of the given operation.
In carefully selected cases, in superficial, easily accessible, healthy vessels,
there will probably be a definite field for this type of radical surgical treat-
ment of aneurysm.
THE TREATMENT OF ARTERIOVENOUS ANEURYSMS
All the various forms of the treatment of aneurysm have been used for this
special class of aneurysms.
Compression and ligation have been particularly unsuccessful (Stimson,
Matas).
Rest, both general and local, together with some form of proximal com-
pression, has been strongly advocated by Makins, Kikuzi, Saigo, etc., as a pre-
liminary to operation. A few cases may, by this means, undergo spontaneous
cure. If the aneurysmal sac, however, shows signs of increasing in size opera-
tion is indicated.
The ideal operations previously discussed will probably find their greatest
field of usefulness in this form of vascular tumor, especially in the recent cases
(see Ideal Operations).
In the older cases and in the recent ones in which the dissection necessitated
by an ideal operation would in the given case disturb the collateral circulation
more than would seem wise, the Matas operations or the intrasaccular suture
of Annandale are preferable, while in selected cases in the smaller peripheral
arteries ligation and excision of the sac are the simplest and safest operative
procedures.
THE TREATMENT OF SPECIAL ANEURYSMS
THORACIC ANEURYSMS
With the advent of the X-ray, the diagnosis of thoracic aneurysms has been
rendered easier, and the type and size of the sac can be more readily deter-
mined than was previously possible.
Whether the ability to recognize the location and the character of the sac
380 THE SUEGICAL TREATMENT OF ANEURYSM
(whether saccular or not) will lead to a greater use of surgical treatment in
thoracic aneurysm is one of the problems of vascular surgery.
For aneurysm in the above location, wiring with electrolysis (Moore-Cor-
radi) has many advocates. Ransohoff, Stewart, Hunner, Matas, Finney, Hare,
Lusk, and others are ardent advocates of the method ; while Freeman, Jacobson,
Rowlands, and others do not believe the benefits obtained are commensurate
with the dangers of the operation.
Finney and Lusk in their recent publications have given the essential
features of this form of surgical procedure. The facts herein stated, and those
in the general statement on wiring, are obtained from these publications.
The essential details are a rigid asepsis, appropriate wire (see Lusk's
description as given in the general statement of treatment in this article), a
constant current, rheostat, ammeter, etc., the use of morphin, and local infiltra-
tion anesthesia.
The method is applicable only to aneurysm with a definite sac, i. e., saccu-
lated aneurysm, and to this form only in the ascending, the transverse, and to
a lesser extent in the descending portion of the thoracic aorta. It is not ap-
plicable to aneurysms of the fusiform variety.
The character of the needle varies with different observers. Finney uses a
hollow needle not too large in caliber, insulated to within a short distance of
the point by the best quality of French lacquer. Lusk recommends the gold
porcelain-covered needle, described above.
The wire receiving the most use is that advised by Hunner (75 parts of
copper to 1,000 of silver). Lusk from his experiments concluded that the gold
platinum alloy "Clasp" wire (gold 62.9 per cent., silver 17.9 per cent., platinum
13.4 per cent., copper 5.8 per cent.) was the most desirable.
The amount of wire to be inserted is usually stated as ten feet. Freeman
believes that the greater the amount of wire inserted the better, but Finney
states that his observations have not borne out the above statement, but that wire
in excess of 10 feet has prevented the contraction of the clot which resulted
from the electrolysis.
The needle should be well insulated to prevent an electric burn along the
track of the needle.
The strength of the current should not exceed 75 ma. (Finney) and the
current should be used for at least 1 hour. In his later cases Finney continued
the current for nearly 2 hours. Lusk suggests the use of a current of 100
ma. for 15 minutes, then 50 ma., 40 ma., and 30 ma., each for 15 minutes,
and states that he found the current used in these strengths and for the above
periods of time as the most favorable for the production of the fibrin.
The passage of the wire through the needle should be so carried out that the
coils come in contact with as much of the sac wall as possible. After the cur-
rent has been used the needle is withdrawn and the wire cut off close to the
sac, and the projecting end of the wire buried beneath the entire thickness of
the skin so that it does not lie immediately under the skin wound.
THE TREATMENT OF SPECIAL ANEURYSMS 381
To prevent hemorrhage along the track of the needle Lusk recommends
the procedure described under wiring in the general statement of that method
in this article, and it would seem that his procedure would be more serviceable
and less dangerous than the pressure recommended by Finney.
The after-treatment should consist in thorough medical treatment, espe-
cially rest and the avoidance of any strain likely to increase cardiac tension,
and the use of potassium iodid in 5 to 15 gr. doses thrice daily.
Result of the Operation. — Esher collected and tabulated 38 cases up to
1910. Bernheim added 21 cases to that number, including 18 unreported cases
of Finney's, a total of 59 up to 1912 which have been submitted to wiring.
Of Finney's personal cases eight were abdominal and will be discussed un-
der abdominal aneurysm. Twelve were thoracic and, inasmuch as this sur-
geon's experience has been so large, a study of the results obtained by him would
seem more profitable than a compilation of all the reported cases with their re-
sults if any practical information is to be gained with regard to the utility of
the foregoing method.
Of Finney's 12 thoracic cases submitted to wiring, 5 were submitted to
second operations, i. e., 17 wirings were done. No cases were reported cured,
but one case was living 3 years after the operation.
Eight cases were reported as improved. In one case the improvement has
lasted thirteen months and the patient is still well. The improvement in 4 cases
varied from 4 to 9 months. In the remainder the length of improvement is
mentioned only up to the time of discharge from the hospital, 13 days to 6
weeks, and is too short for any definite idea as to the relative merit of the
wiring.
Three cases were not improved in any way and 1 case died within a few
days after the wiring as a result of a bronchopneumonia. In that case the wire
was covered by a laminated clot.
The chief relief was obtained in the decrease of pain. In 8 it was ab-
sent after the wiring; in 3 cases it Avas markedly diminished; and in 1 there
was no change. The pulsations diminished in 7 cases and the tumor decreased
in size in 5 cases.
The complications which may ensue are :
1. An electrolytic burn along the course of the needle.
This may occur if the needle is not properly insulated. The slough which
results may permit hemorrhage along the track of the needle or the sac may
actually rupture as result of the area of weakness thus produced.
2. Charring of the sac by the use of too strong an electric current (Hal-
sted's case). Secondary hemorrhage occurred as a result of the subsequent
necrosis about the charred area.
3. Embolism as a result of pieces of the fibrin becoming dislodged and
swept into the peripheral circulation.
Embolism occurred in the brachial in a case quoted by Finney in which
gangrene of the forearm and hand occurred, necessitating amputation.
382 THE SURGICAL TREATMENT OF AKEURYSM
Salinger reports a case of cerebral embolism on the third day after wiring
an aortic aneurysm with recovery of the patient.
4. The passage of the wire into the heart. Parkam reports a case in which
this occurred without fatal results.
5. Infection about the needle wound or in the extravasated blood.
6. Finney states that the newly formed clot may shunt the blood against
a portion of the aneurysmal wall, cause it to bulge at the point of impact of the
arterial stream and even to give way and result in fatal hemorrhage from this
cause.
THE USE OF THE LIGATURE IN THE TREATMENT OF THORACIC ANEURYSMS
Temporary ligation of the thoracic aorta has been unsuccessfully tried in
2 cases, Tormi and Villar, quoted by Boinet.
Ligation of the aorta below the arch was done by Guinard through a pos-
terior thoracostomy. Death supervened due to complete arrest of the urinary
secretion. According to Matas this is the pertinent reason why ligation of the
aorta above the renal arteries always proves fatal.
Ligation of the peripheral arteries distal to the sac (Wardrop) in the treat-
ment of the aneurysm of the arch of the aorta.
The procedures advised for this method may be divided into various groups
as follows : ligation of the common carotids, right and left ; simultaneous liga-
tion of the right common carotid and subclavian arteries ; ligation of the right
common carotid followed after a suitable interval by ligation of the right sub-
clavian; ligation of the left common carotid and left subclavian, either simul-
taneously or at two sittings; simultaneous ligation of the left common carotid
and the left axillary artery.
(This method has been applied not only to aneurysm of the arch of the
aorta but to cases involving the branches of the aorta and no attempt has been
made here to separate the groups in the statements from Jacobsthal and
Guinard inasmuch as it is difficult to distinguish some of the forms.)
Jacobsthal reports 44 cases in which one or more of the above operative pro-
cedures were applied with 23 recoveries. Only 3 cases survived for 3 years.
Guinard reports 15 personal cases. He .recommends simultaneous ligation
of the right common carotid and subclavian and insists upon the ligation of the
carotid as the first step in the operation.
In Guinard's experience the results are better in those cases in which the
aneurysmal sac is farthest from the heart. He furthermore states that from
his experience distal ligation will give some benefit in all the cases in the region
under discussion.
Boinet and Matas believe that the use of distal ligation should be re-
served as an operation of necessity for aortic aneurysm and should only be
employed when medical measures have failed and the increase in the size of
the aneurysm produces pressure symptoms which promise to result fatally.
I
THE TREATMENT OF SPECIAL AXEURYSMS 383
Kiimmell reports a case of aneurysm of the descending aorta in which he
sutured the opening in the vessel after temporary control of the circulation.
He exposed the artery through a posterior thoracotomy wound such as is used
to expose the esophagus. His case died from secondary hemorrhage which he
thinks could have been prevented by not packing the wound and by reinforcing
the suture line by a fascial transplant.
ANEURYSMS OF THE ABDOMINAL AORTA
The Ligation of the Abdominal Aorta. — The abdominal aorta was first ligated
by Sir Astley Cooper in 1817. According to Matas it has been done 15 times
since then and in all of these cases it has resulted fatally.
Keen (1899) ligated the abdominal aorta close to the pillars of the dia-
phragm. His case survived 48 days and died as a result of ulceration and rup-
ture of the aorta at the site of the ligature. In his remarks on his case Keen
considers it remarkable that there was so little change in the urinary secretion
in his patient. The early establishment of collateral circulation after ligation
of the aorta he considers as due to the previous establishment of the collateral
circulation caused by the existence of the aneurysm. As a result of the col-
lateral circulation thus established, the human subject can survive ligation of
the abdominal aorta without gangrene of the limbs or paralysis of a permanent
nature from changes in the cord. But he states further that "death will result
from the cutting through of the ligature and secondary hemorrhage in all cases
in which this method is applied."
It is needless to state that the condemnation of Keen is a sufficient contra-
diction against the performance of ligation for aneurysm of the abdominal
aorta.
Temporary Compression of the Abdominal Aorta. — 1. BY A TOURNIQUET.
—Temporary compression of the abdominal aorta by means of a tourniquet
was devised by Murray in 1864 and used by him successfully.
Barwell reported 5 successful cases up to 1889. Death usually occurs from
injury to the intestines underlying the tourniquet and as stated under the para-
graphs on compression in general the method has little to commend it at this
time.
2. BY THE USE OF INSTRUMENTS APPLIED TO THE ARTERY THROUGH
A LAPAROTOMY WOUND. — Keen as a result of his experience with ligation
devised a clamp so constructed as to cause a conical constriction of the
artery.
By means of this instrument applied to the abdominal aorta through a
laparotomy wound the circulation may be partially or completely arrested for
any length of time according to the effect of this occlusion upon the patient and
the aneurysm. When the occlusion has been satisfactory, the clamp should be
removed.
Keen reports the results of animal experimentation with the clamp and
384
THE SURGICAL TREATMENT OF AKEURYSM
from them concludes that the clamp might have a field of usefulness in the
treatment of abdominal aneurysm.
Stratton has devised an instrument so constructed that a band of tape can
be gradually drawn tight about the aorta, thus gradually constricting it, and
recommends its use in abdominal aneurysm. Like Keen's compressor the in-
strument is left in situ during the period of compression and is removed when
it has served its purpose.
The idea in both is to compress the artery gradually on the proximal side
so that a collateral circulation may develop before the blood stream is com-
pletely arrested.
3. BY METAL BANDS APPLIED TO THE ARTERY.— The Halsted aluminum
bands are also devised for the gradual occlusion of the artery in abdominal
aneurysm. Experimentally these have
proved most satisfactory and their applica-
tion to the human should be followed by simi-
larly successful results.
Intrasaccular suture (Matas' operation) has
been done by Lozano, Munro, Crile, and Gibbon.
All of these were failures due to hemorrhage.
Matas states that the operation is distinctly con-
tra-indicated in aneurysms above the renal ar-
tery and all cases where free access to the sac and
complete preliminary control of the circulation
are impossible.
The result of any operation upon abdominal
aneurysms will depend upon the strain thrown
upon the heart. Katzenstein and Oppergeld have
shown that ligation of the abdominal aorta below
the inferior mesenteric artery is accompanied by
such an enormous rise of blood-pressure on the
proximal side of the ligature that except in
absolutely healthy hearts acute cardiac dila-
tation occurs and death may result from this
cause.
As stated by Keen, the ligature will cut
through in all cases and death will result
from hemorrhage.
Wiring of abdominal aneurysms occurred
sion of the band to the desired degree 8 times in Finney's series. The technic is
by tt".11 (l,t ££L, *"" ^^ tO that A^'^ ™der ^^ «*'
eurysm. Two cases were improved slightly
without any definite change in the aneurysm ; 1 was not improved ; and 5 cases
died. The cause of death is not given in 3, but occurred within a short time
after the operation. In 1 case death was due to the rupture of the sac, in the
other death occurred as a result of infection about a previously placed Halsted
metal band.
A B
FIG. 11. — HALSTED ALUMINUM BANDS.
A shows clamp for the application of
the aluminum band of Halsted. B
shows band on the jaw of the instru-
ment in the process of being curled
about the vessel. Further compres-
THE TREATMENT OF SPECIAL ANEURYSUS 385
Ilalsted, Nassetti, Matas and Allen have; suggested the application of vari-
ous methods which have a proven experimental basis for the treatment of
thoracic and abdominal aneurysms.
Nassetti suggests the use of free fascial transplants so applied as to con-
strict the lumen of the vessel either above or below the sac.
Halsted has used strips of aorta either as a circular cuff or in his later ex-
periments as a spiral strip so applied as to constrict the lumen of the artery
and hence the force and quantity of the blood stream beyond the constriction.
Matas and Allen in some experimental efforts upon plication of the thoracic
aorta by lateral parietal suture in dogs believe from their results that this
method of narrowing the lumen of the vessel is a safer and more certain way
of constricting the lumen of the vessel than can be obtained by metal bands and
believe that it may find a field of usefulness in the reduction of the fusiform,
cylindrical or saccular aneurysms, either by strengthening the wall of the sac
by this plication applied to the sac itself or by plication of the artery above or
below the sac to reduce the vis a tergo of the blood stream to the sac. They
further suggest that the use of free fascial flaps (Nassetti) or the strips of the
aorta (Halsted) to narrow the lumen of the vessel immediately above the ves-
sel should find a greater field of usefulness in producing a partial occlusion of
the artery above or below the sac and a reduction in the size of the aneurysm by
this method pending the development of a collateral circulation. When the
latter has developed further occluding methods might be carried out with a
more reasonable assurance of success.
One is forced to conclude that the treatment of abdominal aneurysm as yet
has not reached its solution. Whether the operation of the future will com-
prise the newer methods of fascial or arterial strip occlusion (Nassetti, Hal-
sted), or the plication method of Matas and Allen, is as yet undetermined.
The success obtained by their use in animals suggests a possibility that they
may solve the problem of the surgical treatment of abdominal aneurysms in
man.
ANEURYSMS OF THE RENAL ARTERIES
Keen collected 12 cases of aneurysm of the renal artery and reported 1 of
his own in 1900.
The treatment advised by Oestreich and emphasized by Keen is extirpa-
tion of the kidney with the aneurysm.
Three cases were submitted to operation and all recovered.
INNOMINATE ANEURYSMS
The treatment of innominate aneurysm is practically limited to the use of
distal ligation and wiring with electrolysis. Acupuncture, wiring, and the
proximal ligation have been discarded for reasons which have been discussed
under the general treatment.
26
386 THE SITEGICAL TREATMENT OF ANEURYSM
The method of wiring with electrolysis has been sufficiently discussed under
thoracic aneurysm and does not differ from that given for use in innominate
aneurysm.
The method of election in the treatment of aneurysms in the innominate
artery is distal ligation (Wardrop) of one or more of the branches of this ves-
sel, i. e., simultaneous ligation of the right common carotid and the right sub-
clavian. The right common carotid should be tied first, then the right sub-
clavian. Jacobsthal states that only 2 of the cases of the 120 known to him
which have been treated by distal ligature have lived for more than 3 years
and regards the prognosis as very unfavorable. Imbert and Pons give the re-
sults as collected by them as apparent cures, 22 per cent. ; failures to influence
the growth of the aneurysm, 30 per cent.
The complications to be dreaded most are cerebral softening due to the
ligation of the common carotid, and secondary hemorrhage.
The Halsted band may have a field of usefulness in preventing such cere-
bral complications by its application to the carotid, with gradual occlusion of
that vessel, which might be made permanent after a suitable interval. Partial
occlusion by the fascial strip (Nassetti) or the spiral arterial strip of Halsted
may find a field of future usefulness.
Infection of the wound (21 wound infections in 51 operations), while a
common occurrence in Burns' statistics, did not apparently affect the outcome.
COMMON CAROTID ANEURYSMS
The operative treatment of common carotid aneurysm is limited to proximal
or distal ligation of the artery, the Antyllian operation, extirpation of the sac,
the Matas operations, and the use of the Halsted metal bands, or in special cases
by some form of clamp so constructed as to cause gradual occlusion of the
vessel.
The proximal ligation (Anel) or the application of a metal band or clamp
to the proximal side of the aneurysm is limited to those cases in which there is
sufficient space between the aneurysm and the origin of the common carotid
from the innominate or the aorta as the case may be.
The use of the double ligature with evacuation of the clot (Antyllus), ex-
tirpation of the sac and the Matas operation, are subject to the same limitations
as the above, inasmuch as proximal control of the circulation to the sac is essen-
tial to their successful outcome.
Distal ligation (Brasdor) or the distal application of the Halsted bands is
especially adapted for application to those aneurysms of the carotid which are
intrathoracic and which fuse with the innominate or the aorta.
The essential difficulty encountered in any of the above forms of treatment
for carotid aneurysms lies in the dangers incident to the cerebral anemia which
follows the arrest of the circulation on the occluded side.
For the purpose of preventing these cerebral complications, the band of
THE TREATMENT OF SPECIAL ANEURYSMS 387
Halsted has a wide field of usefulness. The principal essential features of its
application, in common carotid aneurysm are the use of local infiltration anes-
thesia ; the exposure of the common carotid at the site of election by this method
of anesthesia; the application of a Halsted metal band to the common carotid
distal to the sac, and the closure of the band just tight enough to obliterate the
lumen of the vessel. After the band is tightened the onset of cerebral symp-
toms will occur promptly if the collateral circulation is defective; should such
symptoms arise, the band is cut and removed and with its removal the cerebral
symptoms will subside with the return of the circulation to the anemic area.
Smoler devised a specially constructed clamp to produce gradual occlusion
of the carotid artery to prevent cerebral complications. He reports 3 success-
ful cases in which he used his clamp without these complications.
After the question of cerebral disturbance has been settled, the subsequent
treatment of the sac will depend upon 3 factors, i. e., the absence of pulsa-
tion, of pressure symptoms, and changes in the size of the tumor.
In those cases in which the pulsation, etc., disappear, following the applica-
tion of the band, nothing further need be done.
In cases in which pressure symptoms remain the sac may be exposed and the
vessel ligated on the proximal side and the contents of the sac evacuated ; or the
vessel ligated and the sac extirpated ; or if the proximal circulation can be con-
trolled the sac may be treated by the Matas obliterative endo-aneurysmorrhaphy.
The treatment of the sac must of necessity depend upon the symptoms which its
pressure causes or the structures necessarily injured in its treatment. All of
these factors must be weighed carefully and the result of the decision thus
arrived at carried out according to one of the above described methods.
The dangers in the past have been due to the disturbance in the brain fol-
lowing the ligation of the common carotid. Delbet states that cerebral compli-
cations occur in 20 per cent, of the cases. Jordan says that they occurred in
25 per cent., and of these, 10 per cent. died. Smoler had it happen in 2 of
his cases in which elastic ligatures were used, while it was absent in the 3
cases in which gradual occlusion was produced by his clamp. Halsted states
he has applied the metal band to the carotid "many times" without accident.
In 3 personal cases in which the common carotid was tied for pulsating
exophthalmos, evanescent cerebral symptoms occurred in 1 case and disappeared
with a return of the bruit over the head.
INTERNAL CAROTID ANEURYSMS
These may be intracranial or extracranial. For the treatment of the former,
see pulsating exophthalmos.
The same general conditions spoken of under innominate and common
carotid aneurysms apply in the treatment of internal carotid aneurysms,
namely the dangers of cerebral complications and the efficiency of the collateral
circulation should always be tested preliminary to a ligation of this artery.
388 THE SURGICAL TREATMENT OF AKEURYSM
For this purpose the Halsted metal band or some form of specially constructed
clamp should be used. The temporary occluding agent should be applied
preferably to the common carotid artery, due to the ease with which the vessel
may be approached. In those cases in which the aneurysm is placed low down
upon the internal carotid, ligation or compression of this vessel may be prac-
ticed on the distal side.
Matas advises extirpation or preferably obliterative eiido-aneurysinorrhaphy
for those cases in which ligation does not cure the condition. To reach the sac
he advises the use of the incision necessary for the removal of retropharyngeal
tumors with temporary resection of the lower jaw. He furthermore advises
obliterative endo-aneurysmorrhaphy with packing of the sac as more advisable
and safer than any attempt at obliterating the sac.
Aneurysm of the internal carotid is not common. Herzen records it as
occurring only twice in his cases, once with aneurysm of the external carotid.
Monod and Van Verts in their collected cases mention 1 case (Mullen and
Stanton) in which restorative endo-aneurysmorrhaphy was attempted and failed
because of secondary hemorrhage and death occurred due to that cause. Matas
does not mention it in his paper on the statistics of endo-aneurysmorrhaphy in
1908, but in "Keen's Surgery" quotes Bobbio as stating that there were 18 cases
of aneurysm of the vessel up to 1906 with ligation of the common carotid in 11
cases with 6 recoveries.
Aneurysm of the External Carotid and Its Branches. — Aneurysms of the
trunk of the vessel are rare, while aneurysms of the branches are quite common.
Herzen mentions external carotid aneurysm in 2 cases (1 in combination with
internal carotid aneurysm) . Monod and Van Verts do not mention it in their
collected cases. Delbet (1895) collected 11 cases of aneurysm of the external
carotid.
Aneurysms of the branches of the external carotid are quite common.
The treatment of aneurysms of the external carotid or its branches depends
upon the location of the aneurysm. If the sac is close to the origin of that
artery near its bifurcation from the common carotid, Matas advises temporary
clamping of the common carotid with obliterative endo-aneurysmorrhaphy of
the vessel and that method of obliteration of the sac which best suits the
aneurysm in question.
The small aneurysms either on the trunk or on its branches should be
ligated and extirpated unless the relation of the important structures to the sac
are such that extirpation would be dangerous. In the latter instance they may
be treated by intrasaccular ligation or suture and the sac obliterated.
Dawbarn suggests the obliteration of the external carotid by paraffin injec-
tions for aneurysms of the branches of that artery which are difficult of access.
THE TREATMENT OF SPECIAL ANEURYSMS 389
SUBCLAVIAN ANEURYSMS
The treatment of aneurysms of this vessel comprises every conceivable
remedy suggested for the treatment of aneurysm.
Souchon found that medical measures alone were successful in 11 out of
35 cases. Elliot emphasizes the fact that in slowly growing aneurysms of
small size such treatment is indicated and cites a case of his own treated by
rest and diet in which the aneurysm perceptibly decreased in si/.o and the
patient improved. To the above suggestion one might add the use of potas-
sium iodid in from 5 to 15 grain doses 3 times a day over a long
period.
The other non-operative methods may be dismissed without further con-
sideration as useless.
The Operative Treatment.— Matas divides the operative treatment proposed
as curative for subclavian aneurysms into 6 groups :
1. Incision into the sac, digital plugging of the orifices, and ligation of the
poles of the sac (Syme, 1860).
2. Disarticulation of the shoulder joint.
3. Ligation.
4. Extirpation.
5. Aneurysmorrhaphy.
6. Gradual occlusion by the Halsted metal bands.
Of these, only the last 4 are worthy of consideration.
Jacobsthal summarizes the forms of ligation and divides them into distal
ligations in which the axillary, carotid, axillary and carotid, or third portion
of the subclavian were tied in various combinations. Proximal ligations in
which the subclavian was tied in all 3 of its divisions, or the subclavian with
the carotid, alone or in conjunction with the vertebral; or the innominate
alone or in combination with carotid, subclavian, vertebral, and internal mam-
mary in various combinations. Proximal and distal ligations in which the
subclavian and the axillary were tied :
Jacobsthal, in his collected cases since 1890, 25 in number, states that
the mortality was 16 per cent., gangrene of the arm occurred 3 times, and of
the hand, 4 times.
Matas, in his statistics on arteriovenous aneurysms of the subclavian ves-
sels, found that gangrene occurred in 13.5 per cent, after the ligation of both
artery and vein, and in 1.7 per cent, after ligation of the third division of the
subclavian.
Aneurysms of the subclavian are most frequently found in the first and
third divisions of that vessel. According to their relation to the scalenus anticus
they are called extrascalenic or intrascalenic (Savariaud). The second por-
tion of the artery is usually involved by extension of the aneurysm from one or
other of its divisions.
In the extrascalenic aneurysms, the method of election, if ligation is pur-
390 THE SURGICAL TREATMENT OF AHEURYSM
sued, is proximal ligation or proximal and distal ligation with extirpation
of the sac where it is possible.
In the intrascalenic, proximal ligation is more dangerous than distal liga-
tion and this latter procedure should be attempted first.
In those cases in which it is possible to obtain preliminary hemostasis the
Matas obliterative endo-aneurysmorrhaphy is more advisable than any form of
ligation. Elliot states that the great advantages of the obliterative operation of
Matas are that it is almost always permanent, cures the aneurysm and that the
dangers qf secondary hemorrhage are very slight, once in 63 cases of obliterative
aneurysmorrhaphy ; that gangrene of the extremities is rare, 3 to 5 per cent.,
and that the mortality of the operation was 3 per cent. Relapse occurred in
1% Per cent- Gangrene occurred in 6^2 per cent., and the mortality was
7 per cent, in ligation alone, with 74 per cent, of cures. Excision of the sac
gave 90 per cent, of cures, with 1% per cent, of relapses, and a mortality
of 3 per cent. ; gangrene occurred in 4 per cent. The inference from the
above statistics of Monod, Van Verts, and Matas, according to Elliot, is that
the Matas operation and the treatment of the aneurysm by excision are about
of equal merit and superior to ligation.
Monod and Van Verts, however, do not believe that the Matas operation is
suitable for subclavian aneurysms.
Elliot believes that the most satisfactory treatment of aneurysm of the third
portion of the subclavian is the ligation of the first portion of that artery to-
gether with its branches with the possible exception of the vertebral.
If recurrence takes place, then distal ligation as close to the sac as possible
may be done. Should the aneurysm recur after this procedure, extirpation may
then be done after the ligation of the other vessels to the sac.
Elliot further advises a preliminary resection of the clavicle and, if neces-
sary, of the manubrium.
Halsted has applied his metal band to the subclavian twice without acci-
dent and a thorough trial of this method may prove it to be the method of elec-
tion for aneurysm of the subclavian.
The result of any treatment for subclavian aneurysm may be followed by
some sensory, motor, or trophic disturbances in the extremity. Furthermore,
after ligation, etc., aneurysm of the aorta is prone to develop.
AXILLARY ANEURYSMS
The treatment of aneurysms in this region comprises ligation, proximal and
distal, the Antyllian operation, extirpation of the sac, the Matas operation, the
use of the Halsted band, and one or other of the so-called "ideal" operations.
The objections to the use of the ligature are, its failure to cure, the liability
to relapse, and the dangers of gangrene.
Extirpation of the sac is preferable to ligation but is apt to be followed by
injury to the brachial plexus and the axillary veins.
THE TKEATMENT OF SPECIAL AKEURYSMS 391
For that reason the Matas operation, the Halsted band, or some one of the
forms of the ideal operations is to be preferred.
The selection of the type of the above 3 forms of operative treatment must
of necessity depend upon the conditions to be met at the operation and the
equipment and experience of the operator.
The treatment of aneurysms of branches of the axillary down the arm and
into the hand resolves itself into extirpation or some form of the ideal opera-
tion. Excision is easily carried out in most cases and if the anatomical rela-
tion to nearby nerves is given sufficient consideration, it will result in a cure
without any neurological complications.
In suitably selected cases some reconstructive operation upon the artery or
vein or both (ideal operation) may find a field of further usefulness.
ANEURYSMS OF THE ILIAC ARTERIES
These may, according to Matas, be divided into (a) aneurysms of the exter-
nal iliac tract, including the common iliac artery, the external iliac, the ilio-
femoral, and the common femoral to the origin of the profunda artery; (b)
aneurysms of the internal iliac (hypogastric) and its branches.
Aneurysms of the External Iliac Tract. — Halsted ("The Effect of Ligation
of the Common Iliac Artery, etc.," Johns Hopkins Bull., xxxiii, 191) has col-
lected the cases of ligation of the common iliac arteries and divides them into
2 periods: up to 1880, and from 1880 to 1912. For the older group, the reader
is referred to the original article.
Of the cases collected from 1880 to 1912, 30 in number, 14 died; gangrene
occurred in 12 ; and in 11 that recovered without gangrene function in the
limb was distinctly interfered with. In the 11 cases of recovery recurrence of
the aneurysm occurred in one case and Halsted believes that this would have
happened more frequently had the cases been observeol long enough. Extir-
pation of the sac has rarely been resorted to except in aneurysm of the external
iliac, and gangrene occurred in 20 per cent, in this group (Matas).
Endo-aneurysmorrhaphy in Matas7 opinion would meet the indications ad-
mirably for those aneurysms in which the circulation could be controlled and
he advises compression of the abdominal aorta to bring about this temporary
hemostasis. In 2 cases (Frazier, Mitchell) severe hemorrhage occurred from
collaterals to the sac in spite of preliminary hemostasis. Matas states that the
statistics are not yet sufficient to draw conclusions as to the value of this pro-
cedure.
The obliteration of femoral aneurysms giving off the deep epigastric, cir-
cumflex iliac, and profunda arteries will be followed by more or less serious
impairment in the circulation of the foot and leg due to disturbance of the
collateral circulation. Obliteration of an aneurysm of the iliac artery above
the origin of these vessels should not produce as great a disturbance in periph-
eral circulation.
392 THE SUKGICAL TREATMENT OF ANEURYSM
Halsted reports the cure of an iliofemoral aneurysm by the application of
one of his bands to that vessel and the result of his operation would indicate
that that method is worthy of a more extended trial.
More recent methods for partial occlusion (Halsted, Nassetti, Matas and
Allen), proximal or distal, have not yet been tried clinically. Their success
experimentally would suggest a definite field of clinical usefulness.
From the above meager resume, it would seem that one of the methods
of partial occlusion should be used as the first stage in the treatment of
iliac aneurysm and this preliminary step followed by some further secondary
operation to meet the conditions which remain after the occlusion. The
character of the secondary operation must of necessity be selected in each
case.
Internal Iliac Aneurysms. — Any of the branches of this vessel may become
aneurysmal.
Those branches most frequently involved are the gluteal and sciatic arteries.
These may be intra- or extrapelvic. The former are so infrequent as to need
little consideration. In 1 case of the writer's of intrapelvic aneurysm, which
from its location suggested its origin from the sciatic, operation was refused
and the patient developed sciatic nerve paralysis and subsequently died of
hemorrhage while under medical treatment for that condition.
The extrapelvic variety of aneurysms of this vessel, while not common, is
of sufficient surgical interest to deserve mention. The majority are due to
traumatism and are chiefly outside the pelvis, although some may project
through the sciatic notch into the pelvis.
Frischberg collected 19 cases of gluteal aneurysm submitted to radical sur-
gical procedures. In 2 of his collected cases proximal ligation (Anel) was done
with 1 death ; the internal iliac was tied in 5 cases with two deaths ; the com-
mon iliac was ligated in 1 case which resulted fatally; in 11 cases treated by
the Antylliaii method there were 2 deaths.
Rupp collected 45 cases of gluteal aneurysm and reports a successful extir-
pation of gluteal aneurysm by Lexer.
Bryan collected 24 cases of sciatic aneurysm and reports a case of his own
successfully treated by extirpation.
Of the methods used he mentions injection of chlorid of iron in 4 cases;
medical treatment in 1 case ; compression in 2 cases ; clamping of sciatic in 1
case ; galvanopuncture in 1 case ; ligation of common iliac in 2 cases ; ligation
of internal iliac in 5 cases ; ligation of hypogastric in 4 cases ; ligation of sciatic
in 5 cases.
He considers it , feasible, at this stage of modern surgical development,
to attempt any of the finer surgical procedures of obliteration such as suture,
Halsted's occlusion methods, the Matas operation, or the wiring methods
(Moore-Corradi) for this important terminal artery, but believes that ligation
and extirpation of the sac should be the method of election for the treatment of
aneurysms of this artery.
THE TREATMENT OF SPECIAL ANKTUVSMS 393
Ligation of the common iliac is contra-indicated, owing to the dangers in-
cident to that operation. Temporary ligation or clamping of tin- internal iliac
might be used for those cases in which the aneurysm projects into the notch
until the sciatic artery could be properly secured on its proximal side when the
internal iliac could be freed from the temporary compression.
The method of election in the treatment for aneurysm of the sciatic and
gluteal arteries would then be extirpation of the sac with or without temporary
occlusion of the internal iliac artery.
The incision best adapted for the purpose of extirpation is a long curved
incision from the great trochanter parallel to the gluteal fold across the but-
tock. The tendon of the gluteus maximus should be cut together with the
gluteus medius and these muscles so displaced as to expose the aneurysmal
swelling. After all structures, especially the sciatic nerve, are dissected free,
ligation and extirpation are done in the ordinary manner. Drainage is indi-
cated. Infection occurred in Bryan's case but it seemingly did not interfere
with a successful outcome.
FEMORAL ANEURYSMS
These are aneurysms of that portion of the femoral artery from the origin of
the profunda to the popliteal end of Hunter's canal.
Herzen quotes deep femoral aneurysms as occurring 9 times and superficial
femoral aneurysms as occurring 26 times in the traumatic aneurysms treated
by the Russian surgeons.
Of the older methods, compression in its various forms and ligation were
frequently practiced (Matas, Bolton).
Extirpation, aneurysmorrhaphy, or some form of the ideal operation would
seemingly be the method of election for aneurysm in this region.
Aneurysm of the profunda femoris is rare. A case of the writer's due to
subtrochanteric fracture with successful obliterative endo-aneurysmorrhaphy is
quoted in that portion of this article devoted to the Matas operation (v. supra).
Superficial femoral aneurysm, due to the ease with which the circulation
can be controlled, readily lends itself to the more radical forms of surgical
treatment. In those cases in which the collateral circulation is sufficient to
avoid the dangers of gangrene, extirpation is undoubtedly the method of
choice.
When the vitality of the limb is threatened by occlusion of the vessel,
restorative or reconstructive endo-aueurysmorrhaphy or some one of the forms
of the ideal operations could be used in properly selected cases.
POPLITEAL ANEURYSMS
Aneurysms in this region are the most frequent of all the forms of
peripheral aneurysms.
For this reason there are more methods of treatment than need any aeri-
394 THE SURGICAL TREATMENT OF AKEURYSM
ous consideration. One may divide the therapeutic procedures into ancient and
modern methods :
The ancient methods comprise compression, acupuncture, wiring, ligation,
proximal' and distal, and amputation of the leg. It does not lie within the
province of this article to discuss the demerits of the above forms of treatment.
Those interested in the subject will find the data in Delbet and Matas.
The modern treatment is of chief interest. Of the radical methods, ex-
tirpation and the Antyllian operation are old in years but still have modern
advocates. The Matas operations, the methods of gradual occlusion, and the
ideal operations are of more recent development.
Herzen, Delbet, Monod and Van Verts believe that extirpation is as suc-
cessful as any of the other forms of treatment. Aseptic ablation of the sac is
the ideal operation in their estimation. Herzen believes that infection is an
important factor in the production of the late results of this operation (i. e.,
inflammatory edema, vascular thrombosis, peripheral nerve disturbances, etc.).
Matas regards the various forms of his operation selected to meet the given
conditions as the ideal operation for aneurysms of this region. He quotes 62
cases treated by his method with 1 death ; 2 cases of gangrene of the limb ; and
3 relapses cured by a secondary intrasaccular operation. In 18 of his col-
lected cases the artery was reconstructed so that the continuity of the blood
stream was uninterrupted.
Halsted states that he applied the metal band in 1 case of popliteal aneurysm
but gives no details. Any form of partial occlusion would it seems to me have
a very limited field of usefulness in this locality and should be limited to those
cases in which any more complete operation would undoubtedly cause gangrene.
Under such conditions, partial occlusion might be used pending the develop-
ment of collateral circulation or even to reduce the size of the aneurysm before
proceeding to more radical methods.
The value of the so-called aideal operation" so selected as to fit the indi-
vidual case of popliteal aneurysm is as yet undetermined, but it would seem that
the field of usefulness of these more or less intricate procedures is very definitely
limited. The first limitation is covered by general experience on the part of
the ordinary surgeon in the technic of vascular surgery. That is easily sur-
mountable by a process of education. The second and more important limita-
tion is included in the detail of the operation. This detail is necessarily arduous
and time-consuming and it yet remains to be proven whether the end justifies
the means.
Selected cases, especially of small aneurysms easily ablated or of small
arteriovenous sacs, in the hands of adepts in vascular surgery, will, I believe, be
the restricted field of this form of surgical treatment in popliteal aneurysm.
(See Ideal Aneurysm Operations under the general discussion for further de-
tails.)
In 2 personal experiences with popliteal aneurysm the obi iterative opera-
tion of Matas was easily performed and the result was most satisfactory. One
BIBLIOGRAPHY 395
case was observed for 5 years without any sign of recurrence. The only disa-
bility in either case was a limitation of about 10 per cent, in flexion in the knee
involved in the operation.
It would seem from the above that the operation of election in the treat-
ment of popliteal aneurysm would be the Matas operation in one of its forms.
That form of endo-aneurysmorrhaphy must be chosen which will meet the con-
ditions of collateral circulation prevailing in the case in question (see general
discussion on the Matas Operation).
Should conditions arise during the operation or afterward which render
success more likely by means of some other form of operative procedure, extir-
pation, the Antyllian method, and the ideal operations must be matters of
selective second choice.
In the vessels peripheral to the popliteal space, Herzen mentions aneurysm
of the posterior tibial in 5 cases, anterior tibial in 4 cases, anterior and posterior
together in 3 cases, peroneal in 1 case. All were the result of warfare injuries.
The essential method of treatment is aseptic extirpation of the sac.
BIBLIOGRAPHY J
BROCA. Traite des anevrysmes, Paris, 1856.
STIMSCXN-. Dennis System of Surgery, N. Y. Med. Jour., Nov., 1884.
MATAS. Keen's Surgery, 1909, v.
— — . Ann. Surg., Feb., 1903.
— . Tr. Ala. Surg and Med. Soc., 1905.
— . Jour. Am. Med. Assn., Jan. 11, 1902.
— . Jour. Am. Med. Assn., 1906, xlvii, 990 (statistical).
— . Jour. Am. Med. Assn., 1908, li, 1667 (statistical).
— and ALLEN. Ann. Surg., 1913, Iviii, 304 (literature).
— . Jour. Am. Med. Assn., 1911, 56, 233.
DELBET. Traite de chirurgie, vi.
— . Rev. de chir., 1895, xv, 896.
— . Rev. de chir., 1907, xxxv, 1087.
— . Bull. soc. de chir., Paris, April, 1907.
HALSTED. Jour. Am. Med. Assn., 1906, xlvii. 2147.
— . Jour. Exp. Med., 1909, xi, No. 2.
-. Ann. Surg., 1913, Iviii, 183.
POBTA. Milan, 1845.
1 The appended references do not pretend to comprise a complete list of the voluminous
literature on the subject of aneurysms, but include such portions as were of great value in
the preparation of this article.
The writer desires to acknowledge his indebtedness to the masterly publications of
Matas on the subject. If the critical reader should find the text very similar to that in
some of the Matas publications, the author freely acknowledges his indebtedness to that
writer and pleads the sin of too close reading and an inability to state the desired facts
in any other similar terms.
396 THE SURGICAL TREATMENT OF ANEURYSM
FINNEY. Tr. South. Surg. and Gynec. Assn., 1911.
— . Ann. Surg., 1912, Iv, CGI.
HUNNER. Johns Hopkins Bull., 1900, xi, 263.
STEWART. Am. Jour. Med. Sc., 1892,- civ, 422.
LUSK. Tr. K Y. Surg. Soc., 1912, i, 22.
MONOD et VAN VERTS. Chir. des arter., Rap. au 22me Cong, franc?, d. Chir.,
1909.
— . Du trait, d. aneur., Rev. d. chir., 1910, xci, 784; Rev. d. chir.,
1910, xcii, 163.
— . Du trait, d. aneur. arterio-veneux., Rev. de Chir., 1910, xcii, 729.
— . Du trait, d. hemat. art. et arterio-veneux, Rev. de Chir., 1911,
xciii, 46.
— . De Paneurismorrhaphie, Arch. gen. de chir., 1911, v, 961.
— . Le trait, conservateur d'aneur. et d. hematomes, Rev. de Chir.,
1911, xciv, 663.
MAKINS. London, 1901.
SAIGO. Deutsch. Ztschr. f. Chir., 1906, 85.
KIKUZI. Beitr. z. klin. Chir., 1906, i, 50.
IDEAL OPERATIONS
OMI. Deutsch. Ztschr. f. Chir., 1911, ex, 443.
JEGER. Chir. Blut Gef. u. d. Herz., Berlin, 1913.
TSCHERNIACHOWSKI. Deutsch. Ztschr. f. Chir., 1913, cxxiii, 123 (literature).
LITERATURE FOR SPECIAL ANEURYSMS
Thoracic and Abdominal
FINNEY. Ann. Surg., 1912, Iv, 661.
LUSK. Tr. N. Y. Surg. Soc., 1912, i, 22.
ESHER. Am. Jour. Med. Sc., 1910, clx, 496.
FREEMAN. Tr. Am. Surg. Assn., 1901, xix.
HUNNER. Johns Hopkins Bull., 1900, xi, 263.
MATAS. Loc. cit.
RANSOHOFF. Med. News, 1886, 48.
STEWART. Am. Jour. Med. Sc., 1892, civ, 422.
JACOBSON and ROWLANDS. The Operation of Surg.
SALBINGER. Therap. Gaz., July, 1903.
BOINET. Mai. des arteres, Brouardel-Gilbert, Traite de med., Paris, 1907.
GUINARD. Rev. de chir., Feb., 1909.
ANNANDALE. Lancet, 1876.
. Scottish Med. and Surg. Jour., 1900, vii.
JACOBSTHAL. Deutsch. Ztschr. f. Chir., 1902, Ixiii.
BIBLIOGRAPHY 397
JACOBSTHAL. Deutsch. Ztschr. f. Chir., 190;j, Ixviii.
KUMMELL. Deutsch. med. Wchnschr., 1914, 731.
MURRAY. Med. Chir. Tr., xlvii, 189.
— . Lancet, Lond., Feb., 1873, 193.
BARWELL. Ashhurst Internat. Ency. Surg., ii, 928.
KEEN. Am. Jour. Med. Sc., Sept., 1900.
STRATTON. Ann. Surg., 1903.
— . Jour. Am. Med. Assn., 1900, xlvi, 704.
HALSTED. Loc. cit.
GIBBON. Jour. Am. Med. Assn., July 27, 19 1 2.
KATZENSTEIN. Arch. f. klin. Chir., 1905, Ixxvi.
OPPERGELD. Deutsch. Ztschr. f. Chir., 1907, Ixxxviii.
NASSETTI. II Policlinico, Jan. 12, 1913.
HALSTED. Ann. Surg., 1913, Iviii, 183.
MATAS and ALLEN. Ann. Surg., 1913, Iviii, 304 (literature).
Renal Aneurysms:
KEEN. Phila. Med. Jour., May 5, 1900 (literature).
OESTREICH. Berl. klin. Wchnshr., 1891, xxviii, 1042.
Subclavian Aneurysms:
SONCHON. Ann. Surg., 1895, ii, 545, 743.
SAVARIAUD. Rev. de chir., 1906, xxxiv, 1.
MONOT and VAN VERTS. Loc. cit.
HALSTED. Med. News, 1900, Ixxiv, 573.
MATAS. Jour. Am. Med. Assn., Jan., 1902.
JACOBSTHAL. Loc. cit.
ELLIOT. Ann. Surg., 1912, Ivi, 983.
HALSTED, W. Bull. Johns Hopkins Hosp., 1912, xxviii, 191.
Superficial Palmar Aneurysm:
REGNAULT and BOURRIET-LACONTURE. Rev. d. chir., 1913, xlvii, 357.
Innominate Aneurysms:
JACOBSTHAL. Deutsch. Ztschr. f. Chir., 1902, Ixiii.
— . Deutsch. Ztschr. f. Chir., 1903, Ixviii, 239.
IMBERT and PONS. Archiv. Provincial Chir., 1907, xvii.
BURNS. Jour. Am. Med. Assn., 1908, Ii, 1671.
Carotid Aneurysms:
SMOLER. Beitr. z. klin. Chir., 1903, Ixxxii, 494.
DELBET. Loc. cit.
308 THE SUBGICAL TKEATMENT OF AKEURYSM
JORDAN. Inaug. des Heidelberg, 1907.
MATAS. Loc. cit., Keen's Surgery.
HALSTED. Loc. cit.
HERZEN. Abst. in Jour, de Chir., Dec., 1911. (See Med. Year Book, Chi-
cago, 1913, Gen. Surg.)
MONOD and VAN VERTS. Loc. cit.
BOBBIO. II Policlinico, Feb., 1906.
DAWBARN. Gross Prize Essay, 1903.
BOBBIO and BLAUEL. Beitr. f. klin. Chir., xxxix, Part 3.
WERNER. Deutsch. Ztsch. f. Chir., 1902, Ixvii, 591.
Iliac Aneurysms:
MATAS. Loc. cit.
FRISCHBERG. Arch. f. klin. Chir., 1914, ciii, 679.
RTJPP. Inaug. Dissert., Konigsberg, 1907.
BRYAN. Ann. Surg., 1914, Ix, 463.
ABBE. Ann. Surg., 1908, xlviii, 9.
Femoral Aneurysms:
HERZEN. Loc. cit.
MATAS. Loc. cit.
BOLTON. Dennis' Surg.
Popliteal Aneurysms:
MATAS. Loc. cit.
DELBET. Loc. cit.
HERZEN. Loc. cit.
MONOD and VAN VERTS. Loc. cit.
GUFFIER. Bull, et mem. soc. chir., Paris, 1912, "N. S., xxxviii, 1425.
CHAPTER XI
. LIGATIONS OF ARTERIES IN CONTINUITY 1
WALTON MAETIN
GENERAL CONSIDERATIONS
The ligation of an intact artery is spoken of as ligation in continuity,
and the term is used in contradistinction to the tying of a severed vessel. The
arteries are exposed and ligated in continuity for a number of conditions:
(1) in the treatment of aneurysms, the ligature being placed near or at a dis-
tance from the sac, either distally or proximally (see chapter on Aneurysms) ;
(2) as a preliminary measure in certain operative procedures, thus the lingual
arteries may be exposed and ligated to control the hemorrhage in removal of
the tongue; (3) to check hemorrhage in some branch not accessible; (4) to
modify glandular activity, for example the superior and inferior thyroid
vessels are ligated in certain cases of hyperthyroidism ; (5) for wounds of the
larger arteries.
Instruments. — The instruments required are: scalpels, thumb and mouse-
tooth forceps, retractors, scissors, grooved directors, artery forceps, aneurysm
needles, and ligatures.
Ligatures. — The materials ordinarily used are silk, kangaroo tendon, chro-
mic catgut for the larger vessels and plain catgut for the smaller vessels. In
ligating the larger vessels the material used should be slowly absorbable, suf-
ficiently pliable to tie easily and strong enough to stand considerable tension.
It is also desirable that the surfaces of the ligature material used should offer
sufficient friction to prevent the first loop of the knot from slipping.
Kangaroo tendon is very strong, slowly absorbable and flat on cross-section
rather than round, so that wider surfaces of the arterial walls are brought
in contact. It, however, has a smoother surface than the other ligatures and
therefore there is more tendency for the first loop of the knot to slip. This
objection is met by using the stay knot.
Chromic catgut is slowly absorbable but it is not as strong as kangaroo
aThe anatomical terms employed in this chapter are those given by the Basle Ana-
tomical Nomenclature. These terms have been adopted in the recent editions of the Stand-
ard Anatomies.
399
400 LIGATIONS OF ARTEEIES IN CONTINUITY
tendon, the surface is less smooth and the loops of the knot have less tendency
to slip. Silk is strong and very pliable, and the knots have even less ten-
dency to slip, but it is not as well tolerated by the tissues, and it is nonab-
sorbable. Soft floss silk should be used, as the ordinary plaited or twisted silk
in the heavier ligatures makes a very hard knot.
The Knot*— The pressure in the larger vessels makes it difficult to keep the first
loop of a square knot or even of a surgeon's knot from slipping and loosening and thus
failing to occlude the lumen of the vessel completely; this fact has been frequently
observed and is borne out by the experimental work of Ballance and Edmunds (2).
They suggested the use of the so-called stay knot, and this is the best knot for the
B
FIG. 1. — THE STAY KNOT. A, First loop; B, second loop. (Ballance and Edmunds.)
purpose. Two or more ligatures are passed around the vessel side by side, and the
first loop of a square knot tied, care being taken that the twists of the loops pass in
the same direction. The free ends of the ligatures are then tightened, sufficient force
being applied at the same time to occlude the vessel. The friction of the ligatures
lying side by side is sufficient to keep the first loop of the knot from slipping. The
two ligatures are then treated as a single ligature in tying the second loop of a square
knot (Fig. 1).
The Force to Be Applied and the Question Whether or Not It Is Necessary to
Rupture the Vessel Wall. — It has been asserted that sufficient force should be
applied to occlude the vessel but not to rupture the wall. The vessel wall is
thus thrown into transverse folds, the folds lying in contact with one another so
that the vessel is completely plugged (Fig. 2). Rupture of the arterial coats
of the larger vessels is said to be accompanied by the danger of secondary
hemorrhage. This view was supported by the experimental work of Ballance
and Edmunds (2) on the larger vessels of sheep and horses. Their treatise ap-
peared in 1891. In 1894 Forgue and Bothezat (12), however, disagreed with
these conclusions and, from their experimental work, condemned the ligation
without rupturing the coats. They advised that the ligature be tied with suf-
ficient force to rupture the inner and middle coats. Monod and Van Verts (18)
GEXERAL CONSIDERATIONS
401
in their monograph on the surgery of arteries have adopted this view (1900).
The amount of force necessary to rupture the arterial coats differs greatly
in the living subject and in the cadaver, due to the difference in the intra-
arterial tension, and is dependent on
the size and pressure in the different
vessels. If the stay knot is used, the
force necessary to rupture is said in
some cases to exceed ten pounds, which
Lister said was the maximum force
which could be applied under the condi-
tions of ligation in continuity. There-
fore, in using a stay knot in ligating
the larger vessels one need not fear
erring on the side of excess.
In several of the cases of ligature of
the innominate artery reported since 1891
(7) there is reference to the fact that an
effort was made to draw the ligature suffi-
ciently tight to occlude the vessel but not
to rupture the coats. As the ligature is
tightened there is a distinct give, when the
constricting force becomes sufficient to rup-
ture the inner coats. From vessels the size
of the femoral (8 mm., 0.32 in.) downward,
it is certainly of no consequence if the
coats are ruptured, and I believe even in
the larger vessels there is more danger of
not occluding the lumen than of causing secondary hemorrhage from rupture of the
coats by the ligature.
FIG. 2. — A, INFOLDING OF VESSEL WALLS
BY THE LIGATURE WITHOUT RUPTURING
THEM; B, OCCLUSION OF THE LUMEN BY
THE INFOLDING OF THE VESSEL WALL.
(Ballance and Edmunds.)
Results. — Most of the deaths after ligature of the vessels done before the
nature of infection was understood resulted from secondary hemorrhage due
to infection. Statistics taken from cases reported since the introducing of
antiseptic and aseptic measures show an extraordinary change in mortality.
The ligation of any excepting the largest vessels nowadays creates no com-
ment, and the cases are not as a rule reported excepting incidentally.
The frequence of gangrene of the extremities following the ligature of
the main vessels of the extremities seems, however, to have slightly increased
during the same period, judging from the cases collected and classified by
Wolff (29). This may be due to the fact that ligature of the vessels of the ex-
tremities is often not reported unless something unusual, such as gangrene,
occurs.
Recognition of the Artery. — The arteries during life are pinkish white
and can be seen and felt to pulsate synchronously with the heart. The nerves
are round, pure white cords. The veins, often larger than the arteries, are
27
402
LIGATIONS OF AETERIES IN CONTINUITY
dark blue, flatten readily under the finger and become swollen when pressure
is applied to the cardiac angle of the wound.
Opening the Sheath of the Vessel and Passing the Aneurysm Needle. — The
vessels and nerves are usually surrounded by a connective tissue sheath, and
it is necessary to incise this sheath to pass the ligature about the artery: for
example, the common carotid, the internal jugular and the vagus nerve are
VEIN ARTERY VEIN
FIG. 3. — PINCHING UP THE SHEATH OF THE VESSELS IN A TRANSVERSE FOLD. (Farabeuf.)
contained in a connective tissue sheath, which it is necessary to open in order
to pass a ligature around the carotid. The connective tissue of the sheath
invests the vessel closely. The sheath may be opened by dividing the structure
with a knife, care being taken that the cut simply passes through the sheath;
or it may be pinched up by thumb forceps so that a fold is lifted up trans-
versely to the axis of the vessel and over the artery. The fold is then in-
cised. The incision should be about 10 mm. (2/5 in.). A button-hole is thus
formed in the sheath, and if necessary this may be readily enlarged (Fig. 3).
INNOMINATE ARTERY
403
After the sheath is opened the aneurysm needle is passed. The rule is
to pass the needle away from the point of danger; thus the ligature is passed
from without inward in ligatirig the common carotid, care being taken that
the instrument is kept in contact with the artery, so that a vein or nerve lying
in the sheath may not be included in the ligature.
INNOMINATE ARTERY
Anatomy. — The innominate artery is 3 to 4 cm. (1% in.) long and
about 14 to 15 mm. (% in.) in diameter. It rises from the arch of the
aorta at the junction of the ascending and horizontal portion in front and to
the right of the left common carotid. It passes upward and to the right, and
FIG. 4. — ANTERIOR MEDIASTINUM. NLi., Recurrent nerve; N.V., vagus nerve; N.P., phrenic nerve;
Am., internal mammary artery (section). (After Zuckerkandl.)
opposite the sternoclavicular joint divides into the two terminal branches,
the right common carotid and the right subclavian. It is thus placed en-
tirely within the thorax. The posterior surface of the sternum is separated
from the vessel by the inferior insertion of the right sternohyoid and sterno-
thyroid muscles, the remains of the thymus gland and the left innominate
vein. It is also crossed by the cardiac filaments of the vagus and usually by
the two right inferior thyroid veins. The innominate trunk crosses the
trachea obliquely, and between it and the trachea are cardiac filaments of
the sympathetic and recurrent laryngeal nerves. On its outer side it lies in
contact with the pleura, which separates it from the right lung, and is in
relation with the right innominate vein and the vagus.
The projection of the course of the vessel on the sternum corresponds to
404 LIGATIONS OF ARTERIES IN CONTINUITY
a line passing at the level of the lower border of the sternal extremity of the
first costal cartilage in the mid line (Fig. 4) upward and outward to the level
of a line passing through the middle of the right sternoclavicular articulation.
Operation. — The patient is placed in the dorsal position with the neck
extended and the shoulders slightly raised.
FIRST METHOD. — The incision, about 7.5 cm. (3 in.), commences
just above the clavicle and passes to the interval between the insertions of
the sternal portion of the sternocleidomastoid muscle, where it is joined by a
second incision of about the same length along the mesial border of the sterno-
mastoid muscle. An angular incision is thus made with the apex of the angle
downward. The skin, superficial fascia and platysma, sternomastoid, sterno-
hyoid and sternothyroid are divided in the line of the horizontal portion of
the skin incision. The triangular flap thus formed is retracted. A deep layer
of fascia containing the inferior thyroid veins is carefully divided by blunt
dissection, and the veins are retracted, or, if this is difficult, they are divided
between two ligatures. The sheath of the common carotid then comes in view.
The sheath is opened, the jugular and vagus are retracted and the carotid fol-
lowed downward until the origin of the right subclavian is seen. The upper
portion of the innominate artery is then exposed by blunt dissection and the
right innominate vein retracted with the vagus outward and the left in-
nominate pushed downward, and an aneurysm needle passed from without
inward and the ligature tied.
SECOND METHOD. — The upper portion of the sternum and the right
sternoclavicular joint are resected to gain a better exposure of the vessel. The
incision in this case extends along the anterior border of the sternocleido-
mastoid muscle from the level of the cricoid to 5 cm. (2 in.) below the superior
edge of the sternum. This is joined by a transverse incision passing hori-
zontally inward from the middle of the clavicle. After the sternal muscles
are divided, the right sternoclavicular joint and about 2.5 cm. (1 in.) of the
right upper portion of the sternum are removed by means of trephine and
bone forceps. A flat retractor is passed beneath the bone to protect the vessels
during this part of the operation. The rest of the dissection is carried out
as in the first method.
THIED METHOD. — The manubrium sterni is split in the middle line, then
divided transversely just above the second rib. The two halves can be sep-
arated for 5 cm. (2 in.). The vessel is then exposed and ligated as above
(Curtis, 7).
Results.— In 1905 Sheen (25) published a table made up of 36 re-
ported cases of ligation of the innominate artery. The first of these reports
dates back to 1818 (Mott). The mortality based on these statistics is 78 .per
cent. Statistics based on the cases reported since 1871, that is omitting the
cases reported before the antiseptic period, and adding the case reported by
Burns (4), 1908, and 2 reported by the Japanese army surgeon, Saigo (22),
show a mortality of 47 per cent., 19 cases with 9 deaths.
COMMON CAROTID ARTKKY 405
COMMON CAROTID ARTERY
Anatomy. — The right carotid artery arises from the innominate artery,
the left from the arch of the aorta. They pass upward in the neck to divide,
about 1 cm. (2/5 in.) above the superior border of the thyroid cartilage,
into the external and internal carotid. The level of the bifurcation varies,
and from 4 cm. (1.6 in.) above to 4 cm. (1.6 in.) below the level indi-
cated above as normal is said to be the extreme limit of this variation
(Livini).
From their difference in origin the left carotid is necessarily longer than
the right. A line drawn from the hollow between the angle of the jaw and
the mastoid process to the sternoclavicular joint corresponds to the course of
the common carotid in the neck. The relations of the right and left common
carotid in the neck are the same. The artery lies on the prevertebral aponeu-*
rosis which covers the longus colli and the longus capitis. These muscles
separate the vessel from the transverse processes of the cervical vertebra, a
little mesial to their anterior tubercles. The sympathetic nerve lies behind
the carotids, and its superior and middle branches pass behind the vessel before
they enter the thorax. At the level of the anterior tubercle of the sixth cer-
vical vertebra (tubercle of Chassaignac) the inferior thyroid artery crosses
behind it. On its inner side are the trachea, the esophagus, and the recurrent
nerve, and higher up the larynx and pharynx. The esophagus, owing to its
curve to the left, lies in closer relation to the left carotid than to the right.
On its outer side is the internal jugular vein; when the vein is distended it
partly covers the vessel anteriorly, and as the vessels pass upward the vein
has a tendency to lie in front of the artery, a position which it definitely
occupies in the neighborhood of its termination. The vagus nerve usually
lies between the vein and the artery posteriorly. The artery is covered in
front by the skin, the platysma, and the sternocleidomastoid, with the aponeu-
rosis derived from the cervical fascia. When the head is in the position which
is usual at operation, with the face turned to one side, the vessel at the root of
the neck lies beneath the interval between the sternal and clavicular attach-
ments. In the middle of the neck the artery is covered only by the anterior
border of the muscle. Near its termination the vessel lies a little anterior
to the muscle, covered by the fascia, platysma and skin. The deep cervical
lymph glands which lie beneath the sternocleidomastoid are in relation with
the internal jugular vein rather than with the artery (Fig. 5). The descend-
ing branch of the hypoglossal passes down the surface of the vessel and the
nerve and the loop which it forms with the cervical nerves lies on or within
the carotid sheath. The superior and middle thyroid veins also cross the
artery to empty into the jugular, and a small artery, the sternocleidomastoid
branch of the occipital, crosses the upper part of the vessel. The posterior
border of the lateral lobe of the thyroid gland also lies in front of the vessel.
406
LIGATIONS OF AKTEEIES IN CONTINUITY
The carotid artery and the vagus nerve are contained in a thin-walled but
distinct connective tissue sheath.
Operation. — The artery is usually ligated (1) above the omohyoid; (2)
immediately below the omohyoid. The site of election is immediately above
the omohyoid.
(1) LIGATION ABOVE THE OMOHYOID. — The patient is placed in the
dorsal position with the shoulders slightly elevated and the face turned to the
FIG. 5. — THE STERNOCLEIDOMASTOID DRAWN BACKWARD WITH THE EXTERNAL JUGULAR VEIN WITH
ITS CONFLUENT VEINS, FACIAL, LINGUAL, PHARYNGEAL, ETC. V, v, Internal jugular; c, common
carotid; t, thyroid; p, p, parotid; h, hyoid. (Farabeuf.)
opposite side. The incision is made along the anterior border of the sterno-
cleidomastoid muscle. Its length should be about 8 cm. (3 1/8 in.). The
center of the incision corresponds to the cricoid cartilage.
The skin, superficial fascia and platysma are divided in the line of the
incision. The anterior edge of the sternocleidomastoid is exposed, and the
fascia enclosing the muscle divided. The muscle is retracted outward, ex-
posing the middle layer of the cervical fascia, enclosing the omohyoid. The
fascia is divided in the direction of the fibers of the muscle, and the muscle
is retracted downward and inward. The anterior and middle thyroid veins
then come in view; they are divided between ligatures or retracted. The
sheath of the vessels now appears at the bottom of the wound. A portion of
the sheath is pinched up by forceps, making a fold transverse to the course
COMMON CAROTID ARTERY
407
of the vessels and incised. The opening in the sheath is made well to the
inner side to avoid the vein. When the vein is distended it completely over-
laps the artery. The exact position of the artery can be determined by the
pulsation of the vessel. The opening in the sheath is enlarged sufficiently to
identify the arterial wall, and the edge of the sheath grasped by thumb forceps
and held up while an aneurysm needle is gently inserted from without in-
ward, hugging the artery as it is passed about it, so that the vein or the vagus
nerve may not be injured. The needle is then threaded and withdrawn and
the knot tied.
The thyroid veins sometimes form a plexus which lies in front of the
artery.
(2) LIGATION BELOW THE OMOHYOID.— The incision is made along the
anterior border of the sternocleidomastoid muscle from the level of the cricoid
downward for about 8 cm. (3 1/8 in.). The skin, superficial fascia, and
platysma are divided, and the edge of the sternocleidomastoid exposed by
dividing the fascia; the muscle is then retracted outward. The small sterno-
cleidomastoid artery usually crosses the upper part of the incision and is
divided. The tendon of the omohyoid enclosed in the middle layer of the
fascia of the neck, crossing the artery obliquely, is identified, the fascia cov-
ering it divided, and the tendon retracted upward and inward. Care is taken
not to divide the descending branch of the hypoglossal nerve lying in the
sheath. The sheath is opened and the aneurysm needle passed, threaded, and
withdrawn as in the operation described above.
Results. — Hemiplegia follows in certain cases of ligature of the common
carotid. The accident usually occurs from the end of the first to the end of
the third day. In the great majority of cases it terminates fatally. It is
said to be due to the extension of the thrombus from the site of the ligature
along the internal carotid to the cerebral arteries ; an attenuated infection
is probably a factor in its production. Insufficient arterial communication
LIGATURE
NUMBER
OF
CASES
NUMBER
OP
DEATHS
PERCENTAGE
For nervous affections — epilepsy, elephantiasis
of the face (vascular system sound)
40
1
2.5
For traumatic pulsating exophthalmos
76
4
5.2
For idiopathic exophthalmos
27
6
22.2
For aneurysm (not including exophthalmos)
276
102
36.7
For removal of tumors
115
49
42.6
For hemorrhage
322
163
50.6
408 LIGATIONS OF AKTERIES IN CONTINUITY
between the cerebral arteries of the two sides is also a factor (De Fourmes-
traux, 8).
The mortality rate according to statistics of Siegrist (26) (1900) taken
from 997 cases is 38 per cent.
The table on page 407 taken from Siegrist is of interest.
EXTERNAL CAROTID ARTERY
Anatomy. — The upper portion of the line drawn from the hollow be-
tween the angle of the jaw and the mastoid process to the sternoclavicular
joint corresponds to the external carotid. The bifurcation of the common
carotid into the internal and external carotid usually takes place a little above
the upper border of the thyroid cartilage; it terminates by dividing into
the superficial temporal and internal maxillary, usually about 4 cm. (1.6 in.)
above the angle of the mandible, that is to say a little above the middle of
the posterior border of the ascending ramus (Livini). It is generally about
7 cm. (2.8 in.) long, but varies, according to the position of the bifurcation
and its place of origin, between 3 cm. (1 2/5 in.) and 11 cm. (4 2/5 in.)
(Livini). It is smaller than the internal carotid, its diameter being about
6 mm. (% in.). At its origin it is placed a little within and anterior to the
internal carotid. The first portion of the vessel is relatively superficial. It
is covered by the skin, superficial fascia, and platysma, and the sternocleido-
mastoid or (in the position assumed at operation with the face turned to one
side) the cervical fascia which divides to enclose this muscle. Under this
fascia is a layer of cellular tissue containing a varying amount of fat and a
number of lymph glands. The hypoglossal nerve crosses the artery from 5 to
20 mm. from its origin; and the large vein (the common facial) formed by
the junction of the facial and the anterior division of the temporomaxillary
passes over the vessel close to the bifurcation. This large venous trunk often
completely covers the artery. The vessel lies in this part of the course on the
internal carotid, which it gradually crosses obliquely. It lies at first a little
anterior and internal to the carotid. The glossopharyngeal nerve passes be-
tween the external and internal carotid, and the superior laryngeal passes to
the inner side of the vessels.
The external carotid then passes upward in contact with the phar-
ynx, and under the posterior belly of the digastric and stylohyoid,
and finally enters the substance of the parotid. The artery is held in
intimate relation with the gland by the branch which it gives off in this
part of its course. The other structures passing through the parotid, the
external jugular vein, the auriculotemporal nerve, the facial nerve, and
most of the parotid lymph glands arc situated external to the artery (Figs.
0, 7, 8).
Operation. — The patient is placed in the dorsal position with the head
EXTKKXAL CAKOTLI) ARTERY
409
slightly extended and the face turned to the opposite side. The skin and
superficial tissues are divided in the line extending from the angle of the
jaw to the cricoid cartilage; the platysma and the cervical fascia covering
the sternocleidomastoid are cut through, and the edge of this muscle is ex-
posed and retracted. The cellular tissue and lymph glands are pushed to one
FIG. 6. — LIGATURE OF THE LEFT EXTERNAL CAROTID. M, Angle of jaw; 1, anterior border of the sterno-
cleidomastoid; 2, the artery with the descending branch of the hypoglossal; 3, hypoglossal ; 4, posterior
belly of the digastric; 5, tip of greater cornua of hyoid bone; 6, thyrofacial lingual trunk drawn down-
ward and inward to show the place of election for ligating between the origin of the superior thyroid
and the lingual. (Farabeuf.)
side by blunt dissection, and the tendons of the digastric and stylohyoid mus-
cles with the hypoglossal nerve identified. The artery is, at this point, often
partly covered by the facial vein as it joins the internal jugular; but by blunt
dissection the vein can be pushed to one side, or, if it is too much in the way,
it may be divided between ligatures. The internal jugular is carefully re-
tracted outward and the artery exposed for a distance sufficient to see one
or more of the branches springing from the vessel anteriorly. The aneurysm
needle is then passed from without inward around the vessel, great care being
taken that the needle be kept in contact with the arterial wall so that the
410
LIGATIONS OF ARTEKIES IN CONTINUITY
superior laryngeal nerve may not be caught in the ligature. The needle is
threaded, withdrawn, and the ligature tied.
The internal carotid has been mistaken for the external. If the vessel
FIG. 7. — RELATIONS OF THE INTERNAL AND EXTERNAL CAROTIDS. (Subject in same position as at opera-
tion.) M, Lower border of mandible ; M', angle of mandible ; H, hyoid bone ; h, extremity of the greater
horn of the hyoid ; Sh, sternohyoid ; Oh, omohyoid ; th, thyrohyoid ; ph', inferior constrictor of pharynx ;
ph, middle constrictor; d, posterior belly of the digastric perforation of the stylohyoid ; d', pulley of
digastric ; Hg, hyoglossus ; Mh, mylohyoid ; P, parotid gland covered with aponeurosis of sternomastoid ;
sm, submaxillary gland lifted up; Je, external jugular; Ji, internal jugular, exposed by the retraction
of the sternomastoid; hyp, loop of the hypoglossal; l.s., superior laryngeal nerve; Cp, common carotid;
Ci, internal carotid; C.E., external carotid; t, superior thyroid; 1, lingual; F, facial. (Farabeuf.)
is sufficiently exposed to show the branches, this mistake cannot occur, for
the internal does not give off branches in the neck except very exceptionally
a pharyngeal or occipital branch. The anastomosis between the branches
of the right and left external carotid is very free, so that the ligation of the
INTERNAL CAROTID ARTERY 411
vessel on one side often has not a marked effect on the hemorrhage from the
regions supplied by these vessels.
INTERNAL CAROTID ARTERY
Anatomy. — The linear guide is the same as that for the external carotid,
that is, the upper portion of a line drawn from the hollow between the jaw
and the mastoid process and the sternoclavicular joint. The cervical portion
of the internal carotid at its origin lies a little lateral to the external carotid,
but as it passes upward it is directed mesially, thus passing behind the ex-
ternal carotid and crossing it very obliquely from without inward. The first
portion of the artery is covered only by the skin, superficial fascia and platysma
and sternocleidomastoid. On its inner side is the pharynx and in front of
the vessel is the external carotid. Posteriorly it lies on the transverse processes
of the cervical vertebrae, covered by the longus capitis muscles. The internal
jugular lies in contact with its external wall. As it passes upward, it lies
behind the posterior bellies of the digastric and stylohyoid muscles, and is
deeply placed behind the stylopharyngeus .and the deep surface of the parotid
gland. It is crossed by the occipital and posterior auricular arteries. The
vagus and the upper ganglion of the sympathetic lie behind the artery. The
hypoglossal crosses the vessel, and the glossopharyngeal and pharyngeal
branches of the pneumogastric pass between the external and internal carotid,
and the superior laryngeal lies to the inner side of the vessel. The spinal ac-
cessory nerve at its exit from the skull lies close to the artery, but usually passes
backward and downward beneath the jugular vein. The internal carotid is
slightly larger than the external — 6 mm. (% in.) (Figs. 7 and 8).
Operation. — The patient is placed in the dorsal position with the head
slightly elevated and the face turned a little to one side. The incision is
made along the anterior border of the sternocleidomastoid from the angle of
the jaw downward for about 8 cm. (3 1/8 in.), having its middle point op-
posite the hyoid bone. The skin, superficial fascia and platysma are divided,
and the edge of the sternocleidomastoid exposed by incision of the fascia.
The muscle is retracted outward. The cellular tissue with the lymph glands
is divided by blunt dissection and pushed to one side. The hypoglossal nerve
passing almost transversely across the wound is identified above, and the large
venous trunk (the common facial) a little lower down. This venous trunk is
freed by blunt dissection and retracted inward. The external and internal
carotid and the bifurcation of the common carotid are exposed and the internal
carotid identified by the absence of branches (Figs. 7 and 8). The aneurysm
needle is passed from without inward, hugging the vessel closely.
Results. — In a certain percentage of cases hemiplegia follows the ligation
of this vessel as of the common carotid. In the great majority of cases this
complication is fatal. It is due to a thrombus starting from the point of
FIG. 8. — DISSECTION OP NECK, LEFT SIDE. M, Mastoid; St. cl. m., sternocleidomastoid ; Sp, splenius;
C, complexus; Dig, digastric; Je, external jugular; Ji, internal jugular; H, hyoid; 1, superior thyroid;
2, lingual; XII, hypoglossal; 3, facial; Gl. s. m., submaxillary gland; 4, occipital; 5, auricular
art.; 6, internal maxillary.
SUBCLAVIAX ARTKKY 413
ligation and extending to the cerebral arteries. It is said to occur in 15
per cent, of the cases.
For ligation of the superior thyroid, lingual, facial, occipital and super-
ficial temporal arteries, see special chapters in this work dealing with surgery
of the respective regions.
SUPRA-ORBITAL ARTERY
Anatomy. — The vessel passes out of the orbit through the supra-orbital
notch or foramen at the junction of the inner and middle thirds of the supra-
orbital margin. The notch is usually palpable. The first part of the vessel
passes upward on the forehead in a sagittal direction.
Operation. — The incision is made transversely along the supra-orbital mar-
gin, following the line of the shaved eyebrow. The skin, cellular tissue, and
the orbicular is oculi muscle are divided and the vessel exposed and ligated.
SUBCLAVIAN ARTERY
Anatomy. — The left subclavian arises from the arch of the aorta be-
hind the origin of the left carotid. It is, therefore, very deeply placed within
the thorax. The right subclavian arises from the innominate branch, so
that the left subclavian is longer than the right. The artery passes over
the apex of the lung lying in contact with the pleura, then passes behind
the scalenus anticus muscle, and ends beneath the clavicle, passing on into
the axillary artery. It is divided into three portions by the scalenus anticus
muscle.
The thoracic portion of the left subclavian lies behind the left carotid on
the vertebral column, which is here covered by the lower portion of the longus
colli muscle. The recurrent nerve, the trachea and the esophagus lie to its
inner side and on its outer side are the pleura and lung. The thoracic duct
passes along its inner side and then over and behind the vessel to enter the
junction of the internal jugular and the subclavian veins. It is crossed by
the phrenic and branches of the sympathetic nerve. The vagus descends ver-
tically in front of the thoracic portion. The cervical portion of the left sub-
clavian is crossed by the innominate vein and the sternohyoid, sternothyroid
and sternocleidomastoid muscles. The first portion of the right subclavian
is less deeply placed. In front of the artery are the skin, superficial fascia,
platysma clavicle and the lower insertions of the sternocleidomastoid, sterno-
hyoid and sternothyroid, and beneath these muscles the junction of the internal
jugular and the subclavian veins. The artery is also crossed by the vertebral
and the anterior and external jugular veins which empty into the subclavian.
414:
LIGATIONS OF ARTERIES IN CONTINUITY
The phrenic, branches of the sympathetic, and the vagus pass over the vessel,
and the recurrent nerve passes behind it. The vessel passes over the pleura,
which separates it from the dome of the lung. It lies on the transverse process
of the seventh cervical vertebra and is separated from it by the inferior-
ganglion of the sympathetic and the muscular slip passing from the trans-
verse process to the dome of the pleura (28). The artery then passes
between the scalenus anticus and medius, lying in a groove on the first rib.
FIG. 9. — COURSE AND RELATION OP THE SUBCLAVIAN AND AXILLARY ARTERIES. M, Sternocleido
muscle; t, trapezius; o, omohyoid; the retractor has drawn the external jugular to one side; v, the
subclavian vein; d, deltoid; a, retractor pulling downward the clavicular portion of the pectoralis
major; c, coracoid process; b, retractor pulling down the cephalic vein, making the thyrocervical
trunk visible. (Farabeuf.)
It is separated in this part of its course from the subclavian vein by
the scalenus anticus muscle, and has the cords of the brachial plexus
above it.
The third portion of the subclavian is covered by the skin, superficial
fascia, platysma, descending branches of the cervical plexus, and beneath this
by a layer of fatty tissue in which are imbedded lymph glands. The inferior
belly of the omohyoid lies above and in front of the artery, and the external
jugular vein, as it arches around the outer margin of the sternocleidomastoid,
crosses over it. This portion of the artery lies on the first intercostal space.
The subclavian vein and the suprascapular artery pass between it and the
clavicle, and the scalenus medius is behind it. The linear guide of the cervical
course of the artery is represented by a curved line from the sternoclavicular
SUBCLAVIAN ARTKKY 415
joint to the mid point of the clavicle, and the convexity of the curve extends
upward about 2.5 cm. (1 in.) above the clavicle. This is the course of the
vessel with the shoulder depressed.
The artery gives off a number of branches which usually spring close to-
gether from the first part of the artery : namely the vertebral, the thyrocervical
trunk, the internal mammary, and the costocervical trunk. The vertebral is the
first branch given off. The thyrocervical trunk arises usually close to the
scalenus anticus (Figs. 9, 10).
The vessel can be ligated mesially to the scalenus anticus, that is in its
first portion, either (1) on the peripheral side of the thyrocervical trunk, or
(2) on the cardiac side of the vertebral. (3) The left subclavian may be
ligated close to its origin within the mediastinum.
Operation (1) LIGATUEE OF THE FIEST PORTION OF THE SUBCLAVIAN
(EIGHT OE LEFT) ON THE PEEIPHEEAL SIDE OF THE THYBOCEEVICAL TRUNK.
-The patient is placed in the dorsal position with the head slightly extended
and turned to the opposite side. The incision, about 8 cm. (3% in.) long, is
made along the lateral border of the sternocleidomastoid. This is met by an
incision over the clavicle for about the same distance, the two incisions forming
an acute angle. The skin, superficial fascia, platysma and clavicular attachment
of the sternocleidomastoid are divided. The flap thus formed is retracted in-
ward. The inferior belly of the omohyoid is exposed, the fascia covering it
divided, and the muscle retracted upward or divided. The scalenus anticus
muscle is identified, and its inner border followed downward until the pulsation
of the subclavian is felt. The internal jugular vein is retracted inward, and
the subclavian vein downward. This exposes the first portion of the sub-
clavian. The phrenic and the cardiac branches of the sympathetic and the
vagus are identified, and an aneurysm needle passed about the vessel, threaded,
and withdrawn, care being taken to avoid including the nerves in the ligature.
The ligature passes between the phrenic and sympathetic. The vessel is then
tied with the stay knot, the divided muscles are sutured, and the wound
closed.
(2) LIGATUEE OF THE SUBCLAVIAN ON THE CAEDIAC SIDE OF THE VER-
TEBEAL. — This is a much more difficult operation. The incision, about 10
cm. (4 in.) long, is made over the clavicle. It is slightly curved, the con-
vexity of the curve being upward, and it passes over the sternoclavicular joint
and extends about 1 cm. (2/5 in.) within the sternal border. The clavicular
portion of the sternocleidomastoid is severed, and the clavicle divided about
6 cm. (2 2/5 in.) from its sternal end, and this inner portion subperiosteally
resected. The costoclavicular ligament is divided, and the posterior fibers
of the sternoclavicular ligament, thus exposing the joint. The sternal portion
of the resected clavicle is turned over to the inner side. An incision is then
made in the cervical fascia at its junction with the superior border of the
retroclavicular periosteum, and the lower border of the wound retracted. This
exposes the internal jugular and the subclavian veins. The internal jugular
416 LIGATIONS OF ARTERIES IN CONTINUITY
is freed along its mesial border and retracted outward. The vagus nerve is
identified by blunt dissection. It passes downward vertically, close to the
mesial margin of the internal jugular vein. To the inner side of the vagus
nerve is the carotid artery. To its outer side and beneath it is the subclavian
artery. The artery is exposed and the ligature passed about it. On the right
side the ligature passes almost in contact with the loop of the recurrent nerve.
The clavicle is turned back and sutured. The muscles are sutured and the
wound closed.
(3) LIGATURE OF THE LEFT SUBCLAVIAN WITHIN THE MEDIASTINUM.
—Position as in No. 1. — The incision, about 10 cm. (4 in.) long, is made
over the clavicle and over the upper border of the sternum to the mid line and
then descends vertically to the level of the second costal cartilage. The pec-
toralis major is dissected away from the clavicle and sternum. The inner half
of the clavicle is resected subperiosteally. It is disarticulated from the sternum
and first rib. The finger is then gently introduced behind the sternum in the
mid line, and the dome of the pleura and the elastic mass formed by the
summit of the lung gently pushed outward. The sternum is then divided ver-
tically in the mid line and horizontally at the level of the first costal cartilage,
its posterior surface is carefully freed, and the first costal cartilage is divided
at its junction with the rib. The left half of the manubrium and the first
costal cartilage are then removed in one piece. The innominate vein is thus
exposed. It occupies the entire operative field. Its direction is nearly hori-
zontal. Two or three small veins enter its inferior border. They are divided
between ligatures and the vein gently retracted upward. By blunt dissection
in a vertical direction the vagus is exposed. It descends almost vertically
in front of the artery crossing it with a very slight obliquity. The finger
introduced into the wound palpates the trachea. In the angle between the
trachea and esophagus is the subclavian, very deeply placed. Below is the
aortic arch and anteriorly is the left common carotid. The ligature is placed
about 5 cm. (2 in.) from the aortic arch. The pectoralis is sutured to the
sternocleidomastoid and the wound closed.
Instead of removing the bone a temporary cleidosternocostal resection may
be made. The sternum is divided horizontally and vertically and the clavicle
is divided. The sternum is turned downward and outward. The flap hinges
on the junction of the cartilage and rib (Duval, 11).
Results. — Writing in 1897, B. F. Curtis (6) in reporting a case in which
the first portion of the subclavian had been successfully tied in continuity,
referred to the statistics of Souchon which gave 16 cases with 16 deaths.
The results of cases since then are very different, Saveriaud (23) in 1906,
Monod and Van Verts (18) in 1909, and Rubritius (21) in 1911 have
arranged tables from the cases reported since Dr. Curtis. Adding a case
reported by Schwartz (24) in 1911, there have been 21 cases reported with
3 deaths: that is, the mortality in the reported cases since 1897 is 14.3 per
cent.
SUBCLAVIAN ARTERY
417
LIGATION OF THE THIRD OR SECOND PORTION OF THE SUBCLAVIAN ARTERY
The patient is placed in the dorsal position with the face turned slightly
to the opposite side and the shoulder depressed; a narrow sand bag is placed
under the spine, not under the shoulder.
AURICULAR NERVE
TRANSVERSE
ARTERY OF
SCAPULA
EXTERNAL JUGULAR VEIN
VERSE CERVICAL
NERVE
ASCENDING CERVICAL
ARTERY
INTERNAL JUGULAR
VEIN
THYROCERVICAL TRUNK
FIG. 10. — SUPERIOR CLAVICULAR REGION. (Poirier-Charpy.)
Operation. — The incision is made parallel to the clavicle and about 1 cm.
(2/5 in.) above it. It should be about 8 cm. (3 1/8 in.) long, and the middle
of the incision should be over the middle of the clavicle. The skin, super-
ficial fascia, and platysma are divided and usually a few of the sensory fila-
ments of the cervical plexus.
The external jugular vein, as it passes around the lateral border of the
sternocleidomastoid, is divided between ligatures and the sternocleidomastoid
retracted inward or severed close to its clavicular attachment. The cellular
and fatty tissue are divided by blunt dissection and the inferior belly of the
omohyoid exposed. This muscle or the fascia at its lower border is divided
and retracted upward. The scalenus anticus muscle is identified. The sub-
28
418 LIGATIONS OF ARTEEIES IN CONTINUITY
clavian artery passes outward from beneath this muscle; the cords of the
brachial plexus lie above and behind it. The transverse artery of the scapula
crosses the subclavian and is divided or retracted. The subclavian vein is
retracted downward and the ligature is passed about the artery and tied. In
ligating the second portion the phrenic nerve is identified as it crosses the
scalenus anticus obliquely. It is freed by blunt dissection and retracted in-
ward. The scalenus anticus is then divided and the second portion of the
artery exposed. On the right side the costocervical trunk is usually given
off from the back part of the vessel. If the aneurysm needle is passed gently
and kept in contact with the arterial wall, this branch is not injured. The
muscles are replaced and sutured and the skin incision closed.
Results. — The results of the ligature of the third portion of the subclavian
are very good. In the recent cases in which the artery was ligated for aneu-
rysm Monod and Van Verts (1909) (18, 23) give 10 cases of the ligature of
the third portion with no deaths. These statistics are taken from cases re-
ported since 1884. I can add a personal case operated on in 1912, in which
the third portion of the subclavian and the common carotid were ligated
successfully for innominate aneurysm.
VERTEBRAL ARTERY
Anatomy. — The vertebral artery arises from the first part of the sub-
clavian and passes upward and slightly outward to enter the foramen in the
transverse process of the sixth cervical vertebra.
The vessel, between its origin and its entrance into the foramen in the
transverse process, occupies the deepest portion of the supraclavicular region.
In front of it are the vertebral vein, passing over the vessel to enter the sub-
clavian vein, the anterior portion of the subclavian loop of the sympathetic
nerve (ansa Vieussenii), and the inferior thyroid artery which, as it passes
upward perpendicularly, crosses it. On the left side the thoracic duct crosses
the subclavian below the vertebral artery.
The vessel lies for a short distance at its origin in contact with the pleura
covering the dome of the lung (cupulopleura) (28). On approaching the
foramen in the transverse process of the sixth cervical vertebra, it passes
between the longus colli and the scalenus anticus muscle. The artery passes
upward through the foramina in the transverse processes of the sixth, fifth,
fourth, third, and second cervical vertebras. On reaching the axis it passes
very obliquely upward and outward to reach the foramen in the transverse
process of the atlas; it then passes around the groove in the lateral process
of the atlas and perforates the posterior atlo-occipital ligament.
The vessel is usually ligated in the portion between its origin and its
entrance into the foramen in the transverse process of the sixth cervical
vertebra.
INTERNAL MAMMARY ARTERY 419
Operation. — The patient is placed in the dorsal position with the face
turned to the opposite side and the shoulder slightly elevated. An incision is
made, 8 cm. (3 1/8 in.) long, parallel to the clavicle and just above it, starting
external to the posterior border of the sternocleidomastoid muscle. The skin
and platysma are divided, and the posterior border of the sternocleidomastoid
and the external jugular vein identified and retracted inward. If this does
not give enough room, the muscle is divided just above the clavicle. The
deep cellular tissue is separated by blunt dissection, and the carotid tubercle
and the interval between the scalenus anticus and the longus colli identified.
In this interval the vertebral artery, usually covered by the accompanying
vein, is exposed. After separating the vein by blunt dissection, a ligature is
passed about the vessel. In passing the ligature care must be taken not to
injure the pleura. In ligating the vessel some of the filaments of the sym-
pathetic are likely to be included in the ligature; this produces contraction
of the corresponding pupil.
Results. — The vessel has been ligated a number of times by Alexander
and Baracz for the cure of epilepsy, in many instances on both sides, without
any untoward cerebral complications. Mikulicz (17) successfully ligated the
vessel for aneurysm.
For ligation of the inferior thyroid see page 309, Vol. III.
INTERNAL MAMMARY ARTERY
Anatomy, — The internal mammary artery arises from the anterior sur-
face of the subclavian about 3 to 4 mm. external to the vertebra. It passes
downward, forward and a little inward in contact with the pleura of the
dome of the lung and behind the subclavian vein. At this level it is crossed
by the phrenic nerve. It then passes downward in contact with the posterior
surface of the first costal cartilage and, becoming nearly vertical, crosses the
posterior surfaces of the upper costal cartilages. At the level of the sixth
interspace it divides into its terminal branches; as far as the third rib it is
in relation posteriorly with the parietal pleura ; from the third costal cartilage
downward the transverse muscle of the thorax (triangularis sterni) intervenes
between the pleura and the artery. It is accompanied by two veins and a
chain of lymphatic glands. At the first interspace the artery is about 10 mm.
(2/5 in.) from the border of the sternum; at the level of the sixth it is about
20 mm. (4/5 in.) from this border. The interval between the artery and the
border of the sternum gradually increases from above downward (Fig. 11).
Operation. — The patient is placed in the dorsal position. A vertical in-
cision is made over the third intercostal space extending from the third rib to
the lower border of the fourth rib and about 10 mm. (% in.) from the mar-
gin of the sternum. The skin, subcutaneous tissue and fibers of the pectoralis
major are divided, and the intercostal space with its muscles exposed. The
420
LIGATIONS OF AKTEEIES IN CONTINUITY
aponeurosis of the external intercostal muscle and finally the internal inter-
costal muscle (about 5 to 8 mm. thick at this point) are divided. The artery
with its two veins is separated by blunt dissection from the fatty and cellular
bed in which it lies. After gently separating the veins, a ligature is passed
INTERNAL
MAMMARY ARTERY
1_ LINE OF
LUNG
LINEOF
PLEURAL
FIG. 11. — LINE OF LEFT PLEURA, LUNG AND INTERNAL MAMMARY ARTERY.
Operatoire.)
(Precis de Technique
about the artery. Great care is necessary in passing the aneurysm needle to
prevent injury of the pleura. The transverse muscle of the sternum, which
intervenes between the pleura and the artery, is often poorly developed, or
even partially absent.
AXILLARY ARTERY
Anatomy. — The axillary artery extends from the outer border of the
first rib to the lower margin of the teres major. It is divided into three por-
tions by the pectoralis minor. The first portion extends from the clavicle to
the upper border of the pectoralis minor (Fig. 12). In front of the vessel
are the skin, superficial fascia, pectoralis major, and beneath this muscle a
layer of cellular tissue and fat in which pass the thoraco-acromial artery and
vein, the nerve to the pectoralis major, the terminal part of the cephalic vein,
the subclavian muscle and the strong fascia which extends from the upper
border to the pectoralis minor — the upper portion of the claviculocoraco-
axillary aponeurosis. The vessel lies on the first two digitations of the serratus
anterior, and behind lie the fat and cellular tissue which fill the scapulothoracic
junction. The second portion is covered by the pectoralis minor, and has to
its outer side the coracoid insertion of the coracobrachialis and biceps. Behind
AXILLARY ARTKKY
421
CLAVICLE
it lies the subscapular muscle, covering the head <.f the hnmerus. The third
portion of the artery is slightly overlapped by the euraeuhraehialis, which
separates it from the pectoralis major. Covered by the skin and ajxmeurosis
on its inner side, it passes downward in the groove in the coracobrachialis
lying on the latissimus dorsi. In the first portion the vein lies to the inner
side of the artery. When the vein is distended, it overlaps tin- artery.
This portion of the vessel is crossed by the cephalic and acrornial veins
and by the outer one of the bra-
chial veins. The terminal portions
of the brachial plexus are placed be-
hind and to the outer side. The
nerve to the pectoralis minor passes
behind the artery.
In the second portion the vein is in
less close relation to the artery. One
cord of the brachial plexus lies behind
the artery, one to its outer side, and one
to the inner side, intervening between
the artery and vein. The branches of
the brachial plexus are disposed about
the third portion of the artery. The
radial (musculospiral) and the circum-
flex are behind ; between the artery and
the vein is the ulnar ; on the outer side
is the median. These relations are
given with the arm in position for ligature, that is, abducted (Fig. 12).
With the arm abducted at right angles to the body, a line drawn from
the middle of the clavicle to the junction of the anterior and middle thirds
of the outer axillary wall at the outlet of the axillary space represents the
line of the vessel.
Operation. — The patient is placed in the dorsal position with the arm
abducted at right angles to the trunk and the extended forearm midway
between pronation and supination. The operator stands between the extended
arm and the axilla.
LIGATION OF THE FIRST PORTION. — An incision is made parallel to the
fibers of the pectoralis major downward and outward from the clavicle to a
finger's breadth below the coracoid process. The fibers of the pectoralis major
are separated and retracted, or the fibers of the muscle are divided. The
claviculocoraco-axillary aponeurosis is exposed, and the thoraco-acromial ves-
sels identified, piercing the fascia just above the pectoralis major. The fascia
is then divided, the artery is gently separated from the vein, and a ligature
passed about it. The distended vein generally overlaps the artery. The
cephalic vein and the cords of the brachial plexus must be carefully avoided.
The vessel is deep in this situation and the ligation difficult.
VEIN
FIG. 12. — NEUROVASCULAR BUNDLE IN AXILLA.
(Poirier.)
422
LIGATIONS OF ARTEEIES IN CONTINUITY
LIGATION OF THE SECOND POKTION. — The incision is carried downward
and outward from below the clavicle to 2% cm. (1 in.) below the coracoid
process. The fibers of the pectoralis major are divided, and the narrow por-
tion of the pectoralis minor exposed, its lower border freed from its fascia and
the finger gently inserted beneath the muscle, and the muscle divided. The
artery, the vein and the
cords of the plexus are
immediately beneath the
muscle. The vein is gen-
tly retracted downward,
and a ligature passed
about the artery. The
severed pectoralis minor
and the separated fibers of
the pectoralis major are
sutured, and the wound
closed.
LIGATION OF THE
THIED PORTION. — The in-
cision is made over the
inner border of the coracobrachialis, over the line of pulsation of the artery
which can usually be easily felt. It should be about 8 to 10 cm. (3-4 in.) long.
The center of the incision is above the anterior axillary fold. The skin and
superficial fascia are divided and the thin fascia of the upper arm laid bare.
The coracobrachialis is identified, the fascia carefully divided, and the lower
margin of the wound retracted. The median nerve now appears, imbedded in
loose cellular tissue; it is freed and retracted upward. The artery is thus
exposed and a ligature passed about it (Fig. 13).
Results. — Recent reports of the results of the ligature of the axillary artery
are favorable. According to Delbet (9) gangrene after ligature of the axillary
is extremely rare. V. Bergmann has seen only good results after ligature for
wounds of the artery. Koch (9) has collected 45 cases of ligature without any
trouble with the circulation in the arm.
FIG. 13. — LIGATION OF THE AXILLARY ARTERY. The retractor
(A) has pulled upward the coracobrachialis (1) with themus-
culocutaneous nerve (!'). The director (b) elevates the sec-
ond landmark, the median nerve (2'). The lesser internal
cutaneous nerve (4) has remained in place, generally not no-
ticed like the other nerves and the large vein. The small
collateral vein (5) can be seen in the depths of the wound.
BRACHIAL ARTERY
Anatomy. — The vessel commences at the lower margin of the teres ma-
jor and, passing down the inner and interior aspect of the arm, terminates
about 1 cm. below the bend of the elbow, where it divides into the radial
and ulnar arteries. At first the artery lies internal to the humerus; but as it
passes down the arm it gradually acquires a more anterior position, and at the
bend of the elbow it lies midway between the two epicondyles. The artery is
BRACHIAL ARTERY 423
superficial throughout its entire course, being covered in front by the integu-
ment, the superficial and deep fasciae; the bicipital fascia separates it at the
elbow from the median basilic vein ; the median nerve crosses it at its middle.
Behind, it is separated from the long head of the triceps by the radial nerve
(musculospiral nerve) and superior profunda artery. It then lies upon the
inner head of the triceps, next upon the insertion of the coracobrachialis, and
lastly on the brachialis. On its outer side it is in relation with the commence-
ment of the median nerve, the coracobrachialis and biceps, which overlap
the artery to a considerable extent. On its inner side, the upper half is in
relation with the medial cutaneous nerve of the forearm and the ulnar
nerve. The basilic vein lies on the inner side of the artery, but is separated
from it in the lower part of the arm by the deep fascia. It is accompanied by
two venae comites, which lie in close contact with the artery, being connected
at intervals by short transverse communicating branches.
At the bend of the elbow the brachial artery lies in a triangular-shaped
space, the cubital fossa, the base of which corresponds to a line drawn be-,
tween the two epicondyles of the humerus, the sides to the inner edge of the
brachioradialis muscle and the outer edge of the pronator teres, the floor being
formed by the brachialis and supinator. The contents of this space are: the
brachial artery and its two veins; the radial and ulnar arteries; the median
and radial nerves (musculospiral nerves) ; and the tendon of the biceps. The
brachial artery lies along the middle line of this space and divides opposite
the neck of the radius into the radial and ulnar arteries. The artery is cov-
ered in front by skin, superficial and bicipital fascia, and is crossed by the
median basilic vein. Behind, it lies upon the brachialis, which separates it
from the elbow joint. The median nerve lies on the inner side of the artery,
close to it above, but separated from it below by the slip of the pronator teres,
which arises from the coronoid process of the ulna. The tendon of the biceps
lies to the outer side of the space, and the radial nerve (musculospiral nerve)
still more externally, situated upon the supinator and partly concealed by the
brachioradialis.
If the thumb be pressed into the deepest part of the axilla, just behind
the tendon of the pectoralis major, the pulsation of the axillary artery can
be felt. Between this point and the middle of the crease of the elbow a
straight line is drawn. This line should correspond to the inner border of the
coracobrachialis and biceps, which can always be felt and usually seen. The
pulsations of the brachial artery can often be felt along this line (Fig. 17).
The brachial artery can be ligated at any point in its course. For con-
venience of description, ligature of its upper and middle third and in the
cubital fossa will be described.
Operation. UPPER THIRD.— The patient should be in the dorsal position,
with the arm at a right angle to the body and the hand held by an assistant
in a position half way between pronation and supination. An incision of 8
cm. in length is made, beginning at the lower border of the pectoralis major
424
LIGATIONS OF AKTEEIES IN CONTINUITY
McG
and along the linear guide to the vessel. This incision is carried down to the
deep fascia, which is divided with great care to prevent possible injury to
the internal cutaneous nerve or basilic vein, which sometimes runs on the
surface of the artery as high as
the axilla. After division of the
fascia, care should be taken not to
injure the ulnar or medial cu-
taneous nerve of the forearm,
which lie to the inner side of the
artery, or the median nerve, which
lies usually to the outer side, or
the venae comites, which are on
either side of the vessel. After the
artery has been isolated from
these structures, the needle should
be passed around the artery from
the inner to the outer side (Fig.
14).
MIDDLE THIED. — An incision
of 8 cm. in length is made opposite
the most prominent part of the bi-
ceps and along the linear guide to
the vessel. The fascial lata is di-
vided with care to prevent injury
to the median nerve, which lies
in front of the artery in this
situation, as it passes from its
outer to its inner side. After
retraction of the nerve and iso-
lation of the artery from its
venae comites the needle is passed
around the artery from within outward (Fig. 14).
IN THE CUBITAL FOSSA. — The forearm is held in a position of forced
supination in order to define the tendon of the biceps. An incision of 8 cm.
in length is made along the inner border of the tendon of the biceps, care
being taken not to divide unnecessarily the median basilic vein, which can
be retracted. The bicipital fascia is then exposed and divided. The artery is
seen lying between two venae comites, with the median nerve to its inner side
and the tendon of the biceps to its outer side. After the artery has been isolated
from its veins, the needle should be passed from within outward (Figs. 15, 16).
FIG. 14. — EXPOSURE OF THE AXILLARY AND BRACHIAL
ARTERIES. McG, Coracobrachialis muscle ; F, in-
ner side of fascia of upper arm; M, median nerve;
Ci, medial nerve of upper arm (lesser internal
cutaneous) ; Ca, medial nerve of forearm (internal
cutaneous); Ax, axillary artery; B, biceps; F,
fascia brachii; M, median nerve; A, brachial ar-
tery; V.b, brachial vein. (Zuckerkandl.)
EADIAL ARTERY 425
RADIAL ARTERY
The radial artery can be ligated at any point between its origin at the
bifurcation of the brachial, just below the bend of the elbow, and the point
where it passes forward between the two heads of the first dorsal interosseous
muscle to become, by anastomosis with the deep branch of the ulnar, the deep
volar arch.
Anatomy. — The linear projection of the radial artery on the surface is
represented by a line drawn midway between the apices of the bony epicondyles
FIG. 15. — LIGATURE OF THE LEFT BRACHIAL AT THE BEND OF THE ELBOW. 2, External lip; 3, internal
lip of the fascial expansion of the biceps retracted; 4, origin of the basilic vein; 5, median nerve.
(Farabeuf.)
of the humerus and the inner aspect of the extremity of the styloid process of
the radius (Figs. 16 and 17).
It extends from the bend of the elbow, where it lies opposite the neck of
the radius, to the anterior aspect of the extremity of the styloid process. It
lies to the inner side of the shaft of the bone above and in front of it below.
It is overlapped in the upper part of its course by the fleshy part of the
brachioradialis muscle. Throughout the rest of its course it is superficial,
being covered only by skin and by superficial and deep fasciae. In its course
downward it lies upon the tendon of the biceps, the supinator, the pronator
teres, the radial origin of the flexor longus pollicis, the pronator quadratus and
the lower extremity of the radius. In the upper third of its course it lies
between the brachioradialis and the pronator teres. In its lower two-thirds,
between the tendons of the brachioradialis and flexor carpi radialis. The
radial nerve lies close to the outer side of the artery in the middle third
of its course, and some filaments of the musculocutaneous nerve, after piercing
the deep fascia, accompany the lower part of the artery as it winds around the
wrist. The vessel is accompanied by venre cornites throughout its whole course,
426
LIGATIONS OF AKTEEIES IN CONTINUITY
At the wrist, as it winds round the outer side of the carpus from the
styloid process to the first interosseous space, it lies upon the external lateral
ligament and then upon the scaphoid bone and trapezium, being covered by
5... ^ the extensor tendons of the thumb, subcu-
taneous veins, some filaments of the radial
nerve and the skin. It is accompanied by two
veins and a filament of the musculocutaneous
nerve.
At this situation the surface outline of the
space in which the vessel lies is a triangle,
bounded internally by the tendon of the ex-
tensor, longus pollicis, externally by that of the
extensor brevis pollicis and the base corre-
sponding to the apex of the styloid process of
the radius. If the thumb be forcibly extended,
the outlines of the space will be well
marked.
In the hand it passes from the upper end
of the first interosseous space, between the
heads of the first dorsal interosseous muscle,
transversely across the palm to the base of the
metacarpal bone of the little finger, where it
anastomoses with the communicating branch
of the ulnar, forming the deep volar arch. It
lies upon the carpal extremities of the meta-
carpal bones and the interosseous muscles, be-
ing covered by the adductor pollicis, the flexor
tendons of the fingers, the lumbricales, op-
ponens and flexor brevis minimi digiti.
Alongside of it is the deep branch of the ulnar
nerve (Fig. 18).
Operation. — UPPER THIRD. — With the fore-
arm supinated, an incision 8 cm. in length is
made along the linear guide to the vessel, beginning opposite the inferior angle
of the cubital fossa. Upon division of the fascia, the brachioradialis muscle her-
niates into the wound. Its internal border should be found and the muscle re-
tracted laterally, exposing the artery accompanied by its two veins with the
nerve to the radial side. The artery is then isolated and the needle passed from
without inward.
The vessel has been found lying over the fascia instead of beneath it.
It has also been observed on the surface of the brachioradialis instead of
under its inner border.
LOWER THIRD. — The vessel is superficial, covered only by the skin and
superficial and deep fasciae, and can be readily recognized by its pulsation.
FIG. 16. — EXPOSURE OF THE BRACHIAL
ARTERY IN THE CUBITAL FOSSA AND
OF THE RADIAL AND ULNAR ARTER-
IES. L, Oblique incision of the bi-
cipital fascia; A, brachial artery
with the venae comites; M, median
nerve; V, median basilic vein; Ar,
radial artery; An, ulnar artery; U,
the inner edge of the flexor carpi
ulnaris. (Zuckerkandl.)
RADIAL ARTERY
427
With the arm placed as in the preceding operation, an incision 6 cm.
(2.4 in.) in length is made along the course of the vessel. Upon division of
the skin and fasciae the artery is seen, accompanied by its two veins, lying
between the tendons of the brachioradialis (supinator longus) and the flexor
carpi radial is. The artery is isolated and the needle passed from without
inward, great care being taken not to injure the nerve which lies just to the
outer side of the artery.
AT THE WKIST. — An assistant should hold the hand with its ulnar border
on the table and move the thumb so as to make the extensor
tendons stand out and define the triangular space through
which the vessel passes.
An incision 3 cm. (1.18 in.) in length is made half way
between the two extensors of the thumb and parallel with
them, beginning at the tip of the styloid process of the radius
and continued downward. Upon division of the skin, the
dorsal vein of the thumb is exposed, and is either retracted or
ligated. The deep fascia is divided in the line of the skin
incision, keeping always between the tendons. With the
tendons retracted, the cellular tissue beneath is held up be-
tween two forceps and incised, exposing the artery accom-
panied by its two veins, passing through this space in a down-
ward and backward direction. The vessel is isolated and tied
by passing the needle in either direction.
IN THE HAND. — The linear projection of the deep volar
arch on the surface is a curved line with its convexity down-
ward, drawn parallel to and a finger's breadth above the
linear projection of the superficial volar arch, which is rep- FlG- 17.— LINES OF
. n i . . ,, ,. , INCISION FOR LIG-
resented by a continuation across the palm of a line drawn ATURE OF BRACHIAL
along the palmar border of the thumb when it is held in a ARTERY. (Farabeuf.)
position of forced extension.
An incision 5 cm. (2 in.) in length is made vertically downward in the
mid line, ending just below the line of the superficial volar arch. The palmar
aponeurosis is divided in the line of the skin incision and retracted with the
skin edges, exposing the superficial volar arch crossing the lower part of the
wound. In the upper angle of the wound are seen the flexor tendons, with the
digital branches of the median nerve between them. A division with the
handle of the knife is made between the tendons, great care being taken not
to injure the branches of the median to the three innermost lumbricales, which
are given off at about this point. Blunt retractors are introduced and the
division enlarged by means of them, exposing the deep volar arch accompanied
by the deep branch of the ulnar nerve. The needle should be passed from
below upward, particular care being taken not to injure the branches of the
ulnar supplying the volar interossei.
428
LEGATIONS OF ARTERIES
CONTINUITY
ULNAR ARTERY
Anatomy. — The linear projection on the surface of the lower two-thirds
of the ulnar artery is represented by a line drawn from the apex of the median
epicondyle of the humerus to the radial side of the pisiform bone (Fig. 17).
To project the upper third of the artery upon the surface, the junction of the
ULNAR ARTERY
DEEP VOLAR
ARCH
RADIAL ARTERY
FIG. 18. — DEEP VOLAR ARCH. (Poirier.)
upper and middle thirds of this line is connected with the center of the hollow
in front of the elbow joint. The projection of the superficial volar arch upon
the surface is represented by a continuation across the palm of a line drawn
along the palmar border of the thumb, when it is held in a position of forced
extension.
The ulnar artery commences a little below the bend of the elbow, and
crosses obliquely the inner side of the forearm to the commencement of its
lower half; it then runs along its ulnar border to the wrist, crosses the trans-
verse carpal ligament on the radial side of the pisiform bone, and immediately
ULNAR ARTERY 429
beyond this bone divides into two branches which enter into the formation of
the superficial and deep volar arches. In its upper half it is deeply seated,
being covered by all the superficial flexor muscles, excepting the flexor carpi
ulnaris; the median nerve is in relation with the inner side of the artery for
about an inch and then crosses the vessel, being separated from it by the
deep head of the pronator teres; it lies upon the brachialis and flexor pro-
fundus digitorum. In the lower half of the forearm, it lies upon the flexor
profundus, being covered by the integument and the superficial and deep
fasciae, and is placed between the flexor carpi ulnaris and flexor sublimis
digitorum. It is accompanied by two vena3 comites. The ulnar nerve lies on
its inner side for the lower two-thirds of its course, and a small branch from
the nerve descends on the lower part of the vessel to the palm of the hand.
At the wrist it is covered by the skin and fascia and lies upon the transverse
carpal ligament. On its inner side is the pisiform bone. The ulnar nerve
lies to the inner side and somewhat behind the artery; here the nerve and
artery are crossed by a band of fibers which extends from the pisiform bone
to the transverse carpal ligament.
In the hand the artery, by anastomosis with a branch from the radial
volar artery of the index finger or the superficial volar ramus, branches of
the radial artery, forms the superficial volar arch.
Operation. — JUNCTURE OF UPPER AND MIDDLE THIRDS. — The forearm
should be supinated. An incision 8 cm. (3.15 in.) in length is made along the
linear guide to the vessel, beginning 8 cm. (3.15 in.) below the medial epi-
condyle of the humerus. This incision is carried down through the deep
fascia, which is retracted with the skin edges, exposing the superficial muscle
layer. The line of division between the flexor carpi ulnaris and flexor sub-
limis digitorum is sought for, and these muscles are separated from one
another along this line. The artery is now seen lying upon the flexor pro-
fundus digitorum, accompanied by its two veins, with the ulnar nerve to its
inner side. The artery should be freed and the needle passed from within
outward.
LOWER THIRD. — The position of the patient and the forearm should be as
in the preceding operation. The hand should be forcibly extended so as to
make the tendon of the flexor carpi ulnaris tense. An incision 8 cm. (3.15
in.) in length is made along the radial border of this tendon and carried
down through the deep fascia, permitting the tendon to be retracted in an
inward direction. The artery is found beneath the tendon, accompanied by
its two veins, and with the ulnar nerve lying to its inner side. The artery
should be freed from its veins and the needle passed from within outward.
AT THE WRIST. — With the hand resting on its dorsal surface, a curved
incision with its convexity outward, 5 cm. (2 in.) in length, is made along
the radial side of the pisiform bone. Keeping close to the pisiform bone, this
incision is deepened through fascia and fatty tissue, until the vessel is reached.
After the artery has been isolated from its two companion veins, to avoid in-
430
LIGATIONS OF AKTEKIES IN CONTINUITY
jury to the ulnar nerve, which lies close to the inner side of the artery, the
needle should be passed from within outward (Fig. 16).
IN THE HAND. — The operation for tying the superficial volar arch is the
same as that for ligation of the deep volar arch, as the superficial arch is
exposed in the course of this operation.
ABDOMINAL AORTA
Anatomy. — The abdominal aorta extends from the opening in the dia-
phragm to the body of the fourth lumbar vertebra, where it divides into its
INFERIOR
VENACAVA
INFERIOR
ARTERY OF
THE DIAPHRAGM
SUPERIOR
MESENTERIC
ARTERY /
URETER (
SPERMATIC
ARTERY
MEDIAL SACRAL
ARTERY
INTERNAL
ILIAC
EXTERNAL
ILIAC
ESOPHAGUS
INFERIOR ARTERY
OF THE
DIAPHRAGM
tCELIACAXIS-
RENAL
ARTERY
LUMBAR
ARTERY
SPERMATIC
ARTERY
INF. MESENTERIC
ARTERY
SUP. HEMORRHAQIC
ARTERY •
COMMON ILIAC
CIRC. ILIAC
HYPOGASTRIC
ARTERY
EPIGASTRIC
ARTERY
DEEP EPIGASTRIC
ARTERY.
FIG. 19.— ABDOMINAL AORTA AND COMMON ILIAC ARTERIES.
COMMON ILIAC ARTERY 431
terminal branches. The point of bifurcation of the vessel is approximately
indicated by the intersection of a horizontal line passing through the upper
limits of the iliac crests and the median line of the abdomen. It gives off
large visceral branches to the gastro-intestinal tract, to the kidneys and to the
genital organs. Its lowermost visceral branch is the inferior mesenteric. It
has usually been ligated below this branch in the last two inches of its course.
It lies on the vertebral column, the lumbar veins and the recepticulum chyli;
at its right lies the inferior vena cava. In front are the peritoneum, the sym-
pathetic and the intestines (Fig. 19).
Operation. — The patient is placed in the Trendelenburg position. A ver-
tical incision about 10 cm. (4 in.) long is made through the abdominal wall
just to the left of the navel, and beginning about 3 fingers' breadth above it.
The intestines are pushed upward and kept in place by abdominal pads. The
peritoneum is divided over the vessels, which can be readily seen and felt,
and a ligature passed about it. The peritoneum and celiotomy wound are
then sutured.
EXTEAPERITONEAL LIGATION. — The vessel may be ligated extraperito-
neally. The patient is placed in the dorsal position. The incision extends
from the tenth rib downward and forward to within one inch of the anterior
superior spine of the ilium; the abdominal wall is divided. The patient is
then turned to one side, the peritoneum is gently separated with the fingers
and pushed with the intestines inward. The ureter is raised with the peri-
toneum ; the aorta comes in view on retracting the upper margin of the wound,
and a ligature is passed about it.
Results. — The abdominal aorta has been ligated 15 times; it has been
ligated 12 times for aneurysm and 3 times for hemorrhage. The operation
has been done 10 times through the peritoneum and 5 times extraperitoneally.
Death has resulted in every instance, in from one hour to 48 days. In no in-
stance have there been signs of gangrene of the lower extremities. The
fatal issue has been attributed 7 times to infection; twice to hemorrhage
due to the ligature; 4 times to hemorrhage independent of the ligatures. In
the other cases reported the cause of death is not indicated.
According to animal experimentation the gravity of the operation depends
upon the site of the ligature; yet in Keen's patient, who survived 48 days,
the ligature applied for aneurysm was passed about the vessel just below the
diaphragm. It has been suggested that in this instance a collateral circulation
had already been established (Monod and Van Verts, 18).
COMMON ILIAC ARTERY
Anatomy. — The common iliac artery extends from the bifurcation of the
aorta at the lower border of the fourth lumbar vertebra to the line of the
sacro-iliac junction. It measures about 5-7 cm. (2-3 in.) in length, the right
432 LIGATIONS OF ARTERIES IN CONTINUITY
being a little longer than the left. The vessels pass downward and out-
ward, diverging from one another at an angle of 65° in man and 75° in
woman. The artery lies on the lateral portion of the fifth lumbar vertebra
and on the inner border of the psoas.
The relations of the veins to the arteries vary on the two sides. On the
right the vein lies behind the artery and is intimately attached to it. On
FIQ. 20. — SCHEME OF THE DIFFERENT TYPES OF RELATION OF THE URETER AND ILIAC VESSELS. A, A7,
Normal type; B, B', low bifurcation of common iliac; C, C', high bifurcation. (Proust and Maurer.)
the left the vein lies at first to the inner side of the artery and in contact
with it, and then passes beneath the right common iliac to form the inferior
vena cava. The lymphatic ganglia of the iliac chain are ordinarily placed on
either side of the artery. The ureter normally crosses the left common iliac
artery nearly perpendicularly. On the right side the ureter usually crosses
below the bifurcation, passing over the external iliac ; exceptionally the ureter
passes over the common iliac on the right side (Fig. 20). The vessels are
covered by peritoneum and the subperitoneal cellular tissue.
Operation. — (1) TEANSPERITONEAL. — The patient is placed in the Tren-
delenburg position. An incision about 10 cm. (4 in.) in length is made along
the outer border of the rectus muscle, and the abdominal cavity opened. The
intestines and omentum are pushed upward and held back by suitable gauze
pads. The vessel is identified by touch and sight. A small opening is made
COMMON ILTAO ARTEKY
433
in the peritoneum over the artery and the aneurysm needle threaded with the
ligatures passed about the vessel. The needle is passed from without inward
on the right, and from within outward on the left. The ureter is carefully
avoided in making the peritoneal incision, and the ligature is passed in close
contact with the artery to avoid injuring the veins. The needle is withdrawn
\
FIG. 21. — LIGATURE OF LEFT INTERNAL ILIAC. The utero-ovarian vessels are divided. The ureter is
seen in the upper part of the internal lip of the incision. (Proust and Maurer.)
and the ligature tied, the peritoneum sutured, and the abdominal incision
closed by the usual layers of sutures.
(2) EXTEAPEEITONEAL. — The patient is placed in the Trendelenburg posi-
tion. The incision begins near the apex of the cartilage of the last rib, passes
downward and outward to a finger's breadth above the crest of the ilium, and
then runs parallel to the crest just below the anterior superior spine. The
muscles of the abdominal wall are cut through down to the peritoneum. The
peritoneum is then gently separated by blunt dissection from the tissues be-
29
434 LIGATIONS OF AKTEEIES IN CONTINUITY
neath until the arteries are felt. The peritoneum and abdominal muscles
are then retracted inward. The arteries can now be easily seen. The ureter
is lifted up with the peritoneum. The aneurysm needle armed with a ligature
is passed from without inward on the right, and from within outward on
the left. The needle is made to hug the vessel and is passed very gently
to avoid injuring the veins. The ligature is tied, the peritoneum allowed
to fall back in place, the muscle sutured in layers, and the skin incision
closed.
Kesults. — The mortality, taken from the statistics of Kummell from the
operations done before the antiseptic period, is high, about 75 per cent. In
the recent figures of Delbet (9) the proportion of deaths is 22 per cent. Gil-
lette (13) gives the mortality in 21 cases done since 1880 as 47 per cent.
Gangrene of the extremity is said to follow in 53 per cent, of the cases reported
(Wolff, 29), but Delbet gives its occurrence as 22 per cent., and according
to Gillette (13) it has occurred in 33% per cent, of the cases he has tabulated.
INTERNAL ILIAC ARTERY
Anatomy. — The common iliac artery bifurcates at the lower border of
the fifth lumbar vertebra, near the sacro vertebral angle at 3 to 5 cm. (1 1/10
to 2 in.) from the middle line. The internal iliac extends from this point
downward toward the great sacrosciatic foramen, near the upper border of
which it divides. The commencement of the artery crosses the upper end of
the external iliac veins, and the internal iliac veins lie behind and to its inner
side. The artery is covered by the peritoneum. On the left side the peri-
toneum covering the artery is exposed if the sigmoid is lifted upward. In the
female the infundibulopelvic ligament containing the ovarian vessels crosses
the artery. The ureter is adherent to the peritoneum and is lifted up with
the peritoneum when this is divided. On the right side the ureter usually
passes down to the outside of the artery. Occasionally when the bifurcation
of the common iliac is lower, the ureter passes downward below the internal
iliac after crossing the common iliac (Fig. 20). On the left side the ureter
usually crosses the iliac vessels at their bifurcation; occasionally it crosses
the common iliac internal to this point; and less commonly still, when the
bifurcation is high, the ureter crosses the external iliac and passes downward to
the outside of the internal iliac.
Operation. — The patient is placed in the Trendelenburg posture. The ab-
domen is opened in the middle line, beginning at the level of the navel and
passing downward for about 10 cm. (4 in.). The intestines are pushed up-
ward and held in place by suitable gauze pads. The common iliac is identi-
fied and followed down to its bifurcation. The ureter is easily recognized and
the peritoneum is carefully incised, avoiding this structure. An aneurysm
needle is gently passed about the artery at a point about 2 cm. (4/5 in.)
GLUTEAL ARTERY
435
FIG. 22. — LIGATURE OF THE RIGHT INTERNAL ILIAC. The ureter with the peritoneum retracted to one
side, exposing the internal iliac. (Proust and Maurer.)
from its origin. The needle is kept in close contact with the artery, which at
this point is intimately related to the iliac veins (Figs. 21, 22).
Results. — The vessel has usually been ligated to control the hemorrhage
in pelvic operations. Transperitoneal aseptic ligating is accompanied by a
low mortality rate. Proust and Maurer (20) report 8 cases with 1 death, in
which the vessel was ligated in the course of abdominal hysterectomy for
cancer.
GLUTEAL ARTERY
Anatomy. — The gluteal artery passes out of the pelvis between the pirifor-
mis and the upper border of the sacrosciatic notch. It is accompanied by two
43G
LIGATIONS OF ARTERIES IN CONTINUITY
large veins, one lying in front, the other — usually the larger — lying behind
the artery. The superior gluteal nerve passes out of the pelvis with the
artery, but in front and to the outer side of the vessel. The gluteus maximus
covers the artery (Fig. 23). The artery lies at the junction of the upper and
GLUTEAL ,
ARTERY /
SCIATIC
ARTERY
PUDIC
ARTERY
GREAT
TROCHANTER
TUBEROSITY
ISCHIUM
'GREAT SCIATIC NERVE
FIG. 23. — THE GLUTEAL AND SCIATIC ARTERIES. (Poirier.)
middle third of a line drawn from the posterior superior spinous process of
the ilium to the great trochanter with the thigh rotated inward.
Operation. — The patient is placed face down with the thighs extended and
rotated in. An incision is made along the line extending from the posterior-
superior spinous process of the ilium to the great trochanter. This incision lies
in the direction of the fibers of the gluteus maximus. The fibers of this muscle
are separated, and the gluteus medius covered by its fascia exposed. This fascia
is divided and the lower margin of the gluteus medius freed by blunt dissection
or retracted upward. The upper margin of the great sacrosciatic notch can then
be easily felt, and between this margin and the piriformis the artery is exposed
and ligated, the accompanying veins and nerve being carefully avoided.
INTERNAL PUDTC ARTERY 437
SCIATIC ARTERY
Anatomy. — The sciatic artery passes out of the pelvis below the piriformis
muscle, and passes downward between the great trochariter and the tuberosity
of the ischium. As it passes out of the pelvis it lies to the inner side of the
sciatic nerves and passes over the internal pudic vessels and nerve (Fig. 2^ ).
Operation, — The patient is placed prone. An incision is made parallel to
the line drawn from the posterior superior spinous process of the ilium to the
great trochanter with the thigh rotated inward, and two fingers' breadth below
it. The fibers of the gluteus maximus are separated and the lower edge of the
piriformis exposed. The sciatic nerves are gently retracted outward. The vein
which lies to the outer side of the artery is pushed to one side and a ligature
passed about the artery.
INTERNAL PUDIC ARTERY
Anatomy. — The internal pudic artery leaves the pelvis by the great sacro-
sciatic notch in the space between the border of the piriformis and the superior
border of the lesser sacrosciatic ligament. It then passes over the ischial spine
and through the small sacrosciatic foramen, to continue above the outer wall
of the ischiorectal fossa, being placed about 2 cm. (4/5 in.) above the lower
margin of the tuberosity of the ischium. As it crosses the spine of the ischium,
the sciatic nerve is in front and to its outer side.
The internal pudic nerve, which accompanies the artery, is behind it, pass-
ing over the summit of the ischial spine and over the commencement of the
lesser sacrosciatic ligament. The vessel then runs along the outer wall of the
ischiorectal fossa. It is covered, in this part of its course, by a layer derived
from the obturator fascia (Fig. 23).
Operation. — The vessel may be ligated (1) as it emerges from the sacro-
sciatic foramen or (2) in the perineum.
(1) The incision is made parallel to the line drawn from the posterior su-
perior spine of the ilium to the trochanter major and two fingers' breadth below
it. The gluteus maximus is separated and retracted, and the lower border of the
piriformis defined. The gluteal artery is retracted upward and the pudic
artery, as it passes over the spine of the ischium, is exposed and ligated.
(2) The patient is placed in the lithotomy position. A longitudinal in-
cision, along the mesial border of the tuber ischii and about 10 cm. (3.94 in.)
long, is made through the skin and the cellular tissue. Anteriorly, the trans-
verse muscle of the perineum is avoided and retracted forward ; posteriorly, the
posterior border of the gluteus maximus is exposed. The fascia covering the
internal surface of the obturator is divided, the deeply placed internal pudic
artery and nerve exposed, and the ligature passed about the artery.
438 LIGATIONS OF AHTEEIES IK CONTINUITY
EXTERNAL ILIAC ARTERY
Anatomy. — The course of the external iliac artery corresponds to the lower
two-thirds of a line, drawn from a point 1 cm. below and to the left of the navel
to a second point halfway between the anterior superior spine of the ilium and
the symphysis pubis. The length of the vessel varies according to the point of
bifurcation of the common iliac, averaging 10 cm. In its course downward the
artery rests against the inner border of the psoas. It is covered by the peri-
toneum and is crossed on the right side by the lower part of the ilium and on the
left by the sigmoid flexure. The external iliac vein lies at first behind the
artery and a little to its inner side ; but as the vessels reach the inguinal region,
they are on the same level, and the vein lies to its inner side. Near its termina-
tion the artery is crossed by the circumflex iliac vein and three or four lymph
glands lie along its outer and inner sides. The spermatic (or ovarian vessels)
and the genital branch of the genitocrural intersect it near the inguinal liga-
ment. On the right side the ureter usually crosses the external iliac just below
the bifurcation, except when the latter is very low ; on the left side, it generally
crosses at the bifurcation, only intersecting the external iliac when the division
of the common iliac into its two branches is very high (Fig. 20).
Operation — (i) EXTEAPEEITONEAL METHOD.— The patient is placed in
the Trendelenburg posture. An incision is made parallel to and above the mid-
dle third of Poupart's ligament. The skin, superficial fascia and the aponeu-
rosis of the external oblique are divided. The lower margins of the internal
oblique and transversalis are separated and retracted upward, and the trans-
versalis fascia divided by blunt dissection. The peritoneum and the subserous
tissue are then gently displaced upward and held by retractors. This exposes
the vessels. The sheath is opened and an aneurysm needle with the ligature
passed from within outward.
(2) TRANSPEKITONEAL METHOD. — The usual incision for exposing the ap-
pendix is made midway between the anterior superior spine of the ilium and the
semilunar line. The aponeurosis of the external oblique is divided, the internal
oblique and the transversalis are separated, and the peritoneum opened. A
small gauze pad is inserted into the wound, pushing the coils of intestine away
from the peritoneum covering the external iliac artery. The wound margins are
retracted and the peritoneum covering the vessel pinched up and divided. With
an aneurysm needle a ligature is carried about the vessel from within outward.
Results. — The mortality following ligature of the external iliac has been
much reduced in recent years. Monod and \7an Vert (18) collected 7 cases with
no death. Kermission in the period from 1874 to 1883 gives a mortality of
12.5 per cent.
The frequency of gangrene following ligature of the external iliac has been
variously stated. Wolff (29) gives it as occurring in 5.26 per cent, of the
patients in which the artery was ligated for aneurysm.
FEMORAL ARTERY 439
DEEP EPIGASTRIC ARTERY
Anatomy. — The deep epigastric is given off from the external iliac just as
that vessel passes beneath the inguinal ligament, and continues upward and in-
ward to a point situated 2 cm. (.79 in.) external to the navel. At its origin it
passes mesial to the internal abdominal ring. It lies between the fascia trans-
versalis and the peritoneum and enters the rectus sheath at the semicircular
fold of Douglas. A line drawn from the navel to the mid point of the inguinal
ligament corresponds to the course of the artery.
Operation. — An incision is made parallel to the inguinal ligament and about
3 cm. (1.18 in.) above it. The aponeurosis of the external oblique is divided
and the lower fibers of the internal oblique and transversalis are separated and
retracted upward. The transversalis fascia is then divided, exposing the vessel
with its two accompanying veins. The ligature is passed about the artery and
tied. The vessel may also be tied somewhat high up, as it passes beneath the
margin of the rectus abdominalis.
The incision, parallel to the inguinal ligament and about 5 cm. (1.97 in.)
above it, is made through the sheath of the rectus and the aponeurosis of the
lateral abdominal muscle just external to the rectus. Separation of the trans-
versalis fascia exposes the artery with its veins as it passes beneath the rectus.
DEEP CIRCUMFLEX ILIAC ARTERY
Anatomy. — The vessel passes upward and outward from its origin, outside
of the external iliac, behind the inguinal ligament. It lies on the iliacus muscle
in a fibrous compartment formed by the junction of the transversalis and iliac
fasciae
Operation. — The incision is made over the outer third of Poupart's ligament
and just above it. The skin, subcutaneous tissue and the aponeurosis of the ex-
ternal oblique are divided. The internal oblique and transversalis are sep-
arated and retracted upward. The fascia transversalis is opened, and the peri-
toneum gently displaced upward, thus exposing the iliacus muscle covered by its
fascia. On opening the iliac fascia the artery is exposed and ligated.
FEMORAL ARTERY
Anatomy. — The course of the vessel is indicated by a line extending from a
point midway between the anterior superior spine of the ilium and the symphy-
sis pubis, downward to the adductor tubercle of the femur; the thigh being
flexed, everted and slightly adducted. The upper 4 cm. of this line corresponds
440
LIGATIONS OF AETERIES IN CONTINUITY
4
to the common femoral; the upper two-thirds to the common and the super-
ficial femoral. As it passes through Scarpa's space, the vessel is covered by the
skin, subcutaneous tissue, the iliac portion of the fascia lata and, in the upper
part, by the femoral sheath. It then enters a canal made by the fibrous mem-
brane which passes over the artery from the abductor to the extensor muscles
and is covered by the sartorius muscle.
The femoral vein lies at first to the inner
side of the artery, becomes more posterior
at the level of the apex of Scarpa's tri-
angle, and as it passes down through
Hunter's canal, is situated distinctly be-
hind the artery. In Hunter's canal the
internal saphenous nerve accompanies the
artery, lying along its anterior surface, arid
the internal cutaneous crosses its upper
part.
Operation.— LIGATION OF THE COM-
MON FEMOEAL. — The patient is placed in
the dorsal position with the thigh fiexed
and rotated out. An incision is made
parallel to and just below Poupart's liga-
ment, corresponding to its middle third.
The skin and superficial fascia are di-
vided and the deep fascia exposed. This
is then carefully incised in the line of the
incision and retracted, bringing to view the
artery with the vein to its inner side and
the iliopsoas to the outer side. The sheath
of the vessel is divided over the artery and
an aneurysm needle passed from within
outward, or the vessel may be exposed
through a vertical incision (Fig. 24).
RESULTS. — Ligation of the common
femoral is said to be followed by gangrene in 25 per cent, of the cases (Wolff,
29). But 5 cases are referred to by Monod and Van Vert (18), when the
common femoral was ligated without any disturbance in the nutrition of
the leg.
LIGATUKE OF THE SUPERFICIAL FEMORAL AT THE APEX OF SCARPA'S
TRIANGLE. — The patient is placed in the dorsal position with the thigh flexed
and rotated outward. An incision about 10 cm. (3.94 in.) long is made along
the line extending from the mid point of Poupart's ligament to the adductor
tubercle and terminating just below the junction of the upper and middle third
of the thigh. The sartorius is exposed and retracted to the outer side. The
artery can be felt beneath the fascia. The sheath of the vessel is carefully in-
FIG. 24. — LEFT FEMORAL ARTERY EXPOSED
BY INCISION OF THE INTEGUMENT AND
THE CRIBRIFORM FASCIA. 1, Lymph
gland; 2, inguinal ligament; 3, 3, edges
of the divided cribriform fascia; 4, super-
ficial circumflex artery; 5, superficial epi-
gastric; 6, external pudendal artery; A,
femoral artery; J, superficial femoral; P,
deep femoral.
POPLITEAL ARTERY
441
cised and an aneurysm needle passed from within outward. The vein lies be-
hind and to the inner side of the artery in this situation (Fig. 24).
LIGATURE OF THE SUPERFICIAL FEMORAL IN HUNTER'S CANAL. — The
patient is placed in the dorsal position with the thigh and leg flexed and the
thigh rotated outward. An incision about 10 cm. (3.94 in.) long is made in the
line of the vessel, having its center at the junction of the middle and lower third
of the thigh. The line of the
vessel is the line drawn from ^Tr
the middle of Poupart's liga-
ment to the adductor tubercle
of the femur. The sartorius
muscle is exposed and re-
tracted inward. The fibrous njgOTfff^flfj/ftl ^^ -.^^ — S
membrane extending over the
artery from the tendon of the
adductor m a g n u s to the
vastus internus is divided.
This exposes the artery with
the long saphenous nerve
resting on it. The nerve is
freed and held to one side by
a retractor, and an aneurysm
needle is passed about the
vessel from without inward.
The vein lies behind the ar-
tery and sometimes a little to
its outer side (Fig. 25).
RESULTS. — According to
the table of Wolff (29),
there has been necrosis of
the extremity following the ligation of the superficial femoral in 4.2 per cent,
of the cases reported.
FIG. 25. — EXPOSURE OF THE FEMORAL ARTERY. V.i., Vastus
medialis; S, sartorius. The fibrous sheath of Hunter's
canal is divided exposing the femoral artery and vein.
POPLITEAL ARTERY
Anatomy. — The lineal projection of the popliteal artery is represented by
a vertical line which bisects the popliteal space. In the upper part of the space
the vessel lies a little to the mesial side of this vertical line, beneath the lateral
border of the semimembranosus.
The femoral artery terminates at the point where the popliteal emerges
from the opening for the vessels in the adductor magmis, at the upper part of
the popliteal space, under cover of the semimembranosus. The popliteal artery
terminates at the lower border of the popliteus, on a level with the lower part of
442
LIGATIONS OF AETEKIES IN CONTINUITY
the tuberosity of the table, where it divides into the anterior and posterior tibial
arteries. From its origin the artery descends with a slight lateral inclination
to the interspace between the condyles of the femur, whence it continues its
course vertically downward to its termination.
From above downward it lies upon the popliteal surface of the femur, the
posterior ligament and the fascia covering the popliteus.
Superficial to the artery above is the lateral border of the semimembranosus.
At about the middle of its course it is crossed in a direction downward and
inward by the popliteal vein and more superficially by the tibial nerve (internal
popliteal). In the lower part of its course
it is overlapped by the adjacent borders of
the medial and lateral heads of the gas-
trocnemius and crossed by the plantaris
and the nerves to the soleus popliteus and
plantaris.
On its mesial side from above down-
ward are the semimembranosus, the mesial
condyle of the femur, the tibial nerve, the
femoropopliteal vein and the mesial head
of the gastrocnemius.
On its lateral side from above down-
ward are the tibial nerve, the femoropop-
liteal vein, the lateral condyle of the femur,
the lateral head of the gastrocnemius, and
the plantaris. Lymphatic glands are dis-
tributed about the vessel in an irregular
way.
Operation. — Ligature of the artery in the
upper and lower parts of the popliteal space
will be described.
UPPER PAET OF THE POPLITEAL SPACE.
—The patient should be on his back,
the knee somewhat flexed and supported
by a sandbag, the thigh rotated out-
ward.
An incision 10 cm. (3.94 in.) in length is made parallel and a little posterior
to the adductor magnus, and carried down to the level of the adductor tubercle.
The saphena magna (internal saphenous vein) is retracted inward and the fascia
lata divided, exposing the sartorius. This is retracted inward and backward,
and together with it the saphenous nerve. The tendon of the adductor magnus
is now exposed, with the tendons of the hamstrings lying behind it. A division
is made between the hamstrings and the adductor magnus, and the former re-
tracted inward and the latter outward toward the bone. The artery now comes
into view with the femoropopliteal vein lateral to it, and the tibial nerve (in-
FIG. 26. — EXPOSURE OF POPLITEAL AR-
TERY. S, Semimembranosus; B, bi-
ceps ; T, lateral and medial head of the
gastrocnemius; A, artery; V, popliteal
vein.
POSTERIOR TIBIAL ARTERY
443
ternal popliteal) still more lateral and not in contact. The sheath of the vessel
is opened and the needle passed from without inward.
LOWER PAKT OF POPLITEAL SPACE. — The patient should be prone. An
incision 10 cm. (3.94 in.) in length is made along the linear guide to the ves-
sel, opposite the lower half of the popliteal space. This incision is carried down
through the tendinous intersection of
the gastrocnemius, so as to separate the
upper parts of the two heads of the mus-
cle. The tibial nerve is now exposed
and retracted laterally. The femoro-
popliteal vein is next identified and re-
tracted mesially, exposing the artery.
Care should be taken in passing the
needle about the artery not to injure the
middle, the inferior lateral or the in-
ferior mesial arteries of the knee,
given off at this level (Fig. 26).
Results. — If the collateral vessels
are free, ligature of the popliteal is not
followed by gangrene.
POSTERIOR TIBIAL ARTERY
Anatomy. — The linear projection of
the posterior tibial artery is represented
by a line drawn from the center of the
popliteal space to a point midway be-
tween the mesial malleolus and the tu-
berosity of the calcaneum.
The posterior tibial artery com-
mences at the lower border of the pop-
liteus and terminates at a line drawn be-
tween the tip of the mesial malleolus
and the prominence of the tuberosity of
the calcaneum at the level of the lower
border of the ligamentum laciniatum
(internal annular ligament), where it
divides into the mesial and lateral
FIG. 27. — THE COURSE AND RELATIONS OP
THE POSTERIOR ARTERIES OF THE LEO. lt
Biceps; 2, the tibial nerve (internal popliteal) ;
3, the cut sections of the upper portions of the
gastrocnemius ; 4, the tibial nerve and the
popliteal artery just before they pass through
the opening in the soleus; 5, section of the
soleus; 6, long peroneal muscle; 7, long flexor
of the great toe and the peroneal artery; 8,
short peroneal muscle ; 9, deep aponeurosis ; 10,
section of the tendo Achillis; 11, long flexor
of the toes; 12, tendon of the posterior tibial
muscle; 13, posterior tibial artery; 14, tib-
ial nerve; 15, popliteal muscle; 16, tendon
of the sartorius semitendinosus; 17, aemi-
membranosus.
plantar arteries.
The artery pursues a downward and inward course alorig the back of the
leg, lying upon the deep layer of muscles and covered by the fascia cruris (deep
transverse fascia) and superficial layer of muscles.
From above downward the artery lies upon the tibial posterior, the flexor
444
LIGATIONS OF AETERIES IN CONTINUITY
longus digitorum, the posterior surface of the tibia and the ligamentum talo-
tibiale posterius. The artery is crossed from within outward, about 3 cm. (1.18
in.) below its origin, by the tibial nerve. It is covered throughout its course
by the fascia cruris. More superficially it is covered in the upper part of the
leg by the gastrocnemius and the soleus, with the plantaris between them. In
the lower part of its course the artery is covered only by skin and fascia, except
at its termination, where it passes beneath
the ligamentum laciniatum (internal annular
ligament) and the origin of the adductor
hallucis. The artery has a vein on either
side. The tibial nerve (posterior tibial
nerve) lies at first to the mesial side of the
vessel, then crosses superficial to it, and is
continued down on the lateral side. As the
vessel curves forward behind the mesial
malleolus, it lies upon the tendons of the pos-
terior tibial and flexor longus digitorum, with
the tendon of the flexor longus hallucis be-
hind and lateral to it (Fig. 27).
Operation. — The patient should be on his
back, with the thigh rotated externally and
the knee flexed to a right angle and supported
upon a sandbag. The artery can be ligated
at any point in its course. Ligature in the middle of the leg and behind the
medial malleolus will be described.
IN THE MIDDLE OF THE LEG. — An incision 10 cm. (3.84 in.) in length,
beginning opposite the most prominent part of the calf, is made parallel to, and
about a finger's breadth posterior to the mesial border of the tibia. The large
saphenous vein (internal saphenous vein) and saphenous nerve are identified
and retracted. After division of the fascia lata the mesial border of the gas-
trocnemius comes into view and is retracted laterally, exposing the muscular
fibers of the soleus which arise from the middle third of the mesial border of
the tibia. These are divided in the line of the skin incision exposing the fascia
cruris (deep transverse fascia of the leg). This is opened in the same direc-
tion and the flexor longus digitorum with the posterior tibial lying lateral to
it is exposed. The artery lies between these muscles with the tibial nerve
lateral to it. After the artery has been freed from its veins, the needle should
be passed from without inward.
BEHIND THE MEDIAL MALLEOLUS. — The position should be the same as in
the preceding operation.
A curved incision 8 cm. (3.15 in.) in length, with its concavity anterior, is
made a finger's breadth posterior to the mesial malleolus. The ligamentum
laciniatum (internal annular ligament) is divided in the same direction, expos-
ing the artery lying upon the tendons of the posterior tibial and flexor longus
FIG. 28. — EXPOSURE OF POSTERIOR TIB-
IAL BEHIND THE MEDIAL MALLEOLUS.
The fascia is divided exposing the
artery with the veins. (Zuckerkandl.)
ANTERIOR TIBIAL ARTERY 445
digitorum, with the tibial nerve and tendon of the flexor longus hallucis behind
and lateral to it. After freeing the vessel from its accompanying veins, the
needle is passed from behind forward (Fig. 28).
PERONEAL ARTERY
Anatomy. — The linear projection of the peroneal artery is represented by a
line drawn from the posterior border of the head of the fibula to a point midway
between the lateral malleolus and the tendo ealcaneus (Achillis).
The peroneal artery commences about 2.5 cm. below the lower border of the
popliteus, curves laterally across the upper part of the posterior tibial to the
medial crest (postero-internal border) of the fibula, along which it descends
to the lower part of the interosseous space, and terminates about 1 inch above
the ankle joint by dividing into anterior and posterior terminal branches.
As the artery passes laterally from its origin, it lies upon the posterior tibial
muscle and is covered by the fascia cruralis (deep transverse fascia) and by
the soleus. As it descends along the medial crest (postero-internal border) of
the fibula it lies in a fibrous canal upon the posterior tibial and is covered by
the flexor longus hallucis. It is accompanied by two venae comites (Fig. 27).
Operation. — The artery can be ligated at any point in its course. Ligature
in the upper and lower third of the leg will be described.
UPPEB THIKD. — The position of the patient is the same as in the two pre-
ceding operations. The incision and steps of the operation are the same as in
the ligature of the posterior tibial in the middle of the leg. After the division
of the fascia cruris (deep transverse fascia) the artery is found lying upon the
posterior tibial and partially overlapped by the flexor longus hallucis. After it
has been separated from its veins, the needle may be passed in either direction.
LOWEK THIRD.— The patient should be face down, with a sandbag under
the ankle. An incision 8 cm. (3.15 in.) in length is made along the line of the
vessel on the lower third of the leg. After division of the deep fascia, the soleus
is exposed and drawn inward, bringing the flexor longus hallucis into view.
The attachment of this muscle to the fibula is divided in the direction of the
skin incision, exposing the artery lying upon the lateral border of the posterior
tibial muscle. The artery is separated from its veins and the needle passed in
either direction.
ANTERIOR TIBIAL ARTERY
Anatomy. — The linear projection of the anterior tibial artery is represented
by a line drawn from the superior tibiofibular articulation to a point on the an-
terior aspect of the ankle joint midway between the mesial and the lateral
malleoli.
The anterior tibial commences opposite the lower border of the popliteus and
446
LIGATIONS OF AETEKIES IN CONTINUITY
terminates in front of the ankle joint, where it is continued into the dorsalis
pedis.
From its origin it passes forward between the two uppermost slips of the
posterior tibial and above the upper border of the interosseous membrane upon
which it lies for the upper two-thirds of its course down the leg. In the lower
third it lies upon the shaft of the tibia and the anterior ligament of the ankle
joint. In the upper third of the leg it lies between the extensor longus digi-
torum externally and the anterior tibial in-
ternally; in the middle third between the
extensor longus hallucis and the anterior
tibial ; in the lower third the extensor longus
hallucis crosses in front of the artery to its
inner side, and the lower part of the vessel
lies between the tendon of the extensor
longus hallucis and the innermost tendon of
the extensor longus digitorum.
The anterior tibial nerve lies to the
lateral side of the artery above, in front of it
in its middle third, and to the lateral side
again below, where it intervenes between the
artery and the innermost tendon of the ex-
tensor longus digitorum.
The artery is accompanied by two venae
comites.
In the greater part of its extent the artery
is easily accessible from the surface, being
crossed by the nerve and tendon, as already
described, and covered by skin, fascia, and
the ligamenturn transversum cruris (Figs.
29, 30 and 31).
Operation. — The anterior tibial artery can be ligated at any point in its
course after it has gained the anterior aspect of the leg. Ligature of the artery
in its upper and lower thirds will be described.
IN THE UPPEE THIED. — The patient should be on his back, with the knee
slightly flexed, and supported by a sandbag.
An incision 10 cm. (3.94 in.) in length is made along the line of the artery,
commencing about two fingers' breadth below the lateral condyle (external tu-
berosity) of the tibia, and deepened to expose the aponeurosis covering the
extensor muscles of the leg. This aponeurosis is incised in the line of the skin
incision, the anterior tibial muscle and the extensor digitorum are separated by
blunt dissection, thus exposing the artery on the interosseous membrane. The
artery is separated from its accompanying veins, which lie to either side of it,
and the needle passed from without inward. The deep peroneal nerve lies to
the lateral side and not in contact with the artery.
FIG. 29. — EXPOSURE OF THE ANTERIOR
TIBIAL OF LEFT LEG. The fascia
is divided and the anterior tibial
muscle (La.) retracted medially and
the extensor hallucis (e.h.) laterally;
in the interval between the muscles
the deep peroneal nerve and under it
the artery and veins accompanying
it are visible.
DORSALIS PEDIS AETERY
IN THE LOWER THIRD. — The position of the patient is the same as in the
preceding operation.
An incision 10 cm. (3.94 in.) in length is made along the line of the artery,
just to the lateral edge of the tendon of the anterior tibial muscle, and carried
through the fascia lata. A division is made between the tendons of the anterior
tibial and extensor longus hallucis, care being taken not to open the sheath of
isle'? is 19
87
FIG. 30. — MUSCLES AND ARTERIES OF THE LEG AND DORSUM OF THE FOOT. 1, Anterior tibial; 2, long
extensor of great toe; 3, extensor longus digitorum; 4, anterior tibial artery pulled out of its bed by
a loop; 6, dorsal artery of the foot.
the anterior tibial muscle. The artery is now exposed, lying upon the lateral
surface of the tibia, with a vein to either side and the deep peroneal nerve in
front of it above, and lateral to it below. The needle should be passed from
without inward (Fig. 28).
DORSALIS PEDIS ARTERY
Anatomy. — The linear projection of the dorsalis pedis artery is represented
by a line drawn from a point on the anterior aspect of the ankle joint midway
between the two malleoli to the apex of the web between the great toe and sec-
448
LIGATIONS OF AETERIES
CONTINUITY
ond toe. The artery is subcutaneous throughout the greater part of its course,
and its pulsations can ordinarily be felt (Figs. 30 and 31).
The dorsalis pedis artery, a direct continuation of the anterior tibial, ex-
tends from the front of the ankle joint to the posterior extremity of the first
interosseous space, through which it passes to the plantar surface of the foot,
and, by anastomosing with the lateral plantar, completes the plantar arch.
In its course along the dor sum of the foot it lies upon the
anterior ligament of the ankle joint, the head of the astraga-
lus, the astragalonavicular ligament, the dorsum of the
navicular bone, the dorsal naviculocuneiform ligament and
the dorsal intercuneiform ligament between the internal and
middle cuneiforms. The medial terminal branch of the deep
peroneal nerve, the extensor brevis digitorum and the inner-
most tendon of the extensor longus digitorum are placed
laterally. The tendon of the extensor longus hallucis lies
medially. It is covered by skin, fascia and the lower part of
the annular ligament. It is crossed near its termination by
the innermost tendon of the extensor brevis digitorum.
Operation. — The patient should be on his back with the
foot extended.
The dorsalis pedis can be ligated at any point between its
origin and the posterior extremity of the first interosseous
space. Owing to the shortness of the vessel, ligature at any
point in the vessel's course can be accomplished through one
incision.
An incision is made along the line of the artery, begin-
ning at a point opposite the tips of the two malleoli and carried to the pos-
terior extremity of the first interosseous space. After division of skin and
fascia, the tendon of the extensor longus hallucis will be seen lying to the
mesial side of the incision, with the innermost tendon of the extensor
longus digitorum lateral to it. In the upper angle of the incision, these
two tendons are bound down by the lower part of the annular ligament. In
the lower angle of the incision the innermost tendon of the extensor brevis
digitorum crosses from without inward. To expose the artery in the upper
part of the incision the lower part of the annular ligament must be divided
in the line of the skin incision, and the tendons retracted to either side.
The artery lies between the tendons with a vein to either side and the deep
peroneal nerve to its lateral side. In the lower angle of the incision the
innermost tendon of the extensor brevis digitorum must be retracted lat-
erally to expose the artery. In both instances, after the artery has been
separated from its veins, the needle should be passed from without inward.
In closing the wound care should be taken to repair the divided lower part of
the annular ligament.
FIG. 31. — LINE OF
DORSAL ARTERY
OF THE FOOT AND
OF THE ANTERIOR
TIBIAL.
BIBLIOGRAPHY 449
BIBLIOGRAPHY
1. BALDWIN, J. F. Synchronous Lig. of Subclavian and Carotid for Aneur-
ysm of Innominate, Journ. Am. Med. Assn., Iviii, 113.
2. BALLANCE and EDMUNDS. Treatise on Ligature of Great Arteries in Con-
tinuity, London, 1891.
3. BLAKE, J. A. Aneurysm of the Second and Third Portions of the
Rt. Subclavian; Proximal and Distal Lig., Ann. Surg., 1900, xliii,
919.
4. BUENS, W. B. Successful Lig. of the Innominate Artery, Jour. Am. Med.
Assn., 1908, li, 1671.
5. CHALIEE, A., and MUEAED, J. Lig. of Common Iliac Artery and Neigh-
boring Vessels, Rev. de Chir., 1912, Feb., xxxii, No. 2, 153-368.
6. CUETIS, B. F. Lig. of First Portion of Subclavian, Ann. Surg., 1897,
xxvii, 540.
7. — . Lig. of Innominate Artery, Ann. Surg., 1900, xxxi, 629.
8. DE FOUEMESTEAUX, J. These de Paris, 1906-1907, No. 292.
9. DELBEET, PIEEEE. Chirurgie arterielle et veineuse, xv, Cong. Internat.
de Med., 1906, 46.
10. DESCOMPS, P. Technic of Lig. of External Carotid, Presse med., 1912,
April 20, xxxii, 325-336.
11. DUVAL. Technique operatoire de la lig. de la sous-claviere en dedans des
scalenes et dans le mediastin, Rev. de chir., 1910, xlii, 1095.
12. FOEGUE et BOTHEZAT. Arch, de Med. experiment., 1894, vi, 473-512.
13. GILLETTE, W. J. Lig. of Left Common Iliac Art., Ann. Surg., 1908,
xlviii, 22.
14. HEEZEN, P. Deutsch. Ztschr. f. Chir., 1910, March, civ, 209-423.
15. JACOB and ROWLANDS. Lig. of Arteries of Head and Neck, Operations
of Surgery, 5th Edition.
16. LILIENTHAL. Aneurysm of Rt. Subclavian, Ann. Surg., 1905, xlii, 272.
17. MIKTJLICZ. Ein Fall von nicht traumatischen Aneurysm der Ar. Verte-
bralis, Arch. f. klin. Chir., 1896, Hi, 23-24.
18. MONOD et VAN VEETS. Chir. des arteres, Paris, 1909.
19. NEFF, J. M. Successful Lig. of 1st Part of Subclavian, Ann. Surg.,
1911, Oct., liv, No. 4.
20. PEOUST and MATJEEE. Ligature de Tartere hypogastrique dans Thysterec-
tomie abdominale, Jour, de Chir., 1913, xi, 141.
21. RUBEITIUS, H. Beitr. z. klin. Chir., 1912, Ixxvi, 144.
22. SAIGO. Deut. Ztschr. f. Chir., Ixxxv, 577.
23. SAVAEIAUD. Rev. de Chir., 1906, xxxiv, 1.
24. SCHWATZ. Rev. de Chir., 1911, xliii, 116.
25. SHEEN, W. Lig. of Innominate Art., Ann. Surg., 1905, July, xlii,
No. 1.
30
450 LIGATIONS OF AKTEKIES IN CONTINUITY
26. SIEGRIST. Arch. f. Ophth., 1905, 51.
27. STONHAM. Lancet, 1902, Aug., 2.
28. WALDEYER, WILHELM. Das Trigonum Subclavian., Bonn, 1903.
29. WOLFF, E. Die Hauiigkeit der Extremitatennekrose nach. Unterbindung
grosser Gefasstamme, Beitr. z. klin. Chir., Iviii, T62-802.
CHAPTEK XII
PLASTIC SURGEKY, INCLUDING HAEELIP AND CLEFT
PALATE, ALSO THE PLASTIC SUKGERY OF THE LIPS, CHEEKS, EYELIDS, AND
EARS
PERCY R. TUBNTTRE
Plastic surgery is that branch of surgery which deals with the repair of
defects or malformations, either congenital or acquired, and the improvement
of cosmetic conditions.
GENERAL PRINCIPLES
To obtain successful results in any plastic operation, two fundamental prin-
ciples must be observed: first, as perfect an asepsis as possible in order to
obtain primary union ; and, second, no interference with the vitality of the
parts.
Complete asepsis is of the utmost importance, and the greatest care must be
exercised to insure it. Strong antiseptic solutions must never be used, as they
undoubtedly diminish the healing ability of the tissues. Therefore, if infection
does take place, the operation will not only fail, but the final result may be much
worse than the condition before operation.
To insure the nutrition of the transposed parts, the operation must be so
planned that the blood supply is sufficient, and that the vessels remain patent
and are not obliterated by either twisting or tension after the parts have been
secured in their new positions.
Treves (24) sums up these principles in the most excellent and compre-
hensive way, as follows :
"1. The common feature which underlies plastic surgery, as the term is usually
understood, involves the ready and secure union of refreshed or divided surfaces.
The operations for the most part concern the skin, and are dependent upon the vascu-
larity and elasticity of the skin, its mobility, the readiness with which wounds made
in it unite, and the comparative ease with which it may be displaced and with which
it moulds and adapts itself to a new situation.
"2. In the actual planning of incisions and the mapping out of flaps, little can
be done by following blindly any especial method. Each case must be considered upoa
451
452 PLASTIC SURGERY
its merits, and each operation arranged as the needs of the particular case suggest.
No branch of operative surgery demands more ingenuity, more patience, more fore-
thought or more attention to detail. In connection with certain operations it may
almost be said that no two cases are alike.
"3. As sound and rapid healing is essential in these operations, it is of primary
importance that the patient be in the best possible health and that the tissues in the
operation area be free from disease. Scar tissue can never be relied upon, and it is
needless to speak of the recklessness of plastic operations in the vicinity of active
syphilitic disease, or of lupus, or in aged or broken-down subjects. In many cases the
operation cannot be repeated; there is little before the surgeon but success or a condi-
tion more lamentable than mere failure. A plastic operation may leave the deformity
in a worse condition than it was before the case was approached, and before the pros-
pects of success are compromised the surgeon should be convinced that no possible
element of failure has been overlooked.
"4. In planning the flaps, it is necessary that they be derived from sound tissues,
that they be thick and include the subcutaneous tissue, that their vascularity be as-
sured and that they be so cut as to inflict the least possible damage upon the arteries
which supply them. The flap must be large enough, and as a rule should be one-sixth
larger than the space it has to fill; it must be gently handled, carefully adjusted and
most tenderly and precisely sutured. The pedicle of the flap must not be so twisted
or extended as to occlude the nutrient vessel. It is of the utmost importance that
there be no undue tension upon the parts, and that the edges of the wound be not
merely dragged together.
"5. The margins of any surfaces of skin which are to be brought together must be
evenly and liberally freshened. Throughout the whole progress of the case the strictest
antiseptic 1 precautions must be carried out, and the minutest care must be paid in
the after-treatment."
METHODS USED IN PLASTIC SURGERY
The following are the general methods used in plastic surgery for the re-
pair of loss of tissue or malformation on the surface of the body or mucous
membrane :
1. Suture and Tension. — This method consists simply in the freshening of
the edges of the skin or mucous membrane surrounding the area to be filled in,
and in the drawing together of the freshly cut edges by the correct insertion of
sutures. It is only applicable in small defects, or on parts of the body where
the skin is loosely attached or where a considerable amount of subcutaneous fat
exists. Liberating incisions through the neighboring healthy tissues are some-
times useful to relieve tension and insure the vitality of the parts (Fig. 1).
2. Gliding Flaps. — By this method the parts to be replaced are filled by
adjacent tissue. It is the one most commonly used. In its simplest form it
consists in undermining or undercutting the skin and subcutaneous tissues from
the deeper parts to an extent which will allow them to be placed in apposition
without tension (Fig. 2).
If the area to be covered is so extensive that this simple method cannot be
1 Aseptic.
METHODS USED IN PLASTIC SURGERY
453
I
t
1 U
FIG. 1. — METHOD OF CLOSING DE-
FECT BY SUTURE AND TENSION.
used, it is then necessary to make liberating incisions, usually 2 in number,
parallel to each other, thus forming a flap (Fig. 3).
If the area cannot be covered by the last procedure, either because of its
size or the difficulty in obtaining one flap of sufficient area, 2 flaps can be made,
1 on each side, as shown in Figure 4. To ob-
tain a smooth surface in this case, it may be
necessary to remove small triangles of skin, as
shown at A, B, C, and D. To cover a triangu-
lar defect, one of the 3 methods illustrated in
Figures 5, 6, and 1 may be employed.
3. The Gliding Flap with Rotation. — This
method also makes use of adjoining tissues to
fill the parts to be repaired. It is much used
and most useful, and is well illustrated in the
Estlander operation for restoring the lower lip
(page 502) and in the Davies-Colley operation
of uranoplasty (page 481). Always in this pro-
cedure care must be taken not to interfere with
the vitality of the flap by too sharply twisting
its base or pedicle.
A most useful modification of this method
is described by Croft (2), which may be called
the " granulation method." It is especially recommended for the relief
of cicatricial tissue following burns, and Mr. Croft has had remarkable suc-
cess with it. The method consists in freeing a flap of sufficient size from its
deeper parts, leaving it attached at both ends. The flap must be as thick as
possible, especially toward the center, and consists of all
the tissues down to the deep fascia. A layer of rubber
tissue or oil silk is placed between the raised flap and the
deeper parts, and the wound allowed to granulate for
from 2 to 3 weeks, when one of its attachments is cut and
the flap rotated into the position desired. By using this
method, Croft claims that: "1. The risks of sloughing
of any part are greatly diminished. Instead of being
transplanted when recently drained of blood and reduced
in temperature, it is removed when abundantly vascular
and full of active, living, plastic matter. 2. The trans-
plantation being made two or three weeks after the first
operation, the local effects of shock are avoided or re-
duced to a minimum.'' In this procedure the need of perfect asepsis, not only
for the operation, but during the time of granulation, is obvious and cannot be
too strongly emphasized.
4. Pedunculated Flaps. — These are flaps, lifted from their subjacent tissues
and left attached to the deeper parts by only a small pedicle, by means of which
FIG. 2. — METHOD OF
CLOSING DEFECT BY
UNDERMINING THE
SKIN.
454
PLASTIC SURGERY
FIG. 3. — METHOD OF CLOSING DEFECT BY SINGLE GLIDING FLAP.
the flap is nourished in its new position until healing and a new vascular supply
take place, and which is then severed. By the use of this type of flap it is
B
T-r | i ;
^ja-
I o 1 . \
<r*-r-«T-
*— <
— c
/ill]
I 111 ±7Vx A AI A
4c to
FIG. 4. — METHOD OF CLOSING DEFECT BY DOUBLE GLIDING FLAP.
possible to transfer to the part to be repaired a flap which has been derived
from a distant part of the body. A typical example of this method can be seen
in the operation of rhinoplasty as done
after the Indian technic, where a flap
from the surface of the arm is trans-
ferred to the face.
The reverse of the above is the so-
called pocket method, in which the de-
fect to be closed is brought to the flap.
For example, when it is desired to re-
store the tissues on the back of the
hand, a bridge of skin and subcutaneous
tissue of sufficient size is raised from
the abdomen or chest and the hand in-
serted and fixed until union between the
raw surfaces has taken place, when the attachments of the skin to the abdomen
are cut (Fig. 8).
5. Transplantation of Free Grafts. — These grafts may consist of skin, or
skin and subcutaneous tissue, or bone or cartilage, and can be taken from the
FIG. 5. — METHOD OF CLOSING TRIANGULAR
DEFECT BY GLIDING FLAP.
FIG. 6. — METHOD OF CLOSING TRIANGULAR DEFECT BY DOUBLE GLIDING FLAP.
FIG. 7. — METHOD OF CLOSING TRIANGULAR DEFECT.
, 8. — POCKET METHOD OF CLOSING DEFECT.
456 PLASTIC SUEGERY
surface of the abdomen or thigh. This method is especially useful in the clos-
ing of fresh defects caused by operation wounds, and a great advantage of it is
that the scar resulting from the removal of the flap is out of sight.
6. Skin Grafting. — For skin grafting, see page 519.
Cause of Failure.— The causes of failure are either infection or gangrene,
or both.
1. If infection shows itself along the suture line or in the deeper parts,
the wound must receive the regular treatment for such a condition. The su-
tures must be removed, drainage established, and wet dressings applied.
2. If, after 3 or 4 days, gangrene has developed, its character must be
determined as soon as possible, because if it is gangrene of the moist type, it is
due to infection, and the gangrenous area must be removed immediately. On
the other hand, if it is gangrene of the dry type, it is due to interference with
the blood supply of the flap, in which case it is best to allow the area to remain
until the line of demarcation is distinctly formed, when the gangrenous area
loosens by itself from the underlying tissues and may then be easily lifted off.
HARELIP AND CLEFT PALATE
Congenital fissures or clefts of the lips, the nostrils, the alveolar arch, the
hard palate, and the palatine velum are closely related, from the operative as
well as the embryological point of view. These malformations are frequently
associated, and their treatment consists in a sequence of restorative procedures
upon a very limited area.
Harelip is a fissure or cleft in the lip occurring as a congenital deformity
in children. It usually occurs in the upper lip and is very apt to be complicated
by an alveolar or velopalatine fissure.
Cleft palate is a congenital deficiency of the palate, in which there is a
fissure running in an anteroposterior direction, often involving the uvula, the
soft palate, or the hard palate, separately or together. Unless the condition is
congenital, it cannot properly be spoken of as a cleft palate.
Until the end of the second or the beginning of the third month of fetal life,
cleft palate is physiological. It has been shown by His that up to this time the
tongue lies above the free palatine margins, which later ascend and unite above
the tongue. Occasionally the same patient will have a harelip with a divided
velum or posterior portion of the hard palate and with the intermediate segment
of the palate intact. Malformations consisting of a labial and a velopalatine
fissure are not necessarily continuous, but are generally found to be so in cases
of double harelip associated with a deep double alveolar fissure. The solution
of continuity in these cases extends in the direction of the hard palate and the
velum, reaching from the upper lip to the posterior margin of the roof of the
palate.
Labiofissure or harelip has a predilection for the left side. Statistics indi-
HARELIP AND CLEFT PALATE 457
cate that more male than female children are born with harelip. The relative
frequency of the deformity is illustrated by the occurrence of 1 case among
2,400 infants in the St. Petersburg Asylum (Freobelius). The proportion of
the different varieties of deformities is well brought out in Hang's statistics of
555 cases:
Simple unilateral harelips 130
Simple bilateral harelips 18
Unilateral labiomaxillary clefts 21
Double labial clefts with one or two clefts of the alve-
olar margin 6
Unilateral labiopalatine clefts 27
Bilateral labiopalatine clefts 12
Unilateral labiomaxillary palatine clefts 226
Double harelip with unilateral labiomaxillary pala-
tine cleft 32
Bilateral labiomaxillary palatine clefts 83
Total 555
Summary of relative proportion of the cases :
Simple unilateral harelips 130 (25 per cent.)
Simple bilateral harelips 18 ( 3 per cent.)
Complicated unilateral harelips 274 (49 per cent.)
Complicated bilateral harelips 133 (23 per cent.)
The simple cases accordingly amount to 28 per cent., and the more or less
complicated cases amount to 72 per cent, or nearly % of the total number.
According to the statistics of these large compilations, about i/4 of the hare-
lip cases are bilateral. With special reference to the unilateral cases, % of
these concerned the left side and only !/£ the right. This remarkable pre-
dominance in the left side has never been satisfactorily explained.
VARIETIES OF HARELIP AND CLEFT PALATE
Median Harelip. — This deformity (Fig. 9) is rare, and may vary in ex-
tent from a slight notch in the vermilion border of the lip to a complete cleft
extending upward into the nasal septum. In the latter case the frenum is also
split. In a form described by Witzel, the cleft in the nasal septum extends to
the vomer.
An apparent median cleft may in reality be a bilateral cleft, with the median
portions of the lip and maxilla entirely lacking.
Simple Unilateral Harelip. — The division in this malformation varies in-
creasingly toward the nostril from the mildest cases, where it is merely a notch
458
PLASTIC SUKGEEY
FIG. 9. — MEDIAN HARELIP.
in the outline of the mucosa (Fig. 10), to where, in the severest cases, it sepa-
rates the nostril into 2 halves (Fig. 11). The nmcosa is usually more or less
everted on the cutaneous aspect of the lip. The
more extensive forms of harelip are characterized
by atrophy of the external border of the cleft, an
extensive opening and a flattening of the nostril,
combined with lowering of the nasal ala.
Unilateral Harelip with Fissure of the Bony
Parts. — This presents, in addition to the above de-
scribed deformities of the soft parts, a more or less
marked cleft of the alveolar arch with or without
irregularities of the teeth. In the severer cases
the division involves the full height of the alveolar
margin as well as the most anterior portion of the palatine roof. The cleft is
directed obliquely backward and inward toward the anterior palatine foramen,
where it either stops or is combined with, and pro-
longed into, a complete velopalatine fissure. In
other cases of labiopalatine fissure there is no con-
tinuity of the superficial with the deep malforma-
tion. Simple as well as complicated labiofissure
may be associated with a divided velum and an in-
tact palate. In simple or double harelip cases com-
plicated by bony fissure, the soft parts are some-
times partially absent, the portions of the lip which
should furnish the flaps for a restorative operation
being irregular, retracted, and atrophic. The inter-
maxillary bone leans obliquely toward the normal
side, which is due to the more advanced growth of
the vomer ; the latter, having lost its lateral support
and its growth being impeded, pushes the intermaxillary bone forward into
an oblique position, which interrupts the alveolar arch.
Simple Bilateral Harelip (Fig. 12). — In
these cases the features of simple unilateral
harelip are present on both sides, although
the malformation is not necessarily sym-
metrical or of the same degree. On one side
the fissure may be incomplete, while on the
other it may involve the lower border of the
nostril. Bilateral harelip without any bony
malformation is rare (18 among 555 cases,
according to Hang).
Complicated Bilateral Harelip (Fig. 13).
— In exceptional cases, simple alveolar fissure on one side may be associated
with a complete cleft on the other side. As a rule, the deformities are more or
FIG. 10. — SIMPLE UNILATERAL
HARELIP.
FIG.
11. — SIMPLE UNILATERAL HARELIP
WITH DEFORMITY OF NOSTRIL.
HAKELIP AND CLEFT PALATE
459
less symmetrical, the bony complications assuming one of the following types:
a purely alveolar fissure of both sides, with slight protuberance of the maxillary
bone ; a deep fissure, which extends between the margins of the bony gaps with
preservation of the nasal and buccal
mucosa ; or a complete fissure involv-
ing the mucous membranes as well as
the bone substance and terminating
at the anterior palatine foramen by
two lines converging in an internal
posterior direction ; and with the pal-
atine roof practically always divided.
The forward protuberance of the in-
termaxillary bone increases in pro-
portion with the depth of the fissures,
while the middle labial lobe propor-
tionately diminishes in size. FIG. 12.— SIMPLE BILATERAL HARELIP.
Fissure of the Bony Palate (Pal-
ato-fissure) . — Cleft palate may occur independently or in combination with cleft
lip (harelip). Congenital clefts of the bony palate are always associated with
a divided velum.
Palatofissure Not Complicated by Labiofissure. — In the mildest cases the mal-
formation consists merely of an anomaly of the uvula, but as a rule the velum
is split more or less extensively. The hard palate is also apt to be defective,
having usually a triangular cleft near the posterior por-
tion of the bony roof ; or it may be split longitudinally
or altogether absent.
Palatofissure Combined with Bony Labiofissure. — The
prolongation of the palatine cleft beyond the anterior
palatine foramen gives rise to common bony fissures.
The mild cases present a large palatine gap, bifurcated
anteriorly, with a middle flap consisting of bone, mu-
cous membrane, and skin. Sometimes, when the arrest
of development is very marked, the upper lip is repre-
sented only by a small mass of soft^ parts attached to
the nasal septum.
Displacement of the Premaxillary Bones. — Although
displacement of the premaxillary bones is always more
or less associated with clefts of the palate, the pre-
maxilla may occupy its normal position in any form of
harelip. Protuberance and deflection of the premaxilla are more or less marked
in cases of unilateral harelip with complete cleft palate. When the protuber-
ance and deflection are very slight, the bone may resume its normal position
spontaneously after the surgical repair of the harelip. The premaxillary
process is chiefly responsible for the deformity seen in cases of complete double
FIG. 13. — COMPLICATED
BILATERAL HARELIP.
460 PLASTIC SUBGERY
harelip with complete cleft palate. It is attached by a pedicle of variable width
and strength to the lower anterior end of the nasal septum and projects in front
of the lips, resulting in a most distressing deformity.
TREATMENT OF HARELIP
Age at Which to Operate. — The best results can undoubtedly be obtained by
operating between the ages of 4 and 6 months. This is especially the case if the
labial cleft be extensive or double or complicated. At this age the tissues are
firm and of a moderate size and the stitches hold well. If the deformity of the
ala of the nose be present, the correction of it is much more easily accomplished
at this time than in the first few weeks of life. Jacobson gives the following
reasons for not preferring an operation before the second month :
1. Newborn children do not stand operations well.
2. Children born with this deformity are apt to be weak, and many die in
early infancy from causes not related in any way to the deformity. Opera-
tions, if performed on these children, are usually ascribed as the cause of death.
3. The difficulty of feeding a child with harelip, even if complicated by
cleft palate, has been exaggerated. The feeding can practically always be ac-
complished, with care and attention ; and if the nursing bottle has a nipple of
the proper shape with an opening of good size in the under side, the child will
usually have little difficulty in obtaining sufficient nourishment. The position
of the child while nursing has also much to do with the ease with which it can
be fed.
On the other hand, some surgeons, especially the advocates of the early cleft
palate operation, maintain that the cleft in the lip should be repaired as soon as
possible, for these reasons :
1. The child's nutrition is improved. 2. The operation is very easy —
with less hemorrhage. 3. If a cleft of the palate be present, the repair of
which is delayed, the early closure of the lip has a marked tendency to diminish
the width of the cleft of the palate.
In any case, the lip should be operated upon before the end of the sixth
month, that is to say, before dentition occurs. If a cleft palate be present, upon
which it has been ^decided to operate later, there can be no harm, as Jacobson
has pointed out, in closing the lip; for when the time comes to do the urano-
plasty, and the smallness of the mouth interferes with the clear operative field
in spite of the use of suitable mouth gags, the lip can be split and re-sutured
when the cleft palate operation is completed.
OPERATIONS: CHEILORRHAPHY OR CHEILOPLASTY
Numberless procedures have been devised, recommended, and abandoned
for the correction of the facial deformity. A method which involves the cutting
of 1 or 2 flaps is alone worthy of consideration. Simple cheilorrhaphy, or labial
11AUKLIP AND CLEFT PALATE
461
suture after simple freshening without preliminary cutting of flaps, is not to be
recommended. When the inferior margin of the nostril is intact, the entire
operation consists in the cutting of 1 or more flaps, with the necessary freshen-
ing and suturing. In complete harelip with division of the nostril, the libera-
tion of the nasal ala is of great importance.
The important steps of all operations on either harelip or cleft palate con-
sist in: First, trimming the edges of the deformity and sewing together the
raw surfaces in perfect apposition; second, the abolition of absolutely all ten-
sion on the suture line. If this be not done, the chances of success are very
slight. In many cases it is necessary to free the cheek from the superior max-
illa in order to overcome the tension. Much difficulty is usually encountered in
A B c
FIG. 14. — METHOD OF PARING AND SUTURING FOR SIMPLE UNILATERAL HARELIP.
preventing an unsightly notch in the lip or in the skin margin, and several
incisions have been devised for the correction of this defect. An uninter-
rupted line should result from the union of the two lines of mucocutaneous
junction if the trimmed edges have been properly shaped and fitted
together.
Position. — Dorsal, with head slightly flexed on a firm pillow.
Anesthetic. — For very young children, chloroform by the open method is
preferred. For children over 5 years, ether by the open method.
Instruments. — No special instruments are required for this operation, but
all those used must be fine, light, and well made. A fine, thin, and sharp
scalpel is necessary. The needles should be well curved and small, and the
needle-holder one that really holds the needles firmly.
Operation for Simple Unilateral Harelip. — It must be realized that every
patient requiring a plastic operation presents problems which have to be worked
out for the individual case, and there is no one operation which is applicable to
all. The following is, in my experience, by far the most satisfactory operation,
and the same principles may also be applied to the repair of a complete uni-
lateral cleft, as will be shown later:
Apply Murphy's intestinal forceps (Fig. 51) on the upper lip, as near the
angle of the mouth as possible. By using these, much of the troublesome hemor-
462 PLASTIC SUEGEEY
rhage which always occurs at the beginning of the operation may be easily con-
trolled. Make sufficient traction with an ordinary anatomical forceps on one
angle of the split lip to hold the edge of the cleft tense, and with a very sharp
pointed scalpel, transfix the lip at point A (Fig. 14), and cut to point B. It
is essential to insert the scalpel in a direction at right angles to the skin, and
at a point just internal to the junction of the skin and the mucous membrane,
thus insuring the cutting of a solid, thick flap, which must consist of all the
layers of the lip. A similar incision is then made from point C to B, and short
almost horizontal incisions from points C to D and from A to E. Thus the
pared edges are removed. If the coronary arteries at this stage show a tendency
to bleed, they may be ligated, using the finest mosquito clamps and the very
finest catgut possible. Any other oozing may be disregarded. The flaps formed
by these incisions are now drawn gently down (Fig. 14, B) and a fine silkworm-
gut suture inserted so as to proximate points A and C. The suture should be
placed about 6 mm. from the cut edge and passed into the tissues at right angles
down to but not through the mucous membrane. The stitch is now drawn taut,
and if no tension be present, it is loosened and the remaining sutures inserted,
but not tied. These may be of very fine silkworm-gut, Pagenstecher thread,
or horsehair, and usually 4 will be sufficient. If, however, on tightening the
first stitch, tension is seen to be present, it will then be necessary, in order to
obtain a good result, to incise the mucous membrane on the alveolar border as
high as possible; and, by inserting a sharp-edged periosteal elevator, to lift the
cheek and soft parts away from the superior maxilla. By keeping the instru-
ment pressed firmly against the bone, the amount of hemorrhage from this pro-
cedure will be small and no damage will be done to the soft parts. The extent
to which this lifting must go can only be determined by the amount required
to absolutely abolish all tension on the pared edges, when the stitches are tied.
It is far better to lift too much of the cheek than too little. The sutures now
inserted can be tied, great care being taken to get a perfect approximation of
the skin edges, to avoid tying the sutures too tight and to see that the points
where the mucous membrane of the lips and the skin meet are on exactly the
same line. The projecting tabs of the vermilion border can now be sutured.
It is well to have a slight downward projection of the lip at the suture line, so
that if the labial scar contracts, the formation of a notch will be prevented.
Fine silk and fine curved needles are best used here, and 2 or 3 sutures should
be inserted on the inner side of the lip in the vermilion border. The cut mu-
cous membrane heals well without sutures, and there seems to be less infection
when they are not used (Fig. 14, C).
Sterile vaselin is now applied on the external and internal wounds and fre-
quently no dressing at all need be used. If the cheek has been raised and some
hemorrhage still persists from the resulting wound, or if, in spite of all care,
the stitches appear to have some strain upon them, a strip of sterile adhesive
plaster may be cut into a butterfly shape and applied to each cheek, thus reliev-
ing the tension in the wound. A few layers of gauze may be placed over the
HARELIP AND CLEFT PALATE
463
wound. Care mus^ be taken that the child does not get its hands free and tear
the wound apart.
Operation for Single Complete Harelip (Fig. 15). — The same procedure can
be used in most cases of single complete harelip. The incisions are prac-
A B
FIG. 15. — METHOD OF PARING AND SUTURING FOR SINGLE COMPLETE HARELIP.
tically the same, but of course extending upward into the cleft nostril. The
elevation and liberation of the cheek from the superior maxilla is again the all-
important step, and is absolutely essential in order to obtain a good cosmetic re-
sult and reestablish the proper shape to the nostril. In an upward direction,
this freeing of the cheek may have to extend even as high as the inferior orbital
FIG. 16. — METHOD OF PARING AND SUTURING FOR DOUBLE HARELIP.
foramen. If the nostril is much distorted, the ala must be completely loosened.
The first stitch should be placed within the nostril as high as possible, using a
fine sharply curved needle and fine chromic gut, and the suture should be tied
tight enough to just over-correct the deformity. If the parts do not stay in
464 PLASTIC SUKGEEY
apposition without tension, the cheek will have to be still further freed. The
remaining sutures are placed as in the single incomplete harelip operation.
Operation for Double Harelip (Fig. 16). — Transfix the lip at point A, cut
to B as near the vermilion border as possible, and follow its outline even if
irregular; for in this operation all the tissue must be saved that is possible to
save. Less blood will be lost if this incision be made first. Next transfix the
lip at C and cut to A; then make incision D almost at right angles to and
through the vermilion border ; then cut from E to B and make incision F in a
similar way. The lifting of the cheek, as described above, will frequently be
required in this operation. The guide stitch can now be inserted to proximate
the points D and F and drawn tight, but not tied. If the tension is correct,
the remaining sutures are inserted as shown in Figure 16.
Operation for Complicated Harelip with Projecting Premaxillary Process.
—The premaxillary bone may be replaced by either a simple fracture or by the
excision of an area of the nasal septum.
1. SIMPLE FEACTUEE. — When the premaxillary stem is slight and the
child is very young, provided, however, that the distance between the external
alveolar ridges is sufficient to admit the introduction of the premaxillary bones
between them, it is often possible, by direct pressure of the operator's thumb
on the projecting premaxillary process, to produce a fracture of its attachment.
If this is done, the fracture must be complete and must allow free motion of the
bones and their easy replacement in their new and proper positions. The use
of this method is advised when possible, because there is little shock, practically
no hemorrhage and very little chance of infection.
2. EXCISION OF A WEDGE OE QUADEILATEEAL AEEA FEOM THE NASAL
SEPTUM. — Before making any resection of the septum, Berry and Legg recom-
mend incising the lower free edge of the septum just behind the premaxillary
bone, and with a periosteal elevator removing the soft parts and periosteum
from the septum. The usual operation is then to resect a wedge with a strong
pair of scissors. The great objection to a wedge-shaped incision is the new
and backward position assumed by the alveolar border, causing the incisor teeth
to project in a posterior direction. To avoid this, a quadrilateral section may
be removed, which will allow the teeth to assume a normal position (Fig. 17).
The following figures of classic operations for the repair of harelip are re-
produced not only for their historical interest, but also for the suggestions they
may offer to operators who have to treat atypical or complicated cases. As
they readily explain themselves, no description is given (Figs. 18, 19, 20, 21,
22).
After-treatment and Complications. — If the wound heals without infection,
firm union takes place early ; and as a general rule, the sooner the stitches are
removed, the less scar will remain and the less chance exists of a late infection
occurring. It is often possible to remove every alternate superficial stitch as
early as the second or third day. The deeper or retention sutures should re-
main 6 days. It is important to properly restrain the child, not only in regard
HARELIP AND CLEFT PALATE
465
to the hands and arms, but also to prevent its turning on its face and rubbing
the lip on the pillow.
It is best to make no change in the diet, and as a rule, the child can be
given some liquid nourishment within 3 or 4 hours of the operation.
Complications and poor results are almost always due to either a weak con-
dition of the child at the time of the operation, or to sepsis. Death, if it does
FIG. 17. — SHOWING ADVANTAGE OF RESECTING QUADRILATERAL AREA IN SEPTUM. 1 and 2, resec-
tion of wedge, showing incisor teeth projecting in a posterior direction. (Doyen.)
occur, is almost always due to the low vitality of the child, for it is well known
that children having congenital defects are, as a class, of low vitality.'
Sepsis is the most frequent cause of failure or non-union, but it is rarely
severe enough to endanger the child's life, unless an infection of the bone oc-
curs— fortunately a very rare condition. If the wound has become infected
and the operation on the fourth or fifth day has the appearance of a total fail-
ure, the parts if properly drained — that is to say the sutures removed and a wet
dressing applied — will in many cases heal by granulation and the result be sur-
prisingly good.
In all operations involving the air passages, a not infrequent complication
is pneumonia or bronchitis. The possibility of either of these complications is
much diminished by taking care during the operation to prevent the entrance
of blood and mucus in the trachea.
31
FIG. 18. — KONIG'S METHOD OF PARING AND SUTURE.
FIG. 19. — HAGEDORN'S METHOD OF PARING AND SUTURE.
• FIG. 20. — MALGAIGNE'S METHOD OF PARING AND SUTURE.
lH^^
FIG. 21. — HAGEDORN'S METHOD OF PARING AND SUTURE FOR DOUBLE HARELIP.
FIG. 22. — MODIFICATION OF HAGEDORN'S METHOD OF PARING AND SUTURE.
HARELIP AND CLEFT PALATE 467
An unusual and serious complication is described by Jacobson, where death
is caused by asphyxia. "Thus, where the cleft has been a large one and the
upper lip when restored is tight, when it overhangs the lower, if the nostrils
are flattened and partially closed by the operation, owing to the tension of the
parts, so little breathing space may be left that temporary interference with
respiration may occur, with grave and even fatal results, before the breathing
can be accommodated to the altered circumstances and before the parts dilate
and stretch."
Rose suggests, to obviate this possibility, that the nurse depress the tongue
of the child from time to time; or paint a strip of collodion from lip to chin to
hold the lip open. In case the aperture is known to the operator to be danger-
ously small, an intranasal tube, such as a good-sized catheter, may be inserted.
This allows the child to breathe automatically and may be withdrawn after
twenty-four hours.
Results. — As a general rule, the results of these operations are good, al-
though frequently not as perfect as the operator and the parents desire. So
many factors enter into the composition of the end result that it is wise to give
a fairly guarded prognosis, and before operating to explain to the family the
possibility that the necessity may occur for a second operation. However, if a
second operation proves to be necessary, it is usually of a very slight and simple
character, and ought always to be done after a lapse of several years.
TREATMENT OF CLEFT PALATE
Age at Which to Operate. — The indications for surgical intervention in
cases of harelip and cleft palate are incontestable and obvious; but opinions
differ as to the most favorable period for the performance of the operation.
From the point of view of the operative risks, statistics show conclusively that
operations on children less than 2 years of age are more dangerous than opera-
tions after that age in spite of the brilliant results of certain operators.
I strongly endorse the view held by Jacobson and Berry, and consider that
the best results can be obtained by operating not earlier than the second or the
beginning of the third year instead of in early infancy, for the following rea-
sons:
1. The parts are larger, more easily manipulated and tear much less.
2. Hemorrhage is more easily controlled and better stood by the patient.
3. Children congenitally deformed are apt to be weak and do not stand
operations well.
4. The after-care of the patient is easier and more satisfactory.
5. The liability to such postoperative complications as pulmonary infec-
tion, convulsions, and diarrhea is minimized.
6. It is possible to elect a time when the patient is properly prepared and
in good physical condition,
As opposed to these advantages, J. B. Roberts (22) writes as follows:
468 PLASTIC SUKGEKY
"The view that operations upon fissures of the palate should be delayed until the
child has become two, three or four years old is erroneous. It is better to operate when
the infant is only a few days old, unless there be some grave physical disability. In
that event, the operation may be delayed a few weeks, but such delay is a misfortune.
The time thus occupied in building up the infant's health may be profitably employed
in digital compression applied daily to the two halves of the upper jaw. Squeezing the
separated segments of the hard palate together a few dozen times every morning and
evening will tend to lessen the breadth of the cleft and give the surgeon a better oppor-
tunity of obtaining a bony roof to the mouth by operation/'
Lane and Brophy advocate early operation on cleft palate, that is to say
from the first day after birth up to three weeks, and maintain that :
1. The surgical shock is less than when the child is older and there is no
mental apprehension.
2. The anesthetic is well borne.
3. The newborn child is usually healthy.
4. The tissues heal very readily.
5. The digestion is good.
6. There is slight, if any, postoperative pain, and the child takes food at
once.
7. The loss of blood is necessarily slight, due to the small size of the blood
vessels.
8. A well vascularized flap is very easily obtained.
9. The muscles of the palate are at once brought into use, and do not
atrophy.
10. The passage of air through the nares in the proper channel has a
marked effect on the growth and shape of the bones of the nose and face at a
period when their greatest development takes place.
11. No faulty habits of speech result.
12. If the Brophy operation is performed, the bones may be bent and
moulded without fracture.
OPERATIONS
Position of the Patient. — The so-called Rose position (Fig. 23) is in many
ways the most satisfactory. The child should be on its back on a hard mattress,
wrapped snugly in the sheet to prevent the movement of the hands and arms,
and a firm pillow placed underneath the shoulders. The head must be toward
the light, projecting a few inches beyond the head of the table and allowed to
assume a position of marked extension.
The advantages of this position are : 1. A clear field and direct illumina-
tion; 2. The blood has no tendency to flow into the trachea, the time taken in
sponging and preventing it from so doing is saved, and the chances of post-
operative complications are thus reduced; 3. The low position of the head
tends to overcome any untoward effect of the anesthetic.
Practically the only disadvantages of this position are those resulting from
HARELIP AND CLEFT PALATE
469
the increased congestion of the head and neck, and the frequent postoperative
pain in the back of the neck.
Anesthesia.— Ether is undoubtedly less dangerous than chloroform, and is
therefore to be preferred, but it should always be administered by a competent
and experienced anesthetist. Some English surgeons prefer chloroform be-
FIG. 23. — ROSE POSITION.
cause it is more easily administered than ether, and does not cause as much
congestion of the tissues or produce as much mucus and saliva ; but its dis-
advantages far outweigh its advantages. For the convenience of the operator
and to prevent unnecessary delays, an apparatus which administers intranasal
anesthesia should be employed. Keep the patient only just under the influence
of the anesthetic and at no time should he be so profoundly under that the
pharyngeal reflexes are absent.
Choice of Method of Operation. — I consider the operation of choice to be the
one described by Berry and Legg, for practically the same reasons as those
already given in favor of operations in the second year instead of in early
infancy. The operation is comparatively simple, anatomically correct and
theoretically sound; and has fewer difficult technical details than most other
procedures described .below. At the same time it must be borne in mind that
470 PLASTIC SUEGERY
any operation undertaken to repair cleft palate is per se one of the most diffi-
cult in surgery, requiring, as it does, foresight in planning the work to be done,
great care and patience in its performance and, to obtain a good result, a con-
siderable degree of surgical skill. The field is small and frequently inadequate
to work in, the parts to be dealt with are small, delicate, and easily injured
FIG. 24. — SMITH'S CLEFT PALATE GAG.
permanently, and their final readjustment must be exact. The instruments,
especially the needles, the needle-holder, and the sutures, must be fine and deli-
cate, and therefore difficult to use. It is one of the few operations to-day re-
quiring special instruments and it would be almost disastrous to attempt any
of these operations without the special instruments, which have been designed
to make possible the accomplishment of the different steps.
Berry and Legg's Operation. — The operation described by Berry and Legg is
divided by them into 5 parts :
1. Detachment of the mucoperiosteal tissues of the palate from the oral
surface of the bony palate.
2. Detachment of the soft palate from the posterior edge of the palate
bones.
3. Paring the margins of the cleft.
4. Suturing the pared edges.
5. Making, if necessary, lateral incisions to relieve tension.
The instruments required are:
Smith's cleft palate gag (Fig. 24).
Long-handled forceps, both with and without teeth (Fig. 25).
Raspatory (Fig. 26).
A sharply curved blunt-pointed scissors (Fig. 25).
A rectangular knife (Fig. 25).
FIG. 25. — INSTRUMENTS USED IN OPERATION ON HARELIP AND CLEFT PALATE.
472 PLASTIC SUKGEKY
Sharp and blunt-pointed knives (Fig. 25).
A rectangular needle, for inserting sutures (Fig. 27).
A curved needle, for inserting sutures (Fig. 27).
A needle with double elbow (Fig. 27).
FIG. 26. — BERRY AND LEGO RASPATORY.
The "first stage is best accomplished by making a small linear incision or a
puncture near the alveolar border (Fig. 28). The situation of this puncture
depends on the width of the cleft and the height of the arch of the hard palate.
If the cleft be wide or the arch low, it will be necessary to make the puncture
very near the alveolar margin in order to gain a sufficient mucoperiosteal flap,
and it will in that case be external to the outlet of the posterior palatine artery.
C
FIG. 27. — A, A RECTANGULAR NEEDLE, FOR INSERTING SUTURES; B, A CURVED NEEDLE FOR INSERT-
ING SUTURES; C, A NEEDLE WITH DOUBLE ELBOW. (Berry and Legg.)
Into this wound, which of course should extend directly down to the bone, a
periosteal elevator or raspatory is inserted. The instrument is then moved
toward the middle line with a slight anteroposterior motion, maintaining a firm
and steady pressure against the bone until the tip appears at the margin of the
cleft through which it should now be pushed. Into this last wound, the point
of an ordinary curved aneurysm needle is inserted, and by moving it backward
as far as it will go, and forward to a line with the anterior notch of the cleft,
the required amount of mucoperiosteal tissue is freed from the hard palate
(Fig. 29). The same procedure takes place on the opposite side. If at any
time the hemorrhage becomes troublesome, it can be arrested by direct pressure
on the under surface of the flap by means of a sponge or gauze held by the
operator's finger.
The small puncture wound made in the edge of the cleft must now be ex-
HARELIP AND CLEFT PALATE
473
tended by means of the rectangular knife in a posterior direction to the point
where the junction of the hard and soft palate occurs.
The second step — the detachment of the soft palate from the posterior edge
of the palate bone — the authors
call "the most important in the
whole operation/' because if not
properly and completely accom-
plished, the closure of the cleft of
the soft palate without tension is
impossible.
This part of the operation is
done by inserting one blade of a
pair of sharply curved blunt scis-
sors into the space between the
lower surface of the hard palate
and the mucoperiosteal flap, at the
point where the junction of the
soft and hard palates occurs (Fig.
30, A and B). The other blade
is introduced over the nasal sur-
face. Care must be taken that
the length of the cut be not suffi-
to . t
cient to injure the posterior pala-
tine artery.
The third step — paring the margins of the cleft — is most easily accom-
plished by grasping with a fine-toothed forceps the edge of the cleft at a point
where the junction of the hard and soft palates formerly occurred. A very
fine and sharp scalpel is then thrust through the whole thickness of the soft
palate as near its internal -edge as possible, transfixing all its layers. The in-
cision is then made in an anterior direction as far as the notch. The scalpel
is then withdrawn and re-inserted slightly posterior to the forceps at the same
distance from the free edge, and the incision continued in a posterior direction
toward the uvula. As soon as this becomes difficult, due to the unsteadiness of
the tissues, the scalpel is again withdrawn, and the bridge of tissue, left within
the grasp of the forceps, is divided. Then, by making traction in an inward
and backward direction on the edge that has already been removed, the re-
maining edge can be easily pared off.
The fourth step is the suturing of the pared edges. Berry and Legg con-
sider the best suture material to be silkworm-gut, and recommend the use of
the so-called Smith needle (Fig. 27). The pared edge is now grasped at a
point near the anterior part of the soft palate and there the first suture is
inserted. The needle should be passed in at a point from 3 to 5 cm. from the
cut edge, and in a direction through the tissues slightly outward. As it is passed
back into the mouth from the nasal surface, the needle should point inward, the
FIG. 28.— BERRY AND LEGG OPERATION (1). Situ-
ati°n °f . fi,rst /ncision and ™^od of P™*™?
penosteal elevator or raspatory between mucopen-
osteal flap and surface of hard palate.
474:
PLASTIC SURGERY
object of this being to increase the tendency of the cut edge to evert when the
sutures are tied, which is very important. The next suture, passed in a simi-
lar manner, should be about 5 or 6 cm.
from the first, the same distance from
the edge and in a posterior direction.
When the tip of the uvula is reached,
in order not to interfere with its circu-
lation, the last suture must be made in
a transverse direction. As these su-
tures are passed, they may be tied,
much care being taken not to endanger
the vitality of the flaps by too great
tension. The accurate approximation
of the edges and the avoidance of any
inversion whatever is absolutely essen-
tial. The help of an assistant with deli-
cate tenacula may be necessary at this
point to accomplish this end. The su-
ture of the tissue over the hard palate
now takes place from behind forward.
If it appears that the tension is becom-
ing too great, it may be necessary at
this point to perform step No. 5, If
this is not the case, the suture is com-
pleted (Fig. 31).
If difficulty is encountered in using the Smith needle, the 2-loop method of
passing sutures, as described in Brophy's operation, may be successfully re-
sorted to. Berry and Legg also advise the use of a tension suture of slightly
heavier material, passed at a point in the soft palate near its most anterior
edge, through all its layers about 15 mm. from the internal edge and tied just
tight enough to relieve tension.
The fifth step provides for the making, if necessary, of lateral incisions to
relieve tension. In most cases it will be noticed at this stage that a certain
degree of tension exists in the suture line, and unless this be relieved, the
chances of failure of the operation are much increased. The best incision to
relieve tension in most cases is one beginning a little in front of the junction
of the hard and soft palates near the alveolus, but internal to the posterior
palatine foramen ; it should extend obliquely backward to a point nearly half-
way between the posterior end of the alveolus and the posterior margin of the
soft palate. The incisions may be straight or with a slight curve, the concavity
of which is outward."
Care must be taken not to make these incisions too long, or too far anterior,
or too near the middle line — for each one of these errors has a tendency to
lessen the vitality of the flap.
FIG. 29. — BERRY AND LEGG OPERATION (2).
Insertion of aneurysm needle into wound on
edge of cleft. Dotted area indicates the
extent to which mucoperiosteum is lifted
from the bone.
FIG. 30. — BERRY AND LEGO OPERATION (3). A, Manner of inserting curved scissors to accomplish
the detachment of the soft palate; B, sagittal section of same.
476
PLASTIC SURGERY
Langenbeck's Method of Uranoplasty as Modified by Helbing. — This proce-
dure presents but few changes from the original, but these changes are impor-
tant and have markedly improved the results. The operation consists of 4 steps :
1. Paring the margins of the cleft.
2. Lateral incision through the involucrum palati duri.
3. Detachment of the mucoperiosteal flap from the hard palate.
4. Suturing.
The majority of surgeons perform the entire operation in 1 stage. Helbing,
however, prefers to follow Wolff's modification of 2 stages, with an interval of
from 2 to 5 days. If this be done, the
lateral incisions and detachment of the
flaps (steps 2 and 3) are done at the
first operation; while paring the mar-
gins of the cleft and suturing (steps 1
and 4) are left to the second operation.
Wolff divides the operation into 3,
stages for very small children, making
the 2 flaps at separate operations and
paring the edges and suturing at a third
operation, which takes place 9 days
after the first.
The advantages of performing the
operation in 2 stages are:
1. The more radical phase of the
operation, the lateral incisions and the
detachment of the flaps, usually accom-
panied by loss of blood, takes place at
the first operation; it is, therefore, not
only less dangerous, but allows the child
time to recuperate before the suturing takes place.
2. As soon as the effects of the anesthesia have passed off, the child can
be nourished as usual. This factor is of considerable importance for the suc-
cess of the suture, as is also the fact that the child has time to recover from the
rise of temperature (38° C.) which usually follows the first operation.
3. The circulation and nutrition of the flaps become reestablished before
suturing. By this means the small, circumscribed patches of necrosis which
usually occur along the cleft margins are avoided and in consequence the sutures
hold better. Should there be, however, any necrotic patches, they can be re-
moved at the second operation.
4. The flaps become thickened and more vascular after a few days, and
thus accelerate the healing by enlargement of the raw surface.
5. The hemorrhage at the second operation is very slight and the suturing
can be done with greater exactness, as the view of the field is not obstructed.
6. The gaping of the lateral incision, which some surgeons endeavor to
FIG. 31. — BERRY AND LEGO OPERATION. (4)
Method of suture, and also showing lateral in-
cisions to relieve tension.
HARELIP AND CLEFT PALATE 477
remedy by packing, is avoided except in cases of very wide clefts. When the
flaps have been previously loosened they become adherent again in a better posi-
tion, and are only detached from the subjacent structures along the line of
suture at the second operation, when the sutures are in place. It is only in
very wide clefts that it is necessary to detach the flaps by means of elevators
when the sutures are tied. In ordinary cases the tension of the sutures is suffi-
cient to place the flaps in position without completely detaching them from
the underlying structures, and to avoid the gaping of the lateral incision. The
danger of a fistula is thus greatly diminished.
It may be argued that 2 operations are unnecessary, and that danger of
infection is thereby increased. The advantages of 2 stages, however, far out-
weigh the extra time and trouble. Helbing states that he has followed this
method in over 100 cases without infection in a single one.
STEP 2. — The lateral incision through the involucrum palati duri. — A per-
pendicular incision is made with a pointed scalpel close to the alveolar process
at the right side, passing down to the bone. The length of the incision depends
of course upon the size of the cleft. Bleeding is checked by pressing the left
forefinger against the bone along the incision.
In cases of unilateral cleft through the alveolar process, the incision ex-
tends over the alveolar process between 2 teeth. The incision is carried from
behind over the alveolar process and ends in an inward curve in the buccal
mucous membrane. The latter portion of the incision is superficial, so as not
to injure the palatal muscles. This long incision, confined to the oral mucosa
of the velum, has two advantages, the increased mobility of the velum, and the
preservation of the margin between the hard and soft palates, which materially
lessen the danger of fistula at this place. Helbing has never found that it
makes any difference if the palatine artery be injured, and whenever that acci-
dent has occurred, he has never allowed it to interfere with the proper detach-
ment of the flaps.
STEP 3. — The mucoperiosteal flap is then raised from the subjacent tissue,
with much care, as described in Berry and Legg's operation.
The soft palate is then separated from the horizontal portion of the palate
bone at the margin of the cleft, but laterally it is left attached to the bone.
The 2 halves of the soft palate are next approximated by blunt dissection be-
tween the 2 flaps of mucous membrane. It is of importance that the muco-
periosteal flaps be sufficiently detached to allow apposition of their mucous sur-
faces. It is essential that each flap be loose enough to extend to the middle
of the cleft of the other side without tension.
When this procedure is completed on the right side, the left side is at-
tacked.
Treatment in the interval does not differ from that of other patients — after
12 hours, liquid and soft diet until the third or fourth day, when general diet
is given. Small children have usually a slight rise of temperature (38° C.)
during the first 2 days.
478 PLASTIC SUKGEKY
STEP l. — The paring of the edges. — The second operation takes place on
the fifth day. To insure a full view of the operative field a silk thread is passed
through the tip of the tongue so that it can be drawn well forward before in-
serting the speculum. The lateral incisions and the cleft margins are painted
with dilute tincture of iodin.
The right uvula is grasped with a pair of long fine forceps and a double-
bladed slightly concave scalpel is inserted about 1 cm. from the tip of the
uvula and 2 mm. from the cleft margin. The scalpel is guided obliquely down-
ward and inward with a sawing motion, cutting a strip 1 to 2 mm. wide from
the cleft margin.
STEP 4. — The suturing of the cleft margins. — The first suture is laid at
the tip of the uvula and Helbing is very particular to have the two freshened
ends held at an equal distance from the median line. He uses horsehair and
silk alternately, No. 0 or 1 silk for the velum, and No. 1 or 2 silk for the
hard palate. The sutures are laid at a distance of 2 to 3 mm. on the soft
palate, and 3 to 4 mm. on the hard palate. The sutures are alternately deep
and superficial. In the posterior l^ cm. of the uvula, the oral mucosa only is
penetrated. In the anterior portion, both mucous membranes are caught in the
suture.
It is not practicable to tie each suture, because it would be difficult to in-
sert the next suture with accuracy. Here Helbing's suture-holder is a great con-
venience. It is made of metal and is 1 cm. wide and 17 cm. long. Through
each side are inserted 13 loops of steel wire between which each pair of sutures
may be clasped until they are tied — the first pair in the first right interspace,
the second pair in the first left interspace.
In tying horsehair sutures a certain amount of dexterity is necessary, as
they are apt to break, especially in tying the second knot. Horsehair is, never-
theless, superior to silk for the following reasons: 1. One is not so apt to
pull it too tight. 2. It does not unravel like silk, and therefore does not become
saturated with food particles.
For the uvula a crescent-shaped needle 6 mm. across is best, and a needle-
holder with a long handle. A Hagedorn needle is used for the other sutures.
According to the size of the cleft, from 2 to 4 retention sutures of silver wire
are placed at a distance of 10 to 12 mm. from each other. These are deeper
than the other sutures and are added for the purpose of reinforcing the silk and
horsehair during coughing, sneezing, and vomiting. The posterior silver suture
is placed in the soft palate. None of the silver sutures should be closed until
the other sutures are tied.
The silk sutures are removed on the eighth day, the horsehair on the ninth,
the silver wire on the tenth. In children under 4 years of age, all sutures are
removed under anesthesia on the ninth day.
Brophy's Operation for Patients whose Deciduous Teeth Are Well Erupted and
Whose Bones Are Well Ossified. — 1. Denude the hard palate on its inferior sur-
face, of its covering of mucous membrane and periosteum, by inserting a special
FIG. 32. — B BO PHY OPERATION (1). Showing method of inserting tension sutures and application
of lead plates.
B
FIG. 33. — BROPHY OPERATION (2) . Showing approximation of edges of cleft by means of increased
tension on silver wires. A, A, Lead plates; B, closed palate; C, coaptation sutures.
480 PLASTIC SUKGEEY
curved periosteatome in the edge of the cleft at a point about half way be-
tween the notch and the juncture of the hard and soft palates. Care must be
taken to press firmly upon the bone while this is being done, in order to insure
the complete removal of the periosteum with the flap. The denuded area must
extend anteriorly as far as the notch, or if the cleft be complete, it must ex-
tend along the alveolar border as far forward as the teeth. Laterally it should
extend to the edge of the alveolar margin and posteriorly to the point of union
FIG. 34. — BROPHY OPERATION (3). Transverse section of superior maxilla, showing relative position of
mucoperiosteal flap and hard palate. A, Mucoperiosteum dissected away from the palatal surface of
the superior maxillae; B, silver tension sutures; C, coaptation sutures; D, D, lead plates. (Brophy.)
between the hard and soft palates. Hemorrhage, if troublesome, can be con-
trolled at this stage by simple pressure.
2. Paring the edges of the cleft throughout may be done in the same man-
ner as described under operation of Berry and Legg (page 473).
3. Separation of the soft from the hard palate (Fig. 30).
4. For suturing, the author uses a Deschamp needle by means of which
4 strong silk sutures are passed through the flap in pairs, about % in. apart,
and inserted % in. from the cut edge. The first pair is placed near the
anterior part of the cleft and the second pair near the junction of the hard
and soft palates. By means of these silk sutures, 4 pieces of No. 22 silver wire
are drawn through the tissues and lead plates (No. 22 American gauge, shaped
as in Fig. 32) are perforated to correspond to the position of the wire. These
are then threaded through the plates and twisted together as shown in Figure
32. Interrupted sutures are then placed in sufficient numbers to get exact
approximation of the edges. More twists are then taken in the silver wires
until tension on the interrupted sutures is absolutely relieved (Figs. 33, 34).
HARELIP AND CLEFT PALATE
481
The advantages claimed for this operation are :
"The prevention of the cutting out of the sutures, since the lead plates coming in
contact with the soft palate exert pressure thereon, and consequently the tension is not
made by the sutures alone, which exert pressure on so limited a portion of the tissue,
but it is upon the entire length of the palate covered by the lead plates.
"The lead plates serve as a splint, rendering the palate inflexible to a very great
extent. The movements which are almost constant are suspended ; the active muscles
are put out of use until union of the cleft may take place. After using this method of
closing the soft palate, I feel confident that better results can be secured than by the
employment of sutures alone. As previously stated, this is not to take the place of
the operation of dividing the bones at the malar process, and carrying the greater por-
tion of the maxillary bones together, but it is adapted to the treatment of patients
whose bones are well ossified and whose deciduous teeth are well erupted. It is in such
cases that I recommend this operation."
The Davies-Colley Operation (1) (Fig. 35). — Make curved incision AB
through mucous membrane and periosteum down to the bone on the narrow side
of the cleft. Point A must be at the
posterior limit of the hard palate, at
least .4 cm. (% in.) from the free bor-
der of the cleft, and point B should be
opposite the notch the same distance
from the border of the cleft. Eaise flap
formed from this incision from bone
with periosteal elevator, care being
taken to include all the soft parts, leav-
ing tissue between points A and B to
act later as a hinge.
Then make incision CDE on the
wider side of the cleft down to bone.
Incision CD should be .3 cm. (% in.)
external to free edge of cleft. Now
raise flap with periosteal elevator, great
care being taken not to damage the tis-
sue lying between the points C and E.
The next step is to turn the flap
formed by incision AB downward and
inward, and make fast its free edge with 2 fine catgut sutures to the opposite
margin of the cleft.
The last step is to slide the apex of the second flap across the raw surface of
the first flap, and fasten as is shown in Figure 36. If this last flap appears to
lie somewhat loosely in its new position, this need cause no apprehension be-
cause the pressure of the tongue will force it upward and thus enable the 2
raw surfaces to adhere.
The advantages claimed for this operation are:
FIG. 35. — DAVIES-COLLEY OPERATION (1).
Method of making the incisions.
482
PLASTIC SURGERY
"(1) There is less hemorrhage; (2) less bruising of the parts; (3) less sacrifice
of tissue; (4) less tension upon the flaps; and (5) the operation can be easily per-
formed at an early age, e. g. between the ages of one and two years.
"The disadvantages are: (1) The hard palate alone is united; (2) a foramen is
apt to be left in the front part of the cleft. (This can be closed later.)"
Brophy's Osteoplastic Operation. — This procedure is suitable only in infants
less than half a year old, because after that age the bones become too much
ossified and hardened. It may be neces-
sary, even in the youngest children, to
divide the maxillary bone near its
malar junction before the gap can be
successfully bridged.
The operation can be divided into
the following steps:
1. Pare thoroughly and completely
the whole free edge of the cleft to such
an extent that a small portion of the
bones of the hard palate and alveolar
border shall be excised. By so doing,
it is possible to get real bony union,
which cannot be obtained by simply
removing a strip of mucous membrane,
without freshening the bone.
2. Raise the cheek and, at a point
on the buccal surface of the superior
maxilla, just back of the malar process,
near the extremity of the hard palate and high enough to insure its being above
the palate bone, insert a strong needle, carrying a loop of silk directly through
the superior maxilla. When the point of the needle can be seen to appear in
the mouth, through the cleft, the silk is grasped with an artery clamp and the
needle withdrawn. At a similar point on the opposite side a second needle is
passed and the loop grasped. Thus 2 loops are now to be found in the mouth.
By drawing one loop through the other and making traction (see Fig. 37) a
double through-and-through suture of silk is left. To the external end of the
silk thread a silver wire No. 20 bent on itself is then fastened, and by a reverse
traction, is made to pass through both punctures in the superior maxilla. A
like procedure is then repeated at a point anterior to the malar process, the
same distance above the inferior edge of the alveolar border.
3. Lead plates 1.3 cm. (% in.) wide of about No. 17 American gauge
should be in readiness. These are now cut off sufficiently long to allow a projec-
tion of at least 3/5 cm. (% inO beyond each through-and-through suture.
These plates are then moulded to the external or buccal surface of the superior
maxilla and perforated at the proper places to allow the passage of the silver
wire sutures, which are then twisted together — one pair on each side (Fig. 38) »
FIG. 36. — DAVIES-COLLEY OPERATION (2)
Showing positions of transposed flaps.
HARELIP AND CLEFT PALATE
483
4. Forcible approximation of the bones of the superior maxilla can be
accomplished by increasing the tension on the wire sutures, by twisting the
ends together with an artery clamp or small pliers, and aiding by strong digital
compression of the bones (Fig. 39). In many cases perfect approximation of
FIG. 37. — "TWO-LOOP METHOD" OF PASSING SILVER WIRE THROUGH SUPERIOR MAXILLA.
the cut edges of the cleft in the palate can be accomplished by this means with-
out any further surgical procedure. If, however, the cleft be very wide or the
bones unusually ossified, so that union cannot be accomplished in this way, it
may be necessary to divide the malar process. A very small incision is made
B,
^v*
<r
FIG. 38.— BROPHY OSTEOPLASTIC OPERATION (1). A, Silver wire; B, lead plates; C, tooth; D, cleft.
high in the cheek through the buccal mucous membrane, just below the malar
process. A scalpel is then passed deeply into the tissue in a horizontal direc-
tion, and the malar process and deep parts are severed without allowing the
wound in the mucous membrane to become any larger than is absolutely neces-
484
PLASTIC SURGERY
sary. This can easily be done with any ordinary sharp scalpel. It will now
be found that by increasing the tension on the silver wire, the edges of the cleft
come readily together.
5. Suture of the mucous membrane in the mouth by interrupted suture
insures eversion of the edge and perfect approximation. Fine silkworm or
horsehair may be used for this purpose.
It has been advocated by some that the first step, that is to say the paring
of the edges of the cleft, be delayed until the wire sutures are inserted and the
B
FIG. 39. — BBOPHY OSTEOPLASTIC OPERATION (2). A, Silver wire; B, lead plate; C, tooth; D, cleft;
E, E, mucoperiosteum forming extended wall of the triangular space by forcing the lower frag-
ments of the bone inward; F, F, lines of fracture; G, G, triangular space on nasal surface of bone
made by approximation of the palatal process. (Brophy.)
lead plates affixed. This would seem to have some advantages, especially in
preventing the amount of blood loss and in making it possible to do all the
work in the mouth at one time, with the child in the Rose position.
Brophy recommends that the lead plates be left in place for from 2 to 4
weeks. The sutures in the palate may be removed in from 7 to 10 days.
The objections which have been made to this operation are : 1. The danger
from shock and the severity of the operation ; 2. The extreme probability of
sepsis; 3. Injury to the buds of the non-erupted teeth; 4. Narrowing of the
superior maxilla, with resulting disproportion between the sizes of the superior
and inferior alveolar borders; 5. The possibility of producing an obstruction
of the nares and interfering with proper breathing.
Brophy estimates the mortality to be about 3 per cent. He does not con-
sider the shock resulting from this operation greater than from any other, and
maintains that very young children bear so-called surgical shock very well. As
to the fourth and fifth objections, he says : "The palatal arch is in some cases
HARELIP AND CLEFT PALATE 485
contracted, but this will not be permanent, for if the operation is performed
early enough, when development is complete, the toeth of the upper jaw oc-
clude naturally with those of the lower jaw. It is a well known fact that the
alveolar processes develop with the teeth, and this seems to be a pronounced
factor in the formation of the jaw and the guiding of the teeth into their proper
position." And he also says: "Through a misconception of this surgical pro-
cedure, it has been stated that the closing of the palatal vault, carrying of the
bones together and uniting them in the median line would be followed by
stenosis. If one keeps in mind the anatomy of the parts, and then understands
the details of the operation, he will readily see that the closure of the nasal
passage, or even reducing its dimensions, would be impossible."
The after-treatment, according to the same author, "is very simple, consist-
ing solely of antiseptic cleansing of nose and mouth, at least twice a day ; stimu-
lants, if indicated, the first twenty-four h.ours ; preventing the child from dis-
turbing the parts or introducing into the mouth anything that might interfere
with the sutures ; paying special attention to the care of the bowels ; using alco-
hol sponge baths if the temperature rises above 100 degrees F. and nourishing
the patient on liquid food given by means of a spoon. The nipple should not
be used, as the act of suckling may interfere with the process of repair. Abra-
sions of the mucous membrane caused by the lead plates need not disturb the
•operator, for they are usually slight. The plates are to be left in place from
two to four weeks, but the silk sutures, if employed, should be removed about
one week after the operation."
Lane's Operation (12). — This is an adaptation of the Davies-Colley method.
The operation is very ingenious and very difficult. Great care must be taken
in marking out the flaps, and after they are marked out, not to injure them in
any way, especially during the process of raising them from the bone. They
should be handled carefully and never torn or bruised, if union is expected to
take place. It is an operation which should not be attempted by any surgeon
who has not acquired the habit of doing delicate and difficult work. If unsuc-
cessful, and gangrene of the flap takes place from any cause, it is almost im-
possible to do a secondary operation with any satisfactory results. In the
hands of the author, Mr. Lane, the most brilliant results have been obtained.
The special instruments required in this operation are: Mouth gag (Fig.
25); scalpel; needle-holder, needles and toothed forceps.
Position: Rose position.
Anesthetic: Ether, internasal.
Lane writes:
"The general principles on which most of the operations are based is that of rais-
ing from the roof of the mouth on one side of the cleft a flap, which consists of the
mucous membrane, sub-mucous tissue and periosteum of the roof of the mouth; and
where this flap extends over the alveolus, care is taken to avoid unnecessary damage
to the subjacent teeth. This can only be done efficiently very soon after birth. As
time goes on, the damage done to the temporary teeth by the separation of the super-
486
PLASTIC SURGERY
jacent mucous membrane becomes steadily greater. Still this is a matter of no very
great moment as compared with the importance of the closure of the cleft.
"The manner in which the flap is formed from the mucoperiosteum on one side,
and is fixed beneath the separated mucoperiosteum lining the roof of the mouth on
FIG. 40. — FLAP RAISED AND FIXED IN POSITION. In this case, the cleft is not of sufficient breadth to
render it necessary to strip the alveolus of its covering of mucous membrane. (Lane.)
the opposite side of the cleft in an edentulous infant, is represented in Figures 40,
41, 42.
"In the soft palate, the flap, which is raised, comprises all the soft parts down to
the tensor palati, and may be made as extensive as necessary, by encroaching on the
cheek, if there is not enough material in the remains of the soft palate. As regards
the soft palate, this method of operating is incomparably more certain of success than
the usual mode of paring the edges of the cleft and bringing them together. This last
is only rendered possible by the free ver-
tical division of the palate muscles on
either side, and the junction so effected
frequently breaks down. In my opera-
tion, the continuity of these muscle-
planes is unimpaired, no cicatricial tis-
sue existing in their substance and no
loss of function arising in any part in
consequence, the muscles on both sides
being connected by material on which
they can exert efficiently their traction
normally in their several directions. On
the other side of the cleft, the mucoperi-
osteum is divided along its free margin
until the soft palate is approached. The
extremity of the uvula or its relic is
picked up with forceps, and an incision
is made outward from it along the free
margin of the palate for some distance;
and from its outer limit another is car-
FIG. 41. — CLEFT OF A BREADTH SUFFICIENT TO RE- ried forward and inward along the upper
QUIRE THE EMPLOYMENT OF A FLAP FROM THE t of the soft late to reach the pos.
ENTIRE ALVEOLUS. The heavy lines indicate the ,. . , » ,, . . . . ,
incisions, that to the left of the cleft being on terior limit of the incision running along
the nasal surface of the palate, . while that on the free margin of the hard palate. The
the right is on the buccal aspect. triangular flap of mucous membrane and
sub-mucous tissue, intervening between
the two incisions described, and the margin of the cleft in the soft palate, is raised off
the subjacent muscles and turned inward, and the raw surface left by this procedure
is increased in area by turning outward a further portion of the mucous mem-
brane covering the soft palate externally. By this means the area of the upper
surface of the soft palate, rendered bare by the removal of its mucous membrane
covering, is rendered much greater than before. By means of a stout steel elevator
HAKELIP AND CLEFT PALATE
487
introduced between the mucoperios-
teum and the bone, through the inci-
sion made along the margin of the cleft,
the mucoperiosteum is raised from the
bone up to the inner margin of the
alveolus. The flap, whose edge is at-
tached along the margin of the cleft, is
placed beneath the flap which has been
raised from, and for a considerable dis-
tance beyond, the margin of the cleft;
and it is pinned down by fine curved
needles and 0000 Chinese twist silk in
this position, by a number of sutures
which perforate the free margin of the
reflected flap and the outer part of the
elevated flap, the knots being tied on
the under surface of the latter, whence
they can be removed with facility
when the opposing surfaces have
united firmly, which they do in
about ten days. Then the free mar-
f ' -in ' FlG- 42. — FLAPS SUTURED IN POSITION. The shaded
gm of the raised flap is attached by area represents the surface laid bare by the re-
separate sutures to the raw surface moval of the flap,
of the reflected flap. Finally the
opposing edges of the free margin of the soft palate are united in a similar manner."
-B
FIG. 43. — LANE OPERATION FOR BROAD CLEFT INVOLV-
ING ALMOST THE ENTIRE PALATE.
1. OPEEATION FOB BKOAD
CLEFT INVOLVING ALMOST
THE ENTIRE PALATE (Fig.
43). — The first incision begins
at A, goes to B, is continued to
C, and then through the free
edge of the soft palate to D.
The second incision starts at E,
extends along the edge of the
cleft to the junction of the soft
and hard palates F, is contin-
ued on the superior surface of
the soft palate to a point G. A
third incision starting at G is
carried along the free edge of
the soft palate to H. The fourth
incision, starting at E, extends
to I in a direction anterior and
outward. If the septum is free
the cleft, a fifth incision
in
extending from K to L is made, with 2 smaller incisions M and N, O and P.
The flap bounded by A, B, C, and D is then carefully lifted from the sub-
488
PLASTIC SUKGEKY
C' D
FIG. 44. — FLAPS IN POSITION.
jacent structures with a special-
ly designed knife, and must in-
clude not only the mucous mem-
brane, but also the periosteum.
At the posterior palatine fora-
men the artery can usually be
caught with an artery clamp as
it emerges. The flap bounded
by the incisions I? E, and F is
then raised from the hard pal-
ate in a similar manner. The
flap on the superior surface of
the soft palate, bounded by the
incision F, G, and H, must be
raised carefully and include
only the mucous membrane and
submucous tissue. It is turned
downward and inward, hinging
on a line from F to H. The
first flap can now be turned downward and inward, hinging on the line A and
D, which is one of the edges, of the cleft. This flap is then inserted between
the under surface of the hard
palate and the upper surface
of the raised flap bounded by
I, E, and F (Fig. 44).
If the septum appears in
the cleft, the small flaps
marked out by the incisions
N, K, L, and P, and M, K,
L, and O are raised and
turned down. A small linear
incision is then made through
the mucous membrane of the
first flap to correspond to the
area which will be in apposi-
tion to the raw surface just
produced on the septum when
the first flap is turned over
and fastened to the opposite
side.
rri -i , ,1 FIG. 45. — LANE OPERATION WHEN THE WIDTH OF THE CLEFT
To complete the opera- is EXTREME.
tion, interrupted sutures are
placed, to fasten the free outer edge of the first flap to a line nearly opposite the
alveolar border. A second row of interrupted sutures is then placed, to fasten
H
HARELIP AND CLEFT PALATE
480
c
FIG. 46. — FLAPS IN POSITION.
the free edge of the second flap
to the raw surface of the first flap.
The flap from the superior sur-
face of the soft palate is then su-
tured to the raw surface of the
first flap, as shown in Figure 44.
2. OPERATION WHERE THE
WIDTH OF THE CLEFT IS EX-
TREME.— It is frequently impos-
sible to close the gap in one opera-
tion, so a 2-stage procedure may
be adopted:
The first incision extends from
A to B, completely surrounding
the external surface of the alveo-
lar border (Fig. 45).
The second incision extends
from C to D to E.
The third incision extends
from F to G to H. It is then pos-
sible to lift a mucoperiosteal flap bounded by the incisions D, E, H, and G and
leave a small bridge of tissue which must act as a hinge between the points
D and G. This flap is then
turned downward and backward,
and sutured to the raw edges
created by the incision C and D,
F and G. The next step is to
carefully raise the 2 flaps: the
one marked out by the incision
C-D, D-E, and E-A; the other
F-G, G-H, and H-B. These 2
flaps are now rotated or slid
toward the middle line, and the
lines D-E and G-H are sutured
together in the middle line, there-
by covering the raw surface of the
first flap with mucous membrane
(Fig. 46). This completes the
first stage.
For the second stage (Fig.
47), incisions are made from a
point A, along the free margin of
cleft to B, along the free edge of soft palate to C, and then in an anterior
direction toward the alveolar border to a point D. A similar flap is made on
F
FIG.
B E
47. — LANE OPERATION WHEN THE WIDTH OP
THE CLEFT is EXTREME. Second stage.
490
PLASTIC SUKGERY
the opposite side from the point A, to E, to F, to G. These flaps must include,
as is always the case when flaps are taken from the soft palate, only the mucous
membrane and submucous tissue. These 2 flaps are now brought together in
the middle line by sutures which
finally approximate the points B
and E. Interrupted sutures are
then placed fastening the exter-
nal edge of the flap to the soft
palate B, C' and G, F'. Finally
sutures are placed between the
points C' and F', establishing the
free border of the new soft palate
(Fig. 48).
Roberts' Method.— The treat-
ment of the child, according to
Roberts, should be by what might
be called the composite method.
1. Immediately after birth
the mother should press the two
halves of the upper jaw together
firmly with her finger and thumb
many times a day. This ortho-
Fio. 48.— FLAPS IN POSITION. pedic procedure tends to lessen
the width of the fissure.
2. As soon after birth as possible, the soft and semicartilaginous bones of
the upper jaw should be forced together by means of a clamp or by the more
formidable operation of Brophy, with wire tie-beams and lead plates.
3. About the same time that this replacement of the bones is attempted,
the alveolus should be reconstructed in front, if there be any great deviation in
the alignment.
4. Any protrusion of the intermaxillary bone must be corrected by a
plastic or osteoplastic operation at the front part of the nasal septum of the
nose.
5. A gap remaining in the roof of the mouth must next be closed by a flap
operation.
6. The fissure in the upper lip must not be operated upon until then and
should be closed with carefully applied sutures and the deformity of the nostril
corrected.
7. When the lower lip is very prominent, the excision of a V-shaped piece
and the widening of the upper lip if indicated, by the insertion of this piece or
a flap taken from cheek, chin, or hand.
After-treatment. — The essential points in the after-treatment of opera-
tions on the palate are : 1. Quiet and rest of the parts ; 2. Cleanliness.
The first point may be obtained by the use of such drugs as paregoric or
HARELIP AND CLEFT PALATE 491
chloral for the first 24 hours after the operation. From the second day on the
child must be amused, given plenty of toys to play with, made as comfortable
and annoyed as little as possible. He should be allowed to be with people he
likes. As much sleep as the child can get is very beneficial, and plenty of fresh
air is essential.
As to the second point, cleanliness, it is quite a question if the antiseptic
sprays and douches often recommended do not frequently do more harm than
good. They must necessarily be very weak in antiseptic value, and as the
quantity of fluid used must be very small, the cleaning value cannot be great.
As the administration of these douches always excites violent and continuous
opposition on the patient's part, accompanied by much crying, the harm done
is probably greater than the good. Frequent drinks of a small quantity of clean
water are, in my opinion, much more useful. Of course, in older children and
in adults, local cleanliness can be maintained by direct applications to the
wound, and, in these cases, should be employed.
The diet must consist from the first to the sixth or eighth day of fluids only,
a very small quantity at a time, and given with a spoon. After the eighth day,
custards and soft puddings may be added, but it is best not to give any solid
food until the wounds have been examined and the fact established that heal-
ing has taken place or has progressed as far as it will go. After the adminis-
tration of any food, it is well to give a small quantity of water, with the ex-
pectation that particles of food, which may have lodged in the incisions, will
be washed away.
. Unless some serious complication occurs, such as sepsis or hemorrhage, the
wound should be let alone for at least 3 or 4 days. If the hemorrhage is
secondary and profuse (some cases have been reported as late as the tenth
day after operation), it is probably due to bleeding from the posterior
palatine artery. This may be controlled by the insertion into the pos-
terior palatine foramen of a small pointed piece of wood, such as the
end of a match. Slight secondary oozing is generally due to infection
and gangrene and is rarely serious. Much harm has been done by frequent
examination during the first week, but it is difficult to abstain from making
them.
The use of splints on the child's arm or any other form of restraint after
the first 24 hours, is apt to fatigue and annoy the child and make it restless.
It is, therefore, better not to use them, provided proper attention can be given
the patient by a parent or nurse.
Results. — A complete and perfect repair, as a result of an operation, is un-
usual, and the family should not be led to expect it. It is not uncommon for
the line of junction to present some gaps, after the stitches of flap operations
have been taken out. These gaps, which are the result of infection, over-ten-
sion, or erosion, are usually located at the junction of the hard and soft palates
or directly back of the incisors. They are apt to close spontaneously, through
granulation, in 8 or 14 days. Healing of small but persistent gaps may be
492 PLASTIC SURGERY
accelerated by the application of mild caustic agents. Large defects sometimes
require a secondary plastic operation for their permanent correction.
Gangrene after these operations may be due to a variety of operative causes,
aside from the division of the posterior palatine artery, which is sometimes in-
evitable. A frequent contributing cause is too tight tying of the stitches.
When flaps are torn or detached, they should at once be repaired by means of
fine silk sutures. A cause of gangrene, for which the operator is not respon-
sible, consists in the necessary detachment of very thin flaps, which may at
once become discolored and pale, but which sometimes resume their normal
color in the course of the operation. In less fortunate cases, one or several
flaps may become partly or entirely gangrenous, especially around the margins,
but the loss of substance is often spontaneously repaired to an unexpected de-
gree. Le Dentu mentions a case of repair of the entire palate, after gangrene
had destroyed half of the width of one of the flaps, and at least 2 cm. (% in.)
of its length. Fistulas of different sizes usually persist after solutions of con-
tinuity larger than 5 to 6 mm. in diameter. Lateral fistulas, not due to re-
stricted gangrene or ulceration, may form at the level of the incisions and have
been attributed by Ehrmann to constitutional or intercurrent diseases. Exces-
sive length of the lateral incisions, the position of the incision too near the edge
of the cleft, or traction upon the internal margin of one incision from rapid
healing and contraction of another incision, can also be mentioned as causes
which have a tendency to produce fistulse.
Late Results. — The remote results of operative closure of cleft palate are
discussed by Hageman (8) upon the basis of re-examination of 23 cases which
had previously been operated upon according to the Langenbeck method. In
the majority of these cases, plaster casts were taken of the superior and inferior
maxillaB. Of the seven patients who had been successfully operated upon be-
tween the ages of two and seven years, no less than five presented a very char-
acteristic change, which consisted of smallness of the upper jaw in general,
more particularly a narrowness in the transverse direction, with a transposal
of the teeth in the lower jaw, their crowns having rotated inward. These
changes of the upper jaw are explained as due to the traction of the scar tissue,
which forms in the under surface of the hard palate. This cicatricial contrac-
tion subsequently induces a transverse narrowing of the upper jaw. The
change in the lower jaw takes place through the functional adaptation of the
teeth of the inferior maxilla to the upper jaw. When these changes are very
pronounced, the result is a disfigurement of the face and a general disturbance,
on account of the interference with the act of chewing. Upon the basis of his
findings, Hageman arrives at the conclusion from a practical point of view,
that it is of the greatest advantage in the first place, to apply dental protheses
to stretch the upper jaw after operation; and he advocates the postponement
of the Langenbeck operation, at least in severe cases, until the change of teeth
has been completed, namely until after the tenth year if possible.
The modern operative methods of forcible approximation of the entire
PLASTIC SURGERY OF THE LOWER LIP 493
upper jaw do not appear very promising for the future configuration of the
maxilla?, and are likely to induce an increased degree of transverse narrowing
of the superior maxilla. These methods (Brophy, Sebileau, Hammond, Schroe-
der, Helbing) must therefore be applied with some caution. After the Langen-
beck operation, when it is performed at a very youthful age, the growth of the
upper jaw should be steadily controlled, that it may be enabled by means of
orthodental apparatus to counteract in time the narrowing of the maxilla.
It should be well understood that the repair of the palate, even if eminently
successful, does not correct the defects in speech ; or, even where the operation
is performed in early infancy, prevent them from occurring. All that the
operation can do is to make it more possible for the child to learn to speak
correctly and therefore it is of great importance that the child should receive
careful and intelligent instruction as soon as possible after the operation.
After early operations upon clefts of the soft palate in the first few years of
life, no obturator may be required, but these protheses often act as useful adju-
vants in the speaking exercises of older children. Elastic obturators filled with
air and inserted between the velum and the posterior pharyngeal wall, closing off
the nasal cavity, are recommended by J. Wolff and Schiltsky. This prothesis
has a palatine plate of hard rubber with a narrow handle, which is made to lie
over the soft palate and terminate in a small hollow pharyngeal obturator, made
of vulcanized soft rubber. This pharyngeal obturator is compressible and con-
tains air, and when the palatine velum is raised in speaking, it is pushed back-
ward and sideways, with the result, in favorable cases, that the nasopharyngeal
cavity is shut off and the patient's speech in consequence saved from a nasal twang.
The postoperative results in regard to speech are especially hampered by
the smallness of the soft palate and its lack of adaptation to the posterior
pharyngeal wall. Massage of the palatine velum has been recommended for the
repair of this defect and for the correction of the resulting nasal speech. This
massage, according to Tillmanns, may be applied by means of a small T-shaped
instrument of wood or metal, which is curved to fit the hard palate, and with
which the velum is stretched toward the posterior pharyngeal wall.
Mechanical appliances with a flexible velum — the so-called artificial palates
—were formerly often used as protheses in these deformities, but are not to be
recommended at the present stage of surgical technic. They are sometimes
necessary, however, as a last resort, after repeated surgical • procedures have
proven unsuccessful, because of the sloughing of the flaps, or in those desperate
cases in which any operative measures seem foredoomed to failure.
PLASTIC SURGERY OF THE LOWER LIP: CHEILOPLASTY
The closure of small and moderate sized defects of the lower lip, either
triangular or curved, is successfully accomplished through the approximation
of the flexible parts of the lip, followed by suture without the aid of cheiloplasty.
494:
PLASTIC SUKGEKY
Large triangular defects which cannot be closed by simple suture without over-
stretching of the parts may be treated by enlarging the mouth-gap through
horizontal incisions from the buccal angles, followed by suture. A total loss
of substance, either quadrilateral or curved, of the lower lip may be closed as
described by Bruns, by plastic flaps from the cheek, which are turned over into
the defect and sutured ; or, as described by Langenbeck, by a flap cut from the
chin region, which is turned upward into the defect and stitched in place.
FIG. 49. — A SIMPLE V-INCISION FOB REMOVING
NON-MALIGNANT GROWTH OF LOWER LIP.
OPERATIONS FOR EXCISION OF PAPILLOMA, ANGIOMA, OR OTHER NON-
MALIGNANT GROWTHS
Simple V-Incision. — See Figure 49.
Anesthetic. — Cocain, 1 per cent., or novocain used 2 per cent, for the skin
and followed by 1 per cent, for the deeper parts. Ether is unnecessary in
adults. The addition of adrenalin is
not recommended. The administration
of 6 mm. of Magendie's solution of
morphin before the operation quiets the
patient.
Position. — Shoulders and head ele-
vated and head slightly flexed, resting
on firm pillow or sand-bag.
~No special instruments are required.
Technic. — Apply Murphy's intes-
tinal clamps as near the angle of the
lower lip as possible (Fig. 51). The
area to be removed should be a complete
section through the lip, consisting of all its layers. The angle made by the 2
incisions forming the "V" should be as acute as possible, and each incision can
be easily made with one cut of a sharp scalpel. If the angle is acute and the
area removed is not greater than a third of the lip, excellent approximation
without tension can be secured. Incise the lip not absolutely at right angles to
the skin, but slope the scalpel slightly inward while making each incision, in
order to remove a somewhat larger area of skin than of mucous membrane.
The hemorrhage from the coronary artery can be controlled by very fine liga-
tures, and care should be taken to include nothing more than the artery in the
knots. The slight venous oozing may be neglected. Usually 3 or 4 fine silk-
worm-gut sutures passed in at right angles to the skin down to but not through
the mucous membrane, will suffice to give perfect apposition and stop all oozing.
Care must be taken to get exact alignment of the 2 points where the vermilion
border and the skin join. A few silk sutures in the vermilion border may be
necessary. Doyen recommends the suturing of the mucous membrane first,
and then the skin, with all the sutures superficial, and claims that by doing so,
a stronger and firmer lip is obtained.
PLASTIC SURGERY OF THE LOWER LIP 495
DOUBLE TEIANGLE METHOD (Fig. 50, A).— The growth is removed by the
simple V-shaped incision ABC. An area equal to the area of the section is
removed from the cheek, DEC. The incisions for this should be marked out
on the skin and an area of mucous membrane D F G C left to restore the ver-
milion border of the lip as described on page 497. The incisions FE and EG
go through all the layers of the cheek. Figure 50, B shows the sutures in position
FIG. 50. — A, DOUBLE TRIANGLE METHOD FOB REMOVING NON-MALIGNANT GROWTHS OF LOWER LIP;
B, SUTURES IN POSITION AND THE DEFECT CLOSED.
and the defect closed, with the mucous membrane turned out, making the new
vermilion border.
OPERATIONS FOR EPITHELIOMA OF LOWER LIP
The operation consists of : First, the entire removal of the growth with at
least % in. of healthy tissue surrounding it on all sides ; second, the complete
removal of the submental and submaxillary lymph glands; and, third, the
restoration of the lip by one of several methods.
1. REMOVAL OF GROWTH
If the growth is very small indeed, it may be excised with a sufficient amount
of healthy tissue, by a large V-shaped incision, but the amount of tissue re-
moved by this incision is not as a general rule sufficient, and a quadrilateral
area gives much more satisfactory results. The excising incisions must be at
least more than % in. away from the growth.
2. REMOVAL OF GLANDS
The question as to whether the lymph glands should be removed or not does
not admit of discussion. The only possible reason for not removing them would
be the fact that the patient had an inoperable condition. In every case where
496 PLASTIC SUEGERY
there is the least hope of a cure the glands must be removed. If this is not
done, the operation must be considered a palliative one only, and recurrence
must be expected. It has many times been shown that metastases occur ex-
tremely early, and that as soon as the growth, by microscopic examination,
shows typical epithelioma, the lymph-nodes are by that time involved.
The question as to when to remove the lymphatics is important. Many sur-
geons recommend that the complete operation, the removal of the growth, the
removal of the lymph glands, and the restoration of the lip, be done at the
same time.
I much prefer to remove the glands first and to employ a two-stage opera-
tion: First, because it is possible to do an aseptic removal of the glands, result-
ing in primary union of the wounds when the mouth has not been entered;
and, second, because, by dividing the operation, the disadvantages to the wel-
fare and comfort of the patient are minimized. The length of time required
to do a careful restoration of the lip is necessarily great, and there is always
considerable hemorrhage, from which patients frequently show the so-called
"surgical shock." Some infection of the lip wound and consequent rise of
temperature almost always follow the lip operation, which, by themselves, are
sufficient to affect the welfare of the patient. The longer the anesthetic is given,
the greater are the chances for postoperative complications, especially when the
operative field involves the air passages, and I believe it to be much safer to
give 2 anesthetics of moderate duration than one excessively long one.
In almost all cases it is undoubtedly best to remove the glands first, be-
cause they are thus sure of being removed. It frequently happens that the re-
moval of the growth and the restoration of the lip satisfy the patients, especially
hospital patients, and they refuse to accept the second operation; and because
the restoration of the lip is a long operation and the after-effects of the anes-
thetic are often so prolonged and severe, the patient refuses to take ether again.
I recommend incisions as shown in Figure 61. All lymph-nodes should be
removed, also the submaxillary salivary glands. The wounds do well if closed
with drainage, which can be removed on the third day. For the various meth-
ods, see operations on the neck.
3. RESTORATION OF THE LIP
First Method (Figs. 51, 52). — To insure a symmetrical result it is well to
mark out with the point of the scalpel on the skin the incisions which it is pro-
posed to make in order to fill the gap. If this is not done before the incisions
are made, it frequently will be found, toward the end of the operation, that the
flaps are unequal and have a tendency to drag the lip in either one or the other
direction. Having marked the cuts, make the convex incision CD, the convexity
pointing upward and outward. This incision should be made to follow, so as
to surround, the base of the prominence of the chin, and must penetrate all the
superficial parts. The blood-vessels, which are numerous, must be caught with
PLASTIC SURGERY OF THE LOWER LIP
497
FIG. 51. — RESTORATION OF LOWER LIP (1).
fine mosquito clamps and the vessels ligated with the finest possible catgut.
Then make incision AB in a horizontal direction of a length equal to % °f *ne
space created by the removal of the growth on the lip. This incision should
extend down to but not through the mucous membrane of the cheek. When
this is reached, the scalpel should
be turned upward, separating the
mucous membrane from the sub-
jacent tissues for the distance of
at least % in. Then cut through
the mucous membrane parallel to
the incision AB. This is done in
order to provide sufficient mucous
membrane to turn over the raw
surface of the new lip, and thus
create a new vermilion border.
Repeat the same incisions on the
opposite side of the face. Care
must be taken to stop all hemor-
rhage at this time. By now gently
approximating the cut surfaces IG
and JC, it can be estimated whether the lateral incisions have been extensive
enough to enable these 2 surfaces to be approximated without any tension what-
ever. If there is any tension, the lateral incisions must be extended. During
this part of the operation, some type of aspirating apparatus, which enables the
blood to be removed from the
pharynx, is of great value to
obviate the need of constant
sponging, which not only
does not completely remove
the blood, but also interferes
with the operation, irritates
the patient's mucous mem-
brane, and has a tendency to
increase the possibilities of
postoperative complications.
SUTURING. — B e g i n by
suturing the mucous mem-
brane of one of the lower
incisions, working on both
sides toward the middle line. A medium sized curved needle with fine plain
gut, using interrupted stitches about % in. apart, gives the best results. Care
must be taken, as in all plastic work, not to tie the stitches too tight or invert
the mucous membrane. When these suture lines are complete, one of the flaps
created by the incisions AB and CD can be gently held with a sponge-holder
33
FIG. 52. — RESTORATION OF LOWER LIP (2).
498
PLASTIC SURGERY
-— B
FIG. 53. — RESTORATION OF LOWER LIP (3).
and drawn toward the middle line. Fine silkworm-gut stitches can now be
introduced, beginning at the outer end of the curved incision CD. If the silk-
worm-gut has been previously soaked for some little time in warm water, it will
be much easier to handle and
will adapt itself better to the
tissues. These stitches should
include all the thickness of
the soft parts down to the
mucous membrane, but* must
not pass through the mucous
membrane, and must be tied
so as to just approximate the
cut surfaces. Frequent ap-
plications of peroxid, fol-
lowed by warm salt solution
over the raw areas, has been
found an excellent cleansing
agent and at the same time
a mild hemostatic without
causing much irritation or interfering with the healing. Following the suture
of the 2 lower lateral incisions, a vertical suture of the mucous membrane
created by the approximation of IG and JC is now done. Four or 5 fine
catgut sutures usually suffice. Silkworm sutures
are then passed, as before, in the middle line, care
being taken to get exact alignment between the
junction of the vermilion border and the skin of
the opposite parts. The excess of mucous mem-
brane created when the incisions AB and EF were
made, is now drawn forward over the raw surface
of the new lip and carefully sutured to the skin
with fine silk. If this step of the operation is
carefully done, an excellent new vermilion border
for the new lip will result.
It will now be found that an excess of tissue
in the cheek prevents correct approximation of the
2 upper horizontal incisions. To overcome this, a
small triangular section consisting of the whole
thickness of the cheek can be removed from each
side (Fig. 53).
Morestin's Method. — Morestin (20) advocates very strongly the excision
"ultra-total" of the epithelioma (Fig. 54). The area to be removed is bounded
by 3 incisions. The first one is curved in shape and passes transversely in front
of the point of the chin, continuing at the level of the border of the inferior
maxilla to a point just anterior to the location of the first molar tooth. The 2
FIG. 54. — MORESTIN'S OPERA-
TION FOR CARCINOMA OF THE
LOWER LIP. Showing incision
for removal of the growth.
PLASTIC SUKGEKY OF THE LOWER LIP
499
others start from the angles of the mouth (which are supposedly not involved
in the growth) and pass downward and outward, joining the extremities of the
transverse incision. The part thus removed will be of a trapezoid shape, with
the base inferior.
Morestin uses this procedure because the lesion has a tendency to infiltrate
the muscular tissues and to travel along the lymphatics which pass with the
inferior dental nerve, and deplores the removal of the growth by a V-shaped
incision which does not consider this chance of metastasis. The removal of this
trapezoid gives the best prognosis and removes the greatest possible amount of
doubtful tissue. It is, of course, understood that this operation must be either
preceded or followed by the complete dissection of the lymphatic nodes and
the submaxillary glands.
The area to be filled in is apparently enormous, and at first seems to present
a great many difficulties. But the author does not find these insuperable. He
considers the most suitable cheiloplastic operation for closing this defect to be
that described by Larger (13), but he has made several improvements on this
method.
For the sake of perfect accuracy he advocates tracing an incision on the
skin. He begins by tracing an incision on each cheek parallel to the edge of the
section and at a distance of 3 cm. from it, beginning at the lowest point at the
level of the teeth of the inferior maxilla and going in an upward direction to-
ward the nasolabial sulcus and stopping at a point
within 1 cm. of the ala of the nose. From the
upper extremity of this incision he starts an-
other, which runs obliquely downward and inward
toward the border of the lip. This incision
reaches to but not through the vermilion border,
a certain amount of which is preserved, and this
he detaches by transfixion, cutting outward until
he meets the angle of the mouth. Thus, a little
tongue is formed, attached by its inner extremity
to the upper lip, which is used to restore the angles
of the mouth to an "excellent condition" ; and this
he considers the most delicate part of a total re-
moval of the lip.
Figure 55 shows the traces of the incision, in-
cluding that of the little strip of vermilion border
destined to repair the angle. Great care must be taken to cut the flaps exactly
alike and to give them exactly the same length and size, to insure a symmetrical
new mouth. All the soft parts must be neatly cut following the skin incision,
and the 2 flaps kept of the same dimensions throughout. It is hardly necessary
to use any ligatures.
Figure 56 shows on one side the flap drawn aside and on the other side the
flap fastened in its permanent position. It shows, too, the shape of the areas
FIG. 55. — MORESTIN'S OPERA-
TION SHOWING INCISION FOB
THE FORMATION OF THE FLAPS.
500
PLASTIC SUKGERY
FIG. 56. — MORESTIN'S OPERATION
SHOWING FLAPS DRAWN DOWN.
resulting from the change of position of the flaps and small strip of vermilion
border detached from the upper lip.
The flaps are sutured to each other in the middle line by 2 layers of silk
sutures, the first attaching the skin and muscular layer, the second the mucous
membrane. The stitches, as shown in Figure 57,
are then inserted.
When the upper borders of the flaps, which
now form the free border of the lower lip, appear
to be too thick, which sometimes happens, espe-
cially near the angles of the mouth, it will be
necessary to thin them down by excising sufficient
fat, muscular fiber, and gland tissue to accomplish
the thinning. The two strips of vermilion border
already described are fastened to the flap with
very fine silk. Special, fine silk sutures must be
used, both on the skin and on the mucous mem-
brane. Morestin finds the result of this operation
usually favorable. The upper lip, which is often
stiff at first, rapidly becomes supple. The lower
lip will sometimes continue to be a little heavy
and rigid. The defect is only temporary, and at the end of a certain length of
time will usually adjust itself. If, however, the lip continues too thick, he
corrects this by some retouches done under local anesthesia. Usually this is not
necessary. The mouth is symmetrical, the angles keep their mobility, and
the 2 lips approximate each other perfectly, and
also there is no dribbling of saliva as frequently
happens in other types of cheiloplasty.
Morestin's Operation for Very Extensive Loss of
Substance of the Two Lips and part of the Cheek.
—Half of the upper lip, nearly all of the lower
lip, a large part of the right cheek, and nearly all
the coverings of the chin have been removed (Fig.
58). To close this defect, the opposite cheek can
be made use of, if this is soft, and especially if the
patient is old and has flabby tissues. The cheek
is transformed into a huge flap, of which the an-
terior part must be pulled to the opposite side as
far as the posterior limits of the missing area.
Two long horizontal incisions parallel to each
other are made, the first from the upper part of
the cheek, grazing the malar bone, the other in the neighborhood of the inferior
maxilla. These cuts are made down to the masseter muscle. The mucous
membrane is cut at the bottom of the buco-alveolar junction for its whole
length. Everything that interferes with the free movement of this flap must
FIG. 57. — MORESTIN'S OPERATION.
Sutures in place.
PLASTIC SURGERY OF THE LOWER LIP
501
be cut. Even the posterior attachments of the buccinator muscles may be
vertically cut without hesitation.
Because of these very extensive freeings, the enormous flap is susceptible
of considerable elongation and can be made to pass from one side of the face to
FIG. 58. — MORESTIN'S OPERA-
TION FOR EXTENSIVE Loss
OF SUBSTANCE OF THE LIPS
AND CHEEK.
FIG. 59. — MORESTIN'S OPERA-
TION. Showing flap drawn
over to opposite side.
FIG. 60. — MORESTIN'S OPERA-
TION SHOWING FLAP SUTTJBE
AND NEW MOUTH FORMED.
the other. It forms a sort of a veil (opercule) falling in front of the teeth down
to the chin (Fig. 59). The inferior border is not sutured until later, in order
to make provision for nourishment. The suturing is finished, and after a few
days a window made which becomes, after the suture of the mucous membrane
to the skin, a sort of new mouth (Fig. 60). The case chosen here is a very
extreme one, but more often a much slighter de-
formity is presented.
Dowd's Operation (Fig. 61). — This operation
(3) gives excellent results and is recommended as
the best procedure if the whole operation is to be
performed at one time. As the lymph glands and
submaxillary glands are so intimately connected, it
is always best to remove the submaxillary gland.
IsTo bad results have yet been reported by so doing.
The incisions GH and CD should be made first and
the glands removed before the growth is removed
and before the incisions involving the mucous mem-
brane are made, taking care to leave a considerable amount of tissue attached
to the prominence of the chin. An excellent exposure of the submental and
submaxillary spaces is obtained. If the glandular involvement is extensive,
the dissection will have to extend laterally as far as the great vessels. The
ligation of the facial vein is often necessary. If possible, the facial arteries
FIG. 61. — DOWD'S OPERATION.
502
PLASTIC SUHGERY
FIQ. 62. — JAESCHE'S OPERATION.
should be preserved, although it is reported by Dowd that their ligation does
not seem to interfere with the vitality of the lip flaps. After the glands are
removed and the veins ligated, the incisions AC and GF are made and the
x growth removed. A space of at least % or, better,
(^ ^J % in. of healthy tissue must exist between the edge
of the growth and the incision. If the growth is
near the angle of the mouth, it will be necessary to
remove some of the tissue of the cheek to accomplish
this, in which case incisions AB and FE are then
made, of a length sufficient to allow the easy appo-
sition of the surfaces AC and FG.
Jaesche's Modification of Dieffenbach's Method
(Fig. 62). — Two horizontal enlarging incisions are
made at the buccal angles of the mouth, to which are added 2 longitudinal
incisions at an outward angle. The enlarging incisions at the buccal angles
are made to extend no deeper than the mucosa, which is dissected off a little
higher up, corresponding to
the dotted lines in Figure
62. This flap of mucosa at
the buccal angles is utilized
on each side for supplying
the vermilion border. A
flap at only one side may
suffice to fill the gap if the
defect is small.
Syme's Method (Fig.
63). — From the apex of the
triangle, make 2 curved in-
cisions of sufficient length
to allow the sides of the triangle to assume a horizontal position without tension,
when the flaps are lifted. The incisions, if made to follow the inferior border
of the lower jaw, will leave little, if any, scar.
FIG. 63. — SYME'S OPERATION.
FIG. 64. — ESTLANDER'S OPERATION.
Estlander's Method (Fig. 64). — Lateral triangular partial defects of the
lower lip are very efficiently closed by a flap cut from the upper lip, which is
PLASTIC SURGERY OF THE LOWER LIP
503
FIG. 65. — SEDILLOT'S OPERATION.
nourished from a bridge of tissue left at the lip margins. This flap is lifted
and turned into the defect of the lower lip and the wound closed by sutures.
By taking an analogous flap
from the lower lip, the
same method can be utilized
for cheiloplastics of the
upper lip.
Sedillot's Method (Fig.
65). — Two inferior flaps
are formed from the lateral
region of the cheek and
chin, by cutting in a
straight line from the
buccal angles downward,
through the entire thickness
of the soft parts. Two sec-
ondary parallel incisions
with connecting incisions
are then made. The base of the flap or its connecting bridge is situated at the
angle of the mouth. This method is equally applicable for cheiloplastics of
the upper lip.
Malgaigne Method. — See Figure 66.
FIG. 66. — MALGAIGNE'B OPERATION.
PLASTIC SURGERY OF THE UPPER LIP
Aside from harelip operations, plastic procedures upon the upper lip are
much more rarely required than on the lower lip. Small defects of the upper
lip can be readily repaired by freshening the edges
and drawing together the skin and deeper parts
by properly applied sutures, as shown in Figure
67.
Large defects may be repaired by the double
curved incisions of Dieffenbach (Fig. 68). This
operation consists of 2 incisions on each side.
The first begins at the apex of the defect
and follows completely around the ala of
the nose. At the upper end of this incision
the other one begins and in an inverse curve
reaches toward the cheek as far as is necessary to allow the flap to fill the
defect.
For the complete restoration of the upper lip, the method of Sedillot by
vertical flaps (Fig. 69) or that of Szymanowski by lateral flaps (Fig. 70) is
recommended.
FIG. 67. — METHOD OF REPAIR
OF SMALL DEFECT IN UPPER
LIP BY FRESHENING THE EDGES
AND SUTURE.
504
PLASTIC SUKGEKY
FIG. 68. — DIEFFENBACH'S OPERATION.
FIG. 69. — SEDILLOT'S OPERATION.
FIG. 70. — SZYMANOWSKI'S OPERATION.
The technic of these operations and the formation of the vermilion border
on the new lip are the same as described under Plastic Surgery of the Lower Lip.
PLASTIC SURGERY OF THE EAR: OTOPLASTY
MALFORMATIONS OF THE LOBULE
These malformations usually consist of an enlargement of the lobule in all
directions, and are best corrected by Joseph's method (Fig. 71). The line of
the incisions should be carefully marked out on the skin before beginning the
operation, especially if both ears are deformed. When this is not done it is
very difficult to get a symmetrical result.
The bleeding is profuse, but easily controlled by the sutures. No ligatures
need be used.
One of the advantages of Joseph's operation over the one usually practiced
—the simple resection of a wedge-shaped piece from the lower edge of the
PLASTIC SURGERY OF THE EAR
505
FIG. 71. — JOSEPH'S METHOD FOB DIMINISHING SIZE OP ENLARGED LOBULE.
lobule — lies in the prevention of the postoperative notch formed on the edge of
the ear by the contraction of a linear scar.
MALFORMATIONS OF THE AURICLE
Abnormal Enlargement of the Ear (Macrotia). — This deformity is satisfac-
torily treated by either the Kolle method (Fig. 72) or the Parkhill method
(Fig. 73), combined with the Joseph method for the lobule, if necessary.
FIG. 72. — KOLLE'S OPERATION FOR ABNORMAL ENLARGEMENT OP THE AURICLE.
Care must be taken to plan the incisions carefully before beginning the
operation, and also to make clean, neat cuts with a very sharp scalpel in order
that the resulting scar shall be as inconspicuous as possible.
Abnormally Small Ears or Absence of the Ear (Microtia). — This is a rare
condition and has not yet been satisfactorily treated by plastic surgery. Me-
506
PLASTIC SUKGEEY
FIG. 73. — PARKHILL'S OPERATION FOR ABNORMAL ENLARGEMENT OF THE AURICLE.
chanical prothesis, that is to say, the wearing of an artificial ear, which has been
well modeled and colored, attached to the head by means of spectacles or clamps,
is cosmetically much better than any result obtained by plastic surgery.
MALPOSITION OF THE AURICLE
This condition calls for surgical treatment when an excessively wide angle
exists between the auricle and the side of the head, with the ear standing out
and the upper portion of the auricle usually curving
forward. In early childhood when this condition is
seen to be developing, it may often be arrested and
permanently corrected by the application of a firm
bandage or cap over the ears, which must be worn
continuously, however, and not only at night, as is
usually done. If the condition shows no improve-
ment as the result of this treatment, the removal
of an elliptical area of the skin over the soft and
pliable cartilage at the back of the ear will draw
the ear into a good position, and will be all that
is necessary in the case of young children. (Fig.
74.)
Kolle's Method (Fig. 75).— This method (11)
the writer recommends for adults. It is simple and
gives excellent results.
FIG. 74. — MONK'S OPERATION
FOR ABNORMAL ENLARGE-
MENT OF THE AURICLE.
Kolle writes:
"An incision is made along the whole of the back of the ear as far down as the
sulcus, where the retro-aural integument joins that of the neck.
PLASTIC SURGERY OF THE EAR
507
"The incision should involve the skin only, and vary from three-fourths to one-
half an inch from the outer border.
"At once, the blood will ooze from the line of incision. The operator now presses
the ear backward on the bare skin of the head, leaving an imprint of the bleeding line
on the skin there.
"A second incision is made along this line, giving the total outlining incision a
heart-shaped form, as shown in Figure 75.
"The skin within this area is now dissected up quickly. The wound
FIGS. 75-76. — KOLLE'S OPERATION FOR MALPOSITION OP AURICLE.
cartilage to be removed.
Shaded area shows amount of
should be large enough to over-correct the fault, or the ear springs out more or less
when healed.
"Sutures are now introduced. When necessary, one or two catgut sutures are
taken through the concha — not going through the anterior skin, however — and the
deeper tissue back of the ear and tied. These hold the cartilage in place."
Before the skin is sutured, if the ear has the least tendency to spring back
into its former position, a piece of cartilage must be removed, elliptical in shape,
as shown in Figure 76. In doing this, care must be taken not to buttonhole
the skin on the anterior side of the ear.
Interrupted sutures of very fine chromic gut are then passed, approximating
the cut edges of the cartilage, after which the skin edges are closed by fine silk
or chromic gut stitches. As the result of removing the section of cartilage,
a ridge of skin will be formed on the front of the ear. This will often
contract and disappear in the course of time, but in case it should persist,
it is a very simple matter to excise this small defect by a secondary
operation.
508
PLASTIC SUKGERY
PLASTIC SURGERY OF THE CHEEKS: MELOPLASTY
For the replacement of a loss of substance of the cheek, a large number of
plastic procedures have been suggested, from simple approximation with suture
of the very flexible wound margins in minor injuries, to the formation of pe-
dunculated flaps from the frontal, temporal, maxillary, or mental regions for
the correction of more serious defects. Skin transplantations are sufficient for
the closure of superficial defects limited to the external skin.
The replacement of the cheek is a surgical problem of less simplicity than
one might imagine, and still awaits an entirely satisfactory solution. The so-
called anaplastic Indian or Italian methods, which
utilize 2 single flaps or 1 double flap, are both com-
plicated and unreliable. Numerous procedures
have been recommended which are not free from
disadvantages, such as the insufficient nutrition and
low vitality of a flap which is nourished only by
means of a connective tissue pedicle. This is also
true of the methods of Gersuny, Kraske, and
Thiersch, which, however, have the advantage of
causing only slight surgical injuries. Imperfect
nutrition of a flap exposed to infectious processes
through the inevitable presence of bacteria leads
almost invariably to negative results, and for this
reason failures have been known to follow the
methods of Czerny, Israel, Hahn, and Ombredanne,
whose operations, moreover, yield rather imperfect cosmetic results because
of the unnecessarily large and hypertrophic flaps. Other procedures, like
those of Bardenheuer, Schimmelbusch, Monod, and Vanvert, while more reli-
able, involve very considerable surgical damage and leave a large amount of
scar tissue about the face and neck. It is an additional drawback that in
several of these methods hairy skin flaps are made to take the place of mucous
membranes.
Careful attention must be given in all cases of meloplastics to the avoidance
of distortion of the lower eyelid and the upper lip.
The operator has at his disposal a variety of plastic procedures which
utilize the external skin for the covering of extensive penetrating defects of
the cheek for the replacement of the mucosa, as well as of the outer skin
covering.
Israel's Operation. — A relatively simple and convenient method of melo-
plastics is that recommended by Israel (10). In the first step of the operation
the mucosa is replaced by a very long pedunculated flap, which is taken from
the neck, reaching from the front of the ear in the maxillary angle as far down
as the clavicle, if necessary (Fig. 77). This is turned with the skin surface
FIG. 77. — ISRAEL'S OPERATION
(1). Position and shape of flap.
PLASTIC SUKGERY OF THE CHEEKS
509
FIG. 78. — ISRAEL'S OPERATION
(2). Flap turned and sutured
into gap.
inward and allowed to heal in the gap (Fig. 78). The neck wound is drawn
together as shown.
In the second step of the. operation, which takes place at the end of from 14
to 17 days, the pedicle is cut through and turned on itself over the raw surface
of the healed-in flap with the skin side now out, where, after thoroughly scrap-
ing off the granulations which have formed on the exposed raw surface, it is
sutured in place with drainage (Fig. 79) and forms
the new cutaneous surface of the cheek.
One of the chief advantages of Israel's method
of meloplastics lies in the simplified after-treat-
ment ; the patient is not obliged to hold his head in
a fixed or inconvenient position for any length of
time, as is inevitable in the methods of Hahn and
Hacker, where the flap is formed from the skin of
the chest.
Hahn's Operation. — In Halm's procedure, the
flap is formed from the skin of the chest, the base
beginning at the clavicle, and its end lying near the
nipple. The nutrition of the flap is the weak point
in this method.
Hacker's Operation. — The chief advantage of the
procedure used by Hacker lies in the favorable blood supply of the flap formed
as he recommends (7). A flap is taken from the skin of the chest, having its
pedicle and base at the sternal margin and running parallel with the ribs
toward the shoulder (Fig. 81). This method is specially indicated in cases
requiring secondary plastic operations, owing
either to the partial failure of the first meloplastic
or to the necessity for another excision of tissues
in recurrent malignant growths of the surround-
ings. The position of the head is necessarily awk-
ward for the first fortnight, but it is extremely
important to avoid displacement or traction upon
the flap because of the danger of marginal necrosis.
The fixation of the head may be accomplished in
several ways, which may be left to the ingenuity
of the operator. Hacker cautions against over-
constriction of the thorax by the fixation bandages,
especially in aged patients.
Lexer's Method. — The use of a temporofrontal
flap is given the preference by Lexer (16). For
the substitution of the beard, a strip of the hairy
scalp is included in the portion of the flap which comes to lie on the outside of
the cheek.
Lerda's Method. — Lerda's method is a new procedure for the substitution
FIG. 79. — ISRAEL'S OPERATION (3).
Second stage. Pedicle cut and
flap turned on itself and sutured
with drainage.
510
PLASTIC SUEGERY
FIG. 80. — ISRAEL'S OPERATION (4) . Trans-
verse section of Figure 79.
of the cheeks, and has been recently published by him (15). It offers the fol-
lowing advantages: (1) It is practically devoid of danger. (2) It can be
performed in 2 or 3 stages, under simple local anesthesia. (3) The flaps are
highly vascularized and, therefore, extreme-
ly viable. These flaps, by virtue of their
constitution, meet all the requirements es-
pecially well, as their mucous lining is per-
fectly adapted to their physiological func-
tion, while from the cosmetic point of view
the skin of the lip resembles that of the
cheek more closely than any other. The
extent of the operation is governed by the
existing loss of substance. The procedure
may be advantageously used in combination with other flaps in those cases
where a more extensive operation is necessary.
This new method was successfully employed in a case of cancer of the left cheek
of a man 62 years of age and requiring the ablation of the entire cheek. Under
infiltration anesthesia (40 gr. novocain, solution 1 : 200), the tumor, which involved the
entire cheek, was excised about 2 cm. beyond its
margins, thus ablating the entire cheek, from the
malar bone to the lower margin of the inferior
maxilla, and from the end of the lip to the an-
terior bundles of the masseter muscles, which
were also excised (Fig. 82). In the middle of the
posterior margin of the surgical gap the stump of
Steno's duct was found and was at once stitched
with 2 sutures to the margin of the mucosa of
the ablated geniomandibular sinus. At the lower
margin of the gap the skin under the submaxil-
lary space was mobilized for the removal of the
infiltrated lymph nodules. This completed the
first part of the operation, and it was now neces-
sary to replace the extensive loss of substance
which exposed the 2 left dental arches beginning
with the canines. Two flaps, derived from both
lips, were extensively and sufficiently mobilized
for the plastic substitution of the defect. To make this possible, 2 horizontal in-
cisions were applied at the level of the duplication of the mucosa of the labio-
alveolar sinus. The lips were then severed in their entire thickness, the incisions
beginning at the operative gap and extending through the right cheek until close
to the anterior margin of the right masseter muscle. This served to mobilize a
flap with a mucous lining, derived from the lips and the corresponding segment of
the right cheek. By means of gentle traction, the free ends of the labial stumps
could be placed in contact with the excised mucosa of the geniomandibular sinus ind
the corresponding skin of the left masseteric region. The labial mucosa was then
sutured to the alveolar mucosa with paramucous sutures, and the labial skin was
stitched with silk sutures to the skin margins of the gap in the cheek. The mouth
opening thus came to lie entirely on the left side, with the right buccal angle at the
middle line, the labial margins lying across the left side of the face, showing the left
FIG. 81. — HACKER'S OPERATION.
PLASTIC SUKGERY OF THE CHEEKS
511
FIG. 82. — LERDA'S OP-
ERATION (1).
FIG. 83. — LERDA'S OP-
ERATION (2).
dental arches through the rather drawn and distorted mouth cleft (Figs. 83 and 84).
The new left buccal angle came to lie at the anterior margin of the left masseter, at
the point where the stump of the ablated Steno's duct had been implanted. The
sutures were removed on the eighth day. With the exception of the left buccal angle,
where some sutures had given way on account of the flow of saliva, the entire wound
had healed by first intention. The sec-
ond and third step of the operation, for
the reestablishment of the mouth open-
ing in the middle line, were postponed
until the wound had completely healed.
These 2 simple supplementary opera-
tions were performed under local anes-
thesia at intervals of several days, the
first consisting in an incision through
the entire thickness of the right cheek,
about 3 cm. in length, beginning at the
right buccal angle. The mucosa was
stitched to the skin, and the red lip
margin was reestablished. At the third
operation, the lip margin was freshened,
thus removing the vermilion border, and incisions were made freeing the mucosa in
both the upper and lower lips, reaching from the left buccal angle to approximately
3 cm. to the left of the middle line. Paramucous and cutaneous sutures were applied,
reestablishing a new cheek through the connection of the 2 labial strips (Fig. 85).
Healing proved again most difficult in the region of the left buccal angle, where a
small fistula, due to the flow of saliva, persisted for some time. Two months after the
first intervention, the patient was free from any pronounced or disfiguring cicatrix.
The left cheek was covered with hairy skin, the buccal opening was of normal size and
functionated well. The dental arches can be separated by IMs cm. in the middle line
without difficulty. The opening angle of the jaws is increasing daily in consequence
of the gradual mechanical dilatation.
Hotchkiss's Operation (9). — This is an excellent method for an extensive
defect, and has given most satisfactory results in the hands of several operators.
In the case described by the
author (Fig. 8G) the defect,
bounded by the upper horizontal
line and the dotted curved line,
was the resiilt of the excision of
an extensive infiltrating carci-
noma, which necessitated the re-
moval of a part of the inferior
maxilla. The operation can be
divided into five steps: First, a
vertical incision was made from
the posterior end of the horizontal
line, which formed the inferior boundary of the defect, through the superficial
parts, of a length somewhat greater than the total height of the defect. Second,
from the inferior end of this last incision a horizontal incision was made of a
FIG. 84. — LERDA'S OPERA-
TION (3).
FIG. 85. — LERDA'S OP-
ERATION (4).
512
PLASTIC SUKGERY
length about equal to the width of the defect. Third, another vertical incision,
beginning from the anterior end of this last incision, was made, extending al-
most down' to the clavicle. Fourth, the flap formed by these incisions was raised,
FIG. 86. — HOTCHKISS'S OPERA-
TION (1). Showing amount
of defect and incisions.
FIG. 87. — HOTCHKISS'S OPERA-
TION (2). Showing flap lift-
ed and turned outward, giv-
ing exposure of deep struc-
ture of neck.
FIG. 88. — HOTCHKISS'S OPERA-
TION (3). Showing flap ro-
tated and sutured into place.
with the platysma muscle, and turned in an outward and anterior direction,
exposing the lymphatic and salivary glands of the neck, which were removed
(Fig. 87). Fifth, the flap was then rotated upward into the defect and closed
with through drainage as shown
in Figure 88.
Gersuny's Modification of
Kraske's Method.— This method has
given excellent results and is to be
recommended. The failures which
have occurred have been due to inter-
ference with the nutrition of the flap,
either because the pedicle was too
small or because the blood supply was
shut off when the flap was turned
back upon itself.
The first step, after having
freshened the edges of the defect,
is to outline, on the lower part of
the cheek of the same side, an area
slightly larger than the defect to
be filled (Fig. 89). Second, the
skin and subcutaneous tissue are incised around the projected flap down to the
muscle. The flap is then lifted from the subjacent tissues, leaving, however,
a bridge of tissue of the anterior upper edge of the flap to serve as a hinge.
FIG. 89. — KRASKE-GERSTTNY OPERATION (1). Show-
ing edges of defect fastener and incision for for-
mation of flap made.
AUTOPLASTICS OF THE CHEEK REGION
513
Third, the flap is turned in an upward and outward direction, hinging on
the bridge of tissue and placed in the gap, the skin taking the place of the
missing mucous membrane (Fig. 90).
Fourth, the flap is sutured into place, inserting first the sutures shown in
FIG. 90. — KKASKE-GERSUNY OPERATION
(2). Showing flap turned into the
defect by hinging at the upper and
anterior end.
FIG. 91. — KRASKE-GERSUNY OPERA-
TION (3) . Showing flap in position
and first suture inserted.
Figure 91. The skin is closed over the raw surface as much as possible, and
the wound is drained with rubber tissue.
Esmarch-Koleralzig Operation. — This operation consists of 2 large flaps (Fig.
92, A) thoroughly freed, which are drawn toward each other and sutured as
shown in Figure 92, B.
As no provision has been made in this operation for an epithelium lining
\ B
FlG. 92. ESMARCH-KOLERALZIG OPERATION.
to the inner side of the flaps, the results of the operation are generally faulty.
Much contraction of the scar soon follows, accompanied by deformity of the
mouth.
AUTOPLASTICS OF THE CHEEK REGION
Gussenbauer's Operation for Cicatricial Maxillary Occlusion (22). — This pro-
cedure consists in the division of the cheek and the implantation of double
flaps into the defect, and is only feasible when a sufficient amount of healthy
34
514 PLASTIC SUEGEKY
skin is available. In the case of the deformity of a 7-year-old boy, a flap
measuring 4 cm. anteriorly and 6 cm. posteriorly was formed from the skin of
each cheek. These flaps were dissected free as far as the masseteric margin,
where they retained their pedicles. The subcutaneous soft parts of the cheek
and the cicatrices of the old wounds (the results of ulcer at ive stomatitis) were
likewise divided transversely as far as the masseteric margin. On each side the
dissected skin flap was doubled over into this defect in such a way that its
anterior wound margin was united by suture with the preserved mucosa behind
the masseter, with its external epithelial surface turned toward the buccal cav-
ity. At the end of 4 weeks the healed skin flap was cut through on each side at
its pedicle and the posterior portion of the flap was detached toward the front
and turned to the persisting anterior portion of the defect, so that the epithelial
side of the entire flap now came to lie toward the buccal cavity. In stitching
in the flap, the margin of the cheek cleft at the upper and lower jaw was utilized
as a substitute for the gums. Finally, the external defect in the cheek was
covered by a rectangular skin flap from the region of the lower submaxillary
margin having its base above and behind. The result of the plastic operation
was excellent.
Plastic operations on the face are sometimes necessary for the correction of
disfigurements due to injury of the facial nerve received at the time of radical
operations for middle ear disease. The cosmetic results of anastomosis be-
tween the facial nerve and the hypoglossal or the accessory nerve are unreliable
and imperfect. The patient may gain control over a few of the muscle groups
of the face, but not without associated movements of the shoulder or the tongue.
These failures led Lexer to evolve his method of muscle plastics (19).
The procedure permits the partial substitution of the paralyzed areas by
muscle plastics: areas taken from parts which are not supplied by the facial
nerve.
Nordmann, as the result of favorable experiences with 3 cases of lagophthal-
mos and facial paralysis urgently advocates, instead of nerve anastomosis,
Lexer's simple method, which is certain to yield positive results (18). In
cases of incomplete palpebral closure of the eye on the paralyzed side (lag-
ophthalmos), Nordmann recommends severing a bundle from the temporal
muscle and implanting it in the lateral ocular angle. The patient is carefully
instructed to practice the contraction of the temporal muscle. Although the
palpebral closure may be perfect, a drooping buccal angle may still require at-
tention. To lift the drooping mouth and control the salivary flow, and to
enable the patient to hold his food, muscle plastics from the masseter may be
employed. An incision is made in the nasolabial fold and part of the masseter
is fixed to the buccal angle.
The secondary epidermization of freshened pedunculated flaps, which have
been turned into the buccal cavity for the substitution of cheek defects, was
recently investigated by Lefevre (14) in experimentation upon dogs. The
dissemination of small bits of mucous membrane over the raw surfaces, in the
AUTOPLASTICS OF THE CIIKKK RKGION 515
sense of the old Reverdin technic, gave excellent results. The epidermization
was found to proceed very rapidly and to be favored by the absence of tension
in the flap. It was also favored by having had, when the flap was transplanted,
a good control of the hemorrhage and accurate approximation by suture of the
mucous margins to the wound surface of the flap. The new-formed epithelium
proved sufficiently thick and resistant, although the new cheek was less flexible
and not contractile.
Chavannez obtained excellent results on the human subject by this pro-
cedure.
Hydrocarbon Protheses. — The subcutaneous use of paraffin or vaselin, which
solidify at the body temperature, was described by Gersuny in 1900. The
method consists in warming a given preparation of paraffin so that it can be
forced, by means of a suitable syringe, through the lumen of a hypodermic
needle into the tissues, where, on cooling, it will solidify and remain per-
manently without irritation. This method is used only in the cosmetic correc-
tions of deformities on the surface of the body.
The dangers to be guarded against are many: First, infection. Unless the most
perfect asepsis is maintained, a marked redness of the skin and irritation of the tis-
sues surrounding the injected mass are apt to result, which may even progress to
abscess formation and destruction of tissue by necrosis. Second, necrosis of the tis-
sue due to the pressure of the injected mass on the neighboring blood vessels. Third,
embolism, of either air or paraffin, which is usually due to the accidental insertion of
the point of the injection needle into a vein. Fourth, sloughing of the tissues due to
the excessive heat of the injected mass. Fifth, over-correction of the deformity by
the injection of too much of the mass at one time, which is a serious danger on ac-
count of the very great difficulty of removing the solidified paraffin after it has once
been injected into the tissues. Kolle (11) gives 4 additional dangers to be avoided:
"Secondary infusion of the injected mass. Hyperplasia of the connective tissue fol-
lowing the organization of the injected matter. A yellow appearance and thickening
of the skin after organization of the injected mass. The breaking down of tissue and
the resulting abscess due to the pressure of the injected mass upon the adjacent tissue
after the injection has become organized."
SYRINGES. — A special syringe is made for this purpose, the essential points
of which are: First, great strength; second, a screw on the piston, enabling
the operator to force a measured quantity of the semi-solid mass slowly out into
the tissues; third, the ability to resist the heat of sterilization; fourth, the
lumen, large in proportion to the size of the needle.
PARAFFIN. — The paraffin or mass is prepared by mixing together paraffin
and white vaselin, usually in the proportion of drams to ounces, and by melt-
ing them together over a water bath and thoroughly mixing them with a glass
rod. It is most important to know the melting point of the mass. If too low,
it will not be sufficiently firm at the body temperature after injection ; if too
high, there is the danger, already described, from excessive heat. The desired
melting point has been found to be between 105° and 110° F., no higher. A
simple method, described by Guernsey, of testing the melting point of the
516 PLASTIC SUKGEEY
resulting mixture is to coat the bulb of a thermometer with some of the mass
while in the liquid state. This is allowed to cool, thus forming into a film over
the bulb. The thermometer is then placed in a water bath and the temperature
of the water slowly raised until the film is melted from the bulb and floats on
the surface of the water. The heat of the bath is then slowly reduced. As
soon as the floating particles of the mixture begin to become opaque, the tempera-
ture of the bath is taken, which is the melting point of the mixture.
By using a mixture of such a low melting point the mass can be forced into
the tissues in a semi-solid form, thus avoiding the dangers of excessive heat
and fluid injection. This is the so-called method of "cold injection" and has
many advantages and fewer dangers than the use of a mass with a higher
melting point and a more liquid form.
TECHNIC. — In using this method of protheses, the following technical
points must be carefully observed: First, thorough cleanliness of all instru-
ments, of the paraffin, and of the patient's and doctor's skin. Second, thorough
Sterilization of the mass by heat shortly before its use. The mass should be
poured into the injecting syringe while still in a very fluid condition and then
allowed to solidify slowly. If this is not done, it is almost impossible to avoid
the introduction of air bubbles beneath the patient's skin when the mass is
forced out of the syringe.
Third, no anesthetic need be used. The only discomfort to the patient is
the slight pain caused by the prick of the needle. The use of cocain has a
tendency to infiltrate the parts and distort the contours, thus making the mould-
ing of the injected mass more difficult and more uncertain than necessary. The
use of the ethyl chlorid spray tends to cool the tissues to such an extent that the
solidification of the injected mass is dangerously hastened.
Fourth, the mass must be injected slowly and in small quantities and
moulded into the desired shape at once. Great care must be taken never to
inject too much, for it is always possible to add to the mass by a second opera-
tion. Always under-correct the deformity.
Fifth, care must be taken that the mass is not emerging from the point of
the needle when it is withdrawn from the tissues. This may be avoided either
by withdrawing the piston slightly or by waiting long enough after the inject-
ing pressure has ceased to be sure that none is flowing.
Sixth, when the area to be injected is dense or covered by thick skin, firmly
bound down, subcutaneous freeing incisions should be made (under novocain)
with a fine-bladed tenotomy knife. If this has to be done, it is safer to defer
the injection for 3 or 4 days.
AFTEB-TKEATMENT. — The after-treatment consists in a simple collodion
dressing over the puncture wound. If the area injected is painful, the applica-
tion of cold during the 24 hours following gives much relief.
PLASTIC SURGERY OF THE EYELIDS
517
PLASTIC SURGERY OF THE EYELIDS: BLEPHAROPLASTY
For plastic surgery of the eyelids, two important principles must be ob-
served. First, the necessity of determining at once whether the outer skin
alone is destroyed, or whether the conjunctiva and the tarsus are also involved.
Second, when anything more than the outer skin is destroyed, a flap with a
suitable lining must be provided.
Operations on the lid are delicate and present many difficulties. A simple
skin flap is inadequate for a condition where more than the skin is de-
stroyed. Without a lining, a flap gives distressing results; it adheres to the
eyeball which it very imperfectly covers, and its edge becomes inverted and
very irritating because of the fine hairs and the scar tissue. The extreme
sensitiveness of the conjunctiva of the eyeball makes it difficult to find a
suitable lining for the flap to substitute the missing conjunctiva, and
much trouble has been taken and many experiments made to find a proper
material. The mucous membrane and conjunctiva of animals have been
tried, as well as small pieces of human prepuce, and mucous membrane
from the lips, vagina, and rectum (17).
EOTROPION
Ectropion or eversion of the lids may be due : First, to cicatricial formation
following burns, the removal of growths, or other injuries of the skin; second,
to some nerve injury resulting in the paralysis of the orbicular muscles ; third,
to some abnormal condi-
tion of the mucous mem-
brane of the eye itself,
such as chronic inflamma-
tory conditions or new
growths. The first type is
the one that surgery is
most commonly called
upon to correct and the
following operation is
recommended :
Operation for Ectropion
of Lower Lid : Dieffenbach's
Method. — A V-shaped in-
cision is made through the skin and subcutaneous tissue as shown in Figure
9 3 A. The flap, with all the subcutaneous tissue possible, is dissected from the
muscle layer, as far up as the tarsal border, relieving all tension upon it. It is
then sutured as shown in Figure 93B. If the eversion has been extreme, it will
be found after healing is completed that the amount of tissue in the lower lid is
A B
FIG. 93. — DIEFFENBACH'S METHOD FOR ECTROPION or
LOWER LID.
518
PLASTIC SURGERY
excessive, making the lower lid considerably wider than the upper lid, which is
especially marked when the eye is closed. To remedy this defect, 1 or 2 small
inverted triangles may be removed from each side of
the lid, thus taking up the slack (Fig. 93B, XY).
•v ,-'
RESTORATION OF THE EYELID
There are three general methods of restoring the
eyelid to be considered:
1. The gliding flap method, which includes the
methods of Gibson, Dieifenbach, and Hasner.
2. The pedunculated flap method, illustrated by
the v. Langenbeck operation.
3. The free graft implantation or Wolf method.
1. The Gliding Flap Method of Restoration of the
Lower Lid.— GIBSON >s OPERATION BY A PREGRAFTED
FLAP. — This operation (6) is divided into 2 stages,
separated by an interval of about 10 days. At the
first stage the flap is prepared; at the second, the
deformity is removed and replaced by the flap.
At the first operation an incision is made through
the whole thickness of the skin from the external
canthus in an outward and slightly upward direc-
tion. The length of this incision is determined by
the amount of eyelid it is proposed to remove. (For
an operation involving the external half of the lower
lid, make an incision 1% in. long.) By dissecting
downward from this incision and lifting the skin
from the deeper parts, a pouch is formed', having the
outline of the proposed flap (Fig. 94A). Into this
pouch is slipped a skin graft, previously prepared,
the raw surface of which is turned anteriorly (Fig.
94B). This graft is cut sufficiently large to project
slightly from the pocket, and is turned outward and
downward, covering the inferior raw edge of the
original incision with epithelium. A simple dress-
ing is applied and the graft allowed to heal in place,
which takes place in about 10 days.
At the second operation the growth on the eyelid
is first removed by a quadrilateral incision (Fig.
94C). The cut, as shown in Figure 94D, is then
made of the same length and parallel to the original incision, thus forming a
flap which can now, by gentle traction, be made to slide over toward the middle
line, where it is sutured as shown in Figure 94E.
FIG. 94. — GIBSON'S OPERATION
BY A PREGRAFTED FLAP ON
RESTORATION OF LOWER
LID. (Annals of Surgery. )
PLASTIC SURGERY OF THE EYELIDS
519
FIG. 95. — DIEFFENBACH'S METHOD OF RESTORATION OF
LOWER LID.
There are two great advantages to this method: The first being that an
epithelial lining is given to the posterior surface of the flap, thus avoiding most
of the disadvantages of other methods ; and, second, that there is slight, if any,
postoperative contraction of the flap, which obviates the necessity of planning
a flap larger than the defect to be filled.
DIEFFENBACH'S METHOD (Fig. 95). — This method provides no lining for
the flap. The area to be
filled is represented by the
triangle A, B, and C. An
incision is made starting
from the outer canthus in
an outward and slightly
upward direction, CD, in
length somewhat greater
than the width of the gap
to be filled between A and
C. Another incision is
made parallel to the first, from the apex of the triangle BE. The flap so out-
lined, including the skin and subcutaneous tissue, is dissected from the sub-
jacent muscle and drawn
toward the middle line
where it is sutured as
shown in Figure 95B.
~~ HASNEE 'S METHOD.—
Kasner's method is espe-
cially valuable when the
defect is so large as to
have involved the outer
canthus and a part of both
lids. Line ABC (Fig. 96) defines the limit of the defect, A. Curved incisions
CD and BE are made, and the flap formed by incisions DC and CB is made
FIG. 96. — HASNER'S METHOD OF RESTORATION OF CANTHUS.
pIG 97. — v. LANGENBECK'S METHOD OF RESTORATION OF LOWER LID.
520 PLASTIC SUKGERY
outward and slightly downward. Gliding the lower flap formed by incisions
AB and BE inward and slightly upward, it is possible to restore the canthus
as shown in Figure 96B.
2. The Pedunculated Flap Method. — V. LANGENBECK'S METHOD (Fig. 97).
—The area to be replaced is represented by the dotted lines. A vertical in-
cision AB is made about % in. longer than area to be filled in. A curved
incision BC is then made and the flap is lifted and rotated upward and imvard,
on the pedicle of tissue existing between AC, until it assumes the position
shown in Figure B. It is then sutured, as shown in Figure C.
3. The Free Graft Implantation or Wolf Method. — To make it possible to
use this method, there must be a sufficient amount of lid left to act as a bed for
the graft, and this bed must be covered by healthy granulation. The shape and
size of the defect are carefully noted, and from the skin on the inner surface
of the arm a piece of skin is removed of a similar shape and about a third
larger in size. This is placed over the defect and is carefully sutured in place.
To remove all the subcutaneous fat from the graft seems to increase the chances
of its taking.
The strictest asepsis is most essential to success in this procedure.
SKIN-GRAFTING
ALEXANDER BRYAN JOHNSON
Instruments. — The instruments required in skin-grafting are :
1. A large, heavy, flat razor with a broad blade, or a special knife with a
fixed handle in line with the blade and of such proportions as the surgeon may
elect. The razor or knife must have a keen cutting edge to make thin grafts of
uniform thickness.
2. A scalpel.
3. 2 or more silver probes 8 in. long.
4. McBurney's hooks.
5. Straight scissors.
6. A sharp curet.
7. Sterile rubber tissue in strips 1 to 1% in- wide and 6 to 8 in. long.
8. Sterile salt solution in quantity.
Preparation of Surface from Which Grafts Are to Be Cut. — For reasons not en-
tirely clear, grafts taken from another individual, even a brother or sister,
rarely do well, and never as well as those taken from the patient himself. It
must be from some cause similar to that which produces hemolysis when blood
from 2 individuals is mixed.
The skin of the anterior, outer and inner surfaces of the thighs is commonly
used for cutting the grafts. I have never tried the iodin preparation of the skin
for grafting purposes.
SKIN-GRAFTING 521
Usually the skin is prepared the day before by careful scrubbing with green
soap and water, shaving and thorough douching with sterile salt solution. The
limb is then enveloped in a dry sterile dressing which is removed before opera-
tion.
Preparation of Surface to Be Grafted. — The raw surface to which the grafts
are to be applied may be a recent wound — as in grafting after amputation of
the breast for cancer — to which, if desired, the grafts may be applied at once,
a granulating raw surface, soft parts, or bone.
The cleaner and more healthy the granulating surface the better and the
greater the likelihood that grafts will unite with the surface beneath and live.
Grafts may be applied directly to the raw surface, or the granulations may be
removed by gentle curetting. Bleeding must be stopped by firm pressure with
gauze pads before the grafts are applied.
Technic. — The patient, under a general anesthetic, is so placed upon
the operating table as to expose the surface to be grafted and the thigh from
which the grafts are to be cut. Antiseptics are not used. Soap and water
followed by liberal douching with salt solution suffice for both raw surface and
skin.
The wound, if fresh or if curetted, must be free from blood, as a clot beneath
a graft will prevent its union with the raw surface.
The first graft is cut from the upper part of the front of the thigh. The skin
is lightly scored with the knife in 2 vertical parallel lines, separated by an inter-
val equal to the width of the hooks and 5 or 6 in. long, this being about the
practicable limit of length in graft cutting.
The hooks are then caught firmly into the skin above and below. The upper
hook is given to an assistant, while the operator holds the lower in his left hand
while he cuts the graft from above downward with his right. During the cut-
ting, the hooks are used to stretch the skin and to raise it a little above its
natural level. Thus an elevated ridge is made, bordered by the slight cuts in
the skin on either side, which determine the width of the graft. During the
cutting, the blade of the razor and the skin are kept wet with salt solution by
an assistant who allows it to dribble from wet pads of gauze.
The angle of the razor blade to the skin must be slight. It must be held
firmly against the surface and gradually advanced with a sawing motion.
When the lower limit of the graft is reached, it may be severed with the razor
or with a scissors. The blade and the graft, curled up on it, are then brought
over the raw surface to be covered and the graft is slid off the blade with a
probe. Two probes are used to spread it evenly. The graft should overlap the
skin edge of the wound slightly. Other grafts are then cut until the raw sur-
face is covered. Any blood which may collect beneath the grafts is carefully
pressed out with wet pads of gauze, and the whole area is then covered with
strips of rubber tissue wet in salt solution, after which a linn dressing of dry
sterile gauze is applied.
The dressing may be left in place 5 days or even longer. If the grafting is
522 PLASTIC SURGERY
completely successful, the entire surface may be healed at the end of 10 days
and left with a light dressing of boric ointment for a few days more.
The dressing of the area from which the grafts were taken is important. It
may be dressed in the same way as the grafted surface or it may be dressed with
a covering of sterile silver foil and left exposed to the air under a cradle. I
prefer the former method.
Other methods of dressing the grafted surface are (1) exposure to the air
under a cradle covered with gauze to keep out flies; (2) covering the grafted
area with strips of sterile zinc oxid plaster (Vosburgh).
Other Methods of Skin-grafting. — The old method of Reverdin, useful to
hasten the healing of raw surfaces, consists in sniping minute bits of cuticle
from any sound skin surface and applying them to the surface to be covered with
epithelium. Rubber tissue may be used as a protective covering.
A method devised by Dr. John M. Woodbury and used by him and others,
with good results, in the Roosevelt Hospital Outpatient Department, where he
and I worked together so many years ago that I do not wish to calculate how
long, was to use the parings of corns from the patient's feet for the grafting of
chronic ulcers of the leg. Many intractable chronic ulcers were completely
healed in this way. Careful strapping with diachylon plaster aided the heal-
ing process.
The Wolf method of using the entire thickness of the skin as a graft and
grafting mucous membrane are sufficiently described in an earlier section of this
chapter.
BIBLIOGRAPHY
1. Brit. Med. Jour., Oct. 25, 1890.
2. CROFT. Med. Chi. Trans., 1889, Ixxi.
3. DOWD. Med. Rec., New York, Feb. 20, 1897.
4. EDEN. Beitr. z. klin. Chir., 1911, Ixxiii, 116.
5. GERSTJNY.
6. GIBSON. Ann. Surg., June, 1914.
7. HACKEE. Wien. klin. Wchnschr., 1910, No. 2, 48.
8. HAGEMAN. Beitrage z. klin. Chir., 1912, Ixxix, 573.
9. HOTCHKISS. Ann. Surg., xxv.
10. ISRAEL. Verhandl. d. deutsch. Gesellsch. f. Chir., 1887.
11. KOLLE. Plastic and Cosmetic Surgery, 1911, 139.
12. LANE. Cleft Palate and Harelip, London, 1905.
13. LARGER. Societe de chirurgie de Paris, 1894.
14. LEFEVRE. Arch. gen. de chir., 1913, vii, 148.
15. LERDA. Deutsch. Ztschr. f. Chir., 1913, cxxi, 126.
16. LEXER. Handbuch d. prakt. Chir., 3d Ed., i, 571.
17. — . v. Bergmann's "Surgery," 1904, i, 556.
18. — Verhandl. d. deutsch. Gesellsch. f. Chir., 1912, xli, 133.
BIBLIOGRAPHY 523
19. LEXER. Eden. Beitr. z. klin. Chir., 1911, Ixxiii.
20. MORESTIN. Jour, de chir., June, 1911, vi, No. 6.
21. NORDMANN. Verhandl. d. deutsch. Gesellsch. f. Chir., 1912, xli, 133.
22. EGBERTS, J. B. Surgery of Deformities of the Face, 1912, 117.
23. Tillmans' Lehrbuch d. spez. Chir., 1904, 1, 220.
24. TREVES. Manual Operative Surgery, ii, 2.
OPEEATIONS ON THE PEEIPHEEAL AND CEAKLAL BEEVES.
UNILATEEAL LAMINECTOMY
CHAPTER XIII
OPERATIONS ON THE PERIPHERAL AND CRANIAL NERVES.
UNILATERAL LAM1NECTOMY
ALFRED S. TAYLOR
OPERATIONS ON THE PERIPHERAL NERVES1
Indications. — Operations on the peripheral nerves are indicated for the
relief of pain, spasticity, and paralysis, for the repair of injuries to nerves, and
for tumors of nerves.
Anatomical Considerations. — A nerve trunk is made up of nerve fibers which
are bound together by fine connective tissue, endoneurium, into fasciculi.
These are in turn bound into larger bundles by perineurium, while the entire
nerve trunk is inclosed in an outer sheath, a thick, resistant layer of connective
tissue known as the epineurium. Before nerve fibers will pull apart this layer
must yield. Often the nerve fibers may be ruptured by pressure and the sheath
remain intact. These various connective-tissue structures carry the vessels and
lymphatics of the nerves. As a rule, large nerve trunks run with the main
vessels of the extremity. The notable exception is the great sciatic nerve.
An increasingly important field for peripheral nerve surgery is within the
spinal canal. Here the motor roots come from the anterolateral aspect of the
cord, pass outward, backward, and more or less downward, according to the
level in the canal, to the aperture in the dura. The posterior roots come from
the posterolateral aspect of the cord and run outward and more or less down-
ward to apertures in the dura, separated by very thin septa from the apertures
of the anterior roots. Both the anterior and posterior roots receive extensions
from the dura as they pass through it. In the intervertebral foramen lies the
ganglion of the posterior root, of which it is the trophic center. Except in the
cervical region the nerve makes its exit from the spinal canal through the
intervertebral foramen next below the bony arch of the corresponding vertebra ;
i. e. the seventh dorsal nerve comes out below the arch of the seventh dorsal
vertebra. In the cervical region the nerves come out above the corresponding
1 For the histology, physiology and pathology of nerves the reader is referred to other books
making a specialty of these topics.
525
526 PEBIBHEKAL AND CRANIAL NEKVES
arch. There is an eighth cervical nerve which conies out beneath the seventh
cervical arch.
OPERATIONS FOR RELIEF OF PAIN
PAIN DUE TO TRAUMATISM AND INFLAMMATION
For pain which is the result of traumatism and inflammation in the extra-
spinal peripheral nerves, the various medicinal and local physical methods of
treatment will usually give relief without resorting to operative work. In certain
persistent inflammatory conditions, where such measures have failed to give
relief, operation is indicated. Such operation consists in making an incision
down to the nerve trunk over that portion of it which has been sensitive to
pressure. The nerve trunk is then freed from inflammatory adhesions to sur-
rounding structures, and in case the nerve itself seems to be swollen or too
tightly constricted within its epineural sheath, this sheath may be split longi-
tudinally and the contained nerve relieved from pressure. This method is most
frequently applied to cases of persistent sciatica. The portion of the nerve
which is more often the site of inflammatory adhesions to surrounding struc-
tures is just at and above and below its exit from the true pelvis through the
sciatic notch.
Operative Technic. — The incision is made along the line of the sciatic
nerve which is about % of the distance outward from the ischial tuberosity to
the edge of the great trochanter of the corresponding femur. The incision is
then centered about where the gluteal fold crosses this ischiotrochanteric line.
The incision should be about 10 cm. long through skin, fat, and aponeurosis.
The gluteus maximus is pulled upward and the hamstrings inward. The nerve
is found under the outer edge of the biceps. The nerve sheath is freed from
surrounding adhesions well up into the true pelvis. The nerve may then be
stretched by pulling upon both the peripheral and central ends. The pull upon
the central end must be made with considerable discretion lest some of the roots
be torn from the cord. (See page 536.) If the sheath is much thickened, it
may be split longitudinally. In either case the exposed portion of nerve may
be surrounded by Cargile membrane and the wound closed without drainage.
A similar procedure is not infrequently applied to the ulnar nerve just
back of the inner condyle of the elbow, where the nerve, as a result of trauma-
tism or repeated traumatism, becomes the seat of a chronic productive neuritis.
NEURALGIAS
For the relief of severe neuralgias, such as persistent intercostal neuralgia,
the severe neuralgic pains of tabetic gastric crises, the intolerable pain some-
times caused by new growths, etc., where medical and local physical therapeutic
measures have failed to give relief, posterior root section is the only recourse.
Posterior Root Section. — TECHNIC.— In doing posterior root section for the
OPERATIONS ON THE PERIPHERAL XERVES 527
relief of pain, it is necessary first to indicate clearly the nerve roots involved
in the production of the pain. It is then desirable to divide at least 2 roots
above and 2 roots below the upper and lower limits respectively of the roots
definitely involved in the neuralgic disturbance. This is necessary because of
the anatomical overlapping of the fields of distribution of the posterior roots.
Having determined which roots are to be divided, one may proceed to do a
unilateral laminectomy, as described on page 002, through which the roots on
FIG. 1.— NERVE HOOK WITH BLUNT POINT.
both sides may be readily divided, or one may choose to do the usual bilateral
laminectomy, as described elsewhere. In either case, after the dura has been
opened the full length of the incision, the edges of the dura are caught by 2 or
more silk sutures on each side, which are used as retractors. This retraction of
the dura not only gives a better exposure, with increased light into the dural
cavity, but also serves to stop the venous oozing which always occurs from the
venous plexus which surrounds the dura externally. One then takes a small
blunt nerve hook (Fig. 1) and, starting either above or below, divides the
posterior roots systematically, first on one side and then the other. Inasmuch
as the posterior and anterior roots lie closely approximated at their exit from
the dura, the hook is slipped between them sufficiently near the cord to avoid
hooking up the motor root and including it in the division.
When the posterior root is raised on the hook, it is advisable
to clamp it with a broad, strong clamp for a moment or two,
then to release it and cut through the compressed area (Fig.
2) with a slender pair of scissors. In this way the small
vessels which often run with the posterior roots are com-
pletely crushed and occluded so that there is no leakage of
blood into the spinal fluid to render the operative field in-
distinct. This same procedure is carried out with each of the posterior roots
to be divided.
Inasmuch as these nerves are divided between their trophic centers (which
are the ganglia of the posterior roots) and the spinal cord, there will be perma-
nent degeneration into the cord and, therefore, permanent loss of function.
This, of course, also means permanent relief from pain. Since this upward
degeneration is permanent, it is scarcely necessary actually to resect portions of
the posterior roots.
After the roots have been divided, such blood as has oozed into the dural
canal is carefully removed, the dura is closed tightly, and the remainder of the
wound is closed, as indicated in the operation for unilateral laminectomy.
As a rule, these cases will show a reactionary temperature — often as
high as 103° — which, in the course of 2 or 3 days, descends to normal and
FIG. 2. — NERVE COM-
PRESSED BT STRONG
CLAMP TO PREVENT
BLEEDING ON SEC-
TION.
528 PERIPHERAL AND CRANIAL NERVES
remains there. Frequently there will be considerable pain in the area of the
wound, which is probably due to irritation of the divided posterior roots. After
about 3 days, when the degenerative process is pretty well advanced in these
roots, the pain ceases.
EESULTS. — These cases show very prompt and evident relief from the pain
and a rapid improvement in general health. Many cases of this type which are
submitted for operation have developed the morphin habit during their long
periods of suffering. In these cases the general improvement is not nearly so
rapid, and there is the drug habit to struggle against in addition.
If the roots involved are many, the division of all of them may lead to certain
sensory and trophic disturbances. The trophic disturbances are usually superficial and
frequently show in the form of blebs such as pemphigus. The sensory disturbances take
the form of anesthesia. If the nerve roots involved supply the extremities, the division
of 3 or 4 complete roots consecutively may lead not only to sensory and trophic dis-
turbances, but may also give rise to ataxia of greater or less degree, according to the
number of nerves divided consecutively. Fortunately, the majority of severe neuralgias
involving more than 1 or 2 roots, involve the dorsal nerves, in which the sensory,
trophic and ataxic disturbances are less troublesome after multiple consecutive section.
One of the chief causes of failure to obtain relief from the pain by posterior root
section lies in the division of an insufficient number of posterior roots. There are a
certain number of cases which suffer from disturbance of the peripheral nerves in which
root section gives no relief. Many neurologists classify these cases as having psychic
pain, or memory pains, after the actual causative lesion has disappeared or has been
disconnected from the sensorium by posterior root section.
The results vary more or less with the type of case. In the tabetic gastric
crises relief is obtained in about 50 per cent, of the published cases. In the
other cases where relief has not followed root section the criticism is raised that
an insufficient number of posterior roots has been divided. Foerster advocates
dividing from the fifth to the twelfth dorsal, inclusive, on both sides. Often,
for the first few "days, while the process of degeneration is occurring in the
proximal stumps of the divided nerves, the patient will feel scarcely any relief
from the condition for which the operation was advised, but after the degenera-
tive process is well advanced relief is obtained.
DANGEES. — The chief dangers of the operation are those inherent to a
laminectomy, where an accidental slip may cause damage to the cord. The
other danger lies in the possibility of infection of the wound, which, of course,
occurs but rarely. In 2 of my cases in which infection occurred there was no
involvement except in the tissues superficial to the dura, apparently from de-
fective chromic catgut.
OPERATIONS FOR RELIEF OF SPASTICITY
For the relief of spasticity in muscles (outside of orthopedic measures
which may not properly be considered in this section), there are 2 chief methods
OPERATIONS ON THE PERIPHERAL XERYES 529
of procedure which aim at the peripheral nerves and cause a diminution in the
overactivity of the spastic muscles. One method works upon the peripheral
nerves extraspinally, and the other method upon the posterior roots intra-
spinally.
EXTRASPINAL OPERATIONS
Two methods of extraspinal operation have been described and the authors
report good results.
1. Alcohol Injection. — Allison and Schwab (1) advocate the injection of
alcohol into the peripheral nerve trunks which run to the groups of spastic
muscles. This results in motor paralysis and anesthesia in the distribution of
the injected nerve, which last a variable length of time, according to the amount
and strength of alcohol injected. During the temporary flaccid paralysis of the
previously spastic muscles the extremity is treated by massage, electricity,
and the various other methods of physical therapeutics applied to the antag-
onistic groups so as to improve the muscular balance of the extremity when the
temporarily paralyzed muscles have resumed their activity. As power begins
to return in the paralyzed muscles, the patient is also educated to control the
activities of these muscles. The process may be repeated if necessary.
In general, the operative method consists in determining which groups of
muscles are spastic and in identifying the corresponding motor nerve trunks.
Under ether anesthesia, incision is then made over the accessible part of the
nerve trunk supplying the spastic muscles. This nerve is isolated, elevated on a
blunt hook, and injected with alcohol 80 per cent., % to 1 c. c. according to
the size of the trunk. Immediately spasticity is replaced by flaccid paralysis of
the muscles supplied by this nerve. The wound is closed without drainage.
No fixation of the extremity is made.
This procedure has been applied to the lower extremities at 4 different sites :
the obturator nerve is exposed just below Poupart's ligament in the front of
the thigh, and injected for spasticity of the adductor groups ; the great sciatic
is exposed just below the gluteal fold, and its branches to the hamstring muscles
injected; the internal popliteal is exposed in the popliteal space, and the
branches to the gastrocnemius and soleus injected; the external popliteal is
exposed just below the head of the fibula, at which site branches to either the
peronei or the anterior tibial muscles may be isolated and injected. These
different exposures have usually been made at different sittings. For more
detailed techiiic reference is made to the publications by the authors above
mentioned.
2. Nerve Resection. — Another method of extraspinal operation was brought
forward by Dr. A. Stoffel (19).
Instead of causing temporary paralysis of muscles by injecting alcohol into
the nerves, he resects portions of the motor nerves involved so as to cause a per-
manent diminution in the activity of the spastic muscles. He has demon-
strated that, in nerve trunks, the bundles running to the various groups of mus-
35
530 PERIPHERAL AND CRANIAL NERVES
cles practically always maintain a fixed position in the topography of the main
nerve trunk. With this knowledge at hand, he is able to expose main nerve
trunks and from them to pick out the fasciculi (verified by electric stimula-
tion) which run to the muscles which he wishes to affect by his procedure. The
amount of nerve resected depends upon the size of the muscles involved, the de-
gree of spasticity, and the relative activity of the antagonists. The nerve struc-
ture is resected in such a way as to maintain a permanent defect. This method
requires a very minute knowledge of the topography of the main motor nerve
trunks and considerable experience to estimate accurately the amount of nerve
to resect in order to give well-balanced muscular activity afterward.
It will readily be seen that both of these methods aim to balance the muscu-
lar activities of the extremities by diminishing the amount of power in the
spastic muscles. The method of Stoffel would seem to arrive at this result with
greater precision and permanence. He and many other writers report most
satisfactory results. For minute details of his operative technic reference is
made to his publication above cited.
INTRASPINAL OPERATIONS
Aside from the difficulty of mastering the anatomical and technical operative
details of the extraspinal method, it would seem that a method which would
relieve the spasticity without impairing the voluntary power of the spastic
muscles would be preferable. Such a method was published by Professor
Foerster, of Breslau (7, 8, 9).
Foerster's Operation. — Foerster conceives that the spasticity is due to hyper-
activity of the reflex arc, and that this hyperactivity results from diminished
control by the centers of inhibition caused by some lesion of the pyramidal
tracts which partially separates the upper cortical centers from the spinal
centers. The basis of his method consists in diminishing the reflex activity
by causing a break in the reflex arc. The best place to cause this break is in-
tradurally by the division of the posterior nerve roots.
This theory is supported by 2 observations of considerable interest. For
a long time it had been observed that in spastic paraplegics, if locomotor ataxia
supervened, the spasticity disappeared pari passu with the development of the
ataxia. It is also known that ataxia begins essentially as a posterior root lesion.
The other observation was made many years ago by Frankel and Beer — that in
spastic cases intraspinal injection of a local anesthetic caused relief of spas-
ticity, and with the disappearance of the anesthetic, the spasticity recurred. It
seems, therefore, that permanent interference with the function of posterior
roots should give release from the spasticity of the corresponding muscles, and
this works out fairly satisfactorily in practice.
The method of procedure consists first in determining the relative degree
of spasticity in the different groups of muscles, and then in determining which
posterior roots are most closely allied with the innervation of the spastic
OPERATIONS ON THE PERIPHERAL NKKYKS 531
muscles. It must also be determined that the case is one of pure pyramidal
tract lesion and that the lesion does not completely obliterate the function of
the pyramidal tracts, because, under these circumstances, the relief of spas-
ticity would simply result in flaccid paralysis of the same muscles, and
the functional advantage to the patient would be nothing. The presence of
symptoms of sensory tract disturbance is considered to contra-indicate this
operation, as it is not successful where the sensory difficulty is already
present.
The method works out most satisfactorily in the lower extremities. As a
rule, the fourth lumbar posterior roots should be left intact, as their division
frequently results in undue relaxation of the quadriceps extensor, and locomo-
tion is correspondingly uncertain. Whether the fourth root is related to the
quadriceps extensor may be determined at the time of operation by testing the
fourth anterior root with the faradic current. If stimulation of the anterior
root causes quadriceps extension, the corresponding posterior root should be
left intact. Occasionally this muscle is controlled chiefly by the third lumbar
root, in which case it should be left, instead of the fourth. The roots involved
in spastic paraplegia include from the twelfth dorsal to the second sacral.
Nerves below the second sacral should not be divided for fear of damage to the
functions of the bladder and rectum. No more than 2 consecutive posterior
roots should be completely divided because sensory and trophic disturbances
may occur. The surprising fact that 2 or often 3 consecutive roots may
be divided without causing obvious sensory disturbances is due to the overlap-
ping of fibers of adjacent roots in the distribution of sensory innervation, as
mentioned under Anatomical Considerations. Cases are on record where 3, 4,
and even 5 roots have been consecutively divided without obvious sensory or
trophic disturbances afterward, but this is distinctly against the rule. The
procedure, therefore, resolves itself into choosing which posterior roots shall be
divided in a given case, and these must be determined according to the roots
which supply innervation to the spastic muscles.
OPEEATIVE TECHNIC. — The roots are exposed by the method of unilateral
laminectomy or by the more commonly used method of bilateral laminectomy.
The nerve roots for the lower extremities leave the dura practically on a level
with the middle of the spinous process of the vertebra corresponding in num-
ber to the nerve, and the exit from the dura is the only sure way of identifying
the nerve.
It is often difficult to exactly locate a definite nerve, and one of the best
methods for positive identification is to place a small piece of metal over the
tip of the spinous process of what is thought to be the first lumbar vertebra
and then to take an X-ray picture of this portion of the spine to definitely
identify the spinous process. When the metal is removed, a scratch through
the skin should be made so as to keep the identification of the spinous process
until the time of operation. With one root thus positively identified, it is easy
to get the others. For the relation of the various groups of muscles to the nerve
532 PERIPHERAL AND CRANIAL NERVES
roots the reader may be referred to Bing's "Compendium of Regional Diag-
nosis. "
After the dura has been opened, as in the method of unilateral laminectomy
(Fig. 79), silk retraction sutures are passed through the edges of the dura, 2 or
3 on each side, and it is pulled up firmly over the divided bone surfaces, both to
give better exposure to the intradural contents and to prevent oozing from the
extradural venous plexus. The posterior roots are picked up on a blunt hook
(Fig. 1) after proper identification, thoroughly compressed with a heavy clamp,
and then divided with blunt scissors through the compressed segment (Fig. 2),
This prevents oozing from the divided ends of the nerve, which otherwise would
be sufficient to render the spinal fluid murky and interfere seriously with the
progress of the operation. As the posterior and anterior roots leave the dural
canal they are very closely apposed, and are bound together by a light fibrous-
tissue sheath. The line of division can readily be made out by inspection, and
they may be easily separated from each other and the posterior root elevated
on a hook. After the nerves have been divided and the blood carefully removed
from the dural canal, if any has oozed in, the dura is closed by a continuous cat-
gut stitch, and the remainder of the wound closed without drainage, as described
in the operation of unilateral laminectomy.
No fixation dressings are applied. Prof. Foerster often puts the extremities
in well padded casts to overcome the deformities as far as possible. The pa-
tients are very uncomfortable and in 1 or 2 of my cases pressure sores have de-
veloped, which have been exceedingly slow to heal. Therefore, I have discon-
tinued using casts, leaving the correction of such organic deformities as may
persist after the spasticity has been relieved until a later period when the wound
has healed.
EESULTS. — These patients are very likely to have a fairly sharp reaction
with a temperature running to 103° or 104° for the first 24 or 48 hours, after
which time it descends steadily to normal and remains there. For the first 3
days they usually have severe pains, which are interpreted to be root pains from
the irritation of the root-section. These pains disappear, as a rule, after the
third day, when the process of central degeneration has become well advanced.
For the first week after operation attempts at moving the lower extremities
are very likely to cause pain in the wound, and therefore a defensive rigidity of
all the muscles occurs. When this tenderness and pain have disappeared, the
release from spasticity in the muscles is perfectly obvious. The knees and feet
may frequently be abducted voluntarily with comparative ease. Attempts at
voluntary motion of the extremities do not result in the previously noticeable
associated spasms of the muscles all over the body, and the general condition
of the patient greatly improves. Patients are much less liable to sudden spas-
modic responses to any kind of sensory stimulus, such as sudden light, sudden
noise, etc. It is noticed that the patient's nervous system is very much more
equable and the disposition far less irritable. From this time on the progress
of the case will depend very largely upon the education of the patient in the
U
OPERATIONS ON THE PERIPHERAL XERVES
development of the coordinative movements of the extremities and the develop-
ment of vohmtary dissociated control. This pmci-.-.- may require 2 to 3 years of
educational after-tieatment, and with it should be included massage, passive
motion, etc., for the maintenance of the nutrition and freedom of motion in the
joints and muscles involved.
If the after-treatment, consisting of the physical therapeutics and reeduca-
tion of the patient in the use of his muscles, is systematically and patiently car-
ried out, these patients will frequently get well enough to dispense with their
crutches or other artificial means of support and to get about with reasonable
independence and freedom. They often get so that they can climb stairs by
themselves with a fair degree of ease.
DANGERS AND DIFFICULTIES. — The dangers of the operation are chiefly
those of infection, which, of course, is preventable. In older cases with very
rigid lumbar muscles it is frequently diffkmlt to do a unilateral laminectomy
because of the depth of the wound, the rigidity of the muscles, and the fact that
often in adolescents the laminae are composed of very hard bone. The same
difficulties apply, but in somewhat lesser degree, to a bilateral laminectomy.
If by mistake the third or fourth sacral root should be divided, there may be
disturbances in the functions of the bladder and rectum. If more than 2 con-
secutive roots are divided, there is a possibility of trophic disturbances oc-
curring, even though they may not make their appearance for some few weeks
or months after operation.
In cases where the spastic condition has existed long enough so that organic
contracture has occurred in many of the muscles and there are fixed deformi-
ties of the joints independent of the deformities due purely to the spasticity of
the muscles, it may be necessary to use one or more of the various orthopedic
measures to put the extremities in proper position to take advantage of the
release from muscular spasticity, i. e. tendon lengthening, plaster casts, etc.
INDICATIONS FOR OPERATION. — This procedure is indicated in spastic con-
ditions of all kinds in which there is a pure pyramidal tract lesion which does
not cause complete loss of function in the pyramidal tract, i. e. :
Spastic paraplegia.
Congenital type — Little's disease.
With hydrocephalus.
With spinal syphilis.
Disseminated sclerosis.
Spastic hemiplegia.
Operative attack is contra-indicated in lesions which show active progress.
OPERATION FOR RELIEF OF SPASMODIC TORTICOLLIS
Closely allied to other forms of muscular spasticity is one of the various
types of "wry-neck." The wry-neck which is due to organic change and con-
tracture in the sternomastoid and other rotator muscles of the head and neck,
534 PERIPHERAL AND CRANIAL NERVES
will not be considered here, but rather the type of purely spasmodic wry-neck
without organic changes in the muscular tissues. There are some neurologists
who maintain that this type of wry-neck is more or less a habit spasm and
almost entirely psychical in origin, and that it should never be operated upon,
but rather treated by suggestive therapeutics. On the other hand, many cases
of persistent spasmodic torticollis have been successfully treated by means of
resection of the nerves supplying the muscles involved in the spasmodic process. '
These nerves include the spinal accessory (resection of which has been described
elsewhere), for the purpose of paralyzing the sternomastoid and trapezius
muscles ; the second and third cervical nerves and the suboccipital branch from
the first cervical nerve, for the purpose of paralyzing the splenius capitis, rectus
capitis posticus major, and obliquus inferior muscles.
Resection of the Cervical Nerves (Keen's Operation). — For the resection of
the cervical nerves, Keen's operation is the best procedure.
The patient is laid prone on the table with the head somewhat flexed on the
chest and preferably with the head upon a head-rest, such as is described under
the section on Cranial Surgery.
There is frequently some confusion in the mind of the surgeon as to which
nerves should be resected. Inasmuch as the sternomastoid, trapezius, com-
plexus, and inferior oblique muscles turn the face toward the opposite side, one
would resect those posterior nerves which lie on the same side as the spasmodic
sternomastoid, and it may be stated that, as a rule, resection of the spinal ac-
cessory should be done in conjunction with Keen's operation.
A transverse incision is made through the skin at a level about 2 cm. below
the lobule of the ear, and running from the median line outward for a distance
of 6 to 10 cm., according to the size of the neck. This section is continued
down through the trapezius muscle, which lies just beneath the subcutaneous
structures. The trapezius muscle is reflected downward, and at about 1 to 2
cm. below the level of the incision will be found the occipitalis major nerve,
where it perforates the complexus muscle, which lies just beneath the trapezius.
This nerve is carefully followed through the complexus muscle by means of
section transverse to its muscular fibers. On the deeper side of the complexus
the nerve is followed to its bifurcation with the second cervical. An extensive
piece is then excised from both the occipitalis major and the second cervical.
The upper piece of the complexus is reflected upward until the suboccipital tri-
angle is exposed. This is bounded by the 2 oblique muscles and the rectus
capitis posticus major. At the antero-external angle of this triangle the first
cervical nerve passes outward above the arch of the atlas. A large piece of this
nerve is resected. The lower piece of the complexus is then reflected downward,
and at a level 2 to 3 cm. below the second cervical nerve, which has already
been resected, will be found the third cervical nerve, which supplies the splenius
capitis. The external branch of the posterior division of this nerve is widely
resected. The cut muscles are now united with catgut sutures in layers, and the
skin is sutured with silk, without drainage. Sterile dressings are applied, and a
OPERATIONS ON THE PERIPHERAL NERVES 535
plaster-of-Paris dressing, including the head, neck, and shoulders, is applied,
with the head in overcorrected position. This plaster support is retained from
6 to 12 weeks, according to the severity of the case.
The chief difficulty of the operation lies in finding the nerves in a field
which is exceedingly bloody. The operation itself is not dangerous.
If failure to obtain relief occurs, either there has been some of the element
of organic muscular shortening in the case, or the nerves have not been
completely resected. In case the muscles at the time of operation should
show evidence of organic shortening, they may be divided and left unsu-
tured in a manner similar to that in which they are treated in spastic wry-
neck.
Many satisfactory results have been reported, although the tendency to
recur is very marked.
Posterior Boot Section. — There is one other procedure which may eventually
prove to have some value. It was tried in a case of spasmodic torticollis some
3 years ago. The procedure was based upon the theory of the Foerster opera-
tion for the relief of spasticity. It consisted in the section of the posterior roots
of the upper 4 cervical nerves, in addition to the resection of the spinal acces-
sory, as previously described. This posterior root section was done through
a unilateral laminectomy involving the upper 3 vertebrae. Great care had
to be exercised in cutting the posterior root of the first nerve because of the
close proximity of the medulla. In this case no fixation dressing was applied,
but the patient was simply put to bed with an ordinary sterile dressing. She
was able to lie flat on her back with the face straight forward for the first time
in 3 years. In a couple of weeks she was able to get her face straight forward
and even to rotate the chin about halfway over toward the opposite shoulder.
Under conditions of nervous excitement there was a tendency to return to the
original deformity, but never to the original degree. There was no loss of vol-
untary muscle power after this posterior root section. She was lost to observa-
tion after 3 months.
This operation has been done once, with fair success, but cannot be recom-
mended for general use as yet.
OPERATIONS FOR RELIEF OF PARALYSIS AND REPAIR OF INJURY
TO NERVES
Paralysis may result either from lesions in the central nervous system or
from those in the peripheral nerves. The lesions of the central system include
such conditions as poliomyelitis, hemiplegia, and damage from traumatism,
inflammations, and new growths. Paralysis resulting from lesions of the
peripheral nerves may be due to injuries, including pressure from callus or
apparatus, to new growths, or to inflammations of the nerves which may result
from traumatism, infection, or specific poisons.
many of these conditions non-operative treatment is the most that
536 PERIPHERAL AND CRANIAL NERVES
be given. For certain of the others there are various procedures, one or the
other of which may be used for the relief of paralysis.
A general description of the different procedures may well be given here
and then applied to the various conditions as they arise.
OPERATIVE PROCEDURES
Neurotomy. — Section of the nerve, either transverse or longitudinal.
Neurectomy. — An excision of a greater or less part of the nerve — to be done
with a sharp scalpel, never with scissors.
Neurectasy. — For neurectasy, or nerve stretching, the nerve is exposed and
separated from its surroundings ; the finger is inserted beneath the nerve trunk,
which is pulled firmly, first from the central end and then from its peripheral
end, steadily for about 5 minutes. The amount of force used varies with the
size and situation of the nerve. For small nerves, such as the supra-orbital,
very slight force is permissible, but for a large nerve, such as the sciatic,
the pull may be up to 85 pounds. In pulling from the central end, less
force should be used so as to avoid tearing the nerve roots from the spinal
cord. After the nerve has been thoroughly stretched, it is dropped back
into place and the incision closed without drainage. Motion and sensation
will be absent more or less completely and for a varying length of time,
according to the amount of compression and traction exerted on the nerve
trunk.
Nerve Avulsion. — Nerve avulsion is applied in the case of certain sensory
nerves which are the seat of an intractable neuralgia. The nerve is exposed and
grasped by a curved hemostatic forceps, which is then slowly and steadily
twisted, thus winding the nerve around it until the nerve tears away centrally,
often many centimeters proximal to the avulsing clamp. The twist is then re-
versed, and as much as possible of the peripheral portion of the nerve is avulsed
in a similar manner.
Neurorrhaphy. — Many methods of nerve suturing have been described and
pictured, of which 2 types are worth while. Of these 2 types of suturing, one
consists of the through-and-through method and the other of lateral tension
suturing with peripheral apposition sutures.
THKOUGH-AND-THKOUGH METHOD. — The through-and-through method is
permissible when the nerves to be sutured are of small caliber and apposition
can be maintained without tension on the suture. The suture is passed through
the center of each nerve end, from *4 to % cm- distant from the end (Fig.
3, A and B). Under these circumstances the through-and-through suture
causes good apposition and creates a minimum amount of irritation and conse-
quent secondary cicatrization.
The suture is best composed of either very fine, smooth catgut or, when it
can be obtained, a fine strand of rat-tail tendon, which is very strong and per-
fectly smooth. It is undesirable as a rule to use silk for through-and-through
OPERATIONS ON THE PERIPHERAL NERVES
537
sutures because it is practically nou-absorbable and is apt to cause a certain
amount of chronic irritation, with connective-tissue formation.
In larger nerve trunks, where no
tension at all will occur upon the su-
ture, the through-and-through method
may be used, the sutures being passed
!/2 cm. from the ends. In addition, to
prevent lateral displacement of the
apposed ends, 2 or 3 peripheral su-
tures may be passed through the 2
nerves to keep them in proper align-
ment.
LATERAL TENSION METHOD.
Where the nerve suture will be sub-
ject to some little tension the through-
and-through suture is not satisfactory
because of the damage to the 2 ends of
the nerve consequent to the continuous
pull. Under these conditions each of
the 2 nerve ends is treated as follows
scalpel for about
B
FIG. 3. — A, EPINEDRIUM REMOVED FROM NERVE
ENDS AND THROUGH-AND-THROUGH SUTURE
PASSED READY FOR TYING. B, THROUGH-
AND-THROUGH SUTURE TIED TO APPROXIMATE
NERVE-ENDS. A few small superficial sutures
have been placed at the junction of the
nerves to prevent lateral displacement of
their ends.
FIG. 4.— A, SIDE SUTURES WHICH HAVE BEEN
PASSED THROUGH THE EPINEURIUM AND TIED
so AS TO GET A SIDE HITCH ON EPINEURIUM.
These sutures will stand considerable tension.
B, LATERAL SUTURES TIED AND A FEW PERIPH-
ERAL SUTURES TO PREVENT LATERAL DISPLACE-
MENT OF ENDS. The nerve-suture area is then
wrapped in Cargile membrane, which is not
shown in the drawing.
The sheath is removed by a sharp
cm. from the end of the nerve, which has already been
freshened transversely. On opposite
/* _~j- sides of the nerve, and about 0.5 cm.
*jr — from its end, 2 fine silk sutures are
passed through the epineurium, get-
ting a good hold and being tied in a
square knot' so as to get a side hitch
(Fig. 4, C). These sutures are left
long and, when they have been placed
in both nerve ends, the correspond-
ing pairs are tied together so as to
approximate the nerve ends (Fig. 4,
D). To prevent lateral displace-
ment of the ends, a fine catgut
suture may be run around the
periphery of the nerve joint, or a
few interrupted sutures may be
used.
Greneral Principles. — In all nerve
suture work there are certain general
principles and precautions which must
be carefully observed. The object is al-
ways to get close apposition of nerve fiber to fiber in the 2 ends, to have a suture which
will stand as much strain as may be necessary in the given case, and yet will interfere
538 PEEIPHEEAL AND CRANIAL NERVES
as little as possible with the structure of the nerves and cause as little compression of
nerve fibers as possible. Again, precautions must be taken to prevent the formation of
connective tissue in the space between the 2 nerve ends. To have the nerve ends per-
fectly free from bleeding prevents the formation of a small blood-clot between them,
with later cicatrization and interference with union and regeneration.
The epineurium should be removed by sharp dissection for about 0.25 cm. from
the end of each nerve to prevent it from slipping forward and curving inward between
the nerve ends. To avoid adhesions to surrounding structures and to prevent connec-
tive tissue from growing in between the nerve ends, the junction should be surrounded
by Cargile membrane or some other similar innocuous organic structure.
Nerves should never be grasped directly with either the fingers or instruments.
The best way is to grasp the epineural sheath and then dissect away the surrounding
structures from the nerve, causing the least possible traumatism to the nerve itself.
All dissection should be done with a sharp scalpel and never with scissors, which have
a crushing effect and cause interference with later reunion arid regeneration of the
nerve ends. The sutures should be passed, when possible, simply through the epineural
sheath, at some little distance from the freshened end. As a matter of fact, such a
suture always includes a few nerve fibers.
AFTEK-TBEATMENT. — After the nerve suture is completed and the joint
wrapped with membrane, the nerves are laid back in place, the wound is closed
without drainage after perfect hemostasis, sterile dressings are applied, and the
extremity is put up in such a position as to give the maximum relief from
tension. This position may be maintained by some form of brace, by a plaster-
of-Paris bandage, or by a simple gauze bandage.
SECONDAEY NEUEOEEHAPHY.— In secondary neurorrhaphy we usually
find after the exposure of the nerve ends a large bulbous growth on the proximal
nerve end, and a similar, though smaller, one on the distal nerve end. These
bulbs are made up of a conglomeration of fibrous tissue and immature nerve
fibers. Before a satisfactory nerve suture can be made these bulbous extremi-
ties must be removed until normal-looking nerve bundles appear on the trans-
verse section of the nerve ends. Some writers have reported satisfactory re-
generation when only a portion of these bulbs was removed and end-to-end
anastomosis between the remainder of the bulbs accomplished, but this method
seems less likely to give satisfactory results than the other.
Sherren states that in secondary sutures it is not worth while to remove any
more than the fibrous end of the peripheral stump, as the whole thing is nothing
but fibrous tissue. However, many times, in cases several years after the inci-
dence of the paralysis, I have been able to get to good-looking fasciculi by
resecting a generous piece from the end of the peripheral stump. It is my
custom to take small cross-sections until the fasciculi appear in the stump. This
seems to me to improve the prospects of a satisfactory result.
Neuroplasty. — Neuroplasty is the plastic bridging of defects so as again to
connect damaged peripheral nerves with the central nervous system. It in-
cludes several different procedures.
NEEVE ANASTOMOSIS. — This procedure is accomplished in one of several
different ways. In the first place, the peripheral portion of the paralyzed nerve
OPERATIONS ON TIIK I'KIMIMI KUAL NKKVKS
539
may be connected with the neighboring sound nerve by 1 «>f :; methods. In the
sound nerve there may be made simply a longitudinal slit into which the end of
the peripheral segment of paralyzed nerve is inserted and held fast by sutures
(Fig. 5). A certain number of fibers of the sound ncru- are always divided
by this longitudinal incision and insure union with the paraly/e<l nerve, with
return of function. This procedure reaches its best success when the paralyzed
nerve is small in size and, therefore, needs but comparatively few fibers from
the sound nerve to cause its regeneration.
Another way consists in making an oblique transverse incision through a
5. FIG. 6. FIG. 7.
FIGS. 5, 6, AND 7. — PHASES OF NERVE ANASTOMOSIS. In each figure the dark nerve is the paralyzed
and the light nerve is the sound one. C represents the central end of the sound nerve. 5 shows
the implantation of the peripheral stump of the paralyzed nerve into a longitudinal slit in the sound
nerve. 6 shows implantation into an oblique transverse slit in the sound nerve thus giving more
definite end-to-end apposition of the nerve-fibers in the two. 7 shows end-to-end suture between
the paralyzed nerve and a portion of the sound nerve elevated after transverse section. It is a slight
modification of 6.
portion of the sound nerve and the insertion of the peripheral paralyzed nerve
into this transverse slit (Fig. 6). This insures a considerably greater number
of divided nerve fibers for the regeneration of the paralyzed nerve. The third
method consists in transverse section of a portion of the sound nerve and the dis-
section upward of the portion of nerve thus divided (Fig. 7) and the use of
this central reflected stump for the purpose of end-to-end suture with the para-
lyzed peripheral nerve stump.
With the same 2 nerves 3 other procedures are possible, reversing the 2
things done to the paralyzed and peripheral nerves. For instance, the longi-
tudinal slit, the transverse section, or the reflection of the portion of nerve
trunk may be applied to the paralyzed nerve on the peripheral end and a por-
tion or the whole of the central end of the sound nerve may be used for anasto-
mosis. These last 3 types are rarely of service.
Where the entire peripheral stump of the paralyzed nerve is implanted into
the neighboring sound nerve, in cases where injury or disease has destroyed too
much nerve to permit end-to-end suture with itself, it has sometimes been ad-
540
PEKIPHERAL AND CRANIAL NERVES
vised to implant the central stump of the paralyzed nerve also into the same
sound nerve at a higher level, with the hope that its fibers will grow down along
the sound nerve and reunite with its own peripheral stump. Since, however, it
has been shown that the axis cylinders in the central end of the divided nerve
have no preference for those of its own peripheral end, the results would prob-
ably be better if the central end were not used, as the consequent confusion of
axis cylinders might well interfere with coordination later on.
NERVE CEOSSING. — Nerve crossing refers to the procedure where the cen-
tral end of the sound nerve, divided completely transversely, is sutured to the
peripheral end of the paralyzed nerve, also divided transversely.
NERVE BRIDGING. — Nerve bridging refers to the attempt to cause nerve
regeneration over the gap which exists between the ends of a divided nerve in
cases where nerve stretching, combined with the most favor-
able position of the extremity, still fails to overcome the gap.
The rather frequently pictured and recommended method of
making plastic flaps from each of the 2 ends of the divided
nerve should be most vigorously condemned. No flaps thus
obtained can do more than form a conducting pathway for
the fibers which may regenerate between the two nerve ends.
To divide, transversely, half of the central stump consider-
ably above its end and then to turn this flap downward does
serious additional damage to the nerve. It is sure to cause
considerable formation of connective tissue and also to form
many adhesions with surrounding structures and, as a rule,
gives nothing but disappointment. When this method is ap-
plied to both nerve ends the difficulty is doubled.
NERVE TRANSPLANTATIONS. — The best method of nerve
bridging consists in autotransplantation, i. e. the use of a
nerve trunk from the same individual to fill in the gap. It
is perfectly possible to use a sensory nerve for the purpose
of filling in a gap of motor nerve, inasmuch as the transplant
acts only as the most favorable framework for the down-
growth of the nerve. Instead of using a single transplanted
section of nerve, it may be possible to dissect out a consider-
able length of some nerve — for instance, the long saphenous
—which may be cut into lengths sufficient to bridge the gap,
a bundle of these segments being made equal in circumfer-
ence to the trunk of the nerve to be repaired. These pieces
are sutured end 'to end with the 2 ends of the nerve to be repaired. After
the end-to-end suture is complete, the whole transplant and the 2 nerve sutures
are wrapped in Cargile membrane to prevent the formation of adhesions to
surrounding structures and to prevent the ingrowth of connective tissue into
the nerve joints, the 2 things which will most of all prevent the return of
function (Fig. 8).
FIG. 8. — BRIDGE BE-
TWEEN Two ENDS
OF DAMAGED
NERVE. This
bridge is made by
taking a segment
from some other
nerve in the same
patient's body and
suturing it into
the gap. The
bridged area is
wrapped with Car-
g i 1 e membrane
which is fastened
at each end to the
epineurium by a
few fine catgut
sutures.
OPEKATIONS ON THE PERIPHERAL NERVES
541
I
The next best procedure consists in the use of a transplant from another
human being, closely related to the patient if possible. A transplant taken
from animals — "heterogeneous transplant" — has given exceedingly few satis-
factory results, and this method should not be used.
TUBULIZATION. — Of the many other methods which have been described,
that of tubulization is next best to autotransplantation. The method of tubu-
lization consists in making a framework of catgut strands between the 2 ends
of the divided nerve and then surrounding this framework
by some structure which acts as a tube for the direction of
the regenerating nerve fibers and for the prevention of
interference with regeneration by adhesions with, or con-
nective tissue ingrowth from, surrounding structures.
(Fig. 9.) Cargile membrane is one of the most satisfac-
tory materials to use. It can be wrapped around the cat-
gut strands and the 2 ends of the divided nerve to make a
satisfactory tube. Other materials which have been tried
are sterilized preserved arteries from animals, gelatin
tubes, and paraffin wax tubes, but these are difficult to get
on short notice and have no advantages over the Cargile
membrane.
NERVE BRIDGING BY USE OF A VEIN. — Another
method consists in dissecting a vein from the patient, slip-
ping it up over one end of the nerve until the bridging
sutures have been placed, and then sliding the vein down
so as to form a protective tube covering in both the bridg-
ing sutures and the respective ends of the nerve, to which
it is fixed by 1 or 2 fine catgut sutures at each end. This procedure is by no
means so easy as it sounds, for the vein shrinks and is very difficult to manipu-
late.
The longest distance which has been satisfactorily bridged has been 4 in., but as
a rule, regeneration over so long a distance should not be expected. There is much
more hope of bridging over any space less than 3 in.
BONE BESECTION. — Another procedure, which can scarcely be called a
neuroplasty, but which is a plastic operation done in order to approximate the 2
ends of the nerve, consists in the resection of sufficient length of bone so that
the nerve will come together when the ends of the bone are again fastened to-
gether. Direct end-to-end suture of the nerve is then possible. The level of
bone section should be as far away from that of the line of nerve suture as
possible, so as to have the minimum amount of reaction in the neighborhood
of the nerve junction. This method would be permissible only where no other
method of bridging would offer any chance of success.
CHOICE OF NEUROPLASTIC METHOD. — In dealing with divided nerves, the
procedures just described should be chosen in the following order of preference :
FIG. 9. — GAP BETWEEN
NERVE ENDS BRIDGED
BY MEANS or CHRO-
MIC CATGUT LOOPS;
CARGILE MEMBRANE
USED TO COMPLETE
TUBULIZATION.
542 PEEIPHEKAL AND CKANIAL NERVES
(1) end-to-end suture; (2) nerve bridging, if end-to-end suture is impossible
and if the distance is not more than 2 in. ; (3) (a) lateral anastomosis with a
neighboring nerve, or (b) nerve crossing, if nerve bridging fails after a proper
interval has elapsed — 3 to 12 months, according to the length of the gap.
It is an interesting fact that about %_ of a nerve trunk may be divided trans-
versely without causing obvious motor or sensory disturbance, so that one might
do a lateral anastomosis and get new power in the injured nerve with very
little obvious interference with the function of the nerve used for the anasto-
mosis.
Nerve crossing, which involves the entire transverse section of a sound
nerve, of course causes permanent paralysis of the muscles supplied by the
sound nerve so divided, and this process is justifiable only where the damaged
nerve is of much more vital importance than the sound nerve thus used for
crossing.
Resection of bone, so as to shorten the extremity until end-to-end anasto-
mosis between the ends of the nerves can be accomplished, is only to be chosen
where the other methods promise no success.
Neurolysis. — Neurolysis consists in the freeing of the nerve trunk from
pressure by surrounding structures, such as scar tissue, as, for example, in
Volkman's ischemic paralysis, or callus, as seen in fractures of the middle of
the humerus, where the callus involves the musculospiral nerve. Sometimes
the compressed nerve will also have new connective-tissue formation within its
own epineurium, and in this case it is often desirable to split the external nerve
sheath and to separate from one another the various fasciculi composing the
nerve trunk.
General Considerations in Operations for Relief of Paralysis. — In all these
operations perfect asepsis and hemostasis are essential. Infection not only
interferes with the immediate healing of the nerve, but causes an excessive
amount of scar tissue both around and within the nerve joint, and so leads to
permanent interference with the return of function. Hemorrhage, to a less
degree, gives rise to the same disturbance.
In these operations the handling of the nerve structures must be most care-
ful. No pinching, pulling, bruising, or unnecessary manipulation is ever per-
missible. The nerve sheath must be removed by methods previously mentioned,
from the ends of the nerves to be joined, so as to minimize the possibility of
connective-tissue ingrowth in the space between the nerve ends.
NERVE INJURIES IN GENERAL
In dealing with injuries of nerves, where there is also a division of skin and neigh-
boring muscles or tendons, primary nerve suture should be the rule. Not a few in-
stances have occurred where a divided nerve trunk has been mistaken for a tendon and
sutured end to end with another tendon. Where the damage to the nerve has been
subcutaneous, many surgeons prefer to wait for the development of certain symptoms
diagnostic of lasting injury to the nerve structure. When the nerve is completely
OPERATIONS OX TIIK I'KRIPIIKRAL XKRVES 543
divided either anatomically or physiologically, there is complete loss of function ;m<l
there soon develops complete degeneration of the peripheral segment of the nerve. This
degeneration begins very soon after the receipt of the injury and is complete by the
end of the tenth day, at which time, as a rule, there is a "reaction of degeneration"
present if the nerve has been completely divided. When this reaction is present, it is
wise to expose the nerve at the damaged site and to do such repair work as is indi-
cated by the findings on exposure.
Reaction of Degeneration. — A brief description of the reaction of degenera-
tion will perhaps be helpful. Muscles in their normal relation to the central
nervous system react quickly when stimulated with the faradic current and
also with the galvanic current. With the faradic current the muscle stays con-
tracted during the application of the current ; with the galvanic current a sharp
contraction occurs when the circuit is closed or opened, but there is no reaction
while the current is passing through the muscle. Less current is required to
obtain a contraction when the cathode is used or is applied to a muscle point
than when the anode is used. Also the contraction is more evident when the
current is closed than when it is opened. After its motor nerve is divided, the
muscle ceases to respond to the faradic current after the lapse of from 4 to 7
days. After the tenth day the usual contraction from the application of the
galvanic current may be very hard to get. Instead, this galvanic current will
induce a slow vermicular contraction, originating in the muscle where the elec-
trode is applied to it, and a stronger current must be used to start this contrac-
tion than is necessary to get contraction on the sound side. Also the muscular
contraction comes with the closing of the circuit when the anode is applied to
the muscle instead of the cathode. This failure of the faradic current to cause
muscle contraction, with the change in response to the application of the gal-
vanic current, is a condition to which the term "reaction of degeneration"
(R. D.) is applied.
The length of time after division of the motor nerve that the muscles will
still react to the galvanic current is variable and seems to depend mostly upon
whether or not the contractile substance of the muscle still exists, in which case
the response will come, or whether the muscle substance has undergone fatty
and fibrous degeneration, so that no contractile substance remains, in which
case there will be no response to any current. Often there will seem to be no
response to the galvanic current at one time, and at a later time it will be
present. This is accounted for on the basis that at times the resistance to the
current in the skin and subcutaneous tissues, which varies from time to time,
prevents the stimulus from reaching the muscular substance. Some authors
state that it is not safe to depend entirely upon the stimulation through the
intact skin when the question of treatment depends largely upon the findings.
In cases where great issues depend upon the decision it is safer to cut down
to the muscular substance and to apply the electrode direct. Cases are on
record where, after 23 years from the time of nerve division, the muscles would
still respond to the galvanic current.
544 PERIPHERAL AND CRANIAL NERVES
Deformity Due to Nerve Injuries and the Resulting Paralysis. — It must be re-
membered that, in many of these subcutaneous divisions of nerves, the external
nerve sheath may appear to be perfectly normal, but the nerve structures within
may be completely divided and so damaged as to prevent reunion, regeneration
and return of function, so that, in all cases, the nerve sheath should be split
longitudinally and the nerve structures themselves examined for evidence of in-
jury. With the damage to the nerve there appears paralysis of the muscles
innervated by it. Muscles which are so paralyzed lose their tone and may
readily be overstretched. On the other hand, the non-paralyzed antagonists of
these muscles contract without opposition and before long undergo a process of
organic shortening which will eventually hold the extremity in a deformed
position.
With the joints thus held for a long period in a fixed position, the ligamen-
tous structures of the joint also become more or less fixed in such a way that,
if power should return to the muscles, there would be mechanical fixation of the
joints which would seriously interfere with the proper functioning of the ex-
tremity. In very young children there is an additional element of disadvan-
tage, because the bones of the paralyzed extremity neither grow to their proper
size, nor do the joint ends develop as they would in a limb undergoing its
proper range of motion and usefulness. It is, then, self-evident that, whenever
groups of muscles are paralyzed, the extremity involved should be put up in
some form of retention apparatus, whether it be a plaster-of-Paris cast, ortho-
pedic brace, or bandaging, which shall prevent the non-paralyzed antagonists
from shortening through overaction, and at the same time prevent the paralyzed
muscles from being overstretched by their antagonists. If the paralyzed
muscle is thus overstretched for a long time, it may refuse permanently to
fulfill its proper function and return to its normal length, even after the motor
supply to the muscle is perfectly regenerated. Even if the muscle does finally
regain its normal length and function, the time of recovery is greatly length-
ened. In addition to using some method of fixation, the extremity should be
taken out of the fixation apparatus once or twice a day and given massage,
passive motion, and, if possible, electric stimulation. By these means the de-
velopment of deformity will be prevented, the nutrition of the muscles will be
kept at its best, and, when once regeneration has occurred, the muscular and
bone apparatus will be in normal condition to functionate properly.
This scheme of treatment should not only 'start at once after the incidence
of the paralysis, but should be continued until voluntary motor power has
returned sufficiently to prevent the development of deformities and over-
stretching of the still partially paralyzed muscles. Operation may be looked
upon merely as an incident between the onset of the paralysis and the return of
voluntary motor power, and these means of physical therapeutics should cease
only for a sufficient length of time to allow wound healing, and then be con-
tinued postoperatively till recovery has ensued. Provided the extremity is thus
cared for, the determination of the question as to whether operation should or
1 OPERATIONS OX THE PERIPHERAL NERVES 545
should not be done need not be decided with undue haste. However, it should
be remembered that on general principles the earlier nerve repair is accom-
plished, the more prompt and more satisfactory will be the result.
Return of Function after Operation. — One other thing, also, needs empha-
sizing— that after operation with suture, as a rule, a considerable period of time
must elapse before there will be any evidence of returning function in the dam-
aged nerve. This period is rarely shorter than 3 months with regard to motor
return and oftentimes may be as long as 12 months, depending upon the condi-
tions and the success of the suture in the individual case. The return of sensory
power is apt to start earlier — from 6 to 16 weeks, but the complete return of
sensation as well as of motor power may not occur for as long an interval as 2
or 3 years, during which time the system of treatment previously outlined must
be persisted in.
A few cases have been reported in which motor power was said to have
returned in muscles after "primary nerve suture" within a few days after
operation. "Primary suture" may be considered as a nerve suture done before
the onset of symptoms of degeneration of the peripheral end of the stump, i. e.
7 to 10 days. Most of these cases have been open to question, but recently, in
conversation, Professor Foerster mentioned a case seen by him both before and
immediately after operation, in which there was an undoubted return of motor
power in the field of the sutured nerve within 2 or 3 days. This is a very rare
occurrence, but it must be accepted as a fact.
Causes of Failure in Operation.— The chief causes of failure in nerve operations
lie in rough handling of the nerve structures, improper choice of suture material and
method, the failure to get good apposition, the failure to prevent connective-tissue
ingrowth, and the failure to avoid infection. If infection occurs in the wound, failure
is practically sure, because infection not only causes an infectious neuritis, but also
results in the production of so much scar tissue as to prohibit the return of function
in the nerve.
Results of Operation. — The results depend upon the careful following of
technical details at the time of operation and also very largely upon the per-
sistent systematic use of the various methods of treatment both before and after
operation. In cases of nerve crossing or nerve anastomosis, to these methods of
physical therapeutics must be added reeducation of the new cortical centers in
the control of the muscles which have been previously paralyzed. In the ma-
jority of cases one must not expect a theoretically perfect anatomical and
physiological result, especially in cases of anastomosis and nerve crossing. In
end-to-end suture of the 2 parts of a divided nerve the final result may be so
nearly perfect as to avoid detection of any defect except by most careful ob-
servation.
COMMON TYPES OF NERVE INJURY
Brachial Plexus Lesions — The traumatic Erb's paralysis in the adult and
the brachial birth paralysis of Erb's type so-called, in new-born infants, are
36
546
PERIPHERAL AND CRANIAL NERVES
Cl*
Cvt.
Cvff.
Cvra
essentially the same kind of lesion. This lesion results from the overstretching
and more or less tearing of the primary nerve trunks of the brachial plexus. It
is practically always brought about by the separation of the head and neck from
the shoulder on the side in which the nerves are damaged. Figures 10, 11
and 12 will indicate the slant of the nerves running from the spine to the arm
and also indicate why pulling the shoulder away from the head and neck will
damage the upper nerve trunk first,
and why it is only in the more severe
cases that the lower nerve trunks are
also damaged. The lesions, both in
the birth paralysis and the traumatic
Erb's paralysis in the adult, are of
very common occurrence. The lesion
involves one or more of the roots
from above downward. It may con-
sist of a single mass of scar tissue, or
there may be several scattered areas
of scar tissue which interfere with
the function of the nerve trunk or
trunks in which they are situated.
These lesions may be situated any-
where between the surface of the
spinal cord and the ultimate nerve
trunks which pass off from the
brachial plexus into the axilla. The
lesions, especially in the upper roots,
are very apt to be severe enough to
persist permanently and interfere
with nerve function. In a few cases
the plexus is torn completely across
and there results one large mass of
scar tissue which prohibits any func-
tion whatever in the roots of the
brachial plexus.
Many text-books say that these lesions, more particularly those of new-
born infants, as a rule, get well spontaneously, but this, I am sure, from observa-
tion in many cases, is far from the fact. On the contrary, only a small propor-
tion of the cases get completely well spontaneously. All of them, after a time,
show some degree of recovery of function in the lower roots of the brachial
plexus, but in the great majority of them there will be a persistent defect in
the fifth or in the fifth and sixth roots. In those few cases which do recover
entirely spontaneously the return of function will begin very promptly, i. e.
within a few days of birth, and be complete in 3 months.
As a rule, if the lower roots as well as the upper are involved at first, one
FIG. 10. — SCHEMATIC REPRESENTATION OF BRA-
CHIAL PLEXUS. A is the spinal column from
which pass the various roots which go to make
up the plexus. These roots come together in
the axilla a little to the inner side of the shoulder
B. S is the suprascapular nerve which comes
off from the outer edge of the junction of the
C v and C vi roots. It is obvious that any
force that would increase the distance between
A and B would put these nerves on the stretch,
with the maximum strain coming on the upper
root. Inasmuch as the suprascapular nerve
comes from the outer edge of the nerve which
first bears the maximum strain it is easy to
understand why this nerve is always involved.
OPERATIONS ON THE PERIPHERAL NERVES 547
12-
may feel confident that the upper roots have been so seriously damaged that they
will show a permanent interference with function. In these infants the testing
of the muscles for the
reaction of degeneration
is of very little service
and can be accomplished
only under anesthesia
and after the child is 3
months old. The test is
therefore inadvisable.
Sensory disturbances are
not very extensive, nor
are they of much mo-
ment. In case the fifth
root alone is permanent-
ly damaged, while there
will be very obvious mus-
cular paralysis, there
will be no evidence of
sensory disturbance, be-
cause the fifth root car-
ries no exclusive sensory supply to the skin. Where the sixth nerve is also per-
manently damaged, there may be a small area of diminished sensibility over the
deltoid region. In children, if these cases are neglected, there is failure of
proper development in the muscles, ligaments, and the joint ends of the bones,
FIG. 11. — PLEXUS EXPOSED BY MEANS OF OBLIQUE INCISION
ACROSS BASE OF NECK AND ALMOST AT RIGHT ANGLES TO
COURSE OF NERVES. This wound heals with less scar. 1, C v;
2, scalenus medius muscle; 3, C vi; 4, transversalis colli ar-
tery ligated and divided; 5, suprascapular nerve; 6, external
anterior thoracic nerve; 7, omohyoid muscle; 8, C vii; 9,
transversalis colli artery; 10, internal jugular vein; 11, sca-
lenus anticus muscle; 12, phrenic nerve.
FIG. 12. — BRACHIAL PLEXUS EXPOSED BY AN OBLIQUE INCISION FROM JUNCTION OF MIDDLE AND LOWER
THIRDS OF THE STERNOMASTOID MUSCLE DOWN AND OUT TO JUNCTION OF MIDDLE AND OUTER
THIRD OF CLAVICLE. In this dissection a segment of the clavicle is removed to give a more dis-
tal exposure of the plexus. The structures 1 to 12 are the same as in Fig. 11. 13, Suprascapular
artery; 14, C viii and Di nerves; 15, nerve to subclavius muscle; 16, subclavian artery; 17,
pectoralis major and minor muscles; 18, muscular branch.
FIG. 13. — RIGHT ARM SHOWS TYPICAL DEFORM-
ITY OF AN OLD NEGLECTED SEVERE BRA-
CHIAL BIRTH PALSY. This boy is ten years
old. Note the smaller size of the shoulder
girdle and extremity on the right side, the
flattened shoulder, the inward rotation of
the entire extremity, the flexure of the el-
bow, and the marked flexion and ulnar ad-
duction of the wrist.
FIG. 15. — NINE MONTHS AFTER OPERATION —
NOTE IMPROVEMENT IN SIZE AND POSITION
OF RIGHT UPPER EXTREMITY, ESPECIALLY
OF HAND.
FIG. 14. — THIS SHOWS MAXIMUM POWER OF
ELEVATING HAND TOWARD MOUTH BEFORE
OPERATION.
FIG. 16. — Two YEARS AND SEVEN MONTHS
AFTER OPERATION PATIENT COULD RAISE
RIGHT HAND TO His MOUTH.
OPERATIONS ON THE PERIPHERAL NERVES
549
and deformities result from the contracture of the antji.^mists of the parah/cd
muscles, which, in turn, are apt to be overstretched. Then- mn, lit ions under
neglect give attitudes characteristic of this type of paralysis, as indicated in
Figures l.'J to 21 inclusive.
lii the adult these contractures do not give the
same degree of deformity, because the extremity has
been fully developed before the incidence of the
nerve paralysis. (Figs. 24 and 25.)
The muscles paralyzed fall into groups which
correspond with the motor fibers located in the differ-
ent anterior motor roots (see Fig. 26, from Kocher).
TEEATMENT PRECEDING OPERATION. — The prin-
ciples of treatment from the time of onset of paraly-
sis until the time of operation have been outlined in
the preceding section. The arm or extremity should
be put up in a support which shall entirely relax the
muscles paralyzed in a given case, so as to prevent
their being overstretched. If the hand on the para-
lyzed side be placed on the back of the patient's head
and held there, the relaxation of the paralyzed muscles is almost perfectly
attained. Massage and electricity should not be applied to these cases for the
FIG. 17. — TYPICAL DEFORMITY
IN A CHILD LESS THAN Two
YEARS OLD.
FIG. 18. — X-RAY PICTURE SHOWING SHOULDER GIRDLE IN A FOUR-YEAR-OLD BOY WHO HAD SUFFERED
A RIGHT-SIDED BRACHIAL BIRTH PALSY. Note the interference with the growth of the bones in the
right side of the shoulder girdle, and the infantile type of the shoulder joint.
first 3 weeks after the injury, inasmuch as a traumatic neuritis, which is apt
to be aggravated by these procedures, occurs in the brachial plexus.
EARLY OPERATION IN INFANTS. — In infants operation is indicated in
those cases which show serious damage to the brachial plexus and should be done
550
PEKIPHEKAL AND CRANIAL NERVES
as soon as the general condition will war-
rant the use of an anesthetic, whether this
be after 10 days or 3 months from the
time of birth and the receipt of the injury.
In those cases where no injury suffi-
cient to demand nerve resection and su-
ture is found, the operation results prac-
tically in a simple exploration, with mere-
ly a division of the skin and subcutaneous
fat, practically no loss of blood, and a per-
fectly clear view of all the nerves of the
brachial plexus so that the surgeon may
know just what he is dealing with and
just what has to be done. This procedure
involves practically no risk beyond that of
the anesthetic. If damage is found its
early repair gives the patient the best
prospect of satisfactory regeneration and
there has been no undue loss of time. In
the cases of moderate severity at the time
of injury, it may be legitimate to wait for 3 months, provided the care of the
extremity and muscles, as previously described, is properly followed up.
FIG. 19. — DEFORMITY FOLLOWING COMPLETE
RUPTURE OF LEFT BRACHIAL PLEXUS.
Instead of resembling the typical one as
shown in Fig. 17, the deformity is that
of a complete flaccid paralysis of the ex-
tremity. Child, 11 months old.
FIG. 20.— THREE YEARS AFTER REPAIR OF
PLEXUS CHILD WAS ABLE TO PLAY WITH
LEFT ARM AND TO SUPPORT A HEAVY
DOLL WITH IT.
FIG. 21. — THREE YEARS AFTER REPAIR OF
PLEXUS CHILD COULD ALSO GRASP A
LIGHT-WEIGHT DOLL WITH HER FINGERS
AND HOLD IT OUT IN FRONT OF HER.
OPERATIONS ON THE PERIPHERAL XERVES 551
EXPLORATORY OPERATION IN ADULTS.— In adults, exploration should be
done within a few days of the receipt of the injury, sufficient time being given
for the tissues at the base of the neck to have regained their normal resistance
against operative attack and the possibility of infection. In these cases there
is no risk involved and no time should be wasted in waiting for the development
of the electrical reaction of degeneration, inasmuch as the operation consists
FIGS. 22 AND 23. — TRAUMATIC ERB'S PARALYSIS IN ADULT. This is the same, etiologically and path-
ologically, as birth palsy, but as the extremity has attained full growth before the nerve damage
occurs, the symptoms are chiefly those of paralysis and atrophy of the muscles involved. Note
the atrophy in the deltoid and supraspinatus and infraspinatus.
merely in the skin incision, followed by palpation and inspection of the plexus
and the opportunity for immediate repair of any discoverable damage. These
procedures with a minimum loss of time will give the maximum result.
OPERATIVE TREATMENT. — The patient is placed supine on the operating
table, with a sand-bag under the neck and shoulders of such a size and so placed
as to just catch the occipital protuberance when the head is turned to the op-
posite side from the lesion and retracted somewhat so as to put the skin and
muscles of the operative area somewhat on the stretch.
The plexus may be exposed by either of 2 incisions. One starts just above
the insertion of the sternomastoid muscle and passes outward and slightly up-
ward across the base of the neck, following the natural wrinkles of the skin.
OPERATIONS ON THE PERIPHERAL .VERVES
553
eTXtrnkafiund] ^^ *" *** "" ^^ in the 8ame line' '-''"llv
cAieiiidi juguiar vein, tne transvers'ilis oolli «nH i
and divided. With proper retraction the nerves we pwtty well I™ «d"'
wound falls together naturally and heals without any tendencv in Te scar t
spread. Its disadvantage is that in widespread damage to the plexus Tdoes
not give complete exposure, especially in adults
The other incision starts at the level of the transverse process of the sixth
cervical vertebra and runs obliquely downward and outward to the junction of
the outer and middle tlnrds of the clavicle and divides practically the sle
FIG. 25. — AN ELECTRODE WHICH CAN BE STERILIZED BY BOILING. It has flexible copper wire terminals.
structures as in the preceding case, although at a different angle (Figs. 11
and 12).
After retraction of the wound in either incision, the deep layer of cervical
fascia normally lying just in front of the plexus is found thickened and ad-
herent to the underlying nerves. This is dissected away, thus exposing the
roots and plexus, which are examined by sight, touch, and, if necessary, by a
tiny electrode (Fig. 25), to detect the presence of cicatrices which prevent nerve
regeneration and the passage of nerve impulses.
The cicatrices are removed by transverse section of the nerves above and
below at such levels as expose normal looking nerve bundles in the divided nerve
ends. It is sometimes necessary to make several sections before getting a satis-
factory looking end. It is wise to take off fairly thin segments until good
fasciculi are exposed, so as to save as much nerve length as possible for the ap-
proximation. In the distal nerve trunk one can always get a satisfactory look-
ing end by going far enough. In the proximal end, however, the cicatrix some-
times extends up into the intervertebral foramen. These exceptional cases will
be considered later.
When the nerves have been properly prepared, end-to-end siiture should
follow. The best suture material in adults is fine, strong silk, because it is de-
pendable. On opposite sides of the nerve, about % cm. from its freshened end,
are passed 2 sutures transversely to the long axis of the nerve, and including
mostly nerve sheath. Each suture is tied so as to get a firm hold, and the ends
are left long. The other freshened nerve end is treated in similar fashion and
the 2 are approximated by tying the lateral sutures of the one to the other. One
554
PERIPHEEAL AND CRANIAL NERVES
or 2 fine catgut sutures at the periphery will
complete the apposition.
Another method of suture which is satis-
factory, especially where there is not too much
tension, consists in passing a loop of chromic
catgut through both nerve ends and tying them
together. This is quicker and simpler, but has
the disadvantage of perforating the nerves as
well as not being quite so dependable. This,
however, is the only feasible method in infants.
While the nerve sutures are being tied the
neck and shoulder are approximated. The fat
pad is allowed to fall into place, and the skin
wound is sutured with silk. No drainage is
used.
The approximation of the neck and shoulder
is maintained by means of a steel brace espe-
cially designed for these cases and fitted pre-
vious to operation so that it can be slipped on
just after the nerve sutures have been tied and
thus prevent any chance of tearing them out.
This brace (Fig. 22) is worn continuously,
without a moment's intermission, for 6 to 12
weeks, according to the individual case.
In those cases where the cicatrix extends up
into the intervertebral foramen, a modified procedure is necessary. The cica-
trized root may be split longitudinally up into the foramen, and if good nerve
bundles are exposed above, the distal end
of the nerve may be sutured into the cleft,
with the hope that good union will occur.
If the split cicatrix does not reveal good
bundles above, the only thing left to do is
lateral anastomosis of the distal nerve trunk
into a neighboring sound root.
In those cases where the roots have been
torn from the cord, lateral anastomosis is
the only thing to be done, if any of the
neighboring roots are still functionating.
Where considerable lengths of nerve
roots must be resected to get beyond the
cicatrices and the ends cannot be closely ap-
proximated, it will be found necessary to
resort to nerve bridging or the procedure next mentioned.
When the entire plexus is badly torn, and the freshened nerve ends cannot
FIG. 26. — LEATHER-COVERED STEEL
BRACE MADE FOR EACH OPERATIVE
CASE 1 is a channel to hold the
forearm and hand. 2 is a shoulder
pad which fits over the scapula and
prevents the shoulder from being
displaced backward and so causing
strain on the nerve sutures. 3 is a
band which encircles the head and
to which a cloth skull cap is sewed
so as to hold the head down where
it belongs. A chin-strap prevents
the child from wriggling out from
under the head-piece. The arm
and forearm are fixed in the brace
by roller bandage.
FIG. 27. — HEAD, NECK AND SHOULDER
HELD IN CLOSE APPROXIMATION DUR-
ING HEALING, so PREVENTING ANY
STRAIN ON NERVE SUTURES.
OPERATIONS ON THE PERIPHERAL NERVES 555
be brought together, a subperiosteal resection of the middle third of the clavicle
will permit very greatly increased approximation of the nerve ends. This would
greatly increase the chances of regeneration, and certainly an extremity with a
damaged clavicle, which will, nevertheless, move, is very much to be pre-
ferred to an anatomically complete extremity which is permanently paralyzed
(Fig. 12).
POSTOPERATIVE TREATMENT. — When the proper time for the removal of
the brace has arrived, the extremity may be placed in an ordinary triangular
sling supported by the sound shoulder, and so adjusted as to elevate the para-
lyzed shoulder. The brace and sling not only prevent the paralyzed extremity
from dragging on the nerve suture, but also prevent the weight of the extremity
from overstretching the paralyzed muscles and thus prolonging their period
of inactivity even after nerve repair has occurred.
When the change from brace to sling has been made, the extremity may be
given massage, passive motion, electricity, etc., every day, being taken from
the sling for that purpose. Procedures which would pull the shoulder away
from the neck on the operated side should be avoided for many months.
At any time after 3 months from operation, voluntary motion may begin to
appear in the paralyzed muscles, and as they regain their tone, the sling may
be discarded. With the return of voluntary motion, the patient should be en-
couraged to take systematic exercises for the development of the muscles.
INJURIES BELOW THE CLAVICLE. — Injuries to the brachial plexus at a
level below the clavicle are most frequently due to dislocations of the shoulder
with traumatism by the head of the humerus to the nerve trunks in the axilla,
to pressure from the arm pieces of crutches, or to the injudicious use of the
foot in the axilla in the process of reducing a dislocated shoulder. As a rule,
these injuries undergo spontaneous recovery after a greater or less length of
time, and only the methods of tentative physical therapeutics are indicated.
Injuries to the Suprascapular Nerve. — The suprascapular nerve is injured
in all of the brachial birth palsies and in all of the brachial paralyses of Erb's
type in adults. Its fibers run on the outer edge of the fifth cervical nerve and
therefore in all of the stretching injuries it is the first to bear the brunt of the
injury which causes paralysis of the spinati. This paralysis has much to do
with the peculiar deformity at the shoulder on attempts to raise the arm and
with the inability to place the hand upon the head because of the loss of external
rotation of the humerus.
Falls upon the shoulder suffered by many laboring men past middle life re-
sult in inability to use the shoulder and show paralysis of the deltoid. A care-
ful examination will usually show that the suprascapular nerve has also been
damaged. Such injuries are almost always due to damage of the upper nerve
root of the brachial plexus rather than to injuries of the shoulder joint itself,
although there may be complicating joint adhesions after some little time. If
the paralysis persists, the upper portion of the brachial plexus should be ex-
plored and if the suprascapular has suffered damage, it should be repaired in
556 PERIPHERAL AND CRANIAL NERVES
the manner already described in brachial birth palsy, i. e., either by end-to-end
suture or anastomosis with a neighboring nerve. (Figs. 24 and 25.)
The circumflex nerve also derives its fibers from the fifth root and most of
the deltoid paralyses which are attributed to damage of the nerve in its
peripheral distribution, are really due to a stretching injury to the fifth cervical
root. In these cases, the patient is usually beyond middle life and not in good
condition for operation in other respects, and it is not desirable to operate upon
the nerve unless exceptional circumstances demand it. Often neighboring mus-
cles can be trained to give sufficient abduction to fulfill most of the patient's
needs.
Injuries to the Musculospiral Nerve. — The musculospiral nerve is more fre-
quently injured in fractures than any other nerve, and the site of the injury is
most frequently near the lower part of the humerus, as the nerve winds
obliquely around the bone. These injuries are usually of the type of contusions,
although the nerve is sometimes lacerated by the bone fragments and may very
rarely be torn across. The nerve may be injured at the time of the fracture,
or during the first few weeks afterward from pressure, though involvement in
the bony callus thrown out.
If the nerve is injured in the lower portion of the arm below its external
cutaneous branch, there will be no sen-
sory disturbances, because below this
point the musculospiral furnishes no
exclusive sensory supply to the skin, but
there always occurs a more or less com-
plete drop wrist (Fig. 28). This nerve
is also the one which suffers from what
is known as "anesthesia paralysis"
when the arm is carelessly allowed to
FIG. 28. — CHARACTERISTIC WRIST-DROP RE- -, -. „
SULTING FROM MUSCULOSPIRAL PARALYSIS. nang over the edge of the operating
table and the nerve suffers paralysis
from direct pressure continued for some time. It is also the nerve which is
involved in the so-called "Saturday-night paralysis/7 or paralysis due to sleep-
ing with the arm folded under the neck. This nerve is frequently paralyzed,
also, by the pressure of a crutch in the axilla.
The prognosis in these cases is usually good. Many of the injuries are of
such moderate degree as to undergo spontaneous regeneration and return of
function. In a case where the nerve is more severely injured and nerve suture
is indicated, the results are good in a larger proportion of cases than in the
suture of the other nerves of the arm, perhaps largely because the muscles sup-
plied by this nerve do not perform the finer movements of the hand as do the
muscles supplied by the median and ulnar.
If at the time of fracture there is an open wound — in other words, a com-
pound fracture — the nerve should be explored and, if found sufficiently injured,
should at once be sutured, end to end, after resecting the damaged segment.
OPEEATIONS ON THE PERIPHERAL XERVES 557
Otherwise it may be surrounded by Cargile membrane to avoid adhesions and
left alone. If the fracture is simple and there are evidences of serious inter-
ference with nerve function in the musculospiral, it is advisable to explore the
nerve after allowing a few days to elapse so that the tissues may regain their
resistance against infection. Some men advise waiting for 10 to 14 days and
are then guided by the presence or absence of the reaction of degeneration. 1 1'
the reaction of degeneration develops, exploration is essential. If the muscles
do not show the reaction of degeneration, tentative treatment for a longer pcrin-1
may be justified. Sometimes the nerve is not sufficiently damaged to cause
reaction degeneration, but is so lacerated that later scar formation will pre-
vent a large portion of it from functionating properly, so that operation is
necessary later. In any case, the bony fragments should be carefully aligned
and the extremity put up so as to avoid overstretching of the paralyzed
muscles.
OPERATIVE TREATMENT. — When operation is necessary, posterior longi-
tudinal incision is made through the muscle down to the site of the fracture
and the nerve is explored. If there is evidence of much damage, the damaged
portion of the nerve is resected and end-to-end suture done. If the nerve seems
to be in fairly good shape, but is being compressed by a bone fragment or in-
flammatory infiltration, the bone fragment may be trimmed and the nerve pro-
tected by Cargile membrane.
In many cases the paralysis occurs gradually some little time after the frac-
ture. This always indicates compression and usually this compression is due
to involvement of the nerve in the callus. As soon as symptoms of this diffi-
culty appear the nerve sjiould be exposed and freed from pressure, protected by
Cargile membrane and, if necessary, transplanted a short distance away from
its original site, to avoid the recurrence of pressure. It usually takes about a
year for the return of function.
Injuries to the Ulnar Nerve. — JUST ABOVE THE WRIST.— The ulnar nerve
is most frequently injured just above the wrist joint, very frequently as a
result of a broken window pane or
other accidents of this type. Usu-
ally the wound is a ragged gash
which involves not only the ulnar
nerve, but also most of the tendons
on the ulnar side of the wrist, as
well as the ulnar artery. The ul-
nar nerve is never divided alone, FlG> 29.— TYPICAL DEFORMITY RESULTING FROM
but always in conjunction with ULNAR PARALYSIS.
some of the tendons. Not infre-
quently these wounds are closed without an appreciation of the fact that the
nerve has been divided, consequently there is no union and a permanent paraly-
sis of the portion of the ulnar nerve beyond the section. This leads to atrophy of
the intrinsic muscles of the hand and gives a characteristic deformity (Fig. 29).
558 PEEIPHEEAL AND CRANIAL NERVES
In all such injuries, the nerve should be carefully sought out and when divided
should be most carefully sutured end-to-end. In primary sutures, the results are
usually pretty good, and the return of function may be expected to occur in from 1 to 2
years. In secondary suture the operation is much more difficult and the chances of
success are greatly diminished, although here, even if motor power does not return, the
sensory disturbances, and particularly the trophic disturbances, will be greatly lessened
as a result of the secondary suture.
AT THE ELBOW. — Another site at which the ulnar nerve is frequently in-
jured is at the elbow, where it passes behind the inner condyle of the humerus.
At this site, the nerve may be dislocated from its groove by excessive muscular
action in people with an exaggerated valgus angle at the elbow. Full flexion is
apt to cause a dislocation or a partial dislocation of the nerve trunk. If this
happens frequently, it may lead to irritation of the nerve arid to a chronic pro-
ductive neuritis.
Often a fall upon the elbow, or an occupation which involves continuous pres-
sure upon the inner aspect of the elbow, will cause a similar productive neuritis. In
many patients who have suffered fracture of the internal condyle followed by persistent
valgus deformity, the nerve may be injured and develop a chronic interstitial neuritis.
In all of these instances, the symptoms consist of tingling and paresthesia, with a
greater or less amount of pain and a greater or less amount of disturbance of the motor
function of the nerve below the elbow. In cases of fractures of the internal condyle, a
number of cases are on record where the injury occurred during childhood, but the
symptoms of ulnar neuritis at the elbow did not develop for many years, sometimes
25 or 30 years after the original injury. In these cases the muscular atrophy and pare-
sis resembled pretty closely those due to progressive muscular atrophy, and these cases
are usually mistaken for that disease. Another curious thing, which has been noted
by Spiller and others, is that occasionally in these cases there will also be an atrophy
of the corresponding intrinsic muscles of the opposite hand. This is not easily ac-
counted for, but has been observed to exist, and with the repair of the damaged ulnar
nerve, both hands have shown improvement.
Of course, such a bilateral involvement is very apt to lead one astray in the
diagnosis, and this is more particularly so as the evidence of nerve impairment
begins so many years after the receipt of the injury.
One might, also, in this connection, refer to the interference with ulnar
function in the case of cervical ribs. Here, also, the evidence of nerve disturb-
ance does not appear for many years, although the cervical rib has, of course,
been present during the entire life of the patient.
In all of these cases of interference with ulnar function at the elbow, the
nerve should be exposed there by a longitudinal incision over its course, the
aponeurotic wall over the canal should be divided, and the nerve elevated for
inspection and palpation. As a rule, in these cases, there will be found a dis-
tinct bulbous thickening of the nerve, usually just behind and a little below the
inner condyle, which bulb is due to a chronic interstitial neuritis. It may con-
tain more or less nerve fibers or the trouble may have progressed to a point
OPERATIONS ON THE PERIPHERAL NERVES 559
where the bulbous mass is almost entirely connective tissue. Of course, the
symptoms in the individual case will depend upon the stage to which the
neuritis has developed. With complete replacement of nerve by fibrous tissue,
there will be complete loss of function. In the cases with very marked impair-
ment of function and, of course, in all cases with complete loss of function, the
bulbous mass should be entirely resected. In the case of fractures with a
resulting prominent internal condyle, or where the internal condyle is naturally
overprominent, the groove for the ulnar in the bone should be deepened and
carefully smoothed, and the ulnar nerve wrapped in Cargile membrane and laid
back in the groove. The aponeurotic covering of the canal is then sutured over
it and the limb is put up in a splint in complete extension, in order to relax the
drag on the nerve suture.
In cases where the interstitial process has not advanced very far and where
there is only a beginning interference with motor control and a moderate
paresthesia, the bony canal should be deepened, the nerve sheath split longi-
tudinally to relieve tension, Cargile membrane wrapped around it, and the
nerve replaced in its deepened canal and treated as above.
Injuries to the Median Nerve. — The median nerve, like the ulnar, is most
frequently injured just above the wrist by broken glass, incised wounds, etc.
The symptoms are generally sensory and confined to the palm of the hand, but
there is also a paralysis in the abductor opponens group of muscles and the
outer 2 lumbricales.
With a section of this nerve just above the wrist, there is usually combined
a section of some of the tendons, although this nerve is so superficial that it may
occasionally be the only structure divided in addition to the skin and sub-
cutaneous tissues. After the diagnosis is made, primary suture should be done
in all cases. After primary suture the prognosis is good and the return of
power should be expected in about 10 months. After secondary suture, it is
likely that sensibility will not become perfect, but the return of power in the
muscles involved is apt to be good.
Another site at which the median is sometimes damaged is just above the
elbow, where it is likely to be injured by one or the other of the fragments in a
supracondylar fracture of the humerus. The types of injury are quite similar
to those in the musculospiral nerve and if the symptoms of damage persist long
enough for reaction of degeneration to occur, exploration and repair are indi-
cated.
Injuries Affecting the Median and Ulnar Nerves.— The median and ulnar
nerves are very apt to be injured simultaneously, especially in injuries just above
the wrist, in which most frequently the ulnar is completely divided and the median
only partially divided. The symptoms are a combination of those resulting from the
2 individual lesions previously described. The treatment should be along the lines
there laid down.
Another type of injury in which these two nerves are both interfered with,
is that known as Volkmanns ischemic paralysis. This condition usually follows
560
PERIPHERAL AND CRANIAL NERVES
fractures near the elbow, either of the humeriis or of the bones of the forearm,
and is essentially a condition of muscular damage, presumably as a result of
splints which are too firmly applied and possibly, also, because of some inherent
lack of resistance in the patient. The muscles undergo an acute degenerative
process which results in their transformation into hard, fibrous tissue, giving the
peculiar deformity of this type of injury (Fig. 30).
In many of the cases there de-
velops evidence of damage to the
nerves which, as a rule, is observed
only after some few weeks and is
probably the result of external
compression by the cicatrized mus-
cle tissue, although the nerve dam-
age may be primary and in that
case, should have been noted at the
time of the original injury. With
stretching of the muscles and the
use of hot baths and massage, fre-
quently the firm fibrous mass may
be made to become softer and
more pliable, so that the fingers
can be extended. With this im-
provement, there will usually re-
sult a disappearance of the symp-
toms of nerve pressure. If the
nerve symptoms do not improve,
it may be necessary to cut down
upon the nerves in the upper portion of the forearm, free them from surround-
ing compression, and protect them from a recurrence.
Injuries to the Cauda Equina ANATOMICAL CONSIDERATIONS. — The spi-
nal cord ends in the adult at the lower level of the first lumbar vertebra. The
portion of the cord below the twelfth dorsal vertebra is known as the conus
medullaris. The lumbar and sacral roots arise from the sides of the lower end
of the cord close together, then pass downward and make their exit from the
dural canal considerably below the level of their origins. The third sacral root
leaves the cord just at the upper end of the conus. The ganglia of the posterior
roots of these nerves lie extradurally, therefore intradural damage of the pos-
terior roots leads to permanent degeneration.
CAUSES. — The cauda equina is injured, as a rule, by fractures or fracture
dislocations of the lumbar or dorsolumbar spine. Below the level of the first
lumbar vertebra, the injury usually involves the cauda alone. Above that level
the conus medullaris is also very likely to suffer injury, although it is possible
that an injury as high as the eleventh dorsal vertebra may involve only the
nerves of the cauda. Occasionally there will result evidences of injury to the
FIG. 30. — TYPICAL DEFORMITY IN VOLKMANN'S Is-
CHEMIC PARALYSIS (LEFT HAND) . Note the differ-
ent position of the thumb as compared with Fig.
29.
OPERATIONS ON TTTE PERIPHERAL NERVES
561
canda equhni without any obtainable evidence of l»one injury, although this i.-
a rare occurrence. These cases practically all make a spontaneous recovery.
EESULTS. — In injuries of the cauda alone, sensory symptoms are devel-
oped in the area of the third sacral roots and those below. Tlii- «ii\vs a sa« Idle-
shaped area of sensory disturbances involving the buttocks and perineum
(Fig. 31).
There is paralysis of muscle groups according to the anterior roots damaged,
and the paralysis is of the peripheral type. Often the paralysis is asymmetri-
cally distributed on the 2 sides. .
In injuries both of the cauda alone and of the conus alone, there is paralysis of the
bladder and rectum, resulting in retention of urine and incontinence <»f fc<-.-. In in-
juries involving the conus
alone there is a small area
of anesthesia over the coccyx,
in addition to the paralysis
of the bladder and rectum.
After a few months, lesions
involving the cauda will
show improvement, espe-
cially in the motor disturb-
ances. If the posterior roots
have been damaged suffi-
ciently to cause degenera-
tion, the sensory disturb-
ances will be permanent be-
cause the injury has oc-
curred between the trophic
center, which is the gan-
glion of the posterior root,
and the spinal cord. On
the whole, prognosis is not
very good. While the ma-
jority of cases of pure
caudal injury show im-
provement, they very seldom
progress to complete recov-
ery. When the conus has been damaged, the symptoms are apt
manent. . .
FIG. 31. — SENSORY SUPPLY OF PERINEAL REGION.
(After Gushing.)
per-
TREATMENT.— In those cases with symptoms of caudal and combined conus
and caudal lesions, where the X-ray pictures show injury to the bony spine,
laminectomy should be done at once, and such damage as
i e by end-to-end suture of divided or crushed motor roots, release from I
pressure etc. Delay in the presence of continuing pressure may cause comple
and permanent degeneration of the posterior roots, with coi
nent sensory disturbances. . .
In these cases, bilateral laminectomy is to be preferred, as the
bilateral and the manipulations require extra space. In late cases, when pa
37
562 PERIPHERAL AND CRANIAL NERVES
sis of the bladder and rectum have persisted, it is feasible to do intraspinal
anastomosis, using a root or roots from above the site of injury, dissected for
some distance extraspinally and pulled back within the dura (this to get the
additional length of nerve necessary), and then anastomosed end to end with
the third and fourth sacral roots, which have been divided at their exit from
the cord and raised to meet the sound roots. One successful case by the use of
this procedure has been reported by Frazier (11).
The suggestion has also been made of using this sort of nerve anastomosis
for getting around transverse injuries of the cord. One of the chief difficulties
in this type of nerve anastomosis is the very great tendency toward connective-
tissue formation within the dura and resulting interference with proper re-
generation in the 2 nerves sutured.
Injuries to the Great Sciatic Nerve. — Injuries to this nerve are infrequent,
except in war, where they are very common. It may be injured in fractures
of the pelvis, during manipulations for reducing a dislocated hip and especially
in the manipulations for reducing congenital dislocations of the hip. Usually
these injuries are only partial, and spontaneous recovery ensues after a con-
siderable interval of time.
The great sciatic divides into the external and internal popliteal nerves just
above the popliteal space. It is an interesting fact, however, that the 2 nerves
run entirely separate right up to the sacral plexus and are simply bound to-
gether by an external sheath. Although there is no known reason for it, it is
a fact that the external popliteal nerve suffers damage far more often than the
internal popliteal. In gunshot wounds it is the portion of the great sciatic
damaged in about 90 per cent, of the cases. The symptoms will depend upon
the extent of the damage and will, of course, involve paralysis of the muscles
whose nerve supply has been cut off ; they will vary in the degree of loss of sensi-
bility with the amount of nerve damaged, and also according to the site of the
nerve damaged. Where the damaged portion of nerve is resected and end-to-
end suture done, the first muscular return occurs, as a rule, in the hamstring
muscles, in about a year. In 2 years, the leg muscles begin to show voluntary
power, and complete recovery may occur after 3 years. In general, the return
of function in the great sciatic is very much less prompt and less perfect than
in cases of nerve damage in the upper extremity. For this reason the greatest
care should be exercised to follow all the details of perfect technic, both at
the time of operation and in the after-care, in order to get the best result pos-
sible in the individual case.
The internal popliteal nerve is seldom damaged, but when it is damaged
and then repaired, its recovery is more prompt and more satisfactory than is
that of the external popliteal.
The external popliteal nerve is usually injured just as it winds around the
neck of the fibula. It often suffers from pressure damage as a result of ill-
adjusted leggings or from falls into holes, where the leg is jammed, etc. In
these cases, the damage is usually one of severe pressure, often accompanied
OPERATIONS ON THE PERIPHERAL NERVES
563
by laceration of the nerve trunk. This type of injury is very apt not to
undergo spontaneous regeneration. The paralysis may be complete or may in-
volve only a portion of the muscle supply, according to the extent of injury to
the nerve. In these cases the indication is always to do immediate exploration
on discovery of the paralysis. As a rule this can be done readily uinlrr local
anesthesia, the condition of the nerve determined and the proper means of re-
pair adopted.
The other nerves of the lower extremity are rarely damaged, except in gun-
shot or stab wounds, in which case the wound should be enlarged and the nerve
sutured.
See also Operations for Relief of Pain.
OPERATIONS FOR TUMORS OF NERVES
False Neuromata. — The nerve sheaths are often, either inside or out, the seat
of fibroma, sarcoma, or other new growth, which may seem to be a part of the
nerve, although in reality the fibers pass through the tumor
or beneath it and get around it, so that these growths are,
therefore, not essentially tumors of the nerve tissue. These
are known as false neuromata because they do not contain
nerve cells or nerve fibers. They may cause nerve symp-
toms as a result of the pressure of the tumor causing sec-
ondary degeneration of the nerve. The symptoms will be
those resulting from compression of the nerve.
True Neuromata. — True tumors of the nerves, known
as neuromas, consist of nerve fibers which may be medul-
lary or, more often, non-medullary, and are without nerve
cells. In many of the tumors there is so much fibrous tissue
that they are called neurofibromata. Neurofibromata are
very apt to be multiple and in the majority of cases may
run up into the hundreds. In one case, reported by Prud-
den, there were 1,000 tumors. As a rule, the tumors are
small — about % cm. in diameter — but occasionally they
grow to be of a diameter of 10 cm. Sometimes they appear
on the sensory nerves of the skin and in these cases may be
readily felt and are usually tender. These tumors are often
designated as fibroma mollusca,, or tubercula, dolorosa.
Another form of nerve tumor is what is known as plex*-
form neuroma, this type being found most frequently about
the head, face and neck. It consists of a great enlargement
and plexiform arrangement of nerve fibers, which are not painful nor sensitive
to touch.
Treatment.— In most cases the multiple neuromata cause no symptoms un-
less they become large enough to cause pressure, in which case pain and, possi-
Fio. 32. — MULTIPLE
NEUROMATA. (After
Starr.)
564 PERIPHERAL AND CRANIAL NERVES
bly, motor disturbances result. These neuromata cannot be removed because
they are so numerous. Occasionally neuromata of large size are removed to
prevent the mechanical disturbances arising from their size and situation.
In removing false neuromata the nerve sheath should be split longitudinally,
the tumor grasped and the nerve bundles dissected away from it very carefully,
so as to cause minimum damage to them. In true neuromata involving the
nerve tissue proper, where removal is necessitated because of pain or motor
paralysis due to pressure, transverse section above and below the tumor should
be followed by immediate end-to-end suture.
In some of the neurofibromata there may occur myxomatous, cystic or sar-
comatous degeneration. With the development of sarcoma, pain and paralysis
are apt to appear from pressure. Of course, sarcoma must be removed, but is
very apt to recur elsewhere.
The neuroma which develops at the end of a divided nerve in an amputa-
tion stump is usually, the result of long-continued moderate irritation. These
neuromata are usually painful and very tender to the touch. If nerves at the
time of amputation were resected sufficiently high, neuromata would not form.
Once painful neuroma has occurred, the only treatment is incision down to and
excision of it and as much of the nerve trunk as is feasible.
OPERATIONS ON THE CRANIAL NERVES
Surgical interference is indicated in disturbances of the cranial nerves re-
sulting in great pain, as in trigeminal neuralgia; in motor disturbance, as in
facial palsy; and in certain other functional disturbances, as in persistent
tinnitus aurium, and in a certain small number of cases in which the gastric
crises of tabes seem to have their origin in pneumogastric disorder.
The first four cranial nerves will not be considered here inasmuch as their
disturbances are either non-surgical or result indirectly from the pressure of
neighboring lesions, the treatment of which will be considered under the section
on the skull and brain.
FIFTH CRANIAL NERVE
Trigeminal Nerve
The fifth cranial nerve, or trigeminal, as it is frequently called, has stimu-
lated more surgical interest and the development of more ingenious technic
than any other nerve in the human anatomy.
The indication for surgical interference is always intractable unbearable neuralgia,
and this has usually existed, either persistently or in attacks which occur more fre-
quently as time goes on, over long periods of time.
Anatomical Considerations. — The nerve arises by a small anterior motor and a
large posterior sensory root, which emerge close together from the pons above its cen-
ter, run forward to the upper edge of the petrous bone, where they pass through an
OPERATIONS ON THE CRANIAL XKUVES 565
opening in the dura above the internal auditory mcatus, and then between the <luru and
petrous bone to the depression near the apex of the petrous bone in which tin • < ia^-riaii
ganglion is ensconced, and which is usually just internal to the entrance of tin- middle
meningeal artery to the skull. Only the sensory root enters the ganirlion. Th.-
root lies under the ganglion, passes out of the skull, and then joins tin- inlVrior maxil-
lary branch from the ganglion.
The dura splits so as to ensheath the ganglion, which is said also to have another
thin envelope in immediate contact with its surface. The blood supply to the gam-lion
comes chiefly from beneath.
From the ganglion arise 3 sensory trunks.
THE OPHTHALMIC.— The upper or ophthalmic trunk runs forward along
the cavernous sinus and divides into 3 branches which enter the orbit through
the sphenoidal fissure. The lachrymal branch has no surgical interest. 'UK-
frontal branch emerges from the orbit in 2 parts, the supra-orbital, which
passes through the foramen of the same name, and the supratrochlear, which
emerges nearer the median line. These 2 between them supply sensation to tin;
integument of the forehead and cranium as far back as the occiput. The nasal
branch enters the cranial cavity from the orbit through the anterior ethmoidal
foramen and then passes into the nasal cavity through the cribriform plate. It
supplies sensation to the upper anterior mucous membrane of the nose and to
the tip and ala of the nose externally.
THE SUPERIOR MAXILLARY. — The superior maxillary, or second division,
passes forward through the foramen rotundum, across the sphenomaxillary
fossa, through the sphenomaxillary fissure into the infra-orbital eamil. from
which its terminal branches emerge at the infra-orbital foramen. In its course
it gives off branches which supply sensation to the mucous membrane of the
cheek, palate, pharynx, and nose, to the teeth of the upper jaw, and to the skin
of the nose, cheek and temporomalar region.
THE INFERIOR MAXILLARY. — The inferior maxillary, or third division,
passes downward through the foramen ovale and is joined just outside the skull
by the motor root. This combined nerve then divides into an anterior branch,
almost entirely motor, which innervates the muscles of mastication, and a pos-
terior branch, almost entirely sensory, which supplies sensation to the auriculo-
temporal region, the lower face, the tongue and floor of the mouth through the
lingual nerve, the teeth and integuments of the chin through the inferior dental.
Indications for Treatment. — Concerning the choice of methods in treatment,
there will always be discussion, but there is unanimity in the feelinir that med-
ical treatment should always be given first chance, and that with it should always
be combined careful attention to the mouth (especially to the teeth, with reirnrd
to erosion of the enamel or the presence of pyorrhea), to the nasal cavity and
accessory sinuses, and to the contents of the orbit, to eliminate any causes of
reflex disturbances and pain.
•
Such treatment should be reasonably prompt and durable in its effect. If, in spite
of it, the attacks of pain become more frequent or more severe or both, then some fur-
566 PEEIPHEKAL AND CKANIAL NEEVES
ther means of relief should be given while the patient is still in good general condition,
and before any of the disastrous drug habits, of which these patients are so commonly
the victims, have been fixed.
When the time for surgical interference has arrived a variety of methods is
presented for choice. These methods vary inversely as to the risk involved and
the prospect of permanency of relief from pain.
PERIPHERAL OPERATION
When the pain is distinctly peripheral and is confined to one branch of the
nerve, many men, notably Moschcowitz, believe that permanent relief may be
given by a properly performed peripheral operation. In general the steps of
the peripheral operation consist in the exposure of
the nerve at its foramen of exit, its slow avulsion
by the Thiersch method, and then the interposition
of some obstruction to the reunion of the central
FIG. 33.— SILVEB RIVETS. (After an(j fasfai en(js of the nerve if regeneration occurs.
Moschcowitz.) . ...
The avulsion method consists in freeing the
nerve, at its foramen of exit, from surrounding
connective tissues, then grasping it with a curved clamp, and then very slowly
twisting it about the clamp so as to put the central end on the stretch. After
this slow, steadily increasing strain is applied for some minutes, the nerve
breaks centrally and some few centimeters come away. The twist is now re-
versed, and the peripheral portion of the nerve removed in similar fashion.
The fifth nerve is notoriously inclined to regenerate and cause a return of pain
so that this removal of a long stretch of nerve is important if a permanent result
is to be hoped for.
In addition to the avulsion, regeneration may be further prevented by plug-
ging the foramina of exit with a foreign body, of which the most satisfactory
seems to be the silver rivet of Moschcowitz, made in different sizes and with a
malleable head which can be moulded to fit the bone surrounding the foramen
(Fig. 33). The soft tissues are closed over the rivet with layer sutures and the
wound dressed without drainage.
On the Supra-orbital. — The first division of the nerve is very rarely the seat
of neuralgia, which is fortunate, since this method is not well adapted to the
supra-orbital, which is the only important accessible branch, since its exit is
through a notch rather than a foramen and there is no satisfactory method of
preventing reunion. When this nerve is to be exposed for any reason, the
incision is made in the eyebrow, parallel to its long axis, just above the supra-
orbital notch, which is easily felt. The incision carried through the soft tissues
exposes the nerve lying upon the bone and running at right angles to the line
of incision (Fig. 34).
OPERATIONS ON THE CRANIAL NERVES
567
This is avulsed in the manner previously described, and the wound closed
without drainage.
On the Superior Maxillary.— The second branch from the ganglion, the su-
perior maxillary, is often the primary seat of neuralgia. When the pain is
distinctly peripheral, avulsion at the infra-orbital foramen may !><• indicate,!.
When the pain primarily involves the molars of the upper jaw, it indicates that
the disease is well back in the main trunk of the second branch and that, there-
fore, avulsion of the infra-orbital is not likely to stop the pain.
In those cases where the pe-
ripheral operation is indicated, the
patient is placed supine on the
table with the head slightly raised.
When the foramen cannot be lo-
cated by touch, it may be satisfac-
torily indicated as follows : Draw
a line from the supra-orbital
notch, which can always be felt,
down between the bicuspids of the
upper jaw and also those of the
lower jaw. This line passes
through the supra-orbital notch,
the infra-orbital foramen, and the
inferior dental foramen (Fig.
36). If, now, another line be
drawn parallel to and about 8 to
12 mm. (according to size of face)
below the inferior margin of the
orbit, it will cross the preceding
line over the infra-orbital fora-
men. The line of incision should be about 2.5 cm. long, should begin to the
inner side of the foramen, and should run down and outward so as to avoid
damage to the fibers of the facial as they enter the orbicularis muscle. If local
anesthesia is to be used, and it frequently suffices, the tissues in the preceding
line are infiltrated and after an interval of 5 minutes the incision is carried
through skin, fat, and orbicularis muscle down to bone. The foramen is usually
found at the bottom of a small depression filled with fat, and from it radiate the
terminal branches of the infra-orbital nerve. (Figs. 34 and 35.)
If avulsion is to be practiced, a long slender needle must be passed as far
backward along the nerve as possible and some local anesthetic must be injected
to prevent the pain that would otherwise be caused. This step would not be
necessary if general anesthesia were used unless one were practicing anoci-
association as described by Crile.
The whole nerve, after being freed from fat and connective tissue, is grasped
with the curved clamp and avulsed by the method previously described. A
FIG. 34. — 1, SUPRA-ORBITAL NERVE' AND ARTERT;
2, SUPRATROCHLEAR NERVE; 3, INFRA-ORBITAI.
NERVE EMERGING FROM THE INFRA-ORBITAL, FORA-
MEN.
5G8
PERIPHERAL AND CRANIAL NERVES
silver rivet of a size to fit
snugly is driven into the fora-
men, and the malleable flange
is accurately moulded to the
surrounding bone. The soft
tissues are closed by catgut
layer sutures, the skin by fine
silk. No drainage is used.
The scar lies in the line of
natural wrinkles and will be
scarcely noticeable.
Another method which
avoids an external scar con-
sists in making a longitudinal
incision in the gingivolabial
fold of mucous membrane
over the canine fossa down
to the bone and then strip-
ping up all the soft tissues
until the foramen and nerve
branches are exposed. While
this method does not leave
a visible scar, the working
space and illumination are much less satisfactory, and the chances of infection
from the mouth are considerable.
On the Inferior Dental. — The infe-
rior dental nerve is the one most fre-
quently involved with neuralgia. It
makes its peripheral exit from the men-
tal foramen. This foramen lies on the
line previously mentioned, at a point
about midway between the alveolar and
inferior borders of the jaw. This point
will be found to be nearly submucous.
A longitudinal incision is made in
the gingivolabial fold just below the
two bicuspids down to bone, from which
the soft tissues are separated until the
foramen and the nerve coming from it
are exposed. The lower lip can be re-
tracted downward readily and good light
^,1 i • T, • i A £± j.i FIG. 36. — A STRAIGHT LINE RUNNING FROM Su-
and Working room obtained. After the PRA.ORBITAL NOTCH AND PASSING BETWEEN
nerve is avulsed and the foramen THE Two BICUSPID TEETH WILL ALSO RUN
ij.i i • i THROUGH INFRA-ORBITAL AND MENTAL FOR-
plugged, the wound may be closed with AMINA.
FIG. 35. — AVULSION OF CENTRAL END OF INFRA-ORBITAL
NERVE.
OPERATIONS ON THE CRANIAL NERVES 569
a few sutures of silk through the mucous membrane, or the tissue may be allowed
to fall into natural apposition without any sutures.
Results of Peripheral Operation.— These peripheral operations are easy, sim-
ple, and free from danger. They sometimes give permanent relief, often give
relief for 1 or 2 years, but, as a rule, in the majority of cases have proven un-
satisfactory in the long run.
When the neuralgic process involves the nerve trunks back near the base
of the skull so that operation of the peripheral type is contra-indicated, three
modes of procedure are open to consideration :
1. Resection of the nerve trunks at their exit from the base of the skull.
2. Alcohol injections into the nerve trunks.
3. Intracranial operation on the Gasserian ganglion.
1. RESECTION OF THE NERVE TRUNKS AT THEIR EXIT FROM THE BASE OF THE
SKULL
The various procedures devised for this purpose are all mutilating, bloody,
tedious, and difficult. They involve as much intrinsic risk as the intracranial
attack upon the Gasserian ganglion and in addition give no guarantee of per-
manent relief from the neuralgia for which they are done, because these nerves
show a surprising power of regeneration, and this regeneration is usually fol-
lowed by a recurrence of the pain. For these reasons such operations are not
worth while and will not be described.
2. ALCOHOL INJECTIONS INTO THE NERVE TRUNKS
Alcohol injections into the nerve trunks at their exit from the skull have
had a considerable vogue for several years and have many enthusiastic advo-
cates.
Advantages. — The advantage of the method lies in the fact that by an
operation which is simple and comparatively free from danger, immediate relief
can be given to these sufferers without their being incapacitated for work for
more than a few hours.
Disadvantages. — The disadvantages are several: The procedure is carried
out in the dark, the operator feeling about in the tissues with the point of the
needle until he strikes the nerve trunk. It not infrequently happens that oven
an experienced man will fail to find the trunk itself and have to satisfy himself
with injecting the alcohol into what he conceives to be close proximity to the
nerve.
At best the injection, even when put into the nerve itself, gives relief only
temporarily (6 to 12 months), and must be repeated when the pain recurs. If
injections are repeated too frequently, the muscles of mastication are apt to
570 PEKIPHEEAL AKD CKAOTAL NEKVES
become indurated and so interfere with the free mobility of the lower jaw.
When, in difficult cases, the nerve itself is not found, but the alcohol is injected
into the tissues in the region of the nerve, the relief is not so durable, and the
surrounding tissues are more indurated.
Instruments. — The instruments used consist of a needle 12 cm. long and
1.75 mm. in diameter, rather blunt-pointed, and fitted with a stylet which comes
out flush with the needle tip. This needle is graduated in centimeters. The
proximal end of this needle is constructed to make a tight joint with the thread-
less nozzle of a glass syringe, which will hold 2 c. c. or more (Fig. 37).
Where much induration of the soft tissues has occurred, it is sometimes
necessary to use a slenderer and sharper needle in order to penetrate to the
nerve. Such a needle is more apt to cause injury to vessels, is more flexible,
and so less under control for prodding in different directions in the depth, and is
less apt to give the characteristic pain upon piercing the nerve.
Solution for Injection. — The solution used varies with different writers.
The one used by Patrick (59) in his large series was:
gm. or c. 0.
Cocain muriat
Alcohol 13
Aq. dest. q.s.ad 15
M.
Sig. Usually about 2 c. c. at an injection.
1 (gr. ii)
5 (dr. iiiss.)
5 (oz. ss.)
Anesthesia. — Usually a general anesthetic is unnecessary and undesirable,
for the conscious patient is able to help very decidedly in determining whether
the needle is in the nerve or not.
Contra-indications. — The first or ophthalmic division of the nerve should never
be injected, since its close proximity to very important vessels and nerves renders the
procedure too hazardous. For analogous reasons the injections of the Gasserian
ganglion through the basal foramina do not seem justifiable.
Technic.3 — GENEKAL CONSIDEEATIONS.— The needle penetrates the skin
somewhat more easily if the stylet is slightly withdrawn until the subcutaneous
tissues are reached, when it is fully inserted to give better protection to the
vessels of the deeper structures. The needle is pushed steadily and slowly in
the direction where the nerve trunk should be, until it has reached the depth at
which the nerve is usually found. If the needle, during its progress, enters the
nerve sheath, the fact is made known by a pain in a part or the whole of the
peripheral distribution of the nerve. This pain varies greatly in degree, and is
sometimes only a "pins and needles" sensation.
If the needle has been inserted in the proper direction and to the proper
depth without eliciting any of these sensory disturbances, the point should be
1 After Hugh T. Patrick.
OPERATIONS ON THE CRANIAL NERYKS
571
pressed upward, downward, forward, and backward to see if in some one of
these directions it will not elicit the nerve pain and indicate in what direction
it should be then inserted. The needle is partially withdrawn and re-inserted
in the indicated direction. When the attempts thus far have failed, one must
systematically try to feel out the nerve by pushing
the needle point in various directions in the zone in
which the nerve must be located.
When the characteristic pain indicates that the
needle has entered the nerve sheath, the stylet is with-
drawn, and the syringe with the solution is fitted into
the needle. Two c. c. are injected steadily into the
nerve. Too sudden or forceful injection of the al-
cohol causes unnecessary pain.
In case none of these various attempts have
elicited the characteristic pain, the needle should be
inserted to where the nerve ought to be and a little
alcohol solution injected with a spurt. This will
sometimes elicit the pain when the point of the needle
has failed to do so. If the pain is thus elicited, the
regular dose of alcohol should be injected with the
feeling that it is in the nerve or in close proximity
to it. If all of these methods have failed to discover
the nerve trunk, the patient should be asked to return
a day or two later, when a second attempt may be
more successful.
After the alcohol has been injected, the syringe is
detached and the stylet replaced in the needle, which
is then left in situ for a few minutes to permit hemo-
stasis along the track of the needle, which is then
slowly withdrawn. After a few moments of pressure
over the skin puncture a little collodion is used to
seal it and the procedure is finished.
In the interval between the injection of the alcohol and the withdrawal of
the needle sensory tests should be made of the skin area supplied by the nerve
supposedly injected. If deep pin pricks over the whole area supplied cause no
pain at all, the injection has been perfectly successful. If there is only partial
analgesia, or if the analgesia is delayed in appearing, the injection has been
near rather than into the nerve, and it may be expected that the relief from
pain will be of short duration.
It frequently happens in these tic douloureux cases that sensory stimulation
of a surface supplied by one branch of the nerve will cause spasms of pain in
an entirely different branch. Patrick calls the field in which stimulation starts
the distant pain the " dolor-genetic zone," and states that the nerve supplying
this zone must be injected before the distant pain can be stopped.
FIG. 37. — GLASS SYRINGE,
NEEDLE AND STYLET FOR
ALCOHOLIC INJECTION OF
FIFTH CRANIAL NERVE.
572 PERIPHERAL AND CRANIAL NERVES
INJECTION OF THE SUPERIOR MAXILLARY NERVE. — The point of en-
trance for the needle is at the lower border of the zygoma, 0.5 cm. behind the
line of the posterior edge of the orbital process of the malar bone (Figs. 38 and
39). This edge is easily felt. The needle is inserted in the sagittal plane and
slanted upward so that at a depth of 5 cm. the point would be about on the level
of the lower end of the nasal bones. At this point the needle is supposed to
FIGS. 38 AND 39. — SIDE AND FRONT VIEW OF POSITION OF NEEDLE FOB INJECTION
OF SECOND DIVISION OF FIFTH NERVE.
enter the nerve as it comes into the sphenomaxillary fossa from the foramen
rotundum.
Variations in the bony contour of different skulls make it necessary to
modify the procedure in certain cases. The zygomatic arch is sometimes high,
sometimes low, and sometimes the anterior end of it slants downward at a
fairly sharp angle. The width of the orbital process of the malar bone varies
considerably. These factors influence the entrance and slant of the needle.
The coronoid process of the lower jaw may be so far forward of its usual posi-
tion as tc necessitate the entrance of the needle well in front of and below the
site above mentioned. In these cases the needle may strike the posterior edge
of the superior maxilla if it be well rounded and prominent, and it may then
be necessary to pass the needle through the coronoid notch in the attempt to
reach the nerve.
In cases with atypical bony conformation the operator, to be successful,
must be able to visualize the relation of the nerve to the bony processes, choose
the modification of the approach, and then strike it in the dark so to speak.
OPERATIONS ON THE CRANIAL XKRYES 573
In general, the needle should be inserted about 5 cm. to reach this nerve, al-
though the distance will be slightly less in patients who are narrow in the in-
terzygomatic diameter, and slightly more in those with a wide diameter.
Two dangers are inherent to this injection: (1) entrance into the orbit through
the sphenomaxillary fissure, which comes from slanting the needle too far forward and
can always be avoided by attention to this detail; (2) paralysi8 of the sixth nerve, which
lies deeper than the nerve under consideration but in the line of progress of the needle.
To avoid this latter trouble, when the needle is in position for the injection, the alcohol
is sent in a few minims at a time, and the power of external rotation of the eye con-
stantly tested. On the first sign of weakness in this motion, the injection is stopped
E>
FIGS. 40 AND 41. — POSITION OF NEEDLE FOR INJECTION OF THIRD BRANCH OF FIFTH NERVE.
and the point of the needle is made to seek out another part of the nerve farther away
from the sixth, when the injection may be completed. With these precautions, damage
to the sixth, if it occurs at all, will be slight and transient.
INJECTION OF THE INFERIOR MAXILLARY NERVE. — The point of en-
trance for the needle selected by Levy and Baudoine is just below the zygoma
and 2.5 cm. in front of the anterior root of the zygoma, which runs just in
front of the external auditory canal (Figs. 40 and 41). In patients with long
narrow heads this distance is satisfactory, but in short wide heads it is too
great. As a matter of practice, the point will be found to be on the lower border
of the zygoma about halfway between perpendiculars from the anterior root of
the zygoma and the posterior edge of the orbital process of the malar bone. The
needle is inserted inward, somewhat backward, and slightly upward, for a dis-
tance of about 4 cm., when it should be close to the nerve. The depth of the
nerve from the surface varies from 4 to 5,5 cm., according to the size and shape
of the head,
574 PERIPHERAL AND ORAKIAL NERVES
A helpful landmark is the external pterygoid plate, which lies at about the
same depth but a little anterior to the nerve. If the needle be made to strike
the pterygoid plate at the start, it can be worked backward at about the same
depth and made to strike the nerve with more certainty than by methods having
no fixed landmarks. When the sigmoid notch is very shallow it may be neces-
sary to have the patient open the mouth to permit the needle to pass. If the
needle passes too close to the inferior maxillary joint, this is apt to become stiff
and painful for a time. When the nerve is pierced there is usually pain in the
lip, jaw or tongue.
Results. — From the foregoing it is obviously more or less a matter of chance as to
whether the needle point enters the nerve sheath or not, and when it does not the results
are sure to be unsatisfactory.
Following the injection there is always considerable swelling of the soft
parts, which usually subsides quickly. Occasionally there will be a very un-
fortunate sequel. One woman who had had several injections for a severe
neuralgia of the inferior branch with relief for several months at a time, after
her last injection had immediate marked swelling, discoloration, and pain in
the whole side of the face and head. This was soon followed by sloughing of the
skin and subcutaneous tissues from the midline of the vertex, down along the
front of the ear to the lower border of the lower jaw, forward to the angle of
the mouth, upward to the bridge of the nose, outward under the eye, and up-
ward across the temple to the vertex. Several other such cases have been re-
ported, but fortunately the percentage of such complications is not high.
If it is necessary to give several injections, especially if the intervals be short,
there is a tendency for the muscles of mastication to become infiltrated, with resulting
interference with the free mobility of the lower jaw.
The results of this procedure are at best temporary, the relief lasting from
6 to 12 months (rarely 4 years), according to the severity of the disease and the
accuracy with which the alcohol was placed in the nerve trunk. There is no
mortality connected with the procedure, and the percentage of serious compli-
cations is low.
From its temporary effect and the uncertainty involved in its application, it would
seem to be best reserved for those cases unable, for one reason or another, to obtain the
permanent relief afforded by the Gasserian operation and also for the temporary relief
of patients who wish to get into condition to have the Gasserian operation done.
3. INTRACRANIAL PROCEDURES FOR Tic DOULOUREUX
It is generally conceded, even by those who are enthusiastic about the alcohol in-
jection treatment, that the only sure and permanent relief from tic douloureux lies in
a properly performed intracranial operation upon the Gasserian ganglion or its pos-
terior root.
OPERATIONS ON THE CRANIAL NERVES 575
Many authors and the profession at large, who constantly refer to the great danger
and high mortality of this operation, have gained their entirely erroneous impressions
from the statistics made up before the operation had been brought to its present high
stage of perfection.
Frazier, quoting 230 cases reported by Horsley, Lexer, Dollingcr, Cushing and him-
self, places the mortality at the astonishingly low figure of 3.7 per cent. Moreover,
since .the technic has been improved, injury to the eye, either motor or trophic, is
very unusual, and the sequels resulting from traumatism to the brain substance are
almost unknown.
Such being the case, this operation must be removed from the category of
extrahazardous procedures when properly performed. This removes the chief
prop from the support of those who advocate the trial of the various temporiz-
ing measures until such time as the sufferer has developed a fixed drug habit
or is physically exhausted or both. In spite of the fact that this type of patient
has furnished the majority of operative cases, the refinements of technic have
reduced the mortality to the very low figure quoted above. When patients,
properly selected, are operated upon early in the course of the disease, this
mortality will be still further reduced and they will be saved an enormous
amount of unnecessary suffering.
Indications. — A case should be considered appropriate for intracranial operation
under the following conditions :
1. When prompt and definite relief has not followed :
Measures for the improvement of the general health, especially the regula-
tion of the digestive tract and diet;
Proper dental care of the mouth, especially with regard to enamel erosion
and the presence of pyorrhea alveolaris ;
Appropriate treatment of abnormalities or infections within the nose or its
accessory sinuses, which might be the cause of reflex irritation.
2. When the tic involves the ophthalmic branch. This is the least frequent type,
but is also the least amenable to any of the various forms of peripheral treatment.
3. When the tic involves two of the branches of the ganglion, thus indicating a
deep origin of the irritation.
4. When the attacks are becoming more severe and more frequent in spite of
tentative treatment.
5. When, in borderline cases, satisfactory relief has failed to follow the use of one
or more of the peripheral forms of treatment previously outlined.
Anatomical Considerations. — The large sensory and relatively small motor
root of the ganglion pass from the pons forward beneath the tentorium cere-
' belli, through a small aperture in the attachment of the tentorium at the upper
edge of the petrous bone, and then forward and a little downward to the cavum
Meckelii near the tip of the petrous bone. Here the ganglion lies inclosed in a
special fibrous sheath known as the dura propria, outside of which is an enve-
lope from the regular dura. The blood supply consists of numerous small ves-
sels which enter the ganglion from beneath, which accounts for its firm fixation
to the underlying structures and for the sharp bleeding which follows attempts
576 PERIPHERAL AND CRANIAL NERVES
to raise it from its bed. It gives off 3 branches, the first running along the
cavernous sinus in intimate relation with it, and the third, fourth, arid sixth
cranial nerves; the second entering the foramen rotundum; and the third and
largest entering the foramen ovale. The motor root does not enter the ganglion
but runs beneath it and out through the foramen ovale with the third branch,
which it joins soon after leaving the cranial cavity. All of these branches are
surrounded by extensions of the dural sheath which envelops the ganglion.
The depth of the ganglion from the surface varies somewhat with the shape
of the skull, being deeper in broad skulls and more superficial in narrow skulls.
The relation of the middle meningeal artery is of importance. This vessel enters
the middle fossa through the foramen spinosum, which is quite variable in its relation
to the ganglion. It usually lies external to the ganglion. It may lie between the
foramen rotundum and ovale, or it may lie on a plane posterior to the latter, in which
case it obscures the third branch and also the posterior root, and should then be doubly
ligated and divided.
The upper branch of the facial nerve runs obliquely upward and forward,
crossing the zygoma on a line running from the external auditory meatus to
the external angular process of the frontal bone. This nerve supplies the
orbicularis muscle, the integrity of which is so important in the prevention of
the keratitis which is so apt to develop with the sensory and trophic distur-
bances which follow the extirpation of the ganglion. The incision should be so
planned as to avoid injury to this nerve.
Technic GENEEAL CONSIDERATIONS.— The methods of entering the skull
and the instruments used have already been described in another section.
A brief review of the stages leading up to the present best method of hand-
ling the ganglion itself will be worth while. Upon what is to be done to the
ganglion will depend largely the choice as to the method of its exposure.
Primarily, when it was thought necessary to remove the ganglion complete,
if a radical cure was to be obtained, the ganglion w^as exposed by one of the
various methods, the posterior root divided, the ganglion grasped with a strong-
clamp, and, after division of the middle and inferior branches, was avulsed.
This crude technic resulted frequently in the incomplete removal of the
ganglion and in serious damage to the cavernous sinus and the cranial nerves
running along its wall in close proximity to the ganglion. It was this type of
operation that gave such a bad reputation for danger, mortality, and serious
complications to the intracranial method of relief for tic douloureux. The
prejudice so originated has remained firmly fixed in the mind of the profession,
to this day, in spite of the immensely improved results which refinements in
technic have demonstrated in a large series of cases.
Later it was noted that pain in the ophthalmic branch was unusual and, in-
asmuch as the difficulties and dangers of the operation were chiefly related to
the removal of this branch, the procedure was simplified by removing only the
second and third branches with the corresponding part of the ganglion. This
OPERATIONS ON THE CRANIAL NERVES 577
technic gave as much relief from pain and, in the avoidance of operative
difficulties and dangerous sequela?, was infinitely superior.
Then Spiller demonstrated that division of the posterior root of the ganglion
would cause permanent degeneration of the sensory portion between the ganglion
and the pons. In 1901 Frazier first applied this modification of the technic
and divided the posterior root instead of attempting to remove the ganglion.
Various operators now expose the posterior root, pass a small hook beneath it,
and avulse the root from the pons, leaving it or excising it just proximal to the
ganglion. There are objections to this process of avulsion. It has been demon-
strated repeatedly that simple section of a posterior sensory root between its
ganglion and the central nervous system causes permanent degeneration and
loss of function of the divided nerves. This holds true, not only of the spinal,
but also of the fifth and seventh cranial nerves. If simple section of the root
will cause permanent relief from pain, which it has repeatedly done, there can
be no valid reason for the added traumatism caused by avulsing the root with
the chance of causing superficial hemorrhage on or in the pons.
No cases have been reported in which symptoms of damage to the pons
have followed avulsion of the root, so possibly this objection is chiefly theoreti-
cal. Nevertheless, the surgical maxim should hold, "gain the required result
with the least amount of traumatism."
Another consideration is of real significance. The motor root of the ganglion is
smaller than the sensory and is covered by it, so that it is practically impossible in most
cases to separate them and divide only the sensory root. In avulsing the root the
motor is torn away with the sensory portion and permanent paralysis of the muscles
of mastication results, including the temporal on the side of operation. This causes
not only defective jaw action, but also marked deformity resulting from atrophy of
temporal muscle.
If, on the other hand, the sensory and motor roots are simply divided proximal
to the ganglion, the sensory root undergoes permanent degeneration with loss of func-
tion, while the motor root, being divided distal to its trophic center, which lies in the
central system, will undergo regeneration with return of function after several months.
This sequence of events has followed this technic in 2 cases in my hands, and has
also followed in the seventh nerve case reported elsewhere.
Therefore, the simplest and best technic lies in exposure of the combined roots
of the ganglion, followed by simple section, leaving the cut ends approximated so as
to favor motor regeneration. In the very small percentage of cases in which the
sensory root can be separated from the motor root and alone divided, this, of course,
should be done.
Another advantage of the root section method lies in the almost complete elimina-
tion of danger to the cavernous sinus and the third, fourth and sixth nerves, and the
great saving in time of operation, as the removal of the ganglion was always the most
bloody and tedious part of the procedure.
Tor the purpose of root section, not nearly so large an opening in the skull
is necessary. The Hartley-Krause osteoplastic flap gives ample room, and, with
the Hartley-Kenyon motor saw, can be quickly and accurately turned down.
578
PEKIPHEKAL AND CKANIAL NEKVES
For the extirpation of the ganglion it gives very satisfactory results. The one
objection lies in the wide exposure of the brain cortex to pressure by the re-
tractors, although trouble from this source almost never occurred in the hands of
Dr. Hartley. The method is described elsewhere.
For the root operation the auriculotemporal exposure, as described by
Frazier, and the infratemporal exposure, as described by Gushing, are un-
doubtedly the best.
THE SPILLER-FRAZIER METHOD (DIVISION OF THE SENSORY BOOT BY
THE AURICULOTEMPORAL ROUTE). — From % hour to 1 hour before operation
the patient is given morphin, gr. 1/6,
and atropin, gr. 1/100. Nitrous-
oxid-ether anesthesia is induced, the
patient placed in the sitting posture,
and a horse-shoe-shaped flap made,
beginning at the middle of the zygo-
ma and ending behind and a little
below the helix of the ear. The mus-
culocutaneous flap is reflected, and
bone over an area 3 cm. in diameter
is removed. The center of this hole
will be about on the level of the en-
trance of the posterior root into the
ganglion. This opening is enlarged
downward by the rongeur as far as
the infratemporal crest, which is on
a level with the base of the skull.
The dura is separated from the base
of the fossa and from the anterior
surface of the petrous bone. When
the middle meningeal artery, coming
up through the foramen spinosum, is
encountered, it is ligated and divided.
Instead of using the ordinary liga-
ture, I have found the silver clip devised by Gushing more convenient for the
occlusion of this vessel. Elevation of the dura for a slight distance further
toward the median line will expose the region of the ganglion as it lies sur-
rounded by its dural envelope in the cavum Meckelii near the inner end of the
petrous bone. The inferior dental branch is easily identified as it runs through
the foramen ovale. Just in front of this branch the dural sheath is incised and
the incision is carried backward over the upper surface of the ganglion until the
posterior root is exposed. One can usually see the small foramen through which
the root crosses the ridge of the petrous bone to pass beneath the tentorium to
the pons.
The root is gently hooked up and divided with scissors, or it may be avulsed.
FIG. 42. — AURICULOTEMPORAL APPROACH TO THE
GASSERIAN GANGLION (1). 1, Musculocutaneous
flap; 2, skull trephined; 3, dura. (After Fra-
zier.)
OPERATIONS ON THE CRANIAL NERVES
579
For reasons previously given, the simple division is much to be preferred. The
motor root should be avoided when possible. Dm-iii" tin- cum-.- of the opera-
tion hemorrhage is controlled by means of narrow strips of gauze passed in on
either side beneath the elevated dura, in such a manner as not t,, interfere with
operative progress.
When the sensory root has been divided, the anesthetic can be stopped, be-
FIG. 43. — AURICULOTEMPORAL APPROACH TO THE GAssERiAN GANGLION (2). 1, 2, and 3 are the same aa
in Fig. 42; 4, middle meningeal artery coming up through foramen spinosum with a ligature carrier
passed around it. (After Frazier.)
cause the operative field has now been rendered insensitive. The wound is care-
fully closed by suture in layers, using catgut for the deeper structures and silk
for the skin. Frazier advises a rubber tissue drain for 24 hours in the posterior
angle of the wound, but my experience without any drainage would indicate
that it is not necessary, as a rule.
When the patient has recovered consciousness the reflexes ami sensation in
the operated side of the face should be tested to see if all of the sensory root
has been divided.
The eye on the operated side should be protected from dust and air currents for
about a week. If, by some mischance, the branch of the facial nerve to the orbicularis
has been paralyzed, the eye must be carefully watched and cared for over a long period
of time until the orbicularis has recovered.
580
PERIPHERAL AND CRANIAL NERVES
The protection may consist of gauze pads wrung out of boric acid solution,
or of an automobile goggle, which gives protection and at the same time allows
free inspection of the eye.
THE GUSHING OPERATION (INFKATEMPORAL). — The incision runs from
the temporal root of the zygoma (slightly in front of the ear) upward and then
forward, so that the vertex of the incision is at or slightly above the level of the
upper border of the pinna, and then forward and downward, terminating at
FIG. 44. — AURICULOTEMPORAL APPROACH TO THE GASSERiAN GANGLION 1, 2, 3, and 4, same as Fig.
43; 5, nerve hook passed under and around the posterior root of the Gasserian ganglion. (After
Frazier.)
least 1 cm. from the posterior border of the frontal process of the malar bone.
This modification of the original incision and its termination at the above point
are designed to avoid injury to the upper twigs of the facial nerve which supply
the frontalis and the orbicularis. This skin flap is reflected until the zygoma
is well exposed. Subperiosteal resection of the zygoma is done, avoiding injury
to the branches of the facial nerve as they cross the zygoma. Incision is then
made through the temporal fascia and muscle concentric with, but slightly
within, the skin incision, down to the bone. The muscle flap is elevated from
the bone, to which it is but loosely attached, and retracted downward into the
space previously occupied by the zygoma.
The bone is trephined and the hole enlarged by rongeur to a diameter of
about 3 cm., with the low^er edge at or involving the infratemporal crest. The
582
PKRIPIIERAL AND CRANIAL NERV KS
dura is thus exposed with the middle meningeal artery running across the hole
obliquely upward and forward from its entrance into the skull through the fora-
men spinosum to the arterial sulcus in the anterior inferior angle of the parietal
bone.
With a blunt elevator the dura beneath the arterial arch is raised from the
bone, and a short distance inward the infra-
maxillary branch of the ganglion is exposed as
it passes into the foramen ovale. Further ele-
vation of the dura forward exposes the second
branch entering the foramen rotundum. Be-
tween the 2 the dural envelope of ganglion is
easily incised, and this incision is carried back-
ward along the upper surface of the ganglion
until the posterior root is exposed. The pos-
terior root may then be either avulsed or sim-
ply divided, according to the preference of the
operator, avoiding injury to the motor root
when it is possible to isolate it. Hemorrhage
is controlled as in the previous operation.
The wound is most carefully closed with
layer sutures, Gushing using fine silk, while
most operators prefer absorbable catgut, except
for the skin suture.
FIG. 47. — INFRATEMPORAL APPROACH
TO THE GASSERIAN GANGLION (3).
After complete section of the pos-
terior root of the ganglion there
will be an area of complete an-
esthesia, indicated by the oblique
lines, and, at its posterior border,
an irregular area of incomplete
anesthesia indicated by the stip-
pled area. (After Gushing.)
When the posterior root has been com-
pletely divided, there is total loss of sensation
in the peripheral field of the corresponding
ganglion, except for a narrow, irregular zone
at its posterior and inferior borders where the
fibers of the upper cervical nerves overlap those of the fifth nerve and maintain
some sensibility (Fig. 47).
When the motor root has also been divided, as is usually the case, there is paralysis
of the muscles of mastication, of which the temporal is the most obvious. If the root
has been avulsed, the paralysis will be permanent and there will be marked atrophy
of the paralyzed muscles. If, on the other hand, the root has simply been divided and
the ends left in approximation, it will, in many cases, regenerate and give return of
function in the paralyzed muscles in from 6 to 12 months.
The skin sutures are removed in from 3 to 5 days ; the patient is allowed to
sit up as soon after 3 days as his condition will permit, and may leave the hos-
pital any time after a week.
Advantages of Posterior Root Section. — By the use of this method of posterior
root section, practically all of the difficulties, dangers and complications of the older
operation of excision of the Gasserian ganglion are avoided. Disturbances of the
OPERATIONS ON TIIK CKAXIAL XKKYKS 583
eye on the operated side are less frequent in occurrence and less severe when they do
occur. This is believed by Spiller to be due to the 1'avoral.lc trophic- influence of the
ganglion which is left in situ. The brain is retracted much less, so there is little like-
lihood of disturbance of its function. Failure to obtain relief IMUM !.»• «lt;e to either
missing the posterior root or not completely dividing it. In either ease there will not
be the typical complete anesthesia of the face on the operated side which is usual.
Only in rare cases will hemorrhage be such as to nece»itatc a two-stage operation.
Results. — Complete section of the posterior root gives permanent relief from
the pain and causes permanent loss of sensation in the iidd supplied by the
fifth root, except for a slight increase of function previously mentioni'd. which
sometimes appears after a number of months in the upper en-viral nerves.
When the motor root is permanently paralyzed, there appears a marked
atrophy of the muscles of mastication, of which the temporal is especially notice-
able. The zygoma stands out very prominently and accents the deformity due
to the atrophy. For this reason, Gushing does subperiosteal resection of the
zygoma and discards it. As a result, ho reports that the muscular atrophy
causes a much less noticeable deformity.
The eye on the operated side is apt to be sensitive to strong winds or to cold,
and the patients often complain that that side of the face feels boardlike. Nev-
ertheless, they regain their weight and color and are again able to take up their
proper duties in life unless a fixed opium habit prevents.
SEVENTH CRANIAL NERVE
Indications. — Surgical interference is directed toward the seventh cranial
nerve for 3 different types of disturbance :
1. Facial spasm.
2. Facial paralysis.
3. Neuralgia of the sensory portion of the nerve.
Anatomical Considerations. — For the sake of brevity, the seventh and eighth
nerves and the pars intermedia will all be considered together. Super-
ficially they arise from the upper part of the medulla, external to the olivary
body and pass forward and outward and slightly upward to the internal audi-
tory meatus, which is in the posterior surface of the petrous bone about -
the way in toward its tip. This meatus lies almost directly above the posterior
lacerated foramen, through which pass the ninth, tenth, and eleventh cranial
nerves. This close relation of the 2 foramina and the 2 sets of nerves may be
confusing in an operative field often obscured by hemorrhage.
As they enter the internal meatus, the seventh lies above the eighth, with
the pars intermedia between the two (Fig. 48). At the depth of the internal
auditory canal the seventh enters the aqueductus Fallopii, alonir which it passes
outward to the geniculate ganglion. It then passes abruptly backward along the
inner wall of the tympanic cavity just above the fcnostra ovalis, and then
straight downward through the mastoid portion to the stylomastoid foramen,
584
PERIPHERAL AND CRANIAL NERVES
from which it passes downward and forward, crossing the styloid process
obliquely on its outer surface, to enter the parotid gland, just before doing
which it divides into its 2 main branches.
The landmark for locating the exit of the nerve is the receding angle be-
tween the anterior border of the mastoid and the posterior border of the vaginal
process of the temporal bone, which lies just below the bony external meatus.
At a slightly greater depth than
these bony processes lies the upper
part of the styloid process, behind
the base of which, and at a slightly
higher level than the receding bony
angle previously mentioned, is the
stylomastoid foramen, from which
the nerve makes its exit.
The pars intermedia runs out-
ward in the aqueductus Fallopii to
the geniculate ganglion, into which
its fibers enter. From this ganglion
communicating fibers pass forward,
and others pass outward to supply
sensation to part of the tympanic
membrane and a portion of the ex-
ternal auditory meatus. This nerve
and ganglion are now pretty well
proved to be the sensory portion of
the seventh cranial nerve and may
be the seat of very severe neuralgia,
quite comparable to that in the fifth
nerve, as will be seen later.
The eighth nerve passes into the internal meatus, and at the end of the in-
ternal auditory canal sends its terminal branches through the various foramina
in the lamina cribrosa to the structures of the internal ear. The eighth nerve
leaves the medulla in the form of a number of small fasciculi, which run to-
gether just before they reach the internal meatus.
In a certain number of cases the seventh and pars intermedia may be nearly
concealed by the eighth, which receives them in a groove in its upper mesial
border. It may then be difficult or impossible to separate them for the purposes
of operation.
OPERATION FOB FACIAL SPASM
For facial spasm there are 2 methods of surgical treatment :
1. The injection of alcohol into the trunk of the nerve.
2. Transverse section of the nerve and the anastomosis of its distal stump into a
neighboring motor nerve.
FIG. 48. — RELATIONS OF THE FACIAL NERVE. 1,
Auditory nerve; 2, cochlear branch; 3, vestibu-
lar branch; 4, facial nerve; 5, nerve of Wrisberg
or pars intermedia. This shows how the facial
and pars intermedia may rest in a groove in the
auditory nerve. (After Testut.)
OPERATIONS ON THE CRANIAL NKKVI.S 585
Alcohol Injection. — For the alcohol injection the same instruments are used
as were described in the case of the fifth nerve.
The stiletted needle is pushed through the skin just below the receding
angle between the anterior border of the mastoid and the posterior border of
the vaginal process, which was described above, and carried straight in in the
sagittal plane for from 1 to 2 cm., according to the size and shape of the skull
and the amount of superficial fat. At from 1 to 2 cm. depth the styloid process
should be sought with the point of the needle, and when found, the needle should
be worked up and down for a short distance in the hope of striking the main
trunk of the nerve, which crosses the styloid process obliquely at about this
level. If the point of the needle pierces the nerve, there will be a spasm of the
face on the same side, and the alcohol may be injected at once (0.5 to 1 c. c.—
50 per cent.). If the needle does not locate the nerve at this level, its point
must be made to follow up the styloid process to its base, and then, by a slight
displacement backward, it can be inserted into the stylomastoid foramen, when
the nerve can be easily located and injected.
When the nerve has been injected there follows immediate paralysis of
the same side of the face, which lasts for a varying period of time (a few
weeks up to several months). When the nerve regenerates, voluntary mo-
tion usually returns without the presence of the spasm, which may never
again develop. It may, however, recur a few months after the appearance
of voluntary motion, or may accompany the return of voluntary motion in
a modified degree. The injection may be repeated from time to time if
necessary.
Facial tic, as contrasted with facial spasm, is a habit grimace, a physiologic
perversion, and can usually be corrected by proper educational measures. In
severe cases of even this type the alcohol injection may be given in order to give
temporary relief from the habit and to give the patient a better opportunity to
regain control of the muscle groups as voluntary power returns with the regen-
eration of the nerve.
Section of the Facial Nerve and Anastomosis with a Motor Nerve.— When the
injection of alcohol has failed to give satisfactory relief 'from facial spasm, sec-
tion of the facial nerve at its exit from the stylomastoid foramen, followed by anas-
tomosis with a neighboring motor nerve, should be done. Naturally, only
patients suffering from a severe and uncontrollable facial spasm would consider this
radical treatment.
This method removes the control of the facial muscles from a perverted set
of cortical cells and ^ives it to another set of cells, reached through the nerve
with which the facial is anastomosed. Moreover, the period of paralysis gives
the muscles a prolonged rest from the spasm.
The technic of this procedure will be described under the treatment of
facial paralysis.
586 PEEIPHEKAL AND CRANIAL NERVES
OPERATION FOR FACIAL PARALYSIS
Facial paralysis may result from a lesion in the central system, from a lesion
of the peripheral portion of the nerve between the medulla and the stylomastoid
foramen, and from a lesion of the peripheral portion of the nerve distal to the
foramen.
In this last case, if the paralysis is the result of a stab or gunshot wound,
the wTouhd should be enlarged, the ends of the nerve identified, freshened, and
united by end-to-end suture. When the lesion involves the main trunk or the
two primary branches of the nerve, this procedure may not be hopelessly diffi-
cult, but when the lesion involves the pes anserinus, there is little likelihood of
success, and the most one can do is to avoid infection in the wound and thus
favor prompt healing with a chance of spontaneous union of the divided fibers.
Where the paralysis results from infection or new growth in the parotid,
there is nothing to do beyond the ordinary surgical treatment of the primary
condition.
Anastomosis of the Peripheral Portion of the Nerve with a Neighboring Motor
Nerve. — In paralysis resulting from lesions proximal to the stylomastoid fora-
men, relief may be had by anastomosing the peripheral portion of the facial with
some neighboring motor nerve. As this operation is done largely for cosmetic
reasons, and as the results are not fully developed for 2 years or more after
operation, it should not be done in cases where the expectation of life is short
or where the general health is so affected as to add greatly to the risk of opera-
tion. In cases following mastoid operations the wound should be healed and the
region free from infection before the nerve work is attempted.
In cases where these contra-indications are absent, operation should be done
as soon as it is evident that spontaneous regeneration and return of function
will not occur. The determination of this factor is still the chief bone of con-
tention. Some are so conservative that they insist on waiting 2 years because
an occasional case has been reported in which some spontaneous return of power
has occurred after this interval. This, however, is not the rule. Others advise
1 year and those who are called radical are willing to operate after 6 months
from the onset of paralysis if no spontaneous return of power has occurred.
Between these different periods one must choose, and the surgeon should always
associate a competent neurologist with him in the decision of this question. If
the reaction of degeneration persists in the paralyzed muscles up to 6 months,
it is more than likely that spontaneous regeneration will not occur. Some men
feel that if no regeneration has occurred at the end of 3 months and the reaction
of degeneration still persists, operation may be advised at once. It must be
remembered that, on general principles, the earlier the operation is done after
paralysis, the better is the prognosis. The care of the paralyzed muscles before
and after operation should follow the principles laid down in another section.
Spontaneous regeneration is less likely to occur when the nerve trunk has
been completely divided, as by gunshot, or chisel during mastoid operation, etc.,
Ol'KKATIOXS OX TIIK CKAX1AL NKKYKS
SHOULDER
than when it is simply involved in a non-suppurativc inflammation, as in I Jell's
palsy, so that in the former cases operation would be justified at an earlier
period.
The two nerves to choose between for the anastomosis are the spinal acces-
sory and the hypoglossal. The spinal accessory was first use.l, |,ut the majority
of later operators have chosen
the hypoglossal because of the
more intimate association of
the cortical centers, the spinal
centers, and the peripheral
muscle groups of the facial and
hypoglossal nerves (Fig. 49).
METHODS OF ANASTOMOSIS. FACE
—Two methods of anastomosis TONGUE '•••
have been used; one a lateral
slit in the hypoglossal with im-
plantation of the peripheral
stump of the facial. The other
partial or complete transverse
section of the hypoglossal with
end-to-end suture between the
peripheral end of the facial and
the central end of the hypo-
glossal nerves. The opinion of
the majority favors the second
method because of the belief
that regeneration in the facial
nerve is more prompt and more
complete. This method causes
complete permanent paralysis
in the muscles supplied by the
portion of hypoglossal divided.
The patients soon learn to accommodate themselves to this loss of hypoglossal
power and do not suffer much discomfort. It has been advised that the distal
portion of the hypoglossal nerve so divided should be implanted into one of the
neighboring cervical roots. My own cases, 12 in number, have been done
by the lateral implantation method, and the results, as far as indicated
by the published pictures, compare very favorably with those done by the
transverse section method, and there is less permanent disturbance of the
hypoglossal.
TECHNIC. — FACIOHYPOGLOSSAL ANASTOMOSIS. — The operation involves the
following steps: (1) the incision; (2) the isolation and section of the facial
nerve; (3) the exposure of the hypoglossal nerve; (4) the implantation; (5)
the closure of the wound; (0) the after-treatment.
ItfVENTRI
LOS...
FIG. 49. — SCHEMA SHOWING RELATIONS or NUCLEI or
vii, xi, AND xii CRANIAL NERVES IN CORTEX AND
MEDULLA. It is obvious that the vii and xii are much
more intimately associated than vii and ri.
588
PERIPHERAL AND CRANIAL NERVES
1. Incision. — The patient is etherized; a firm cushion is placed behind
the head and neck ; the head is turned slightly to the opposite side and extended
a little upon the neck ; the operative field is thoroughly cleansed. The incision
involving the skin and subcutaneous tissues passes along the anterior margin of
the mastoid process and the sternomastoid muscle for about 5 cm. (2 in.), start-
ing at the level of the external auditory meatus. The temporofacial veins may
or may not be disturbed.
2. Isolation and Section of Facial Nerve. — The deep fascia is divided in
the same line, with special care
to keep close to the anterior bor-
der of the mastoid process to
avoid damage to the parotid
gland. This gland, covered by
its capsule, is separated from the
mastoid by an elevator and held
forward by a blunt retractor, ex-
posing the posterior belly of the
digastric muscle, which is then
pulled downward and backward.
When the digastric is large, it
may be necessary to divide its
upper border transversely to its
long axis to allow the retractor
to give a proper exposure of the
field.
The index finger, pushed- into
the depth of the wound and
slightly forward, readily identi-
fies the styloid process. Near
the base of this process the trunk
of the facial nerve passes almost
directly forward to enter the
parotid gland, and it can usually
be felt to roll as a distinct small cord, surrounded by connective tissue, between
the finger and the styloid process (Fig. 50). When there is difficulty in
identifying it in this manner, one should remember that it emerges from
the stylomastoid foramen, which is just behind the base of the styloid
process.
The nerve, once identified, is enucleated from the surrounding connective
tissue, and is divided as far up the stylomastoid foramen as a narrow-bladed
sharp knife will allow. Usually one can get from 1 to 2 cm. (% to 1 in.) of
free nerve trunk.
Where the facial trunk is very short, an extra % cm. can be gotten by re-
moving the outer bony wall of the canal at the stylomastoid foramen and divid-
FIG. 50. — ANATOMY AND RELATIONS OF THE FACIAL
NERVE. 1, Tip of the mastoid process covered by
sternomastoid muscle; 2, posterior belly of the
digastric muscle; 3, Styloid process; 4, facial nerve
showing bifurcation just before entering; 5, parotid
gland; 6, prominence of the transverse process of the
second cervical vertebra; 7, occipital artery.
OPERATIONS ON THE CRANIAL NKKVKS
FIG. 51. — CHISELS CONVENIENT FOR REMOVING LOWER PART OF CANAL IN WHICH FACIAL NERVE RUNS
so AS TO OBTAIN A SLIGHTLY LONGER PERIPHERAL FACIAL STUMP FOR ANASTOMOSIS.
ing the nerve just so much higher up. I have done this several times with ad-
vantage. (Figs. 51, 52, 53.)
At this point it is desirable to
prepare the nerve for the final su-
ture. About % cm. (Vs in.) from
its free end 2 fine silk sutures
are passed through the nerve sheafh
on opposite sides of the nerve, and
each is tied in a square knot. The
ends are left long (15 to 20 cm., 6
to 8 in.) (Fig. 54). The nerve end
is trimmed to a wedge shape with
a sharp scalpel. The sutures and
nerves are protected from damage
during the next step.
In cases in which the mastoid
has previously been operated upon,
the bony landmarks are often con-
fused and the scar tissue interferes
somewhat with the easy perform-
ance of the first stage of the opera-
tion. Under such circumstances,
the incision is made along the an-
terior border of the bony remnant
of the mastoid, and, keeping just
behind the parotid gland, the dis-
section is carried through the scar
FIG. 52.— MALLET. tissue till the deeper landmarks
(the digastric muscle and the styloid process) are identified, when the opera-
tion proceeds as before.
FIG. 53. — SLENDER
KNIFE FOR SPLIT-
TING THE HYPO-
GLOSSAL, AND SPE-
CIAL NEEDLE WITH
A FIXED HANDLE
FOR PASSING SU-
TURES THROUGH
H YPOGLO88AL
SHEATH.
590
PEEIPHEKAL AND CRANIAL NERVES
3. Exposure of Ilypoglossal Nerve. — The isolation of the hypoglossal
nerve is the most difficult and tedious step, and involves whatever danger there
is in the operation. The finger in the wound readily identifies the prominent,
smooth, transverse process of the atlas (Fig. 50). Not infrequently the occipi-
tal artery runs upward and outward
across the anterior surface of this promi-
nence. It should always be looked for,
and when present, either displaced out-
ward, or divided between 2 ligatures, as
an unexpected division of it gives rise to
annoying hemorrhage and blurs the an-
atomical field.
Lest they be inadvertently damaged in
the following steps of the operation, it
should also be remembered that over this
same transverse process, but more toward
the median line, the spinal accessory nerve
runs obliquely downward and outward
(sometimes in front of, sometimes behind
the internal jugular vein), while the in-
ternal jugular vein runs vertically in front
of it. These 2 structures are covered by
a layer of deep cervical fascia, through
which a vertical incision is made over
the outer border of the transverse pro-
cess and is continued upward and down-
ward till it is about 4 cm. (1% in.)
long. Through this slit in the fascia
the internal jugular vein is exposed
and is separated posteriorly by blunt
dissection. The spinal accessory nerve
should not be disturbed during the oper-
ation. The fascia and vein are then
retracted forward and inward by a
blunt retractor. Imbedded in the con-
nective tissue thus exposed in the
depth of the wound are seen 2 white
cords, the hypoglossal and pneumo-
gastric nerves, with the internal caro-
tid artery pulsating just to their inner side (Fig. 51).
Usually the more superficial of the 2 nerves is the one sought. It must be
positively identified, however. Mechanical or electrical stimulation will cause
its proper muscles to contract (styloglossus, hypoglossus, geniohyoid, geniohyo-
glossus, thyrohyoid, sternothyroid, sternohyoid) or one may follow its course
FIG. 54. — STAGES IN TECHNIC OF FACIO-
HYPOGLOSSAL ANASTOMOSIS. The small
special needle (Fig. 53) may be used
instead of the needle shown in the
drawings which would require a holder.
The working space is small and a needle
holder is clumsy.
OPERATIONS ON THE CRANIAL XKKVKS
591
anatomically downward to the point where it turns i'orwanl, around the occipital
artery and gives off the descendens hypoglossi nerve.
Once identified, it is dissected upward till the stump of the facial nerve can
be approximated to it without ten-
sion. This must be done with care
not to divide the communicating
branches from the pneumogastric,
upper ganglion of the sympathetic
and the 2 upper cervical nerves,
all of which are in the immediate
neighborhood.
4* Implantation. — While the
nerve is supported on a blunt hook,
a longitudinal slit % cm. (% in.)
long is made well into the nerve
trunk. A fine, curved needle is
threaded on to one of each pair of
long silk ends previously left tied
to the stump of the facial nerve.
One suture is passed through the
inner and the other through the
outer margin of the wound in the
hypoglossal nerve. When the su-
tures are tied, the wedge-shaped
end of the facial is snugly held in
the Cleft in the hypoglossal nerve FIG SS.-NERVE ANASTOMOSIS. 1 to 7 same as Fig. 50;
J r 8. hypoglossal nerve held up on blunt hook; 9, inter-
and IS Usually best turned slightly nal jugular vein; 10, vagus nerve.
upward by means of a probe, a
procedure suggested by Dr. Weir. These sutures must not be tied too tightly
lest they injure the fibers of the hypoglossal nerve, a few of which are almost
surely included in their grasp (Fig. 53, B and C).
If one elects to do a transverse section of the hypoglossal nerve, in part or
in whole, and then do end-to-end suture, the site for transverse section is chosen
at a point sufficiently low so that when the hypoglossal segment is dissected
free upward it will allow approximation between the ends of the hypoglossal and
facial without tension upon the sutures. A single suture is passed through the
center of the ends of both nerves and tied sufficiently tight to give good approxi-
mation. With nerves as small as these it is scarcely worth while to attempt
perineural suture where there will be no tension whatever.
To prevent the ingrowth of connective tissue elements, Cargile membrane is
wrapped about the nerve junction. The hypoglossal is dropped back to its
normal position, and there is usually no tension on the sutures.
5. Closure of the Wound. — If the digastric muscle has been partly divided,
it should be sutured with catgut. No other deep sutures are required, since the
592
PEEIPHERAL AND CKANIAL NEKVES
parts naturally fall back into position. The skin is closed with silk sutures.
No drainage is used. Sterile dressings are applied. Fixation of the head and
neck is, as a rule, not necessary.
6. Postoperative Course. — The temperature reaction is usually very mod-
erate. There is a disturbance of
phonation and deglutition. Care
must be exercised when the pa-
tient drinks to put the liquid in
on the sound side of the mouth,
and the patient must learn the
trick of swallowing with a more or
less complete unilateral paralysis
1 I fa- SMUSSSK^A of the m u s c 1 e s of deglutition.
There is a tendency at first for
liquids to enter the larynx and
trachea. The patients learn to
swallow readily within a few
days. The voice is husky, and the
patient feels somewhat as though
he had a laryngitis. These dis-
turbances wear away in the course
of a few weeks. The wound heals
by primary union, and the skin
sutures are removed on the third
to the fifth day, after which no
dressing is necessary.
FIG. 56. — NERVE ANASTOMOSIS. Same as Fig. 55 ex-
cept that it shows the facial sutured into a lateral
slit in the hypoglossal.
The after-treatment is the most important factor in obtaining the desired result.
Massage, electricity and, later, coordinated muscular movements must be persistently
and systematically resorted to for months. It is now well recognized that after any
nerve transplantation, the return of coordinated power involves a reeducation of the
nerve centers, both in the spinal cord and in the cerebral cortex.
The education of the spinal centers progresses fairly rapidly, while that of
the cortex requires long periods of time, often years, for its completion.
Experimental work on animals has shown steady progress in return of
function for periods of 5 to 10 years.
As soon as voluntary power over the muscles begins to return the patient
should be taught systematic exercises before a mirror for the development of
muscle power and coordination. The cortical volitional impulses thus sent
down far surpass in value either electricity or massage as a stimulus to nerve
and muscle regeneration.
Results. — The result of the operation will depend upon a number of con-
ditions.
1. The best results follow in those cases in which the cause of the paralysis
OPERATIONS 01ST THE CRANIAL XKKYI •> 593
has been a traumatic division of the nerve. Less hopeful of complete recovery
are those cases due to neuritis, especially when suppurative in character, i. e.
in suppurative mastoiditis.
2. The longer the time between the paralysis and the anastomosis, the
slower and less complete is apt to be the recovery. In cases of traumatic
paralysis, anastomosis should be immediate. In interstitial neuritis (Bell's
palsy) it is necessary to wait a few months for signs of spontaneous recovery,
which so often occurs. At the end of 3 to 6 months of treatment the neurologist
can decide as to the propriety of operating. In the suppurative forms opera-
tion should be done as soon as the danger of infection of the wound is passed,
as there is small likelihood of spontaneous recovery.
3. The condition of the paralyzed muscles — flaccidity, contracture, spasm,
changes in electrical reaction, and, most particularly, the degree of atrophy — is
important. The more atrophy, the less hope. Therefore massage and electricity
must be systematically used from the onset of the paralysis to keep the muscles
in good condition in case either spontaneous regeneration of the nerve occurs, or
operation becomes necessary.
4. The technic must be precise and delicate. The nerves must not be
pinched or unduly handled, the sutures must be fine and involve only the nerve
sheaths. The importance of these details is accentuated by the postoperative
appearance of temporary interference with the functions of the hypoglossal
nerve. The degree and duration of this interference are directly proportionate
to the traumatism inflicted on the nerve during operation. There must be the
least possible amount of scar tissue. Asepsis is essential, because suppuration,
aside from being dangerous in itself, would reduce the probability of nerve
union to the minimum, and there would later be pressure on the nerve due to
contraction of the cicatrix.
5. The importance of the after-treatment has been indicated above. The
first degree of recovery consists in symmetry of the face during quiescence, but
without volitional control over the muscles. The next degree consists in the
return of volitional control of the muscles, but with the paralyzed side of the
face uninfluenced by the emotions (laughing, crying, etc.). The third and com-
plete degree consists in the return of emotional control of the face.
This was acquired to a certain extent in Korte's case (43). The reasons
for preferring the hypoglossal to the spinal accessory nerve as a medium for
anastomosis are rendered more- intelligible by Figure 49, which represents
schematically the sharp contrast between the close relationship of the nuclei of
the facial (seventh) and hypoglossal (twelfth) nerves, and the wide interval be-
tween the facial and spinal accessory nuclei. Again the face and tongue centers
in the cortex are closely associated, indeed, overlap, while the face and shoulder
centers are widely separated, a fact emphasized by Ballance and Stewart.
The physiological association of the 2 nuclei in the medulla is strikingly
shown in the frequent affection of both in disease, as labioglossal palsy, and by
the fact that the transverse fibers of the tongue and the orbicularis oris can con-
39
594
PEEIPIIEEAL AKD OR AXIAL XEITVES
FIG. 57. — COMPLETE FACIAL PA-
RALYSIS FOLLOWING MASTOID
OPERATION.
tract only together. The close anatomical connection of all the cranial nerves
through the posterior longitudinal bundle should bs considered in the light of a
rudimentary plexiform arrangement analogous to
that of the cervical, brachial, and crural plexuses.
This close association of the cortical and medul-
lary centers of the facial and hypoglossal nerve
renders the process of reeducation (previously dis-
cussed) shorter and simpler than in the case of the
spinal accessory.
Results. — The immediate results are the dis-
turbances of phonation and deglutition previously
mentioned, plus a unilateral paralysis of the tongue
on the same side as the operation, which is more or
less complete, according to whether the hypoglossal
nerve has been partially
or completely divided.
This paralysis of the
tongue persists fora
number of weeks and gradually disappears if the
hypoglossal nerve has not been divided but has been
used for lateral implantation. Even after the
tongue, in these cases, has regained its full range of
mobility, there persists permanently a diminution
in size of that side of the tongue.
Remote Results. — Frequently 6 weeks after
operation the face at rest will have regained its
symmetry, and the pa-
tient will say that the
paralyzed side has lost
its boardlike feeling, but
there will be no evidence
of voluntary motion, nor will there be any change in
the electrical reaction of the muscles. At any time
from 3 months on, according to the individual case,
a beginning of voluntary motion may be expected.
This practically always appears first in the muscles
about the chin, then at the corner of the mouth and
cheek, then around the eye, and at last in the mus-
cles of the forehead. The patients soon get so that
they can control these groups of muscles independ-
ently of each other or can use them all at the same
time. It is only after several years and after pro-
longed training on the part of the patient that symmetry in the expression of
emotion, such as laughing and crying, may appear. Usually this spontaneous
FIG. 58. — SAME BOY, THREE
YEARS AFTER FACIOHYPO-
GLOSSAL ANASTOMOSIS, SHOW-
ING ABILITY TO LAUGH AL-
MOST SYMMETRICALLY.
\
FlG. 59. — CORRUGATOR SUPER-
CILII MUSCLES ACTING
EQUALLY WELL ON BOTH
SIDES.
OPERATIONS ON THE CRANIAL SERVES
595
emotional control does not develop, although the patient, if not caught unex-
pectedly, may simulate it so accurately as to escape detection, by volun-
tarily making the paralyzed side balance tin- norm;.] side. (Figs. 57 58
and 59.)
FACIOSPINAL-ACCESSORY ANASTOMOSIS. — The exposure and pn-pjiration of
the facial nerve are the same as
in the preceding operation.
The spinal accessory will be
found running downward and
outward across the front of the
second transverse process, com-
ing either from in front or be-
hind the internal jugular vein,
passing beneath the posterior
belly of the digastric, and en-
tering the inner surface of the
sternomastoid muscle about %
of its length downward from its
mastoid origin. When the
nerve has been exposed, the
portion running to the sterno-
mastoid muscle is divided
transversely and dissected up-
ward for end-to-end suture with
the facial. Using this portion
of the nerve avoids the disfigur-
ing deformity of the drop-
shoulder which often results
from division of that portion of
the spinal accessory which in-
nervates the trapezius muscle.
(Figs. 60 and 61.)
The wound is closed as in the preceding operation.
Where the faciospinal-accessory anastomosis has been done, attempts to use
the face, or attempts to use the muscles innervated by the spinal accessory
nerve, result in associated movements of both groups of muscles. This
leads to unexpected contortions and grimaces which are disagreeable. Uy
training for a year or more, some patients are able to rntiivly dissociate
these 2 groups of movements; others are not completely successful in this
dissociation.
POSTOPEEATIVE EXEKCISES. — No matter which nerve has been used, the
final results will not be attained until 2, and in some cases 3, years have elapsed
from the time of operation, and during this time the patient must follow per-
sistently a series of systematic progressive exercises for the development of
FIG. 60. — NEKVE ANASTOMOSIS. 1, Facial m-rvr; '-, spinal
accessory nerve; 3, posterior belly of the digastric mus-
cle; 4, internal jugular vein. (After Gushing.)
596
PERIPHERAL AND CRANIAL NERVES
control in the previously paralyzed muscles, as well as the systematic use of
massage and electricity.
When regeneration begins in the facial nerve after such an- anasto-
mosis, the after-treatment really amounts to the education of an entirely new
set of cortical cells in the control of the previously paralyzed muscles of one side
of the face.
Briefly the progressive exercises may be outlined as follows : When volun-
tary motion first appears in the chin
and at the angle of the mouth, it may
be greatly intensified in faciohypo-
glossal cases if the patient will vol-
untarily cause excessive action of the
muscles supplied by the hypoglossal
on the sound side and as much of the
hypoglossal as may remain undivided
on the paralyzed side. Pushing the
tongue firmly against the front teeth
seems to be a particularly good adju-
vant. This overactivity of the hypo-
glossals seems to cause a great over-
flow of nerve impulse into the anas-
tomosed facial nerve with consequent
increased activity in those muscles
supplied with regenerated fibers.
The rate of improvement is thus ac-
celerated.
In the early period all the mus-
cles which have regained any power
contract together, with a resulting
grimace. The training then aims at
the control of individual muscles or small related groups before the mir-
ror until the grimace is dissociated into its component parts, and the different
small groups of muscles can be used freely and independently of all the other
groups.
Then finally the attempt is made to regain emotional symmetry of the face.
Standing before the mirror, the patient voluntarily makes the paralyzed side of
the face symmetrical with the normal side during various expressions of emo-
tion. After long practice, a very few patients can balance the face automati-
cally, but the great majority of them, if caught unexpectedly, express the emo-
tion only with the normal side of the face until they catch up and balance volun-
tarily.
It will thus be seen that no face resulting from a facial anastomosis will
ever be as good as a perfectly normal face, but it is infinitely better than a
permanently paralyzed one.
Fig. 61. — NERVE ANASTOMOSIS. Numbers same as
in Fig. 60. (After Gushing.)
OPERATIONS ON THE CRANIAL NERVES 597
NEURALGIA OF THE SENSORY PORTION OF TIM; SI.VI.NTII CUAMAL XEBVE
It has been pretty definitely proven that the pars intermedia, or nerve of
Wrisberg, is the sensory root of the seventh cranial nerve, and runs out to the
geniculate ganglion, which is its trophic center. This ganglion and its sensory
root may be the seat of severe neuralgia analagous to that in the Gasserian
ganglion and its nerves (Hunt, 42). (See anatomical relations previously
described.)
The pain in neuralgia of this nerve is severe, sharp, and stabbing, and is
referred to the external auditory canal and the upper posterior adjoining por-
tion of the inner surface of the auricle. It may be associated with neuralgic
pains in the Gasserian ganglion region, or with neuralgic pains in the distribu-
tion of the 2 upper cervical nerves. When this pain cannot be controlled by
medical means, the only relief lies in surgical attack. Since some of the sen-
sory filaments may be included in the motor part of the seventh or in the upper
portion of the eighth cranial nerve, or in both, the only sure relief from pain
consists in the division of the motor seventh, the pars intermedia, and the
upper portion of the eighth. An operation for this purpose has been reported
only once. (Clark and Taylor, 33.)
Division of the Motor Seventh, Pars Intermedia, and the Eighth. — The only.
feasible site of attack is in the posterior cranial fossa, where all 3 nerves con-
verge to enter the internal auditory meatus. Section of the nerves just pos-
terior to this meatus will cause facial paralysis through division of the motor
seventh, and will cause temporary disturbance of hearing from division of the
upper part of the eighth, but the pain is completely relieved. Inasmuch as the
sensory fibers are divided between their trophic center (geniculate ganglion)
and the central nervous system, there will be a permanent degeneration of the
fibers and, therefore, permanent relief from pain. The motor fibers on the
other hand being divided distal to the central nervous system and therefore
distal to their trophic centers, will unite, regenerate, and again take up their
function. This return of control of the face muscles started in the 1 case
reported after about 6 months, and was nearly complete in a year. The patient
was seen only at long intervals, so that the exact time of return of power in the
face was not noted.
This is quite in line with the results obtained in section of the posterior roots
in the Gasserian neuralgia, where motor power will return in the muscles of
mastication if the roots are simply divided and not avulsed.
TECHNIC — Ether is used, and is administered through rubber tubes passed
through the nares to the laryngeal entrance, so as to keep the etherizer out of
the way of the operator.
The patient is placed prone on the table with cushions under the shoulders
and the head hanging forward so as to give a good exposure of the operative
field and still leave the chest free for respiratory movements. Some of the
head-rests specially devised for operations on the posterior fossa are very useful.
598
PERIPHERAL AND CRANIAL NERVES
(See chapter on Cerebellar Surgery.) An osteoplastic flap is turned down. Its
outer edge lies just within the posterior border of the mastoid, the upper border
about 2 cm. above the line of the lateral sinus, and the inner border just to the
same side of the median line ; the lower, or hinge border, well down toward the
foramen magnum. A dural flap is cut with its base turned toward the median
line, its upper edge just below the lateral sinus, its outer and inferior edges just
within the corresponding bone
edges. A flat blunt retractor is
passed along the outer side of the
cerebellum beneath the dura to
the base of the petrous bone, along
the posterior surface of which it
is gently inserted, retracting the
cerebellum, backward and toward
the median line, until the cerebro-
spinal fluid at the base of the
brain escapes in considerable
quantity with a rush. Immedi-
ately the cerebellum retracts eas-
ily, and the nerve field is exposed.
Care must be taken not to mis-
take the ninth, tenth, and eleventh
nerves passing through the fora-
men lacerum posterius, for they
lie directly beneath the internal
auditory meatus, into which the 3
nerves sought enter. In the one
case operated upon this hap-
pened at first, and only the jump-
ing of the shoulder when the
eleventh nerve was stimulated in-
dicated which nerve was under inspection. Retraction, which exposed the
space immediately above, readily brought into view the seventh and eighth
nerves and the pars intermedia (Fig. 62). The seventh, the pars intermedia,
and the upper fasciculus of the eighth nerve are cut. The retractor is slowly
withdrawn, allowing the cerebellum to return to its proper space. The dura
is closed by a continuous catgut suture. The bone flap is laid back in place.
The periosteum is sutured with 20-day chromic catgut. The muscles are
sutured with plain gut, and the skin with a continuous silk suture. No
drainage is used. Sterile dressings are applied.
DISCUSSION OF TECHNIC. — The flap is made large so that the cerebellum
may be retracted easily and without undue compression. It is carried well
above the lateral sinus so as to get bone thick enough to bevel on 3 sides and thus
enable one to lay the flap back without bone sutures and without danger of its
FIG. 62. — INTRACRANIAL NERVE SECTION. A, Dura
covering occipital lobe; B, Osteoplastic flap; C, ix,
x and xi cranial nerves entering foramen lacerum
posterius exposed by retracting the cerebellum toward
the median line; D, vii and viii cranial nerves and
pars intermedia entering the internal auditory mea-
tus; E, lateral sinus.
OPERATIONS ON THE CKAXIAL NERVES 599
pressing on the brain. The inferior portion of the occipital bone is quite thin.
The bone flap is cut by the Hartley-Kenyon motor saw.
After the dural flap is made and the cerebellum ivtrnrtod. -2 things are found
very useful: a suction apparatus working on the principle of the Sprengel
pump, which keeps the field free from cerebrospinal fluid and blood; and a
small cystoscopic bulb-light on a flexible stem, so that the light can be placed
right in the operative field.
When the internal auditory meatus is exposed, the nerves are seen entering
it with an artery of moderate size — the auditory. This artery is carefully re-
tracted, as it would be rather troublesome to tie in a wound of such depth. If
it must be divided, the Gushing silver clips will be most convenient.
The seventh, the pars intermedia, and the upper fasciculus of the eiirhth
cranial nerve are divided with a scalpel. The result is a complete facial palsy,
some temporary disturbance of hearing, and complete disappearance of the
characteristic pain.
This operation gives ample exposure for carrying out this division of the
seventh and its associated nerves just posterior to the internal auditory meatus.
If the bone flap is carried well out toward the mastoid, but little manipulation
of the cerebellum is necessary, so that the removal of bone from behind both
lobes of the cerebellum is not required. Hemorrhage is free while making the
incision through the eoft tissues down to the bone, but may be readily con-
trolled by the usual means. With displacement of the cerebellar lobe, there
usually escapes a considerable quantity of cerebrospinal fluid from the great
posterior cistern, and then the cerebellum may be displaced with considerable
freedom and the operative field opened up very satisfactorily.
EESULTS. — The wound heals by primary union and after a time the bone
flap becomes solid with the rest of the skull, so that there is no ultimate defect.
There is complete and permanent disappearance of the pain. There may be
slight disturbance of the auditory sense on the side of the operation, but this
disappears within a short time. The paralysis of the face gradually disappears
in the course of the first year after the operation.
This type of case is by no means infrequent, and when it comes to be recog-
nized, many cases of intractable otalgia will be relieved by surgical interven-
tion.
Many operators do not use the osteoplastic flap, feeling that the thick layers
of muscle and fascia give sufficient protection to the cerebellum, but the ease
with which the operation just described was done and the perfect skull
which resulted would lead me to attempt the same method a second time.
Instead of doing the osteoplastic operation, they reflect the soft parts from
the occipital bone on the side to be operated upon and remove all of the
bone within the limits of the lateral and occipital sinuses, the posterior
border of the mastoid externally, and the edge of the foramen magnum
inferiorly. From this point on, the operation is the same as that previously
described.
GOO PERIPHERAL AND CRANIAL NERVES
EIGHTH CRANIAL NEEVE
The eighth cranial nerve is attacked surgically in cases of persistent tinnitus
aurium, incurable by other means, and also occasionally in cases of very per-
sistent vertigo, due to derangement of the internal ear. Not many cases have
been reported, but there has been an occasional complete success. Erazier re-
ports complete success in a case of tinnitus aurium.
The operation is the same as that described for division of the facial nerves,
except that only the auditory nerve, provided it can be isolated, need be divided
after the group of nerves entering the internal auditory meatus has been ex-
posed. With the division of the entire auditory nerve, there will, of course, re-
sult absolute loss of function of the nerve on that side forever.
Bryant says that those cases of persistent tinnitus aurium are most apt to
get relief from section of the auditory nerve in which there is complete deaf-
ness to air-conducted sound but good appreciation of bone-conducted sound.
In aggravated vertigo of labyrinthine origin this operation has afforded
marked relief in many cases, but has resulted in real cure in very few.
TENTH CRANIAL NERVE
The tenth nerve is occasionally injured in the course of operations in the
neck. Under these circumstances, immediate end-to-end suture of the nerve
should be done. If the nerve is injured on only one side, there is seldom any
serious resulting disturbance.
The tenth nerve is sometimes resected on one side of the neck in the course
of block dissection for malignant growths without serious consequences result-
ing from this particular feature of the operation.
Operations on the tenth nerve, as such, are few and have not been sufficiently
standardized to warrant detailed description. As a matter of interest, it may be
stated that in one case (Byrne and Taylor, not yet published) the upper
ganglion of the right pneumogastric nerve was removed in toto in a case of
tabetic crises, in which pain was the minor symptom, but nausea and vomiting
were constant. It is in this type of case that Professor Eoerster of Breslau
says the lesion is in the pneumogastric. The patient died on the third day,
after delirium cordis, dyspnea, edema of the lungs, and coma had rapidly fol-
lowed each other. During this time, however, he did not vomit at all, except
once or twice during his recovery from the ether.
Another operation has been done several times in Germany for tabetic
crises of the above type. It consists in resecting several inches of both the right
and left pneumogastric nerves as they pass onto the stomach after passing
through the diaphragm with the esophagus. The persistent vomiting is said to
have ceased.
PEEIPHEEAL AND CRANIAL XKKYKS
G01
ELEVENTH CRANIAL NERVE
Anatomical Considerations. — The eleventh nerve passes through the foramen
lacerum posterius in company with the ninth ami tenth nerves, passes down-
ward and outward either in front of or behind the internal jugular vein, crosses
the second transverse process and enters the deeper surface of the sternomastoid
muscle at about the junction of its upper and middle thirds, gives motor
branches to this muscle, and then the remainder passes through the muscle and
leaves the .posterior border at or just above its middle. It then runs obliquely
downward and outward across the posterior cervical triangle to enter the
trapezius muscle.
Indications for Operation. — This nerve is not infrequently divided during
the excision of glands of the neck, either in the anterior or posterior triangle.
If divided in the anterior triangle, both the sternomastoid and trapezius muscles
are paralyzed; if in the pos-
terior triangle, the trapezius
muscle alone is paralyzed and
there results a marked drop-
shoulder with undue promi-
nence of the upper angle of
the scapula, and marked
atrophy of the trapezius.
While these combined factors
cause marked deformity, there
is surprisingly little loss in
range of motion of the extrem-
ity. In some cases where the
trapezius gets much of its
motor supply from the upper
cervical nerves (II, III and
IV), division of the spinal ac-
cessory causes almost no symp-
toms. If the accidental di-
vision of the nerve is discov-
ered at the time of operation,
immediate end-to-end suture
should be done, and the ex-
tremity should be sustained by
a sling or brace to prevent un-
due traction on the paralyzed
muscles until regeneration of the nerve and return of power have occurred.
If section of the nerve is discovered only by the appearance of the paralysis
during convalescence, the wound should be promptly opened and the divided
ends sought and sutured.
FIG. 63. — EXPOSURE OF SPINAL ACCESSORY BY A TRANS-
VERSE INCISION FOLLOWING NATURAL WRINKLES OF
SKIN OF NECK. 1, Spinal accessory nerve; 2, in-
ternal jugular vein; 3, posterior belly of the digastric
muscle.
602 UNILATEKAL LAMIKECTOMY
Even after years, it is worth while to seek the ends, freshen and suture them.
The danger is practically nothing and the reward, in successful cases, is great.
In these old cases, if in the posterior triangle, the downward displacement of
the shoulder drags the distal stump far downward, so that the search must be
made in the line which the nerve, thus pulled upon, would naturally follow.
The shoulder, after the nerve is sutured, must be held well up toward the neck
to relieve tension, both on the nerve and the paralyzed muscle, until function
has returned.
Outside of its use for anastomosis with the facial nerve, which has previ-
ously been described, the only operation on the eleventh nerve consists in resec-
tion of it for wry-neck in conjunction with section of the upper cervical nerves.
Technic. — The best incision is parallel to the transverse creases in the cervi-
cal skin (Fig. 63). The incision should be about 3 to 5 cm. long and should be
placed at the level of the junction of the upper and middle thirds of the sterno-
mastoid muscle. The incision runs through the skin and subcutaneous tissues
down through the layer of deep cervical fascia which surrounds the sternomas-
toid muscle. The edges of the wound are retracted and the anterior edge of the
sternomastoid muscle is retracted outward and somewhat everted. After com-
plete hemostasis, one will usually see the spinal accessory nerve coming down-
ward and outward over the second transverse process and entering the deeper
surface of the muscle. If the nerve is not thus easily located, one must seek
upward and downward along the deeper surface of the muscle for a short dis-
tance until it is located. It may be tested by the electric current to positively
identify it. Having been identified, as much of the nerve trunk as can be con-
veniently resected is removed. The space in the sternomastoid muscle is sutured
over the buried distal nerve end and the proximal stump may also be buried in
the cervical fascia in order to increase the security against regeneration and
union of the nerve ends. The wound is closed without drainage (catgut for the
fascia, silk for the skin) and the dressings are applied.
TWELFTH CRANIAL NERVE
The twelfth nerve is not important as a surgical entity. It is used as de-
scribed in facial anastomosis as a source of new nerve supply. It is often in-
jured in cut-throat accidents and sometimes in surgical operations in its neigh-
borhood. When so injured it should be sutured end to end.
UNILATERAL LAMINECTOMY
Indications. — The indications for unilateral laminectomy are as follows :
For any exploration of the spinal canal.
For section of the posterior roots on either 1 or both sides.
For spinal decompression.
UNILATERAL LAM I X K< TOM V
603
When a tumor is exposed by this method, if m-n-ssjirv !'••!• its safe removal,
the laminae of the opposite side may be readily removed and the operation con-
verted into a bilateral laminectomy.
The method is scarcely applicable to work on fractures of the spine where
the injury is bilateral.
Anatomical Features. — The anatomical features to be appreciated are the
spinous processes, surmounted by the supraspiimus li^nim-iit, nnd the row of
FIG. 64. — RETRACTOR ESPECIALLY DESIGNED FOR LAMINECTOMY. It has the advantage of holding the
skin and superficial muscles well out of the way and so allowing plenty of light to get to the depth of
the wound.
FIG. 65. — PERIOSTEAL ELEVATOR.
FIG. 66. PERIOSTEAL ELEVATOR FOR LIFTING MUSCLES FROM SPINOUS PROCESSES AND LAMINJB.
FIG. 67. — HUDSON SET.
UNILATERAL LAMINECTOMY
605
articular processes on each side with the lamina? between. In the cervical
region the groove formed by these bony elements is broad and somewhat shal-
low ; in the dorsal region narrow and fairly deep ; while in the lumbar region it
is of medium width and considerable depth.
In the dorsal region the Iamina3 overlap each other so that there is no inter
laminar space through which to
enter the canal, while in both
the cervical and lumbar regions
there is a definite interval
which may be increased by
flexion of the spine. The lam-
inae are connected by strong
ligamentous structures.
Between the inner wall of
the bony canal and the dura is
a layer of fat with a connective tissue framework carrying a freely anastomos-
ing set of vessels. This layer is from 2 to 4 mm. thick.
Within the dura, which is somewhat less than 1 mm. thick, lies the cord sus-
pended in a liberal amount of spinal fluid and anchored by the ligamentum
denticulaturn which runs down each side of the cord between the anterior and
FIG. 72. — SCISSORS DESIGNED TO ALLOW RAPID CUTTING
OF DURA WITHOUT DAMAGE TO UNDERLYING STRUC-
TURES.
FIG. 73. — LANE NEEDLE-HOLDER AND NEEDLES. Very useful in closing the dura.
posterior roots as they pass downward and outward to perforate the dura and
pass into the intervertebral foramina where the ganglion lies attached to the
posterior root.
The cord ceases at the level of the second lumbar vertebra, and below this
level are found only the conus and the nerves forming the cauda equina.
FIG. 74. — PEASLEE NEEDLE.
Instruments. — The instruments consist of a special set of retractors (Figs.
64 to 74), a periosteal elevator, a set of Hudson burrs, special rongeurs, special
dura scissors, Lane's needle holder, Peaslee needle, in addition to the ordinary
supply of knives, scissors, hemostats, thumb forceps, needles, ligatures, sutures,
606
UNILATEKAL LAMINECTOMY
FIG. 75. — A CERVICAL, VERTEBRA. 1 shows
how beveling under the spinous proc-
"ess gives good exposure of the oppo-
site side of the cord. 2 indicates how
the removal of the lamina out to that
line gives a good view of the dorsum
and side of the cord, and, with very
little'elevation of the cord, a good view
of at least half of the anterior surface
of the cord.
etc., which are used in all operations. Horsley's bone wax is occasionally useful
when there is persistent bleeding from the divided bone.
Technic. — After it has been decided which laminae are to be removed, an
incision is made parallel to the spinous
processes but just to the side from which
the laminse are to be taken, so as to preserve
the supraspinous ligament. First the skin,
then the deep aponeurosis, and finally the
muscles along the sides of the spinous
processes are divided, hugging close to the
bone.
With a broad periosteal elevator, the
muscles are raised from the laminse well
out to the articular processes. Hemorrhage,
which is often profuse at this stage, is con-
trolled by packing the wound with sponge
pads wrung out of hot saline solution,
which are left in place for from 3 to 5
minutes. It is very rarely necessary to use
a hemostatic forceps.
With the special retractors, the wound is held well open, exposing the de-
nuded laminae in the depth of the wound. These retractors with the obliquely
placed prongs have the advantage of holding the skin and superficial layers of
muscle well outward and making the wound a broad wedge-shaped one instead
of the narrow deep one which is given
by the usual right-angled retractors.
In the cervical and lumbar re-
gions, where the laminae are not closely
apposed, the ligamentous structures
attached to the lower edge of one of
the laminae, usually near the middle
of the wound for convenience, are di-
vided with the knife, and then the
rongeur or punch (Fig. 66) is slipped
under the lamina and is made to
punch a groove upward through the
various laminae to the upper end of
the wound. The punch is then re-
versed, and the lower laminae punched
out in like manner. The bone on each
side of the groove is then removed as far as necessary by using the various
rongeurs. Considerable increase in space and illumination is obtained by
beveling under the base of the spinous process (Figs. 75 to 77), and still more
by encroaching upon the articular processes when necessary (Fig. 77). In
FIG. 76. — A DORSAL VERTEBRA.
UNILATERAL LA M I \ K( TOM Y
607
the dorsal region, where the lamina- an- <-l<>s<-ly imbricated, the start for the
punch is obtained by boring through one or more of tin- lamina* with the Hud-
son burrs which make a hole large enough to give easy entrance to the punch.
When the lamina have been satisfactorily removed, oozing from the bone
surfaces is controlled by
bone wax, and the other
hemorrhage by hot saline
sponge pads. The layer of
fat between bone and dura
is divided longitudinally,
exposing the dura. (Fig. 78.)
With a sharp-pointed
knife the dura in about the
middle of the wound is
punctured and the spinal
fluid allowed to escape
somewhat slowly. Then
the snout of the special
dura scissors (Fig. 72) is
passed into the aperture,
and the dura is divided the
length of the wound. It
will readily be seen that
these scissors properly used
give perfect protection to
the subdural structures.
(Fig. 72.) _
No special attention is paid during the course of the operation to the escape
of spinal fluid.
After the object of the operation has been accomplished and hemorrhage
within the dural canal stopped, the dura is closed tight by a continuous, fine
catgut suture. This is best accomplished by means of the Lane holder and
needles (Fig. 73).
By means of the Peaslee needle (Fig. 74), which is passed through the
muscles previously separated from the spinous processes and lamina1, and then
between the spinous processes and up through the muscles of the opposite side,
chromic catgut sutures are passed at the rate of 1 for each vertebra. When
these are tied (after all are in situ), the muscles are held snugly against the
spinous processes where they belong, and oozing from the muscle is controlled.
The deep aponeurosis is closed by a combination of interrupted and continuous
chromic catgut sutures. The skin is closed by silk sutures.
FIG. 77. — A LUMBAR VERTEBRA. If the removal of bone be-
tween 1 and 2 does not give sufficient space, the removal may
be carried out to line 3 including the articular process.
This gives ample exposure and has no disagreeable sequels.
No drainage is ever used. The dressing consists of sterile gauze pads fixed in
place by adhesive plaster straps, over which cotton is held in place by a bandage or
608
UNILATERAL LAMINECTOMY
binder. No attempt is made at immobilizing the spine by plaster or other means of
fixation.
Patients are kept in bed for 14 days and then allowed to get about gradually.
If at any time during the course of the operation it seems desirable to convert the
procedure into a bilateral laminectomy, this is readily accomplished. The spinous
FIG. 78. — UNILATERAL LAMINECTOMY FROM
THE D xii TO S v. The nerves leave
the spinal canal just about on a level
with the spinous process of the corre-
sponding vertebra.
FIG. 79. — SAME DISSECTION WITH DURA SPLIT
AND HELD OPEN BY 6 SILK SUTURE RE-
TRACTORS SHOWING CAUDA EQUINA.
processes may be clipped off at their bases by bone forceps or divided by saw, and then
the spinous processes and the muscles are pushed over so as to expose the laminaB of
the opposite side, which are removed by the rongeur as far as necessary.
Advantages and Limitations — With the special tools devised for the purpose,
BIBLIOGRAPHY 600
this operation is but slightly more difficult and somewhat slower than the ordinary
laminectomy. There is rather less hemorrhage and decidedly less damage to the bony
protection of the cord. After healing has occurred, the anatomical conformation, the
flexibility and the function of the spinal column are perfect.
The author has used the method in 45 cases, in all parts of the spine from the
first cervical to the second sacral, and it gives a very satisfactory exposure. Its limi-
tations are chiefly found in cases of tumor so large as not to be safely extractable
through one side, and in cases of fracture of the spine involving laminae of both sides.
For exploratory purposes, one can see the entire dorsum of the cord, the roots of
both sides, and, with very slight manipulation of the cord, can expose the anterior
half of the cord on the side of the operation.
BIBLIOGRAPHY
PERIPHEEAL NERVES
1. ALLISON and SCHWAB. Am. Jour. Orthop. Surg., August, 1910.
2. BERGER. Die Chirurgie der peripherischen Xerven, Deutsch. med.
Wchnschr., 1911, xxxvii, 2292.
3. CLARK and TAYLOR. Xew Treatment of Spastic Paralysis by Resection
of the Posterior Spinal Nerve Roots, Arch. Pediat., 1909, xxvi, 927.
4. , - - and PROUT. A Study of Brachial Birth Palsy, Am. Jour.
Med. Sc., 1905, cxxx, 670, 707; Jour. Xerv. and Ment. Dis., 1905,
xxxvii, 652.
5. FOERSTER, OTFRID. Indications and Results of Excision of Posterior
Spinal Roots in Man, Med. Rec., X. Y., 1912, xxxii, 916.
6. . Die operative Behandlung gastrischer Krisen durch Resektion
hinterer Dorsalwiirzeln, Therap. d. Gegenw., Berlin, 1911, lii, 337.
7. . Ueber die Beeinflussung spastischer Lahmungen durch die Resek-
tion hinterer. Riickenmarkswiirzeln, Deutsch. Ztschr. f. Xervenh.,
Leipzic, 1911, xli, 146-169.
8. . Ueber die operative Behandlung spastischer Lahmungen mittels
Resektion hinterer Ruckenmarkswurzeln, Therap. d. Gegenw., Berlin,
1911, lii, 13-18; Berl. klin. Wchnschr., 1910, xlvii, 1441-4; Mitt. a. d.
Grenzgeb. d. Med. u. Chir., Jena, 1909, xx, 493-558; Verhandl. d.
deutsch. Gesellsch. f. orthop. Chir., XI, Kong. Stuttgart, 1912, 269-81.
9. . Resection of the Posterior Spinal Roots in the Treatment of Gas-
tric Crises and Spastic Paralyses, Proc. Roy. Med. Soc., London, 1911,
iv, Surg. Section, 226-254.
10. FOERSTER, O., and KUTTNER. Ueber operative Behandlung gastrischer
Krisen durch Resektion der 7-10 hinterer Dorsalwiirzeln, Beitr. z. klin.
Chir., 1909, Ixiii, 245 ; Allg. med. Centr.-Ztg., 1909, Ixxviii, 189.
FRAZIER, C. H. Intradural Root Anastomosis for the Relief of Paralysis
of the Bladder, and the Application of the Same Method in Other
Paralytic Affections, Jour. Am. Med. Assn., 1912, lix, 2202.
40
610 UNILATERAL LAMINECTOMY
12. FRAZIER, C. H. Supraclavicular Subcutaneous Lesions of the Brachial
Plexus, in a Case of Avulsion of the Anterior and Posterior Spinal
Roots, Jour. Am. Med. Assn., 1911, Ivii, 1957.
13. KILVINGTON, B. Lecture on Surgery of the Nerves, Intercolonial Med.
Jour. Australasia, 1909, xiv, 521-539.
14. KOLLIKER. StoffeFs Operation, Zentralbl. f. Chir., 1913, xl, 1372.
15. LUXEMBOURG. The Operative Treatment of Traumatic Paralysis of
Peripheral Nerves, Deutsch. Ztschr. f. Chir., cxxiii, Nos. 5 and 6.
16. SCHILLER, K. Treatment of Spastic Paralysis by Peripheral Nerve Re-
section, StoffeFs Operation, Budapest Orv. Rysog., 1912, x, 432.
17. SHERREN, J. Injuries of Nerves and Their Treatment, London, 1908, J.
Nisbet and Co.
18. SPITZY, D. H. Fortschritte auf dem. Gebiete der Chirurgie der
peripheren Nerven, Allg. wien. med. Ztg., 1911, Ivi, 83-95.
19. STOFFEL, A. Die Technik meiner Operation zur Beseitigung spas-
tischer Lahmungen, Verhandl. d. deutsch. Gesellsch. f. orthop. Chir.,
xi, 1912, 1-22, 38-54.
20. TAYLOR, A. S. Causes Underlying Prolonged Loss of Function in Cer-
tain Injuries about the Shoulder Joint, Med. News, 1905, Ixxxvi, 1013.
21. . Cases- Illustrating Results of Periph. Nerve Anastomosis, Jour.
Nerv. and Ment. Dis., 1906, xxxiii, 588.
22. . Results from the Surgical Treatment of Brachial Birth Palsy,
with a Note on the Pathology by T. P. Prout, Jour. Am. Med. Assn.,
1907, xlviii, 96-104.
23. . Nerve Bridging: One Successful Case, Jour. Am. Med. Assn.,
1908, 1, 1029-32.
24. . Volkmann's Ischemic Paralysis, Ann. Surg., 1908, xlviii, 394-
408.
25. — . Contribution to the Surgery of the Peripheral Motor Nerves, Am.
Jour. Orthop. Surg., 1908-9, vi, 210.
26. - and CASAMAJOR. Traumatic Erb's Paralysis in the Adult, Ann.
Surg., 1913, Iviii, 577, 683.
CRANIAL NERVES
27. ABBE, ROBERT. Surgery of the 5th Cranial Nerve for Tic Douloureux,
Jour. Am. Med. Assn., May 5, 1900.
28. ALDERTON, H. A. Some Facts Pertaining to the Surgical Anatomy of
the Facial Nerve, Trans. Am. Otol. Soc., 1907, x, 556.
29. BROCKAERT and DE BEULE. La resection physiologique du ganglion de
Gasser: technique, J. de Chir. et Anat. Soc. Beige de Chir., Brux.,
1909, ix, 208-213.
30. CAMPBELL, W. F. The Surgical Anatomy of. the Gasserian Ganglion
with Special Reference to the Deep Injection of the Nerve Roots for
BIBLIOGRAPHY 611
Trifacial Neuralgia, N. Y. State Jour, of Med., N. Y., 1910,
x, 15-18.
31. GATES, B. B. A New Method of Dealing with the Peripheral Branches
of the 5th Cranial Nerve in Tic Douloureux, Boston Med. and 6
Jour., 1913, clxviii, 384.
32. CLARK, L. P., and TAYLOR, A. S. Tic Douloureux of the Sensory Fila-
ments of the Geniculate Ganglion : Operation ; Recovery, J. Nerv. and
Ment. Dis., 1910, xxxix, 242.
33. — , . Jour. Am. Med. Assn., Dec. 25, 1909.
34. GUSHING, H. A Method of Total Extirpation of the Gasserian Ganglion
for Trigeminal Neuralgia.
35. . The Sensory Distribution of the 5th Cranial Nerve, Johns Hop-
kins Hosp. Bull., Vol. xv, Nos. 160-161, July, Aug., 1904.
36. . Remarks on Some Further Modifications in the Gasserian Ganglion
Operation for Trigeminal Neuralgia (Sensory Root Evulsion), Tr.
South. Surg. and Gynec. Assn., 1906.
37. . Remarks on the Surgical Treatment of Facial Paralysis and of
Trigeminal Neuralgia, Tr. Am. Surg. Assn., 1907.
38. DENCH, E. B. Division of the Auditory Nerve for Persistent Tinnitus.
Operation. Recovery, Interstate Med. Jour., St. Louis, 1912, xix.
39. EDEN, R. Ueber die chirurg. Behandlung der periph. Facialislahmung,
Beitr. z. klin. Chir., 1911, Ixxiii.
40. FURBRINGER, F. Zur Kasuistik der Extirpation des Ganglion Gasseri
wegen Trugeminus Neuralgie, Erlangen, Nurnberg, 1910, B. Hitz
50, p. 80.
41. HUNT, J. R. The Sensory System of the Facial Nerve and Its Symp-
tomatology, Jour. Ophth. and Oto-LaryngoL, iv, 89-93.
42. — . Jour. Nerv. and Ment. Dis., February, 1907.
43. KORTE. One Case of Faciohypoglossal Anastomosis, Deutsch. med.
Wchnschr., April 23, 1903.
44. KRAUSE, F. Die chirurg. Behandl. der Trigeminus Neuralgie, Neurol.
CentralbL, 1910, xxiv, 1161-68.
45. KUMMER, E. Du traitement chirurgical des nevralgies du trijumeau,
Rev. med. de la Suisse romande, 1910, xxx, 539-46.
46. MILLS, C. K. The Sensory Functions Attributed to the Seventh Nerve,
Jour. Nerv. and Ment. Dis., 1910, xxxvii, 273.
47. OTTO, K. Yergleichende Untersuchungen iiber die Erfolge der chirur-
gischen Behandlungsmethoden bei Trigeminusneuralgie (mit besondere
Beriicksichtigung der Alkoholinjection nach Offerhaus.), Mitt. a. d.
Grenzegeb. d. Med. u. Chir., 1912, xxv, 78-99.
48. PAYR, E. Durchtrenmmg des Trigeminusstammes bei Trigeminusneural-
gie, Yereinsheil. d. deutsch. mediz. Wochn., 1936, Nos. 21-23.
49. PATRICK, H. F. Seventy-five Cases of Trifacial Neuralgia Treated by
Deep Injections of Alcohol, Jour. Am. Med. Assn., liii, 1987-92.
612 UNILATERAL LAMINECTOMY
50. PATRICK, H. F. Three Cases of Facial Spasm Treated by Injections of
Alcohol, Jour. Nerv. and Ment. Dis., xxxvi, No. i, Jan., 1909.
51. PFUNGST, A. O. The Course of the Facial Nerve through the Petrous
Bone and the Significance of Its Injury.
52. SCHACHNER, A. Peripheral Operation for Trigeminal Neuralgia, Ken-
tucky Med. Jour., 1910, viii.
53. TAPTAS, T. Les Injections d'alcool dans le ganglion de Gasser a travers
le trou ovale, Presse med., Paris, 1911, xix, 798.
54. TAYLOR, A. S. Special Instruments for Faciohypoglossal Anastomosis,
Med. Bee., Mar. 4, '05.
55. . Trifacial Neuralgia ; Section of Postr. Root of the 5th Nerve
Proximal to the Ganglion Cure, Ann. Surg., 1912, Iv, 905-7.
56. TAYLOR, A. S., and CLARK, L. P. The Surgical Treatment of Facial
Paralysis: With Technique of Faciohypoglossal Anastomosis, Med.
Rec., 1904, Ixv, 34-5.
57. , - — . Results of Faciohypoglossal Nerve Anastomosis for Facial
Palsy, Jour. Am. Med. Assn., 1906, xlvi, 856.
58. , - — . True Tic Douloureux of the Sensory Filaments of the Fa-
cial Nerve, Cured by Physiological Extirpation of the Geniculate
Ganglion, Jour. Am. Med. Assn., 1909, liii, 2144.
59. TRENDELENBURG, F., and ENGENBRODT. Chirurgische Krankheiten der
Gesichtsnerven.
60. WEIDLER, W. B. Keratitis Neuro-paralytica after Removal of the Gas-
serian Ganglion, N. Y. State Jour. Med., 1912, xii, 558-63.
CHAPTER XIV
OPERATIONS UPON THE MUSCLES, TENDONS, BURS^J AND FASCIA
ARTHUR SEYMOUR VOSBURQII
THE MUSCLES
INJURIES OF THE MUSCLES
Conditions calling for operative interference in diseases of the muscles
are rare. The surgeon is more often called upon to treat wounds, subcutaneous
injuries, hernia and ruptures of muscles.
Subcutaneous Injuries of Muscles. — Subcutaneous injuries of muscles result
from external violence or from muscular action. The lesions vary from
the tearing of a few fibers to the rupture of the entire muscle belly. The
predisposing causes are degeneration of the muscle from any cause, such as
typhoid, disuse, and chronic alcoholism. The lesser degrees of muscle tears are
quite common, and aside from the pain and inconvenience experienced during
the period of repair, cause no permanent disability. The sufferer from such
an injury should have the part firmly strapped, and should be encouraged to
use the injured member as much as possible. Prolonged rest of the part is
the worst treatment that can be employed, as it greatly lengthens the period
of convalescence. The amount of exercise to be employed each day should
be measured by the surgeon. If not followed by pain, persisting for some time
after discontinuance of the exercise, the limb has not been too much used.
Repair takes place through organization of the blood clot filling the gap in
the torn muscle.
Hernia of Muscles. — This is a rare lesion of muscles. It occurs most
often in the recti and the adductors, their fascial sheaths having been torn by
direct violence, by muscular action, or from some slight exertion in one suf-
fering from disease, such as typhoid. The underlying muscle often shares in
the injury. Recognition of the injury from the history and the presence of the
characteristic physical signs is easy. Repair of the tear in the muscle should
be made, as well as suturing the rent in the sheath.
Rupture of Muscles in the Arm and Leg as the Kesult of Muscular Violence.
— Muscular violence is the most common cause of rupture of muscles in the ex-
tremities. The origin or insertion of a muscle may be torn loose, or the tear
613
614 THE MUSCLES, TENDONS, BURS/E AND FASCIAE
may extend across the belly of the muscle. Restoration of function is not possi-
ble without resort to operative measures.
The muscles most frequently ruptured in the arm are the biceps, its long or short
head or its attachment to the tubercle of the radius ; the coracobrachialis ; and the long
FIG. 1. — RELAXING SUTURES: DISTANT
AND MATTRESS.
FIG. 2. — DISTANT SUTURE: IM-
MEDIATE SUTURE.
head of the triceps. If these injuries are not to be followed by marked weakness and
loss of function, operative interference is imperative.
The procedure to be followed in a given case will be determined by the
nature and location of the injury. Rupture of a muscle belly calls for suture.
This is best done with chromic gut,
using 2 varieties of suture : distant, for
relaxation; and immediate, for accu-
rate adjustment of the divided ends.
The distant sutures, utilizing the fas-
cial s'heath, embrace large masses of
muscle, thus offering better holding
qualities; and are therefore used,
wherever possible, for bringing the
ends of the muscle together and hold-
ing the immediate line of suture re-
laxed. The mattress suture is the best
for this purpose. The immediate su-
ture, continuous or interrupted, se-
cures close alignment of the muscle.
Where the tendon of a muscle is torn
from its origin or insertion, it is best
secured by suturing it under a flap of
periosteum, or securing it by 1 or 2
chromic gut sutures passed through
holes drilled in the bone.
FIG. 3. — RUPTURE OF INNER BELLY OF RIGHT
GASTROCNEMIUS. ^n the leg, the muscle most frequently
torn is said to be the plantaris, resulting
in what is called "tennis players' leg." As the pain from this alleged injury is often
situated in the lower part of the leg, where this muscle is tendinous, there is grave
THE MUSCLKS
615
doubt that the plantaris is always at fault. The gastrocnemius and soleus, also of the
superficial group, may have their fibers torn and be responsible for the symptoms com-
monly laid at the door of the plantaris. There is no proof that the tibialis posticus and
the long flexors of the toes and of the big toe may not at times be torn and give rise
to the symptom-complex.
Proof is not always at hand, but the accompanying figure, made from
a picture of an actual condition, shows that the gastrocnemius may be the
torn muscle, producing the train of symptoms usually ascribed to the plantaris.
Treatment has been indicated above.
Subcutaneous Rupture of Muscles. — Subcutaneous rupture of a muscle ac-
companying fractures and dislocations is but a minor part of the lesion and
receives attention only when an open operation is undertaken for repair of
the principal injury. Open wounds of muscles, resulting from trauma or in-
volving laceration of the soft parts, or occurring in the course of an operation,
are treated along the lines laid down for suture of muscle.
DISEASES OF MUSCLES
Degeneration and Atrophy of Muscles — Degeneration of muscles occurs
from prolonged intoxication, in sepsis, tuberculosis and typhoid, and chronic
poisoning from lead and alcohol. Re-
generation can take place on recovery
from disease, as is seen in typhoid cases,
exhibiting tbat form of waxy degenera-
tion known as Zenker's.
Atrophy of muscles may occur from
disuse, overwork, malnutrition, and cut-
ting off of their nerve supply, or may be
of the physiological or senile type.
The treatment of the forms sus-
ceptible to improvement consists in the
removal of the cause and the use of
massage, electricity, hydrotherapy and
exercise. In cases where the muscle
atrophies from being deprived of its
nerve supply — the nerve being torn as
the result of some injury, involved in a
callus during the repair of a broken
bone, compressed in a mass of scar tis-
sue, or accidentally divided in the
course of an operation — return to nor-
mal, and relief from paralysis is possible, even after long periods of time, by
suture of the nerve ends or by freeing the nerve from the structures that com-
press it.
FIG. 4.— PARALYSIS OF TRAPEZIUS. Double,
following nerve section in removal of cervical
lymph nodes; diagrammatic.
616 THE MUSCLES, TENDONS, BUKS.E AND FASCIA
Volkmann's Ischemic Contracture. — Volkmann and Leser describe a condi-
tion in the muscles following injury, occurring most often in the forearm, but
sometimes in the leg, and resulting in the speedy degeneration of the muscles
involved.
The injury most frequently causing this condition is a fracture of the humerus
near the elbow, or a fracture of the bones of the forearm, in some way interfering with
the arterial blood supply. In this manner, together with the application of too tight
splints (though in some of the cases these have not been used), a condition of ischemia
is brought about, inducing a speedy degeneration of the muscles deprived of their
arterial blood.
Efforts to produce this condition experimentally have not been successful,
yet when we consider that the muscles are the most highly specialized tissues
in the extremities, it seems a rea-
sonable inference that they should fol-
low the rule of all tissues cut off
from their blood supply ; i. e. the more
highly specialized the tissue, the more
quickly, when deprived of blood, does
it show degenerative changes. That
the condition is not due to nerve in-
jury, is proved by the failure to demon-
strate disease of the nerves in the cases
examined, and to the very prompt de-
velopment of the hard, indurated mus-
cle masses (often occurring within 24
hours) which is the characteristic lesion
of this condition. That it is not an ex-
tension to the muscles from the pres-
sure spots seen in the skin, is shown by
the fact that the induration in the mus-
cles occurs, at times, remote from the skin lesion.
The secondary deformities and the paralysis of distant groups of muscles
are the result of the contracture of the degenerate muscle mass. The short-
ened and functionless muscles cannot be extended, and the fingers are held
flexed in the palm. If the wrist is flexed, the fingers can be extended. If
the wrist is extended, the fingers are drawn back into their former position
of flexion.
The paralysis of the muscles of the thenar and hypothenar groups comes
later, due to the compression of the median and ulnar nerves as they traverse
the indurated and contracting muscle mass in the forearm. These are not a
part of the lesion, but the natural consequence of compression of nerve trunks
traversing contracting scar tissue.
TEEATMENT. — Treatment, to be intelligent, must be carried out with
FIG. 5. — ANTERIOR VIEW OF FIGURE 4.
THE MUSCLES
617
two conditions in mind: the one, the degenerated muscle mass; the other, the
paralysis of distant groups of muscles due not to the original lesion, but to
nerve compression by secondary contraction of scar tissue in the transformed
or degenerated muscles. No rules can be laid down as to procedure, as each
case must be judged by itself. It might be thought that prevention would
be the best treatment. While not minimizing for a moment the importance of
exercising the utmost care in the application of splints, especially those en-
circling an extremity, there seems to be plenty of evidence that this condition
FIG. 6. — VOLKMANN'S ISCHEMIC CONTRACTURE. (Drawing from a photograph loaned by Dr. F. S.
Mathews.)
is the result of a combination of unfortunate sequences — unfortunate in that
they occur close together — rather than the result of improper treatment on the
part of the surgeon.
Not all cases are of like severity. In those where much muscle tissue has
undergone degenerative changes, the prognosis is bound to be bad. In the
lesser degrees of the lesion much can be accomplished by efforts at continuous
traction, massage, hydrotherapy and the use of electricity. Volkmann ad-
vised the stretching of the muscles under an anesthetic. This was seldom
followed by permanent improvement. Attempts to improve the position of
the hand and diminish the deformity by lengthening the tendons, resecting
the bones of the forearm, and dividing the tendons, have been undertaken.
Division of the tendons gives no actual relief. Resection of the bones of the
forearm, while accompanied by the risk of non-union, can only diminish the
deformity and do little to help function, as it renders the muscles on the back
of the forearm too long and in no way corrects the paralysis of the degenerated
group. Lengthening the tendons was the only measure, among the earlier
618 THE MUSCLES, TENDONS, BURS^E AND FASCLE
operations, attended by any degree of success. Drehmann in 1904 tried to
dissect out the imprisoned nerves. He divided the sclerosed muscles, length-
ened them and sutured them to the healthy flexor profundus. Bardenheuer,
in 1906, and Hildebrand, in the same year, dissected through the scar tissue
and freed the nerves. Bardenheuer "dissected off" the contracted muscles
and freed the nerves. Hildebrand, Ferguson, Powers, Quinby, and Gushing
dissected out the nerves, in some cases transplanting the nerves from their
bed to beneath the skin and superficial fascia.
The procedures to be undertaken in an individual case must depend upon
its peculiar features. Estimating the degree of involvement of the muscles in
the primary lesion, recognizing what groups of muscles remain uninjured,
which could be utilized to attach the tendons of paralyzed muscles to those
having similar function, noticing what nerves must be freed to restore func-
tion in distant groups of muscles rendered useless by the compression of their
nerve trunks traversing the cicatricial mass, will determine just what steps are
necessary to improve the condition.
Liberation of the nerves should begin in healthy tissue on the proximal
side of the lesion; the nerves are thus more easily followed through the dense
cicatrix of the muscles. To correct the deformity, lengthening of the tendons
of the involved muscles and their transplantation, in whole or in part, to
tendons of muscles uninvolved, having similar function, should be undertaken.
Time is an element to be considered, as most of those suffering from this con-
dition are young subjects. It is inadvisable to attempt too much at a single
operation. It would seem better to follow the nerves through the cicatrix,
resecting and suturing when necessary, longitudinally dividing the sheath,
freeing the axis-cylinders if there is scar tissue within the sheaths, and placing
the nerves beneath the superficial fascia.
A second operation for the relief of the contractures and deformity, and
tendon transplantation for the reestablishment of function, should be under-
taken if these cannot be accomplished within reasonable time at the first opera-
tion. The after-treatment of these cases is most important, and if not pains-
takingly carried out, all benefit from the operative procedures will be lost.
It should consist in active and passive movements, massage, use of the faradic
current, and hydrotherapy. These measures must be carried out for months
to secure the full benefit from the operative work.
Inflammation of Muscles. — Simple myositis is usually the result of trauma,
and being a stage in the process of repair, calls for no operative treatment.
Suppurative myositis occurs in 2 ways: (1) where the infecting pyogenic
organisms reach the muscle through some wound or from some neighboring
acute phlegmonous inflammation of the skin and subcutaneous tissue; (2)
where the organism is carried by the blood stream in the acute infectious
diseases, such as pyemia, typhoid, etc. As the muscle tissue itself is very
resistant, the interstitial tissue is found to be the site of the cell proliferation
and accumulation of pus cells. The pressure thus produced interferes with
THE MUSCLKS G19
the nutrition of the muscle bundles, and they undergo granular, fatty, or
hyalin degeneration. The process may be so intense that the muscle bundles
disintegrate and gangrene occurs. The process may limit itself to the forma-
tion of 1 or more larger or smaller abscesses, or the process may involve the
entire muscle.
Eecovery in the majority of the cases of moderate severity, and in those
not overwhelmed by the systemic disease, occurs by the evacuation of the pus,
either spontaneously or surgically; and some restoration of function, by the
formation of granulation tissue between the muscle fibers, takes place.
TEEATMENT. — Treatment should be directed to the tennination of the
inflammatory process by early incision, thus limiting as far as possible the
destructive tendencies of the disease, and promoting nature's efforts at repair
by supporting measures. Operative interference should be confined to early
and wide incision; scraping and cleaning such an abscess cavity is unneces-
sary, as once the pus is evacuated and pressure relieved nature will restore
much that at the time looks beyond repair.
Acute parenchymatous myositis (or polymyositis hemorrhagica) and der-
matomyositis are forms of disease but rarely seen, and their causes are but
little understood. Their treatment is purely empirical.
Tuberculosis of Muscles. — The two varieties of muscle disease due to the
presence and growth of the tubercle bacillus differ more in the method of
invasion than in any essential difference in type. One type of the disease
is an extension from some neighboring tissue or organ. In the other type the
disease seems to be "primary" in the muscle. Tuberculosis of a muscle is
an infiltration and replacement of the connective tissue stroma by tubercle
tissue, often with the products of inflammation added. The muscle tissue
itself is pushed aside and, compressed, undergoes atrophy or waxy or hyalin
degeneration and may finally be entirely destroyed. The tubercle tissue goes
through the various stages of its formation, development, degeneration, and
final destruction ; or if sufficient resistance on the part of the host is developed,
it is transformed into connective tissue or is encapsulated. It is immaterial
whether the exciting agent, the tubercle bacillus, reaches the muscle from some
nearby focus, or is carried to the muscle by the blood from a distant part of
the body — the disease is the same. In the second form the diagnosis may be
delayed and treatment instituted too late to save the muscle from destruction.
TEEATMENT. — In the discussion of the nature of this disease and its de-
velopment, it was noted that the tuberculous tissue grows in the connective
tissue stroma; that it destroys the muscle fibers themselves only through the
effects of pressure, causing them to undergo waxy and hyaline degeneration,
because of the diminished blood supply. The indication for treatment is,
therefore, plain. When the disease in the muscle is secondary to tuberculosis
of bone, articulation, or lymphatic system, the cure of the primary lesion is
essential ; otherwise the removal of the local disease in the muscle will be fol-
lowed by a recurrence. When the disease in the muscle seems to be "primary,"
620 THE MUSCLES, TENDONS, BURS^E AND FASCIAE
having originated from some undiscovered focus elsewhere in the body, through
the medium of the blood stream, the careful removal of the entire muscle is
probably the best procedure.
It is unnecessary to describe the precise steps to be taken, as the condi-
tions calling for interference are too numerous to warrant an attempt at detailed
discussion. Where an abscess or sinus has formed, its complete removal is
indicated whenever possible. Where the anatomic conditions preclude this
possibility, the abscess should be opened, its contents evacuated, and its cavity
filled with an emulsion of iodoform in glycerin. The wound should be closed
and sealed with an aseptic dressing, and the part immobilized.
It may be necessary to repeat this procedure. It should never be forgotten
that one may prevent the infection of the wound by pyogenic organisms through
the exercise of great precaution in the performance of these operations. In-
ability to pursue either of the above courses compels one to adopt other methods
of treatment of tuberculous lesions, such as removal of as much of the diseased
tissue as possible, sterilization of the tract or cavity with tincture of iodin,
and treatment of it as an open wound.
Another method that has given very excellent results in the hands of its originator
and many others, especially for the ramifying sinuses about a tuberculous articulation,
is that described by Emil G. Beck.
Beck injects the sinuses with a mixture of bismuth subnitrate and vaselin
in the proportion of 33 per cent, of the bismuth to 66 per cent, vaselin. This
mixture is first rendered sterile, and is then liquefied before use by heating.
The injection of the paste is made through a small incision, which allows the
evacuation of larger particles of tuberculous debris than could be passed
through a trocar or aspirating needle and assures the operator that he has en-
tered the sinus. In cold abscesses Beck advises the use of 10 per cent, bis-
muth and vaselin paste. The danger of this procedure is in bismuth poisoning.
Should symptoms of poisoning appear, the paste must be removed by washing
out the cavity with warm olive oil. The sterile oil is retained from 12 to 24
hours, in order to make an emulsion and is then withdrawn by means of suction.
The care of tuberculous patients, whether suffering from surgical or general
tuberculosis, should include fresh air, sunshine and proper hygiene. The
use of heliotherapy, as practiced by Rollier in his children's clinic at Leysin,
is one of the best examples of the benefit obtained by the action of sunshine
in combination with proper surgical treatment.
Actinomycosis of Muscles. — This has been discussed at considerable length
in the chapter on Inflammations of the Abdominal Wall, and a further elabora-
tion of the subject in this chapter is unnecessary.
Hydatid Disease of Muscles. — This subject has also been discussed in the
chapter on Inflammations of the Abdominal Wall.
Syphilis of Muscles. — In both the congenital and the acquired forms of
THE MUSCLES 621
this disease, involvement of the muscles takes place. The most common form
is the development of gummata in the connective tissue planes of the muscles.
These, according to the activity of the disease, grow slowly or rapidly; are
painless or, when near nerves that are pressed upon, painful; they infiltrate
the muscular planes, producing atrophy of the muscular bundles, and — in
cases where the resistance of the individual or treatment does not bring about
resolution — break down and form ulcers involving the muscle, fascia, subcu-
taneous tissue and skin. Except in the very exhausted and non-resistant, re-
covery is easily brought about by suitable specific treatment, and healing takes
place by the replacement of scar tissue.
A rarer form is the so-called diffuse syphilitic myositis, evidenced by a
stage of infiltration, rendering the muscle hard and rigid, followed by atrophy
and sclerosis, and finally ending in contractures.
If treatment is instituted in the stage of infiltration, before the destruc-
tive changes due to the sclerosis have taken place, recovery and return to
normal are possible.
Trichiniasis. — This disease is caused by the trichina spiralis. Infection
occurs in man from the ingestion of insufficiently cooked pork. The muscle
of the diseased pig contains the embryos of the parasite in an encysted condi-
tion. In the stomach the capsule of the worm is dissolved and the embryos are
set free. They mature rapidly, increasing in size, and the females give birth,
in the small intestines, to large numbers of young. These find their way
through the mucous membrane and wall of the gut into various parts of the
body. Their exact course in leaving the gut is not fully established; they
probably traverse the tissues in different ways. At any rate, they find their
• way to the voluntary striated muscle tissue, which they penetrate, and enter
the muscle fibers. In this situation they become encapsulated, the capsule
after a time becoming partially calcified, and in this encysted state they may
remain inactive but living for an indefinite time.
As a result of the presence of these parasites in the body, if the invasion
be severe, acute catarrhal enteritis with diarrhea and vomiting, high fever
and severe pain, is apt to occur. Edema of the face and other parts of the
body, bronchopneumonia and fatty degeneration of the liver may be found in
cases that have succumbed to the disease.
The flat muscles, especially near their tendinous insertions, is the favorite
site for the lodgment of these parasites. A valuable diagnostic sign is the
marked eosinophilia that regularly accompanies this disease.
TEEATMENT. — Treatment consists in removing as many of the parasites
as are still harbored in the intestine by active catharsis and intestinal anti-
septics, while supporting the strength of the patient during the height of the
disease. In the non-fatal cases the disease limits itself.
Ossification of Muscles.— Ossification takes place under conditions and for
reasons little understood. One form manifests itself, usually in young per-
sons, by an invasion of the interstitial tissue of the muscles, commencing in
622 THE MUSCLES, TENDONS, BURS^E AND FASCIAE
the groups of the neck and back. The disease is progressive, and nothing we
now know can arrest its progress.
A second form, occurring in muscles subjected to sudden strain or repeated
injury, would seem to have trauma as a causative factor. The bony growths
seen in the shoulders of infantrymen and in the adductor group of horsemen
appear to sustain this theory.
Bone formation is initiated by the dislodgment of small shreds of perios-
teum, which produce new bone near and continuous with the insertion of the
muscle. In cases where the new bone is entirely free from the aponeurotic
insertion of the muscle, we must believe that some shred of periosteum or
fragment of bone has been pulled up into the belly of the muscle by muscular
contraction. In opposition to this, we know that bone can be developed in
any of the tissues of the body when there has been no possibility of trans-
plantation. Whatever theory we may entertain as to causation, we do know
that these last forms of ossification in the muscle, where they cause mechanical
disability, can be benefited and cured by operation.
Tumors of Muscles. — Tumors of muscle usually develop in the connective
stroma. Eibroma, chondroma, lipoma, myxoma, and sarcoma may occur as
primary tumors. Carcinomata and sarcomata may develop secondarily in
muscles, by extension from adjacent parts.
TBEATMENT. — Treatment is the same as for these conditions elsewhere in
the body.
THE TENDONS
The tendons are composed of white fibrous tissue. To the naked eye the
fibers appear as silvery-white, glistening bundles, running parallel with each
other. They are covered by a quantity of loose, flocculent tissue binding them
together and carrying the blood vessels. They are inelastic and exceedingly
strong, but easily split. Regeneration, after division or rupture, takes place
by the formation of new connective tissue between the divided ends. Whether
this new tissue is developed from fibroblasts — derivatives from preexisting
connective tissue cells — or is in part formed from vascular and lymphatic
endothelium given off as buds from the new capillary loops, is a problem for the
pathologist rather than the general surgeon to determine. It suffices for the
surgeon to know that the change from the young vegetative connective-tissue
cells into long thin compressed cells surrounded by fine fibrils, and eventually
into adult connective tissue, takes place in about 6 weeks.
INJURIES TO TENDONS
Subcutaneous Injuries. — Subcutaneous injuries to tendons are the result
of great force applied to the tendon where it is traversing a part of its course,
supported by bone. Where it is lying among soft parts it is little Jiable to
THE TENDONS 623
injury. When crushed, its fibers become frayed, and if this occurs in a narrow
canal, as the sheaths of the palmar flexors, the subsequent healing leaves the
tendon no longer smooth and of the same diameter, but gives rise to symptoms,
the treatment of which will be described later.
Rupture of Tendons. — Rupture of a tendon is less frequent than tears in
the muscle belly to which it belongs. When the tear is confined to the tendon
alone, it occurs usually in the form of a "sprain fracture," i. e. a small scale
of bone is torn from the tendon's attachment.
TEEATMENT. — Treatment has been indicated in the section under muscles.
Here it is only necessary to state that the earlier the operative relief is insti-
tuted, the better is the chance of success. Delay means shortening of the
muscle and the filling in of the tendon's bed with connective tissue. An im-
mobilizing dressing should be applied after operation, with the part in such
position as will afford relaxation. This should be worn for a period of 6
weeks, or else the new formed tissue will stretch and there will be diminution
of function, owing to redundancy in the length of the repaired tendon.
Dislocation of Tendons. — This condition is rare and occurs most frequently
to the peronei muscles, 1 or both tendons being dislodged from their groove
behind the external malleolus, after rupture of the fibrous bands and synovial
sheaths which commonly hold them in place.
TEEATMENT.— (A) CONSERVATIVE. — Reduce the dislocation and maintain
the foot in such position, by means of an immobilizing dressing, as will hold
the tendons in their place. Persist for about 6 weeks. This failing, one
must operate.
(B) OPERATIVE. — Make an ample incision along the line of the fibula, but not
directly over the groove. Search for the torn sheath, replace the tendons, and suture
the sheath. If the canal has filled up and the margins of the sheath cannot be identi-
fied, reconstruct a canal behind the malleolus from neighboring fascia, or use a flap
of periosteum, as suggested by Konig, turned downward or backward from the fibula.
Wounds of Tendons. — These occur more frequently in the hands, less often
in the feet, from cuts with knives, sharp objects, bits of glass ; and in associa-
tion with extensive injuries and lacerations, as the maiming accidents from
machinery. The tendons are cleanly divided, crushed, or fibrillated, according
to the character of the wound.
Often in incised wounds about the wrist, the back of the hand and on the fingers,
the division of the tendons is not discovered. In sharply bleeding wounds of
character the inexperienced operator is more concerned in checking the hemorrhage,
and the disabling injury to the tendon goes unrecognized. It should always be the
rule to test the function of all muscles, whose tendons traverse such a wound
the tendons are cleanly divided, the contraction of the muscle withdraws the proximal
end from the field, and unless this precaution is observed a second opei
necessary.
624 THE MUSCLES, TENDONS, BIJRS^E AND FASCLE
TEEATMENT. — In all wounds that can be rendered clean, or reasonably so,
primary suture of the divided tendons gives the best results. In cases where
the injury has not been recognized, and in wounds that are infected, secondary
suture is of necessity the procedure to be adopted. Here it should be borne
in mind that all wounds appearing black and soiled are not necessarily in-
FIG. 7.
FIG. 8.
FIGS. 7-9. — METHODS OF TENDON SUTURE.
fected. As primary suture gives so much better results and entails such a
saving of time, an attempt should be made at repair, even in the cases where
the skin and surrounding tissues are soiled and black from the grime and
grease of the machine. These wounds can often be rendered clean by placing
a sterile pad over the wound, removing as much of the black and grease as
will come away on 2 or 3 pads wet with tur-
pentine, then cleaning the interior of the
wound with salt solution, removing with
forceps all foreign material, and finally
painting the entire region with tincture of
iodin. A wound so treated will often sur-
prise one by healing as kindly as one sur-
gically prepared. Too much scrubbing, in
an effort to render the wound cosmetically
clean, will defeat one's purpose.
PRIMARY SUTURE OF TENDONS. — The
wound being clean, or prospectively so, after
arresting all hemorrhage begin the search
for the divided ends. The distal ends will
retract but little and are easily found. The
proximal ends may require an extensive search. Manipulate the part by flexion
or extension as the case requires ; "milk" the muscle belly toward the wound by
pressure with the fingers or by means of a bandage applied from above down-
ward; try to grasp the retracted ends by small hooks passed upward along the
tendon's sheath, and draw them into the wound. Failing in these efforts, incise
freely the overlying tissues and discover the tendon. Cleanly divided tendons
V
FIG. 10. — METHOD OF TENDON SUTURE.
THE TENDONS
625
Fio. 11. — METHOD OP TENDON LENGTHENING, SINGLE FLAP.
can, as a rule, be easily brought together. Unite them with sutures of
silk passed in various directions. If the tendons are held in place with oon-
FIG. 12. — TENDON LENGTHENING, DOUBLE FLAP.
siderable difficulty, the sutures are apt to pull out, by the splitting of the
longitudinally running bundles. This can be obviated by encircling the
FIG. 13. — TENDON LENGTHEN-
ING: HIBBS-SPORON METHOD.
FIG. 14. — TENDON LENGTH-
ENING: HIBBS-SPORON
METHOD.
ends with a piece of silk and passing the retention sutures in such direc-
tions as to embrace the encircling ligatures. The method of placing the
41
I.
FIG. 15. — TENDON TRANSPLANTATION. I, Flap
from live tendon to tendon of paralyzed
muscle; II, grafting "dead" tendon to "live"
tendon.
626 THE MUSCLES, TENDONS, BUES^ AND FASCIA
sutures is shown in the above diagrams. The simpler methods of suture are
the best.
SECONDARY SUTURE OF TENDONS. — Secondary suture is necessary in the
cases in which, at the time of the original injury, the division of the tendons
was unrecognized; and in which, by reason of infection or too great injury
to the soft parts, it was deemed unwise
to attempt a primary suture.
The rules for secondary suture are
the same as for primary suture, but in
the latter many more difficulties must be
overcome. The tendons will be retracted
and bound down in their new positions,
the tendon sheaths will be found blocked
with new connective tissue, and in the
cases originally the site of suppuration
it will be found necessary to resort more
frequently to tendon lengthening and
tendon transplantation. Great ingenu-
ity will be called for in the utilization
of the material at hand, and considerable surgical dexterity will be required
in dealing with tissues that do not readily lend themselves to plastic
work.
In secondary suture valuable use can be made of free flaps of the sub-
cutaneous fat to wrap around the suture, and to line the new beds made for
the reconstructed tendons. Other material, such as serous sacks, may be used
if at hand.
AFTEH-CARE FOLLOWING TENDON SUTURE. — The surgeon, in these cases, is of two
minds. To secure firm union and proper organization in his plastic work, he desires
to keep the part at rest for 6 weeks. For the reestablishment of function, he desires
to begin the passive movements early. If he begins passive motion too early, the newly
united tendons will stretch and, owing to redundancy, the functional result will be
poor. If he delays too long, ankylosis will take place and all benefit of the operation
will be lost. A middle course will be found the safest.
At the end of the third week, a few passive movements can safely be
made. The wound in the soft parts will have healed, and massage of the part,
with hot and cold bathing, can be done every day, care being taken to put the
part back in its immobilizing dressing after each treatment. Voluntary ef-
forts should not be attempted before the end of the sixth week.
TRANSPLANTATION OF TENDONS
The principle that underlies these operations consists in utilizing part oi
the power of a healthy muscle or group, and transferring it to a paralyzed
THE TENDONS 627
muscle or group; or in attaching a healthy muscle to the bone or periosteum
to correct a deformity resulting from injury or disease.
It is impossible in the limits of this article to do more than indicate the
uses to which this principle can be applied and leave tin- detailed description
of individual cases to the writers of the chapters on orthopedic operations.
It must be borne in mind that the successful outcome of these operations de-
pends upon a nice balance of judgment, and that they sin mid not be undertaken
until the contractures and deformities have been corrected. There must be
proof that actual paralysis of muscle exists. Often the loss of function is
due to overstretching of the muscles while in a condition of temporary paralysis
from a diseased, severed or bruised nerve.
The Use of Foreign Substances in Tendon Transplantation. — The most suc-
cessful operations in tendon transplantation are those in which use is made
of autogenous grafts. Heterogenous grafts are now successfully employed, but
always will hold a second place to those taken from the same individual.
Use has been made of silk and linen threads of various sizes and strength,
to piece out defects in tendons. Where these have been used about the foot,
it has been found that the strain is too great and they have pulled out. In
the hand they have met with more success. The reason for this seems to be
that there is not sufficient organization of connective tissue about the implants,
and the strain has eventually to be borne by the foreign material.
TENOTOMY
Two methods are in use for performing tenotomy: the open operation
and the subcutaneous operation. In the open operation the tendon is cut down
upon and divided under the guidance of the eye. In the subcutaneous opera-
tion the tendon is put upon the stretch and divided with a tenotome passed
through the skin to the side of the tendon. Division is usually made from
within outward, or away from important structures. Each has its uses. The
open operation is more used where fascial bands are to be divided in the neigh-
borhood of important structures, as in the neck. The subcutaneous method is
more in use for tendons. Tenotomy is useful in lengthening tendons, especially
in young children. When a subcutaneous tenotomy is done to the tendo
Achillis in these young subjects, the divided ends are drawn apart by the
correction of the deformity, and a considerable gap is left in the bed of the
tendon. By the time the little patients are ready to use the foot, the gap
will have been bridged and perfectly good function of the divided tendon will
be present. This would seem to indicate that the elaborate operations for
tendon lengthening, at least in the young, are unnecessary.
The many conditions for which tenotomy is employed will be mentioned
arid the operations described in another part of this work.
628 THE MUSCLES, TENDONS, BUKS^ AND FASCIA
TENDON SHORTENING
It is sometimes found necessary to reef or shorten tendons. This should
seldom be the case, as stretching takes place at the expense of the muscle and
shortening the tendon will not help matters if its muscle belly remains func-
tionless. In the cases where it seems indicated, resect and suture.
THICKENING AND NODULATION OF THE TENDONS
As a result of trauma, small extravasations of blood will frequently take
place in a tendon. This blood organizes and forms a nodule, or degenerates
FIG. 16. — SNAPPING FINGBRS. (Weir.) Needle in tendon: Payer's case. Split tendon: Haegler's case.
and forms a cyst. Again, as a result of long-continued pressure (wearing a
ring, Weir), thickening takes place in the sheath. At times the tendon is
bruised and some of its fibers are split, becoming curled up and forming a
nodule. Any of these conditions can give rise to the condition known as trigger
finger.
Treatment. — In the cases where the symptoms are due to a nodule, cyst
or frayed portion of the tendon, incise the sheath, expose the tendon and remove
the obstruction at the expense of the interior of the tendon. Diminish the
diameter of the tendon after excision of the cyst, or removal of the nodule by
very fine silk sutures buried in the interior of the tendon. Where the symp-
toms are due to a narrowing of the sheath Weir advises its simple division.
THE TENDONS 629
GANGLION
A ganglion is a cystic formation developing in the tissues, usually in
the neighborhood of the capsule of a joint, on a tendon sheath, or in the tendon
itself. It is most frequently found on the extensor surface of the wrist, less
often on the flexor aspect. Occasionally ganglia are seen on the dorsuin of
the foot, and still less frequently in the neighborhood of joints in other parts
of the body. They are thin, connective tissue sacs, containing a clear trans-
parent gelatinous fluid, attached to the joint capsule or tendon sheath by a
broad or narrow base. Formerly they were thought to be extrusions, or
FIG. 17. — I, TUMOR CAUSING TRIGGER FINGER; II, ENLARGEMENT OF DEEP FLEXOR. (Weir.)
evaginations from the synovial membrane lining the joint, forced out by strains
put upon the articulation, and later shut off from the joint by cicatricial con-
traction of the scar tissue (Gosselin). Later investigators have proved that
these small cysts result from degenerative changes in the capsular tissue and
in the tendinous and paratendinous tissue.
As the result of some slight trauma to the capsular tissue or tendon, an
extravasation of blood takes place in the tissues and, associated possibly with
an obliterating endarteritis, degenerative changes are initiated. Examination
of the recently formed tumors shows trabecula3 running in various directions,
evidence that the degenerative process is not complete and has not converted
the tumor into a single sac. Very recent ganglia may even be semi-solid.
Treatment. — The indication for treatment of these small benign tumors
arises from the sense of weakness, often experienced, and occasionally from
neuralgia-like pains, seldom from interference with function.
NON-OPEEATIVE TEEATMENT. — In the thin-walled cysts a cure can often
be effected by rupturing the cyst with a heavy blow, the part having first been
rendered tense. Compression should be employed after this method of treat-
ment. Recurrences may take place, and the treatment will have to be repeated.
I have on several occasions ruptured the cysts by powerful pressure with the
fingers, the part having first been made tense.
630 THE MUSCLES, TENDOHS, BURS^E AND FASCLE
OPERATIVE TREATMENT. — Upon failure in the above measures, an opera-
tion conducted with the strictest aseptic precautions is advisable. As anything
less than complete removal is apt to be followed by recurrence and consequent
embarrassment to the operator, these operations should be conducted with
great care, aided by artificial ischemia and the closest attention to surgical
technic. The joint or the tendon sheath will often have to be opened, and
infection occurring in a patient suffering from such a minor condition will be
attended by great hurt to the surgeon's reputation and grave injury to the
individual.
BURS.® AND TENDON SHEATHS
Synovial membranes of the body are divisible into 3 varieties or subdi-
visions : articular, bursal and vaginal. These membranes are derived from the
connective-tissue layers and have in their interior a viscid fluid. This fluid
is derived from the disintegration of other connective-tissue cells. The old
theory of mucilaginous glands as the source of the synovial secretion has been
abandoned. The bursal synovial membranes seem capable of development in
any part of the body where the overlying skin is subject to pressure or friction
on hard unyielding parts beneath. Thus we find bursse interposed between
the integument and bony surfaces. The bursal synovial membranes are again
divided into the bursaB mucosa9 and the burs»3 synovia?. The bursse mucosa?
are large, irregular cavities lying in the subcutaneous or areolar tissue, and
contain a clear viscid fluid. This is the form found between the integument
and the front of the patella, over the olecranon, the malleoli and other promi-
nent parts of the body. The bursa? synovise (synovial sheaths) are found in-
terposed between muscles or tendons as they project over bony surfaces or as
they line the osseo-aponeurotic canals. These are found investing the tendons
of the hand and foot. The membrane is here arranged in the form of sheaths,
1 layer of which adheres to the wall of the canal, and the other is reflected upon
the surface of the contained tendon. The space between the 2 free surfaces
of the membrane contains the synovia. The layer lining the sheath is known
as the parietal layer, that covering the tendon is called the visceral layer.
The diseases of the articular synovial membranes are treated under their
appropriate headings in other chapters of this book.
The diseases of the bursal and synovial membranes are the same as these
attacking membranes in all parts of the body.
INFLAMMATIONS OF THE BURS-ffi
Acute Bursitis. — Acute bursitis is usually the result of a single injury and
is more properly described as a hemorrhage into the bursal sac, as a result
of the injury.
TREATMENT.— Treatment should be directed to the removal of the hemor-
BUKS^E AND TENDON SIIKATIIS 631
rhage by measures which will promote absorption. This is best accomplished
by rest and compression of the part, together with an ice pack for a few days,
followed by the use of hot and cold bathing and massage. Aspiration of the
contents of a hemorrhagic bursitis is seldom indicated.
Chronic Bursitis or Hygroma.— This results from the persistence of the
acute hemorrhagic variety, or develops as the result of continued irritation of
these membranes as seen in the so-called "occupation bursitis," as the prepa-
tellar bursitis or "housemaid's knee" and the olecranon bursitis or "miner's
elbow."
TREATMENT. — When the condition is of recent origin and in sacs not un-
duly thickened, resolution can often be brought about by rest and compression
of the part with or without aspiration of its contents and the injection of tin-
sac with a tincture of iodin. The more chronic cases with thickened walls
will not yield to these measures, and excision of the bursa becomes necessary.
Acute Suppurative Bursitis. — This may arise in old chronic cases of bur-
sitis or result from open, incised, or punctured wounds of the bursae. Rarely
does infectious bursitis occur through the medium of the blood stream. The
simultaneous development of bursitis in various parts of the body would sug-
gest rather a constitutional disease, such as tuberculosis or syphilis, as its
etiology. The free communication which exists between the bursal sacs and
the lymphatic system renders infection of the bursa3 quite common from sup-
purative processes in their neighborhood. They may also become infected by
direct extension along the subcutaneous layers from nearby suppurative foci.
The situation of the bursse beneath fascial planes renders their infection
peculiarly dangerous, by reason of the extensive cellulitis that may result from
extension of the suppurative process beneath these confined spaces. Thus
suppuration in the prepatellar bursa and in the olecranon bursa often gives
rise to extensive cellulitis in the leg and arm. The pus, unable to make its
way to the surface by reason of the resistance of the strong aponeurotic layers,
invades wide areas of the extremities. As a result of the retention of inflam-
matory products beneath the fascial planes, grave constitutional symptoms
due to the septic absorption are common.
TEEATMENT. — As in the treatment of chronic bursitis, excision of the sac
is indicated whenever possible. Unfortunately, owing to the peribursal in-
flammation, this cannot always be done. Here one must be content to incise
the sac, giving vent to the pus, and taking care that by free division of the
surrounding fascia exit is given to inflammatory products that may have made
their way outside the bursal sac into the surrounding subcutaneous tissues.
Care should be exercised that the materials used for drainage of the sac and
fascial planes do not act as a plug. This can be obviated by transverse di-
vision of the fascia so that it is made to gape, and by placing the rubber tissue
drains or rubber tubes in the extremities or angles of the wound. The dressings
should be moist, light and preferably in the form of evaporating lotions. They
should be changed frequently. The practice of using rubber tissue or rubber
632 THE MUSCLES, TENDONS, BUKS^E AND FASCLE
sheeting to keep the moisture in should not be tolerated, as this converts our
wet dressings into poultices and favors the spread rather than the hindrance
of the progress of the inflammation.
Tuberculosis of the Bursae. — This is of slow and insidious development
without the usual signs of inflammation. The diagnosis is often difficult, and
only to he determined by operation or inferred from the presence of tubercu-
losis elsewhere in the body. Like all forms of surgical tuberculosis, the great-
est measure of safety lies in its complete removal. A less efficacious method of
treatment consists in attempts at sterilization of the contents of the bursse by
injection with iodoform and glycerin. Syphilis of the bursal sacs usually
takes the form of gummata formation. These should be removed by operation
whenever possible, and appropriate constitutional treatment instituted.
DISEASES OF SPECIAL BURS^
Subacromial Bursitis. — Subacromial bursitis may be acute, chronic, or
suppurative. This bursa, when it does not communicate with the subdeltoid
bursa — which, however, is often the case — is easily approached and excised by
incisions through the skin at the top of the shoulder.
The Subdeltoid Bursa — ACUTE INFLAMMATION. — Acute inflammation of
this bursa often develops as the result of a single injury, and very often
leads to mistakes in diagnosis. It is often confounded with inflammation
of the shoulder joint proper. Its situation deep beneath the deltoid, em-
bracing the head of the humerus, gives rise to this confusion. Under the
name of "peri-arthritis humeroscapularis," Duplay describes this as a chronic
adhesive inflammation. It is distinguished from pure articular conditions
by the ability to move the arm in a sagittal plane and to rotate it in its long
axis. Abduction of the arm is not possible without movement of the
scapula.
TREATMENT. — This consists in the avoidance of restraining dressings and
the encouragement of the patient to use the arm as much as possible. Where
the diagnosis has not been promptly made and great limitation of motion
exists as a result of the extensive adhesions, these should be broken up under
ether and active and passive motions continued daily, combined with hydro-
therapy and massage.
TUBERCULOSIS. — Tuberculous disease of this bursa is recognized by the
crepitus obtained by the rubbing of the rice bodies in its interior, by its slow
formation, and by absence of inflammatory signs. Tuberculous lesions else-
where aid one in forming a diagnosis.
TREATMENT. — The best treatment consists in total extirpation of the sac.
This is accomplished through a longitudinal incision placed over the most
prominent point of the swelling, entering between the fibers of the deltoid.
Care should be exercised not to wound the circumflex nerve in its course on
the deep surface of the muscle. Inability for any reason to pursue this method
BUKS^E AND TENDON S1IKAT1IS 633
of treatment compels one to treat this condition by aspiration of the fluid
contents and the injection of a sac with iodin or other antiseptics.
The Olecranon Bursa.— The olecranon bursa is subject to the same diseases
as the other bursse. It is rarely tuberculous, more often subject to chronic
inflammation or hygromatous, at times the site of acute infectious bursitis.
Owing to its situation beneath the strong aponeurosis back of the arm, infec-
tious processes in this bursa require special attention to the freeing of pus
which may have made its way into the subfascial planes. The chronic and
tuberculous forms are likewise best treated by excision.
The bursse in the neighborhood of the wrist and hand are small and un-
important. The diseases of the tendon sheaths are hero more important and
will be dealt with later.
The Bursae About the Hip. — There are numerous bursa! about the hip.
Those between the insertions of the glutei muscles to the trochanter are seM<»m
the subject of surgical interference. The bursa overlying the tuberosity of
the ischium is frequently the subject of surgical interference. This bursa
is best approached with the thigh in the flexed position ; the glutens maximus
is then withdrawn from over the tuberosity. The large multilocular bursa
between the fascial expansion of the gluteus maximus and the trochanter
major can be approached and excised by an incision parallel with the fibers
of this aponeurosis. The iliac bursa beneath the psoas iliacus lies in the mus-
cular compartment beneath Poupart's ligament, and can be incised and drained
by an incision placed over the head of the femur to the outer side of the
femoral artery. Care should be exercised not to wound the anterior crural
nerve in dealing with this bursa.
The Bursse About the Knee THE PKEPATELLAR BURSA.— The prepatellar
bursa is the most frequently involved of the bursa? about the knee. Operations for
chronic and acute conditions of this sac are best performed through a transverse in-
cision placed over the most prominent part of the swelling. This transverse incision
should be extended laterally into the uninvolved tissues at the side of the bursa. The
flaps are then more easily dissected in both directions. The approach to the bursa from
the side and posteriorly will enable one to do a clean excision with less danger of
entering the cavity of the sac.
THE POPLITEAL BURSSE. — The popliteal bursse most frequently the site
of disease are connected with the tendon of the semimembranous and the tendon
of the popliteus, the one at the inner side of the joint, the other at the outer
side of the joint. As these two bursse frequently communicate with the joint,
total excision is impracticable. Injection of the interior of the sac with vari-
ous irritants is attended with danger, owing to the liability of the injected
material entering the interior of the joint. TJie best treatment is partial ex-
cision with careful suture of the remnants of the sac, compress
cation of a splint to insure rest.
The Burs* About the Ankle, —The various small burs* about the foot do
634 THE MUSCLES, TENDONS, BUKS^E AND FASCLE
not need a detailed description. The bursa situated between the tendo Achil-
lis and the upper portion of the tuberosity of the os calcis, however, is im-
portant. This is approached for its various diseases by incisions placed on
either side of the tendo Achillis. If necessary for complete enucleation, this
tendon may be divided and later sutured.
THE TENDON SHEATHS
Owing to their great importance and greater liability to infection, the tendon
sheaths of the hand should be dealt with in fuller detail than those of the foot. One
cannot approach the proper operative treatment of the tendon sheaths of the hand
without a knowledge of their anatomy.
Anatomical Points. — A brief review of the special anatomy of the hand
with reference to the tendon sheaths would seem indicated. The skeletal and
vascular anatomy of this region is too well known to require repetition. The
hand as a whole presents a convex
surface dorsally, and a concave sur-
face ventrally, and appears as a trun-
cated cone — its base toward the fin-
gers, its apex toward the wrist. The
annular ligament bridges the concave
aspect of the carpal bones, attached
to the tuberosity of the scaphoid and
ridge of the trapezium on its radial
side, and to the pisiform bone and
hook of the unsiform on the ulnar
side. A canal is thus formed which
lodges the tendons of the long flexors,
their synovial sheaths and the median
nerve. The floor of the hand widens
out as we proceed distally, corre-
sponding to the ray-like arrangement
of the metacarpal bones. Between
these last lie the interosseous muscles,
covered by an aponeurosis, thin
above, stronger below, continuous
with and helping to form the (deep)
transverse metacarpal ligament. The
muscles of the thumb and little finger
bound this region of the hand on either side. From the central portion
of the anterior annular ligament the palmar fascia extends to the base of
the fingers. This is the central strong part of the palmar fascia. Its thin-
ner lateral parts invest the muscles of the thumb and little finger. The
FIG. 18. — POSITION OF THE PALMAR ARCHES.
Diagrammatic.
BURS^E AND TENDON SIIKATI1S
635
middle region of the hand containing the tendons of tin- long flexors and
their synovial sheaths is thus converted into an osseo-aponeurotic compart-
ment. The central part of the palmar fascia divides into 4 slips, which
go to the 4 inner fingers. It becomes perforated in this region by the wide
interlacement of its longitudinal and transverse bands. The majority of the
longitudinal fibers become continuous with the fibrous sheath or theca of the
tendons. The remaining bundles of longitudinal fibers intertwine, dip down,
and become attached to the deep transverse metacarpal ligament, serving to
separate the flexor tendons from the digital nerve and artery and the lumbrical
muscle of each interdigital cleft. We thus see that the hand is divided into 3
compartments, an outer and an inner, giving lodgment to the muscles of the
thumb and little finger; and a central compartment lodging the tendons and
their synovial investment as mentioned above. The subcutaneous tissue of
FIG. 19.— FETAL TYPE.
FIG. 20. — USUAL TYPE.
Fio. 21. — OCCASIONAL TYPE.
the front of the hand, and especially of the palm, is scanty and dense. The
subcutaneous tissue on the dorsum is, on the contrary, lax, and has but a
slight association with the skin. At the interdigital clefts or webs of the
fingers, the subcutaneous tissue is continuous with that about the fingers, and
merges into the loose areolar tissue on the dorsum of the hand. It is continued
into the space beneath the central portion of the palmar fascia, blending with
the areolar tissue found there. The transition in the character of the sub-
cutaneous tissue found in the web of the fingers from that of the palm ex-
plains why exudates make their way to the deep surface rather than to the
superficial surface of the palmar fascia.
The lymphatics of the palm are scanty and very small, whereas on the
dorsum they are large and profusely distributed. This is the reason why
infections on the dorsum of the hand and fingers are followed by lymphangi-
tis, and abscess formation is more common on the palmar aspect of the hand.
According to Rosthorn, during fetal life there is a synovial sac for each
finger, extending from the ungual phalanx to the head of the metacarpal bone.
At birth, or soon thereafter, a fusion usually takes place between the synovial
sacs of the thumb and little finger with the 2 large bursse in the palm of the
636 THE MUSCLES, TENDONS, BUKS^E AND FASCLE
hand: the little finger sac uniting with the ulnar bursa, and the thumb sac
uniting with the radial bursa. The 2 palmar bursse extend into the forearm
about a thumb's breadth above the anterior carpal ligament.
In the palm of the hand we have two large bursal sacs. The ulnar sac
envelops both the superficial and deep flexors and extends upward above the
wrist joint. This sac is prolonged downward along the inner tendons to the
beginning of the digital sheath of the little finger with which it usually com-
municates. The tendons of the ring and little fingers are more extensively
invested by this membrane than those of the index and middle fingers. The
radial bursa is of less extent and invests the tendon of the flexor longus pollicis.
This sac invests the tendon on its anterior, radial and posterior surfaces, but is
FIG. 22. — LARGE ULNAR BURSA OF THE PALM SHOWING INVAGINATIONS OF THE SAC. (Poirier
and Charpy.)
attached by a mesentery along its ulnar border. In a certain number of cases
a separate sac is found about the deep flexor tendons of the index finger. A
sagittal septum or space is placed behind the median nerve, which serves to
mark off the separation between the radial bursa and the ulnar bursa. If we
open the ulnar bursa and note the position of the tendons in relation to the
sac, we will see that there are 3 invaginations : 1 anterior to the superficial
flexors; 1 between the superficial and deep group; and 1 behind the deep
flexor. This arrangement was first described by Leguey, who called them the
pretendinous, intertendinous, and retrotendinous spaces of the great carpal
bursa. From the foregoing description it will be readily seen that infection
of the synovial sheaths of the index, middle and ring fingers will be, for a
time, confined to these spaces. Infection in the thumb and little finger sheaths
BUKS;E AND TENDON 811 K AT I IS
637
can readily extend, the one into the radial bursa, the other int., the ulnar bursa
and thence into the forearm.
The synovial sheaths of the extensor tendons at the back of the wrist lie
beneath the posterior annular ligament, but superficially. The accompanying
FIG. 23. — SYNOVIAL SHEATHS OF PALM, IN-
JECTED.
FIG. 24. — SYNOVIAL SHEATHS or •
EXTENSOR TENDONS, INJECTED.
diagram shows well their arrangement and position. A further description is
unnecessary.
Suppurative Diseases of the Hand in General.— A description of the infectious
processes of the tendon sheaths cannot be undertaken without mention being made of
the other sites where pus is found in the suppurative diseases of the hand. Thus, we
must recognize the exact level at which the pus is situated, or else our operative efforts
for the relief of these conditions will do much harm.
We recognize the following levels for the situation of the pus:
1. Subepidermic infections.
2. Subcutaneous infections.
3. (a) Subfascial infections, (b) infections in the tendon sheaths.
4. Subperiosteal or rather osseoperiosteal infections.
If one observes closely the symptoms referable to pus in these various
levels, a distinct clinical picture will be obtained. Unless this is done, one
may, by careless approach to the pus, transfer infectious material from
638 THE MUSCLES, TENDONS, BUES^K AND FASCLE
a superficial to a deeper level, or, not finding the pus at a super-
ficial level, desist and fail to give the relief necessary. Extension of the
inflammatory products from one level to another very soon takes place, and
unless these conditions are recognized in their very beginning permanent
damage will be done to structures which otherwise might have been saved by
prompt recognition of the condition. Tendons bathed by pus for 48 hours
will die. Two stages of the inflammation must be recognized: A stage of
invasion and a stage of frank formation of pus. To save tendons involved
in suppurative inflammations, relief must be instituted during the period of
invasion or inflammation. If it is undertaken later, the tendons will have
died and the pus will have extended into the palm of the hand or into the
1 ? 3 4'5
1 ! ! • !
C...
8
FIG. 25. — DIAGRAMMATIC REPRESENTATION OF THE SITUATION OF THE Pus, a, b, c, d, and e. (Simon
Duplay.)
forearm. Operation, then, will be concerned in combating a general sepsis
rather than the saving of anatomical structures. The inflammatory products
make their way from one part of the fingers or hand to another by direct ex-
tension, by lymphatic channels and by the blood stream. By direct extension
the pus in the subcutaneous level makes its way from the finger into the inter-
digital cleft, thence it can extend readily onto the dorsum of the Hand or into
the palm beneath the palmar fascia. The readiness with which inflammatory
products travel along a given level renders the Kanavel explanation of
the way pus makes its way onto the back of the hand or into the palm un-
necessary. Kanavel believes that the lumbrical muscles or their fascial
investments offer the channels along which pus extends from the fingers
into the palm or vice versa. The well known resistance of muscle
tissue to inflammatory processes seems to render this explanation
erroneous.
BUKS^E AND TEXDOX SI IK AT I IS 639
DISEASES OF THE TENDON SIH.ATIIS
The diseases of the tendon sheaths are due to injury, over-use, rheumatism,
gout, gonorrhea, syphilis, tuberculosis, and infection with j)v..inMiic organisms.
Rheumatism, gout, gonorrhea, and syphilis of the tend<m >ln-;itl,s seldom call
for surgical interference, their treatment being embraced in the treatment
directed to the cure of the underlying condition.
Injury of a tendon sheath, where the tendon itself is not severely damaged,
appears in the form of a hemorrhage occurring in its interior. The treat-
ment is the same as for other small hemorrhages occurring in various tissues
and cavities of the body.
Acute Tenosynovitis. — In the hand this form of inflammation occurs most
often in the extensor tendons of the thumb. In the foot it occurs less often,
usually in the sheaths of the peronei. It arises as a result of excessive use
of the part, commonly in one unused to that particular form of exercise. The
initial stage of the inflammation, evidenced by pain and the characteristic
creaking (that has given the name of "tenosynovitis crepitans" to this par-
ticular stage of the disease), is, as a rule, soon followed by a pouring out of
a serous effusion. With the occurrence of the serous exudate, there are dis-
appearance of the pain and cessation of the crepitus.
TEEATMENT. — It has been found that recovery is hastened by allowing
a certain amount of use of the part, combined with support and compression
in the form of a snug dressing, such as adhesive plaster. Discontinuance of
the particular form of exercise that gave rise to the condition is, of course,
essential.
Chronic Tenosynovitis. — Chronic tenosynovitis occurs when the exudate in
the acute form persists, and in sprains of, and fractures about, joints treated
by too prolonged rest. Here adhesions form between the layers of the sheath,
and much disability results, until the adhesions are broken down and kept
from reforming by exercise, massage, baking and hot and cold bathing.
PLASTIC TYPE OF CHKONIC TENOSYNOVITIS. — This type is sometimes
met with, and is apt to give rise to much uncertainty in diagnosis. It occurs in
those who persist in the exercise that gives rise to the acute variety. From the
continued irritation, recovery is not allowed to take place in the inflamed
sheaths, and the exudate, becoming thickened, forms a jelly-like mass that
resembles very closely a type seen in the tuberculous form of disease.
This was the case in an organist in one of our cathedrals, who was operated upon
by me. The patient, a thin, wiry man, had the extensor tendons of the wrist involved.
Operation disclosed a jelly-like exudate filling the sheaths of the extensors of the wrist
and the common extensors of the fingers. This was excised together with the sheaths,
and in the belief that the case was one of tuberculosis, the wound was dusted with
iodoform powder and closed without drainage. The patient made a perfect recovery
and was soon at his old occupation. Examination of the tissue by Dr. Hodenpyl failed
to reveal any evidence of tuberculosis. About a year later the patient returned and
640 THE MUSCLES, TENDONS, BTJRS^E AND FASCIAE
presented a similar condition on the back of the other hand. Operation disclosed an
exudate of the same character. The same method of treatment was employed and
again was followed by complete recovery. A few years later the patient returned, this
time with a swelling in the palm of the right hand. This was found at operation to be
of the same character. The sheath involved was about the tendon of the deep flexor
of the index finger, and did not communicate with either the radial or large ulnar
bursa. For a third time the patient made a perfect recovery, and has since remained
well. At no time did he show any evidence of tuberculosis, and the case must be
classed as one of chronic plastic tenosynovitis.
Syphilitic Tenosynovitis. — Syphilitic tenosynovitis occurs in the early
stages of syphilis in the form of a serous exudate, in the later stages it takes
the form of a gummata-like infiltration of the sheaths. Pain is not a promi-
nent symptom, and recovery can usually be brought about by appropriate
treatment directed toward the underlying condition.
Gonorrheal Tenosynovitis. — Gonorrheal tenosynovitis is most often of the
serous variety, but ,is characterized by greater pain and more pronounced
swelling in the tendon sheaths. The differential diagnosis is made on finding
the gonococci in the urethral or cervical discharge.
TEEATMENT. — Treatment in the vast majority of cases consists in the
application of a splint, the use of an ice bag over the inflamed tendons, and
the cure of the primary condition. Rarely will it be found necessary to
puncture the sheaths and draw out the fluid if a proper fitting splint is em-
ployed to give absolute rest to the part. The autogenous vaccines have of
late been extensively employed in this type of inflammation. Their method
of administration will be found described in another part of this work.
Tuberculous Tenosynovitis. — Tuberculous tenosynovitis occurs as a result
of the presence and growth of the tubercle bacilli in the tendon sheaths. The
character of the inflammatory products presents a great variety. In the
earliest form the exudate is generally serous. In the later stages the exudate
becomes thicker and more fibrinous, often with the formation of rice bodies.
The sheaths become thickened, and tuberculous granulation tissue forms in
their interior, forming cheesy masses which are very liable to break down and
form cold abscesses. The commonest site for this form of synovitis is in the
great carpal bursse of the hand.
TEEATMENT. — From the point of view of surgical treatment tuberculosis
of the tendon sheaths divides itself into 2 classes: one where the exudate
remains fluid, or contains, at the most, rice bodies, the other where the sheath
contains a plastic or cheesy exudate, or shows the various stages of tuberculous
degeneration.
Cases of the first group may be treated by evacuation of the fluid exudate
and the rice bodies, if they are present, and the filling of the sheath with a
5 per cent, emulsion of iodoform and glycerin. This may have to be repeated.
The parts should be kept at rest by means of a splint for a period of 3 to 4
weeks.
BUKS.E AND TENDON SHEATHS 641
The other forms of tuberculosis of the tendon sheaths should be treated
by excision. This should be done through ample incisions, and with the help
of artificial ischemia. Superficial portions of the tendons will have to be re-
moved as well as the sheaths in some of the cases. The after-care, as in all
forms of surgical tuberculosis, is most important, and should combine proper
feeding together with an out-door life.
Acute Suppurative Inflammation of the Tendon Sheaths. — In the descrip-
tion of the anatomy of the tendon sheaths it was pointed nut how important it
was, for a clear understanding of these conditions, to have a classification based
on the anatomical site of the original inoculation. The rapidity with which
inflammatory products can make their way from one level to another, and
extend to other parts of the same level, makes it necessary to seek for symp-
toms of inflammation of each particular level. When the disease has pro-
gressed, and one form has merged into another, unless one has followed the
pathological picture closely, endless confusion in the conception of these diseases
will be the result.
Infection may reach the tendon sheaths by extension from some neigh-
boring focus in the skin or subcutaneous tissues, or may extend to the sheath
from an underlying disease of bone or joint. It will thus be seen how impos-
sible it is to discuss suppurative conditions in the tendon sheaths without
taking count of other inflammatory conditions in the various parts of the hand.
The most usual way, however, for pyogenic bacteria to gain entrance, is
through punctured wounds caused by some small, sharp object, such as a
pin, needle or fish-hook.
Two stages of the inflammation must be considered, and the treatment
employed differs according to the particular stage of inflammation. The first
stage is characterized by a serous exudate with few pus cells. If treatment
is initiated during this period, it is often possible to terminate the inflammatory
process; if, however, relief is not started within 48 hours, the inflammation
will have passed to the stage of frank suppuration. The treatment during
the first stage is directed to the termination of the infection, and if successful,
recovery and return to normal follow.
In treating the second stage, one must recognize the impossibility of saving sheaths
and tendons bathed in pus. Here one is concerned in confining the inflammatory
process to its original site, or in opening regions to which the disease has spread. If
left untreated, the purulent exudate ruptures its synovial envelope and spreads to the
subcutaneous regions of the hand and fingers, thence makes its way through the skin,
and fistulous tracts are formed which give exit to the pus, with relief from pain and
subsidence of the swelling. Eventually the necrotic tendons which have died during
the course of the inflammation are cast off in shreds, or, remaining in the wound, keep
up endless suppuration in the fistulous tracts.
' The articulations may be invaded, and periostitis and ostitis of the
phalanges take place, prolonging the period of the disease. The finger freed by
the loss of the tendons yields to the action of the extensors and assumes a
42
642 THE MUSCLES, TENDONS, BURS.E AND FASCIAE
position of permanent extension. If healing takes place, the finger remains
ankylosed, rigid and useless. When the articulations are involved and ostitis
of the bones supervenes, great pain is experienced from lack of support to
the joints, and amputation becomes necessary.
When the disease originates in, or has extended to, the palm, one must
distinguish whether the suppuration lies in the bursal sacs in this region or is
situated in the loose areolar tissue beneath the palmar fascia. When, in the
great carpal bursa, the inflammation will have extended above the wrist joint.
When, in the loose areolar tissue beneath the palmar fascia, the swelling will
be more centrally placed. Determination of the original site of infection and
a recognition of the progress of the inflammation will help one in determining
the region involved.
COMPLICATIONS. — Gangrene, diffuse cellulitis, erysipelas and secondary
foci in the forearm are among the chief complications.
In diabetics, gangrene of the tissues readily takes place.
Erysipelas adds its special symptoms and burdens to those already suf-
fering from a severe disease.
Cellulitis of the forearm in the deep cellular planes, from extension of the
disease in the 'hand, adds its dangers and often even jeopardizes the life of
the patient from profound sepsis.
Lymphangitis occurs more commonly from subcutaneous foci on the dor-
sum of the fingers, their interdigital clefts, and the back of the hand. Ex-
tension through the deep lymphatics, following the line of the blood vessels
into the forearm, may account for some of the abscesses found there.
INCISIONS. — Incisions for the relief of the above conditions should be
placed as follows:
Small abscesses or furuncles on the dorsum of the hand or the dorsum or sides
of the fingers should be incised over the most prominent part of the swelling. These
arise usually from small wounds, abrasions, or infection of the hair follicles. The
pus may be found just beneath the epidermis, or, following the tract of a hair follicle
or sudoriferous gland, it may have reached the subcutaneous layer. When the epi-
dermis is removed, a communication may be discovered between a superficial and
deep abscess, constituting the variety known as the dumb-bell, or, as the French call it,
"panaris en bouton de chemise."
Abscesses on the palmar aspect of the fingers and in the interdigital clefts
are usually of the subcutaneous variety, arising from cracks, small wounds
and punctures. If left untreated, they can rapidly extend into the areolar
tissue beneath the central portion of the palmar fascia, gain entrance to the
tendon sheaths, or extend to the back of the hajid. These are best opened by
incisions^ placed over the most prominent part of the swelling. Care should
be taken not to' transfer the pus in this variety to the tendon sheaths by care-
lessly placed or carelessly made incisions. The webs of the fingers should
be preserved whenever possible, 2 incisions, 1 on the palmar aspect and 1 on
THE FASCIAE 643
the dorsal aspect of the web, being preferable to an incision that divides the
web. The palmar incisions may be extended well into the hand, care being
taken, in making them, to avoid the superficial palmar arch.
These palmar incisions give free access to the central space beneath the pal-
mar fascia. Transverse division of this fascia may be necessary to insure free
drainage.
Longitudinal division of the palmar fascia is usually not sufficient, unless
drainage tubes, which are objectionable, are used.
Infection in the tendon sheaths of the fingers during the early stage of invasion
is best relieved by incisions entering the sheath on either side, opposite the 2 proximal
phalanges. These tentative incisions, combined with a thorough flushing of the sheath
and the use of rubber tissue drains, will often terminate the infection in this stage.
Complete restoration of function may be hoped for.
In dealing with infections of the sheaths in the second stage of inflamma-
tion, one cannot hope to save the tendons in their entirety, and the sheath must
be opened from end to end. This, however, can be done through incisions
which do not divide the folds of the skin opposite the articulations.
When the pus has invaded the great ulnar bursa3 it can be evacuated and
the interior of the sac thoroughly exposed through an incision that occupies
the lower 2/3 of a line extending from the styloid process of the radius to
a point over the head of the fifth metacarpal bone.
This line will be found to approximate closely the radial border of the hypothenar
eminence. The bony landmark must be remembered, because, when the hand is
swollen, the line of the second guide will be obliterated. In infections of the radial
bursaB, an incision placed directly over the tendon opposite the lower 2/3 of the
metacarpal bone of the thumb will give access to this sheath with but slight injury
to the short muscles of the thumb.
Counter openings should be made on the proximal side of the annular
ligament to drain portions of both these bursaa which extend into the forearm.
THE ANESTHETIC. — A general anesthetic should be given when performing
these operations, as complete control of the operative field is very essential.
THE FASCLE
The fascia is of great interest to the surgeon. His intimate knowledge
of this structure will greatly facilitate his operative procedures (especially
in dealing with the fluid products of inflammatory conditions) and greatly aid
his understanding of the course that exudates and collections of blood tako
when occurring in various regions of the body. Thus the fascia of Colles
offers the sole explanation of the course of the extravasation in rupture of
the urethra. The position and the direction taken by the exudate in cold
644 THE MUSCLES, TENDONS, BUKS^E AND FASCLE
abscesses occurring in the cervical and lumbar portions of the spine are only
to be appreciated by a knowledge of the fascia of those regions.
While the fascia determines the direction and progress of fluids along quite
definite anatomical lines, instances are not uncommon where an abscess or
growth seems to ignore these membranes, and to pursue a course of its own.
This can, however, usually be explained by the abscess or growth having
destroyed the limiting membrane, and gained access to different levels. The
destructive character of cervical abscesses depends, without doubt, upon the
unyielding nature of the fascia. The invasion of the thoracic cavity by in-
flammatory products in the neck and the extension of exudates and secretions
following operations on the larynx, trachea, and esophagus are too well known
to require mention.
The controlling and limiting effects of the fascia in various parts of the
body will be discussed by the writers dealing with the diseases and operations
of those regions. It remains for me to describe the general diseases of the
fascia, which are not numerous. The involvement of the fascia associated with
the various forms of wry neck is more properly dealt with by the writers
on that region.
Injuries to and Rupture of the Fascia. — Injuries to and rupture of the
fascia have been discussed in connection with the diseases of muscles.
Dupuytren's Contracture. — The disease of the fascia which the general sur-
geon is called upon to treat more often than his orthopedic brother is that
known as "Dupuytren's contracture." This condition of the palmar fascia
was first accurately and anatomically described by Dupuytren. A wide dif-
ference of opinion still exists as regards its etiology. The unfortunate fre-
quency with which the disease returns after operation would make a complete
understanding of its causation desirable. Lacking this complete elucidation
of the subject, the surgeon must continue to base his treatment upon the
pathology of the disease and the facts at present accepted as contributing to
its causation. Langham believes the new formation of connective tissue to
be of an inflammatory nature, as he describes nuclear proliferation in the cells
in the coats of the arteries, as well as in the connective tissue betwreen individual
fibrous strands. This nuclear proliferation is best seen in the fibers which
attach the fascia to the skin.
The growth of the connective tissue is not evenly distributed, as nodular
formation takes place in the contracting bands.
Gout and rheumatism are commonly mentioned as contributing factors.
Trauma, however, seems to play the greater part in the causation of the disease.
Some authors believe that the loss of the subcutaneous fat, thus exposing the
fascia to greater trauma, is a predisposing cause.
More recently Ledderhose, from clinical and microscopic study, has ad-
vanced the theory that the beginning of the disease is inflammatory in char-
acter from the proliferation of cells seen in the coats of the vessels and
between the fibrous bands. He believes that trauma, acting upon the inflamed
TIIK FASCIA
fascia, produces a reaction followed by nodular formation and subsequent
contraction of the new tissue. Until proof of a very convincing character is
produced, trauma, in the minds of most surgeons, will stand as the greatest
causative factor.
The occurrence of the disease on the ulnar side of the palm, the side \vhirh
bears the majority of blows and which is used in many occupations to deliver
blows, as in the carpenter's use of the chisel, must convince one that trauma
plays a most important part.
Fibromata occur in various parts of the body as the result of injury to the
connective tissue. Ganglion is now believed to result from the transformation
of small hemorrhages occurring in the fibrous tissue about joints and sheaths
of tendons. Both the above arise as the result of injury to the- fibrous tissue,
and it is reasonable to suppose that the change in the fascia of the palm takes
place in the same manner.
The measures for the relief of this condition are divided into palliative
and radical operations. In the palliative operations the eontracte«l tissue
is divided subcutaneously, or a single or several incisions are made across
the long axis of the bands without attempting to remove any of tin-
tissue.
In the radical or open operations, as they are called, the removal of the
restraining tissue, in part or in whole, is attempted.
Transplanting or shifting of skin flaps forms a part of some of these
operations. The disease after a shorter or longer time involves the skin, thin-
ning it out and making it very difficult to reflect it as a flap from the under-
lying fibrous tissue.
PALLIATIVE OPERATIONS. — DUPUYTREN'S OPERATION. — Extend the fin-
gers and divide the bands by means of transverse incisions placed opposite
the metacarpophalangeal joints. The incisions are carried through the skin
and fascia, naturally not through the flexor tendons. The fingers are fixed
in the extended position by means of a splint.
ADAM'S OPERATION. — At places where the skin is not adherent to the sub-
jacent band, a fine tenotome is introduced and the band divided. This is
done at several points. Fix the fingers by means of a splint in the extended
position.
MULTIPLE TRANSVERSE DIVISION. — This is the same as Dupuytren's opera-
tion. After the division of the contracture, the fingers are extended. The
skin will be found to gape at the site of the incisions. These gaps are covered
by a Thiersch graft and treated accordingly.
After healing has taken place in the above operations, make use of mas-
sage, and retain the splint until there is no tendency in the fingers to resume
their former position.
EADICAL OR OPEN OPERATIONS (KOCHER, HARDIE, ETC.).- \oiTUDI-
NAL INCISION. — Through a longitudinal incision, after reflecting the skin to
either side, excise as much of the contracted palmar fascia as can be reached.
646 THE MUSCLES, TENDONS, BTJES^E AND FASCIAE
(Hardie divides the fascia transversely, excising portions at times.) The
after-treatment is the same as for the palliative operations.
THE Y-SHAPED INCISION, with base toward the finger involved, sometimes gives a
wider exposure to the disease in the hand. After excision of the scar tissue and ex-
tension of the finger, the wound will gape widely and the subsequent suture of the
wound will be Y-shaped.
LOTHEISSEN'S OPERATION. — This procedure exposes and removes the fas-
cia through an L-shaped incision placed along the ulnar border of the hand
and across to the base of the thumb. After excision of the contracture and
straightening of the hand, the wound will be found to gape where the incision
crosses the wrist. This incision gives access to a region in the hand ordi-
narily uninvolved by the disease, and a poor exposure of the region actually
involved.
LEXER'S METHOD. — Lexer recommends, even in the less advanced cases,
excisions of the entire aponeurosis and sacrifice of a wide area of skin. The
wound is closed by a whole-skin flap, the hand being placed beneath a flap
raised from the abdomen.
«
The frequency with which our operative effort for the relief of this condi-
tion meets with failure, renders comment on these more ambitious operations
unnecessary.
CHAPTER XV
GUNSHOT WOUNDS AND THEIR TREATMENT
ALEXANDER BRYAN JOHNSON
GENERAL CONSIDERATIONS
Before discussing gunshot wounds and their treatment a few preliminary
remarks may not be out of place. In order to treat these wounds intelligently
special knowledge is necessary. They differ in many ways from other in-
juries. They are produced by projectiles fired by means of an explosive from
rifles, pistols, shotguns, and from cannon. Another group of wounds which
must be considered with gunshot wounds includes those made by the explosion
of bombs, shells, hand grenades, and similar Devices.
In character gunshot wounds resemble both punctured, contused and
lacerated wounds. Sometimes these wounds are almost identical with punc-
tures ; in other cases the wounds resemble contusions, lacerations, and crushes.
In severity they may be of any grade from a slight contusion to the loss of an
entire limb, decapitation, etc. When made by bullets the wounds of entrance
and of exit may resemble mere punctures, and often furnish no direct evidence
of the extent and gravity of the destruction wrought in the deeper tissues.
Often such destruction is extensive, and though it cannot be seen from without,
it may be inferred from the known peculiarities of bullet wounds, such as
loss of function, shock, and other local and general signs and symptoms.
These peculiarities of bullet wounds are many and varied. Xo practical
rules for treatment can be given without taking them into account; hence
it will be necessary later to discuss at some length the effects of different
kinds of projectiles upon the different tissues and organs of the human
body.
Practically, an important distinction may be made between wounds re-
ceived in warfare, whether afloat or ashore, and wounds received in civil life
in times of peace. Not only are the weapons, the projectiles, and the wounds
themselves, as a rule, quite different, but also the circumstances under which
they are received and the facilities for their treatment.
647
648 GUNSHOT WOUNDS AND THEIE TREATMENT
WOUNDS RECEIVED IN CIVIL LIFE
The gunshot wounds coming under our care at the New York and Hudson
Street Hospitals are numerous. They are with few exceptions pistol shot
wounds, fired at close range from pistols loaded with relatively small charges
of black powder. The most common calibers are .22, .32, .38, and in a few
cases of wounded Chinamen, caliber .45. The bullets are usually of soft lead.
Such bullets, more especially of the smaller calibers, frequently lodge. They
are easily turned by bone, by tendons, even by fascial edges, and thus an
irregular track made by the bullet is common, as, for example, contour shots
following the outer surfaces of the ribs sometimes half-way around the body.
An explosive action is scarcely observed, except in the case of revolver shots of
45 caliber. These bullets are driven usually by the equivalent of about 40
grains or more of black powder, and the wounds resemble rather rifle bullet
wounds of the old-fashioned type. With the small calibers the shafts of the
long bones are rather rarely broken, and if fractures are produced comminu-
tion is not very extensive. Even on structures so soft as the brain the dis-
integrating effect of the bullet is often limited to a narrow tract in the cere-
brum. Bullets of .22 caliber sometimes fail to penetrate, and are flattened
against the thicker portions of the skull.
On the solid organs of the abdomen, the liver, spleen, and kidney, an ex-
plosive effect is absent or only slightly marked. These organs are usually
drilled, sometimes with radiating fissures, but they are not burst and disin-
tegrated in the manner observed after wounds made by modern military rifle
bullets. The urinary bladder, if* wounded, usually shows a ragged perforation,
not much larger than the caliber of the bullet.
Wounds of the lung, unless the large vessels near the root are injured, are
usually recovered from quickly. In a few cases empyema follows ; in others a
pneumothorax may persist for months.
In wounds of the alimentary canal the perforations, unless tangential, cor-
respond pretty closely to the size of the missile. The perforations may be sur-
rounded by a rather narrow rim of devitalized tissue. Escape of intestinal
or stomach contents is the rule, followed by acute purulent peritonitis, or, if a
part of the colon is wounded, uncovered by peritoneum, a fecal abscess is
formed.
Wounds of the main blood vessels of the abdomen are, as a rule, rapidly
fatal from hemorrhage. The main blood vessels of the extremities are only
rarely injured, though an occasional traumatic aneurysm or arterial hematoma
is observed.
Arteriovenous aneurysm is observed as a rarity in the extremities, and
has followed in one or more cases bullet wounds of the base of the skull, with
pulsating exophthalmos. In a number of instances small bullets have
remained indefinitely quiescent in the brain until the patients were lost
sight of.
GENERAL CONSIDERATIONS
Wounds of the nerve trunks of the extremities may be complete or partial
divisions and may be followed by neuritis.
Shock is most marked after complicated abdominal wounds, and in these
cases the symptoms of both shock and hemorrhage are often combined. In
uncomplicated wounds and wounds of the extremities shock is usually absent
or not marked.
During the past few years many of the homicides and suicides in this city
were done with automatic pistols. The bullets are usually steel- jacketed, and
the wounds produced are often more serious than those ina-lc by the <» 1.1 -fash-
ioned revolver. The bullets are usually not large, but thov have an unusual
velocity, much greater than is the case with ordinary revolvers. The wounds,
indeed, resemble those made by the small caliber rifle at greater ranges.
Some years ago I conducted a few experiments with automatic, pistols,
more to determine the effects of smokeless powder upon the skin than for anv
.other reason, but incidentally I observed the effects of these bullets when
at close range into the head and into the extremities. I quote from an article
which I wrote at that time:
Wounds produced by Automatic Pistols: The Mauser pistol, caliber 7.63 milli-
meters; the Luger pistol, caliber 7.65 millimeters; the Colt automatic pistols, caliber
.32 and .38. In 1897 Bruns conducted experiments with the Mauser pistol, and con-
cluded that the effects of its bullet were identical with that of the military rifle at
proportionately longer ranges. The following relations were found to exist: At 20
to 200 meters the effect of the Mauser pistol was the same as the effect of the military
rifle at 1,000 to 2,000 meters respectively. In this connection, I insert the results of
certain experiments made by me with automatic pistols in order to determine the
effects of smokeless powder at short ranges upon the skin, and incidentally to observe
the effects of the bullets upon the tissues, in comparison with the old-fashioned black-
powder revolver firing a soft-lead bullet and a small charge of black powder.
A description of some of the shots in detail follows :
Shot I. Colt's automatic pistol, caliber .32; 4 grains of Walsrode powder; bullet
weight, seventy-six grains, full cupronickel jacket; distance of muzzle of pistol from
the skin, two inches. The shot was fired at the side of the head in front of the ear,
skin covered with short hair. The hair was not singed. The skin was not burned.
A few grains of a dark gray residue were found upon the hair, and upon the skin
over an area one inch in diameter, surrounding the bullet wound. These grains were
readily wiped off with a dry cloth, leaving no visible mark behind. The wound of
entrance was a small circular orifice one-sixteenth of an inch in diameter. There was
no fraying or discoloration of the edges. The wound at the point of entrance in the
skull was found to be a round hole through the bone about the diameter of the bullet
The wound of exit from the scalp upon the opposite side of the head, back of the ear,
was a mere slit in the skin one-fourth of an inch in length. The wound of exit from
the skull was a round hole about the diameter of the bullet. No explosive effect was
observed. The bullet struck, but failed to penetrate a barrel of sand used as a barking,
and was picked up slightly flattened at the point.
Shot II. Colt's automatic pistol, caliber .38 of an inch; cupronickd ja<-k«-t. in-
complete in front (what is known as a soft-nosed bullet); charge, 7 grains of \V;ils-
650 GUNSHOT WOUNDS AND THEIR TREATMENT
rode powder; weight of bullet, 130 grains. The shot was fired into the temporal
region at a distance of two inches. Wound of entrance was a round orifice in the skin
one-eighth of an inch in diameter. Edges of orifice were slightly frayed. There were
a few faint grayish stains upon the skin surrounding the wound. These specks
appeared to be embedded in the skin and could not be removed with a wet cloth.
The hole of entrance through the skull was round and about the diameter of the
bullet. The wound of exit in the skin upon the opposite side of the head was an
irregular tear about one inch in length, with radiating slits along its border. Brain
substance escaped freely from this orifice, as well as from the external auditory canal
on the same side of the head. Palpation of the skull showed a comminuted fracture
surrounding the wound of exit. The comminution of the skull extended over an area
three inches in diameter in the temporal and parietal regions. There was also
evidently present a fracture of the base of the skull. After leaving the head the
bullet buried itself in a barrel of sand. The explosive effect of this shot was well
marked.
Shot'III. For purposes of comparison, a shot was fired from a Hopkins and Allen
revolver, caliber .32, ten grains black powder, Smith and Wesson ammunition, soft-
lead bullet. The shot was fired into the temporal region with the muzzle of the pistol
three inches from the scalp. The hair was singed. The scalp was burned and tat-
tooed with powder grains, so that the skin was blackened over an area one and one-
half inches in diameter. The wound of entrance in the skin was one-eighth of an
inch in diameter, the edges were slightly contused and stained with lead. The hole
in the skull was about the diameter of the bullet. The bullet lodged.
Shot IV. Luger automatic pistol; steel- jacketed bullet; jacket incomplete over
a small circular area at the point of bullet where the lead interior is exposed; dis-
tance, three inches. Shot was fired into the cheek over malar bone backward, down-
ward and inward. No powder marks were upon the skin. Orifice of entrance was
three-sixteenths of an inch in diameter, and circular. Edges were slightly contused
and white in color. No tearing of tissues nor explosive effect was observed. Bullet
was extracted later undeformed.
Shot Y. Mauser automatic pistol; caliber 7.63 mm.; steel- jacketed bullet; dis-
tance of muzzle of pistol from skin three and one-half inches.. Shot was fired at outer
aspect of upper third of right thigh. Powder stain was one inch in diameter, a gray-
ish smudge without deposition of distinct grains. Wound of entrance was circular.
Edges were slightly frayed and contused, white in color. Wound of exit on inner
surface of limb was oval, three-sixteenths of an inch in diameter, slightly ragged.
There was a wound of entrance on inner aspect of left thigh; wound of exit on
opposite side the same. The bullet then passed through the distal phalanx of left
thumb and entered a barrel of sand, penetrating a distance of one foot. Although the
bullet passed through the center of both limbs, neither femur was fractured, nor was
the bullet deformed.
Shot VI. Mauser pistol ; fired into upper third of right thigh at a distance of one
foot; full-jacketed bullet. A few dark-colored specks or grains were present on the
skin around the wound over an area three inches in diameter. These were readily
wiped off with a dry cloth. The bullet caused a fracture of the right femur, and
passed across the body above the perineum, passed through the pelvic bone and was
found just beneath the skin above the left great trochanter. The bullet was slightly
deformed.
Shot VII. Hopkins and Allen revolver, black powder, .32 caliber, Smith and
Wesson ammunition. Shot was fired at outer aspect of right thigh; distance, one
foot. Skin was tattooed with powder marks too numerous to count over an area three
and one-half inches in diameter. Wound of entrance was circ.ular, three-sixteenths of
an inch in diameter; edges stained with lead. Bullet lodged.
GEXKRAL CONSIDERATIONS &51
As a matter of experience, however, most of the pistol-shot wounds we see
in the hospitals are produced by old-fashioned revolvers with soft-lead bullets.
The patients are generally received soon after the receipt of the injury. They
walk into the hospital, or the more severely injured are brought in by the
ambulance. Cases requiring surgical interference are operated upon at once.
They are surrounded by every care that a modern hospital affords, and the
results are as a rule excellent, even though many of these patients are acutely
alcoholic, and not in the best of physical condition, belonging, as the majority
of them do, to the city's underworld.
Pistol-shot wounds of the extremities and trunk, when uncomplicated, heal
as a rule promptly without suppuration, whether the bullet lodges or not. It is
rare to find portions of clothing or other material as a cause of suppuration.
A large number of such wounds are treated yearly in the Hudson Street Hos-
pital, and when the injuries are not necessarily fatal the results are almost
uniformly good.
Wounds from shot-guns are rarely seen. If fired at close range these
injuries are often severely contused and lacerated, compound, comminuted
fractures, or, if of the head or trunk, immediately fatal injuries. If the
range be 50 feet or more the gravity of the injury will depend to a great extent
upon the size of the individual shot pellets, and may be slight or serious. But
in all these cases the patients may, and usually do, receive immediate and
skilful treatment under favorable surroundings, aseptic treatment of their
wounds, complete rest, good food, in short, they are well cared for from the
start.
WOUNDS RECEIVED IN WARFARE
In warfare conditions are quite different. The weapons, though usually
fired at great ranges, are of a far more deadly character, both on land and sea.
We shall consider the conditions of land warfare first. In land warfare gun-
shot wounds are caused by military rifle bullets, by shells and shell fragments,
by shrapnel and canister, and in the most recent wars by fragments of bursting
hand grenades, or from similar grenades fired by means of a small, blank
cartridge from the muzzle of the military rifle. These grenades are now used
both in day and night attacks in the final rush from the trenches. Their use has
been attended by a terrible mortality,, far greater than is possible by rifle fire
at close quarters, where the rifle is at best rather an unhandy weapon. The
fragments from these grenades produce wounds resembling those made by
shrapnel and shell, namely, complicated extensively lacerated wounds usually
infected and far more difficult to treat successfully than the clean perforations
commonly made by the small caliber rifle bullet.
The modern military rifle sacrifices some of the destructive characteristics
of the old-fashioned, heavy leaden bullet, for the sake of greater range and
flatness of trajectory, but other qualities none the less or even more deadly are
retained or acquired. The bullet is of small caliber, about .30 of an inch. At
652 GUNSHOT WOUNDS AND THEIR TREATMENT
ordinary ranges it passes entirely through the body, no matter in what position.
The character of the wound varies greatly under different conditions, and we
shall now consider some of the peculiarities of modern bullet wounds.
Recently the United States, England, France, and Germany have adopted
a new bullet (model 1906), which differs from the one which preceded it in
several important particulars. Its use in actual warfare has now been sufficient
for us to draw some general conclusions from actual experience, and experi-
ments seem to show that the wounds produced are different in some respects
from other bullet wounds. This bullet has a sharp point instead of the ogival
shape of the old bullet. The particulars are as follows : The new bullet is of
the same caliber as the model immediately preceding it, but is shorter, lighter,
has a higher velocity, and a much sharper point. Its length is but 1.08 inches
as against 1.25 inches for the model of 1903 ; its weight 150 grains, as against
220 grains of its predecessor. Its muzzle velocity is 2,700 feet per second, an
increase of 400 feet. Its structure is as before, a core of lead and tin composi-
tion inclosed in a jacket of cupronickel. The charge is of pyrocellulose
composition, very similar to the powder used for propelling charges in field
and sea coast guns. The grains are cylindrical, perforated, and graphited.
The normal charge weighs from 47 to 50 grains, varying with the lot of pow-
der used. By the use of this cartridge (powder and bullet) the trajectory has
been flattened, and the point blank danger space has been raised to 718.6 yards.
At 1,000 yards the bullet will penetrate 12.8 inches of pine, and at 100 yards
will penetrate a steel plate 0.3843 inch thick. Some experiments with simi-
lar bullets, quoted in Johnson's aSurgical Diagnosis," were made and recorded
by Riedinger, and are here reproduced :
ADDITIONAL EEMARKS IN REGARD TO GUNSHOT WOUNDS PRODUCED BY MILITARY RIFLE
BULLETS OF THE MOST RECENT TYPE
At the present time, Germany, England, and France have adopted a military rifle
which fires a bullet of a caliber of 88 mm. The bullet differs from those used by
other nations in certain- particulars. Instead of a rounded or ogival point, the bullet
is sharply pointed. It is probable that other nations will soon adopt this form of
bullet. The pointed bullet offers less resistance to the air than other forms, and con-
sequently a flatter trajectory is possible. The center of gravity of the bullet lies nearer
its base than in the ogival-tipped bullets, an(J this produced, so it is said, a tendency for
the bullet to tip over after it has reached a certain point in its flight. In order to
overcome this tendency at ordinary ranges, the initial velocity given to the bullet is
very high indeed. The German bullet is 27.8 mm. long and weighs 10.0 gms. A re-
view of the experiments of others and the results of certain experiments made by him-
self has been published by Dr. Riedinger, and from his monograph the following
data are derived:
The powder load is 3.2 gms. On account of the relatively small weight of the
cartridges, soldiers are able to carry a larger number without notable effort. The
rifle is most 'efficient up to ranges of from 800 to 1,000 meters. The initial velocity
of the bullet is 855 meters per second. The extreme range is 4,500 meters. At a
range of 800 meters the bullet will perforate in a sagittal direction any portion of
GE.XKKAL COXSIDKKATIONS 653
the human body. At the same range, if the body is struck lengthwise, wounds are
observed from 400 to 600 mm. in length. If at this ran^e the bullet strike flatwise,
a wound of 130 mm. deep may be produced. At very great range the weapon is less
efficient than the military rifles at present in use by other nations, and at similar
ranges the bullet shows a decided tendency to tip over. It is therefore probable that
wounds made by the bullet striking flatwise will be more common. Further, then- i^
some tendency for the bullet to be deflected when it strikes hard bone.
In general, the destruction of bones and soft parts and the wounds produced
closely resemble those made by the ordinary ogival-pointed bullet. In the shafts of
the long bones the bullet produced comminuted fractures, the area of comminution
and the lines of the fracture suggesting in shape the outlines of an ordinary en\.
or in other cases the outspread wings of a butterfly. At close ranges a large number
of minute bone fragments of a generally quadrilateral shape nn- produe,-,!. At in-
creased ranges the comminution is less marked, the number of fragments is smaller,
and the size of the individual fragments greater. In these particulars the wounds do
not differ markedly from those ordinarily observed. Comminution of the shafts of
long bones, tibia and femur is observed up to a range of 2,000 meters. If the shaft
of the long bone is struck near its border without opening the medullary canal, a
groove may be cut in the bone without notable comminution and without any marked
radiating lines of fracture. (Fessler.)
Upon the spongy ends of the long bones simple perforations are often produced,
resembling those made by the ogival-shaped bullet. In other cases perforation occurs
with more or less marked radiating lines of fracture. The more nearly the wound
approaches the hollow diaphysis of the bone, the more marked are the splintering and
comminution.
The wound of entrance in the skin from direct shots is very small, smaller usually
than the diameter of the bullet. The edges of the wound usually show fine, radiating
tears. The wound of entrance is slightly stained of a grayish color, due to powder
residue which clings to the bullet. It is thus possible to differentiate the wound of
entrance from the wound of exit. If the bullet strikes the skin obliquely or flatwise,
the wound of entrance will, of course, be larger and of a different shape. The wound
of exit is also, as a rule, quite small, irrespective of the amount of destruction of the
bone or subcutaneous soft parts. When bones are fractured, minute particles of bone
are scattered through the tissues and may sometimes be seen in the wound of exit. If
the bullets strike flatwise, the wound of exit is usually much larger, and through it
torn tendons and muscular bellies may protrude.
Eiedinger says in regard to the most modern French military rifle that the ball
is solid ; it consists of copper, to which a small amount of zinc is added. It is pointed
at the end, resembling in shape a torpedo or cigar. It is longer than the German
bullet, 39.9 mm. as compared with 27.8 mm. The caliber is 8.0 mm. The bullet
weighs 13.2 gms., and is therefore heavier than the German bullet. The initial vel
however, is lower, 730 as compared with 830 meters. The trajectory is not as flat as
the German rifle, but the weapon is effective at greater ranges.
Eiedinger considers that the most important differences in the wounds produced
by these pointed bullets will depend upon the tendency for the bullet to be upset in its
flight and co strike flatwise. Sufficient observations have not as yet been made to
determine how often such wounds will occur. (Experience in recent wars, notably
the Balkans, indicates that these bullets are more destructive than was supposed,
are so easily upset that mutilating wounds are frequent, and there are manj
wounds which do not come under treatment. The wounded die on the field.-
If the bullet strikes point foremost, wounds of the soft parts alone will probably be
simpler even than those produced by the ogival bullet, and the same will bo true for
wounds of the spongy bones. If, on the other hand, the bullet upsets, a considerable
654 GUNSHOT WOUNDS AND THEIR TEEATMENT
cavity will be produced in the track of the wound. The wounds of the shafts of the
long bones do not differ materially from those made by other small-caliber bullets.
When the bullets strike flatwise, the destruction of both bone and soft parts will be
greater. The wounds of entrance and exit will be larger and aseptic healing will be
more difficult to obtain. Biedinger says that, if the bullet strikes some very massive
obstruction when moving at high velocity, any massive hard portion of bone, for
example, the mantle may be torn and the leaden core of the bullet may split up into
fragments, producing very severe wounds.
The pointed bullet is even more apt to make a clean perforation in blood vessels
than the ogival form. Wounds of nerve trunks will probably resemble those already
observed. Fessler fired twelve experimental shots through the abdomen. In all but
one the intestine was wounded. The effects upon the skull were said to be even more
destructive than usual. Wounds of the thorax, when the bullet preserves its proper
line of flight, will not differ from those produced by the ogival bullet. If, however,
the bullet is upset and strikes flatwise, more serious injuries are to be expected. Thus
a certain proportion of the wounds will be more serious than ordinary, and there will
exist another group in which the injuries will be relatively slight.
With the exception of the greater tendency of these bullets to upset in their flight,
or to upset when they strike home, it does not seem to me that the wounds produced
are likely to differ materially from those ordinarily observed.
In regard to the cavalry arm of the U. S. Navy and Military Service, recent ex-
perience and experiments seem to show that revolvers of .38 caliber are not sufficiently
powerful and do not produce sufficient shock to stop a charging horse, unless the shot
be a particularly fortunate one. Experiments were conducted upon steers for the
purpose of testing the stopping power of various pistols. It was found that a heavy
revolver of .45 caliber, when fired through the body of an ox, would nearly always
cause it to drop instantly, so that it was unable to regain its feet. Revolvers with
lighter bullets and of smaller calibers fail to do this. The automatic pistols, there-
fore, of the United States Cavalry have been increased in size and caliber to .45, and
at present this is the standard pistol both for the Army and Navy. The bullet is
jacketed.
It is necessary for us to revise our conclusions in regard to the humane
character of the wounds caused by the pointed bullet. They are much more
destructive than was supposed, chiefly owing to the ease with which they are
upset. Thus, La Garde, "Gunshot Injuries," 1914, page 60, says:
The effects of the pointed bullet in the Turko-Balkan War of 1912-1913 have sus-
tained the estimates of the experimenters as to its degree of deadliness. The body
wounds in the two belligerent armies seldom lived to receive hospital care. The high
ratio of wounds by shrapnel, which in themselves cause an excessive mortality among
body wounds, have come in to mask the deadliness of the pointed bullets, but the re-
ports of all the observers are unanimous on the field mortality.
Major P. C. Fauntleroy, M. C. U. S. A., our attache with the armies in the field
from January 1 to March 15, reports approximate total casualties in the Bulgarian
Army as follows:
KILLED
WOUNDED
DIED FROM WOUNDS
Officers
400
1 000
300
Soldiers . .
23.000
55.000
10.000
GENERAL TREATMENT
About 20 per cent, of all wounds were from shrapnel. If we add the number of
officers and men killed and wounded, we find the ratio of killed to w<»iind<-d to be
1 to 2.5. The very few abdominal wounds that lived to n-a.-h th«- hospital care were
prone to develop septic peritonitis with abscess. Penetrating <-h,-st wounds by the
Spitz-ball, as the pointed bullet is called over there, were prone to the development of
complications like pneumohemothorax, pyothorax, etc.
Of the wounded by the Spitz bullet that reached hospital care, the majority were
not serious, and recovery occurred in from four to six \vrrk-.
Much to the surprise of the observers, the pointed bullet often lodged; this was
attributed erroneously to defective ammunition.
It requires no prophet to predict that the war wounds of the future will be much
more grave. Body wounds will be more uniformly fatal; injury to the bones will be
more extensive and prone to suppuration.
The humane character of the reduced caliber bullet wounds so happily noted in
recent wars will be less frequent. This will be especially true of wounds of the lungs
and epiphyseal ends of the bones.
GENERAL TREATMENT OF GUNSHOT WOUNDS
Experience shows that in a large proportion of uncomplicated gunshot
wounds conservative treatment gives excellent results. This treatment is
absolutely simple, and may be outlined in a few words. tThe external wounds
and the surrounding skin are painted with tincture of iodin, without previous
washing in water. If the skin be grimy and oily, the surface may be cleaned
with turpentine, with equal parts of alcohol and ether, with alcohol, or with
benzin or gasoline. After wiping dry with a pad of sterile gauze, the iodin
may be painted on with another similar pad, or a plug or pad of gauze sat-
urated with iodin solution may be left in or upon the wound. An occlusive
sterile dressing follows, preferably covered by an immobilizing splint. In
addition, rest, food, and attention to the bowels are usually all the treatment
that is needed. The Medical Department of the Army now furnishes iodin to
troops in the field. It is issued in sealed glass tubes, each tube containing
one gram of iodin and one and one-half grams of potassium iodid. The con-
tents of a tube dissolved in 50 cubic centimeters of alcohol, or, in default of it,
in water, makes a solution of suitable strength for ordinary use.
So long as a bullet wound is not infected, does not penetrate an important
body cavity, and is not attended by the signs and symptoms of injury to a
large blood vessel or a nerve trunk, its lodgment is rarely of much importance.
Probing of bullet wounds is unnecessary and unwise. The bullet can be lo-
cated quite accurately by two X-ray pictures, preferably stereoscopic or with
Sweet's localizer or some similar device. Such a bullet can usually be re-
moved by a suitably placed aseptic cut if desired, with but little or no risk.
Many patients are anxious to be rid of such lodged bullets, and in general
their wishes may be granted. Such removal can often be done under local
anesthesia (novocain and adrenalin). It will usually be wise to cut down
upon the bullet directly, irrespective of its track through the tissues. There
656 GUNSHOT WOUNDS AND THEIE TREATMENT
are conditions under which a large missile should be removed even at con-
siderable risk, for example, when a missile is lodged in a position such that it
presses upon a nerve trunk, causing pain or even serious neuritis, or when
it lies at the bottom of an infected track or free in a joint. These conditions
will be mentioned more fully under the wounds of various structures and
characters.
It has been observed in recent wars that rifle-bullet wounds involving the
spongy ends of long bones and large joints may heal perfectly under an oc-
clusive dressing with little or no impairment of function. It was learned first
by German surgeons in the war between France and Germany, and has been
emphasized by experience in every war since then, that under the conditions of
an active campaign the wounds would do far better under an occlusive anti-
septic dressing with immobilization of the wounded part until they can be
transported to a well-equipped hospital, than by attempts at active interference
in the field, except in cases of absolute necessity, as, for example, the arrest of
active bleeding. In recent wars this has been notably true of gunshot wounds
of the abdomen. When operations have been done in these cases in field hos-
pitals the mortality has been very high, higher than would be normal after
the same injuries and operations done in a well-equipped hospital in time of
peace. Among the cases treated conservatively without operation the mor-
tality has been high, yet there has been a fair proportion of recoveries, though
in some of these it seemed certain that the alimentary canal was perforated.
The recoveries were due apparently to the fact that the soldiers went into
action hungry and with but little food, either in the stomach or in the intestine.
In consequence no leakage occurred and no infection.
The very high mortality following laparotomy for gunshot wounds in-
volving injury to the abdominal viscera in battle depends upon three factors,
namely :
(1) Time.
(2) Unavoidable absence of aseptic surroundings.
(3) Improper after-care owing to the necessity of transporting the wounded often
to great distances, entailing want of rest and quiet and the passing of the wounded
through many different hands. Moreover, at the field hospitals, the number of the
wounded may be very great. The number of attendants and surgeons is of necessity
small. But little time can be given to the individual case.
In civil practice in time of peace it is a matter of common experience that
the prognosis of operations for perforation of the stomach and intestine,
whether due to injury or disease, depends largely upon the number of hours
elapsed since the perforation took place. Thus, after twelve hours, the
chances of recovery grew smaller rapidly hour by hour. Toxemia and,
paralysis of the bowel, having reached a certain grade, render the patient's
condition hopeless. Under the conditions met on the battlefield many hours
may elapse before the wounded receive even first-aid attention. Transportation
GENERAL TREATMENT
to a field hospital consumes some time, and still further delay may occur
before the wounded can be operated upon, and then under conditions anything
but favorable.
Following such operations in time of peace the patient has absolute rest
and unremitting skillful care and attention, without which he will al:
tainly die. Unavoidable absence of aseptic surroundings and want of proper
after-care, however, contribute to render abdominal operations upon or near
the battlefield desperate measures only justifiable under exceptional condi-
tions, or in cases where the indications are absolutely plain, as when intestinal
contents, gas, or feces escape from the wound, when active bleeding calls for
control, or when, after shell wounds, the bowel or some other abdominal
viscus, spleen, kidney, or omentum, is prolapsed.
In time of peace in well-equipped hospitals attended by surgeons of ex-
perience gunshot wounds of the abdomen should be, and commonly are, treated
by an exploratory abdominal incision at once, whenever perforation of the
abdominal wall is probable, whether the symptoms of shock or hemorrhage
point to the injury of important structures or not. The exploration adds
little or nothing to the peril of the wounded individual, and if any serious
injury has occurred to the viscera immediate operation gives the best possible
chance of recovery.
The position of the incision will depend to some extent upon the position
of the external wound and the probable course of the bullet. Where no signs
or symptoms are present to serve as guides to the probable situation of the
mtra-abdominal injury a median cut is commonly regarded as best. The
abdomen having been opened, search is made for the lesions present according
to the rules and principles governing modern aseptic surgical tevhnie as
applied to the interior of the belly, fully described elsewhere in this book. It
is well, in my experience, if much free blood is found, to search for the blee.l
ing points and stop the hemorrhage first, before searching for wounds in the
bowel, stomach, or other viscera. It often happens that the necessary manipu-
lations will start wounded vessels bleeding afresh and violently, and if such
bleeding be disregarded while holes in the intestine or stomach are sought for
and sutured the surgeon may suddenly find himself finishing his operation
hurriedly and perhaps inefficiently upon an exsanguinated patient. It is bet-
ter to stop the bleeding first, whatever its source, by ligature or suture, if
possible— by packing, if necessary— and to attend to the removal of blood and
intestinal contents and the suture of perforations later. If, however,
operating-room be equipped with an efficient aspirating device, such as de-
scribed in Chapter VII, Volume I, a good assistant may, with advantage, and
without much interference with the operator, remove much of the blood
other material, while search is made for the source of hemorrhage.
these operations well requires an experienced operator, trained assistants, good
retraction, etc.— in fact, a well-equipped and well-conducted operating-room.
Though haste never produces efficient work, speed may be essential to success,
43
658 GUNSHOT WOUNDS AND THEIE TREATMENT
and this is only to be attained in work of this kind by a thoroughly trained
staff accustomed to working daily together.
It has been suggested that wounds of the belly should be treated on the
battlefield or in the field hospitals by complete rest, starvation, and large
doses of morphin or opium. It seems probable that some patients might thus
be saved who would otherwise die. A very marked difference certainly exists
between the results of wounds made by old-fashioned, large, heavy, soft-lead
bullets and the modern hard projectile fired at high velocity and used at
present. A larger proportion of the wounds made by the latter are immedi-
ately fatal, but in those who recover wound infection is less frequent, and
complete and rapid restoration to health is the rule, so that wounds ap-
parently of a serious character may be recovered from in ten days or a fort-
night, and the soldier again be ready for duty in a surprisingly short time.
With the old lead bullets prolonged suppuration, resections, amputations, and
greatly delayed convalescence were the rule rather than the exception. The
recent wars in the Balkans have seemed to show that the sharp-pointed, small-
caliber bullets produce in general wounds of a character even more deadly
than those with the rounded point.
WOUNDS RECEIVED IN LAND WARFARE
We shall now consider the conditions of fighting on land in more detail.
Soldiers fighting on land may find themselves in one of three positions. (1)
They may be attacked while occupying a fortified post. Here the conditions
for the care of the wounded are relatively favorable. The fortifications
themselves usually offer some protection for the wounded and for the sur-
geons, who are able to care for them on the spot, and immediately.
Moreover, a good hospital is usually within easy reach, and transpor-
tation of the wounded to it is not difficult; neither is it exposed to the
perils of transportation to a field hospital during an engagement. Even if a
fortified post be captured, the peril of the wounded need not thereby be
increased.
(2) Troops may be employed as an attacking force against a fortification.
Such operations give time to the medical department in consultation with the
commander of the forces to arrange its field hospitals and dressing stations in
suitable places where, except in case of disastrous repulse and counter attack,
the wounded can readily be transported and cared for. If, however, the attack
is not successful, the wounded who fall between the advance lines of the
attack and the fortifications must lie sometimes for hours or days without
help, unless a truce is declared for this purpose. This belt of ground between
the lines will be so swept by rifle and artillery fire that no aid can be given
until the engagement is over. Such conditions happened before Port Arthur
after assaults made by the Japanese, and occurred repeatedly in the battles of
WOUNDS RECEIVED IX LAM) WAKFAIM
our Civil War. Under these conditions the wounded suffered -neatly, ;lnd
many died whose lives might have been saved by prompt assistance.
(3) One mobile body of troops may attack another force :ilso movable.
Here the conditions for the care of the wounds! are m^t ditiimlt. Th«
of modern artillery and of rifles is so deadly, even at -reat ranges, that tin-
Medical Department may find it very difficult to establish - at once
sheltered from fire and accessible to the wounded.
Method of Giving Aid to the Wounded on the Battlefield. — The following
very brief summary of an article written by General Knhert M. O'Keillv. in
Keen's "Surgery," gives the method of aiding the wounded that is used in the
United States Army.
The wounded are cared for in four ways, or, one might say, stages.
1. Regimental Aid.
2. Dressing Stations.
3. Ambulance Stations.
4. Field Hospitals.
1. EEGIMENTAL AID. — Eegimental aid is such as may be rendered by the
regimental surgeon and his assistants. The regimental surgeon or the medical
officer next in rank has under his command the men of the hospital corps de-
tailed for first-aid work. They are distributed in the rear of the fighting line
and as near to it as possible, within 1,000 yards, if practicable, and on rough
ground perhaps much nearer. Their duties are to render first aid to such of
the wounded as can be reached, to apply first-aid dressings, to check bleedinir.
to provide improvised splints, to secure immobilization, to help the wounded
to places sheltered from fire if possible, and to help them to the rear. The
regimental surgeons also supervise the work at the dressing stations, preserve
order, and see that malingerers return to the front, and that those who require
transportation by ambulance are properly cared for. If necessity requires, the
members of the regimental band and a detail of men from each company
act as litter bearers. During an engagement, however, most of the badly
wounded must lie upon the field where they fall, because litter bearers can
rarely reach them in safety, or, if they do, can only attempt to carry thorn to
the rear at great peril to both bearer and wounded. Accordingly this work
can only be accomplished in a satisfactory manner after firing has ceased, or
after a considerable advance has been made by the firing line. The only aid
that the wounded can receive at the immediate front will be such as can be
given to them by their companions on the firing line. The better the soldier
is instructed in first-aid duties, the better the care he will receive.
In the United States Army each soldier is supplied with a first-aid packet,
in a light metal case. The contents are a sterile gauze pad and bandage, so
arranged that the pad can be applied to the wound and bandairod to the limb or
other part without handling the pad itself. A small tube of iodin in solution,
if such can be made stable, is valuable to pour over the wound and the sur-
rounding skin, or, if the wound is large, the pad of gauze may be soaked in
660 GUNSHOT WOUNDS AND THEIR TREATMENT
iodiii solution and applied to the raw surface. It is important that these first-
aid dressings should extend well beyond the wound edges, and that they should
be so applied as to remain firmly in position, protecting the wound area com-
pletely from soiling by dust or by the friction of dirty clothing. If well ap-
plied, such dressings will protect a wound from outside infection for many
days, or until danger of infection from without has passed, unless the wound
surface be extensive and much contused.
In city hospitals many dressings are held in place by strips of oxid of zinc
plaster. This does not slip, nor does it irritate the skin, and affords some
support to the wounded part. A small roll of such plaster would be a valu-
able addition to a first-aid packet. It is useful for support and immobili-
zation, for holding splints and dressings in place, and for many other
purposes.
In recent wars many wounds have been healed under this first-aid dressing.
On no account should a finger or an instrument be inserted into these fresh
wounds. The less the interference the better, except for the control of active
bleeding. For extensive lacerated wounds the so-called "shell wound packet, "
now in use in the navy and artillery arm ashore, is efficient.
Before applying the first-aid dressing the clothing should be cut away and
the wound completely exposed to the air. No oiled silk, rubber tissue, or other
impervious material should be used, either on the wound or outside the dress-
ing; such a covering prevents evaporation, keeps the wound from drying, and
thus favors bacterial growth.
On no account should the wounded be brought to the rear by unwounded
comrades engaged on the firing line. The defense is thus weakened to no
purpose, and often seriously. This was observed many times on the Russian
lines when fighting the Japanese. To prevent this those detailed to render
first aid should make every possible effort to reach and bring back the wounded.
If they fail in this, human nature will assert itself against the strongest dis-
cipline, and from sympathy — not from cowardice — the soldier will desert the
firing line in order to help his wounded comrade to the rear.
2. DKESSING STATIONS. — The dressing stations are in charge of the
brigade surgeon. These are located as near the firing line as possible, but
sheltered from fire. They should be as near as practicable to some road or
track over which horse or automobile ambulances can travel to the field hos-
pitals. From the dressing stations squads of litter bearers are sent to seek and
bring back the wounded from the firing line, or as near to it as they can ap-
proach without too much exposure. When the wounded reach the dressing
stations they are examined and classified as to the apparent gravity of their
injuries. Each man is tagged with a provisional diagnosis, and an "urgent"
tag is attached to those who require immediate attention. Only emergency aid
is given at these stations. Active bleeding is controlled, first-aid dressings are
applied, injured limbs are immobilized, and remedies are given to combat
shock.
WOUNDS RECEIVED IN LAM) WAI {FAKE CGI
3. AMBULANCE STATIONS.— The function of the unbalance station
transport the seriously wounded with the least possible delay to the Held hos-
pital. When practicable, the dressing stations and ambulance stations may be
consolidated.
4. FIELD HOSPITALS.— At the field hospitals the wounded are more care-
fully classified. Dressings and splints suitable for transput t.. tin- base hos-
pital are applied. Only such operations as are absolutely neeessiry an- ,,.-r
formed, since aseptic teclmic is almost impossible under the rniiditi..'ns. II. ,w-
ever, with boiled water, tincture of iodin, boiled instrument., ;1,M Uiled rub-
ber gloves, and with a trained staff, the necessary proee.ln,,., may I,,-
ried out with some approach to cleanliness. The lar-e number of .-uses to be
cared for is always a serious handicap to efficiency, and exj.erienee shows that
the patients suffer less if they are sent at the earliest possible moment to a
base hospital or to a civil hospital in the nearest large city.
The several kinds of missiles and their effects may be taken up seriatim.
They are:
1. Eifle bullets.
2. Projectiles fired from cannon, shell, shrapnel, and canister.
3. Hand grenades.
4. Explosion of mines, etc., in naval warfare.
WOUNDS DUE TO EIFLE BULLETS
Modern rifle fire is said to be annoying at 2,000 yards, effective at 1,200
yards, decisive at 600 yards. The pointed bullet is more easily upset than
the heavier bullet with an ogival point, hence, it might be expected that the
former would more often strike sidewise, and produce graver injuries. Ob-
servations during the most recent wars show that this is very often the case.
The following description is based upon experience with the earlier type of
bullet, which is still being used by troops in the Philippines and elsewhere.
The effects upon different tissues when struck by the small calil>er hard bullet
vary with the range and also with the physical quality of the tissues or organs
struck. The kinetic energy of the bullet at ordinary ranges is enormous, and
the destructive effect upon the body varies in severity directly with the resist-
ance offered by the tissues. Thus, upon skin, subcutaneous tissue, muscle,
tendon and blood vessels, since these structures offer but a trifling resistance,
the missile, assuming that it travels head on, produces a mere puncture or nar-
row tract with little or no lateral destruction. If the bullet is upset in its flight
and strikes sidewise or butt end foremost, or if it be deformed by ricochet,
the laceration of the soft parts will be much more widespread and the skin
wounds larger, particularly the wound of exit, and consequently more apt to
become infected. When the bullet strikes the skin point foremost, and tra-
verses only soft parts, the wounds of entrance and of exit are much alike, cir-
662 GUNSHOT WOUNDS AND THEIR TREATMENT
cular, with slightly ragged edges, about 1/3 in. in diameter. The orifice is
soon filled with a black crust of clotted blood. Slight necrosis of the edges
may occur after a few days, but if the wound is covered with an aseptic dress
ing and not disturbed, primary union occurs as a rule in a week or ten days.
If the bullet strikes the skin obliquely, the wound of entrance will be oval.
As stated, these results are modified when the bullet is deformed or strikes
sidewise.
Upon solid organs or hollow organs filled with fluid, liver, spleen, kidney,
stomach and urinary bladder, the resistance offered is much greater, and at
ordinary ranges, extensive laceration and bursting are to be expected. Upon
the spongy ends of the largest bones, femur and tibia, clean perforations with
radiating fissures are common. Upon the smaller bones, metacarpals, meta-
tarsals, etc., the part struck is usually pulverized. Upon the hard shafts of
long bones, which offer great resistance, extensive splintering and widespread
destruction of bone and soft parts are the rule. In the immediate vicinity
of the point of impact the bone is pulverized. The bone dust and bone splint-
ers become secondary missiles, and often cause widespread destruction of the
soft parts, and a wound of exit of large size, sometimes slit-like with radiating
tears. If the bullet strikes the bone obliquely, a large part of the shaft may
be reduced to bone dust and splinters. These explosive effects are observed up
to a range of 600 yards, beyond which they gradually diminish, while at great
ranges, 1,500 to 2,000 yards, they nearly or quite disappear, so that the track
of the bullet becomes a simple channel with little or no lateral destruction,
modified, however, by deformed and upset bullets, when, on account of the
greater striking area, the destruction of tissues is increased.
With these general remarks we may consider the effects of rifle bullets more
in detail. As already noted, the modern rifle kills a larger proportion of those
hit outright than the earlier rifle; for example: 1 in 2.5 in the Turko-Bul-
garian War and 1 in 4.12 of those wounded in the Anglo-Boer War as com-
pared with 1 in 5.57 in the American Civil War. However, with the modern
bullet, of those wounded who do not die on the field, a large proportion recover
completely and promptly. Permanent disability is also less common. No
doubt these results are modified by early aseptic and antiseptic treatment, and
by avoidance of fingering and probing the wound. Also, while in earlier wars
immediate .amputations and resections were done in field hospitals and were
nearly always infected, at present, great conservatism is the rule, and a large
proportion of the wounded recover without infection.
We have already noted the characters of wounds of the skin.
Wounds of Tendons. — Tendons are not pushed aside, but are cut and may
be cleanly severed, as from the cut of a knife. Such severed tendons should be
sutured at the earliest possible 'moment.
Wounds of Nerves. — Nerves may be wholly or partially divided. While
early suture is the best %treatment, such nerve injuries are peculiarly liable to
be followed by peripheral neuritis and rather extensive central degeneration
WOUNDS RECEIVED IN LAND WARFARE 663
with paralysis and severe pain. The prognosis following even early nerve
suture is not as favorable as after suture following incised wounds or nerves.
If a nerve trunk is included in a mass of scar tissue, and is very painful, it
may be freed by careful dissection with hope of relief.
Wounds of Blood Vessels. — Arteries and veins are cleanly cut or perforated
by rifle bullets. If the main artery of a limb or a large artery anywhere is cut,
speedy death from bleeding may occur. In some cases if the hole in the vessel
is small, and the track of the bullet uncomplicated and narrow, passing through
firm tissues, the bleeding may stop spontaneously. The caliber of the vessel
may be subsequently normal, reduced in size, or even obliterated by scar tissue.
In other cases an arterial hematoma or traumatic aneurysm will form. It is
said that, in a few cases, mere contusion of the vessel wall has resulted in an
aneurysm resembling the pathological variety. Arteriovenous aneurysm and
aneurysmal varix have both been observed.
The treatment of wounds of vessels will depend upon whether the bleeding
stops spontaneously after rest and immobilization or continues or recurs. In
the last two groups aseptic incision and distal and proximal ligation of the
vessel is the method of choice. If, however, this is not possible, proximal liga-
tion through a separate incision nearer the heart may be done, always with the
risk of gangrene, especially of the lower extremity. Such risk will increase
proportionately to the destruction of tissue and infiltration at the site of the
original wound. If the wound is or becomes infected, gangrene is all the more
likely to occur.
A caution of value is this. Bleeding from many of these bullet wounds
tends to stop spontaneously. This result may be favored by moderate pressure
over the wound or by aseptic packing, by rest, immobilization and elevation of
the limb. A little knowledge is a dangerous thing. The immediate and pro-
longed application of a tourniquet has cost in civil as well as military practice
the loss of many a limb and many a life. The natural impulse of the inex-
'perienced is to apply a ligature to a limb for bleeding, even though it be quite
moderate in amount. Such a ligature should remain in place for the briefest
possible time. If it must remain for an hour or more, it is better to loosen it
now and then for a few moments, thus permitting some blood to reach the
parts beyond the wound. This caution does not apply to the cases of furious
bleeding where the main artery of the limb is cut, but in such cases the wound
will usually be fatal before any help is given.
RECURRENT BLEEDING. —From the necessity of transporting the wounded
to some distance and the consequent jarring and shaking, bleeding from fresh
wounds may recur. The wounded should be inspected from time to time with
this fact in mind.
SECONDARY HEMORRHAGE. —Secondary hemorrhage is a complication <
badly infected and sloughing wounds, and is due to necrosis of the vessel wall.
It should be treated by proximal and distal ligation of the bleeding vessel in
healthy tissues. For this purpose the infected wound must be enlarged and
664 GUNSHOT WOUNDS AND THEIR TREATMENT
cleaned as carefully and gently as possible with a weak iodin solution. The
vessel must be sought for and tied above and below the seat of the bleeding. If
the main artery of the limb be the source, amputation will often be the safest
mode of treatment.
Wounds of vessels in body cavities, thorax and abdomen, where the sur-
rounding soft parts afford no hindrance to the continuance of bleeding are
particularly dangerous. If the surroundings are such that search for the
bleeding point under aseptic conditions is impossible, then absolute rest and
quiet, the application of cold to the surface, and a full dose of morphin, hypo-
dermically, together with adrenalin, are the measures offering the best chance
of spontaneous arrest of bleeding.
Gunshot Fractures. — -The recognition of gunshot fractures of the long bones
is usually very easy. Only incomplete fractures may escape recognition. The
details of the fractures are best learned by taking a series of X-ray pictures.
The treatment, so long as the wound remains clean, is by the application
of an aseptic, occlusive dressing, and immobilization, according to the princi-
ples and rules which guide the surgeon in the treatment of fractures in gen-
eral. Moulded plaster-of-Paris splints are applicable to many fractures, as are
also moulded wire splints, and during the early days of treatment are to be
preferred to circular splints of plaster-of-Paris. The former are easily re-
moved and renewed. They permit easy inspection of the wound, and will not
cause gangrene by constriction of the limb. If the wound remains clean, after
the position and nutrition of the limb are assured, the moulded splint may be
replaced by a circular one in suitable cases, with a window cut over the wound
for inspection and dressing. In such a splint, early ambulatory treatment
is possible in nearly all fractures except those of the spine, pelvis and
femur.
If a gunshot fracture becomes infected it must be treated on general sur-
gical principles. Incisions must be made for the relief of tension and for
drainage. Loose fragments must be removed. Pus pockets should be care-
fully sought for and opened. The wound should be cleansed frequently but
gently by irrigation with iodin solution, saline solution or both. Open air
treatment day and night, impossible, is of great benefit. The various vaccines
are sometimes useful.' Food should be abundant but easily assimilated, such
as milk, cream, eggs, soup. Under good surroundings many of these cases
finally do well, good union is obtained and the limbs regain their usefulness.
If they do badly and become so septic that the general and local conditions
grow progressively worse, amputation should not be too long delayed. If
amputation is done, it will usually be wise to leave the amputation wound
open. The skin flaps may be held loosely approximated by one or two silk-
worm-gut sutures. The face of the stump may be lightly packed with sterile
gauze. If the amputation must be made, as sometimes happens, through in-
fected tissue, the wound may be painted with strong tincture of iodin or with
a solution of camphor and carbolic acid in alcohol (Chlumsky's Solution). In
WOUNDS RECEIVED IN LAND WARFARE 665
these cases the use of autogenous vaccines is sometimes beneficial. In default
of these, mixed commercial vaccines may be tried.
Wounds of Joints. — Recent wars have shown that rifle bullet wounds of
the larger joints may do very well under conservative treatment; so long as the
wound remains aseptic, rapid healing and more or less perfect restoration <»f
function are the rule. The result will be modified by the greater or less i
larity of the joint surfaces, due to displaced fragments and the formation <>f
new bone, causing mechanical interference with the free mobility of tin- joint,
and also by the greater or less extent of fibrous ankylosis remaining. In de-
ciding for or against a secondary operation upon such joints, the X-ray will
usually furnish important information. My own experience leads me to be-
lieve that conservatism in these cases is often the wisest course. A stiff joint
in good position is often more comfortable and useful than a weak and movable
one.
Wounds of the smaller joints, owing to the small size of the bones and the
smashing effect of the bullet upon them, are commonly followed by more or less
complete destruction of the joint surfaces, and consequent loss of function in
the joint.
INFECTED WOUNDS OF JOINTS. — No more deadly and insidious type of
sepsis exists than a badly infected wound of a large joint. Some of these cases
baffle the most skillful and earnest efforts of modern surgery. Only rarely
does the patient recover with a movable joint. Ankylosis is the result in some,
amputation in many, and death from septic poisoning, often with pyemic
abscesses, is all too frequent. The treatment consists in free drainage, irriga-
tion, and frequent and careful dressings. The use of vaccines is sometimes
valuable; also open air treatment and plenty of easily assimilable food.
The progress of these cases should be watched with exceeding care. They
usually run a semi-chronic course, and since human nature is imperfect
and acute cases are more interesting, the dressing of these unfortunates
is apt to be relegated to inexperienced members of the staff, who
fail to recognize the insidious spread of the infection until it is too
late.
Various elaborate methods have been devised for the treatment of infected
joints ; more especially the ankle and the knee. Infection of the ankle joint
may be treated with good results in certain cases by removal of the astragalus.
In several instances I have treated infections in one or other of the smaller
tarsal joints by removal of one or more of the tarsal bones with good results.
In the knee, the method of opening the joint widely and treating it in a flexed
position has not furnished good results in my hands, though highly spoken of
by several competent surgeons. Usually the joint will be treated conserva-
tively by tube drainage, irrigation, etc., until decided improvement occurs, or,
if the case does badly, until resection or amputation will be the only resource
left. Amputation in the bad oases of knee and ankle infection is, as a rule,
safer than resection. In the hip, free drainage, resection if necessary, and dis-
666 GUNSHOT WOUNDS AND THEIK TREATMENT
articulation at the hip joint in the worst cases are the several steps in the
downward path.
In the upper extremity, drainage, followed if necessary by resection, are
the methods used. Amputation will be less often called for than in the lower
extremity. It is to be borne in mind that any live appendage to the shoulder
and elbow joints, armed at its end by a thumb and one finger, is a member of
the greatest usefulness. An artificial arm and hand, though never so skillfully
devised, is an expression not of our mechanical deficiency as makers of ma-
chines, but an accentuation of the fact that no device born of human intelli-
gence can compare with the most perfect mechanism with which we are ac-
quainted, namely, the human hand. Therefore, in the upper extremity, the
utmost conservatism is to be practiced, and no effort omitted to avoid ampu-
tation. A stiff shoulder accommodates itself through the movable scapula to
nearly all the exigencies of a strong and useful arm. A stiff elbow in half-
way good position is almost no handicap at all to most occupations. A stiff
wrist is unpleasant, but scarcely crippling, and some sort of a hand, however
crippled, is an invaluable possession.
Bullets Lodged in or near Joints. — A bullet lying free in a joint cavity
will usually require removal. Unless it can be felt and identified, it should be
carefully located by the X-rays. The removal should not be attempted until
the patient can be surrounded by every aseptic precaution. If the bullet is
lodged in the spongy end of a long bone near a joint, there is no more reason
for removing it than though it lay elsewhere, so long as it is not associated with
wound infection, and does not interfere mechanically with joint mobility.
Here again no random search should be undertaken. The missile must be
accurately located. If possible, it should be removed through the overlying
bone without invading the joint.
Wounds of the Head. — Wounds of the soft parts covering the skull not in-
volving the bone are serious only on account of possible bleeding, as from the
occipital or temporal arteries, or infection. Wounds of the scalp are treated
on general surgical principles.
Wounds involving the skull are serious. At short range the explosive effect
of the small bullet when it traverses the cranial cavity is well marked. The
brain may be extensively disintegrated, the wound of exit large, and the skull
extensively comminuted. In such cases death is instantaneous, or nearly so.
As the range increases, the lateral destructive effect diminishes. At extreme
ranges it may be absent and the bullet will often lodge. An upset bullet will,
however, cause greater and more widespread destruction.
As a matter of practical experience it has been observed that even at
moderate ranges the small caliber bullet produced less lateral destruction in
its passage through the brain than experiments on the dead body would seem
to render probable. Its path may be a simple track with little or no lateral
destruction.
Tangential shots may cut a groove in the outer table and this may be asso-
WOUNDS RECEIVED IN LAM) \YAIM-ARE 667
elated with fracture of the inner table and laceration of the dura and brain.
All bullet wounds involving the skull, whether they appear to penetrate or not,
deserve careful exploration under aseptic precautions. It will often be found
that a tangential shot has produced comminution of the inner table and
laceration of the dura and brain of unexpected gravity. Loose fragments of
bone, hair, and other foreign bodies should be searched for and miiuvi-d. In
some cases the rongeur and periosteal elevators will be the only bone instru-
ments required. In others, one or other form of trephine, or the circular saw,
or some other of the common instruments in use may be required. The main
object in these, as in all surgical work on the skull and brain, is to limit tin-
bleeding and to prevent infection. If infection occurs several results are pos-
sible. Abscess of the brain may follow, and may or may not be opened with
success. In other cases a localized meningitis will ensue which may be drained.
In bad cases diffuse meningitis will develop and end fatally.
PENETRATING AND PERFORATING GUNSHOT WOUNDS OF THE SKULL.
—The signs and symptoms of these injuries will, of course, depend upon the
seat and extent of cerebral laceration and intracranial hemorrhage. The out-
look is worse when the wounds involve the lower temporal and parietal regions
and the cerebellum than when the frontal and upper portion of the parietal
regions are the seat of injury.
In civil practice my own observations of pistol shot wounds of the brain
have caused me to be astonished at the recoveries, apparently complete, follow-
ing penetrating wounds of the cerebrum, with lodgment of the bullet. Some
of these are mentioned in Johnson's "Surgical Diagnosis." Others I have seen
since that book was published. Some of these patients have passed out of our
observation apparently quite well. In others, some focal symptoms have re-
mained, slight paralysis representing destruction of small motor areas or inter-
ference with special senses.
The question of the removal of such lodged bullets must be decided by the
circumstances of the particular case. If the wound is healed, and no symp-
toms of irritation are present, it is probably wiser to do nothing, unless the
foreign body is easily accessible and its removal involves no risk of destruc-
tion of important areas, whether . centers or nerve paths. If, however, the
wound is slightly infected, and remains open, or if the bullet is manifestly
causing irritation, as shown by headaches or other significant local or general
symptoms, search for the missile through the track left in the brain involves,
in my experience, no great risk. The foreign body must be accurately 1
ized, so that the operator knows exactly the depth and direction from a £
point on the surface of the skull (usually the wound of entrance) to the t
tion of the bullet. The hole in the skull may then be enlarged to corn-emeu
'size with the rongeur, and a toothed forceps of suitable size and
Kocher clamp is often good) or some form of bullet forceps
serted in the proper direction and to the measured depth,
then be opened to an extent sufficient to clasp the bullet in the diameter whi
668 GUNSHOT WOUNDS AND THEIK TKEATMENT
it is known to present in that plane, then advanced a little, and gently closed.
If the bullet is seized, the forceps and bullet are carefully withdrawn. If not,
another effort may be made to touch and grasp it with the forceps, or the for-
ceps may be gently withdrawn and a thick, blunt-pointed probe introduced in
order to recognize by touch the metallic surface. If these manipulations are
made with due care and gentleness, no great harm will be done, and they will
usually be successful. When the bullet has ploughed through and lies more or
less completely imbedded in the base of the skull, it is better to let it alone, for
under these conditions the surgeon may have great difficulty in touching and
recognizing the missile, and even greater trouble in extracting it without doing
more damage than the conditions warrant. In some cases the telephonic probe
might be useful. I have never used it,
When bullet wounds of the brain are infected and are complicated by
abscess or localized meningitis, the indications are for drainage. The outlook
is not very good. When as the result of a bullet wound there are considerable
loss of substance of the skull and laceration of the dura which cannot be
repaired, a so-called "hernia cerebri" may develop. If not complicated
by severe infection, it is not so serious a condition as wrould appear to
those not familiar with the course of this phenomenon. For a time it grows
larger and may form a large protrusion. After some weeks the mass
always shrinks, and upon healing the scar is depressed below the level of the
skull.
Wounds of the Face. — Gunshot wounds of the face may be of any degree
of severity. No rules for their care can be given other than that they should
be kept as clean as may be by mouth washes, sterile food, and nasal douches.
In general their treatment must be modified according to the special charac-
teristics of the individual case.
When the undeformed bullet strikes point foremost, the face may be tra-
versed in almost any direction without producing grave injury. The track
of the bullet is simple, and if clean soon heals. Two types of injury are,
however, more serious: (1) Fractures of the lower jaw and fractures of the
upper or lower jaw when the bullet strikes the teeth, (2) wounds of the
eye and orbit. In wounds of the jaw, more especially the lower jaw, it is to
be borne in mind that the bone is hard and dense, and that the increased resist-
ance offered permits the flying bullet to expend a larger part of its energy.
Hence, comminuted fractures are produced. The teeth also may become sec-
ondary missiles, and greatly increase the extent of the injury. In these cases
modern dental surgery may do much by the use of interdental splints and
cleanliness, and later by plastic operations upon the face and by the use of
cleverly devised artificial teeth, plates, and their addenda.
The eye may be injured in any degree of severity, from a mere contusion
to a complete destruction of one or both eyes, or the optic nerve may be cut.
In some of these wounds the anterior fossa of the skull may be entered. The
treatment of destruction of one eye is immediate enucleation. Less severe
WOUNDS RECEIVED IN LAND WARFARE
injuries may be treated conservatively sometimes by iridectomy, by the use
of atropin and cocain, iced cloths, etc.
Wounds of the Neck. — Gunshot wounds of the neck may be slight, severe,
or immediately fatal injuries, according to the structures through which the
bullet passes. The large vessels, the nerves, the larynx and trachea, the esopha-
gus, the spine and spinal cord may any of them be injured. Those which
come under the surgeon's care will not be as a rule very severe injuries. Tin-
small caliber bullet may pass through the neck in almost any direction, *and
yet the important vessels, nerves, etc., may not be touched.
Aneurysm and aneurysmal varix as well as varicose aneurysm have all
been observed. Their treatment is operative. Wounds of important nerves
can rarely be treated by operation with success.
TEACHEA AND LAKYNX. — Wounds of the trachea and larynx demand im-
mediate tracheotomy to avoid the danger of laryngeal obstruction.
ESOPHAGUS. — Wounds of the esophagus demand immediate exposure of
the esophagus, repair of the wound in the gullet, and open drainage to avoid
abscess and cellulitis. The patients should be fed through a long rubber tube,
size about 24 French, passed through the nose or mouth into the stomach.
Wounds of the Thorax. — Wounds of the thorax may be penetrating or non-
penetrating. The former group as a rule present no serious problem to the
surgeon, provided they remain clean. An intercostal artery, if cut, should be
tied. The internal mammary may bleed fatally, and should be exposed and
tied if possible.
Penetrating wounds of the thorax, when they wound the heart or the great
vessels, are usually immediately fatal and do not come under treatment.
THE LUNG. — The lung offers but slight resistance to the small bullet, and
the track through its substance is usually narrow. The treatment is at first
conservative by an occlusive dressing and immobilization of the chest by strap-
ping and bandages. Empyema is to be treated by resection of a rib and drain-
age. In most instances, hemothorax is best let alone, for a time, for the bleed-
ing to cease permanently. If the blood accumulates in large amounts it may
be removed by a powerful aspirator. If the surgeon chooses to dp an open
operation this must be performed under intratracheal anesthesia, in a regu-
larly equipped hospital. Under less perfect conditions interference would not
be justifiable. I recently treated a gunshot wound of the lung where a largi
amount of blood had accumulated in the pleural sac, first by aspiration,
a few days, however, empyema developed and required the resection c
and drainage.
Pneumothorax is to be treated by rest and later by lung exerci es, n iely,
by blowing water from one bottle to another.
The signs and symptoms of injury of the lung when marked are pain,
hemoptysis, com*, subcutaneous emphysema, friction sounds and
changes determined by physical examination, sometimes shock and
symptoms of bleeding. External bleeding is rare.
670 GUNSHOT WOUNDS AND THEIR TREATMENT
Wounds of the lung usually remain clean, but if the bullet has passed
through the stomach or bowel first, then empyema or abscess of the lung will
be very likely to follow. When a bullet enters and lodges in the lung, it may
remain quiescent indefinitely, and do no harm.
Wounds of the Spine. — Bullet wounds of the spine may or may not in-
volve the spinal cord. Those which injure the bodies of the vertebrae may be
mere perforations. Those which involve the processes and arches are more
apt" to be comminuted and the latter are usually attended by cord symptoms.
The nerve roots may also be cut. In the wounds involving destruction of the
cord the prognosis is bad and operation, as a rule, useless. Wounds without
cord symptoms heal, if clean, under conservative treatment. The only method
of determining the situation of a bullet in the spine is by means of the X-rays.
If such a bullet appears to be pressing on the cord, and its presence is attended
by the symptoms of a partial lesion, it may be removed with possible benefit.
Wounds of the Abdominal Viscera. — Theoretically, wounds of the abdom-
inal viscera should be operated upon and the injury repaired. Practically, the
conditions of warfare forbid interference in most cases. There is a fair per-
centage of recoveries reported as the result of conservative treatment. To
surround a patient in a field hospital with the necessary asepsis and after-care,
is well-nigh impossible. Still, the surgeon must be guided by circumstances,
and if he be well trained in abdominal work, as many of our young men who
leave our large city hospitals and enter the army are, he may find opportunity
to operate and save lives in gunshot wounds of the abdominal viscera. He will
bear in mind that time is everything. A man with a wounded bowel or stom-
ach or one who is bleeding to death from a hole in his mesentery may be
operated on successfully now, an hour after he is wounded. After 6 hours
it may be too late. I have observed this more especially in perforated ulcers
of the stomach. If these cases are operated upon within 1 or 2 hours after the
perforation has occurred, the mortality is very small, and should not exceed 5
per cent. After peritonitis is well developed, the mortality rises very high
indeed, and even after 12 hours many of these cases are hopeless.
WOUNDS OF THE LIVEE. — It will rarely happen that a bullet wound of
the liver can be treated successfully on the battlefield. The wounds are either
slight, mere gutters on the surface of the liver, in which case bleeding may
stop spontaneously, or they are more or less wide tracks through the liver sub-
stance, sometimes with widespread destruction of tissue. Some of these can
be treated successfully in civil practice by packing, but many die in spite of the
best care. In warfare, operative interference upon the battlefield is scarcely
likely to be beneficial.
WOUNDS OF THE SPLEEN. — In civil life, gunshot wounds of the spleen
may often be treated successfully by splenectomy. On the battlefield operative
interference would not be justified.
WOUNDS OF THE URINARY BLADDER, — Wounds of the urinary bladder
are to be treated by suture if possible, usually with drainage. They require,
WOUNDS RECEIVED IX LAND WAKI-AIM «.T1
careful after-treatment by frequent aseptic catheterizatioiL Sometimes it
may be found best to tie a catheter in the bladder for several days. The signs
and symptoms of urinary infiltration are to be treated by incision and perinea I
drainage.
WOUNDS OF THE URETHRA. — Wounds of the urethra may sometimes be
treated conservatively. Usually they will require perineal draimu
WOUNDS OF THE TESTES. — Wounds of the testes are rarely serious, and
may be treated conservatively in most cases.
Wounds of the Extremities. — In an earlier part of this chapter an outline
has been given of the treatment of gunshot wounds of the extremities. It
should be conservative whenever possible. It is well to rememlx-r that, while a
wooden leg is very useful, an artificial hand is a poor substitute for one of
flesh and bone.
WOUNDS PRODUCED BY PROJECTILES FROM ARTILLERY
AND HAND GRENADES
"Artillery projectiles are classified as shot, shell and ease shot.
"Shot. — Solid shot is no longer used in modern cannons, the projectile called
a shot being hollow with thick walls. It is principally used to perforate armor
and carries a small bursting charge.
"Shell. — The shell is a hollow projectile with thinner walls than the pre-
ceding. It is also provided with a large bursting charge. It is u-ed to destroy
persons or material. Pom-pom shell is another kind of shell. It deriv.
name from the report of its discharge. It is fired from the one-pounder V'n-k-
ers-Maxim Automatic Gun. It is 1.457 inches in length, and w. -ii:h-= !«'•
ounces. It explodes by percussion. This shell is used to kill and wound the
enemy; hence, like the common shell, it breaks into many fragments.
"Case Shot. — This consists of a number of shot hehl together in a metal
case, which may be ruptured by the shock of discharge or by a bursting charge.
The term canister or grape shot is applied to the latter.
"The modern projectiles of the artillery are all cylindrical with an «
head, except the canister, which has a flat head.
"Canister. In this projectile the metallic envelope is filled with small balk
which are liberated by the shock of discharge. Canister is used at short r
when the guns of a battery are in danger of capture. Each 3-inch car
contains 244 iron balls, % of an inch in diameter, weiirhinir :'° to the pound,
placed in a receptacle the shape of an elongated can. The canister has
entirely superseded by the modern shrapnel.
"Shrapnel.— The shrapnel is of special interest to surgeons been
increasing importance in augmenting the casualty list of battles in modern
wars. The shrapnel is a projectile which carries a number of bullets at
tance from the gun where they are discharged with added euenry over a .
area from the point of bursting. It has become the principal project
672 GUNSHOT WOUNDS AND THEIR TREATMENT
modern field artillery. It forms 80 per cent, of the ammunition supply of
field guns. It is used against troops in masses and material as well" (1).
"It is used, als*o, in mountain and siege artillery, and in the smaller guns
of sea coast fortifications to repel land attacks. In this shrapnel the case is
a steel tube with a solid steel base. The weight of the 3-inch field gun shrap-
nel complete is 15 pounds, length 10 inches, muzzle velocity, 1,700 f. s. The
bursting charge is composed of 2% ounces of black powder placed in a cham-
ber at the base. There is a stopper of gun cotton in the central tube to hold
the powder in place and to assist in the explosion. There are 252 round balls,
flattened on six faces, of .50 inch caliber, composed of lead. The balls are
surrounded by a smoke-producing matrix, which is used to locate the point of
bursting. This shrapnel is said to be a man killer at 6,500 yards. At the
latter distance the shrapnel has a remaining velocity of 565 f. s. On bursting,
an additional velocity of 300 f. s. is conferred on the lead bullets, making alto-
gether a remaining velocity of 865 f. s. at G,500 yards. The fuse can be set
to cause the projectile to explode at any one-fifth second of its flight.
"The older shrapnels were made up of a cast-iron case and diaphragm that
separated the balls. The case was constructed to invite rupture into a num-
ber of fragments. The bursting charge was placed generally in the head of
the projectile.
"The old-time shrapnel broke into a greater number of fragments, but they
were not always possessed with sufficient energy to inflict severe injury. The
present shrapnel has the bursting charge located in its base. It is made of a
stout case, which remains intact at the time of bursting, except for the blow-
ing out of the head" (2).
Modern Artillery. — Modern field artillery is terribly effective, even at great
ranges. Several varieties of projectiles are in common use. Common shell is
used against defences to break them down and render an assault more hopeful.
Shrapnel is the most common form of projectile used against troops. The
only smoke on the modern battlefield is made when these shells, filled with
powder and leaden bullets, burst, thus enabling the artillerists to estimate the
accuracy of their fire, or the want of it. In modern field operations, artillery
plays an important part, and is used massed, and very freely, to render posi-
tions untenable for infantry or to silence the artillery fire of the enemy while
the infantry advance by short rushes. The rapidity of fire is such that a
storm of shells can be brought to bear on a position. It is said that the modern
French Canet field gun can be fired ten times a minute. At short ranges canis-
ter was formerly used, but it has been superseded by shrapnel.
Hand Grenades. — Hand grenades, though not fired from cannon, are shell
filled with a bursting charge of powder. The effect of shrapnel and hand
grenades is much the same. Wounds are produced by fragments of the steel
case and by the bullets. The wounds made by the bullets themselves do not
differ essentially from those made by rifle bullets of the old soft lead type fired
at low velocity. Often the bullets will lodge. The wounds are, as a rule,
WOUNDS RECEIVED IX LAM) \V.\i; I -ARE
severe and frequently become infected. Their treatment n<-< ••; < -rial no
tice here.
Nature of Wounds. — Shell fragments, the case of shrapnel and hand
grenades produce wounds of a very varied but commonly very serious rharac-
ter. They are contused and lacerated wounds often of la:
them from infection is very difficult — under the eonditinns ,,t warfare practi-
cally impossible. It can be readily understood that a living, jagged mass of
iron, besides producing a ragged wound surrounded by devitali/ed tissues, is
apt to carry with it into the wound portions of clothing or whatever it may
chance to pass through before entering the body. It is one thin.ir to seal a
tically a mere puncture, such as the small pointed bullet makes, and quite an-
other to protect effectually an extensive contused raw surface. The wound-
produced by shell fragments are often multiple — in naval warfare, commonly
so. Hence the conditions to be met in their treatment are far more compli-
cated than is the case with wounds produced by rifle bullets. In the worst
cases, where the victim is struck by an unexploded shell, or large fragment.
decapitation, disembowelment, the loss of an entire limb, etc., are common in-
juries, or the front of the chest or the abdominal wall may be torn away. Th<-
modern shell breaks into hundreds or thousands of fragments, and a hundred
wounds have been observed in one individual. Some of the fragments are
minute, and the wounds produced may, therefore, be of any grade of severity.
from a mere scratch to instant death. In wounds characterized by extei
loss of substance and contusion of the adjacent tissues shock is frequent
usually severe. In fact, many shell wounds closely resemble the extei
contused, and lacerated compound fractures seen in civil life as the result of
machinery accidents, dynamite explosions, and the like.
Treatment. — The so-called "shell-wound first aid packet," and the "Si
shell wound dressing," furnished to the navy, which contain a large aseptic
absorbent dressing with a wire netting basis for support and immobilization,
are better first aid dressings for this class of injury than the simple pad and
bandage furnished to the infantry of the line.
Of all the local applications to wound surfaces, in the probably infected,
contused, and lacerated wounds of civil life, nothing compares with tincture of
iodin liberally swabbed into every crack, crevice, and corner of the raw surface.
Its irritating effects are insignificant and it is a really efficient disinfectant.
It does not even interfere with primary union when used on well-nourished
tissue, such as the scalp and face. Any excess should be wiped away.
Since shell wounds are more or less contused, the bleeding from small
sels is usually not so severe as in incised wounds. If a large vessel
bleedinc- will be profuse and often fatal. Large shell wounds of the extremi
ties resemble railway crushes and machinery accidents. They will often i
quire amputation. If an attempt is made to save the limb, shredded and ev
dently dead tissues are cut away, all visible vessels ligated, and the wound
cleaned as thoroughly as possible. Doubtful skin may usually be left
44
674 GUNSHOT WOUNDS AND THEIK TKEATMENT
line of demarcation to form. The after-care of these cases is that of infected
wounds in general.
See Chapter on the treatment of infected wounds, Volume I.
In smaller shell wounds where suppuration persists, aseptic exploration is
indicated for the removal of a shell fragment, a piece of cloth, or other foreign
body, as well as for disinfection and drainage. The X-rays will detect the
presence and location of a piece of metal, if such is present. As in similar
injuries observed in civil life, the more grave shell wounds require, first, treat-
ment for shock and bleeding. Abundance of water should be introduced into
the system by enema, subcutaneously, by the Murphy irrigation, or into a
vein. Warmth, rest, immobilization, and the other common measures are used.
These patients should not be transported while in shock, if it is possible to
avoid it. No serious surgical procedure, except the control of bleeding, should
be undertaken until the patient has emerged from shock. If he must be moved,
the removal should be delayed, if possible, until he has reacted to some de-
gree, the wound has been cleansed and dressed, and the limb or body immo-
bilized. Too much stress cannot be laid upon the importance of such immo-
bilization. One of the long bones may have been injured, but not completely
fractured. If the entire extremity is immobilized, a complete fracture may be
avoided. Without such immobilization, transportation of the patient over
rough roads will probably render the fracture complete.
WOUNDS RECEIVED IN NAVAL WARFARE
Conditions During Engagement. — Whoever has gone over a modern battle-
ship and kept his eyes even half open must have realized that in action the
wounded, while the battle lasts, must of necessity receive but scant attention.
To pass from one compartment of the ship to another may be a physical im-
possibility. The crew are, of necessity, confined in coffers of massive steel, to
open which might imperil the entire ship. To get from a turret magazine to
the open air, even in time of peace, one must climb a vertical iron ladder per-
haps 76 feet high, and thence pass through a small hole in the bottom of the
turret and descend by an iron ladder to the deck. Communication through
the bowels of the ship can only be carried on by the telephone, electric signals,
or a speaking tube. At the time of going into action, the crew, in groups of
varying size, are confined, each group in its own compartment, the steel doors
are closed, and there the men must remain so long as the battle lasts. To open
such a compartment during the action might place the entire ship in serious
peril. Those working in the engine and fire rooms are fairly protected from
gun fire, but not from torpedo attack, mines or internal explosions. A whole
shell may, of course, drop to the bottom of the ship and burst ; but this will be
rare. The men in the several compartments are as effectually shut in from
escape as though buried in a steel coffin underground. The superstructure and
WOUNDS KECE1VED IN NAVAL \VAK1 -AUK 675
secondary battery cannot be protected from the mighty .-hork of tin- he;,
of modern guns. One shell from a 14-inch »un, or even a much smaller
exploding in one of these more lightly armorod parts of a ship may kill every
man in the compartment. Those not killed by Hying fragment- mav U- j-.i
soned by the fumes and gases of the powder i < '< ) and NO, i, -ealded to death
by steam from broken pipes, or burned. The ship may be set on tire and the
whole compartment turned into a scrap heap in a moment. Thus, in one of
the battles of the Russian-Japanese War a shell entered the sick bay of one of
the Kussian ships and exploded. The surgeons and others who were ;
attending to- the wounded were killed to a man, and the entire compartment
wrecked. For such reasons, at the present time no attempt will be made in
battle to use the regular hospital compartments of the ship, which for hygienic
reasons are always above the water line. Everything will be tran-ported be-
low the water line and behind the heaviest armor. In action between 1 tattle-
ships in the daytime the secondary batteries will not be manned, .-ince oi
great ranges of the big guns the former would be ineffective, beinir only useful
for repelling torpedo attack, and the like. Indeed, when a battleship goes into
action, not more than six or eight men will be exposed outside the armor.
These will be the men in the tops, one or two officers, and a few men whose
business it is to determine the ranges and the effect of the fire. The extreme
range of a 14-inch gun is about 14 miles ; at 8 or 9 miles it can be fired rapidly
and accurately at a moving target.
Just what the next naval battle between the dreadnaughts and the super-
dreadnaughts of to-day may be like no man knows, but that it will be terrible
there can be no doubt. The action will probably not last more than twenty
minutes or half an hour. It is now possible to fire even the largest guns with
great rapidity, so that a perfect hail of monstrous projectiles will fall upon
that ship which fails to get the range of its antagonist.
Treatment During Engagements. — During an engagement then, the
wounded, no matter how elaborate the preparations may be for their care at
other times, must, for the most part, lie where they fall. Certain precautions,
however, may be taken. First-aid dressings in abundance may l>e distributed
at various stations, and the men may be made to bathe and put on clean cloth-
ing before going into action. Suits of sterile underclothing should bo dis-
tributed to the entire personnel of the ship, and outer clothing should l>c clean
or as nearly so as possible, and the smallest amount of clothing should be worn.
In hot climates, and in enclosed parts of the ship, the men light, as a rule, as
nearly naked as may be. Plentiful supplies of cold drinking water should be
placed in every compartment, and a bucket of boric acid with absorbent cotton
for bathing the eyes irritated by powder gases. Such a bucket should be placed
near each gun; also plenty of dressings, splints, iodiu solution, adhesive >trips,
etc., should be close at hand, with a nurse or orderly to apply them. In the
newest ships the effort has been made to provide stations, more ,,r less pro-
tected from fire, and accessible in a definite area to a certain proportion of the
676 GUNSHOT WOUNDS AND THEIK TKEATMENT
ship's company during action. These stations may be of three kinds, or,
rather, may be arranged in three groups. At least two stations, fore and aft,
should be placed within the citadel, or beneath the water line, behind filled
coal bunkers. Here, necessary operations for the control of bleeding may be
performed, and dressings may be applied. These spaces may be quite large,
and would offer protection to a large number of wounded. In each, both hot
and cold water can be had. Several secondary stations should be established
in less protected positions, where first-aid dressings, tourniquets, etc., may be
applied, and when it is necessary to man the secondary battery, dressings,
water, boric acid solution should, as already stated, be kept in the vicinity of
each gun. Provision must also be made for the temporary disposal of the dead,
since the sight of their mangled bodies must be terribly depressing to the other
members of the crew. Empty coal bunkers may be used for this purpose.
Blood should be cleared away at the earliest possible moment, since it soon
putrefies and emits a horrible, cadaveric odor. When men can be moved
within the ship to dressing stations, or to places of greater safety during action,
it has been found that one or two men, without any apparatus, can carry a
wounded companion through the narrow spaces on shipboard better than in
any other way. If a wounded member of the crew is to be carried by one com-
panion, he may take him on his back ; if by two, they may make a chair with
their arms and hands. The battle over, the severely wounded must be trans-
ported to hospital ships at once.
Nature of Wounds Received. — In naval warfare, expeditions are often sent
ashore in boats for special duty. Under such circumstances they fight with
rifles, and may be wounded by rifle fire or field artillery. These wounds will
be the same as are observed in land warfare.
In fights at sea, the wounds will nearly all be caused by shell fire, and by
the secondary missiles which exploding shells create from the structure of the
ship itself.
From the size and terrific force of the projectiles and the havoc created
when they penetrate and explode within the ship's structure, it will follow that
many of the injured will be killed outright, burned to death, smothered, torn
to pieces, decapitated, cut in two, have their limbs amputated. In fact, whole
groups of men are often annihilated in an instant by a single shell of even
moderate size. The victory will be gained by the ship that in the shortest time
pours the heaviest fire into the enemy, and the conquered vessel may be literally
torn to pieces in a few minutes, soon after her victorious adversary gets the
range.
The wounds of the injured who survive will usually be multiple. They
will all be contused and lacerated wounds. Moreover, the heat from impact
and from the burning charge of powder makes the fragments nearly red-hot,
so that the tissues are seared and devitalized. The burning powder may also
inflict serious or fatal burns of the skin, and if, as sometimes happens, a quan-
tity of ammunition is lying near by and is exploded, all the men in a com-
WOUNDS RECEIVED IN NAVAL WAlil AKI.
partment may be burned to death; in fact, these burns arc among the most
frequent and painful injuries received in modern naval engagements. AM
unexploded shell of large size may destroy the human body, or cut off the ln-a.l
or a limb.
Amputations. — If a limb is cut off, the stump may be fairly smooth. The
far side of the stump may be filled with bone dust, and the skin and muscles
shredded, contused and torn, but if the missile was moving at high velcx-ity.
the bone will be cut quite cleanly, without much splintering. 1 t' tin- shell was
moving slowly, the splintering of bone will be more marked, and the contusion
and laceration of the soft parts more widespread. If extensive, reamputation
will be required, but not necessarily a formal amputation at once. These
cases resemble closely the accident cases seen almost daily in large metroj>«ili
tan hospitals: machinery accidents, crushes of limbs from locomotives and
trolley cars, elevator accidents, and the other numerous forms of violence
which take their toll of human life among the dwellers in a great city. A long
experience with such cases teaches that it is well in the first instance to proceed
as follows :
First, wrap the body in heated blankets.
Second, stop bleeding by ligation of bleeding points at once.
Third, treat shock by intravenous saline infusion, .9 of 1 per cent, in strength, at
a temperature in the hand irrigator of 118 degrees F., using any convenient, sub-
cutaneous vein, the median basilic vein in the bend of the elbow, for choice. In
amount, the infusion may be from 1,000 to 2,000 c. c., or it may be continued until
the volume of the pulse is plainly increased and its frequency diminished. If 3,000
c. c. is given, because less produces no improvement, the patient will die.
Hypodermoclysis is simpler and efficient.
At the same time, a hot, stimulating enema is given, which consists of
^ Extract of coffee 3»
Tincture of digitalis fllx
Whiskey 3)i
Hot water 5iv
We also administer beneath the skin sulphate of strychnin, 1/30 grain.
This may be repeated once. Morphin sulphate is also useful in the dose of
about one-third of a grain and atropin sulphate up to about 1/50 grain. Cam-
phor dissolved in sterile olive oil is a useful subcutaneous stimulant,
wound may be washed and disinfected as elsewhere described, and dead tissues
cut away. A large dressing of loosely shaken gauze is applied firmly to the
raw surface of the stump, and a large sterile dressing over that A splint of
wood, wire netting, or moulded plaster-of-Paris, according to the site of the
injury, secures immobilization. These various measures should be carried out
as rapidly as may be, and the patient placed in a bed previously warmed.
foot of the bed should be elevated, and in an hour or two a Murphy irrigation
started. The question of further operative treatment must be decided accord-
ing to the conditions of the particular case. Certainly nothing should be done
678 GUNSHOT WOUNDS AND THEIE TKEATMENT
until the patient has entirely reacted from shock. To perform a serious ampu-
tation upon a man in a state of profound depression from a recent injury is to
kill him without fail. Every means should be used to refill the depleted circu-
lation. If a donor offers, blood transfusion may save a life. Failing this
method, water must take its place, and the Murphy drop method is usually
the most efficient means to this end. Strychnin and other heart stimulants
may be given at intervals as long as the patient remains depressed, and hot
liquid food should be given in small and often repeated doses as soon as the
stomach will retain it. The nature of the operation to be done must be decided
by the surgeon after the patient has entirely emerged from shock. Since these
wounds are always infected, the character of the infection and the severity of
the septic and sapremic symptoms must be taken into account, as well as the
position and character of the wound. Sometimes the surgeon may wait with
advantage until the wound has cleaned up and commenced to granulate. In
other cases, a spreading infection, with severe symptoms of intoxication or the
presence of a cadaveric odor from the wound, will demand early interference.
This may be in the nature of wide multiple incisions, or amputation above
the infected area, if this be possible, leaving the stump sufficiently open for
the freest drainage. No fixed rules can be formulated for the character of the
amputation. It will often be atypical and devised to save the greatest amount
of tissue and secure the most useful stump. As elsewhere stated, conservatism
is most important in the upper extremity, less so in the lower.
Shock. — Some additional remarks in regard to shock as observed in naval
engagements are here added. In the care of the injured, shock will often be
the all-important condition to combat. The effect upon the nervous system of
the men, of the awful din, the jar and vibration, the intense nervous strain,
the smoke and the stifling fumes from the guns and bursting shells, the cries of
the burned and wounded men, and, in fact, every horror of a positive inferno,
with much in addition never dreamed of by any mediaeval imaginer of Hell,
is terribly demoralizing, and yet the effects upon the wounded vary much with
the temperament of the individual. If the ship is punishing the enemy while
she herself is suffering less, the intense elation of spirit may enable a man to
receive the gravest hurt and yet show few symptoms of shock for hours; in
other cases, the wounded become delirious ; in others, even the bravest are over-
come by uncontrollable fear, and are rendered weak and horror-stricken to a
pitiable degree.
Care on Board Battleship. — It is the aim of the hospital ship to remove and
care for all who are seriously hurt as soon as the battle is over. In the mean-
time the ship's surgeon may do much to relieve suffering and aid the wounded.
If the operating room and sick bay are not destroyed, they are, of course, in-
valuable after the action is over; -but placed, as they are, in less heavily
armored parts of the ship, they must often be destroyed. It has been sug-
gested that on shipboard local anesthesia and spinal anesthesia should, as far
as possible, take the place of chloroform, and this on several grounds : namely,
WOUNDS KECE1VED IN NAVAL WAK1-AKK 679
a smaller number of assistants is required in operating: patients do not need
so much after-care and attention, and they may be able to walk and care for
themselves at once. I am not an advocate of local anesthesia for serious sur-
gical procedures, and in my experience it often re.juin - . but several
persons, to hold down the wretched patient. Under such ein-um>tances, good
surgery is difficult, or impossible. Spinal ancsthoia is only applicable in a
restricted way to operative work, and is at best a dangerous substitute for
chloroform. It has not been used in the New York Hospital for a number of
years.
Transportation of Wounded. — For transferring the wounded to launches,
hospital ships, etc., special stretchers of many kinds have been devised in-
tended to protect the wounded from falling while being transported and from
the movement of injured limbs. The best is probably that of Stokes. They
consist of a light steel frame, with a covering of wire net ting. In this, the
patient, however badly wounded, can easily be immobilized, and can be slung
by a rope and hoisted or lowered from the vessel without danger of falling out,
no matter in what position the stretcher may be. Stokes has devised an ap-
paratus whereby the wounded in the stretchers may be transferred from ship
to ship by trolley. These stretchers are kept in numbers in the U. S. battle-
ships. They are readily nested, and occupy but little space.
Treatment. — When heavy shells burst, the fragments are numerous and of
various sizes, some large, some small. Of the larger fragments, some will be
large enough to inflict frightful mutilation, a detailed description of which is
scarcely possible. If not immediately fatal, the wounds produced, whether
the fragments are large or small, have certain characters in common. Many
are wounds with loss of substance. The velocity of the fragments is not
great, and hence they often lodge. The wound of entrance is often smaller
than the size of the fragment. The walls of the cavity in which the fragment
lies are devitalized. The depth to which such necrotic tissue extends is varia-
ble and often extensive. Its limits cannot be determined from early inspec-
tion. Fractures may or may not exist. Hair, clothing, dirt and other fo;
bodies are often carried into the depths of the wound. When wounds, with
loss of substance, are made by large fragments, they are often terrible injuries.
A large part of the abdominal wall may be carried away, and the viscera torn
and contused. The loss of a large part of the chest wall is another fatal in-
jury. The outer wall of the orbit may be torn away, leaving the eyeball ex-
posed. The lower half of the face, including the lower jaw, may be shot
away, leaving a hideous mutilation, or a portion of the skull may l>o carried
away, leaving the brain exposed. There is, indeed, no end to the possible
variety of these mutilating injuries.
In all blind wounds, the indications are to remove shell fragments and all
other foreign bodies, through a suitable incision, to dean and disinfect the
walls of the wound cavity, to stop bleeding and to establish the freest possible
drainage. Such wounds should not, as a rule, be sutured; yet in certain
680 GUNSHOT WOUNDS AND THEIE TREATMENT
regions, the face and scalp, for example, the wound edges may be drawn partly
together, and, even in less vascular regions, a suture or two, here and there,
may be used to support the tissues. Such wounds should be packed with sterile
gauze, or, if evidently infected or widely necrotic, they may be packed with
gauze, soaked in Chlumsky's solution. Voluminous absorbent dressings are
required, and such dressings require frequent renewal. If the wound be of an
extremity, some form of supporting and immobilizing splint is necessary, and
the entire limb should be immobilized. The subsequent treatment will depend
upon the character and severity of the infection, and upon the extent of slough-
ing of the skin and deeper structures. Drainage must be of the freest descrip-
tion. Pocketing, burrowing, and tension must be relieved by free cuts, and the
case must be most carefully watched for such insidious complications.
When such wounds have cleaned up, skin grafting by Thiersch's method
greatly hastens healing, and diminishes scar tissue formation, deformity, and
loss of function. Concerning the treatment of shell wounds of special regions,
the principles of their treatment are those already briefly described. They are
all lacerated and almost invariably infected wounds.
Injury to the Ear. — Rupture of the tympanic membrane is a frequent ac-
cident. It is caused by the sudden blast of air from exploding shells and the
gun fire of the ship itself. In addition, a permanent gun deafness occurs in cer-
tain cases from repeated shocks to the auditory nerve. Prevention is, therefore,
all-important. The shocks can be made less dangerous by various devices. Ordi-
narily the ears may be plugged with cotton wool. A more efficient device now
in use in the United States Navy is that of Elliott. It consists of a small tube
with rubber washers of a size suitable to fit the external auditory canal. The
tube is perforated by a minute canal, sufficiently large for hearing purposes,
but small enough to protect against the sudden increase of atmospheric pres-
sure. The men may wear rubber-soled shoes, and are advised to stand on tip-
toe at the moment of gun fire. Rupture of the tympanum is, nevertheless, a
very frequent accident. The men, not realizing the danger, think it unmanly
to use precautions and suffer in consequence. The accident is, however, only
serious when it becomes infected. Theoretically, before going into action, the
men should have their ears washed clean with warm boric-acid solution, and the
ears plugged with sterile cotton wool. Their prejudice against plugging of the
ears is quite natural, since it is all-important that they should hear and answer
instantly to the word of command, and this is hard enough to do under the con-
ditions, even with perfect hearing.
BIBLIOGRAPHY
1. Lagarde. Gunshot Injuries. William Wood and Co., 1914, 6.
2. Lissak, Ormond M. Ordnance and Gunnery.
CHAPTER XVI
THE TKEATMENT OF WOUNDS AND THEIR DISEASES
JAMES M. HITZROT
The effect of mechanical violence is to produce some form of injury to the
tissues it acts upon. Depending upon the nature and force of this violence and
of the presence of various chemicals, of a specific virus, or of bacteria, the
changes which occur require variable forms of treatment.
To facilitate the description of the treatment to be used, a classification is
appended merely to serve as a working basis for discussion.
The constitutional effects of injury, shock, collapse, and syncope are treated
elsewhere in this work, and will only be spoken of here when mention of the
treatment would otherwise be incomplete.
The classification of wounds is as follows :
1. Subcutaneous wounds (contusions).
2. Open wounds.
(a) Abrasions.
(b) Incised wounds: Linear and punctured.
(c) Contused and lacerated wounds.
3. Gunshot wounds (for description of treatment, see Vol. I, Chap. XV).
The open wounds may be :
1. Penetrating.
2. Perforating.
3. Poisoned or infected.
A. Non-bacterial, i. e., those in which the resulting symptoms are due to:
1. A definite chemical poison.
a. Insect bites and stings.
b. Bites of reptiles.
c. Poisoned weapons.
2. A specific virus.
a. Hydrophobia.
b. Vaccination.
B. Due to bacterial invasion, i. e., the infectious wound diseases.
1. Group of the ordinary wound infections in which the infection in
the wound may cause :
681
682 THE TREATMENT OF WOUNDS AND THEIR DISEASES
a. Abscess formation (infected wound).
b. Lymphangitis or lymphadenitis.
c. Cellulitis (including erysipelas).
d. Varying types of blood infection (bacteriemia) and the metastatic
infections (pyemia).
2. Putrefactive infections.
3. Group of wound infections due to specific micro-organisms.
(a) Tetanus.
(b) Wound diphtheria.
(c) Anthrax.
(d) Glanders.
(e) Tuberculosis.
(f) Syphilis.
(g) Actinomycosis.
(h) Blastomycosis. 1
SUBCUTANEOUS WOUNDS (CONTUSIONS)
The effect of blunt violence which does not break the skin is to injure the
skin and underlying structures. The extent, force, and location of the violence
will determine the result.
For injuries to the head, see Vol. II, Chaps. IX and X; to the chest, see
Vol. Ill, Chap. XI; to the abdomen, see Vol. Ill; to the eye, see Vol. Ill,
Chap. I; to the nerves and blood-vessels, see Vol. I, Chaps. VIII and XIII;
to the bones, see Vol. II, Chap. V. These will not be considered here.
In general, the result of such blunt violence on the tissues is to produce
capillary hemorrhage and an exudative reaction in the tissues far beyond the
injury. This hemorrhage and the exudative reaction are best treated by cold
applications, preferably by an ice-bag placed upon a few thicknesses of moist
gauze. The sooner this cold is applied, the less marked will be the tissue reac-
tion. The cold applications should be applied from 12 to 24 hours, depending
upon the degree of reaction to be anticipated, and applied over an area at least
3 times the size of the contusion. Care should be taken not to have the cold too
intense, as otherwise the skin may undergo a dry gangrene. To prevent this
latter complication, it is wise to move the bag every few minutes, so that its
action is widespread without being too definitely localized.
In places where it is applicable (joints, extremities), a tight bandage pos-
sessing some elasticity will aid in preventing the exudate. Elevation of the
part will also help.
As soon as the exudative reaction has ceased, hot moist applications should
be used, followed by massage to help carry off the extravasated blood and the
exudate.
Should a hematoma form, which cannot be dissipated by the above method,
OPEN WOIXDS 683
it should be opened under strict aseptic precautions and the blood washed out
with saline solution, the cavity dried, and the wound closed by suture. A ti^ht
bandage is then applied, to bring the walls of the cavity in close contact.
piration and small punctures of such hematoma, with or without drainage, are
more likely to become infected than is the case in the above-mentioned method,
and for that reason are not recommended.
OPEN WOUNDS
Abrasions. — Abrasions may consist in small areas in which the superficial
layers of the skin are scraped off, or in more or less extensive skin abrasions
into which are ground cinders, stone, sand, and other forms of grit and dirt.
The former should be painted with iodin and covered with a sterile dressing
until a scab forms, after which simple protection is all that is essential. In
the latter, the area should be painted with tincture of iodin and the grit, etc.,
removed by scrubbing it with a scrubbing brush and alcohol, after which it may
be dressed with alcohol to hasten scab formation. After the scab has fully
formed, the area may then be covered by some bland grease (Liq. Petrolatum
U. S. P.).
Should suppuration occur under the scabs, moist dressings of warm saline
solution will hasten the healing process.
Incised Wounds. — LINEAR WOUNDS. — Linear wounds comprise a number of
wounds of varying depth, from those which merely pass through the skin to
deep wounds to the bone, which sever all the intermediate soft parts and fre-
quently cut off a fragment of bone or actually pass through it, and, in the small
extremities, sometimes actually sever it from the patient.
FIRST AID. — For the simple wounds a clean dressing, with or without
tincture of iodin painted over the injured area, will suffice until the more com-
plete treatment can be carried out.
In the larger incised wounds the first essential is to control the bleeding,
which is free and rapid. The hemorrhage may be controlled by elevation in
the extremities, by a tourniquet, by digital compression, or, where these do not
avail, by hemostats. After the hemorrhage is temporarily arrested, the skin
area may be painted with iodin and covered by sterile dressing, or a sterile
dressing may be firmly bound over the wound to protect it.
LATER TREATMENT. — In any case, the interference under improper sur-
roundings should only be sufficient to protect the wound until the patient can
be brought into surroundings suitable for proper treatment. When the patient
has been brought into suitable surroundings, all hair should be removed by
shaving. Grease should be removed by wiping with irnsolinp. then with a mix-
ture of alcohol and ether. When the skin is dry, it should again be painted
with the tincture of iodin.
. In small cuts the skin may be drawn together by strips of chiffon painted
684 THE TREATMENT OF WOUNDS AND THEIK DISEASES
over with collodion or sutured by a iine needle and horsehair suture, and suit-
ably dressed to protect the suture line by a sterile pad.
In the more extensive lesions the patient should be anesthetized (local or
general, as the case may indicate), the wound washed with sterile salt solution,
all bleeding points caught and tied, and all severed structures appropriately
sutured so that the normal anatomical conditions are reproduced. The skin,
etc., is then closed in layers with fine horsehair for the skin, and the wound is
dressed with sterile dressings, etc. If ideal conditions can be carried out,
drainage is unnecessary unless the wounds involve the trachea, esophagus, or
rectum, and repair will proceed as in an operative wound.
Irrigation of the wound by any form of chemical antiseptic is to be con-
demned. Should the operator doubt the wisdom of immediate closure, the
wound had better be left wide open and closed after reaction has set in, rather
than to resort to doubtful attempts at chemical sterilization, which are more
apt to injure the tissues than to kill any germs which may be present.
Should infection occur, the wound should be widely opened, dressed with
saline solution, and kept wet. (For further details, see Infectious Wound Dis-
eases. )
PUNCTURED WOUNDS. — Punctured wounds comprise a group of wounds in
which the skin opening gives no idea of the depth of the wound. Punctures
are produced by a large variety of implements and vary extensively in their
character, for example, pin pricks, nail wounds, stab wounds, wounds by
spicules of glass, iron, etc., punctured wounds by insects, reptiles, various forms
of animal bites, etc., all of which may be found in this group. Undoubtedly
a large number of the minor puncture wounds never require surgical treatment,
but a sufficient number result in infections of varying extent to make it wise to
take precautions in all. Infections from these small pricks will decrease in
number if the area involved is. painted with tincture of iodin and temporarily
protected by an alcohol dressing. All other puncture wounds should be con-
verted into incised wounds and explored throughout. Under the proper surgi-
cal precautions, they may then be cleansed with salt solution, any foreign ma-
terial removed, the nerves sutured, blood-vessels sutured or ligated, and the
wounds closed with capillary drainage by a few strands of silkworm-gut intro-
duced to the bottom of the wound. Wounds of the feet and where infection
seems inevitable may be left open and drained by a small piece of rubber or
rubber tissue. After 24 hours the drainage may be removed and the wound will
heal like an incised wound. Infection is a rare exception in the cases thus
treated.
Punctured wounds which involve the joints and tendon sheaths should be
opened and treated as above, except that the wounds in these cases should be
closed with drainage down to but not into the tendon sheath or joint.
Punctured wounds of the head, chest, abdomen, and any other regions are
treated elsewhere in this book and are not considered here.
Probing and cauterization by strong chemicals can only do harm, and a
OPEN WOINDS 685
drain shoved into a wound of the character dcsn-ilM-d, through tlu- small aperture
in the skin, can do little but act as an irritant plu^. Tin- e.\<-«-pti..ii> t«» the
statement regarding cauterization will be found under the punctures produced
by snakes, poisoned weapons, dog bites, etc.
Contused and Lacerated Wounds. — ( 'ontused and lacerated wounds are the
result of blunt mechanical violence which bruises, tears, GllMhef, lacerates, or
actually pulpifies the tissue. Extremities may be crushed or torn off, fingers
or arms avulsed. The lesions vary extensively in type t'n.m small
such as saw cuts, to those horrible injuries in which the body is actually cut
asunder.
Among the injuries of this variety are found railroad accidents, injuries by
vehicles and machinery, the injuries by building materials and explosives — in
fact, the vast majority of the injuries of industrial life. The injuries may like-
wise be multiple and comprise injuries to the head, chest, abdomen, and ex-
tremities in. a great variety of combinations.
The essential features in the treatment of such a complex group are : ( 1 )
The treatment of hemorrhage; (2) the combating of the shock; and (3) the
prevention of infection. The remaining steps in the treatment comprise prac-
tically all of the surgical methods of traumatic and plastic surgery.
The treatment of the hemorrhage is placed first because in traumatic ampu-
tations and avulsions its rapidity and volume are especially dangerous. A
tourniquet should be placed above the injury to compress the vessels. A
hypodermic injection of morphin should then be given ; the patient should be
covered by blankets or other warm covering, and surrounded by hot-water bags
or bottles, hot stones or bricks, in fact, anything hot which is available; and
the wound should be covered by a sterile or clean dressing. If any hot tap
water, coffee, or tea is available, a quart of it may slowly be introduced into the
rectum through a funnel, catheter, rectal tube, or anything at hand which can
be inserted into the rectum to permit of the introduction of the above fluids.
The patient is then transported, with the head lower than the hips. t.. a
location suitable for the further treatment and the shock combated by intrave-
nous saline infusion, hypodermoclysis, and hot rectal irrigation, as the condition
demands. As soon as the patient reacts, further treatment, amputation, etc.,
may be proceeded with. In cases which show a slow reaction fn.ni the >h.*'k of
the injury, the better procedure is to coat the injured area with the tincture of
iodin, rapidly ligate the bleeding vessels, and postpone any further operative
treatment until the following day.
In the less severe lacerations, the wound is cleaned with iodin, the
shaved, all foreign material removed by picking it out or cutting away the
tissues which it involves with a flat curved scissors. The wound is then thor-
oughly washed with saline solution, ragged, devitalized tissues are cut away,
and the wound dressed wide open in copious, moist saline dressings and
wet. Continuous saline irrigation or saline bath may also be use
in certain cases.
686 THE TKEATMENT OF WOUNDS AND THEIE DISEASES
In those lacerated wounds into which so much sand, lime, or grit is ground
that its removal would cause too much tissue destruction, 4 or 5 drams of a
mixture of iodin, 1 ; kali iodid, 2 ; guaiacol, 5 ; glycerin to 100, may be poured
into the wound to increase the tissue reaction and prevent putrefaction.
When the wound becomes a granulating one, it may be closed by secondary
suture, drawn together by adhesive plaster, covered by skin grafts, or allowed
to granulate as the case may demand.
Small lacerated and contused wounds, especially those about the head and
face, may be cleaned and loosely sutured. Especial care must be taken in the
tying of these sutures not to tie them too tightly, since strangulation of the
tissue will result.
Should any of the above wounds become infected, they should be treated as
infected wounds (see below).
POISONED AND INFECTED WOUNDS
NON-BACTERIAL WOUNDS
Wounds in Which the Resulting Symptoms Are Due to a Definite Chemical
Poison. — In one group of these wounds the resulting symptoms are referable
to the action of a definite chemical substance, and the treatment to be instituted
is to combat the action of these poisons by neutralizing or destroying them
locally, and by such constitutional measures as are suitable to bolster up the
patient until the crisis is passed.
INSECT BITES AND STINGS. THE BITE OF THE MOSQUITO, FLY, TICK, BED-
BUG, ETC., may convey certain special diseases as malaria, yellow fever, try-
panosomiasis, etc., the treatment of which belongs to works on general medicine.
The resulting local reaction (itching, swelling, etc.) may be treated by the
use of alkaline solutions, such as sodium bicarbonate and carbonate, dilute
ammonia, aromatic ammonia, saturated permanganate of potash solutions, etc.
On the face and about the lips and eyes the application of cold compresses of
these solutions, especially the bicarbonate of soda, may aid in restricting the
excessive swelling which is so apt to occur.
In old neglected wounds and ulcers, eggs may be deposited by flies and
hatch into the larvae (maggots) which permeate the wound in all directions.
These may be removed by irrigation with dilute iodin, formalin, carbolic acid,
or mercury oxycyanid solutions, and dressed with wet dressings of 1 :100 per-
manganate solutions.
Should the bites of these insects become infected, they are treated as de-
scribed under infected wounds (see below).
THE STINGS OF BEES, WASPS, AND HORNETS (THE HYMENOPTERA) . — The
local reaction of the stings of these insects is due to an acid which may be
neutralized by dilute alkaline solutions. In emergencies, a moist poultice of
mud or clay may be very effectual.
OPEN WOUNDS 687
In bee stings, the barbed sting is usually left behind in the wound and
should be removed. In severe cases with multiple stints, nmrphin and strychnin
should be injected, and hot saline irrigations of the rectum given to combat the
constitutional symptoms which may occur.
If the punctures become infected, they are treated as infected wounds (see
below).
SPIDERS, TARANTULAS, CENTIPEDES, AND SCORPIONS produce local and gen-
eral symptoms of varying intensity. The treatment should be constriction of
the limb above the sting, free incision in the wound, and the application of
permanganate crystals or strong ammonia to the wound.
Should constitutional symptoms occur, these should be treated by appro-
priate stimulation. Should infection or gangrene occur, these are treated by
the measures detailed elsewhere.
SNAKE BITES — The first essential is to determine whether the bite is that
of a poisonous or a harmless snake.
If this is not possible from the patient, the character of the wound produced (i. e., the
double uniform row of tooth marks in harmless snakes and the fang marks, double on
each side in vipers, single on each side in the cobra, with or without tooth marks) will
aid in determining the character of the treatment to be instituted.
The psychical symptoms in bites of harmless snakes are best treated by
morphin injection and a local dressing of alcohol. When the patient awakes
to find himself in the land of the living he will usually believe that recovery is
possible and a cure may be expected.
LOCAL MEASURES. — For the bites of poisonous snakes, energetic local and
constitutional treatment must be instituted promptly. Local treatment after
the first half hour is probably useless. A tourniquet should be placed above
the site of the bite, i. e., on the proximal side, to prevent the absorption of the
venom. The fang wounds should be opened widely and the venom cupped or
sucked out.
Pure crystals of permanganate should be rubbed into the wound and a solu-
tion 1 :100 of permanganate should be injected into the tissues about the wound
(Mitchell) ; or 1 : 60 solution of calcium chlorid (Calmette) ; or 1 : 100 solution
of chromic acid (Kauffman) injected into and about the wound. If these can-
not be obtained, the wound may be cauterized by hot coals, red hot iron, a knife
blade, pipe, bar/ fuming nitric acid, etc. Mason suggests bandaging the limb
from both extremities toward the wound, to squeeze out the venom.
CONSTITUTIONAL TREATMENT. — Whiskey, brandy, etc.. may be given by
mouth in repeated small doses. Hot coffee and tea should be given by mouth
and rectum ; 10 to 20 drops of dilute ammonia or aromatic ammonia may be
injected intravenously.
Free lavage of the stomach should be practiced with dilute permanganate
solutions to wash out the venom excreted into it and free catharsis may be
resorted to in the more chronic cases.
688 THE TREATMENT OF WOUNDS AND THEIR DISEASES
Artificial respiration should be resorted to, and a pulmotor used, if avail-
able, for a long period.
Noguchi (15) states that antivenene should be used if obtainable, but that
the success of treatment by this method requires an antivenene of greater po-
tency than now exists.
WOUNDS DUE TO POISONED WEAPONS. — (See Johnson's Surgical Diag-
nosis (8) for varieties.) While the wound produced may be relatively insig-
nificant, it is usually sufficient for the introduction of the alkaloidal poison
with which the arrow or spear has been coated.
Treatment, to avail, must be prompt. The limb should be constricted above
the wound, the wound freely incised, and the poison removed by sucking or
cupping the wound. The wound should be irrigated with permanganate of
potash solutions or pure crystals of that salt may be rubbed into the wound.
The remainder of the treatment is symptomatic and is directed toward counter-
acting the symptoms as they arise.
Wounds in Which the Resulting Symptoms Are the Kesult of the Action of a
Specific Virus. — VACCINATION. — The wound resulting from vaccination pro-
duced as a prophylactic against smallpox needs no treatment unless the local
reaction is unusually marked, in which case moist dressings of saline solu-
tion, aluminum acetate, etc., may relieve the coincident pain.
HYDEOPHOBIA. — The main wound disease of this group is hydrophobia.
The essential feature in the treatment of this condition is the determination
whether the animal which produced the wound has rabies or not. Rabies is
not a common disease, and many of the so-called mad dogs are sick from other
diseases. In the dog, at least, the symptoms are characteristic, if observed
without undue hysteria.
Since rabies most commonly results from the bite of a rabid dog, the treat-
ment of the bite of a suspected dog may be used as descriptive of the type.
In general, the wound or wounds should be opened widely and cauterized
by fuming nitric acid, carbolic acid, iodin, or the actual cautery in the sus-
pected cases and left wide open. Rambaud suggests mercuric chlorid
(1 : 1000) as the best antiseptic.
The animal should either be killed and sent to a reliable pathologist for
examination, or kept under observation in an enclosed kennel, if the former is
not available, and observed by a competent veterinary to determine whether it
has rabies or not.
Meanwhile the patient should, in cases in which any doubt exists or in
which rabies was undoubtedly present in the animal, undergo the Pasteur
treatment.
The Pasteur treatment consists in the injection of an attenuated virus of
fixed strength, made from the spinal cord of rabbits dying of rabies, in gradu-
ally increasing doses, and extends over a period of 2 to 3 weeks. The theory
is that this immunizes the individual against the disease. For the treatment
the patient may be sent to the nearest Pasteur Institute or the set of vials re-
OPEN WOUNDS 689
quired for the treatment may be obtained from a reliable- linn jir.Mlueini: tin-
fixed virus for the treatment.
To be of value the Pasteur treatment should be begun before the symptoms of rabies
appear. When these are undoubtedly present, treatment avails littl.
symptomatic. The patient should be placed in a darkened room and kept absolutely
quiet; morphin and chloroform should be used freely from th.
should be forcibly restrained.
Care should be taken to destroy all clothing, sheets, gauze, etc., which have come in
contact with the patient, by burning them.
THE INFECTIOUS WOUND DISEASES
The infectious wound diseases are those in which the resulting symptoms
are due to the entrance of bacteria into the wound and their growth there, with
(1) the dissemination of the micro-organisms from the portal of entrance by
way of the lymphatics; or (2) the dissemination of a toxin with manifesta-
tions at a distance (tetanus, diphtheria) -or (3) the production by the micro-
organisms of changes in the tissue known as putrefaction, in which case the
resulting symptoms are due to the absorption of the products of this putrefac-
tion.
The general principles of any treatment for such infections are based upon
the fact that the tissue reaction is insufficient to overcome the infection. In
general the treatment should, then, be such that a free exit for the toxic
products of the bacterial growth is provided (free incision) ; the local tissue re-
action should be increased by hot moist dressings or cupping (active and passive
hyperemia) ; the dissemination of the micro-organisms or their toxins should be
prevented by increasing the constitutional resistance, by the regulation of inter-
current conditions, etc. ; and, when it exists, the specific antitoxin should be
given to combat the action of the toxic products of the bacteria.
The type of the infection in a wound determines its treatment. On page
681 is given a classification to form a working basis for treatment.
Ordinary Wound Infections. — WOUNDS INFECTED BY THE ORPIXAKV PYO-
GENIC BACTEEIA. — Should a wound become infected, it should he freely
opened, rubber dam or split rubber tubes inserted for drainage, and the wound
dressed with saline solution and kept wet. A hot water bag may he placed
against the dressing to keep it hot or a constant drip of hot saline solution may
be allowed to fall on the dressing. If the wound is in an extremity, the extrem-
ity may be placed in a warm saline bath. When the acute necrotic process has
subsided and the discharge begins to decrease, the wound may he dressed on
alternate days with balsam of Peru and a solution of iodin, 1 ; kali iodid. J :
guaiacol, 5 ; glycerin, to 100, to stimulate the granulations. When the wound
becomes healthy, it may be strapped or dressed dry.
LYMPHANGITIS. — Lymphangitis should be treated by a moist dressing,
preferably of salt solution or aluminum acetate, and the part elevated. An ice-
45
690 THE TREATMENT OF WOUNDS AND THEIR DISEASES
bag should be placed over the lymph glands which drain the infected area.
Should suppuration occur along the course of the lymphatics (suppurative
thrombolymphangitis), the foci of suppuration should be freely opened and
drained and dressed as in the suppurating wounds.
LYMPHADENITIS. — Should the lymph glands become swollen and tender,
they should be treated for the first 24 to 48 hours by an ice-bag, and after that
by a hot water bag on top of moist dressing. Should the inflammation extend
beyond the gland or the gland suppurate, it should be incised and drained and
dressed, as in simple infected wounds.
The complete and radical excision of the lymph glands draining the infected area,
especially in rapidly spreading infection, has been practiced, but it is based upon the
erroneous supposition that the infection can be stopped by this means and has nothing
to recommend it.
CELLULITIS. — When the infection enters and spreads along the deeper
cellular lymphatic planes, these should be opened by appropriate incisions and
drained and dressed as an infected wound.
EEYSIPELAS. — The treatment of erysipelas, when it occurs as a wound in-
fection, has simplified itself materially in recent years. The disease is pri-
marily self-limited, and attempts at limiting the disease locally by scarification,
the injection of carbolic acid, etc., ahead of the disease, have little justifica-
tion. Painting the infected area and a wide zone about it with the tincture of
iodin is of doubtful utility. Probably the most comfortable local application
consists in a cold moist compress of boric acid or 2 per cent, sodium bicar-
bonate solution to the involved area. This should be changed every few min-
utes and the part kept cool and moist.
Constitutional treatment should be instituted to meet the requirements of
the case, and such intercurrent conditions as starvation, alcoholism, nephritis,
diabetes, etc., treated by appropriate measures.
In general, water, lemonade, and fluids should be given generously. The
patient should be sponged for temperatures above 103° F. and the bowels kept
open. The diet should be fluid and high in caloric value.
Antistreptococcic sera, vaccines, etc., have proven of no value.
Patients with erysipelas should be isolated and care taken not to carry the infec-
tion. All attendants should wear rubber gloves while dressing these cases, and all
dressings, etc., used in the case of erysipelas patients should be sterilized by immersion
in formalin solutions or burned.
GASEOUS OE EMPHYSEMATOUS CELLULITIS. — When crepitation is found
about a lacerated wound into which street dirt has been ground, the crepitant
area and the tissue around and beyond it should be opened by long incisions
and the wound and the line of incision irrigated with hydrogen dioxid solution,
and the part dressed with dressings dripping wet with the peroxid solution.
OPEN WOUNDS 691
Should the smears and -cultures from the wound show the presence of the
gas bacillus (Bacillus capsulatus aerogenes, Welch), especially if the organism
occurs in conjunction with the streptococcus, great care must be used t«. j.n-vont
pocketing of the discharge. Unless free im-isiun is ma«lc, this |>o<-k<-ting is
bound to occur, and the infection will spread from this source along the con-
tiguous lymphatics.
The subsequent treatment will depend upon the presence or absence of th«-
gas bacillus in the circulating blood. Once the organism gains a foothold in
the blood stream, such local treatment as amputation avails little. When tin-
extremity is so badly lacerated by the original injury that its circulation is
seriously interfered with, the early recognition of a gas bacillus infection and a
prompt amputation are indicated.
When the laceration is extensive, without any definite injury to the main
circulation, the treatment is that used for lacerations in general. Should tin-
lacerated tissues show signs of extensive necrosis and the wound give a sweet-
ish, fetid odor, with a grayish green surface, the patient should be am-
(gas and oxygen) and the whole wound filled with pure strength formalin solu-
tion. After 5 minutes the necrotic mass should be cut away, rvcrv recess of
the wound opened, and the action of the formalin then neutrali/.rd by a 10-vol-
ume solution of peroxid. The wound may now be dressed in this solution. The
essential feature in the treatment of this type of infection, in my experience,
has been the prevention of pockets in which the anaerobic conditions suitable for
the growth of the gas bacillus exist.
VAEYING TYPES OF BLOOD INFECTION (BACTERIEMIA, SEPTICEMIA.
SEPTICOPYEMIA, PYEMIA, ETC.) WHICH RESULT FROM WOUND INFECTIONS.
— PREVENTIVE MEASURES. — Kigid surgical asepsis and the proper treatment
and drainage of all injuries will reduce the above infection to a minimum.
LOCAL TREATMENT. — Any infected wound should be freely opened and
proper drainage provided (see Wounds Infected by the Ordinary Pyogenic Or-
ganisms).
GENERAL TREATMENT. — The patient should be put to bed and, if the tem-
perature is high or if there is marked delirium, sponged. The diet should be
liquid, easily digestible, and of a high caloric value, and nourishment should be
given at short intervals (every 2 to 3 hours). Those patients who can take a
relatively large amount of nourishment show greater resistance to this type <
infection and the vast majority of the recoveries from general blood infections
of the surgical type will be found among such patients. \Yator. lemonade, etc.,
should be given freely, and the case treated symptomatically by strychnin, digi-
talis, whisky, etc.
SPECIAL FORMS OF TREATMENT.— Many other forms of
been recommended, as follows :
1. Intravenous injections of various antiseptics (bichlor
silver nitrate, colloidal silver, electrargol, formaldehyd solutions). The pui
pose of these injections is to render the blood antiseptic and ttraf
692 THE TKEATMENT OF WOUNDS AND THEIR DISEASES
growth of or to destroy the micro-organisms. All* of the above antiseptics can
be introduced in sufficient quantity to theoretically inhibit the growth of the
micro-organism. Practically the only result of their introduction is an in-
creased leukocytosis. In the human, blood-cultures in streptococcus infections
show no change after repeated injections of any or all of the above chemicals.
2. A second type of treatment is suggested, which has as a basis for its
existence the increase of the bacteriolytic action of the blood (a) by causing an
increased leukocytosis, or (b) by increasing the opsonins in the blood-stream.
The increase in leukocytosis may be produced by saline infusion, the injection
of nucleinic acid, etc. The opsonins, etc., are increased by the so-called vaccine
therapy, i. e., the injection of the dead bodies of the infecting micro-organisms,
either autogenous (made from the culture obtained from the patient) or from
stock cultures. (See Vol. I, Chap. VI, for complete exposition of the subject.)
3. The production of chemical abscesses in suitable localities (for ex-
ample, the buttocks) by the injection of such substances as turpentine, zinc
chlorid, formaldehyd solutions, etc. The purport of such treatment is stated
to be the formation of abscesses in which a sufficient number of micro-organisms
are destroyed to produce an autovaccination and an active immunization against
the specific infection.
' 4. The introduction of drugs by mouth, rectum, or inunction to destroy the
micro-organisms in the circulation (quinin, unguentum crede, etc.).
5. Serum Therapy. — Many forms of antistreptococcic sera have been pre-
pared, but none have proven of any value.
It is probable that a lengthy search would reveal many more equally ineffi-
cacious forms of treatment. Of the above, only the vaccine therapy is of proba-
ble value, and that only in the hands of an expert. The indiscriminate injec-
tion of the stock cultures is not likely to do any good and may do harm.
The Putrefactive Infections. — The features essential for the development of
putrefactive infections are (1) the presence of necrotic or sloughing tissue; (2)
pocketing of the wound secretions; (3) the infection by putrefactive micro-
organisms. (The chief micro-organisms of this group are the proteus vulgaris,
the colon bacillus, and the anaerobic bacilli, of which the bacillus capsulatus
aerogenes is the chief member; see gaseous cellulitis). (Here likewise may be
grouped diabetic and moist gangrene, noma, and wound phagedena or hospital
gangrene. )
It is difficult to group the treatment of conditions of such a wide etiologic
organ. Since the resulting processes are all susceptible to the same general
laws and differ only in the location of the process, such an attempt will be made.
Inasmuch as the presence of necrotic or sloughing tissue, that is tissue in
which the circulation has been destroyed, is one of the main factors in the
putrefactive infections, all sloughing and necrotic tissue should be removed by
free incision to the normal tissue or by amputation as the case requires. Wide
incision should be made into the adjacent normal tissue (when amputation is
not done) and all pockets and recesses freely opened and drained. Since the
OPEN WOUNDS
majority of the infections of this type exhibit their most virulent form under
anaerobic conditions the wounds should be filled with peroxid of hydrogen solu-
tion, dressed, and kept wet with this solution.
In those cases of gangrene in diabetes, in senile gangrene, and in traiimat it-
gangrene which do not permit of immediate amputation, the part should be
subjected to constant dry heat (that is, submitted to desiceati*.
This may be done by passing a current of dry hut ail ;ited by a gas
or alcohol flame over the involved area, which may either be left e*p..Sed t«. tin-
air or covered with dry gauze and protected from the bed clothes by a suitable
wire or wooden cradle with openings at both ends to allow the mm-nt «.f hot
air to pass freely over the tissue. Later when demarcation is evident and
desiccation is so far completed as to permit of the rapid removal <.f the
tissue, amputation is indicated. Wet dressings are to be avoided inasmuch as
the putrefactive processes develop rapidly under the influence of moisture and
heat.
Noma and allied condition should be treated by excision by the actual
cautery through the normal surrounding tissue (see face, etc.). For putrefac-
tive infections in the uterus, penis, scrotum, perineum, and peritoneum, see
the chapters devoted to these regions.
Group of Wound Infections Due to Specific Micro-organisms. — TKTAN 08. — Te-
tanus results from the entrance and growth of the tetanus bacillus in a
wound. Due to its prevalence in street dirt and in the excreta of herbivenm-
animals, it is prone to complicate wounds received in locations likely to be con-
taminated by street dirt, manure, etc. The treatment of wounds likely to be
contaminated by infection from the tetanus bacillus may be divided into twu
parts: First, the local treatment of the wound; second, the prophylactic injec-
tion of 1,500 units of tetanus antitoxin into the region proximal to the injury,
that is, if a wound of the right hand, into the right arm; of the foot, into
the leg, etc. This latter procedure is the most important of the two, and in view
of the danger of tetanus, especially in blank cartridge wounds and lacerated
wounds into which street dirt, etc., has been ground, its more extensive use
would seem warranted.
When the manifestations of the tetanus infection become definitely m;i
the treatment likewise becomes local and constitutional, and here again the
latter is of the greater importance.
INTKASPINAL AND INTRAVENOUS INJECTION OF TETANUS AXTITOXIN.-
Park and Nicoll (16) recommend the use of intraspinal and intravenous injec-
tions of antitoxin.
In every case of suspected tetanus, from 3,000 to 5,000 units of tetanus
antitoxin should be given intraspinally through a lumbar puneture. The pa-
tient should be anesthetized, lumbar puncture done, and an amount of eerel.m-
spinal fluid slightly in excess of the amount of antitoxin to be given should be
withdrawn. To insure its dissemination, the antitoxin should be diluted to a
volume of from 3 to 10 c. c., according to the age and size of the patient The
G94 THE TREATMENT OF WOUNDS AND THEIR DISEASES
diluted antitoxin is then allowed to flow into the spinal canal slowly by gravity.
In acute cases this procedure should be repeated in from 24 to 36 hours.
In addition to the above, from 10,000 to 15,000 units of tetanus antitoxin
should be given intravenously, coincidently with the intraspinal injection.
After a period of from 3 to 5 days 10,000 to 15,000 units should be given sub-
cutaneously to insure a continuance of the highly antitoxic condition.
•
It does not lie within the scope of this article to discuss the merits and demerits of
the various methods recommended for the use of antitoxin in cases of tetanus, but the
above treatment of Park and Nicoll meets the conditions to be treated more satisfac-
torily and deserves a much more extended trial than the other less efficacious forms of
treatment.
INTEACEEEBEAL INJECTION OF TETANUS ANTITOXIN. — Roux and Borrell
(18) injected the antitoxin through a trephine opening into the brain tissue
directly, believing that the toxin was more quickly neutralized by this method.
As stated by Frazier (5), it is difficult to understand the rationale of injecting
the antitoxin into the brain when the toxin acts chiefly upon the cord and
medulla.
INTEANEUEAL INJECTION OF TETANUS ANTITOXIN. — Marie and Morax
(11) in their experiments on animals found that toxin was absorbed by the end
plates of the nerves. Meyer and Ransom (13) found that the toxin was ab-
sorbed by the motor nerves and explained the period of incubation by the
length of the nerve from the site of the original infection. They also found
that the intraneural injection of the antitoxin into the nerve trunks which sup-
ply the area of the wound infection prevented the passage of the toxin to the
cord; hence tetanus did not result. From this arose the intraneural injection of
antitoxin into the nerve trunks. Rogers (16) was the first to apply this method
clinically, but in his cases he likewise injected the antitoxin subcutaneously,
intravenously and into the spinal cord, so that it is difficult to determine the
relative value of this method from his clinical observations.
OTIIEE THEEAPEUTIC MEASUEES. — Of the other therapeutic measures sug-
gested in the treatment of tetanus, mention must be made of the carbolic acid
treatment of Bacelli (1), the subdural injection of magnesium sulphate by
Melzer (12), and the use of chloretone by Hutchings, 1909 (7).
The carbolic acid treatment for tetanus (Bacelli) consists in the subcu-
taneous injection of a 1 per cent, solution of carbolic acid until 80 gr. (5 gm.)
have been given in the 24 hours. The results outside of Italy are not convinc-
ing.
Subdural Injections of Magnesium Sulphate (Melzer). — Melzer advises 1
c. c. to every 20 pounds of body weight in the adult male, 1 c. c. for every 25
pounds of body weight in the female, and in the child never more than 1 c. c.
for every 25 pounds of body weight. Blake (3) considers it a reasonably safe
means of relieving the pain and modifying the convulsions in the disease.
Chloretone. — Hutchings considers chloretone a very useful medicament in
OPEN WOr.XDS 695
controlling a convulsion. It is given in from 30 to 60 gr. doses dissolved in
whisky or hot olive oil — by mouth or rectum — and repeated sufficiently often
to control the convulsions.
LOCAL TREATMENT OF SUSPICIOUS WOI:M>S. — Tin- l<M-al treatment of a sus-
picious wound, or one in .a case in which the symptoms of tetanus an- pn
should be radical. Under an anesthetic the wound should be widely opened
and disinfected with iodin or carbolic acid solutions, and freely drained.
In cases in which tetanus has developed, or in suspicious wounds, McFar-
land advises the use of a dry powdered form of tetanus antitoxin as a dusting
powder for the wound.
The further treatment consists in the use of rest in a quiet room, the use
of sedatives to control convulsions, together with chloroform inhalations in the
severe forms. Care, however, should be used in not overdoing the use of seda-
tives. The nourishment should be fluid, and care should be taken to keep the
bowels open.
WOUND DIPHTHEEIA. — This is found, as a rule, secondary to nasal, throat,
or laryngeal diphtheria. It occurs in many forms (see Knowles and Frescoln,
9, for types and literature).
Since the treatment is dependent upon the presence of the Klebs-Loeffler
bacillus in the wound, it should wait for a culture made from the wound.
When the Klebs-Loeffler bacillus is reported as present, from 5,000 to 20,000
units of diphtheria antitoxin should be given, depending upon the severity of
the case. Locally the wound should be cleansed with peroxid and dressed with
a moist alcohol or saline dressing.
Patients with wound diphtheria should be isolated, and all dressings, etc.,
which have been used should be burned.
ANTHEAX. — The- essential lesion of the infection, as a wound disease, is
the malignant pustule.
The treatment depends upon the recognition of the type of the infection be-
fore it has spread beyond the localized lesion. When seen early and recognized,
complete radical excision of the involved area by the knife or cautery or both
may be successful. If seen after the lesion has lasted for some days, excision
is likely to avail little, as the blood stream is invaded early in the course of the
disease.
Sclavo (18) advises the use of a serum prepared by actively and passive!.!
immunizing an animal, especially the ass. The dose suggested by him is i
to 40 c. c. of the antitoxin injected into the abdominal wall at 3 or 4 different
points. In severe cases the injection should be made intravenously and the
dose repeated every few hours.
When the serum cannot be obtained and when excision in imposj
been too long delayed, injections of carbolic acid, 1:20 (Strubel, 1
hot moist compresses, may be used.
The general treatment should be dietetic and symptomatic, but in t
sence of the serum, avails little.
696 THE TREATMENT OF WOUNDS AND THEIR DISEASES
GLANDEBS. — This disease is transmitted to man from an infected animal,
usually the horse, and the cutaneous lesions, i. e., the small superficial skin
wounds, closely resemble chronic pyogenic infections. There is, however,
usually an acute febrile disease (acute glanders), or the case may continue as
chronic glanders as a result of the local infection.
Wounds, therefore, received by stablemen, etc., had best be regarded with
suspicion, and, if a history of attention given to a sick horse is obtained, the
wound area should be freely excised, cauterized with pure carbolic acid, and
dressed with alcohol or with the iodin-guaiacol solution.
Chronic abscesses may form periodically, and these should be opened, cau-
terized by pure carbolic acid, and dressed with the iodin-guaiacol solution previ-
ously described.
In a case reported by me (6) an abscess on the arm appeared 8 months after
the infection. This abscess, located on the radial side of the forearm, resem-
bled a gumma, but the man's history made the diagnosis of chronic glanders
possible, and the injection of some of the pus into a male guinea pig proved the
presence of the bacillus mallei. The treatment above outlined produced a cure
of the local abscess, and no others occurred during the succeeding year.
Mallein (Bonome, 4) may be used in the chronic cases.
TUBEKCULOSIS. — Tuberculosis may occur as the result of wound infection
from infected meat, or in post-mortem wounds.
THE ANATOMICAL TUBEKCLE. — This result of local infection by the tuber-
cle bacillus should be excised.
SYPHILIS. — Syphilis may result from wounds infected by instruments
which have come in contact with a syphilitic. The recognition of the chancre
and its treatment by calomel ointment, salvarsan, mercury, etc., need no fur-
ther comment.
ACTINOMYCOSIS. — Actinomycosis occurs chiefly as an infection about the
head and neck (mouth and teeth), the digestive tract, pulmonary tract or the
skin. In the latter it may be present as an infection of a wound due to the
presence of a foreign body, splinter, piece of straw, etc., in the wound.
The treatment of actinomycosis consists in excising the infected area when
possible, cauterizing the area of the excision with pure carbolic acid, and
dressing it with the phenol camphor solution of Chlumsky (phenol 30, cam-
phor 60, alcohol 10). When the area cannot be excised, all the sinuses should
be widely opened, cauterized with pure carbolic, and packed with gauze satu-
rated with the iodin-guaiacol solution or with the phenol-camphor solution.
Potassium iodid should be given internally in large doses at broken inter-
vals, i. e., the drug should be given for 1 week, then stopped for 1 week.
Bevan (2) recommends the use of cupric sulphate internally in from % to
% gr. doses thrice daily. He also advises irrigating the wound and sinuses
with a 1 per cent, copper sulphate solution.
The further treatment is hygienic, and should consist in rest, fresh air,
sunshine, and an easily assimilated diet of high caloric value.
BURNS AND MULTIPLE I NM TRIES 697
MADUEA FOOT.— Madura foot is closely allied to actinomycosis, and its
treatment is similar to that described for the latter. Permanent cure follows
the amputation of the involved foot.
BLASTOMYCOSis.— (For literature, etc., see Lexer-Bevan, 10.) In the
cutaneous cases, this disease has occasionally followed a local wound and may,
therefore, be considered a wound disease.
When the disease remains a localized cutaneous infection, the entire lesion
may be excised. Abscesses occurring in the generalized forms require incision
and drainage. Radiotherapy may be tried in localized infections. Const it u
tional treatment consists chiefly in the administration of large doses of potas-
sium iodid (600 gr. a day in some of Bevan's cases).
Bevari also recommends cupric sulphate in 14 gr. doses 3 times a day, and
a dressing of 1 per cent, cupric sulphate solution as a wet dressing.
BURNS DUE TO HEAT AND COLD, ACIDS, ELECTRICITY, AND
LIGHT RAYS; POISONING BY CARBON MONOXID, ETC. AC-
CIDENT CASES PRODUCING MULTIPLE INJURIES
BURNS AND SCALDS
The injuries produced by the various agents (thermal, chemical, friction,
electrical, light rays) which cause the tissue injuries known as burns, are
divided into three degrees — first degree, second degree, and third degree —
according to the extent to which they involve the tissues.
In general the reaction in the tissues to the injury produced is greater than
is required for the repair process, i. e., excessive reaction. This excessive re-
action exhibits itself primarily as an excessive exudation of serum into the
tissues which, in given localities, the throat for example, produces obstructive
symptoms of alarming nature. The later excess in the tissue reaction produces
an amount of scar tissue far in excess of that necessary for the repair of the
injured area, hence the disfiguring scars and contractures so commonly found
following burns.
The constitutional effects of these injuries comprise shock, edema of the
brain, anuria, ulcer of the duodenum, and areas of toxic necrosis in the various
solid viscera.
Hence the essential features in the treatment of burns must be directed
toward the alleviation of the pain, the treatment of the shock, and the use of
such local treatment of the burned surface as will tend to prevent the excessive
tissue reaction above mentioned.
The treatment will of necessity be directed toward relieving those symp-
toms which are most pressing. That is, shock and pain in the extensive burns
and tracheotomy in burns of the mouth with obstructive larvn-eal symptoms,
will need the most attention, while the use of merely local measures at the site
of the injury will suffice when the constitutional phenomena need no attention.
698 THE TBEATMEOT OF WOUNDS AND THEIK DISEASES
First Aid. — The most useful application and one which can be obtained
everywhere is a solution of baking-soda made by adding a heaping teaspoonful
of baking-soda to a pint of cold water. This solution should be applied cold on
clean cloths or cotton to the burned area and kept moist. The applications
should be quite cool so that the excessive tissue reaction may be limited in so
far as it is possible to limit it.
It has been my experience that those cases which have been treated by oil in any
form, usually the abomination known as Carron oil, have taken longer to heal and have
caused more discomfort than occurred when the soda solution was employed. Estes
("Keen's Surgery/' Vol. VII) states that he has found that flour paste, oils, etc., are not
desirable forms of treatment.
In extensive burns of the trunk and especially over the abdomen, the appli-
cation of this solution cold is contra-indicated and in that case it should be
applied after heating it (tepid application).
The patient should be given a cup of hot coffee, tea, milk, or even water and
kept quiet.
Local Treatment. — FIEST-DEGEEE BUENS.— The most comfortable applica-
tion is something cooling. Many lotions fill that requirement.
The two which have given me the most satisfaction are cold compresses of
sodium bicarbonate in one to two per cent, solutions, or one of the many forms
of lubricating jellies put up in collapsible tubes under various trade names.
These should be applied until all the burning sensation has disappeared,
when a bland oil, such as petrolatum or acold cream" may be rubbed over the
part to relieve the itching.
SECOND-DEGEEE BUENS.— The most advantageous application to second-
degree burns is a one-half to one per cent, aqueous solution of picric acid. The
solution should be applied on sufficient gauze to make a firm moist compress
and the compress moistened with cold sterile water for the first 12 hours, when
it may be allowed to dry. When the burned area is large, the weaker solution
should be used and a certain amount of judgment must be employed to de-
termine just what amount of the body may be safely covered without symptoms
of picric acid poisoning. In healthy adults little danger is to be feared unless
more than one-third of the body is covered, while in debilitated individuals, and
in the two extremes of age, the area should be restricted to one-quarter or less
of the body area.
Should the above not be available, compresses wet with sodium of bicar-
bonate solution, or weak solutions of alcohol (25 per cent.) may be used. Blis-
ters should not be opened at the first treatment. After the use of one of the
above solutions for from 24 to 48 hours, the blisters which remain may be
opened and the burned surface dressed in a variety of ways; that is, covered
with silver foil, zinc stearate powder, or rubber tissue, or dressed in a moist
saline compress'.
When the irritant symptoms have disappeared and desquamation has begun,
BUKNS AND MULTIPLE INJURIES
paraffin oil, cocoa butter, or one of the toilet cold creams will render the
quamation less annoying and relieve the itehi
THIRD-DEGREE BURNS.— The local treatment for this class of burns may
be substantially that given for the second-degree burns or tin- h:mn-d surface
may be dressed with moist saline solution. The main effort in bums of
type is to prevent, or at least to limit the amount of in feet ion which occurs.
Two other rather different forms of treatment may be used to advantage in
selected cases, namely the dry treatment and the continuous bath.
In the dry treatment the patient is placed naked on a sterile or a clean,
freshly laundered sheet.
The bed clothes are placed on a cradle over the patient so that those por-
tions of the body not resting upon the bed are entirely free from covering.
The patient is kept warm by the heat of an electric stove, or more ad van-
tageously by the dry heat generated by a gas or alcohol flame passed under
the bed covers by a suitably protected piece of stove pipe. The essential
is to dry the serum discharging from the tissues into a protecting scab by this
process of desiccation. It is necessary that the heated air should have an nut-
let at the upper opposite end from the site at which it enters the cradle-.
[The electric hot air apparatus used by women to dry the hair is a safe and
reliable substitute for the lamp. — EDITOR.]
In hot weather the heating apparatus may be dispensed with.
Various dusting powders have been used such as talcum, starch, zinc oxid
and stearate, etc., to aid in the drying process. If used at all they should be
dusted upon the sheet upon which the patient rests to aid in the absorption of
the secretions. Elsewhere they are a hindrance rather than an aid.
Should too much secretion form or should the scabs become malodorous
they may be softened by moist saline dressings and removed or the patient may-
be placed in a tub of clean water containing a little borax and the scabs washed
off, when the drying process may be repeated.
The continuous tub (Hebra) is especially valuable in burns which involve
the trunk, the axillae, the buttocks, or the groin.
The water should contain sufficient salt to make a normal saline so1
(teaspoonful to the pint) and the water should be kept between •.»:, and
F. and frequently changed. (The temperature should be mrulatod to suit
patient's comfort but the mean average temperature will be found between the
figures given.) The patient should be kept in the bath until
has ceased and reparative reaction in the tissues has been established,
cases in which the tub bath is well borne usually do better than those in '
the relaxation incident to the constant immersion causes cardiovasc
muscular depression. In the latter a combination of the wet and dry methoc
is often more efficacious than either one alone. In those ft
burned surface becomes infected this latter combined method i
The Late Local Treatment of the Burned Area.— This is laigelj
upon the area involved and includes practically all the expedien
700 THE TREATMENT OF WOUNDS AND THEIR DISEASES
surgery devised to correct and relieve deformities, skin grafting, strapping with
adhesive plaster, or the use of rubber tissue strips laid over the granulating
area. If the area is near a joint or over an important muscular area, skin graft-
ing should be resorted to as soon as possible. Cicatrices which break down and
ulcerate should be excised and the area covered by skin grafts.
The General Treatment. — Morphin should be given hypodermically to re-
lieve the pain. The shock should be combated by such measures as hot saline
solution, water or coffee by rectum, or saline by hypodermoclysis.
In extensive burns water should be given freely by mouth preferably
slightly acidulated by lemon or orange juice. In cases which cannot be made
to take water in this way it should be given by proctoclysis by the Murphy
drip. In many cases the two methods may be advantageously combined. It
is important that the patient receive a large volume of fluid, throughout the
early stages of the treatment. The nourishment should be fluid with a high
caloric value.
BURNS DUE TO CHEMICALS
Burns Due to Acids. — The action of carbolic acid may be neutralized by
alcohol.
The caustic acids, sulphuric, nitric, hydrochloric, etc., are best neutralized
by dilute alkalies. Care should -be taken not to allow this process of neutraliza-
tion to occur too rapidly as the heat generated may increase the degree of the
burn.
The Burns Due to Caustic Alkalies. — The burned area should be washed with
a dilute acid (vinegar or acetic acid preferably). After the process of neutrali-
zation of the chemical substance the treatment should be that advised under the
local and general treatment of burns in general.
BURNS DUE TO LIGHT RAYS
Sunburn. — Mild degrees of solar burns may be treated by evaporating lo-
tions or any of the lubricating jellies.
The severe forms should be treated by cold compresses of sodium bicar-
bonate or aluminum acetate solutions until the intense burning has subsided.
Skin blebs should then be opened and the area covered by silver foil or weak
picric acid solutions.
The late irritating itching may be relieved by a bland oil or a toilet cream.
X-ray Bums occur in two forms: (1) an actual burn, and (2) X-ray
dermatitis.
The chief treatment should be preventive and all individuals repeatedly
exposed to the action of the X-ray should be properly protected.
The operator should not expose himself to the direct rays unless his hands
are protected by specially prepared gloves. Preferably he should work behind a
lead screen.
BURNS AND MULTIPLE IN-HKIES 701
Patients exposed to the X-ray for diagnostic purposes should not be sub-
mitted to long exposures. When patients are exposed to tin- X-ray f,,r thera-
peutic purposes the rays should be administered through a suitable filter and
the exposures made at suitable intervals.
When a burn occurs no further treatments should be given. The buni«-d
area may be treated by various light rays, as red light rays (Ban, and blue
light rays (Kaiser).
The burns are painful. For the pain, aspirin, the bromids, codein, and
morphin may be necessary. Due to the chronicity of tin- U-al process tin-
opium alkaloids must be used with considerable caution. In 2 cases under the
writer's care the involved area was excised and the raw surface skin grafted
with most satisfactory results.
The X-ray dermatitis is best treated by excision of the involved skin area
and skin grafting. Should the involved area show signs of epitheliomatous
change amputation may be necessary.
Radium burns are similar to those produced by the X-ray but extend more
deeply into the tissues and are more difficult to handle. The same treatment
outlined for the X-ray burns is indicated.
INJURIES DUE TO ELECTRICITY. ELECTRIC SHOCKS, BURNS, AND INJV
DUE TO LIGHTNING
Death after exposure to the high tension electric currents is usually due to
the inhibition of the respiratory center. The affected individual should there-
fore be freed from contact with the current, the mouth opened and the tongue
pulled out, and artificial respiration done. This should be kept up as long
as the heart continues to beat. (In electric plants, or wherever high ten-
sion currents are in constant use, a pulmotor should be kept for this pur-
pose.)
In shocks due to low tension currents, especially alternating currents, death
is due to cardiac paralysis due to fibrillary tremor of the heart muscle and
when this occurs treatment avails little.
Burns due to electricity depend upon the duration and degree of contact,
dampness of the skin, etc., usually extend deeply into the tissues and, at tin-
point of exit, frequently cause complete charring of the tissues, that is, a dry
gangrene.
The treatment is substantially that of third degree burns. Amputation is
indicated for those cases in which the part is killed by the current.
The constitutional and local effects of lightning are similar to those pro-
duced by the commercial currents, and the same statements apply to their
treatment as to those given above.
For the late general symptoms, such as the psychoses, functional neuroses,
epileptiform attacks, eye symptoms, etc., the reader is referred to the various
works dealing with these diseases.
702 THE TREATMENT OF WOUNDS AND THEIR DISEASES
THE EFFECTS OF COLD ON THE TISSUE
The Treatment of Individuals Exposed to Low Temperature or Submersion in
Cold Water.— The patient should be placed in a cold room, artificial respiration
performed, and the extremities rubbed with dilute alcohol solutions containing
a little camphor. (Alcohol 50 per cent, with 1 per cent, camphor.) When
the patient begins to react (reaction should be brought about slowly), the tem-
perature of the room should be slowly raised and the patient given warm drinks
of coffee, tea, or whiskey.
The local results of cold are divided into first, second, and third degree
injuries as given under burns.
The essential features of the treatment for frozen tissues is to bring about
a gradual thawing of the part and a slow return of the circulation in the
affected extremity. This may be done by gentle friction with snow or the
immersion of the part in ice water and gentle friction. As the circulation re-
turns the temperature of the water should be slowly raised.
The resulting conditions after the thawing process are due to the reaction
in the involved tissues.
The erythema (chilblain) must be protected from changes of temperature
by warm covering. This may also be satisfactorily supplemented by the use
of a protective coating of vaselin containing about 2 per cent, camphor.
Fordyce ("Keen's Surgery," Vol. II) advises the use of a hot saturated solution
of alurn to relieve the venous congestion and itching.
When bullse form (second degree) the part may be dressed with alcohol or
1 per cent, alcoholic solution of picric acid. The bullse should not be opened
until the second dressing. Should infection occur the part should be dressed
with the above solution and kept moist. When gangrene seems imminent the
extremities should be suspended.
In third degree frost bites with slough formation desiccation should be en-
couraged by dry heat, absolute alcohol, or dilute formalin solution and the
part amputated when a line of demarcation has developed.
THE TREATMENT OF ILLUMINATING GAS POISONING; CARBON MONOXID AND
CARBON BISULPHID POISONING
Carbon monoxid poisoning occurs in two forms, each of which needs sep-
arate treatment, i. e., the acute form and the chronic form. Illuminating gas
poisoning requires practically the same treatment and is included under this
heading.
Acute Carbon Monoxid Poisoning. — The patient should be removed from the
room or area which contains the gas, and artificial respiration done. A pul-
motor should be used for this purpose if accessible. Oxygen inhalation should
be given and generous doses of strychnin, caffein, etc., should be given hypo-
dermatically. *
BURKS AND MULTIPLE ENJUBIES 703
Saline solution should be given intravenously ami, in plethoric individuals,
bleeding may be practiced from the distal end of the v.-in int.. which the >,iline
solution is being injected.
In desperate cases blood transfusion may be done.
The chronic forms of poisoning such as occur in workers about el»
furnaces, in brick and tile workers, the "miner's disease," •
by removing the patient from exposure to the -;i>, the use of hemat
to overcome the anemia, and an outdoor life in the t'n-h ;iir ami
shine.
Chronic Carbon Bisulphid Poisoning. — This occurs in workers emplox,
making rubber goods.
The treatment should be largely preventive and workmen should be tan-lit
to use instruments for dipping the material into the l.isulphid solution,
cial means for ventilation should be employed to carry oif the fumes from the
bisulphid tanks and the workmen should be cautioned a.nain.-t inhalin-
vapor.
When symptoms of chronic poisoning develop, complete removal from ex-
posure to the bisulphid is indicated. An outdoor life with mild exercise and a
generous diet, very largely fluid, are probably of the greatest value. Alcohol
should be prohibited. The treatment otherwise should be symptomatic for the
headache, constipation, and nervous symptoms. The local eczema should be
treated by appropriate measures.
THE TREATMENT OF ACCIDENT CASES, RAILROAD INJURIES AND OTHER
FORMS OF MECHANICAL VIOLENCE PRODUCING
MULTIPLE INJURIES
The detailed features of the treatment of such injuries will be found scat-
tered throughout the entire work and such information as is not iriven here will
be found under the various regional chapters and in Vol. IT, Chapters I ami
II, Postoperative Care and Postoperative Complications.
The essential factor in the treatment of such injuries is tho establishm*
a temporary dressing station or the application of sufficient first aid d
to protect the injured areas until suitable medical aid can be obtained ..r until
the patient can be transported to proper surroundings for the pr. ^ical
treatment/
It would seem wise to have workmen employed in pursuits which are
inherently dangerous properly instructed, as are soldiers, in the application of
first-aid dressings, the methods of stopping hemorrhage, and in the ways and
means of immobilizing injured parts so that the patient may he transported
without increasing the extent of the injury, and with a minimum doirree of
pain.
The first-aid treatment often determines the outcome of tho inju
pointed out in the chapters devoted to the treatment of wounds and of frac-
THE TREATMENT OF WOUNDS AND THEIR DISEASES
tares, meddlesome interference under improper surroundings with insufficient
materials or experience usually means disaster to the injured individual.
It should be stated as axiomatic that no operative procedures should be
attempted until the patient has been removed to suitable surroundings. Such
treatment as is undertaken, whether it be lay or medical, should be limited to
the protection of the wound, the stopping of hemorrhage, the temporary immo-
bilization of the part, and the combating of the shock. This latter, the com-
bating of the shock, must needs be largely medical in that drugs such as
morphin, etc., given hypodermatically cannot safely be entrusted to the laity.
The introduction of hot coffee, tea, or water into the rectum, surrounding the
patient by hot water in such containers as are accessible or by anything that
can be heated are matters necessarily subject to medical direction.
In general in accident cases of the severe type received in railroad accidents,
crushing injuries, etc., the chief aim, after the patient is received into a proper
place for treatment, should be treatment directed toward the shock. This con-
sists in using all the methods elaborated in the chapter devoted to that subject,
Vol. II, Chap. I, Postoperative Care, etc., and in many other chapters.
Hemorrhage should be stopped and where a tourniquet has been applied
elsewhere this should be inspected and adjusted if necessary. A tourniquet
should be placed close to the injured area or on the injured tissue if possible
rather than at too great a distance from it, especially if it must be left in posi-
tion for any length of time.
In severe injuries with internal hemorrhage, the hemorrhage must of necessity
be sought for by operation and only such operative steps carried out as are neces-
sary to check the hemorrhage and prevent infection.
Idealism has a definite field in other realms of surgery, but any time-consuming
operation, no matter what its theoretical merits may be, has no place in this par-
ticular field. The urgency of haste and of as little interference as possible
should always be kept before the surgeon. When the stage of reaction has set
in and the patient has sufficiently recovered to bear the operation, then the ideal
may be attempted if the existing conditions warrant it.
The above applies with special significance to traumatic amputations and
to those complicated lacerating or crushing injuries of the extremities in which
a surgical amputation is necessary. See also Vol. I, Chap. V, Contra-indi-
cations, etc.
It is wiser to tide such patients over their first crisis before shoving them
into a state of further depression by additional traumatism no matter how
skillfully conducted as to the surgical technic or equipment.
In accident cases into which street dirt, manure, etc., are ground into the
wound a prophylactic dose of tetanus antitoxin should be given. (This is
especially indicated in localities known to be infected by the tetanus bacillus.)
In all severe traumatic injuries special care should be taken to prevent
infection, to drain all dead spaces, and to avoid any form of compression either
by suture or dressing which will interfere with a free circulation through the
BIBLIOGRAPHY 705
part. Extremities should be elevated and exposed muscles, etc., protected by
sterile saline dressings to protect them from the drying action of the air.
BIBLIOGRAPHY
1. BACELLI. Policlinico, Nov. 15, 1895.
2. BE VAN. Jour. Am. Med. Assn., Nov. 11, 1905.
3. BLAKE. Surg., Gynec. and Obst., May, 1906.
4. BONOME. Deutsch. med. Wchnschr., 1894, 703.
5. FRAZIER. Keen's Surgery, i, 496.
6. HITZROT, JAMES M. Ann. Surg., 1911, 573.
7. HUTCHINGS. Surg., Gynec. and Obst., 1909, ix, 11.
8. JOHNSON. Surgical Diagnosis, ii, 21.
9. KNOWLES AND FRESCOLN. Jour. Am. Med. Assn., August, 1914, Ixiii,
No. 5, 398.
10. LEXER-BE VAN. General Surgery, D. Appleton and Co., 1908.
11. MARIE AND MORAX. Ann. de 1'Inst. Pasteur, 1902, xvi, 1 1.
12. MELZER. Med. Record, Dec. 16, 1905.
13. MEYER AND RANSOM. Arch. f. exper. Path. u. Pharmakol., 1903.
14. NOGUCHI. Osier's Modern Medicine, i.
15. PARK AND NICOLL. Jour. Am. Med. Assn., Ixiii, No. 3, 235.
16. ROGERS. Jour. Am. Med. Assn., July, 1905.
17. Roux AND BORRELL. Ann. de 1'Inst. Pasteur, 1898.
18. SCLAVO. Turin, 1903.
19. STRUBEL. Quoted by Frazier in Keen's Surgery, i, 509.
46
PKEPAKATION AND APPLICATION OF PLASTEK-OF-PABIS
DKESSINGS
CHAPTER XVII
PREPARATION AND APPLICATION OF PLAHTEK OF 1'AKIS DKKSSINGS
J. F. COWAN
INTRODUCTION
Because of the ease and accuracy with which it can be moulded to the body,
and because of its lightness, firmness, and rapidity of setting, plaster-of-Paris
is the best material for use in making splints, casts, and jackets. For these
reasons it is the most frequently employed material in the treatment of frac-
tures. There are few fractures which cannot be treated satisfactorily at some
period by the proper- use of this material.
It has an extensive application in orthopedic surgery in the treatment of
tuberculous disease of the bones and joints and after the correction of deformi-
ties. It is applied in the form of plaster-of-Paris bandages, whieh are employed
in making the following forms of dressings: (1) moulded plaster splints; (2)
circular plaster dressings.
PREPARATION OF PLASTER-OF-PARIS BANDAGES
These may be purchased ready for use from various surgical dressing manu-
facturers, or may be easily and cheaply made 1>\ the surgeon, an assistant, or
nurse. The plaster-of-Paris should be of good quality, dental casting plaster
being the best. Good plaster will set in from 5 to 10 minutes. High-grade
commercial plaster-of-Paris may be used, but is slower in setting.
The best material to use as a foundation for the plaster is crinoline. Ordi-
nary commercial crinoline contains considerable sizing or irlne, which makes it
quite stiff. To render it more serviceable, this should be washed in lukewarm
water, thoroughly rinsed and dried. Crinoline sized with starch is preferable.
The crinoline is cut into strips, 4 to 6 yards in length, with widths of 3, 4. :>.
and 6 inches respectively. In order to avoid frayed edges, threads may be
pulled, and the crinoline cut along the space of the pulled threads. Loose
threads at the edges of the crinoline strips should be pulled, as they interfere
materially with the smooth rolling of the bandage.
707
708 PLASTER-OF-PAKIS DRESSINGS
The crinoline strip is now laid upon a flat, smooth surface. A handful of
plaster is placed upon it and swept along with the hand or a light piece of wood
with a straight edge, the plaster being thoroughly worked into the meshes of
the crinoline. It is important in preparing the bandages to put just sufficient
plaster into the crinoline to fill the meshes and to have it evenly distributed.
This amount can only be learned by experience in making and applying the
bandages. As the meshes of the crinoline are filled with the plaster, the bandage
is loosely rolled. Tight rolling of a bandage prevents the water from reaching
the inner layers.
The bandages are wrapped in papers, which are folded over the ends, and
held by means of strings or rubber bands. They are then placed in an ordinary
tin bread-box, or other can with a tightly fitting cap. If kept in a dry place,
many bandages may be made at a time, and their efficiency preserved for a long
period. Should the plaster become damp, the bandages are placed in a warm
oven till thoroughly dry. Special apparatus have been devised for rolling plas-
ter bandages, but the above method is equally easy and satisfactory. By the
preparation of his own plaster bandages the surgeon can. always get bandages
of the desired length and width, and with the proper amount of plaster. They
will be fresh and therefore set more rapidly.
MATERIALS NECESSARY FOR THE APPLICATION OF PLASTER
DRESSINGS
The following materials are required for the application of plaster-of-Paris
dressings: (1) plaster-of-Paris; (2) plaster-of-Paris roller bandages ; (3) crino-
line; (4) sheet-wadding in large sheets; (5) sheet-wadding made into roller
bandages; (6) flannel roller bandages, or seamless tricot material; (7) muslin
roller bandages; (8) muslin for slings; (9) bass-wood splints, or strips of
perforated tin; (10) strips of malleable iron; (11) adhesive plaster; oxid of
zinc and moleskin; (12) knife with short stout blade for cutting plaster, and
saw; (13) pair of heavy bandage scissors; (14) spica stand.
PLASTER-OF-PARIS DRESSING FOR FRACTURES
After reduction of a fracture, some form of retentive dressing is applied to
maintain the fragments in proper position. Plaster, properly applied, is the
best retaining material. Whether applied in the form of moulded plaster
splints or circular plaster dressings, certain general principles should be ob-
served :
General Principles to be Observed — (1) In all cases the skin should be cleansed
with soap and water, followed with alcohol and a dusting powder. If blebs are present,
PLASTER-OF-PARIS DRESSING FOR PRACTUB 709
they should be punctured arid the exudate pressed out. Th. •<- ;,n-;,s ..,,,,1 ;,|,r.,
should be dusted with boric acid powder, and an aseptic gnu/.r j>;.,l appli, ,|.
(2) In general, the joint above and below the rite ..f fr:,. fur, ihould I, iinmo-
bilized, care being exercised to prevent stiffness of the joint and atrophy of the
muscles by early massage and passive motion.
(3) The dressing should not interfere with the circulation of the limb, nor cauae
undue pressure on prominent parts of bones or prominent tendons. Allowance should
always be made for swelling, especially during the first few days after injury.
(4) The patient and his attendants should be warned of these dangers, and should
be instructed to watch the color, temperature and freedom of motion of the distal por-
tions of the limb, which should always be left exposed by the dressing.
(5) After reduction of displacement and the application of a properly fitting
plaster dressing, with immobilization of the fragments, pain is greatly relieved Should
the patient continue to complain of pain, especially if this is not at the point of frac-
ture, but at the site of a bony prominence, or prominent tendons, the dressing should
be loosened or removed at once. Ulcers, the result of pressure, may cause considerable
trouble, and furnish atria for pyogenic organisms.
(6) The surgeon should see the case at least once a day for the first 3 or 4 days.
(7) A radiograph, while not essential for diagnosis of fracture in the majority of
cases, should, whenever possible, be taken immediately after the application of the
dressing, and a second one 10 days or 2 weeks later, to determine the result of reduc-
tion and retention.
Preparation for Plaster Work. — An objection to plaster-of-Paris is that it
soils objects with which it comes in contact. To avoid this, certain preparations
for plaster work should be made. This is especially important in private prac-
tice.
Above all the surgeon and assistants should do their work neatly as well as rapidly.
They should have their forearms bared, and should be protected by gowns or rubber
aprons. If these are not at hand, a sheet draped about the body will serve the purpose.
The patient and bed should be protected by rubber sheets or bed sheets, and the floor
by rubber sheets, bed sheets or newspapers. If the bandages are properly made, and
wrung until they cease to drip, there will be little cause for soiling the surroundings.
If, however, the plaster has been spattered on clothing or carpets, it should be left until
it is dry before attempting to remove it. Spots on woodwork or furniture are removed
while moist, or moistened if dry.
Moulded Plaster Splints.— If plaster-of-Paris is used as a primary dressing,
it should, as a rule, be in the form of moulded splints which can be easily
loosened or removed. Moulded splints are especially serviceable in the treat-
ment of fractures of the arm, elbow, wrist, and ankle.
PEEPAEATION.— A flannel or sheet-wadding bandage, about 2 inches longer,
and a little wider than the desired plaster splint is measured off on the part to
which the dressing is to be applied. By having the length and breadth of the
flannel or sheet-wadding bandage a little in excess of the plaster, the ends and
sides of the latter are prevented from coming in contact with the skin and cans
ing irritation. A plaster roller bandage is then placed in warm water, without
710 PLASTER-OF-PARIS DRESSINGS
the addition of alum or salt. There should be sufficient water to cover the ban-
dage when set up on end. Only one bandage should be immersed at a time.
When all the air bubbles have ceased to escape, it is carefully lifted from the
water by holding an end with each hand so as to prevent as far as possible the
escape of the plaster.
The bandage is wrung until it ceases to drip. It is then rapidly and evenly
spread upon a smooth surface to the desired length, and brought back and forth,
each turn being smoothed by the hand, and the plaster thoroughly worked into
it. From eight to fifteen turns are usually required, but the number will depend
upon the thickness of the material used and the part to which it is to be applied.
The flannel or sheet-wadding strip is placed upon the plaster splint, and the
ends of the former folded over the ends of the latter. It is best not to spread the
plaster upon the flannel or sheet-wadding bandage, as the latter should be dry
when applied to the skin. Plaster splints may be reenforced by thin strips of
basswood, or perforated tin, cut in proper dimensions and incorporated between
the layers of the plaster bandages. By the use of these the weight of the splint
may be reduced, while the strength is maintained. Reenforcement can best be
used in parts where the plaster will not require much moulding.
APPLICATION. — The part is firmly held by assistants, and the fragments
maintained in the correct position by traction and counter-pressure. The plas-
ter splints are rapidly applied, moulded to the part by gentle pressure, and held
in position by a muslin roller bandage. The part is carefully supported by the
assistant, or by sand bags, until the plaster hardens. This dressing can be
easily loosened to allow for swelling, thus lessening the danger of constriction,
and can be readily removed when massage and passive motion are desired. As a
general rule, a roller bandage should not be applied to the limb previous to the
application of a plaster dressing, as it may interfere with swelling and do harm.
Moulded splints may also be made by first applying a circular plaster dressing.
When the plaster is set, it is cut through the entire length, laterally, or an-
teriorly and posteriorly. Anterior and posterior or lateral splints are thus
made.
Circular Plaster Dressings. — A circular plaster dressing should rarely be
used as a primary dressing in the treatment of fractures.
Complete encasement of a part in plaster before swelling has occurred, exposes
it to the dangers of constriction and subsequent gangrene or ischemic contracture,
if swelling takes place after the application. If applied while the limb is swollen,
the subsidence of the swelling will leave the dressing loose, so that the fragments are
not properly immobilized. Such conditions call for the removal of the dressing.
The circular plaster dressing is the most serviceable dressing for fractures after swell-
ing has subsided, and at a later period in cases of fracture in which treatment by
continuous traction- has resulted in a fair degree of union. It is also applied after
open operations for fractures.
APPLICATION. — The limb is carefully raised by two assistants, one of whom
makes steady traction in order to secure the full length and proper alignment ;
PLASTER-OF-PAR1S DRESSING I-OK FRACTUKJ 711
the other supports the limb at the site of fracture. The surgeon applies a roller
of sheet-wadding smoothing about the limb. This is made th
of pressure and about bony prominences, and is made to extend beyond the
limits of the cast, so as to prevent irritation of the skin \>\ tin- <-n<ls of the
plaster.
The first plaster roller should bo carried from below upward, in spiral turns,
never reverses, as far as it will go, completing the dressing once, Turks are taken
in the bandage posteriorly, so that the spirals will he evenly applied. The suc-
ceeding turns should go over this from bc-i-iniiinir to end, care being taken to
have the dressing of equal thickness throughout. In certain cases the dressing
will require reenforcement at particular places. This will be described in the
application of special dressings. The turns of the first layer of the plaster roller
should be drawn just tight enough to retain them in place, and the succeeding
turns applied without increasing the pressure. The turns, as they are made, are
smoothed with the hand, always in the same direction, and the plaster thoroughly
worked into them. They are accurately moulded to the prominences and de-
pressions of the limb, thereby preventing subsequent movement of the limb
within the dressing. Rubbing a large quantity of plaster cream into the turns
as they are applied adds to the weight.
A plaster dressing should be as light as is compatible with strength. The
weight of the dressing may bo reduced by the use of strips of basswood, or
perforated tin, incorporated between the layers of the plaster bandages.
After the completion of the dressing, the limb should be properly supported
by the hands, or by sand-bags, until the plaster has become firm. This usually
requires from 10 to 15 minutes. The dressing should not be covered with the
bed clothing, but should be left exposed to the air, in order to effect a thorough
hardening. The ends of the flannel or sheet-wadding bandage are brought over
the plaster like a cuff, and are held by means of adhesive plaster, or by the
last turns of the plaster as they are made. A circular dressing should always
extend well above and below the site of fracture, and the fingers and toes should
always be left exposed and carefully watched for signs of interference with
circulation.
It is quite important that a radiograph shall be taken immediately after the
application of a circular dressing for fracture, and a second one 10 days or f
weeks later to determine the position of the fragments. If this is not possible,
the dressing should be cut down and removed, and a careful examination of the
limb made. The position of the fragments may be improved and the dressing
readjusted, or a new one applied. If the dressing is to be replaced, the limb
protected by another flannel or sheet-wadding bandage, the dressing readjusted
and held in position by several strips of adhesive plaster applied circularly about
it If swelling has subsided so that the dressing is loose, a greater thickne*
protecting material is necessary. Whenever the dressing
should be thoroughly cleansed.
Fenestrated Plaster Pressings.— In cases of laceration of the skin, compound
712
PLASTEK-OF-PAEIS DRESSINGS
fractures, or after operation, e. g. fracture of the patella, where dressing or in-
spection of the part is necessary ; or when it is desired to relieve the pressure at
a certain point, as in plaster dressings applied after the correction of club-foot,
an opening or fenestrum is cut in the dressing before the plaster is dry. To
make provision for the cutting of an opening a gauze compress, the size of the
desired fenestrum, is applied over the wound. When the dressing is completed,
an elevation on the surface marks the position of the wound and enables the
surgeon to make the fenestrum in the proper position and of the proper size, and
at the same time protects the wound. The edges of the fenestrum may be pro-
tected from the wound discharge by dental rubber or oiled silk.
Interrupted Plaster Dressings. — If the skin or soft parts have been exten-
sively injured, as in certain compound fractures, or in cases of an infected
joint, such as the knee, where the wound cannot be dressed through a fenestrum
without weakening the dressing, or where injury to the
deeper structures forbids any constriction or pressure, the
dressing may be interrupted. This is done by incorpor-
ating one or two curved iron bands (Fig. 1) into the plas-
ter in the following manner : The limb is covered with
sheet-wadding or flannel bandage up to the lower limit of
the part which is to be left exposed. The same material
is then applied from the upper limit of the part to be ex-
posed as far as may be desired. To these covered portions
of the limb a few turns of a plaster roller are applied. A
straight iron band, sufficiently long to extend well above
and below the area at which the dressing is to be inter-
rupted, is placed on the plaster opposite the wounded area,
and is fixed in place by a few turns of the plaster bandage.
One or two stout iron bands bent in the form shown above
are next incorporated in the subsequent turns of the plas-
ter, and the dressing completed. The limb is held in the
desired position till the plaster hardens.
Plaster-of -Paris Spica for the Hip, — The plaster-of-
Paris spica is employed in the treatment of fractures of
the femur, either as a primary dressing or after union has
become fairly firm by treatment with continuous traction.
It is used as a retentive dressing after the open method, in
which the fragments are fixed by plate or wire. It has an
extensive application in the treatment of tuberculous dis-
ease of the hip, and after reduction of congenital disloca-
tion of that joint. The details are as follows:
APPLICATION. — The patient is placed upon a box or stand about 6 inches in
height, and of sufficient size to support the head and upper portion of the trunk.
A spica stand, well padded with layers of sheet-wadding, is placed beneath the
sacrum. The extremities are supported by assistants, A folded towel, or
FIG. 1. — TREATMENT OF
COMPOUND FRACTURE
(INFECTED), INVOLV-
ING THE KNEE-JOINT.
Two plaster casts,
inclosing the thigh
and leg, connected by
U-shaped pieces of
iron incorporated into
the plaster.
PLASTKU-OF-PAUIS DKESSING FOB FRACTUR]
several thicknesses of sheet-wadding, the ao-cullc.1 "dinner ,,a.l" is placed over
the abdomen. The entire abdomen, pelvis, and whole or part of th, extremity
depending upon the case, are covered with several thicknesses of iheet-waddiM
in the form of 4 or 6-inch roller bandages. Extra pads of the Mine material arc
placed over the crests of the ilia and symphysis ,>ul,is, the Ham.,,, IHM,,* pro-
tected by the pad on the arm of the spica stand. This pad remains in portion
alter the removal of the stand.
With the limb held in the desired position by an assistant, the ...rgeon ap-
plies the plaster rollers, beginning at the pelvis. The bandage is can-in! around
the pelvis, over the hip to the thigh, around the latter, and l,rnu»|,t bark t.. rh.>
pelvis in a figure-of-eight. After several figures-of-ri^ht have l^n made aUnt
the hip, the bandage is carried down to the extremity in spiral turns. S]
FIG. 2. — LONG PLASTER SPICA INCLUDING THE FOOT. Dressing for fractures of the femur.
turns, beginning at the pelvis, are carried upward about the abdomen, returned
to the pelvis, and carried down the extremity. This is continued with spiral
turns to the abdomen and extremity, and figures-of -eight about the hip until
the dressing is of the desired strength.
The weak portion of the spica, over the groin, is reenforced anteriorly and
laterally by layers of plaster rollers extending from well above the pelvis to the
knee and incorporated between the layers of the spiral turns. Strips of bass-
wood may be used in the same manner. The turns, as they are made, are
smoothed with the hand, and the plaster thoroughly worked into them. After
completing the application of the plaster, a semi-circular portion is removed in
front by making a cut extending from the upper border at the sides to the
level of the umbilicus. This, with the removal of the abdominal pad, gj
more freedom to the respiratory movements. The edges of the dressing above
and ajbout the perineum are now trimmed. If the foot is included in this
dressing, it should be well padded on the dorsum, and held in the right-angled
position. If flexion is less, drop-foot will result, causing considerable difficulty
in walking after the removal of the dressing.
Removal of Circular Plaster Dressings. — Several instruments have been de-
U4: PLASTER-OF-PAKIS DKESSINGS
vised for cutting plaster dressings. Of these, Stille's shears are most useful.
The ordinary knife with a short, stout blade is, however, quite efficient. The
plaster is moistened along a straight line with hot water, or H2O2, and cut
through with a knife. There is diminished resistance to the knife when the
lower layers of the plaster are reached. These with the sheet-wadding are cut
with heavy bandage scissors and the sides of the dressing forcibly pulled apart.
Removal of Plaster from the Hands.- — To prevent the plaster from sticking
to the skin, one may thoroughly anoint the hands with vaselin before beginning
the plaster work. After completion of the work, the hands are washed with
soap and warm water, which leaves the skin soft and clean. If the hands have
not been previously anointed with vaselin, they may be washed in a solution of
sodium carbonate, a teaspoonful to a basin of water. Friction with granulated
sugar or corn-meal may be used in removing the plaster. Eubber gloves may
be worn.
PLASTER-OF-PARIS DRESSING FOR SPECIAL FRACTURES
In the application of plaster dressings for fractures, it must be borne in mind
that the function of the dressing is only to retain the fragments in the corrected
position, and not to reduce displacement. Replacement of the fragments should
therefore be made as complete as possible, and the limb should be held firmly
in the corrected position both during the application of the dressing and the
hardening of the plaster.
EPIPHYSEAL FRACTURE OF THE UPPER END OF THE HUMERUS
The muscles inserted into the tuberosities draw the tipper fragment up-
ward and forward, so that the articular surface of the head looks downward.
Further elevation is prevented by the impinging of the greater tuberosity on
the acromion process. Codman (5) has shown that when the arm is rotated in-
ward and abducted to the horizontal, the greater tuberosity impinges on the
acromion process and prevents further elevation of the arm on the scapula, and
that for further abduction, it is necessary to rotate the arm outward. The
upper fragment, being rotated inward and drawn forward, is anatomically fixed
in this position by the contraction of the muscles inserted into the tuber-
osity, and by the counter-impinging of the greater tuberosity on the acromion
process.
In an open operation on one of these fractures, Albee (1), after wiring the
fragments and attempting to bring the arm to the side, noticed that the upper
fragment was so firmly fixed that it would not rotate downward, and the wire
began to cut through. He therefore elevated the arm forward and slightly out-
ward, with slight inward rotation of the humerus, and flexed the elbow at a
right angle.
PLASTER-OF-PAklS DUKSSI XG FOR SPECIAL PRACTtJRES 715
Dressing. — With the shoulder, arm, and forearm in the above position, a
plaster-of-Paris spica is applied, reaching from the \vri.-t to tlic wai.-i. The
patient is kept in bed during the first week after the application of tin- dressing,
the weight of the dressing and the arm bein-
supported by suspension. At the end of •'!
weeks the dressing is removed, and massage and
passive motion begun.
FRACTURE OF THE SURGICAL NECK OF THE
HUMERUS
The action of the muscles tends to displace
the lower fragment upward and inward, and to
flex, abduct, and externally rotate the upper
fragment. As in the epiphyseal fracture, the
capital fragment is too small to be directly in-
fluenced by the splints. The lower fragment
must therefore be brought into alignment with
the upper. The dressing applied by Albee in
the treatment of fracture of the upper epiphysis
may be used in this fracture. Anterior and
posterior moulded splints (Hitzrot, 8) forming
a cap for the shoulder, with axillary pad, may
be used also.
Application. — The forearm is flexed and supported at the wrist by a sling.
A modified Stromeyer cushion is placed in the axilla and firmly held in position
by a bandage over the opposite shoulder, and about the waist. The cushion
should extend from the apex of the axilla to just above the internal condyle of
the humerus, and should be broad enough at its base to bring the lower fragment
into proper alignment. If the cushion is too short, there is danger of causing
angulation of the fragments. It should be sufficiently firm to maintain its shape
under pressure of the arm.
Strips of adhesive plaster are applied to the arm. extending from the level
of the deltoid insertion to 6 inches below the elbow. These are held by an as-
sistant, who applies traction, or a weight of from ."> to 10 pounds is attached
to the ends. The posterior splint begins at the base of the mvk and
down the arm and forearm to the wrist. The anterior splint be-ins at the
vertebral column, passes over the scapula and posterior splint above the shoulder
joint, and down the arm and forearm to the wrist, the latter joint being left
free. With the lower fragment appropriately abducted, traction is made upon
the adhesive strips, and the corrected position carefully maintained by an
assistant, while the surgeon applies and gently moulds the splints to the limb.
The splints are held in position by a muslin bandage extending from the
wrist, with a spica to the shoulder. The latter aids immobilization and opposes
TIC PLASTER-OF-PARIS DRESSINGS
overriding. If overriding occurs, the shoulder cap formed by the crossing of
the 2 splints rises above the shoulder, so that the finger may be introduced be-
neath it. A weight attached to the adhesive strips or to a bandage over the
elbow is useful to prevent overriding, or to overcome shortening which may
have occurred. As the action of the muscles tends constantly to produce dis-
placement, and as it is difficult to fix the upper end of the splints so as to prevent
overriding, the dressing should be examined at frequent intervals and readjust-
ment made when necessary. Points of pressure should be carefully watched,
especially the nerves and vessels of the axilla, and the inner aspect of the arm.
Massage is begun during the third week. The splints are removed at the end of
the fourth week, and active and passive motion begun. The forearm is sup-
ported at the wrist by a sling for a week after the removal of the splints.
FRACTURE OF THE SHAFT OF THE HTJMERUS
Displacement of the fragments varies with the site of fracture. If the
fracture is in the upper third of the shaft, the upper fragment is displaced
inward by the action of the pectoralis major, and the lower fragment is drawn
upward by 'the deltoid. In the middle and lower thirds, the upper fragment is
drawn forward and outward by the deltoid, while the lower fragment is dis-
placed upward and backward by the triceps. Reduction is accomplished by
traction upon the flexed forearm and manipulation of the fragments.
Dressing. — The above described anterior and posterior moulded splints with
axillary pad is an efficient dressing for these fractures, especially if there is a
tendency to displacement of the fragments. The Stromeyer cushion should be
about 3 inches wide at its base, so that the arm is but slightly abducted. A
moulded plaster-of-Paris splint forming a cap for the shoulder may be used.
This dressing is prepared in the following manner : A pattern correspond-
ing to the dimensions of the splint is made by placing a piece of muslin upon
the shoulder, anterior, and posterior aspects of the chest, and outer side of the
arm and forearm, and cutting it to fit the parts. The pattern is then laid upon
the table, and from 6 to 8 thicknesses of crinoline are cut to correspond. These
are soaked in plaster cream and laid one upon the other, the plaster being thor-
oughly worked into the meshes by the hands. Six-inch plaster rollers may be
used instead of the pieces of crinoline. These are unrolled back and forth over
the pattern until the desired thickness has been secured. The edges are trimmed
with scissors to correspond to the pattern. Several layers of sheet-wadding, a
little larger than the pattern, are prepared, and the splint placed upon these. A
firm axillary pad, giving slight abduction to the arm, is applied, and the forearm
is supported by a sling at the wrist.
With the limb firmly supported by an assistant, the surgeon applies the
splint and gently moulds it to the parts. It is held in position by a muslin
bandage about the forearm, arm, and chest, the opposite axilla being protected
by sheet-wadding. This dressing does not exert active traction upon the lower
PLASTEU-OF-PARIS DKKSSING FOR SPK( '1 AL FRACTURES 717
fragment and its application is therefore limited to cases in whirl, tl,.
little tendency to displacement. The dressing should be Amoved once a
and the parts carefully examined. If displacement baa ooem I,,,,,!,! be
corrected if possible. As the swelling subside, it is nocessm
splint with a new one. The fluoroscope is a valuable idjuvanl in the tpl
tion of the dressing to these fractures.
Massage is begun during the third week.
Union is usually firm in from 3 to 4 weeks
in children, and in from 5 to 6 weeks in
adults. Eemoval of the splints will depend
upon the solidity of the callus. Delayed
union, the result of improper fixation of 'the
fragments, is quite apt to occur in these
fractures.
After the removal of the moulded splints,
coaptation splints of basswood are applied,
or those portions of the moulded splints ap-
plied to the arm are left. Coaptation splints
are worn for one week, the sling used for
one week after all dressing has been removed.
In fractures of the shaft of the humenis,
a careful examination should be made to
determine whether injury to the musculo-
spiral nerve has occurred. This injury is
most common in fractures of the middle
third. If the injury is not determined at the time of the application of the
splints, but later upon their removal, the cause of the paralysis cannot be read-
ily determined, and the patient may attribute the result of injury to faulty
application of the splints.
Fio. 4. — MOULDED PLASTER- or -PARIS
SPLINT FOR USE IN TREATMENT or
FRACTURES OF SHAFT OF HUMMUS.
FRACTURES OF THE LOWER END OF THE HUMERUS
Because of the proximity to the joint, it is most important to secure accurate
reduction of the fragments, and to fix these, so as to prevent the two common
forms of displacement, viz., overriding and lateral auirular deformity. Th«
considerable diversity of opinion among surgeons as to the position in which the
elbow should be placed in the treatment of these fractures. As a general rule,
however, the position of the forearm on the arm, in a given fracture, should be
that in which it is found by manipulation that the fragments are best retained
in position after reduction. The following positions are employed: (1) acute
flexion; (2) flexion at a right angle, or slightly beyond: ( :'. ) extent
In supracondyloid fracture, fractures of the internal epicondvle. fracture of
internal and external condyles, acute flexion reduces and retains the fragments
in position.
718 PLASTER-OF-PARIS DRESSINGS
Supracondyloid Fracture.— Of the two varieties, flexion and extension frac-
tures, the latter is the most common. In this fracture the lower fragment is
displaced backward and upward. Reduction is accomplished, under anesthesia,
by hyperextension of the elbow, traction on the forearm, counter-traction and
pressure backward on the upper fragment, and flexion of the elbow.
In the acutely flexed position, the untorn periosteum on the posterior surface
of the humerus, and the triceps, together with the fasciae posteriorly and later-
ally, hold the fragments reduced. In this position also the forearm prevents
forward riding of the upper fragment by the pressure exerted on the latter by
the parts within the flexure of the elbow. Lusk (11) has shown in an X-ray
of one of these fractures that, in extreme flexion, the coronoid process of the ulna
can impinge against the anterior margin of the lower end of the upper fragment
and prevent anterior displacement. The degree of flexion which can be used
will depend upon the amount of swelling of the soft parts. If this is marked,
the flexion must be less.
DEESSING. — The circular plaster dressing described by Lusk is applied in
the following manner : A layer of absorbent cotton is placed between the skin
surfaces at the flexure of the elbow. A flannel bandage is applied to the lower
portion of the forearm and upper portion of the arm, the flexure of the elbow
remaining free so as not to interfere with extreme flexion. A few turns of a
plaster roller are applied about the wrist and upper portion of the arm sepa-
rately, then about the two together, and made to include the elbow, which is pro-
tected laterally and posteriorly by sheet-wadding. The circular turns applied
to the wrist and upper portion of the arm prevent the dressing from slipping;
the turns including these two maintain flexion and prevent lateral displacement.
The limb should be inspected frequently during1, the first few days. The radial
pulse is carefully watched for signs of compression of the vessels at the flexure of the el-
bow. The position gives some discomfort, but should not cause actual pain. The latter
symptom indicates too great pressure, and calls for a decrease in the angle of flexion.
This dressing holds the fragments firmly in position, but acute flexion may
itself cause an angular displacement by a tilting forward of the lower fragment.
In cases where the swelling is marked, the angle of flexion must be decreased.
Some surgeons prefer the position of flexion at a right angle, or slightly be-
yond it.
APPLICATION OF SPLINTS. — In this position, anterior and posterior splints
may be applied. These are well padded with sheet-wadding and extend from
the level of the axilla to the middle of the palm and dorsum of the hand. They
are held in position by adhesive strips and a muslin bandage. The forearm is
supported at the wrist by a sling. A posterior moulded splint combined with a
U-shaped splint about the elbow (Hitzrot, 9) may be used. To prevent the gun-
stock deformity, the arm of the U over the inner side of the forearm is placed a
little more upward than the posterior limb of the splint. The forearm is sup-
ported at the wrist by a sling.
PLASTER-OF-PARIS DRESSING FOR SPKcl.M. FRAOTDBEfl 719
The position of extension is an uncomfortable one. In some cases, however
because of the tendency to recurrence of displan ,,„ nt, it may be necessary*
After a week or 10 days in this position, the elbow ma v [„• il,..W to a right angle!
Internal and external moulded splints are applied, extending from the axilla
to the webs of the fingers. These are held in position by adhesive strips, and
the entire extremity bandaged with a muslin bandage.
In the treatment of these fractures it is most essential to preserve the normal
carrying angle, and in the application of splints tin- prn,,,.r degree of abduction
of the forearm must be maintained. If the normal ando is destroyed, it should
be restored. A circular dressing extending from the axilla to th,- mi, Idle of the
hand may be used also. Splints are removed once a week and re-applied. Mas-
sage is begun after subsidence of the swelling, the posterior splint being left in
FIG. 5. — ANTERIOR AND POSTERIOR PLASTER SPLINTS APPLIED. Dressing for fractures high up the
forearm and at the elbow and lower portion of the arm.
position meanwhile. The splints are removed at the end of the fourth or fifth
week, and passive motion begun. Function is usually restored, especially in
children. In children, where there is no displacement, union is sufficiently firm
in two weeks to permit of the removal of the splints. The forearm is supported
in a sling at the wrist for another week. After removal of the splints, a firm
bandage is applied to the elbow for support.
Fracture of the Internal Epicondyle. — Immobilization with the elbow in
hyperflexion to relax the pronator radii teres and the superficial flexor muscles
of the forearm, which tend to draw it forward and downward. This position is
maintained until union is firm. Union is firm, as a rule, in 2 weeks in children.
The forearm is carried in a sling for another week.
Fracture of the Internal Condyle. — In this fracture the principal point to be
considered in the application of the dressing is the prevention of displacement
upward of the lower fragment, thereby causing adduction of the forearm. Tn
as much as the lower fragment is too small to be influenced directly by the
splint, its position must be controlled through the ulna to which it is attached.
In applying moulded splints, the surgeon must exercise care to keep the
fragment well down in position while the plaster is setting. If the right-angled
720 PLASTER-OF-PARIS DRESSINGS
position is used, the forearm is supported at the wrist by a sling. Xo pressure
upward on the elbow is permitted. Union usually results in 3 weeks. The sling
is used for 1 week after the splints are removed. Care should be taken not to
force passive motion.
Fracture of the External Condyle. — It. is often more difficult to reduce dis-
placement of the fragments than to maintain them in the correct position after
reduction has been accomplished. After reduction is made as complete as pos-
sible, the forearm is hyperflexed and a posterior moulded splint extending from
the shoulder to the wrist is applied and held in position with strips of adhesive.
If the right-angled position is used, anterior and posterior moulded splints are
applied as in supracondyloid fractures.
T- or Y-shaped Fracture. — Because of comminution and displacement of the
fragments, these fractures are quite certain to result in marked limitation of
motion in the elbow joint. Reduction should be done under anesthesia. As a
rule, the fragments are best held reduced by the acutely flexed position. In
cases where there are considerable comminution and displacement, deformity,
such as a widening of the joint, with anteroposterior thickening^ is quite liable
to occur. This results in limitation of motion. In these cases the forearm
should be placed in the position which will give the best functional result if
stiffness occurs. The elbow is flexed to a right angle, or slightly beyond, and
anterior and posterior moulded splints, described above in the treatment of
fracture of the surgical neck, are applied.
In applying these, they should be carefully moulded to the elbow joint and
held firmly at and above the condyles while the plaster is setting. Splints are
removed once a week and re-applied. Gentle massage is begun at the end of
the second week, with the posterior splint in position. Splints are removed at
the end of the fourth week, and the forearm is supported by a sling. The
patient is encouraged to make slight active movements increasing the range of
motion a little each day. Forced movements should not be made until the end
of 5 or 6 weeks. Full use of the arm is not permitted until the tenth week.
Separation of the Lower Epiphysis of the Humerus. — The elbow is placed in
the right-angled position, and anterior and posterior moulded splints, used in
the treatment of supracondyloid fractures, are applied. Special precaution
should be taken to prevent inward displacement of the lower fragment.
FRACTURE OF THE OLECRANON PROCESS
As a rule, there is little separation of the fragments in this fracture. The
periosteum, the lateral aponeurotic attachments and ligaments, and the ex-
tension of the insertion of the triceps along the lateral and posterior surfaces
of the olecranon prevent this. Two positions of the forearm are used in the
treatment of this fracture,, viz., full extension and partial flexion.
Full extension gives closer apposition of the fragments, because, as Stimson
(13) observes, the triceps cannot draw the fragment above the position which it
PLASTEH-OF-PAMS DKESSIXG FOR SPECIAL FRACTtfK
takes in complete extension unless the ligament* binding it to tin- lnm,,n,s are
torn, a complication which happens only rarely. In era wh..«. thi, |
tionof the fragments, which is increased by hVxin, ,),, ,IUu . ,],i> ,,n.i,i,,n ,U,M
be used.
The degree of flexion which may bo used will d<-,,«Mid up<,n tin- amount of
separation of the fragments. Tf this is slight, aii.l it not InmMed l,v H-xIon.
or if the fragments can be easily approximated by gentle downward prcssm
FIG. 6.— -MOULDED PLASTER SPLINT FOR FRACTURE OF THE OLECRANON. Arm in extension. Splint
held in position by adhesive straps. Note strap applied obliquely so as to drag downward on the
loose upper fragment. Fingers are slightly flexed.
the upper fragment, this position, which is the more comfortable one, may be
employed.
In either position an internal moulded splint extending from the axilla to
the tips of the fingers is applied. The fingers are slightly flexed and pieces of
sheet-wadding are placed between them to prevent chafing. The splint is held
in position by 4 strips of adhesive, placed circularly about the limb, two above
and two below the elbow. An obliquely placed strip of adhesive is so adjusted
as to draw downward on the upper fragment. A muslin roller bandage is ap-
plied from the fingers to the axilla to prevent swelling of the hand. If the pM-i-
tion of partial flexion is used, the splint is reinforced at the angle by addi-
tional layers of a plaster roller.
Massage is begun at the end of the second week, and slight active and pas-
sive movements during the third week. Union occurs usually in 4 wivks.
the splints are removed, and the elbow is supported by a bandage.
FRACTURE OF THE CORONOID PROCESS
With the forearm semipronated, the elbow is immobilized at a right angle,
or an acute an^le, depending upon the degree of displacement of the fragment
47
722
PLASTER-OF-PARIS DRESSINGS
by the brachialis anticus. Anterior and posterior moulded splints extending
from the axilla to the wrist are applied and held in position with strips of
adhesive. Light passive and active movements are begun during the third week,
at the end of which splints are removed. The forearm is supported in a sling
for another week.
FRACTURE OF THE HEAD AND NECK OF THE RADIUS
If there is no marked displacement of the fragments, the elbow is flexed to a
right angle or beyond, the forearm is placed in the position midway between
pronation and supination, and anterior and posterior moulded splints, extend-
FIG. 7. — U-SHAPED MOULDED PLASTER SPLINT FOR FRACTURE OF FOREARM.
ing from the axilla to the middle of the palm and dorsum of the hand are ap-
plied. The U-shaped splint may be used, as in fractures of the shaft of the
radius and the ulna. The forearm is supported at the wrist by a sling.
Massage is begun in 10 days or two weeks. Union occurs, as a rule, in three
or four weeks. The splints are then removed and the sling continued for an-
other week. Attention must be paid to the movements of pronation and supina-
tion. They should be made passively at the end of the third week.
FRACTURE OF BOTH BONES OF THE FOREARM
In these fractures it is quite essential to secure accurate reduction and re-
tention of the fragments, for the movements of pronation and supination are
easily interfered with, or lost by displacement or failure of union. Reduction
is effected by traction, counter-traction and direct manipulation of the frag-
ments near the seat of fracture, with the thumbs in front and the fingers be-
hind.
The position of the forearm in most cases is that which is midway between
PLASTEK-OF-PAR1S DRESSING FOR SPECIAL FRACTIKKS 723
supination and pronation. This is the most favorable for the following reasons :
(1) When the radius is brought into semipronatiou (so that tin- thumb will
point upward), the bones are most nearly parallel, and at the greatest possible
distance from each other. (2) It is the natural position assumed \vh< ».
forearm is suspended beside the body, with the elbow llex.-d at a ri»lit a
(3) It is the position which affords most comfort.
With the forearm held in the above position, anterior and posterior moulded
splints, extending from well above the elbow to the middle of the palm and dor-
sum of the hand, are applied. These are held in position |,v adh<-m- .-trips and
a muslin bandage. The extension of the splints above the elbow jnint j
ter fixation and opposes shortening. A U-shaped moulded splint iStimson)
beginning at the middle of the palm, extending up the flexor surface of the fore-
arm, about the back of the elbow, and down the extensor surface of the fore-
arm to the dorsum of the hand, is an efficient dressing for these fractures.
The splints should be as wide as the most muscular portion of the forearm.
Although union of the callus of one bone to that of the other is infrequent, it
is most apt to occur if the splints are narrower than the forearm, thus pressing
the bones together. A circular plaster dressing should not be used during the
first week after injury. When swelling has subsided, this dressing may be used,
special care being taken not to exert any lateral pressure. Gangrene or
ischemic contracture is very apt to follow too tight application of splints in
these fractures.
With the subsidence of the swelling, the splints may be made narrower by
cutting away a strip along the entire length of the edge. The entire forearm
is supported by a sling, the hand being left free.
The splints are removed once a week and readjusted. Massage is begun during
the third week. At the end of the fourth or fifth week union is usually firm and tin-
splints are removed. Passive and active movements are begun, special attention being
given to the movements of pronation and supination.
FRACTUEE OF THE SHAFT OF THE ULNA
Reduction is made by pressure on the displaced fragments, traction Ix-ini:
practically without value. Lateral displacement toward the radius is the most
important, and this is corrected by pressing the thumb and tinirers between th-
bones. As the radius acts as a splint to prevent overriding the forearm is
placed in the position of semipronation, and anterior and posterior moulded
splints, like those used in fractures of both bones of the forearm, are applied.
The forearm is supported in a sling, care being taken to avoid too pr-at pressure
upon the ulna. The after-treatment is the same as in fractures of both bones.
FRACTURE OF THE SHAFT OF THE RADIUS
Displacement varies according to the seat of the fracture. Angular dis-
placement, with the apex of the angle directed forward and inward, is the more
724 PLASTER-OF-PABIS DRESSINGS
common form. If the fracture is in the upper third, i. e., above the insertion
of the pronator radii teres, the upper fragment is completely supinated by the
biceps, while the pronator muscles displace the lower fragment inward and
fully pronate it.
In fractures at or below the middle of the shaft, the upper fragment is
drawn forward by the biceps and inward by the pronator radii teres, while the
lower fragment is drawn toward the ulna by the pronator quadratus. Reduc-
tion is made by traction upon the wrist and by exerting pressure over the ends
of the fragments. Pressure with the fingers and thumb between the bones may
help to bring the fragments into the correct position. If the fracture is in the
lower third, and the lower fragment is displaced inward, traction on the hand
downward and toward the ulnar side may bring the fragment back into posi-
tion.
If the fracture is above the middle of the bone, the forearm is held in the
supinated position. If the fracture is below the middle third, the forearm is
held in the position of semipronation. In each case the elbow is flexed to a
right angle, and the forearm is firmly held by an assistant, while anterior and
posterior moulded splints, used in treatment of fractures of both bones, are
applied. The after-treatment is the same as in fractures of both bones. In
fracture of the shaft of the ulna or radius alone, the same precautions as to the
width of the splints should be observed as with fractures of both bones.
COLLES' FRACTURE
In this fracture, the following displacements of the lower fragment may
occur: (1) Toward the dorsal or extensor surface of the forearm, (2) toward
the radial side of the forearm, and (3) there is often an axial rotation on an
anteroposterior axis. Complete reduction is essential to prevent permanent de-
formity, and this is carried out in the following ways: (1) In the simpler cases,
the surgeon grasps the patient's hand with his corresponding hand and makes
traction, at the same time making direct pressure upon the dorsum of the lower
fragment. (2) If impaction has occurred, a general anesthetic will be re-
quired for reduction. The fragments are grasped firmly between the thumb
and fingers and the lower fragment freed from the upper by traction, back-
ward, forward, and lateral movements, and pressed into place. Pressure is
made upon the radial side of the lower fragment in order to correct the eleva-
tion of the styloid process of the radius, which is brought about by the rotation
of the lower fragment on an anteroposterior axis. With the hand and fore-
arm in semipronation, the assistant makes traction on the hand and holds the
fragments in the corrected position while the surgeon applies anterior and pos-
terior moulded splints.
These should be a little wider than the forearm in its most muscular por-
tion and should extend from a little below the elbow to the metacarpophalangeal
joint. A crescentic piece is removed from the outer edge of the anterior splint
FIG. 8. — MOULDED PLASTER SPLINTS FOR COLLCS' FRACTUBE.
(Stimson.) Note grooves for thenar eminence and
of ulna. Splints applied with adhesive plaster.
PLASTER-OF-PARIS DRESSING FOR SPECIAL FRAOTDBES
for the thenar eminence; a small wedge-shape.,! piece i- , uf from ,!,, i,
f the posterior splint over the prominent head ,,f ,|,,. ,,|,,;, Tbe M,li,,U im,
well padded with sheet- wadding.
Small retentive pads of gauze arc sometimes necessary. The anterior of
these ,s placed over the lower end of the upper fragment, the porterior ov,r tl, •
dorsum of the lower frag-
ment. While the plaster is
setting, the splints are held
firmly against the sides of
the wrist so as to keep the
radius and ulna together.
These splints, accurately
moulded to the forearm
hand, retain the fragments
and carpus in the corrected
position hetter than any
other.
The forearm is carried in
a sling adjusted to bear its
whole weight. The hand
rests free from upward pres-
sure. The patient should be encouraged to exercise the fingers frequently, to
prevent stiffness due to tenosynovitis. The splints are removed once a week
and reapplied. Massage is begun during the second week, only one splint at a
time being removed during this. Passive motion of the wrist is begun during
the second week. Union is firm at the end of three weeks, and the splints are
removed. The wrist is supported by a bandage or a leather bracelet.
In the treatment of a reversed Colics' fracture, the same splints are applied.
There is a reversal of the retentive pads, the anterior one being placed over the*
lower fragment, and the posterior one over the lower end of the upper frag-
ment.
FRACTURE OF THE BONES OF THE HAND
A circular plaster dressing may be used in fractures of the carpal bones, or
of the base or shaft of the metacarpals, but it is most efficient for fractures of
the thumb. In fractures of the carpal or metacarpal bones, a circular plaster
dressing extending from the webs of the fingers to two inches above the wrist
is applied. In fractures of the bones of the thumb, the hand is covered with a
cotton glove or flannel bandage, the thumb is extended and abducted and a
plaster spica is applied. This should reach from the head of the metacarpal
bones below to one inch above the wrist. Dressing is removed in 10 days or 2
weeks. Massage, douching and active motion should be used after this
time.
726 PLASTER-OF-PARIS DRESSINGS
FRACTURES OF THE FEMUR
In fractures of the femur, complete encasement in plaster-of-Paris is used,
as a rule, at some time during the course of treatment. The plaster spica may
be applied after union has become well advanced by treatment with continuous
traction, as in the older methods. It may be applied as a primary dressing in
fractures of the neck, as recommended by Whitman, or in cases of fractures of
the shaft, in which there is no displacement, or in which displacement can be
corrected by traction, counter-traction, and manipulation at the time of the
application of the plaster dressing. It is also used after the open method, in
which the fragments are fixed by plate or wire.
Fractures of the Neck of the Femur. — That fractures of the neck of the fe-
mur are the most difficult fractures to treat is evidenced by the unsatisfactory
results following the ordinary methods of treatment.
TEEATMENT BY EXTENSION AND COUNTER EXTENSION: HODGEN'S
SPLINT. — In this method of treatment, displacement caused by the weight of
the limb and the action of the muscles is corrected by support equivalent to that
destroyed by the injury. To this end, several forms of apparatus have been de-
vised. Of these, the Hodgen's splint is the most convenient and satisfactory,
for it gives more freedom of motion and is more comfortable to the patient. It '
is an especially serviceable splint in the treatment of fractures of the neck
in elderly people who are too weak for the ambulatory method of treatment. It
is used also in the treatment of fractures of the shaft close above the condyles,
and in fractures of the middle portion of the shaft in muscular subjects.
The Hodgen's splint combines the principles of the double inclined plane
and Buck's extension. It consists of a rigid iron or steel frame made in the
form of the letter U. The outer bar is a little longer than the inner, and ex-
tends from the level of the anterior-superior iliac spine to 3 inches beyond the
sole of the foot. The inner bar extends from the adductor longus tendon to the
same level where the two are connected by a cross-bar. Above, the two bars are
connected by a semicircular rod, which passes over the anterior surface of the
thigh and is so placed that it is parallel to Poupart's ligament. The side-bars
taper with the limb and should be % incn farther apart than the diameter of
the limb at any point. The bars are bent at the knee to an angle of 130°. Two
hooks are attached to each bar, one above, the other below. To these cords are
fastened and brought over the limb to a traction cord which passes through a
pulley attached to an upright at the foot of the bed. To the traction cord a
weight is attached. The adjustable Hodgen's splint shown in the figure is so
constructed that the length of the side bars, the width between them, and the
angle at the knee can be varied. The splint can therefore be adjusted to any
]imb and applied to either right or left side.
PREPARATION OF THE SPLINT. — Strips of flannel bandage 6 inches wide are
cut in lengths, a little in excess of the circumference of the limb at the levels to
which they are to be applied. These are applied to the side-bars in the follow-
PLASTEK-OF-PAKIS DRESSING FOR SPECIAL FRACTURES 7_'T
ing manner : The strips are passed over the bars with the free ends external.
The lower end of the strip is brought up over the har for an inch or more. The
upper end is then folded over the lower, and the 4 thicknesses of bandage are
made fast with safety pins. This makes a trough in which the limb rests. The
strips should be so adjusted that the side bars will be u little below the level of
the anterior surface 6f the limb.
APPLICATION OF THE SPLINT TO THE LIMB. — The limb is shaved, and the
skin thoroughly cleansed with soap and water followed by alcohol. Strips of
moleskin adhesive plaster, which is stronger and !<•— irritating to the skin than
the ordinary adhesive plaster, are cut .*> inches in width and long enough to
reach from just above the knee to four indies beyond the sole of the foot
Oblique cuts are made along the edges of these, so that they may be applied
more readily to the part.
About 3 inches above the malleoli, the strips are cut obliquely on each side
for one-third the width, and the sides below this are folded over each other so
as to cover completely the adhesive surface. Similar strips are prepared for
the thigh and made sufficiently long to reach from the trochanter on the out-
side and the adductor longus tendon on the inner side to one foot beyond the
knee. Oblique cuts are made also along the edges of these strips. The adhesive
surface of the strips is now heated over an alcohol lamp or moistened with
ether, and the strips are applied to the leg and thigh respectively. A flannel
or muslin roller bandage, beginning at the toes, is applied to the foot, ankle
and lower 3 inches of the leg. It is then made to include the adhesive- strips
and carried up over the knee. About 3 inches above the knee it includes the
adhesive strips applied to the thigh, and is carried to the upper portion of the
latter.
The limb is now placed in the trough of the splint, and the sides adjusted.
The traction strips applied to the leg are fixed to the cross bar at its junction
with the side bar, care being taken to have the width of the cross bar sufficient
to protect the malleoli from pressure by the strips. The ends of the strips ap-
plied to the thigh are brought over a spreader of sufficient width to prevent
pressure of the strips on the condyles. A cord is attached to the spreader. The
cords attached to the hooks on the side bars above and below are brought over
the limb to the traction cord. The latter should be arranged so that
to 30° from the vertical, and the weight should be sufficient to lift the limb free
from the bed.
The cord fastened to the spreader below the knee is passed o*
a weight applied. To the suspension and traction afforded by the splint, there
is additional traction in the line of the femur. The upright which supports
the splint is fixed to the foot of the bed and arranged so t
swung outward to give the desired amount of abduction. When
is properly suspended in this apparatus, there are traction in the
the femur, flexion at the hip and knee joints, and abducti
thigh.
FIG. 9A.
FIG. 9B.
FIG. 9, A AND B. — HODGEN'S SUSPENDED SPLINT. Splint used in the treatment of fractures of the
femur. Note traction on lower fragment in line of thigh.
PLASTEK-OF-PAHIS DRESSING FOR SPECIAL 1 KA( 11 KKS
Traction is measured and constantly maintained. The foot should be kept in the
right-angled position, and the patient encouraged to exercise it daily. The splint re-
quires watching and readjustment from time to time. The traction cords should be
taut. Laxity of these indicates slipping of the splint The bed should have a firm
hair mattress and be supported by fracture boards beneath it to prevent sagging. The
foot of the bed is raised 6 inches by blocks to secure counter extension. The draw
sheet must be kept smooth, and the patient's back rubbed with alcohol and dusted with
powder twice daily.
After 5 or 6 weeks, when union is fairly well advanced, the splint is re-
moved, and a long plaster spica including the foot is applied. This is worn
for 5 or 6 weeks. After the removal of the spica, a long external lateral moulded
splint is applied. Massage and passive motion are begun with the removal of
the spica. This is given every other day, and the knee and hip joints moved.
At the end of the fifteenth week all dressings are removed, and the patient is
permitted to bear light weight on the injured limb.
Unimpacted fractures of the neck may unite, but often remain ununited.
Impacted fractures unite readily, but with deformity. In these latter cafes,
the neck of the femur is depressed, giving rise to the condition of traumatic coxa
vara and, as impaction is most marked on the posterior surface, there is ex-
ternal rotation. The effects of the elevation of the trochanter are shortening,
external rotation, and limitation of abduction and flexion. In the older
methods of treatment, viz., by extension or immobilization, no special at-
tempt was made to reduce the deformity, hence the resulting functional
disability.
TEEATMENT BY EEDUCTION AND RETENTION: WHITMAN'S METHOD.
— In fractures of the neck of the femur, in adults as well as in early life,
Whitman (16) has recommended and employed the following method of re-
duction and retention, in which the affected limb is placed in the position of
abduction, which as nearly as possible corresponds to the normal abduction of
45°.
CASES WITH IMPACTION. — The patient is anesthetized, and the pelvis sup-
ported by a spica stand. The sound limb is abducted to the normal limit to
serve as a guide and to fix the pelvis. The assistant holds the injured limb and
with gentle traction slowly abducts it. The surgeon, at the same time, supports
the joint with his hands and presses gently downward upon the trochanter.
When the normal limit has been approximately reached, a long, clos«
plaster spica is applied, including the foot. In this method, the abducted posi-
tion serves to reduce the deformity, without altogether separating the frag-
ments and completely breaking up the impaction.
CASES WITHOUT IMPACTION.— If the fracture is complete, there is a mar
tendency toward separation of the fragments. As a rule, the shaft is drawn
upward, rotated outward, and displaced backward.
The patient is anesthetized and placed in the position descried alwve.
limb on the injured side is slightly flexed and rotated inward to disengage the
730
PLASTEE-OF-PAEIS DKESSINGS
folds of the capsule that may have fallen between the fragments. Traction and
counter-traction are made till the limbs are shown by measurement to be of
equal length. The assistant then abducts the extended limb on the pelvis, which
is fixed by full abduction of the opposite limb. The pperator at the same time
supports the joint and presses the thigh upward from beneath to force the frag-
ments forward against the tense anterior wall of the capsule. When the
trochanter is firmly fixed against the side of the pelvis, the long plaster spica
is applied. "This is strengthened beneath the joint by a bar of steel or alumi-
num shaped like the Thomas' splint, in order to support the femur in a plane
FIG. 9, C. — PLASTER SPICA FOR FRACTURE OF NECK OF FEMUR, LIMB IN ABDUCTION.
somewhat above that of the trunk, and to prevent it from sinking backward
below the inner fragment." The outward rotation is corrected at the same
time.
In complete and unimpacted fractures the abducted position adjusts
the fragments and fixes them. The particular advantages of this position
are:
(1) "When the extended limb is placed in complete abduction, the trochan-
ter is firmly apposed to the side of the pelvis, so that upward displacement of
the femur is impossible.77
(2) "In this attitude the capsule is made tense; thus it should serve to
direct the fragments toward one another."
(3) "The deforming influence of muscular contraction is removed, since
PLASTER-OF-PARIS DRESSING FOR SPECIAL FRA< TI'KKS 731
the abductor group is relaxed, while the contraction of the iliopsoas muscle in
this position would draw the fragments toward one another."
Subtrochanteric Fracture of the Femur. — Displacement of the fragments in
these fractures occurs as follows: The upper fragment is ilcxr.i ami abdu
while the lower fragment overrides the upper and is slightly a// Be-
cause of the position and shortness of the capital fragment, it cannot be directly
influenced by the splint, and the lower fragment must then-fore be brought into
alignment with it, i. e., must be placed in the position of flexion and al"h;rtion
with traction. This alignment is most satisfactorily accompliahed by tin- use of
the Hodgen's splint, traction being made in the line of the elevated thiirh. If
this proves inefficient, open operation is indicated. After the splint has been
used for from 4 to 6 weeks, or after the open operation, a long plaster spica is
applied with slight flexion and abduction of the thigh and with slight flexion at
the knee.
Fracture of the Shaft of the Femur. — In fractures of the shaft of the femur,
without displacement, or in cases where displacement can be corrected by trac
tion with the patient anesthetized, the spica may be applied
at once. To effect reduction, and to maintain the fragments
in apposition while the spica is being applied, the method
described by Huntington (10) is quite serviceable.
"A skein of heavy woolen yarn is passed over each leg
to serve as a medium for perineal traction. To each of these
is attached a cord whose distal ends are tied to a ring in the
end wall of the room. Another similar skein is applied to
the ankle of the affected limb with a clove hitch. To this is
attached a small set of pulleys, which in turn are anchored
to the wall at the foot of the operating-table, and the pulley
rope intrusted to an assistant."
While the steady pull is being made by the assistant,
the surgeon manipulates the fragments to effect reduction.
If satisfactory reduction is accomplished, a long spica is
applied.
When the foot is to be included in the plaster dressing,
adhesive strips may be used instead of the yarn. These are
applied to the sides of the leg and thigh as high as the seat
of fracture, and traction made upon them. They are in-
cluded in the plaster and are cut off at the points of emer-
gence upon completion of the dressing. In applying the
long plaster spica, care should be exercised to have the
anterior-superior iliac spine, mid-patella, and middle of the
ankle in the same alignment as on the normal side. In cases where the i
method fails to overcome muscular contraction, contu
fractures of the middle two-fourths of the femur, Buck's extension with
Fio. 10. -- PLASTER
SPICA FOR FRACTTRB
OF SHAFT or FEMUR.
732
PLASTEE-OF-PATCIS DRESSINGS
the Volkmaun sliding rest is generally employed. If lateral displacement of the
fragments is present, the lateral traction advised by Bardenheuer and Graess-
nera may be added.
In the application of Buck's extension, the adhesive straps are applied to
the leg in the same manner as described for the Hodgen's splint, but are carried
up to the seat of fracture. These are held in position by strips of adhesive
placed circularly and spirally about the leg and
lower fragment, or by a muslin bandage begin-
ning at the toes. Beyond the sole of the foot,
the ends of the traction strips are attached to a
spreader with a weighted cord, the cord passing
over a pulley at the foot of the bed.
While steady traction is being maintained,
a long posterior gutter splint of plaster-of-Paris
is applied to the thigh, and three coaptation
splints, one placed anteriorly, one internally,
and one externally, are added, and the whole
held firmly in place by strips of adhesive plas-
ter passed circularly about the thigh. A Volk-
mann sliding rest is next adjusted. The foot
of the bed is raised six inches by blocks to pro-
vide counter-extension. The foot is kept in
right-angled position by the footpiece of the
rest, and sand bags may be placed along the
inner and outer sides of the limb to give addi-
tional support.
Traction by sufficient weight prevents
shortening. The weight must necessarily vary
with the individual, the amount of resistance
to be overcome, and the degree of longitudinal
The weight is increased gradually as the corn-
Usually 15 to 25 pounds is required for adults.
FIG. 11. — PLASTER-OF-PARIS USED for
FRACTURES OF THE SHAFT OF
THE FEMUR OR OF THE NECK OF
THE FEMUR. (Davidson.)
displacement to be corrected,
fort of the patient will permit.
The effect of extension should be noted from day to day, and measurements
made, until shortening has disappeared or has been reduced to a minimum.
Slight abduction prevents outward bowing of the thigh, and the pulley over
which the cord makes extension must correspond with the axis of the limb in
this position. The Volkmann sliding rest prevents eversion of the foot, and
therefore outward rotation of the leg with the lower fragment. The pos-
terior gutter and coaptation splints prevent backward displacement of the
fragments.
If lateral displacement of the fragments is present, traction in opposite di-
rections upon the ends of the fragments is made by attaching bands to weighted
cords which pass over pulleys, one on each side of the bed. At the end of 5
or 6 weeks, when displacements are no longer to be feared, the apparatus is re-
PLASTER-OF-PAR1S DRESSING FOR SPECIAL FK.\( 1TKKS 733
moved and a long plaster spica, including the foot, is applied to furnish tin-
necessary immobilization till union is complete. This is worn for 5 or 6 weeks,
and the patient is then permitted the use of crutches. Massage and passive
motion are begun with the removal of the spica.
Supracondyloid Fracture of the Femur.— In this fracture the upper end of
the lower fragment is displaced backward, chiefly through the action of th-
gastrocnemius muscle. Because of this, treatment in tin- extended positim, if
usually unsatisfactory. To relax the gastrocnemius, the leg is tli-xi-,1. ami the
Hodgen's splint applied. The degree of flexion should be sufficient to bun
fragments into proper alignment. A pad placed behind the upper end of t In-
lower fragment will assist in keeping the lower fragment lifted f,,rw:inl. After
4 or 5 weeks the apparatus is removed and a long plaster spica, including tin-
foot, is applied. In the application of the spica, care should be taken to have
the alignment the same as on the sound side. The patient is permitted the
use of crutches. At the end of eight or nine weeks, union will usually be firm :
the spica is removed, and massage, active and passive movements, are given
daily.
Fractures of the Shaft of the Femur in Young Children. — Vertical suspen-
sion suggested by Schede is the most convenient and satisfactory method of
treatment. Adhesive straps are applied to each limb as in Buck's extension
and then attached to a spreader beyond the sole of the foot. The spreader
is attached by means of a cord to a right-angled upright. Traction should
be sufficient to lift the nates free from the bed. The counterweight of the
body acts to correct overriding, and the sound limb serves as a splint to pre-
vent angulation of the fragments. After 3 weeks, union is fairly firm, and
a light plaster spica is applied, the foot being left free. This is worn for 2
or 3 weeks.
Fractures of the Lower End of the Femur. — These are (a) intercondyloid
fractures, (b) fracture of either condyle, and (c) separation of the lower
epiphysis. As in fractures of the lower end of the humerus, the chief objects to
be sought are accurate reduction of the fragments and prevention of ankylosis
of the knee joint.
INTERCONDYLOID FRACTURES. — These are T- or Y-shaped and extend into
the joint. If the main fracture is not oblique, the tendency to overriding and
angular displacement is not so marked, and the limb may be immobilized in the
extended position by a long circular plaster dressing, extending from Poupart's
ligament and including the foot. The plaster should be carefully moulded about
the knee joint. If the main fracture is oblique, it may be necessary to employ
traction. This is accomplished by the use of the Hodgen's splint, with the leg
slightly flexed.
FRACTURE OF EITHER CONDYLE. — Displacement is usually slight As the
lateral ligaments are tense when the leg is extended, this posit inn -ives more se-
curity to retention. A circular plaster dressing is applied as in the intercondy-
loid fractures. In the application of the dressing in these fractures, special care
734 PLASTEK-OF-PAKIS DRESSINGS
should be taken to have the anterior-superior spine, middle of the patella, and
middle of the ankle in the same line as on the opposite side. Early massage is
an important factor in the treatment. To provide for this, a removable plaster
dressing is made. Passive motion should be begun at the end of 4 weeks. The
plaster dressing is used 8 or 10 weeks.
SEPARATION OF THE LOWER EPIPHYSIS. — If separation of the fragments
is closed, every effort should be made to reduce the fragments without incision.
As a rule, the lower fragment is displaced forward, the lower end of the upper
fragment being drawn backward into the popliteal space by the gastrocnemius.
Reduction may be accomplished by the method suggested by Reisman. The leg
is strongly flexed, and traction is made upon the calf by an assistant, while the
surgeon makes traction upward on the thigh and at the same time pushes down-
ward with the thumbs upon the upper border of the displaced epiphysis. If re-
duction is successful, the leg should be flexed at a right angle, or an acute angle,
and immobilized in a circular plaster dressing, extending from Poupart's liga-
ment and including the foot. At the end of 4 weeks, the leg is gradually ex-
tended and a new dressing applied. This is removed at the end of the eighth
week, and massage and light passive movements begun.
FRACTURE OF THE PATELLA
The degree of separation of the fragments depends upon the contraction of
the quadriceps extensor cruris, the extent of the rupture of the lateral aponeu-
roses, and the amount of distention of the joint by blood and synovial fluid.
After absorption of the hemorrhage and effusion, the interposition of aponeu-
rotic and periosteal shreds may prevent complete apposition of the fragments.
An attempt to reduce the fragments should not be made until nearly all the fluid
has been absorbed from the joint. In order to hasten absorption, the knee-joint
is immobilized with the leg in the extended position upon a posterior moulded
splint, extending from just above the ankle to the fold of the buttock. This
should be wide enough to extend for a short way on to the sides of the thigh
and leg, and should be moulded to the parts and held in place by a muslin
bandage about the foot, leg, and thigh, the knee being left exposed. About the
knee, an elastic bandage is firmly applied. If the limb is to be treated with
massage, the muslin bandage is removed after the plaster has hardened, and the
splint is held in position by adhesive straps passed circularly about the limb.
When the swelling has subsided, the limb is elevated in order to relax the
quadriceps extensor muscle, and the lower fragment is fixed by an adhesive
strap, an inch or more in width, placed across the lower margin with the ends
carried upward and backward on either side to the back of the splint. The
upper fragment is then drawn downward by traction with a similar strap passed
across the upper margin and fixed to the posterior surface of the splint. This
strap will need frequent adjustment. Adhesive straps cut in the form of a broad
U will fit the part more accurately. To prevent tilting forward of the frag-
PLASTER-OF-P ARTS DRESSING FOR SPK< I A 1. I K.\( TTIIKS 735
ments, a third strap is placed across the knee over the line of fracture. As an
auxiliary to the straps, the quadriceps is held iinnly hy rMaptatinn splint-.
These are fixed in position by adhesive straps owm-lini: tin- limh and interior
splint. When massage is given, the coaptation splints alone are removed.
FIG. 12.-CIKCULAR PLASTER DRESSING FOB F^CTURK OF £ONW ^ tK&imeQi ^ih posterior
patella. Applied after open operation or after ^ unlon ^ dhesive gtra ^ 8hown by d«tt«l lino
splint and adhesive rtmp Fenestrum °™g£% ^ &o( leg. (Scudder.) C, Compound
ffift ' t^ Wound. (Scudde,)
736 PLASTER-OF-PARIS DRESSINGS
At the end of 5 weeks union will be found and this dressing is removed.
A light circular plaster dressing is now applied and the patient permitted the
use of crutches. The circular plaster dressing applied in these cases, as well as
after operation, should extend from the upper part of the thigh to about three
inches above the ankle joint. To prevent slipping of the dressing, two straps of
moleskin adhesive plaster, extending from above the knee to the sole of the foot,
are applied to the sides of the limb. After several layers of plaster bandages
have been applied, the lower ends of these straps are folded back over the end of
the plaster and fixed by the subsequent turns of the plaster bandages.
This dressing should not be too heavy and should fit snugly. In the plaster
dressing applied after operation, a fenestrum is made over the patella. In
these cases, it is well to reinforce the dressing posteriorly by extra layers of
plaster bandages applied longitudinally and incorporated between the spiral
turns. If massage is to be given, a removable dressing is made by cutting the
plaster along the median line in front before it hardens, and sponging it off the
limb. Strips of leather supplied with lacing hooks are stitched to the edges.
Passive movements are begun at the end of the sixth week. The circular dress-
ing is removed at the end of the eighth week, and a light posterior moulded
splint applied as protection against sudden accidental flexion of the knee. The
knee should be protected for 6 months.
FRACTURES OF THE TIBIA AND FIBULA OR OF THE TIBIA ALONE
In the treatment of simple fractures of these bones, the choice of a dressing
will depend upon (1) the degree of swelling, (2) the amount of displacement,
and (3) the ability to retain fragments in the corrected position after reduction.
In fracture of either bone without displacement, and with but slight swell-
ing, a circular plaster dressing extending from the toes to the middle of the
thigh may be applied. Before the plaster has hardened, it is cut down along
the median line in front and held by means of adhesive straps passed circularly
about the dressing. The toes should be watched carefully for signs of interfer-
ence with the circulation.
If subsidence of swelling renders the dressing loose, a new one must be ap-
plied. At the end of 5 or 6 weeks union will be sufficiently firm to permit re-
moval of the dressing. Massage, active and passive movements are begun.
In cases with swelling and displacement, reduction of deformity should be
effected as early as possible, preferably under an anesthetic, by traction on the
foot, counter traction on the thigh, with the knee slightly flexed, and by manipu-
lation of the fragments at the seat of fracture. The subcutaneous crest of the
tibia should be brought into line and the fragments carefully held in the cor-
rected position while a posterior and a U-shaped moulded splint are applied.
The posterior splint begins at the toes, extends along the sole of the foot and
posterior surface of the leg and thigh to the middle of the latter. The U-shaped
splint extends from the middle of the thigh on one side, along the side of the
PLASTER-OF-PARIS DRESSING FOR SPECIAL FRA<H 1;
limb around the solo of the foot, and along tin- o|,|,,,.,it«. .,',,1,. ,,f the li,,,!, to the
same height. These are carefully moulded to the; liml) and held in j...,iti,,ii by
a muslin bandage. After the plaster has hardened, the lianda-r is rnu-.v. d and
the splints are held in position by adhesive straps or circular bandages, the crest
of the tibia in the region of the fracture being left exposed so that examinations
can be made.
At the end of 2 weeks the splints are cut so that the knee joint can be moved
and massage is begun. These splints can be loosened to permit swelling, tight-
ened as swelling subsides, and are easily removed when massage and passive mo-
tion are to be given.
In applying the circular plaster dressing or moulded splints, the pati«
FIG. 13. — CIRCULAR PLASTER DRESSING FOR FRACTURE OF BONES OF THE LEO. Feoeotnim
external malleolus.
placed so that the hips rest at the edge of the table, with the normal limb rest-
ing on a stool or chair. One assistant supports the heel with one hand, maiir
right-angle flexion and slight adduction with the other and makes traction. A
second assistant flexes the knee and supports the limb by placing one hand be-
neath the lower portion of the thigh and the other hand beneath the upper por-
tion of the leg.
In cases in which there is comminution of the upper end of the tibia or in
oblique fractures with displacement, where it is difficult to retain the frag-
ments in position after reduction, continuous traction may be emplo
Instead of the fracture box and the dressing suggested by Niell, a plaster-
of-Paris dressing with extension and counter-extension (Lovett, 12) may be
employed.
The plaster dressing is applied in the following manner : The limb is si
and the skin thoroughly cleansed. Moleskin adhesive straps are applied to the
sides of the limb, extending upward and downward from the seat of the frac-
ture. These are held in place by strips of adhesive passed circularly and spirally
about the limb. The foot, leg and lower half of the thi-li are inclosed in sheet
wadding and a pad 2 or 3 inches in thickness is placed below the sole of the foot
A circular plaster dressing is now applied from the toes to the middle of the
48
FIG. 14. — POSTERIOR AND U-SHAPED PLASTER SPLINTS FOR FRACTURE OF BONES OF THE LEO.
PLASTER-OF-PAULS DKKssiXG FOB SPECIAL FRACTUEE8 739
After 2GrwWlti * C°rd,attachcd f°r tracti0"- Tl'" !""! below the foot is removed.
tter 2 ! weeks, this dressing » removed and a circular plaster dressing applied
In fractures w,th considerable swd.hu: ,,,,! ,.,,;'„.,, ;,„„,,.., £ J'^
parts, a temporary dressing is indicated.
As a substitute for the fracture box or Volk,,,,,,,,,'. trough splint the stock-
mg or bwnlve plaster splint of Stimson (14) is .juite useful. It is preplreTin
FIG. 15. — PLASTER TRACTION SPLINT FOR FRACTURE OF BONES OF LEO. Note adhesive strap* for
traction and space below sole of foot to allow for traction.
the following way: Two pieces of muslin are cut in the shape shown in the
figure, and of a size to fit the limb. These are stitched together along the median
line. Twelve or fifteen pieces of crinolin, each a little smaller than a lateral
half of the muslin pattern are prepared, soaked in plaster cream and placed in
each half of the pattern, between the two layers. The splint is then applied
smoothly to the limb and held by means of a muslin bandage.
When the plaster has hardened, the muslin bandage is removed and the
splint held in position by strips of muslin bandage applied circularly and tied.
This splint combines the advantages of the Volkmann splint and later en-
casement. It can be loosened or tightened as needs arise, permits easy inspec-
tion to detect and correct deformity, and permits dressing of associated wounds.
Marked displacement of the fragments should he corrected as far as possible
before the application of the splint. Blebs are opened under aseptic precau-
tions and dusted with an antiseptic powder. Associated wounds are cleansed
and sterile gauze applied.
740
PLASTER-OF-PARIS DRESSINGS
After swelling has subsided, a more accurate reduction of the fragments is
attempted under anesthesia, and a permanent dressing is applied. If wounds
of the soft parts have not healed, and a circular plaster dressing is applied, a
fenestrum is cut over the site of the wound.
FRACTURES OF THE FIBULA ALONE
In these fractures, displacement, as a rule, is slight for the tibia serves as a
splint to prevent this. A circular plaster dressing is applied to prevent move-
ment of the lower fragment by twisting of the foot.
In fractures of the upper end of the fibula the knee is slightly flexed to
relax the biceps femoris.
POTT'S FRACTURE
With the spreading apart of the malleoli, there are lateral displacement of
the foot outward and anterior posterior displacement of the foot backward.
Reduction is best effected under anesthesia by mak-
ing lateral outward pressure upon the internal mal-
leolus, lateral inward pressure upon the foot, and for-
ward pressure upon the heel. Retention is most satis-
factorily maintained by the use of the posterior and
external lateral moulded splints of Stimson.
These are made of 4-inch plaster rollers. The pos-
terior extends from the toes, along the sole of the foot
and up the calf nearly to the knee.
The lateral splint begins just in front of the exter-
nal malleolus, passes over the dorsum of the foot to the
inner side, under the sole, and up along the outer side
of the leg to the same height.
These are snugly moulded to the limb and held in
position by a muslin bandage and, while the plaster is
setting, the foot is maintained in right angle flexion,
inversion, and adduction. After the plaster has hard-
ened, the bandage may be removed and the splint held
in position by adhesive straps or circular bandages
about the foot, just above the ankle, and at the upper part of the leg. If there
has been considerable displacement, the splints are carried to the middle of
the thigh.
These splints are preferable to complete encasement in plaster because they
permit inspection of the inner side of the ankle, can be easily loosened to allow
for swelling and can be tightened as swelling subsides without disturbing the
position of the fragments.
Massage of the exposed parts is begun during the third week. Splints are
removed in 5 or 6 weeks.
FIG. 16. — STOCKING OR BI-
VALVE SPLINT FOB FRAC-
TURE or BONES OF LEG
WITH CONSIDERABLE
SWELLING OF SOFT PARTS.
A substitute for Volk-
mann's trough splint or
the fracture box. (Stim-
son.)
PLASTER-OF-PARIS DRESSING FOR SI'KCIAL FUA< "ITKKS 741
FEACTUEE OF BONES OF THE FOOT
The skin of the foot and leg should 1x3 thoroughly dcan-rd and covered with
a sterile dressing. The heel and ankle should be well protected by sheet-wad-
ding and a posterior moulded splint extending from the toes to the knee may
be applied and held in position with a banda
After swelling has subsided, a removable circular plaster dressing ix applied
Fio 17 -POSTERIOR AND EXTERNAL LATERAL PLASTER SPLINTS FOB POTT'S FKACTUB..
Note (a)— exposure of inner side of ankle.
to the foot and leg with the foot in the right-angle position. Special care should
be taken to have the heel and malleoli well padded.
For the application of this dressing an anesthetic shot
placement corrected.
In fractures of the metatarsal hones, a felt pad should be placed
plantar surface to assist in supporting the transverse arch.
In fractures of the tarsal bones, the circular drcssmg should be worn for (
742
PLASTEK-OF-PARIS DRESSINGS
or 8 weeks. In fractures of the metatarsal bones, the dressing is worn for 4
weeks. If pain persists when the patient begins to walk a metal insole should
be worn.
PLASTER JACKETS
The plaster jacket has its widest application in the treatment of tuberculous
disease of the spine. It is used also in the treatment of lateral curvature, in
cases in which the deformed spine is
painful, and in fractures of the verte-
brae. As with splints applied for
fractures, the jacket is not used to
correct deformity, but to immobilize
the spine, and thus protect the affect-
ed vertebra from injury during the
process of repair, and to limit any
increase of deformity. Again, as in
fractures, the plaster jacket should
extend sufficiently above and below
the affected part to secure complete
immobilization, and all bony promi-
nences, including the deformity,
should be protected from pressure by
proper padding.
Jackets are made by applying layers of plaster bandages around the trunk,
after the improved position of the spine has been secured by traction or hyper-
extension. During the application of the jacket, the patient is either in the
upright or the recumbent position. In the recumbent position, he may be
placed either prone or supine.
FIG. 18. — LATERAL PLASTER SPLINTS FOR FRAC-
TURE OF BONES OF LEG. Prepared by first
applying a circular plaster dressing and cutting
it in the median line anteriorly and posteriorly.
APPLICATION OF JACKET WITH PATIENT SUSPENDED (SAYER)
The patient's clothes are removed, and the skin thoroughly cleansed with
soap and water, followed by an alcohol rub and a dusting powder. A snugly
fitting seamless undershirt, or tricot hose, is slipped over the head or feet. If
the tricot hose is used, cuts are made in the mid-axillary lines and the ends
brought up over the shoulders and tied. It is fastened beneath the perineum
with a safety pin. The shirting should reach from the neck to the ankles. In-
side this, two strips of muslin bandage, the "scratch bandages of Lorenz" are
placed, one in front, the other behind.
The head sling devised by Calot (12) is now adjusted. This consists of a
circular piece of canvas 6 cm. wide (2.4 inches) and 168 cm. (67.2 inches) in
circumference, to which is sewed a tailpiece 104 cm. (416.6 inches) long. The
occipitofrontal circumference of the patient's head is measured, and 2 cm. added
PLASTER JACK I 743
to this. This length is measured off on the circular part of the sling, and safety
pins are inserted in such a way that the tailpiece wines in tin- middle Miin.i the
occiput. The sling is adjusted to the chin ami occiput, an.! the two loops are
fixed to the notches at the ends of the iron cross har. The tailpiece is attached
to the center of the bar and prevents the head from tilting backward.
center of the bar is attached a system of ropes and pulleys^ fastened to a crane,
swung from the wall, or to a wooden tripod, or two ladders hinged at their upper
ends.
The arms are extended, and the hands grasp the cross bar. This aids exten-
sion of the spine, and diminishes the strain upon the neck. The patient i- then
raised so that the tips of the toes touch the floor or a stool. Tin- patient's trunk
should be on a level with the arms of the sui-emi, seated and applying tin-
bandages. An assistant steadies the legs, to prevent swaying of the body and
inadvertent flexion of the thighs.
Before beginning the application of the plaster, all wrinkles are smoothed
out of the shirt, and pads of felt are prepared for the anterior-superior spines
and crests of the ilia. Two strips of felt, each 6 inches long, one inch wide,
and of sufficient thickness to prevent pressure of the plaster on the protruding
spine, are also prepared. These are to be placed longitudinally at the sides of
the kyphosis, and to press upon the lateral masses of the vertebrae.
The surgeon, seated behind the patient, applies the plaster rollers, beginning
below the great trochanters and extending upward under the axilla and
the top of the sternum, fixing each pad in position as the turns of the bandage
reach it. Several thicknesses of sheet wadding or gauze are placed in the axillae
to protect the skin from friction of the finished jacket.
The bandages are applied smoothly, in circular and spiral turns, the plaster
thoroughly worked into them by the hand, and the whole carefully moulded
over the bony prominences. It is important to have the jacket strong in front
as well as behind, and it should extend as high as possible in front in order to
secure the necessary extension. While the plaster is hardening, and while the
patient is still suspended, the edges of the jacket are tri mined. Below, a cres-
centic piece is removed on each side at Poupart's ligament to permit flexion of
the thighs, a tongue-shaped piece being left over the symphysis pubis. At the
sides, the jacket is cut away until it conforms with the upper limit of the great
trochanters, and posteriorly it is trimmed so that it will not interfere with the
sitting posture. Above, a crescentic piece is removed from ea<-h axilla to per-
mit adduction of the arms. Anteriorly it must not be cut below the level of the
suprasternal notch, and posteriorly it is cut across from the upper limits of the
axillary folds.
After trimming is complete, the lower portion of the shirting is turned up
over the jacket and sewed to the upper part along the edge of the jacket. This
prevents the edges of the jacket from irritating the skin. The ends of the
"scratch bandages" are brought together over the jacket and tied.
With good plaster sufficient hardening will have occurred by the time the
744
PLASTEK-OF-PAKIS DRESSINGS
jacket has been completed to permit the release of the patient from the ap-
paratus. The patient is lifted out of the apparatus by placing the hands in the
axillae. He should either stand or lie upon his side for several hours. The sit-
ting posture should not be assumed until the plaster has thoroughly hardened.
R. Tunstall Taylor adds to the suspension forward pressure at the seat of
deformity by an instrument called the kyphotone. In this method the patient
is seated on a bicycle saddle, and while strong traction is applied to the head, for-
ward pressure is made over the kyphosis.
APPLICATION OF THE JACKET WITH PATIENT IN THE RECUMBENT POSITION
(PRONE)
In the application of the jacket, with the patient in the prone position, the
gas pipe frame (Bradford) is used. This is a rectangular frame made of gas
FIG. 19. — APPLICATION OF JACKET WITH PATIENT IN THE RECUMBENT POSITION. Patient placed prone
on the gas pipe frame. (Bradford.) Plaster rollers applied as far as the apex of the kyphosis.
pipe, within which, at the head end, there is a smaller frame fixed to the side
bars by hinges. The inner frame can be elevated, and its position fixed on a
curved upright as shown in the figure. To the cross bar of the inner frame is
attached one end of a hammock, made of stout cloth or canvas. The other end
of the hammock is fixed to a movable bar, connected by ropes to a ratchet at the
foot end of the frame. By turning the ratchet the hammock is tightened. The
PLASTER JA< K!
patient is prepared, as described above, and placed (face down) on the ham-
mock, with the kyphosis on a line with the hinge of the inner frame.
The hammock cloth is cut longitudinally along the sides of 'the patient'-
body, and the parts not under the body are removed. A circular opening is cut
for the face, and the forehead is supported on a strap placed Ix-twcrii tin* bars.
A cross-piece about 8 inches in width is placed beneath tin- hammock at the up-
per portion of the thighs, and to this the patient is fixed 1 p. The bony
prominences are padded, and strips of felt of sufficient thickness to pr<
pressure of the plaster on the spines are placed at the sides of the defon
FIG. 20,-APPLicATioN OF JACKET WITH PATIENT IN THE RECUMBENT P°8'™«-
secured by raising the inner frame. Jacket is now t<
The plaster rollers are applied beginning below and are carried upward as far
as the apex of the kyphosis and allowed to harden. The desired amount
hyperextension is secured by raising the inner frame.
ried to the point of slight discomfort, and the jacket complete,!. In t
hyperextension is secured at the seat of the disease.
the manner described above.
APPLICATION OF JACKET WITH PATIENT IN EECUMBENT POSITION (SUPINE)
To avoid compression of the chest ami flattening of .l,,:,!,,!,,,,,,,,. wh
occur, to some extent, when the jacket is applied with the Pa -,,
position, the jacket may be applied with the patient lying on In*
To secure the necessary hyperextenswn of the spine, Goldth«;
746
PLASTER-OF-PAKIS DRESSINGS
vised the following apparatus : An upright steel rod is arranged with a forked
top, on which two attachable pad plates can be placed. The rod fits "on a frame,
and can be raised or lowered by means of a screw. The patient is so placed
that while the shoulders and pelvis are supported on cross-pieces of the frame,
the kyphosis rests upon the pad plates. By raising the bar, the counterweight
of the body acts to hyperextend the spine at the seat of deformity. Exaggerated
lordosis is prevented by flexing the thighs. The jacket is applied in the usual
manner, and after its completion, the rods within are withdrawn.
In the absence of one of these forms of apparatus, the jacket may be applied
in one of the following ways :
(1) The patient is placed between two tables, so that his shoulders rest on
one, while his thighs rest upon the other. The thighs are held firmly by one
FIG. 21. — FRAME FOR THE APPLICATION OF PLASTER JACKET IN DORSAL POSITION.
assistant, who makes steady traction, while counter-traction is made by
a second assistant, who grasps the patient's arms close to the axilla. The
weight of the trunk gives the necessary hyperextension to overcome the
deformity.
( 2 ) A hammock may be made of muslin or canvas and suspended between
two walls. The patient is placed on the hammock, face downward, with arms
and legs extended. The hammock may be made taut or allowed to sag, and in
this way the desired degree of hyperextension is secured. The plaster bandages
include the hammock, the excess of which is cut away after the plaster has
hardened.
The ordinary jacket is most serviceable for diseases below the ninth dorsal
vertebra. For diseases of the cervical and upper dorsal vertebra, a jury mast,
or head sling, is incorporated in the dorsal portion of the jacket in order to re-
lieve the spine f om the pressure of the superimposed weight of the head. This
is unsatisfactory, because it is difficult to adjust and to keep adjusted, and is
uncomfortable to the patient. For disease of these parts of the spine, for dis-
ease with much deformity, and for cases of Pott's paraplegia, the jacket de-
vised by Calot is the most efficient.
PLASTER JACK!
747
THE CALOT JACKET (7)
The patient is prepared and suspended as described above. If the "grand
jacket is to be applied, a piece of stockinet... ,,,,rl,ii,^ over the top of the head
and with a hole cut out for the nose, is applied, and the patient", chin and
occiput are carefully padded. For the jacket with military ,,,lh,rf a collar of
felt is sewed to the top of the shirt. An assistant steadies thfl patient bf hold-
ing the arms at an angle of 45° with the body. A larg« trim,
absorbent cotton is placed provisionally over the sternum
and anterior aspect of the ribs, and the bony prominences
protected by pieces of felt in the usual manner.
Calot uses plaster bandages, freshly prepared, bv im-
mersing crinoline bandages in plaster cream, unrolling
and rerolling them rapidly. The plaster bandages pre-
pared in the ordinary way are preferable.
The plaster bandages are applied smoothly, beginning
below as in the ordinary jackets, but passing upward, tin-
turns include the shoulders and axillae and encircle the
neck if the jacket is to be one with the military collar, or
include the head, avoiding the hole cut for the nose in
case of the "grand jacket." After several layers of the
plaster bandages have been completed, the auxiliary pieces
are applied. These consist of several sheets of crinoline,
previously measured to fit the parts, and impregnated with
fresh plaster cream. For the jacket with military collar
there are three, two aprons, front and back, and a collar:
for the grand jacket, two aprons, a chin-piece, and a piece
for the occiput. The aprons are the length of the trunk
plus one-half, and the width of each is equal to one-half
the circumference of the trunk. Each apron is slit at
its upper end for one-third its length, and the slit ends are passed over the
shoulders and into the axillae, the ends from the front and back being super-
imposed. The lower ends of the aprons are folded upon themselves and worked
in with the circular turns. These are nicked with the scissors if necessary in
order to make them fit smoothly. The collar is made about the height of the
patient's neck, and one and a half of its circumference. The pieces for the chin
and occiput in the grand jacket should bo about 4 by 6 inches, and should
tend downward from these points.
After the auxiliary pieces have been placed in position, the jacket is com-
pleted as quickly as possible by circular and spiral turns of the plaster bandages
outside of these, and the whole carefully moulded to the pelvic and shoulder
girdles. The jacket is now trimmed. A small triangular opening, apex up-
ward, is made over the sternum, and the cotton pad removed. The jacket is
trimmed below as in ordinary jackets. Above, the jacket with the military col-
Fio. 22.— STEPS IK AP-
PLICATION or GRAND
JACKET. (Cabot.)
PLASTEB-OF-PAKIS DEESSINGS
lar is trimmed at the junction of the chin and neck, while the grand jacket in-
cludes the chin and occiput, leaving the ears free. The shoulders are exposed,
and the crescentic piece is removed from each
axilla to permit free range of motion to the arms.
The patient is now released from the sling and
placed face downward over the edge of the bed.
He is watched for a while to see that his breathing
is not impeded.
At the end of 48 hours, a larger window is cut
anteriorly as shown in the figure. Posteriorly
over the kyphosis another window 6 by 3 inches
is made. The shirt is opened by two cross cuts,
the skin anointed with vaselin, and pieces of cotton
a little larger than the window are wedged under
the shirting by means of a spatula. The edges of
the opening in the shirt are folded back in place,
and successive layers of cotton are placed over the
kyphosis until they project beyond the level of the
jacket. These are held in place and pressed upon
by circular turns of plaster bandages. This pro-
cedure drives the kyphosis forward, and the large
window anteriorly permits the chest to yield under
At intervals of two months, as the kyphosis recedes,
FIG. 23. — GRAND JACKET COM-
PLETED. (Cabot.) Front view.
pressure from behind.
additional layers of cotton are applied.
The jacket should be well padded, fit snugly and be comfortable. It should be of
uniform thickness throughout, and should be as light as is compatible with strength.
Parents should be instructed in the use of the "scratch bandages," and these should
be used daily in order to keep the skin in good condition. Parents should be cautioned
against letting any object fall inside the jacket, and should be instructed to watch
carefully for any foul odor emanating from the jacket. This indicates excoriation of
the skin, and calls for the immediate removal of the jacket.
The jacket is removed by cutting it along the median line in front. By
making a fenestrum over the site of the excoriation, the pressure is relieved and
treatment made possible. The jacket is readjusted and held by adhesive straps
till the wound has healed, after which a new jacket is applied. A good jacket
will last from 2 to 6 months. If the "scratch bandages77 are properly used, the
skin will remain in good condition.
E. EEMOVABLE JACKETS: After the jacket has been applied, it is cut
down in front, and straps provided with lacing holes are sewed to the edges.
These jackets do not furnish such efficient support as the fixed jackets during the
acute stage of the disease, but are most suitable for use in convalescent cases, or
cases where sloughs or excoriations are present.
SPICAS FOll CONGENITAL DISLOCATION OF 1111'
APPLICATION OF JACKET FOE FRACTURE OF THE VERTEBRJE
A plaster-of -Paris jacket is employed in cases of fracture of the spinou*
processes alone, in cases of fracture of the bodies without recognizable displace-
ment or symptoms of injury to the cord, and in cases of recognizable displace-
ment without cord symptoms. It is also indicated in cases with recognizable dis-
placement with symptoms of injury to the cord, if correction of deformity and
relief of symptoms can be secured by manipulation or operation.
In the reduction of deformity and the application of the jacket, the utmost
care should be exercised to prevent further displacement of the fragments and
increased injury to the cord. Young patients may be suspended and the grand
jacket applied. With large and heavy patients, the jacket is applied in the
following way : A buttonless shirt, or sheet wadding is applied, and the bony
prominences padded in the usual manner. The patient is placed upon his back
with a support under the pelvis, and pillows under his head and shoulders. The
deformity is protected by pads of felt placed over the lateral masses of the verte-
brae, a sling is passed around the back under the pads at the seat of the de-
formity, and the ends of the sling are attached to the horizontal bar of a suspen-
sion apparatus. As the bar is slowly and gently raised, the counterweight of
the body operates to correct the deformity.
When the deformity has been corrected, the plaster bandages are applied.
These include the sling, the excess of which is cut away at the points of
emergence after the plaster has hardened. After operation the jacket may be
applied with the patient in the prone position on two tables. With the arms and
thighs extended and firmly secured by assistants, the tables are slowly sepa-
rated, thus permitting the trunk to remain unsupported between them. The
weight of the body gives the necessary extension. The jacket is applied in the
usual manner.
SPICAS FOR CASES OF CONGENITAL DISLOCATION OF THE HIP
In cases of congenital dislocation, the rudimentary acetabulum is not of
sufficient capacity to retain the head of the femur when the limb is in the normal
attitude. After reduction has been secured by manipulation, the thigh is placed
in right-angled flexion and hyperabduction, with the leg flexed, and s posi-
tion is maintained by a short spica encircling the lower portion of the abdomen
and the pelvis and reaching the knee joint. It is essential in the treatment
these cases to have a well-fitting plaster dressing, which will retain the 1
the femur in the acetabulum while the patient walks about, for the acetabul
enlarges by the presence of the head, and the use of the mus
prevents their atrophy.
Application of Spica.— After reduction, and while the child is sti
anesthetic, it is placed upon a pelvic support and the thighs are held in t
750 PLASTEK-OF-PARIS DKESSINGS
hyperabducted position with the legs flexed, by an assistant. The scratch
bandage is placed over the abdomen and thigh, and the abdomen, pelvis, and
one or both thighs and knees (depending on the case) are covered with sheet
wadding in the form of roller bandages. The perineum is entirely covered by
figure-of-eight turns, and extra pads of the same material are placed over the
anterior-superior spines and crests of the ilia and the sacrum. The method of
applying the plaster rollers varies somewhat in unilateral and bilateral cases.
UNILATEEAL CASES. — In the unilateral cases, the plaster roller begins at
the anterior-superior spine of the sound side, is carried across the pelvis, down
the inner surface of the thigh, and round the knee of the affected side, then
along the posterior surface of the thigh and pelvis to the starting point. This is
repeated several times and when the bandage reaches the knee, spiral turns are
applied to the thigh till the pelvis is reached, when this part is covered by fig-
ure-of-eight turns, and the lower portion of the abdomen with spiral turns. This
is repeated with spiral turns to the thigh and lower abdomen, and figure-of-eight
turns for the pelvis until the dressing is of the desired thickness.
BILATEEAL CASES. — In the bilateral cases the plaster roller begins at the
knee of one side, passes along the inner surface of the thigh, across the pelvis,
along the inner surface of the opposite thigh, around the knee, and is then car-
ried posteriorly to the starting point. Several complete turns are made, and
when the knee is reached, spiral turns to the thigh are begun. These are carried
upward to the pelvis, when figure-of-eight turns are applied to the latter and
spiral turns are carried down the opposite thigh to the knee. The dressing is
reinforced anteriorly by several layers of plaster bandages extending from knee
to knee, and completed with spiral turns to the thigh and lower abdomen, and
figure-of -eight turns to the pelvis.
After the application of the plaster bandages is complete, a large fenestrum
is cut from the perineal region, and the dressing trimmed about the knee to
permit walking. Above in front, the dressing is cut down to the level of the
umbilicus. The ends of the scratch bandage are brought over the spica and
tied. As soon as soreness and discomfort have disappeared (in about a week or
10 days) the patient is encouraged to walk. Such efforts force the replaced head
deeper into the acetabulum, stimulate its growth and thus increase the stability
of the reposition. In unilateral cases a shoe with a high sole is used on the
affected side ; in bilateral cases, a small stool on wheels has been devised,
by means of which the patient propels himself and thus makes use of the
muscles.
The spica is worn 3 months, after which it is removed. Abduction is
lessened, and a new dressing applied with the limb in the new position. After
the removal of the last dressing, massage and passive motion are begun, and a
hip splint is worn for several months. The scratch bandage should be used
daily. The same general rules for the use of the X-ray, given under fractures,
are to be followed in these cases to determine the results of reduction and re-
tention.
CIRCULAK PLASTER DRESSIXc; FOR ( LI B-FOOT
CIRCULAR PLASTER DRESSING FOR CLUB-FOOT
For the treatment of club-foot, plaster-of-Paris is the best dressing in ordi-
nary hands. Here again, it must be remembered that the plaster is empl
only to retain the foot in corrected position after .]<-f.,rniiiv has been reduced
by manipulation or open operation, and is n.,t, in any case, used to overcome the
deformity.
Correction of deformity should be made shortly after birth (second or third
FIG. 24. — PLASTER DRESSING APPLIED AFTER CORRECTION OF CLUB-FOOT.
over instep. Sole flattened to permit walking.
Note triangular
week) for the plastic tissues of infants are easily moulded and results are more
readily obtained.
By manipulation, the foot is brought from the equinus position into that of
a right-angle flexion with the leg, and adduction (varus) and inward rotation
are overcome.
After a thorough reduction of all the abnormal positions, so that the foot
can be placed in an overcorrected position, th<> foot and 1« - an- \v<-Il covered
with sheet wadding in the form of roller bandages.
The plaster rollers are snugly applied, beginning at the ankle. For tli«
foot, the plaster roller passes from right to left over the sole, and for the right
foot in the reverse direction.
The dressing invests the foot and extends up the leg to the tuberosities of the
tibia.
The foot is held in the over-corrected position till the plaster hardens. After the
plaster has become firm, preparation for swelling is made by cutting a triangular
fenestrum over the instep in front of the external malleolus and the toes are exposed.
The circulation of the toes is carefully watched after the application of the dressing.
In small children, it is difficult to prevent the dressing from slipping. To guard
752
PLASTER-OF-PAEIS DEESSINGS
against tins, strips of moleskin adhesive are applied to the leg. The lower ends of
these are brought through the sheet wadding above the ankle and the plaster roller
applied over them.
If the child is ready to walk, a thick sole of plaster is applied. This is flat-
tened with a board.
If the deformity cannot be entirely corrected by the first manipulation, it is
repeated in two or three weeks and a new plaster dressing is applied. With
each renewal of the dressing, an attempt is made to improve the position of the
foot.
CIRCULAR PLASTER DRESSING FOR FLAT-FOOT
To correct the deformity of a rigid flat-foot, an anesthetic is administered
and the foot is forcibly manipulated into an exaggerated adducted and inverted
position and held at a right angle. It is maintained in this position by a plaster-
of -Paris dressing extending from the toes to the tuberosities of the tibia. The
dressing is worn for 4 weeks.
After the removal of the dressing, a plaster mould is made directly from the
foot in the corrected position, and a steel insole prepared from this for the shoe.
MANIPULATIONS FOR REDUCTION OF COMMON DISLOCATIONS
DISLOCATION OF THE LOWER JAW
The common dislocation of the inferior maxilla is forward.
The following methods are used in reduction :
(1) The thumbs are covered with gauze
and inserted over the molar teeth upon either
side of the jaw. The lower border of the jaw
is grasped by the remaining fingers. Back-
ward and slightly downward pressure is made
upon the molar teeth by the thumbs, and the
chin is lifted up and pressed backward by the
remaining fingers. As soon as the condyles
are felt to pass over the articular eminence,
the thumbs are quickly withdrawn, and the
teeth permitted to come together.
(2) In order to relax the lateral ligaments
of the joint, the mouth is still farther opened
by downward pressure upon the incisor teeth.
With the lateral ligaments somewhat relaxed,
direct pressure backward will effect a reduction.
After-care.— The jaw is immobilized with a Barton bandage for two weeks
FIG. 25. — METHOD or REDUCTION IN
DISLOCATION OP LOWER JAW.
REDUCTION OF COMMON DISLOCAT1-
during which time only liquid food is given. After the removal of the l.audage,
the patient is cautioned against opening the mouth too widely.
DISLOCATION OF THE SHOULDER
The common dislocation of the shoulder is the suhcoracoid. Reduction is
effected (1) by manipulation; and (2) by traction.
Reduction by Manipulation: Kocher's Method. — The patient lies upon his
back and the surgeon stands on the side of the dislocated shoulder. Tin- manipu-
lations are carried out in four steps.
(1) The surgeon firmly grasps the injured arm above the condyle of the
humerus with one hand, and the patient's wrist with the other. The forearm is
flexed at a right angle and the elbow is slowly carried to the side of the body.
(2) The humerus is externally rotated
until the forearm points directly out-
ward, when a distinct resistance can be
felt. This movement relaxes the rent in
the capsule through which the head of
the humerus left the joint. (3) With
the humerus strongly rotated outward,
the elbow is gradually adducted by mov-
ing it forward, or forward and slightly
inward until the arm is nearly in the
horizontal position. (4) When the elbow
has been raised as high as it will go, the
hand is placed upon the opposite shoul-
der, thus rotating the humerus inward.
Eeduction is indicated by a click as the head slips into the glenoid cavity.
All steps should be carried out gradually and steady traction downward in
the direction of the long axis of the
humerus should be maintained by the
surgeon.
Traction: Stimson's Method (15). -
The patient lies on his side upon a can-
vas cot, in which an ojKMiing is ni;
through which the injured arm is passed
so as to hang vertically downward. The
cot is raised upon blocks or chairs so that
the arm will hang free of the floor. \
weight of 10 pounds is attached to the wrist or elbow. In from 5 to 1 5 minutes
the parts are sufficiently relaxed and the head slips into the glennM
It may be necessary in some cases to increase the weight attach
and also to advance the head toward the glenoid cavity by adc
against the fist placed in the axilla. Instead of the cot, the patient may be put
49
FIG. 26.— KOCHER'S METHOD or REDUCTION
IN SUBCORACOID DISLOCATION OF
DER. First step.
FiG. 27. — KOCHER'S METHOD OF REDUCTION
IN SUBCORACOID DISLOCATION OF SHOUL-
DER. Second step.
754
PLASTER-OF-PAEIS DRESSINGS
upon two tables, placed end to end with the body resting on one and the head
on the other, the arm hanging down between.
A simple method which will
often suffice is the following: The
arm is grasped above the elbow and
steady traction is made in a down-
ward and outward direction. The
FIG. 28. — KOCHEB'S METHOD OF REDUCTION
IN SUBCORACOID DISLOCATION OF SHOUL-
DER. Third step.
FIG. 29. — KOCHER'S METHOD OF REDUCTION
IN SUBCORACOID DISLOCATION OF SHOUL-
DER. Fourth step.
arm is now gradually abducted until it is nearly or quite at right angles with
the body. An assistant manipulates, by pressure, the head of the humerus
while traction is being made.
After-treatment. — After-treatment consists in partially immobilizing the
shoulder joint by an arm and chest bandage, the forearm being supported at the
wrist by a sling. In a day or two after reduction, gentle passive movements are
begun. These are continued daily and the range of motion gradually increased.
Active movements are begun during the third week.
DISLOCATION OF THE ELBOW
The common dislocation of the elbow is that of both bones of the fore-
arm backward.
Reduction, in uncomplicated cases, is effected by hyperextending the fore-
arm, thus freeing the coronoid process from the olecranon fossa and the pos-
terior surface of the humerus, followed by direct traction on and flexion of the
forearm.
The method suggested by Sir Astley Cooper (6) is as follows: The surgeon
places his knee in front of the elbow joint, grasps the patient's wrist, presses
upon the radius and ulna with his knee, and slowly but forcibly bends the fore-
arm.
After-treatment. — The after-treatment consists in immobilization of the el-
bow with the forearm flexed to a right angle. A firm bandage is applied to the
elbow and the forearm is supported in a sling. Light passive movements are
begun during the third week and active movements during the fourth week.
KEDUCTION OF COMMON DISLOCATIONS
DISLOCATION OF THE THUMB
755
Complete backward dislocation of the first phalanx of the thumb in the com-
lon form. Reduction is made by hyperextending th.- thumb while traction is
FIG. 30. — REDUCTION OF DISLOCATION OF SHOULDER BY TRACTION. Stimaon's n>f*thod.
made upon it, pressing the base of the phalanx forward and finally quickly flex-
ing the thumb into the palm.
If the ligament has caught behind the head, it may sometimes be freed by
rotating the phalanx while pressing it forward.
Reduction of forward dislocation of the thumb is easily effected by traction
and forced, flexion with downward pressure on the base of the phalanx. The
thumb is immobilized in the straight position for one week, after which gentle
passive and active motion is begun.
DISLOCATION OF THE HIP
For the reduction of a dislocation of the hip an anesthetic should always be
administered.
Reduction of Dorsal Dislocation: Stimson's Method (13). — The patient is
placed face downward upon a table with his legs projecting so far beyond tin-
edge that the injured thigh hangs directly downward. The sound limb is held
in line with the body by an assistant. The surgeon grasps the ankle of the dislo-
cated limb and flexes the knee to a right angle. The weight of the limb now
makes the needed traction in the desired direction and the surgeon has only to
wait for the muscles to relax and the bone to resume its place without further
effort on his part than a slight rocking or rotation of the limb. The added
756
PLASTEK-OF-PA1US DRESSINGS
weight of a small sand-bag at the knee or sudden slight pressure at the same
point may facilitate reduction.
The everted dorsal dislocations are reduced by first converting them into the
dorsal form by flexion and inward rotation with adduction if necessary.
BIGELOW'S (4) METHOD OF SEDUCTION OF A DOKSAL OE POSTERIOR
DISLOCATION. — The patient lies on his back upon a blanket on the floor. The
pelvis is steadied by an assistant who exerts pressure upon the anterior-posterior
spines. The leg is flexed
upon the thigh, and the thigh
upon the abdomen, the posi-
tion of adduction and slight
inversion being still main-
tained so that the knee ex-
tends beyond the midline of
the body. This position with
traction upward is main-
tained for some moments
and the limb is then freely
circumducted outward and
brought down into the posi-
tion of extension.
ALLIS' (2) METHOD. —
The patient is placed in the
same position as described
above in Bigelow's method.
The surgeon kneels by the
patient's side and, if the
right femur is dislocated, he
grasps the patient's ankle
with his right hand and
places the bent elbow of his
left arm beneath the flexure
of the knee. He now turns the bent leg outward and lifts upward (skyward),
then turns the bent leg inward and brings the thigh down in extension.
Reduction of an Inward or Anterior Dislocation. — i. ALLIS ' DIRECT METHOD.
— (1) Flex and abduct the femur; (2) make traction outward; (3) fix the head
by digital pressure and adduct.
2. ALLIS' INDIRECT METHOD. — The patient lies upon his back with the
femur flexed. The surgeon places his bent elbow beneath the flexed knee and
grasps the ankle with his other hand ; he then extends with traction in the line
of the long axis of the femur, adducts, and rotates outward.
BIGELOW'S METHOD OF REDUCTION OF A THYROID OR ANTERIOR DIS-
LOCATION.— "Flex the limb toward a perpendicular and abduct it a little to dis-
FIG. 31. — REDUCTION OF DISLOCATION OF HIP BY TRACTION.
Stimson's method.
REDUCTION OF COMMON DISLOCATK
engage the head of the bone. Then rotate the thigh strongly inward, u
it, and carrying the knee to the floor." After rodiiHi..n. tin- |.:nii-i.
to remain in bed for three weeks, after which massage and j.a^ivr m.,ti,,n arc
begun. The use of the limb is permitted during the fourth week.
DISLOCATION OF THE KNEE JOINT
Dislocation of the tibia forward is the most frequent form. Reduction is
effected by traction on the leg while the thigh is flexed, cmiihiiifd with manipu-
lation in order to guide the head of the tibia into its normal posr
The limb is placed on a posterior splint for three weeks, at't<-r which passive
movements are carefully made. A knee support is worn for several months.
DISLOCATION OF THE ANKLE JOINT
These dislocations are quite rare and are often associated with fracture of
one or both bones of the leg.
1. Backward Dislocation. — Backward dislocation is more frequent than the
forward variety.
Reduction is made by forced plantar flexion, the foot being pulled forward
and the lower end of the tibia pressed backward. Dorsal flexion of the foot com-
pletes reduction.
2. Forward Dislocation. — Reduction is made by marked dorsal flexion of the
foot, pressure forward on the lower end of the tibia, and pressure backward on
the foot. Plantar flexion completes reduction.
The foot is immobilized by a posterior splint for three weeks. Light passive
motion is begun at the end of the third week.
DISLOCATIONS AT THE WBIST
These dislocations are rare:
Dislocations at the Lower Radio-ulnar Joint. — Dislocation of the ulna may be
forward or backward.
DISLOCATION FOE WARD. — Reduction is effected by direct pressure upon
the ulna with counter pressure on the radius.
DISLOCATION BACKWAED. — Reduction is effected by direct pressure on th«?
radius, aided sometimes by abduction or supination of the hand.
Dislocation of the Radiocarpal Joint— BACKWARD DISLOCATION.— Re-
duction is effected by traction upon the hand and direct pressure on the
carpus.
FOEWAED DISLOCATION. — Reduction is effected by traction upon the hand,
counter traction on the forearm, while direct pressure is made upon the dis-
placed carpus.
758
PLASTER-OF-PARIS DRESSINGS
Dislocation of the Carpal Bones DISLOCATION OF THE MEDIOCARPAL
JOINT. — Dislocation between the first and second rows of carpal bones is ex-
tremely rare and may be forward or backward. Reduction in these cases is
effected by flexion or extension of the hand aided by traction and pressure over
the distal carpal row.
DISLOCATION OF THE SEMILUNAE BONE. — Reduction of anterior disloca-
tion of the semilunar bone is effected by hyperextension followed by hyper-
flexion over the thumbs of an assistant, held firmly in the flexure of the wrist
on the semilunar.
Dislocation of the Carpometacarpal Joints. — The joint most frequently in-
volved is that of the thumb and the displacement is almost always backward.
Reduction is effected by traction upon the hand while pressure is made over the
base of the dislocated bone.
DRESSING FOR FRACTURE OF THE CLAVICLE
HOWARD D.
In cases of extreme deformity an open operation may be necessary for the
retention of the fragments in good position. In other cases where the deformity
is slight the Sayre dressing is efficient. This
is too well known to require a separate de-
scription. In passing, however, it may be
said that while the Sayre dressing is theoret-
ically correct in that the lines of force oper-
ate in the proper direction, yet serious
practical objections arise in regard to this
method: namely, first, the zinc oxid plaster
after a few days irritates the skin, more espe-
cially in stout subjects: second, in a short
time the body adjusts itself to the dressing
in such a way that the whole force of the
traction is lost and the reduction is no longer
maintained. This requires a renewal of the
dressing, and such renewal is annoying
and painful to the patient since the zinc
oxid plaster during its removal pulls
violently upon the skin and often leaves an
excoriated or an irritated surface behind.
The following dressing was devised by me to meet these objections. The
material used consists of heavy moleskin adhesive plaster, which, while more
troublesome to apply does not irritate the skin and firmly adheres thereto. The
support and contraction resembles those of the Sayre dressing.
FIG. 32. — DRESSING FOR FRACTURE OF
THE CLAVICLE. Posterior view, show-
ing arm loop and body piece. Shaded
. area of bandage outlines portion re-
duplicated or lined, so that no ad-
hesive surface is presented to the
skin at those points.
FIG. 33. — DRCMUNO FOR FRACTURE or TH»
CLAVICLE. Posterior view, showing shoul-
der cap and elbow aline.
DKESSDTO FOR FRACTURE OF THE CLAVK 1 K 759
The dressing is applied as follows:
First, a piece of moleskin 4 or 5 inches wide is passed about the Immenis
as high up in the axilla as possible, and the ends, for aUut two in«-h«-s of t
length, caused to adhere to each other. This piece should I*- f,,r tin* average
about eighteen inches long. Before apply-
ing, the whole strip should be warmed so
as to cause it to adhere to the circumference
of the arm. At the posterior end of this
loop, i. e., where the ends are adherent to
each other, six holes are punched and eye-
lets inserted (these eyelets are similar to
those through which the laces of shoes are
passed and are made with a little 1m ml
punch devised for the purpose). A second
strip of moleskin, the same width as the
first, passed about the body, extending from
the midline behind around the chest on the
healthy side as far or even across the mid-
line in front. The posterior end of this strip is turned over on itself for about
two inches and a similar row of eyelets inserted. The two rows of eyelets should
be about 6 inches apart and then an ordinary corset lace put in. With this lace
the ends are drawn together with the result that the shoulder can be pulled back
as far as desired. The second part of the dressing is applied as follows:
A broad piece of moleskin about seven
inches wide and a foot long is applied over
the healthy shoulder in the form of a cap
extending well down on the arm. (In order
to secure a cap-like structure, it is necessary
to cut a "dart" in the moleskin.) The free
ends are turned back on themselves and cut
to a taper, so that the margin is not more
than three inches wide. A row of four eye-
lets is placed in each end. The last piece of
the dressing consists of a long strip of mole-
skin three inches wide, passed around the
forearm of the injured side close to the elbow,
one end extending up the front of the chest,
the other up the back. The ends of this strip
are also turned back on themselves and each
FIG. 34. — DRESSING FOR FRACTURE OF
THE CLAVICLE. Anterior view, show-
ing shoulder cap and elbow sling.
has a row of four eyelets. This strip should be lined with muslin so that there
is no adhesive surface exposed except where the moleskin is in contact with the
forearm and elbow. A lacing joins this elbow piece with the shoulder cap in
front and another is placed behind. The front and back
elbow sling and shoulder cap permit the injured shoulder to be raised or, by
760 PLASTER-OF-PARIS DRESSINGS
tightening one lacing more than the other, the elbow may be brought forward
or back as desired.
In applying this dressing, it should be borne in mind that the pieces should
be carefully cut and fitted before the adhesive surface has become thoroughly
secured to the skin.
The only disadvantage of this apparatus is the length of time required for
its application. This disadvantage is more than offset by the advantages, which
are: (1) a non-irritating dressing that may be worn three or four weeks; and
(2) the chance to tighten the lines of traction as occasion may require without
removing the adhesive.
BIBLIOGKAPHY
1. ALBEE, FEED H. Epiphyseal Fracture of the Upper End of the Humerus,
Post-Graduate, June, 1908.
2. ALLIS, OSCAR H. The Hip.
3. BARDENHEUER, B., and GRAESSNER, R. Ergebnisse der Chirurgie und
Orthopedic, Ersterband, 1910.
4. BIGELOW, HENKY J. The Hip.
5. CODMAN, E. A. Boston Med. and Surg. Jour., 1906, cliv, 617.
6. COOPER, SIR ASTLEY. A Treatise on Dislocations and Fractures of the
Joints.
7. ELY, L. W. Joint Tuberculosis.
8. HITZROT, J. M. Treatment of Simple Fractures, Ann. Surg., Iv, 1912.
9. . Loc. cit.
10. HUNTINGTON, THOMAS W. Fractures of the Femoral Shaft, Ann. of
Surg., xlviii, 1908.
11. LUSK, WM. C. Reduction of Supracondyloid Fracture of the Humerus,
Ann. of Surg., xlviii, 1908.
12. SCUDDER, C. L. The Treatment of Fractures.
13. STIMSON, L. A. A Practical Treatise on Fractures and Dislocations, 1907.
14. — . Loc. cit, 93.
15. — . Loc. cit, 570-743.
16. WHITMAN, ROYAL. Further Remarks on the Abduction Treatment of
Fracture of the Keck of the Femur, Therap. Gaz., May 15, 1906.
CHAPTER XVIII
EADIUM IN SURGERY
A. SCHUYLEB CLAEK
Kadio-activity was first demonstrated by Beequerc] in IS'.M; in uranium salts
by means of a photographic plate. In 1898 Madame Curie- an.l M. Srhmidt
proved that thorium was also radio-active and, being struck by the fact that
some samples of pitchblende were infinitely more radio-active than others,
finally in 1903 developed from it polonium and radium.
Debierne, about this time, also isolated actinium which, thouirh more radio-
active than radium, cannot be used therapeutically owing to the difficulty of ex-
traction. Other radio-active substances have been discovered but, up to the
present time, radium has proven the most practical, owing to its possible isola-
tion in the state of a pure salt. It is used in combination as a sulphate or
bromid therapeutically, but we can quantitatively determine the amount of
radium element in any specimen or apparatus.
Radium is found in uranite and carnotite ore deposits, of which those in
southern Colorado are probably the most extensive in the world. It is recovered
at great expense of time and ore, for it is present in infinitesimal amounts and
at the present market value costs from $100 to $120 per mg. of the element
The Standard Chemical Company of Pittsburg are the largest producers
in this country. There is an international standard of measurement, deter-
mined by the rapidity with which a definite amount of air is ionized, and the
stated amount of element in any preparation can now be verified at the Bureau
of Standards, Washington, D. C.
Radio-activity. — The so-called radio-activity consists of a series of disinte-
grations of the radium element into gaseous emanations which in time decom-
pose, resulting in the formation of different active products which it deposits
on every substance it touches, rendering them radio-active. This induced activ-
ity, as in water, vaselin and other substances, is more or less varied and limited.
When, however, it is confined in an hermetically sealed capsule or varnish, as
in the various radium apparatus, radio-activity exists indefinitely and tlii-
plains the fact that several months must be allowed to pass before an apparatus
reaches its full power, when it becomes a stable quantity with a duration of even
761
762 BADITJM IN SURGERY
thousands of years without appreciable loss of the original element or activity.
These sealed deposits result in rays with various powers of penetration, the so-
called Alpha, Beta and Gamma rays.
The Alpha rays are material particles charged with positive electricity —
they have very slight powers of penetration and are lost in 1 in. of air space or
are filtered out with even 2 layers of rubber tissue.
The Beta rays are charged with negative electricity and are comparatively
soft and hard, the softer rays can be filtered out by 2Vi> to 3% in. of air space or
by % to 1 mm. of platinum foil.
The Gamma rays are believed to be due to the anatomic explosions which
generate the Alpha and Beta particles and are caused by electromagnetic pulsa-
tions or disturbances transmitted through the ether in the same manner as the
Hertzian waves, light and X-rays. They are ultrapenetrating up to 2 in.
through living tissue and are not deflected by the magnetic field and some of
them can penetrate even 2 in. of lead or many inches of stone or wood.
Filtration. — Radium in thin glass containers emits approximately 90 per
cent, of Alpha rays, 9 per cent, of Beta rays and 1 per cent, of Gamma rays.
Aluminum, silver, platinum and lead filter out varying proportions of these
different rays and these screens are, therefore, of practical therapeutic value in
varying the proportions of the rays.
Two layers of rubber tissue will filter out practically all the Alpha rays; 0.5
to 1 mm. of platinum or aluminum will filter out the Alpha rays and the softer
Beta rays ; 1 to 2 mm. will filter out also the medium Beta rays, and 4 to 5 mm.
will filter out practically all of the Alpha and Beta rays, allowing the Gamma
rays to pass through. It is in this way that one can determine a superficial or
deep penetrating radio-activity with a single apparatus, naturally varying the
time of exposure according to the amount of rays transmitted through the filter.
All these varieties of rays are capable of producing a radiodermatitis and de-
struction of normal tissue, if a sufficient amount of them is administered.
Radium, to-day, is not only supplied in small glass and thin metal tubes and
cells but can be incorporated in an especially prepared varnish, uniformly
spread over definite areas for the treatment of more extended superficial lesions,
and water can be activated to a more or less definite degree by exposure to
radium emanations, developing an induced activity and so making it possible
to employ radium rays internally in various ways and diseased conditions.
Dosage. — The dosage can be determined fairly accurately in radium thera-
peutics, owing to the practically constant amount and character of rays emitted
from an hermetically sealed apparatus. Four main factors enter into consid-
eration in determining this: 1. The degree of susceptibility of the tissues to
the rays ; 2. the amount and character of the radio-active source ; 3. the screens
employed or not ; 4. the duration, methods and distance of the application.
In a general sense, younger tissues are progressively more susceptible and
older tissues progressively less susceptible to the influence of the rays, and the
dosage, therefore, must be varied in youth, adult life and adolescence.
THERAPEUTICS OF RADIUM IN SURGERY 763
Action of Bays on Living Cells. — Living cells exposed to rays of radium
may be stimulated or depressed and retarded in their growth, or degenerated
and completely destroyed, depending on the amount of rays absorl* -idee
this, the rays seem to have a selective action on certain tissues which, without
destroying the cells, they have the power of changing back, an it w»-n-, to more
nearly the embryonic type from which they developed. In diseased tissu.- tin--*-
cellular reactions are much more promptly and easily produced than in normal
tissue, and it is largely owing to this characteristic that radium has achieved
what success it has in the treatment of the malignant diseases we common ly
call cancer. Epitheliomatous tissue exposed to sntHcimt radium rays shows,
after a few days, a cellular disorganization, going on t<> a softening and gradual
disappearance by absorption. The connective ti»ue immediately surrounding
the mass apparently is stimulated and regenerated by the invasion of embryonic
nuclei dissociating and finally replacing the cancerous cells. Thus takes place
a sort of embryonic fibrous transformation of the tumor, which eventually
changes into a sclerotic mass, healing being produced with a minimum amount
of scarring or deformity. This occurs with little or moderate inflammatory
reaction of the surrounding or overlying healthy tissue necessarily included in
the exposure, from which it regularly returns to a normal condition.
This selective action of radium, or particular susceptibility of the malig-
nant tissue to the rays, is conceded to be even more pronounced in degenerations
of connective tissue than in those of epithelial tissue. It is equally pronounced
on embryonic vascular tissue — nevoid growths — and a specific alterative and
restorative action in this tissue can be produced, resulting in a shrinking of the
tissue and an obliteration of vessels and cavernous spaces with little or no real
destruction of tissue.
The effects of an application of radium begin to make themselves demon-
strable in from 2 or 3 to 10 days and are progressive up to 3 weeks, depending
on the character and the amount of the irradiation. Radium rays are germi-
cidal but act very slowly.
THERAPEUTICS OF RADIUM IN SURGERY
Since Becquerel received his notorious burn from carry ing some of thi<
substance in his pocket, shortly after its discovery and isolation, Wickham and
Degrais have been the leading investigators therapeutically, and i
to their publications that others have resorted to its use in TOTgicml
and that we now have what working knowledge we possess in i
peutic applications. So comparatively little is yet understood of i
chemistry that it must necessarily still be in its infancy from a therapeu
of view, but statistical reports, going up into the thousands, have den
its peculiar qualifications and fitness for the treatment of certain
ditions and to-day it must be recognized as a useful and even essential part
764 EADIUM IN SURGERY
surgical armamentarium. That it has its limitations must be conceded, but that
its use may become less limited in the future is within the realm of probability.
That it is a powerful force in any considerable quantity should be constantly re-
membered, and the greatest care should be exercised in its applications, both for the
patient and for the operator. Severe dermatitis and extensive burns which may be
very painful and slow in healing, may result from the careless handling of radium
apparatus. Even keratoses and degenerative ulcerations may result from repeated
exposures but, generally speaking, they are less to be feared and more easily controlled
than similar conditions resulting from X-ray exposures.
Warts and Papillomata, Senile and Seborrhoic Keratoses. — Warts and papil-
lomata, senile and seborrhoic keratoses yield readily to radium applica-
tions. The ordinary papillomatous wart will undergo a retrograde metamor-
phosis, returning to a normal tissue without apparent inflammatory reaction or
the slightest scarring when exposed by contact to even small amounts of radium
element filtered through 2 layers of rubber tissue for a sufficient length of time.
A cell, 2% to 3 nig., of the element uniformly spread over an area of 14
sq. cm. so applied for 30 minutes is satisfactory on such a lesion.
Papillomata of the hollow or tubular portions of the body, such as of the
larynx, can be removed permanently without ulceration or contractures, but
here it is necessary to use much larger amounts of the element, filtered through
thin layers (J/2 to 1 mm.) of platinum or silver foil. It can be carried to its
destination in the closed end of a tubular container or an applicator is inserted
through an open incision made for the purpose. At least 50 mg. would be
required here.
Senile and seborrhoic keratoses, so frequently found on the faces of older
people, particularly those who have been exposed to the weather, fade away as if
by magic, and even where a degeneration has become established, it is of such a
low grade of malignancy that small non-inflammatory applications of lightly
filtered radium permanently remove it without visible scarring.
X-ray keratoses and ulcerations, such as are seen to-day on the hands of the
older X-ray operators, often respond kindly to radium irradiations and with
less discomfort than usually follows applications of liquid air and carbonic
snow.
Fibromata undergo a retrograde metamorphosis under the influence of
radium and interesting reports are at hand of a considerable success with it in
the treatment of fibromata of the uterus.
In the interstitial variety, frequently demanding a complete extirpation,
radium has in a few instances spared the patient so extensive an operation.
Very considerable amounts of well-filtered radium passed up into the cavity of
the uterus and surface irradiations, through the abdominal wall from several
locations directed toward the uterus, are said to be of advantage in combination.
The metrorrhagia from the endometritis accompanying this condition is regu-
larly favorably influenced.
THERAPEUTICS OF RADIUM IN SUIHJKUY
Keloids and Disfiguring Scars.— Wickham and Degrais an<l other ob*
have removed most successfully deforming and painful keloi.U l.v means of
radium irradiations. The so-called spontaneous keloi<l regularly responds to
non-inflammatory doses, leaving in its place a pliable, level, \vh • :,y tissue
that does not tend to relapse. Here again a selective action <»u tissue varying
from the normal must explain these excellent results. In a similarly satisfao*
tory way do acne keloids and keloidal cicatrices fade away, as it were, under its
influence, with moderate doses of slightly filtered rays. Tin- old hard. / t.rous
keloids and fibrosclerotic bands require more intensive applications, even to the
production of an inflammatory reaction or a superficial ulccration. when healing
is said to begin in the deep-seated tissue of the keloid in embryonic cells, which
gradually replace the mass. When refractive to tins method of treatment, sur-
gical extirpation of these dense tissues can be resorted to with mild prophylactic
irradiations directly healing is established. Excellent results have followed in
my hands even after several recurrences following excision.
Angiomata. — The above-mentioned investigators, with (Jaud. have seen
microscopically in angiomatous tissue after radium applications "an alteration
of the cells which lined the inner surface of the blood-vessels and connective tis-
sue surrounding them, causing an obliteration of the small vessels and resulting
in a sclerotic transformation and exsanguination of the tumor." In this way
superficial level port wine stains are regularly decolorized by slightly filtered
doses of radium with little or no inflammatory reaction or scarring. As these
lesions usually are situated about the face and great care must, therefore, he
used in determining the dosage, Kromayer linlit applications, with a thick blue
glass filter and firm pressure, should be preferred, as they are equally
and without danger of resulting scarring. In the lesions that are more or lees
infiltrated and in which it is difficult or impossible to press out the discolora-
tion, radium alone or in combination with the Kromayer liirht seems to give the
best results. Extensive, flexible, radiferous toiles, separated from the lesion hy
% to 2 mm. of foil, applied over prolonged and repeated periods, through their
more penetrating rays, can produce the above-described changes in this tissue
and often give most excellent cosmetic results.
Extensive, cavernous, erectile angiomata have been reported and pictured
satisfactorily removed by repeated applications of considerable amounts of well-
filtered radium, and equally brilliant results are to be attained in si 1 1 .cutaneous
cavernous angiomatous tumors where surgery has heretofore l>een qr
less. Surpenetrating rays from large amounts of the dement well
to 3 mm. of aluminum) are required, and the "cross-lire" method by i
tions from various points of vantage directed toward the tumor (from the mu-
cous membrane out, also in lesions of the cheeks) is necessary in order to project
enough rays into the tissues without destruction of the overlying i
cous membrane.
Often it is necessary, after a certain amount of sclerosis is esta
tumor, to surgically imbed tubes of moderately filtered radium throughout the
766 BADIUM IN SURGERY
mass. Naturally, inflammation, telangiectases and scarring can result from
such strenuous but necessary methods of raying. It is here that radium has
probably achieved its greatest success for, up to the present, no such uniformly
good results have been attained by other methods.
Malignant Neoplasms, Cutaneous Epitheliomata, etc. — It is in the treatment of
this latter condition that radium has clinically demonstrated its wonderful power
of changing and destroying cancer cells, more or less permanently, with the least
possible inconvenience and deformity and the best possible end results. — In lesions
about the face, and particularly those at or near the eye, radium has
proven to be at great advantage over other therapeutic agents, because of the
ease and comfort of its application, its cosmetic results — the scar being a com-
paratively level, smooth and perfectly pliable one without contractures — and
the comparative infrequence of recurrences.
The more recent reports of the Radium Institute of London and of the
Vienna Institute concur with other opinions that, generally speaking, radium
even in moderate doses, if applied over a sufficient period of time, is preferable
to other methods of treatment, and Pinch, of the former institution, thinks it
may be effective in this class of case because single doses with full-strength
applicators unscreened can be used. Because of their situation these results
would seem to be due to the ability to secure the penetration of rays in sufficient
amount to all parts of the tumor.
The single or massive dose method would seem to be the method of choice
with considerable amounts of unfiltered or slightly filtered rays, and this method
is practicable because of the comparative susceptibility of these diseased tissues
to radium irradiations, it being estimated that the margin of time exposure be-
tween the destruction of the cancer cells and up to a destruction of the adjacent
normal tissue cells is at least a fifth of the whole time necessary to destroy the
cancer, a pretty safe working margin for any slight error in over-exposure.
The superficial epitJieliomata of the rodent ulcer type are the most easily
influenced of the skin cancers, but radium is very effective in either the cicatri-
cial, squamous, ulcerating or fungating variety, the length and strength of ex-
posures varying according to the depth of the lesion. Flat varnish applicators
of varying dimensions have an advantage in cutaneous epitheliomata, but a cell
or tube may be used and irradiations made at a short distance (!/2 inch) from
the lesion in order to cover a larger area at each application, remembering the
law of inverse proportions in this latter method.
Extensive indurated cutaneous epitheliomata in the region of the nares and
eyes, involving the subcutaneous and underlying tissue, even with bony involve-
ment, are as successfully treated by massive doses of light and moderately fil-
tered radium as by surgical intervention and, when successful, with far better
cosmetic results. A cure, dating back a sufficient number of years to be so
called, of a very extensive involvement of one naris and the corresponding
maxillary sinus, is reported.
Epitheliomata of the mucous membranes have been notoriously less in-
THERAPEUTICS OF RADIUM IN SURGEKV 767
fluenced and are more apt to recur after radium, than nkin cariocr*. '1
be due to their greater lymphatic supply with a consequent U-nd. , ,f*tu-
tases, to a greater susceptibility of normal mucous membrane ti^iu-'than is the
case with normal skin tissue, and to the inconvenient location «.f tin- l<«ion,
often making prolonged application difficult.
Inoperable lesions can be regularly reduced and the pain ami <li*-liarge
diminished, and latterly, with the larger amounts of radium at mir dinpoaal, a
total dissipation has occasionally resulted with a fair j moot re-
lief. Generally speaking, up to the present writing, im ,,,„ -rable case of mucous
membrane cancer should be treated by radium before it i ,lly n-mov«-d.
but radium should be resorted to in all inoperable cases and is recommended by
several observers as a prophylactic measure of considerable value. Meta*
glands, when discovered or often even where suspected, should always be exposed
and surgically extirpated.
E pitheliomata of the lower lip would seem to be more successfully treated,
no matter how superficial or limited, by surgery than by radium, except as a
prophylactic measure after operation. Should radium therapy for rnsmotic rea-
sons be demanded here, extensive applications of well-filtered radium could be
employed both from the mucous membrane and skin surfaces directed toward
the interior of the lip, and an accompanying surgical operation of the subinax-
illary glandular tissue should be advised. It is to be remembered that occa-
sionally an extensive, inoperable mucous membrane cancer can be made operable
by powerful radium applications and 1 or 2 such post operations apparently have
been successful.
Inoperable carcinomas of the tonsil and pharynx are reported improved and
lately, since larger amounts of radium can be obtained, even more may be looked
for, from the patient's point of view, by a combination of imitation, cross-fire
and surface irradiations.
Cancer of the tongue, with the usual involvement of the sublingual glandular
tissue, even in the early cases, is a surgical indication, but recurrences and in-
operable lesions should be intensively irradiated, for occasionally a startling
amelioration of the lesion and symptoms intervenes.
Deep-seated Cancers, Carcinoma, Sarcoma, etc. — Wickham. in his book pub-
lished in 1913, sums up his experience with radium from the Laboratoire
Biologiqne du Radium in these classes of cases as follows: "Acknowledging:
their special and very selective susceptibility to the influence of radium, I do
not consider this action complete enough to warrant the use of radium as a pri-
mary therapeutic agent in any form of operable cancer with the single exception
of cancer of the skin." And the Radium Institutes of both London and Vienna,
after a big experience, absolutely concur with him in this opinion. Marvelous
improvement has resulted and even apparent cures in some inoperable cases fol-
lowing the more recent methods of irradiation, and the above authorities urge
the use of radium in inoperable cancers, no matter how severe and extensive
they may be. More or less relief of pain or of discharge or pressure symptoms
768 EADIUM IN SUEGEKY
through the reduction of the size of the mass can be expected, as after no other
known means of treatment, in these inoperable cases.
Inoperable tumors can sometimes be made operable, and a cachectic general condi-
tion can often be greatly improved by radium applications to the offending mass or
masses. The increasing success, as shown by results reported in the more recent years,
undoubtedly has been due to a concerted effort to project greater masses of rays more
equally distributed throughout the tumor and the immediately surrounding tissues.
This is accomplished by the employment of far larger amounts of the element than
were formerly used, by the "cross-fire" method of application of rays projected into the
tumor from various parts of its circumference, and the imbedding into the mass,
through surgical incision, of one or more strong tubes suitably distributed and well
filtered with very prolonged exposures to get a greater penetration (2 to 4 mm. of
platinum foil). In the irradiation of these cancers it is generally conceded that tubes
containing less than 25 mg. of the element are inefficient, and larger tubes are propor-
tionately more effective. The dangers of such extensive and powerful applications
should always be borne in mind and with reasonable care can mostly be avoided.
Dermatitis, radium burns and ulceration can result even though the Alpha and
softer Beta rays are filtered out. Other dangers are thrombosis or hemorrhage of
an included vessel, ulceration of a hollow viscus, and sloughing and ulceration
at the site of imbedded tubes, either from the breaking down of destroyed cells or
a secondary infection, which is exceedingly apt to occur, due to the lowered re-
sistance against germ invasion of the irradiated cells, with a more or less severe or
fatal toxic absorption from either source.
Epithelial cancers of the uterus, rectum and breast have seemed to be more
influenced by radium treatment than the other inoperable or recurring epithelio-
mata.
Carcinoma of the cervix and uterus is anatomically well situated for radium
applications, owing to its tendency to spread around the walls of the organ, leav-
ing the cavity of the vagina, cervix and uterus patent for the insertion of radium
tubes on various applicators or in catheters. A 50-mg. tube of the element fil-
tered with 2 to 4 mm. of foil and left in place for 24 hours will relieve pain,
hemorrhage and discharge and, in a few rare cases, the lesion has entirely dis-
appeared over a period of months after radium treatment, the cervix and uterus
tending to resume somewhat their original contour and appearance. In the
more extensive cases, curettage of the fungating mass, involving the uterus or
cervix and vagina, followed by severe irradiation and irradiation of the recto-
vaginal septum by means of a well-filtered tube in the rectum, has been producj
tive of a marked regeneration and relief.
Such applications to inoperable carcinomata of the rectum have occasionally
prolonged life for months and even years and saved the patient the discomfort
of an artificial anus. Recurring nodules and inoperable carcinomata of the
breast have occasionally been dissipated by radium and, when this treatment
has been combined with resection of diseased glands, a few cases have been free
after many months. In most extensive cases well-filtered radium may be im-
bedded within the tumor — inserted beneath it by elevating the mass and pass-
THERAPEUTICS OF RADIUM IN SURf.KKY 769
ing the applicator along the chest wall— and may be applied from with-.,
varnish applicators and tubes, over mapped-out areas ,,f th,
toward the center of the mass, thus, in so far as possible, in-urinjr a Mitli.
and equal distribution of rays throughout the entire mass.
A striking percentage of excisions, without recurrence of carcinomaia of the
breast, prophylactically irradiated directly healing was established, are reported,
and a few cases have been made operable by radium applications.
Internal cancers involving or in the immediate vicinity of vessel* and r-
must be approached with care because of the possibility of a destruction of the
walls of these organs; nevertheless, in these usually inoperable cases, something
can be hoped for from a surgical exposure, with or without a partial extirpa-
tion of the malignant mass followed by irradiation by i initiation. Frequently
severe shock and septic infection follow such an effort, but if survived, a very
considerable prolongation of life can result.
Inoperable carcinoma of the esophagus and stomach can be irradiated by
esophageal radium carriers or, in the case of the stomach, through a gastrotomy
wound made for the purpose or for exploration, often with the amelioration of
distressing symptoms and a prolongation of life.
Cancers of the neck and groin, involving the deep vessels, more or less have
by irradiation after partial extirpation shown marvelous improvement up to an
apparent resorption of the mass.
It is in the malignant sarcomata that radium seems to exert its greatest selec-
tive action. Several cases of giant-celled sarcoma of the femur have disappeared
entirely after imbedding tubes of radium uniformly throughout the mass. One
or 2 very extensive cases, dating back several years, are apparently free iron
disease. This method of treatment is to be considered in comparison with
so serious and deforming a surgical procedure as amputation at the hip.
often followed by extension of the disease in spite of so heroic an
effort.
Even extensive sarcomata of the parotid gland and tonsil are sometime-
marvelously influenced, and radium, by imbedation and surface irradiation, is
here indicated when surgery has failed or is likely to fail.
Inoperable sarcoma of the prostate offers a field for radium therapy by im-
bedding tubes in the mass itself and irradiations directed to\yard the mass per
bladder and per rectum.
Epulis, when it defines an osteosarcoma, is readily influenced bvr
rays, and inoperable or borderline cases should be so tr< j.relimiua
curettement of the softer broken-down tissue is advantageous.
large amounts of well-filtered radium are essential.
The indications for radium treatment of metastatic glandular in re
in cancerous disease are the same as in cancer itself-extensive inoperable
masses of enlarged matted glands are reduced and the cons^m-..
swelling from pressure often present are more or less idle*
Koenig and Gans, after a large clinical experience with coi
50
770 RADIUM IN SURGERY
ties of radium at their disposal, have formulated the following indications for
the radium treatment of cancer :
1. When cancer is operable, but can be easily controlled by sight and touch,
employ radium.
2. When cancer is operable and not easily controlled by sight and touch,
operate, provided the postoperative mortality is not too high.
3. When inoperable, radiate.
4. After operation, when there is a probability of a recurrence, radiate.
These broad indications are in a fair way to be justified in the near future.
In the face of the startling results that have been attained in the radium treat-
ment of cancer, it is well to bear in mind that the disappearance of a cancer
growth and the cure of cancer disease are far from synonymous terms.
A field for experimentation along these lines lies in the injection of soluble
and insoluble salts of radium in and around the tumor, in water and oily
media, respectively. The results in animal experimentation up to the present,
while not very striking, are not yet condemning.
Tuberculosis. — Lupus vulgaris and tuberculous nodules are favorably in-
fluenced by radium but it is necessary to produce a considerable inflammatory
reaction to get results, with more or less scarring and telangiectases resulting.
Ultraviolet rays from the Kromayer or Finsen lights are equally effective, with
better cosmetic results, and are, therefore, to be preferred. In infiltrated, iltiick,
granulomatous lupus vulgaris lesions, inflammatory radium exposures followed
by Kromayer light treatments after the inflammatory reaction has subsided are
of advantage. Rather extensive and lightly filtered irradiations are here indi-
cated.
In lupus of the mucous membrane, however, because of its inaccessibility,
the various radium appliances are the most convenient and successful thera-
peutic agents. Radium has healed tuberculous sinuses, and ulcers and tuber-
culous glands are frequently reduced by ultrapenetrating radium rays from the
surface. There seems to be no particular susceptibility on the part of tubercu-
lous tissue over other tissues to rays of radium and they are not actively germi-
cidal.
Goiter. — Several cases of exophthalmic goiter have been reduced and the
nervous and other symptoms relieved by frequently repeated exposures to ultra-
penetrating rays. The "cross-fire" method, with large amounts of the element,
can be applied conveniently in these cases because of the anatomical situation
and configuration of the tumor. Radium tubes may also be imbedded in the
substance of the gland.
Hodgkin's Disease. — Some cases are temporarily relieved, the glandular and
splenic swellings reduced and the anemia and blood picture improved by irradi-
ations with large amounts of ultrapenetrating rays.
A case of splenomegaly is reported with a reduction from 300,000 to 6,000
in the white cell count and a greatly enlarged spleen reduced to normal in a few
weeks, improvement still persisting after several months. Inflammatory glandu-
THERAPEUTICS OF RADIUS IN SIKCKKY 771
lar enlargements in general are more or less influenced by a decongestive action
of radium rays without any inflammatory reaction.
Leukoplakia.— Leukoplakia, a condition prone to d<-i_MMirrate, notoriously re-
bellious to treatment and, because of the extent of tin- li-siuns. ..iVn not amena-
ble to surgical methods, when thick, indurated, niuniuiillati-d ami cracked, can
be reduced to a smooth, level, grayish membrane by slightly iutlami: -adi-
ations,the pain and tenderness relieved and the liability t<> ati«.n dimin-
ished. The level or slightly grayish, painless patches, show littl.- imp:
and are better treated with soothing or mildly astringent lotions and applica-
tions and the interdiction of tobacco, alcohol and irritating foods and drink*.
Chronic, sluggish liberations, such as are often seen on the lower legs, with
a poor circulation and with varicose veins, can often be made to heal by re-
peated, mild, stimulating applications of radium.
Neuralgic and Itching Conditions.— The marvelous neurotrophic effect of
radium in relieving indefinite neuralgic and itching conditions and its broad
application in the field of dermatology should always be remembered.
Compared with the X-ray, radium in sufficient amounts will accomplish,
therapeutically, anything that the former can do. Its Gamma rays are more
penetrating than any of the X-rays so far produced, and its portability and the
convenience of the method of application are important considerations.
The stability of the amount and character of rays emitted from an hermeti-
cally sealed apparatus is a very important advantage in radium therapy.
INDEX
Abderhalden ;s defensive ferments, 225
diagnostic value of, 227
experimental observations in, 227
in pregnancy, 226, 227
methods of determining presence of, 227
dialization method, 227
optical method, 228
origin of, 227
Abdomen, aspiration in, during operation,
237, 238
post-operative use of, 244
gunshot wounds of, in civil life, operative
treatment for, 656
technic of, 657
in warfare, treatment of, 656, 658
operative, 656
operation for, 657
Abdominal affections, acute, complicating
typhoid fever, 153
Abdominal aorta, aneurysm of, 383
free fascial transplants in, 385
intrasaccular suture in, 384
ligation of aorta in, 383
plication by lateral parietal suture in,
385
strips of aorta used in, 385
temporary compression of aorta in, 383
by instruments through laparotomy
wound, 383
by metal bands, 384
by tourniquet, 383
wiring with electrolysis in, 384
ligation of, in continuity, 430
anatomy of, 430
operation in, 431
extraperitoneal ligation in, 431
results of operation in, 431
Abdominal viscera, gunshot wounds of, 670
conservative treatment in, 670
operative treatment in, 670
Abrasions, treatment of, 683
Abscesses complicating erysipelas, 158
Accident cases, treatment of, 703
Acids, burns due to, 700
Acne, vaccine therapy of, 205
Actinium, 761
Actinomycosis, treatment of, 696
Actinomycosis of muscles, 620
Acupuncture in treatment of nevi, 329
Adams' operation for Dupuytren's contrac-
ture, 645
Adenitis, vaccine therapy of, 210
Adhesive plaster, 12
moleskin, 12
zinc oxid, 12
Adrenalin to cheek bleeding in capillaries,
Albuminuria complicating scarlet fever, 156
Alcohol for sterilization in aseptic surreal
tec hi
Alcohol injections into nerve trunks in treat-
ment of disturbances of fifth
cranial tn^eminal) nerve 569.
See alto under Cranial ner
into peripheral nerves for relii •
ticity, 529
into seventh cranial nerve for treatment of
facial spasm, 585
Alcohol ether bio hlo rid method of skin sterili-
zation for operations, 149
dangers of, 149
drawbacks of, 149
modifications of, 149
precautions in, 149
Alcoholism, 164
contra indication to operations, 164
surgical complications of, 166
treatment of, preceding operations, 164-166
treatment of delirium tremens in, 166
Lambert's method of, 166
M cBride's method of, 167
Alkalies, caustic, burns due to, 700
Alkaloidal narcotics, as adjuncts in ether an-
esthesia, 102 tt icq.
use of, following anesthesia, 103
as adjuvants in nitrous oxid anesthesia
technic of administration of, 124, 125
Alpha rays of radium, 7
Aluminum alloys for suturing, 8
Alypin in local anesthesia
Amboceptor and i-omplement combination in
si«le chain theory of immu
199
Ambulance stations for wounded on battle
field, 661
Amputations through infected tisi
genous vaccines used in, 664
Chlumsky 's solution for, 664
iodin painting in, 664
Anastomosis, arterial, en. I to end, 262
choice of methods in, 272
Outhrie on general restoration in, 273
indications and contra- indications for, 2(
instruments for, 263
methods used in, 263
broad marginal apposition methods, 24
Brian Jaboulay, 265, 266
Dorrance, 266
Inapinamft and Eisenstaedt, 266, 267
Salomoni, 265, 266
773
774
INDEX
Anastomosis, arterial, end-to-end, methods
used in, direct marginal approx-
imation methods, 266
Carrel's method of, 267, 273
general rules in, 267
instruments for, 268
preparation of vessels and hemosta-
sis in, 268
reestablishment of circulation in, 269
sutures in, 269
stay, 270
Dobrowolskaja's technic of, 271, 272
Guthrie 's technic of, 270
Horsley 's technic of, 271
Jeger's technic of, 270, 271
O 'Day's technic of, 272
invagination methods of Murphy, 263,
272
early method, 263
recent method, 264
invagination method of Payr, 264, 272,
273
Hoepfner's modification of, 264, 265
results of, 274
Anastomosis, arteriovenous, 275
choice of methods in, 279
end-to-end, 275
Carrel's method of, 275
Murphy's method of, 275
end- to- side, 275
Carrel and Guthrie 's methods of, 275, 276
Jeger's method of, 277
Wieting's method of, 276
results in, 281
side-to-side, 277
Bernheim and Stone 's method of, 279
Carrel's method of, 277
Guthrie 's method of, 278
Lespinasse and Eisenstaedt 's method of,
278
Anastomosis, nerve, 538
Anastomosis, venous, to restore or reestablish
circulation, 288
end-to-end, 288
operative technic in, 288
results in, 289
in veins of animals, 289
end-to-side, 289
side-to-side, 290
Anatomical tubercle, treatment of, 696
Anemia, a centra-indication to operations.
151
simple chronic, 152
shock in, 152
and operations, 191
Anesthesia, general, 71
ace-dents in, 134
cardiac failure, 139
etiology of, 139
prophylaxis of, 140
treatment of, 140
from decomposition and ignition of an-
esthetic agent, 134
nerve lesions, 141
prophylaxis of, 141, 142
obstruction to respiration, 135
bronchial, 137
glottal, 136
Anesthesia, general, accidents in, obstruction
to respiration, mouth, 135
nasal, 135
pharyngeal, 135
tracheal, 136
pulmonary edema, 138
respiratory failure, 138
etiology of, 138
symptoms of, 138
treatment of, 139
surgical shock, 140
etiology of, 140
treatment of, 141
vomiting, 137
anoci-association method in, 127
technic of, 127, 128
artificial respiration in, 130
by intratracheal insufflation, 130
by lung-motor, 131
by pharyngeal insufflation, 130
by pulmotor, 130
Anesthesia, general, chloroform in, 105
administration of, 108
by open drop method, 108
by vapor methods, 109
continuous vapor delivery in, 110
interrupted vapor delivery in, 109
clinical course of, 107
first stage or stage of conscious ex-
citement in, 107
second stage or stage of involuntary
excitement in, 107
third stage or stage of surgical anes-
thesia in, 108
fourth stage or stage of overdose in,
108
fifth stage or stage of recovery in,
108
effects of, on body function, 106
on circulation, 106
on respiration, 106
on sensorium, 107
excretion of, 107
irritant action of, compared with ether,
106
physiological action of, 106
Anesthesia, general, Connell anesthetometer
in, 131
advantages of, 133
description of, 131
differential pressure methods in, 128
negative pressure in Saurbruch chamber
in, 129
positive pressure by face mask in, 129
by intratracheal insufflation in, 130
by pharyngeal insufflation in, 130
Anesthesia, general, ether in, 72
administration of ether in, by absorption
by serous surfaces, 102
by insufflation, apparatus for, 97
accessories, 99
air compressor, 97
ether vaporizer, 98
filter and humidor, 97
intubating catheter, 98
safety valve, 98
by intratracheal insufflation, 91
maintenance of positive pressure in, 94
INDEX
775
Anesthesia, general, ether in, administration
of ether in, by intratracheal in-
sufflation, physiology of, 91, 92
technic of, 92-94
by pharyngeal insufflation, 95
maintenance of positive pressure in.
96
technic of, 95
by subcutaneous injection into mus-
cles, 102
general technic of, 85
closed method in, 87, 88
open method in, 85
administration by pouring of
small portions (open cone
method), 87
administration by successive drops
(drop method), 85
apparatus for, 85
in children, 86
technic of, 85
vapor methods in, 88
negative pressure methods of
vapor delivery, 88, 89
positive pressure methods of vapor
delivery, 89
apparatus for, 89
technic of, 90
intravenous, 99
physiology of, 99
technic of, 100
rectal, 101
oil-ether method in, 101
theoretical consideration of, 78
action of ether on body in, 78, 79
details of induction of anesthesia in,
79
establishment of anesthetic tension
in, 80
phenomena and utility of zones in,
82
zone 1 : the zone of confusion, 82
zone 2: the light subconscious
zone, 82
zone 3 : the subconscious zone. 83
zone 4: the zone of light surgical
anesthesia, 83
zone 5 : the zone of full anesthesia,
83
zone 6: the zone of deep anes-
thesia, 84
zone 7: the zone of profound an-
esthesia, 84
zone 8 : the slowly lethal zone, 84
zone 9: the rapidly lethal zone,
84
stage of recovery in, 81
agents used as adjuncts of, 102
alkaloidal narcotics, 102
atropin, 103
dosage of, 103
morphin, 102
dosage of, 103
scopolamin, 102
use of, following anesthesia, 103
chloroform, 104
technic of, 105
ethyl chlorid, 105
Anesthesia, general, ether in, agent* used as
adjunct* of, nitrous oxid, 103
technic of, 103, 104
nitrous oxid oxygen, 104
clinical course of, 75
first stage or stage of conscious ex-
••it.-iii.-iit in. 75
second stage or stage of involuntary
excitement in, 75
third stage or stage of surgical IBM
thesia in, 76
fourth stage or stage of overdose in,
fifth stage or stage of recovery in, 78
excretion of, 75
physiological action of, 73
local anesthetic, 73
on body function, 74
on blood pressure, 74
on heart action, 74
on respiration, 74
• on sensoriuro, 74, 75
on fatty substances, 75
on skin, mucous and serous surfaces, 73
Anesthesia, general, ethyl chlorid in, 125
administration of, 126
closed method of, 126
semi-open method of, 126
period of recovery in, 126
physiological action of, 125
on respiration, 125
on sensorium, 125
zones in, 126
Anesthesia, general, nitrous oxid in, 110
adjuvants of, 123
alkaloidal narcosis, 124
technic of, 124, 125
ether anesthesia, 123
technic of, 124
postoperative narcosis, 125
administration of, 118
of nitrous oxid oxygen mixtures, 1
advantages and limitations of, 122
apparatus for, 115
for control of gases, 116
for gas supply, 116
inhaler in. 11".
general considerations of, 118, 119
methods of delivery in, 119
by Connell method. 1-1
by continuous flow »ethod
(Boothby), 120
by insufflation, 121
partial. 1'Jl. 1'J'J
by interrupted flow or rebreathing
method (Hatch), 120
of nitrous oxid, pure, 118
physiological action <>f. HI
with nitrous oxid-oxygen mixture, 112,
113
zones in, 113 111
with undiluted nitrous oxid, 111
overdose in, 111, 112
theory of. 7-
Anesthesia, local. 47
by chemical agents, 48
adjuvant* in, 51
epinephrin, 51
776
INDEX
Anesthesia, local, by chemical agents, agents
in, 49
alypin in, 51
beta-eucain in, 51
by action on nerve terminals, 48
by action on nerve trunks, 49
by infiltration, 52
apparatus for, 52
for celiotomy, 57
for hemorrhoids, 59, 60
for minor operations on neck and
throat, 56
for operations about head and face, 55
for operations on fingers, 60
on inguinal and femoral hernia, hy-
drocele of the cord, and gland
of the groin, 58
on knee, 59, 60
on toes, 60
for reduction of fractures of long
bones, 60
for thyroidectomy, 56
for thoracotomy, 56
for tracheotomy, 56
general considerations of, 52
general technic of, 53
preferred technic of, for special
groups of operations, 53
extensive operations on acutely in-
flamed areas, 55
major operations on non-inflamed
areas, 54
minor operations on inflamed areas,
53
minor operations on non-inflamed
areas, 53
by injection into medullary canal, 64
agents employed in, 67
apparatus for, 66
limitations of, 66
physiology of, 65
circulation in, 65
respiration in, 65
skin in, 66
uterus in, 66
preparation of anesthetic agent in, 66
preparation of patient in, 68
technic of, 68
by intra-arterial injection, 70
technic of, 70
by intraneural infiltration, 61
brachial plexus anesthesia in, 62
by intravenous injection, 69
technic of, 70
by osmosis, 51
cocain in, 52
by perineural infiltration, 63
technic of, 63, 64
cocain in, 49
for mucous membranes, 51
preparation of solution of, 49, 50
eucain in, 51
holocain in, 51
novocain in, 50
quinin and urea hydrochlorate in, 51
resume of, 71
stovain in, 51
tropocain in, 51
Anesthesia, local, by physical agents, 48
pressure, 48
refrigeration, 48
indications and limitations of, 48
technic of, 48
Anesthesia, regional, 61
by injection into medullary canal, 64
agents employed in, 67
apparatus for, 66
limitations of, 66
physiology of, 65
circulation in, 65
respiration in, 65
skin in, 66
uterus in, 66
preparation of anesthetic agent in,
66
preparation of patient in, 68
technic of, 68
by intra-arterial injection, 70
technic of, 70
by intraneural infiltration, 61
brachial plexus anesthesia in, 62
by intravenous injection, 69
technic of, 70
by perineural infiltration, 63
technic of, 63, 64
Anesthesia, surgical, 47
general, nature of, 47
local, nature of, 47
Aneurysm, and operation, 191
arteriovenous, in bullet wounds of blood
vessels, 663
treatment of, 379
axillary, operative treatment of, 390
in gunshot wounds of neck, 669
medical treatment of, 363
of abdominal aorta, 383
free fascial transplants in, 385
intrasaccular suture in, 384
ligation of aorta in, 383
plication by lateral parietal suture in,
385
strips of aorta used in, 385
temporary compression of aorta in, 383
by instruments through laparotomy
wound, 383
by metal bands, 384
by tourniquet, 383
wiring with electrolysis in, 384
of carotid, common, operative treatment of,
386
cerebral complications in, 386, 387
pressure symptoms in, 386
external, and its branches, 388
internal operative treatment of, 387,
388
of femoral artery, operative treatment of,
393
of iliac arteries, operative treatment of,
391
in external tract, 391
in internal branches, 392
extirpation in, 392, 393
of innominate artery, treatment of, 385
complications in, 386
distal ligation in, 386
wiring with electrolysis in, 386
INDEX
777
Aneurysm, of popliteal artery, operative treat-
ment of, 393-395
of renal arteries, 385
of subclavian artery, 389
medical treatment of, 389
operative treatment of, 389
ligation in, 389
surgical treatment of, 363
aneurysmectomy, 377
compression in, 364
digital, 364
direct, 364
elastic, 364
postural, 364
endo-aneurysmorrhaphy and aneurysmo-
plasty operations in, 370
technic of closure of arterial stomata
of sac in, 370
treatment of sac following closure of
stomata in, 374
ideal operations in, 377
ligation in, 365
distal, 368
early methods of, 365
objections to, 368
proximal, 367
results of, 368
technic of, 366
needling in, 369
refrigeration in, 363
wiring in, 369
Moore's method of, 369
with electrolysis (Moore-Corradi), 369
syphilis and, 173
thoracic, 379
ligature of thoracic aorta in treatment
of, 382
saccular form of, 380
wiring with electrolysis in, 380
complications in, 381
results of, 381
Aneurysmal varix in bullet wounds of blood-
vessels, 663
in gunshot wounds of neck, 669
Aneurysmectomy, 377
"ideal" operations in, 377
Aneurysmoplasty operations, 374
Angina, vaccine therapy of, 210
Angina Ludovici, contra-indicating opera-
tions, 187
Angiomata, of the lower lip, operation for
excision of, 494
radium therapy of, 765
vascular, operations on capillaries for
treatment of, 328. See also
under Capillaries.
Ankle, bursae about, diseases of, 633
Ankle joint, dislocation of, 757
backward, 757
forward, 757
infected wounds of, treatment of, 665
Anoci-association anesthesia, 127
technic of, 127, 128
Anthrax, in animals, vaccine therapy of,
206
in man, serum therapy of, 206
treatment of, 695
carbolic acid injections in, 695
Anthrax, treatment of, operative, 605
serum therapy in, 095
Anti»H>dies, 198
AntigeuM, 198, 201
Anti*-j.ti nous injections of, for
treatment of wound* in blood
infections, 691
Antitoxin, diphtheria. See Diphtheria anti
toxin.
effect of heat on, 200
tetanus. See Tetanus antitoxin.
Antyllus, use of ligature by, for aneunrim.
860
Anuria, contra indication to operation, 192
"Anesthesia paralysis," 556
Anesthetic, intraspinal injection of, tempo-
rary relief of spastieity by, 530
Anesthetometer, Connell, 131 134
Aorta, abdominal, aneurysm of. See under
Abdominal aorta,
ligation of, in continuity, 430
anatomy of, 430
operation in, 431
extraperitoneal ligation in, 431
results of, 431
thoracic, aneurysm of. Sec Thoracic
aneurysm.
Appendicitis, perforative, in tabetics, 173
Arms, anesthetization of, 64
fractures of. See under Fractures.
gunshot wounds of, 671
infected wounds in joints of, 666
muscles of, ischemic contracture of, 616
causes of, 616
results of, 616
treatment of, 616-618
rupture of, operative treatment of,
613
Arterial anastomosis. See under Anastomo-
sis.
Arteries, embolus in, arterial section for, 283
arteriovenous anastomosis for femoral
of, 275. See aUo under Arter-
ies.
Arteries, ligation of, in continuity, 399
force applied in, 400
force necessary to rupture coaU in, 401
in abdominal aorta, 430
anatomy of, 430
operation in, 431
extraperitoneal ligation in, 431
results of, 431
in axillary artery, 420
anatomy of, 420
operation in, 421
ligation of first portion in, 421
ligation of second portion in, 422
ligation of third portion in, 422
results of operation in, 422
in brachial artery, 422
anatomy of, :
operation in, 4:M
in cubital fossa, 424
in middle third, 424
in upper third, 423
in carotid, common, 405
anatomy of, 405
operation in, 406
778
INDEX
Arteries, ligation of, in continuity, in caro-
tid, common, operation in, liga-
tion above omohyoid in, 406
ligation below omohyoid in, 407
results of operation in, 407
external, 408
anatomy of, 408
operation in, 408-411
internal, 411
anatomy of, 411
operation in, 411
results of operation in, 411
in circumflex artery, deep, 439
anatomy of, 439
operation in, 439
in dorsalis pedis artery, 447
anatomy of, 447
operation in, 448
in epigastric artery, deep, 439
anatomy of, 439
operation in, 439
in femoral artery, 439
anatomy of, 439
operation in, 440
in common femoral, 440
in superficial femoral at apex of
Scarpa's triangle, 440
in superficial femoral in Hunter's
canal, 441
in gluteal artery, 435
anatomy of, 435
operation in, 436
in iliac artery, common, 431
anatomy of, 431
operation in, 432
extraperitoneal, 433
transperitoneal, 432
results of operation in, 434
external, 438
anatomy of, 438
operation in, 438
extraperitoneal, 438
transperitoneal, 438
results of operation in, 438
internal, 434
anatomy of, 434
operation in, 434
results of operation in, 435
in innominate artery, 403
anatomy of, 403
operation in, 404
first method of, 404
second method of, 404
third method of, 404
results of operation in, 404
in mammary artery, internal, 419
anatomy of, 419
operation in, 419-420
in peroneal artery, 445
anatomy of, 445
operation of, 445
in lower third, 445
in upper third, 445
in popliteal artery, 441
anatomy of, 441
operation in, 442
in lower part of popliteal space, 443
in upper part of popliteal space, 442
Arteries, ligation of, in continuity, in pop-
liteal artery, results of opera-
tion in, 443
in pudic artery, internal, 437
anatomy of, 437
operation in, 437
in radial artery, 425
anatomy of, 425
operation in, 426
in hand, 427
in lower third, 426
in upper third, 426
in wrist, 427
in sciatic artery, 437
anatomy of, 437
operation in, 437
operation in third or second portion of.
417
results of, 418
in subclavian artery, 413
anatomy of, 413
operation in first portion of, 415
results of; 416
in supra-orbital artery, 413
anatomy of, 413
operation in, 413
in tibial artery, anterior, 445
anatomy of, 445
operation in, 446
in lower third, 447
in upper third, 446
posterior, 443
anatomy of, 443
operation in, 444
behind the medial malleolus, 444
in middle of leg, 444
in ulnar artery, 428
anatomy of, 428
operation in, 429
in hand, 430
in juncture of upper and middle thirds.
429
in lower third, 429
in wrist, 429
in vertebral artery, 418
anatomy of, 418
operation in, 419
results of operation in, 419
indications for, 399
instruments for, 399
knot in, 400
ligature material for, 399
opening of sheath of vessel and passing
aneurysm needle in, 402
recognition of artery in, 401
results of, 401
Arteries, operations on, 255
to check bleeding, 255
bandages and compresses in, 256
digital pressure in, 256
forcipressure in, 257
ligation in, 258
postural compression in, 255
torsion in, 258
tourniquet in, 256
elastic, 256
massage and elevation in use of, 256, 257
pneumatic constrictor as, 257
INDEX
Arteries, operations on, to restore or reostab-
lish circulation, 259
arterial anastomosis in, 262
choice of methods in, 272
Guthrie on general restoration in, 273
indications and contra- indications for,
262
instruments for, 263
methods used in, 263
broad marginal apposition methods,
265
Briau-Jaboulay, 265, 266
Dorrance, 266
Lespinasse and Eisenstaedt, 266,
267
Salomoni, 265, 266
direct marginal approximation
methods, 266
Carrel's method of, 267, 273
general rules in, 267
instruments for, 268
preparation of vessels and
hemostasis in, 268
reestablishment of circulation
in, 269
sutures in, 269
stay, 270
Dobrowolskaja's method of, 271,
272
Guthrie 's method of, 270
Horsley's method of, 271
Jeger's technic of, 270, 271
O 'Day's technic of, 272
invagination methods of Murphy,
263, 272
early method, 263
recent method, 264
invagination method of Payr, 264,
272, 273
Hoepfner's modification of, 264,
265
results of, 274
arterial section, 283
operation in, 283
results of, 284
arteriovenous anastomosis, 275
choice of methods in, 279
end-to-end, 275
Carrel's method, 275
Murphy's method, 275
end-to-side, 275
Carrel and Guthrie 's methods of,
275, 276
Jeger's method of, 277
Wieting's method of, 276
results in, 281
side-to-side, 277
Bernheim and Stone's method of,
279
Carrel's method of, 277
Guthrie 's method of, 278
Lespinasse and Eisenstaedt 's method
of, 278
lateral suture in, 259
instruments in, 259
preparation for, 259
technic of operation in, 260-2
transplantation of arteries in, 285
Arteries, trauma of, arteriovenous anastomo-
sis for removal of obstruction
»r aUo under Arter-
ies, operations on.
Arteriosclerosis and operation, 191
Arteriovenous anastomosis. Bee «
tomosis.
Arteriovenous aneurysm, treatment, 379
Arthritis, <• o HI j» I i c a t i n g scarlet few,
106
vaccine therapy of, 206
Artificial respiration. Bee Respiration, arti-
Id
Artillery, moilrrn, of land warfare, 672
Ascites, Handley 's operation for establish t«g
artificial channels for lymph
(irania^- in, 332
Aseptic surgical techn
agents of infection in, 2
aspirating syringes in, 14
autoclave or steam sterilizer in, 22-25
drainage in, 13
cigarette drain for, 13
glass tubes for, i:i
rubber tissue drains for, 14
rubber tubes for, 13
dressings in, 8
bandages for, 1 1
mull, 11
plaster-of -Paris, 11
silicate of soda, 12
adhesive plasters for, 12
moleskin, 12
zinc oxid, 12
cotton, 10
gauze, 9
impregnated, 10
sponges for, 10
fractional sterilization of materials in, S
hands in, preparation for, 16
rubber gloves for, 16, 17
putting on of, 19
sterilization of, 18
use of, arguments for, 18, 20
hypodermic syringes in, 14
instruments in, 14
selection of, 14
sterilization of, 15
methods of prevention and counteraction
of intVrtiun in, 8
by germicidal agents, 3
chemicals, 3
alcohol, 4
bichlorid of mercury, 4
carbolic :«« i :
formaldehyd gas, 5
iodin, 4
iodoforni. 4
potassium permanganate, 4
heat, 3
boiling, 3
cautery, S
hot air, 3
live steam, 3
by mechanical means of sterilisation,
3
skin of patient in. -1
sources of infection in, 2
780
INDEX
Aseptic surgical technic, suture material
in, 5
aluminum alloys, 8
catgut, 6
preparation of, 6
by chromic acid method, 7
by cumol method, 6
by iodin method, 7
kangaroo tendon, 8
Pagenstecher 's thread, 8
silk, 8
silkworm-gut, 8
silver wire, 8
water sterilization in, 25
Aspirating bottle, Connell, 229
Aspirating syringes, 14
Aspiration in operative surgery, 229
continuous, application of, during opera-
tion, 236
advantages of, 235
for production of hyperemia, 246
in abdomen, 237, 238
in gall-bladder and ducts, 238
in genito-urinary tract, 238
in head, 236
in intra-abdominal conditions, 238
in mastoid region, 237
in mouth and pharynx, 237
in spinal cord, 237
in stomach, 238
in thorax, 237
postoperative application of, 239
apparatus for, 239, 240
in abdomen, 244
in head, 240
in mouth and pharynx, 241
in thorax, 241
Kenyon's method of, 242-244
producing of, 229
care and cleaning of apparatus in, 232
connections between suction pump and
wound in, 232
first use of pumps in, 232
in private houses, 231
pumps in, 229
ejector, 230
filter, 230
mechanical, 229
operated by fluid or vapor, 230
tips or nozzles in, 232
double tip, 233
for mouth and pharynx, 235
for use as retractors, 235
single tube, 232
Atropin as adjunct in ether anesthesia, 103
dosage of, 103
Atropin sulphate, hypodermic injection of,
for shock, 677
Autoclave, 22-25
Autogenous vaccines, 204, 205
Avulsion, nerve, 536
Axillary artery, aneurysm of, operative
treatment of, 390
ligation of, in continuity, 420
anatomy of, 420
operation in, 421
ligation of first portion in, 421
ligation of second portion in, 422
Axillary artery, ligation of, in continuity, op-
eration in, ligation of third por-
tion in, 422
results of operation in, 422
Babcock's method of excision for varicose
veins, 322
Bacillus aerogenes capsulatus infection, vac-
cine therapy of, 206
Bacillus pestis. See Bubonic plague.
Bacterial immunity, 200
bacteriolysis in, 201
phagocytosis in, 200
Bacterial toxins, immunity conferred by injec-
tion of small quantities of, 199
immunity to, 199
intracellular, 199
Bacteriemia, treatment of, 691
Bacteriolysis, 201
Bacteriotropins, 201
Baking-soda solution for burns, 698
Balkan war, statistics of mortality of pointed
bullet in, 654, 658
Bandages, 11
mull, 11
plaster-of-Paris, 11
silicate of soda, 12
Bandages and compresses to check bleeding
in arteries, 256
in veins, 286
Bath, continuous, in treatment of burns of
third degree, 699
Beck's subnitrate and vaselin injection in
treatment of tuberculosis of
muscles, 620
Bedbugs, bites of, treatment of wounds due
to, 686
Beebe's antithyroid serum, 208
Bees, stings of, treatment of wounds due to,
686
Bennett inhaler for nitrous oxid-ether anes-
thesia, 103
Bentley Squier's portable table, 42, 43
Benzin method of skin sterilization for opera-
tions, 149
Beraneck's tuberculin, 216
Bernheim's transfusion tube and technic in
direct blood transfusion, 306
Bernheim and Stone's method of side-to-side
arteriovenous anastomosis, 279
Berry and Legg's method of operation for
cleft palate, 470
Beta-eucain in local anesthesia, 51
Beta rays of radium, 762
Bichlorid of mercury for sterilization in
aseptic surgical technic, 4
Bichlorid of mercury poisoning, 184
operation contra-indicated in, 185
stripping of capsule of kidney in, 184, 185
symptoms of, 185
Bismuth subnitrate and vaselin injection in
treatment of tuberculosis of
muscles, 620
Bladder, diseases of, and operations, 192
gunshot wounds of, 670
Blastomycosis, treatment of, 697
Bleeding in arteries, operations to check, 255
bandages and compresses in, 256
INDEX
781
Bleeding in arteries, operations to check, dig-
ital pressure in, 256
forcipressure in, 257
ligation in, 258
postural compression in, 255
torsion in, 258
tourniquet in, 256
elastic, 256
massage and elevation in use of, 256.
257
pneumatic constrictor as, 257
Bleeding in capillaries, operations to check,327
ligation en masse for, 328
local coagulants in, 327
adrenalin, 327
gelatin, 327
hot-water, 327
hydrogen peroxid, 327
packing for, 328
Bleeding in veins, operations to check, 286
bandages and compresses in, 286
cautery in, 286
digital pressure in, 286
forcipressure in, 286
gauze packing in, 286
ligation in, 286
postural compression in, 286
torsion in, 286
Blepharoplasty. See Eyelids, plastic sur-
gery of.
Blood infections, due to bacterial invasion
from wounds, 691
treatment of, 691
Blood transfusion, 299
choice of methods in, 316
contra-indications for, 300
dangers of, 318
agglutination in, 318
air embolism in, 319
alteration of gaseous tension of blood in,
319
blood embolism in, 319
dilatation of heart, acute, in, 319
hemolysis in, 318
transmission of disease in, 318
defibrinated blood in, 341
direct transfusion in, 303
artery-to-vein method of, 303
Bernheim's tube in, 306
Brewer 7s tubes in, 308
Carrel's suture in, 308
Crile's eannula in, 303
Elsberg's eannula in, 305
vein-to-vein method of, 309
Fauntleroy's tubes in, 309
for immunization, 225
for shock, 30, 678
general management of, 300
amount of blood to be transfused in,
303
controlling of inflow of blood in, 301
testing blood of donor and recipient in,
300
history of, 337
apparatus used in, early, 337
later, 339
recent, 340
syringe methods of recent times in, 340
Blood transfusion, indication* for, 299
indirect tranafuaioi:
-y and Yatiffhan'a method of, 312
<furti» an-i l'u'...| m.-th.,
K.mptons method of,
l.indeman'a tnetho : (15
McGrath 'a met ho. t
Satterlee and Hooker 'a method of, 316,
operation with h.ru.im-coftted pipet*
in.
preparation of pipeta with hirudin
in.
operation with paraffin -totted PJPtt fa.
apparatus in, 346
instrument* in, 840
preparation of pipet* with para tin
• \i in. 352
technic ot
theoretical consideration* aad prin-
••iplea underlying, 342
instruments for, 300
paraffin metho
Blood-vessels, compression of, through intra-
muscular incision for
of hemorrhage in
SI
gunshot wounds of, 663
recurrent bleeding in, 663
secondary hemorrhage in, 663
spontaneous stopping of bleeding in,
663
treatment of, 663
inoperable cancer of or near, radium
therapy for, 769
ligating of, in hemostasis in operation*, 29
in pedicles, 29
operations on, 249. See alto under Arter-
ies, Veins, Capillaries and
Lymphat
anatomical considerations in, 251
general considerations of, 249
instruments used in, 253, 254
methods ueed in, 255
surgical procedures in, 250
on arteries, 250
on capillaries, 251
on lymphatics, 251
on veins, 250
Blundell, James, blood transfusion ejtperi
ments of, 338
Blundell 's gravitator, 339
"impell
Boiling, in sterilization, 3
Boae bleeding, checking of, in operation*, 29
Bone operations, techi
Bone resection in neuroplasty, 541
Bones, fractures of, due to gunshot wound*.
infected. r,r,»
gunshot wounds of, 662
Bootlihy apparatus for nitrous o\
air and other mixtures, for anee-
thesia. 11''. 117
continuous flow method of administration
of gaaes in nitron* oxid oxygen
' ' 120
782
INDEX
Boothby method of setting stay sutures in
vein before removal for trans-
plantation, 293
Bordet-Gengou phenomenon, 222
Brachial artery, ligation of, in continuity,
422
anatomy of, 422
operation in, 423
in cubital fossa, 424
in middle third, 424
in upper third, 423
Brachial birth paralysis, Erb's type of. See
Brachial plexus lesions.
Brachial plexus anesthesia, 62
Brachial plexus lesions, 545
below the clavicle, 555
in adults, exploratory operation in, 551
in infants, early operation in, 549
nature of, 546
operative treatment of, 551
postoperative treatment of, 555
treatment for, preceding operation, 549
Bradford frame for application of plaster-of-
Paris jacket with patient in
prone position, 744
Breast, inoperable cancer of, radium therapy
for, 768
Brewer's tubes and technic in direct blood
transfusion, 308
Briau-Jaboulay interrupted suture for arter-
ies, 261, 262
method of end-to-end suture of arteries,
265, 266
Bridging, nerve, 540
by nerve transplantations, 540
by tubulization, 541
by use of a vein, 541
Bronchi, diseases of, and anesthetic in op-
eration, 189
Bronchial obstruction to respiration in anes-
thesia, 137
Bronchopneumonia complicating measles, 156
Brophy's method of operation for cleft pal-
ate in patients whose bones are
well ossified and deciduous teeth
well erupted, 478
osteoplastic operation for cleft palate in
infants, 482
Bubonic plague, serum therapy of, 212
vaccine therapy of, 212
Buck's extension for fractures of shaft of
femur, 731, 732
Bullets, modern military pointed rifle, 652
French, 653
German, 652
Kiedinger's experiments with, 652-654
wounds produced by, 653
in Balkan war, 654, 658
rifle, wounds due to, 661. See also under
Gunshot wounds.
Burns, 697
due to chemicals, 700
acids, 700
caustic alkalies, 700
due to cold, 702
due to electricity, 701
due to heat, 697
first aid in, 698
Burns, due to heat, general treatment of, 700
local treatment of, 698
in first degree burns, 698
in second degree burns, 698
in third degree burns, 698
late, 699, 700
due to light rays, 700
due to radium, 701
due to sun, 700
due to X-rays, 700
Bursae, 630
about ankle, diseases of, 633
about hip, diseases of, 633
about knee, diseases of, 633
diseases of, 632
inflammations of, 630. See also Bursitis.
mucosae, 630
olecranon, diseases of, 633
physiology of, 630
popliteal, diseases of, 633
prepatellar, diseases of, 633
subacromial, 632
subdeltoid, 632
acute inflammation of, 632
treatment of, 632
tuberculosis of, 632
treatment of, 632
synoviae, 630
tuberculosis of, 632
Bursitis, acute, 630
treatment of, 630
acute suppurative, 631
etiology of, 631
treatment of, 631, 632
chronic, 631
treatment of, 631
occupation, 631
subacromial, 632
subdeltoid, 632. See also Subdeltoid bursa.
Calmette's conjunctival tuberculin reaction,
221
Calot's head sling, 742
plaster-of -Paris jacket, 747
removable, 748
Camphor dissolved in olive oil, hypodermic
injection of, for shock, 677
Cancer, inoperable, radium therapy of, 767
metastatic glandular involvement in,
769
of breast, 768
of cervix, 768
of esophagus, 769
of groin, 769
of neck, 769
of rectum, 768
of stomach, 769
of uterus, 768
of or near blood vessels, 769
of or near viscera, 769
of tongue, radium therapy of, 767
of tonsil and pharynx, radium therapy of,
767
radium therapy of, indications for, 770
Canister in land warfare, structure of, 671
Capillaries, operations on, 327
to check bleeding, 327
ligation en masse in, 328
INDEX
Capillaries, operations on, to check bleeding,
local coagulants in, 327
adrenalin, 327
gelatin, 327
hot water, 327
hydrogen peroxid, 327
packing in, 328
to obliterate vascular channels in small
angiomata and nevi, 328
choice of method in, 330
desiccation in, 328
excision in, 328
freezing in, 328
injection in, 329
ligation in, 329
Carbolic acid cautery in actinomycosis, 696
Carbolic acid in treatment of tetanus, 694
Carbolic acid injections in anthrax, 695
Carbon bisulphid poisoning, chronic, 703
Carbon dioxid snow in freezing of nevi, 328
Carbon monoxid poisoning, acute, 702
Carbon tetrachlorid method of skin steriliza-
tion for operations, 150
Carbuncle, vaccine therapy of, 205
Carcinomata of muscles, 622
Cardiac failure in anesthesia, 139
etiology of, 139
prophylaxis of, 140
treatment of, 140
Carotid artery, common, aneurysm of, opera-
tive treatment for, 386
cerebral complications in, 386, 387
pressure symptoms in, 386
ligation of, in continuity, 405
anatomy of, 405
operation in, 406
ligation above omohyoid in, 406
ligation below omohyoid in, 407
results of operation in, 407
external, aneurysm of, 388
ligation of, in continuity, 408
anatomy of, 408
operation in, 408-411
internal, aneurysm of, operative treatment
of, 387, 388
ligation of, in continuity, 411
anatomy of, 411
operation in, 411
results of operation in, 411
Carpals, dislocation of, 758
in mediocarpal joint, 758
of semilunar bone, 758
Carpometacarpal joints, dislocation of, 758
Carrel 's method of end-to-end arterial anasto-
mosis, 267, 273
general rules in, 267
instruments for, 268
preparation of vessels and hemostasis in,
268
reestablishment of circulation in, 269
sutures in, 269
stay, 270
Carrel's method of end-to-end arteriovenous
anastomosis, 275
Carrel's method of side-to-side arteriovenous
anastomosis, 277
Carrel's suture method in direct blood trans-
fusion, 308
Carrel and Outline's methods of end to side
arteriovenous •"•f^mAtig, 275.
Case shot in land warfare, structure of, 671
Catarrh, chronic, and operative, 180
Catgut for suturing, 6
preparation of, 6
by chromic acid method, 7
by cumol method, 6
I >y iodin meth-
Cauda <'<juinu, injuries to, 560
anatoinir.-ii <-.,iiM.l.-ratioii» in, 560
causes of, 560
treatment of, 561
results of, 561
Cauterization in sterilization of wounds, 8
in treatment of nevi, 329
to .•tir.-k Mee.|iiikr in veins, 286
Celiotomy, infiltration anesthesia for, 57
Celiotomy position in operations, 40
Cellulitis, complicating acute suppurative in-
flammation of tendon sheaths of
hand, 642
gaseous or emphysematous, treatment of,
690
treatment of, 690
Centipedes, treatment of wounds doe to, 687
Cerebral complications in treatment of com-
mon carotid aneurysm, 886
Cerebral softening due to ligation of com-
mon carotid in treatment of in-
nominate aneurysm, 886
Cerebrospinal meningitis, epidemic, 157
lumbar puncture in, 157
lumbar puncture in, 210
serum therapy of, 211
vaccine therapy in, 211
Cervical adenitis complicating diphtheria, 156
Cervix, inoperable cancer of, radium therapy
for, 768
Chapman filter pump for aspiration, in op-
erative surgery, 880
Charcot's knee joint, resection in, in syphili-
tic patients, 173
Cheeks, plastic surgery of, 508
Esmarch-Koleralzig operation in, 513
Gersuny's modification of Kraske's opera-
tion in, 512
Hacker's operation in, 509
Hahn's operation in, 509
Hotchkiss's operation in, 511
Israel's operation in, 508
Lerda's operation in, 509-511
Lexer 's operation in, 509
Cheeks, region of, autoplastic operations in,
513
for cicatricial maxillary occlusion, Oossen-
bauer's operation of, 513
for disfigurements due to facial paralysis,
514
hydrocarbon protheses, 515
preparation of paraffin in, 515
syringes in, 515
technic of operation in, 516
treatment following operation in, 5
muscle plastics in. Lexer method of, 514
Cheiloplasty. See Harelip, operations for,
also under Lip, lower.
784:
INDEX
Cheilorrhaphy. See Harelip, operations
for.
Chemical abscesses, production of, for treat-
ment of wounds in blood infec-
tions, 692
Chemicals, use of, in hemostasis in operations,
29
Chicken pox, surgical complications of, 154
Chilblains, treatment of, 702
Chloretone in treatment of tetanus, 694
Chloroform, as adjunct in ether anesthesia,
104
technic of, 105
danger of ignition of, 134
physical properties of, 105
Chloroform anesthesia, 105
administration of chloroform in, technic of,
108
by open drop method, 108
by vapor methods, 109
continuous vapor delivery in, 110
interrupted vapor delivery in, 109
clinical course of, 107
first stage or stage of conscious excite-
ment in, 107
second stage or stage of involuntary ex-
citement in, 107
third stage or stage of surgical anes-
thesia in, 108
fourth stage or stage of overdose in, 108
fifth stage or stage of recovery in, 108
effects of chloroform on body function in,
106
on circulation, 106
on respiration, 106
on sensorium, 107
excretion of chloroform in, 107
irritant action of chloroform in, compared
with ether, 106
physiological action of chloroform in, 106
Chlumsky's solution as an antiseptic for
wounds, 160
for painting of infected wound after am-
putation, 664
in treatment of actinomycosis, 696
Cholera, preventive vaccination in, 206
serum prophylaxis in, 206
Chondromata of muscles, 622
Cicatrices, radium therapy of, 765
Cigarette drain, 13
Circular plaster dressings for fractures, 710
application of, 710, 711
Circulation, operations to restore and re-
establish, in arteries, 259. See
also under Arteries,
in veins, 286. See also under Veins.
Circumflex artery, deep, ligation of, in con-
tinuity, 439
anatomy of, 439
operation in, 439
Clamps, artery, use of, in operative technic,
35
Clavicle, fracture of, Collins' dressing for,
758-760
Sayre dressing for, 758
Cleft palate, 456
general considerations of, 456
treatment of, 467
Cleft palate, treatment of, operations in, 468
after-treatment in, 490
age at which to operate in, 467
anesthesia in, 469
Berry and Legg 's method of, 470
Brophy's method of, for patients
whose bones are well ossified and
deciduous teeth well erupted,
478
Brophy's osteoplastic method of, for
infants, 482
choice of method in, 469
Davies-Colley method of, 481
Lane 's methods of, 485
for broad cleft involving almost en-
tire palate, 487
for extreme width of cleft, 489
Langenbeck's method of, as modified
by Helbing, 475
. position of patient in, 468
results of, 491
late, 492
Roberts' method of, 490
varieties of, 459
combined with bony labiofissure, 459
not complicated by labiofissure, 459
with displacement of premaxillary bones,
459
Clover crutch, 44
Club-foot, plaster-of-Paris dressing for, 751
Cocain, habitual use of, 170
cure of, 171
symptoms of, 170, 171
in local anesthesia, 49
for mucous membranes, 51
preparation of solution of, 49, 50
Coenen's suture method of treatment of
varicose veins, 324
Cold, exposure to, treatment of 'patient fol-
lowing, 702
Colle's fracture, 724
moulded plaster splints for, 724, 725
reduction of, 724
Collins' dressing for fracture of clavicle,
758-760
Colon bacillus infections, vaccine therapy of,
206
Complement in side-chain theory, 199
Complement-fixation tests, 221-223
Compression in treatment of aneurysm, 364
digital, 364
direct, 364
elastic, 364
postural, 364
temporary, of aorta, in treatment of
aneurysm of abdominal aorta,
383
by instruments through laparotomy
wound, 383
by metal bands, 384
by tourniquet, 383
Connell anesthetometer, 131-134
apparatus for nitrous oxid, oxygen, ether
mixtures, for anesthesia, 117,
118
aspirating bottle, 229
method of administration of gases in nit-
rous oxid-oxygen anesthesia, 121
INDEX
786
Connell, nasopharyngeal tube for pharyngeal
insufflation in ether anrstli. M...
95
pharyngeal breathing tube, 136
Contusions, 682
treatment of, 682
Contusions and lacerations, treatment of, 685
Cooley and Vaughan's method of indirect
blood transfusion, 312
Coronoid process, fracture of, 721
moulded plaster splints for, 722
Coryza and operation, 189
Cotton for dressing of wounds, 10
Cranial nerves, disturbances of, 564
eighth, operative treatment for, 600
eleventh, operative treatment of, 601
anatomical considerations in, 601
indications for, 601
technic of, 602
fifth (trigeminal), 564
alcohol injections into nerve trunks in
treatment of, 569
advantages of, 569
anesthesia in, 570
centra-indications for, 570
disadvantages of, 569
instruments for, 570
results of, 574
solution for, 570
technic of operation for, 570
general considerations of, 570
on inferior maxillary nerve, 573
on superior maxillary nerve, 572
anatomical considerations of, 564
inferior maxillary division, 565
ophthalmic division, 565
superior maxillary division, 565
indications for treatment of, 565
intracranial operation on Gasserian
ganglion for, 574
advantages of, 582
anatomical considerations of, 575
indications for, 575
results of, 583
technic of, 576
posterior root section by infratem-
poral route in (Gushing
method), 580
sensory root division by antriculo-
tempoVal route in (Spiller-
Frazier method), 578 '
care of eyes in, 579
medical treatment of, 565
peripheral operation for, 566
on inferior branch, 568
on superior maxillary branch, 567
on supra-orbital branch, 566
results of, 569
resection of nerve trunks at their exit
from base of skull in treatment
of, 569
seventh, operative treatment in, 583
anatomical considerations in, 583
for facial paralysis, 586
anastomosis of peripheral portion of
facial nerve with a neighboring
motor nerve, 586
choice of motor nerve in, 587
51
nerves, seventh, operative treatment
in, for far in I paraly«t«, anas
t-niosls of peripheral portion
of facial nerve with a neig!
ini: motor nerve, lesions causing.
method-
.
laelu
in f.« to hvpofflossal •MffcoMMaB*
-ion, 588
isolation and section of fa-
cial nerve, 588
exposure of hypogloosal
•arm MM
(4) implantation. 591
(5) closure of wound, 501
(6) postoperative course, 508
(7) results, 592-595
in facio spinal accessor
sis, 595
time of operation in, 586
for facial spasm, 584
alcohol injection in, 585
section of facial nerve and
sis with a motor nerve in, 585
for neuralgia of sensory portion, 597
by division of motor seventh, pars in
lia and eighth, 597
results of, 599
terhnic of, 597
indications for, 583
tenth, operative treatment of, 600
Crile 's method of anastomosis in direct blood
transfusion with cannula, 308
Cripps-Avelintf method of blood transfuskm,
340
Croft's granulation method in plastic sur-
gery. 453
Crossing, nerve, 540
"Cunningham bridge" attachment on
ating table, 4:
Curtis and David's method of blood
fusion with paraffin coated re-
ceptacles.
of indirect blood transfusion, 310
Cuprie sulphate in treatment of actinomyco-
sis, 696
Curvature of spine, lateral, plasterof-Paria
jacket for,
Cushing method of posterior root section of
Gasserian ganglion ty infra-
temporal route, for disturbance*
of fifth .-ranial trigeminal)
nerve, 580
Cutaneous epitheliomata, radium therapy of,
766
indurated. 766
superficial, 766
DaviesCollev method of operation for cleft
palate, 481
Defibrinated blood, use of, in blood trans-
fusion. 341
Delbet *s suture method of treatment of vari-
cose veins.
Delirium tremens in erysipelas, 160
786
INDEX
Denys' blood transfusion operation, 337, 338
Denys' bouillon filtrate (B. F.), 216
Dermatitis, X-ray, treatment of, 701
Dermatomyositis, 619
Desiccation, electric, of vascular nevi, 329
Deviation of complement, 221-223
Diabetes mellitus, a centra-indication to op-
erations, 174
diet in, 175"
prognosis of, 180
surgical complications of, 174
diabetic gangrene in, amputation for,
180-182
Diabetic gangrene, amputation for, 180-182
Dieffenbach 's method of correction of defects
of upper lip, 503, 504
of operation for ectropion of lower eyelid,
517
of plastic restoration of lower eyelid,
519
of restoration of lower lip in operation for
epithelioma, Jaesche's modifica-
tion of, 502
Diffuse syphilitic myositis, 621
Digestive organs, preparation of, preceding
operation, 145
Digital pressure to check bleeding in arteries,
256
in veins, 286
Diphtheria, antitoxin in, 207
dosage in, 207
protective immunization with, 207
surgical complications of, 156
wound, treatment of, 695
•Diphtheria antitoxin, in treatment of wound
diphtheria, 695
Diphtheria carriers, vaccine treatment of, 207
Dislocations at wrist, 757
of carpal bones, 758
in mediocarpal joint, 758
of semilunar bone, 758
of carpometacarpal joints, 758
of lower radio-ulnar joint, 757
backward, 757
forward, 757
of radiocarpal joint, 757
backward, 757
forward, 757
of ankle joint, 757
backward, 757
forward, 757
of elbow, 754
reduction of, 754
after-treatment of, 754
of hip, 755
dorsal or posterior, reduction of, by
Allis' method, 756
by Bigelow's method, 756
by Stimson's method, 755
inward or anterior, reduction of, by Allis*
direct method, 756
by Allis' indirect method, 756
by Bigelow's method, 756, 757
of knee joint, 757
reduction and immobilization of, 757
of lower jaw, 752
reduction of, 752
after-care in, 752, 753
Dislocations of shoulder, 753
reduction of, by manipulation (Kocher's
method), 753
by traction (Stimson's method), 753,
754
treatment following, 754
of tendons, 623
of thumb, 755
reduction of, 755
Dissecting forceps, 36
Dobrowolskaja's technic of end-to-end arterial
anastomosis, 271, 272
Dorrance mattress suture, for arteries, 261,
262
method of end-to-end suture of arteries,
266
Dorsalis pedis artery, ligation of, in conti-
nuity, 447
anatomy of, 447
operation in, 448
Dowd's method of restoration of lower lip
in operation for epithelioma,
501
Drainage, employment of, in operations, 34
in aseptic surgical technic, 13
cigarette drain for, 13
glass tubes for, 13
rubber tissue drains for, 14
rubber tubes for, 13
Dressing stations for wounded on battlefield,
660
Dressings, application of, in operations, 34
in aseptic surgical technic, 8
adhesive plasters for, 12
moleskin, 12
zinc oxid, 12
bandages for, 11
mull, 11
plaster-of-Paris, 11
silicate of soda, 12
cotton, 10
gauze, 9
impregnated, 10
sponges for, 10
plaster - of - Paris. See Plaster - of - Paris
dressings.
Drugs in preparation of patient for opera-
tion, 145
in treatment of wounds in blood infections,
692
Dry heat treatment of patient in burns of
third degree, 699
Dupuytren's contracture, 644
etiology of, 644
treatment of, 645
palliative operations in, 645
Adams', 645
Dupuytren's, 645
multiple transverse division, 645
radical operations, 645
Lexer's, 646
longitudinal, 645
Lotheissen 's, 646
V-shaped incision in, 646
Dysentery, serum therapy of, 207
against Flexner-Harris type, 208
against Shiga type, 207, 208
vaccine therapy of, 207
LNJJKX
Ear, injury to tympanic membrane of, in
naval warfare, 680
prevention of, 680
plastic operations of, 504
for malformations of auricle, 505
abnormal enlargement of « ,n, r,u.~)
abnormally small ears, 505
for malformations of lobule, 504
for malposition of auricle, 506
Kolle's method in, 506, 507
sterilization of, in preparation for opera-
tions, 150
Eck fistula operation, 290
Ectropion, plastic operation for treatment
of, 517
Edema, Handley 's operation for establishing
artificial channels for lymph
drainage in, 330
in ascites, 332
in face, 332
in lower extremities, 332
in upper extremities, 331
pulmonary, in anesthesia, 137
Ehrlich, side-chain theory of. See Side-chain
. theory of immunity.
Elbow, dislocation of, 754
reduction of, 754
after-treatment of, 754
Electric shock, treatment of, 701
Electricity, burns due to, 701
Elliott's device for prevention of rupture of
tympanic membrane during
naval warfare, 680
Elsberg's cannula and technic in direct blood
transfusion, 305
Embolic infection of veins, operations to pre-
vent, 326
Embolus in arteries, arterial section for,
283
arteriovenous anastomosis for removal of,
275. See also under Arteries.
Emphysema, and operations, 189
Emphysematous cellulitis, treatment of,
690
Empyema, a surgical complication of lobar
pneumonia, 164
Endarteritis, arteriovenous anastomosis for
removal of obstruction in, 275.
See also under Arteries.
Endo-aneurysmorrhaphy operations, 370
in aneurysm of external iliac tract, 391
Endocarditis, a contra-indication to opera-
tion, 190
Endotoxins, action of, 199
Enemata, stimulating, for shock, 677
Enteroptosis, operation contra-indicated in,
188
Epigastric artery, deep, ligation of, in con-
tinuity, 439
anatomy of, 439
operation in, 439
Epididymitis, vaccine therapy of, 210
Epinephrin as adjuvant in local anesthesia,
51
Epitheliomata, cutaneous, radium therapy of,
766
indurated, 766
superficial, 766
KpitheliomaU of lower lip. operations for,
495. .SVr aUtt under Lip, lower,
radium therapy of,
of mucous membrane, radium therapy for,
766
Epulis, radium therapy of, 760
Erb's paralv*in, traumatic. Set Braeaiai
;><«laa alba, 160
Erysipelas, complicating acute
inflammation of
of hand, 642
contagiousness of, 150
contra in.li.-.-.tion to operations, 158
surgical complications of, 158
abscesses, 158
delirium tremens, 161
gangrene of *kin, 160
lymphadenitis^ 160
160
and empyema, 160
treatment of, 600
vaccine and serum therapy of, 208
Esmarch banda^ for limiting of
in oj« -ration*, application of,
Esmarch Koleralzig operation in plastic sur-
gery of the cheeks, 513
Esophagus, diseases of, a contra indication t*
operations, 188
gunshot wounds of, 660
inoperable cancer of, radium therapy for,
769
Estlander's method of restoration of lower
lip in operation for epitheliossa,
502
Ether, as anesthetic. See Ether ••nsthssii
danger of ignition of, 134
physical properties of, 73
Ether anesthesia, 72
administration of ether in, bj absorption
by serous surface, 102
by insufflation, apparatus for, 97
accessories, 99
air compressor, 97
ether vaporizer, 98
filter and humidor, 97
intubating catheter, 08
safety valve, 98
by intratracheal insufflation, 01
maintenance of positive pressure ia, 04
physiology of, 91, 92
toehak of, 92-94
by pharyngeal insufflation, 05
maintenance of positive pressure ia, 06
technic of, 95
by subcutaneous injection into
general technic of, 85
closed method in. S7, 88
open nii'tho.l in, 85
administration by pouring of
portions (opea cone method),
87
administration by
(drop method). 85
apparatus for, 85
in children, 86
technic' of, 85
788
INDEX
Ether anesthesia, administration of ether in,
general technic of, vapor meth-
ods in, 88
negative pressure methods of vapor
delivery, 88, 89
positive pressure methods of vapor
delivery, 89
apparatus for, 89
technic of, 90
intravenous, 99
physiology of, 99
technic of, 100
rectal, 101
oil-ether method in, 101
technic of, 101, 102
theoretical consideration of, 78
action of ether on body in, 78, 79
details of induction of anesthesia in,
79
establishment of anesthetic tension in,
80
phenomena and utility of zones in, 82
zone 1 : the zone of confusion, 82
zone 2: the light subconscious zone,
82
zone 3 : the subconscious zone, 83
zone 4: the zone of light surgical
anesthesia, 83
zone 5 : the zone of full anesthesia,
83
zone 6: the zone of deep anesthesia,
84
zone 7: the zone of profound anes-
thesia, 84
zone 8: the slowly lethal zone, 84
zone 9 : the rapidly lethal zone, 84
stage of recovery in, 81
agents used as adjuncts of ether in, 102
alkaloidal narcotics, 102
atropin, 103
dosage of, 103
morphin, 102
dosage of, 103
scopolamin, 102
use of, following anesthesia, 103
chloroform, 104
technic of, 105
ethyl chlorid, 105
nitrous oxid, 103
technic of, 103, 104
nitrous oxid-oxygen, 104
as adjuvant in nitrous oxid anesthesia, 123
teehnic of, 124
clinical course of, first stage or stage of
conscious excitement in, 75
second stage or stage of involuntary
excitement in, 75
third stage or stage of surgical anes-
thesia in, 76
fourth stage or stage of overdosage in,
77
fifth stage or stage of recovery in, 78
excretion of ether in, 75
physiological action of ether in, 73
local anesthetic, 73
on body function, 74
on blood pressure, 74
on heart action, 74
Ether anesthesia, physiological action of
ether in, on body function, on
respiration, 74
on sensorium, 74, 75
on fatty tissues, 75
on skin, mucous and serous surfaces, 73
Ethyl chlorid anesthesia, 48, 49, 125
administration of ethyl chlorid in, technic
of, 126
closed method of, 126
semi-open method of, 126
as adjunct in ether anesthesia, 105
period of recovery in, 126
physiological action of, 125
on respiration, 125
on sensorium, 125
zones in, 126
Ethyl chlorid group of drugs, 127
Eucain in local anesthesia, 51
Excision method of treatment for varicose
veins, 320
of nevi, 328
Exhaustion theory of immunity, 197
Exophthalmic goiter, a centra-indication to
operation, 192
radium therapy for, 770
serum therapy of, 208
Eye, gunshot wounds of, 668
sterilization of, in preparation for opera-
tions, 150
Eyelids, plastic surgery of, 517
in ectropion, 517
of lower lid, 517
in restoration of eyelid, 518
free graft implantation or Wolf
method in, 520
gliding flap method in, 518
Dieff enbach 's, 519
Gibson's, 519
Hasner's, 519
pedunculated flap method in, 520
Face, edema of, Handley's operation for es-
tablishing artificial channels for
lymph drainage in, 332
gunshot wounds of, due to rifle bullet, 668
Facial paralysis, disfigurements due to, cor-
rection of, by plastic operation,
514
lesions causing, 586
operative treatment for, 586
anastomosis of peripheral portion of fa-
cial nerve with a neighboring
motor nerve, 586
choice of motor nerve in, 587
methods of, 587
technic of, 587
in facio-hypoglossal anastomosis,
587
(1) incision, 588
(2) isolation and section of facial
nerve, 588
(3) exposure of hypoglossal nerve,
590
(4) implantation, 591
(5) closure of wound, 591
(6) postoperative course, 592
(7) results, 592
INDKX
Facial paralysis, operative treatment fur. by
facio-spinal aeeesnory ana*t<»mo
sis, 595
postoperative exercises in,
time of operation in,
Facial spasm, operative treatment of, 584
alcohol injection into trunk of 8«\.i,th
cranial nerve in,
section of facial nerve an. I anastomosis
with a motor nerve in, 585
Faradaic current in nerve injury, 5i:;
Farcy. See Glanders.
Fasciae, 643
Dupuytren's contracture of, 644
etiology of, 644
treatment of, 645
palliative operations in, 645
Adams', 645
Dupuytren's, 645
multiple transverse division, 645
radical operations in, 645
Lexer's, 646
longitudinal incision in, 645
Lotheissen 's, 646
V-shaped incision in, 646
transplanting of skin grafts in, 645
injuries to, 644
rupture of, 644
Fat, suturing of, 33
Fauntleroy 's modification of Brewer 's tubes
in direct blood transfusion, 309
Felt dressings, 10
Femoral artery, aneurysm of, operative
treatment of, 393
ligation of, in continuity, 439
anatomy of, 439
operation in, 440
in common femoral, 440
in superficial femoral at apex of
Scarpa's triangle, 440
in superficial femoral in Hunter's ca-
nal, 441
Femur, fractures of neck of, 726
treatment of, by extension and coun-
ter extension (Hodgen's splint),
726
application of splint in, 726
preparation of splint in, 725
by reduction and retention (Whit-
man's method), 729
in cases with impaction, 729
in cases without compaction, 729-
731
of lower end of, 733
epiphyseal, plaster-of-Paris dressing
for, 734
intercondyloid, plaster-of-Paris dress-
ing for, 733
of either condyle, plaster-of-Paris
dressing for, 733
of shaft of, 731
Buck's extension with Volkmann slid-
ing rest for, 731, 732
in young children, 733
plaster spica in, 733
long plaster spica for, 731
reduction of, 731
subtrochanteric, 731
Femur. fr». • Mipraron.1 •
Ionic I»la*ter N
inojiermble sarcoma of, radium therap>
Fraectrated planter dressings fur fracture*,
diagnostic value of, 227
experimental observations in, 227
in pregnancy, 226, 227
met
diulysation n,
<>|.ti<-al method, 22ft
origin of, 227
Fibromata, of muscle*, 563, 022
ra.linm tli.-rapy of, 764
in 764
Fibula. I r:fti:rr- of. planter of Paris dfWftv
ings for, 740
Fibula an- 1 tibia, t ra.-t.irm of, 736
pl.t IH ((rearing* ia rase of, with
difficult; frag-
ments in position,
v.ith su.-l!.nU' an. I .li»|.la<-«'m.-i.t. 736
without •li»|il:n-«-m.-iit. 736
Field hospitals for vv.amded OB tl*ttl*i*»,
661
Finger, trigger, 628
Fingers, infiltration anesthesia for operatic**
on, 60
perineural infiltration anesthfgi* of, 63,
First aid packet for soldiers oa battfeitJd,
659, 673
First aid to wounded on tttttleneld,^65«)
Fixation of complement, 221-223
Flaps, gliding, in plastic surgery, 452
with rota-
iii.-tho.l for restoration of ey
pedun.Milat.-d. in plastic surgery, 453
Flat foot, plaster of Paris dresaing for.
Flexner Harris bacillus. Set *mdcr IHsra
Flexner Jobling serum fur <*rebro*piaal
nHMiinuitiii. I'l 1
Flies, bites of, treatment of wounds da* to,
6M
Foerster's operation for relief of sp**tkity
in musrle*. 530
dangers and dinVultiea of, 533
indications for.
results ot.
tech in
Folli, Francesco, origin*] tranafuawa *pp*
rat>.-
Foot, anesthetization of, 64
fracture of bones of. plaster of Paria- dress-
ings for, 7 1 1
PS. us- of. in ojH-rati\e tevhnie, 36
Foroipressure t<» check bleeding ia
in veins, 286
Fractional sterilization in operative
Fractures, Colle's, 7
moulded plaster splints 1
reduction of.
790
INDEX
Fractures of bones due to gunshot wounds,
664
infected, 664
of bones of foot, plaster-of-Paris dressings
for, 741
of bones of hand, 725
circular plaster dressing for, 725, 726
of clavicle, Collins' dressing for, 758-760
Say re dressing for, 758
of coronoid process, 721
moulded splints for, 722
of femur, of lower end, 733
epiphyseal, plaster-of-Paris dressing
for, 734
intercondyloid, plaster-of-Paris dress-
ing for, 733
of either condyle, plaster-of-Paris
dressing for, 733
of neck, 726
treatment of, by extension and counter
extension (Hodgen's splint),
726
application of splint in, 726
preparation of splint in, 725
by reduction and retention (Whit-
man's method), 729
in cases with impaction, 729
in cases without impaction, 729-
731
of shaft, 731
Buck's extension with Volkmann slid-
ing rest for, 731, 732
in young children, 733
plaster spica in, 733
long plaster spica for, 731
reduction of, 731
subtrochanteric, 731
supracondyloid, 733
long plaster spica for, 733
of fibula alone, plaster-of-Paris dressings
for, 740
of humerus, of epiphysis of upper end, 714
plaster-of-Paris dressing for, 715
reduction of, 714
of lower end, 717
epiphyseal, 720
of external condyle, 720
of internal condyle, 719
moulded splints in, 719
of internal epicondyle, 719
supracondyloid, 718
plaster-of-Paris dressing in, 718
plaster-of-Paris splints in, 718, 719
T- or Y-shaped, 720
moulded splints in, 720
of shaft, 716
plaster-of-Paris dressing for, 716, 717
reduction of, 716
of surgical neck, 715
plaster-of-Paris dressing for, 715, 716
reduction of, 715
of long bones, infiltration anesthesia for
reduction of, 60
of olecranon process, 720
moulded plaster splint for, 721
reduction of, 720
of patella, 734
•plaster-of-Paris dressing for, 734-736
Fractures of radius, of head and neck, 722
moulded splint for, 722
of shaft, 723
moulded plaster splints for, 724
reduction of, 723, 724
of radius and ulna, 722
moulded plaster splints for, 723
reduction of, 722
of tibia alone, plaster-of-Paris dressings
for, 736
of tibia and fibula, 736
plaster-of-Paris dressings in cases of,
with difficulty in retaining of
fragments in position, 737
with swelling and displacement, 736
without displacement, 736
of ulna, of shaft, 723
moulded plaster splint for, 723
reduction of, 723
of vertebrae, plaster-of-Paris jacket for,
742, 749
plaster dressings for, circular, 710
application of, 710, 711
fenestrated, 711
interrupted, 712
moulded, 709
application of, 710
preparation of, 709
spica for hip in, 712
application of, 712, 713
Pott's, plaster-of-Paris dressing for, 740
Free fascial transplants in treatment of
aneurysm of abdominal aorta,
383 '
Free graft implantation method for restora-
tion of eyelid, 520
Free grafts, transplantation of, in plastic
surgery, 454
Freezing in treatment of aneurysm, 363
in treatment of nevi, 328
of tissues, treatment of, 702
Freund's method of blood transfusion, 340
Frost bites, treatment of, 702
Furunculosis, chronic, vaccine therapy of,
205
Gabets, Robert des, transfusion apparatus of,
337
Gall-bladder and ducts, aspiration in, during
operation, 238
Gamma rays of radium, 762
Ganglion in tendons, 629
clinical nature of, 629
treatment of, 629
non-operative, 629
operative, 630
Gangrene, complicating acute suppurative in-
flammation of tendon sheaths of
hand, 642
diabetic, amputation for, 180-182
of skin, complicating erysipelas, 160
typhoid, 153, 154
Gas, illuminating, poisoning, 702
Gaseous cellulitis, treatment of, 690
Gatch interrupted flow or rebreathing method
of administration of gases in
nitrous oxid-oxygen anesthesia,
120
INDEX
T'.'l
Gauze for dressing of wounds, 9
impregnated, 10
Gauze packing to check bleeding in capil-
laries, 328
in veins, 286
Gelatin to check bleeding in capillaries, 327
Genito-urinary tract, aspiration in, during
operation, 238
preparation of, preceding operation, 145
Gersuny's modification of Kraske's operation
in plastic surgery of the cheeks,
512
Gibson's pregrafted flap method for restora-
tion of lower eyelid, 518
Glanders, diagnosis of, 208
treatment of, 696
vaccine and serum therapy in, 208
Glass tubes for drainage of wounds, 13
Glottis, edema of, complicating mumps, 157
obstruction of, to respiration in anesthesia,
136
Gluteal artery, aneurysm of. See under
Aneurysm of internal branches
of iliac artery.
ligation of, in continuity, 435
anatomy of, 435
operation in, 436
Goiter. See Thyroid, diseases of.
Goldthwait's frame for application of plas-
ter-of -Paris jacket with patient
in dorsal position, 745, 746
Gonococcus infections, complement-fixation
diagnostic test in, 208, 209
vaccine and serum therapy in, 212
Gonorrhea, serum therapy of, 210
vaccine therapy of, 209
Gonorrheal tenosynovitis of hand, 640
treatment of, 640
Gout, a centra-indication to operations, 184
Gouty tophus, removal of, 184
Grafting, skin. See Skin grafting.
in plastic surgery, 456
Grafts, free, implantation of, for restoration
of eyelid, 520
transplantation of, in plastic surgery, 454
Granulation method in plastic surgery, 453
Graves' disease. See Exophthalmic goiter.
Grenades, hand, in land warfare, 672
wounds produced by, 651, 672, 673
treatment of, 673
Groin, inoperable cancer of, radium therapy
for, 769
Gussenbauer 's operation for cicatricial max-
illary occlusion by autoplasty,
513
Guthrie, method of, in end-to-end arterial
anastomosis, 270
in side-to-side arteriovenous anastomosis,
278
on general restoration in end-to-end arterial
anastomosis, 273
Gunshot wounds, 647
general treatment of, 655
received in civil life, 648
abdominal, operation for, 656
technic of, 657
experiments with various automatic
weapons in, 649
Gunshot wounds received in land warfare,
651, 658
abdominal, treatment of, 656. 658
due to art. II, TV projectilea, 671
classification of projectile, in, 671
nature of, 673
treatment of, 673
'!"<• to hand grenades, 673
tr.-ntiiM-nt «.!. •;: ;
•I'M' to rifle bullets, 661
lodged in or near joint*, 666
of abdominal viscera, ••
conservative treatment in, 670
operative treatment in, 670
of blood-vessels, 663
recurrent bleeding in, 661
secondary hemorrhage in, 664
spontaneous stopping of hemorrhage
in. 663
treatment of, 663
of bones, 662
fractures in, 664
infected, 664
of esophagus, 669
of extremities, 671
of eye, 668
of face, 668
of head, 666
ted and complicated, 668
non- penetrating, 666, 667
penetrating, 667
removal of bullet in, 667
of jaw, 668
of joints, 665
infected, 665
ankle, 665
hip joint, 665, 666
knee, 665
upper extremity, 666
of liver, 670
of neck, 669
of nerves, 662
treatment of, 662
of organs, 662
of soft tissues, 662
of spine, 670
of spleen, 670
of tendons, 66S
treatment of, 662
of testes, 671
of thorax, 669
of trachea and larynx, 669
of urethm
of urinary bladder, 670
due to shells, 673
treatment of. 673
due to shrapnel, 673
treatment of, 673
first aid packet for, 659
from new pointed rifle bullet, 6SS
in Balkan war, 654
linger '» experiments with, 652654
in. I in in dressing of. 655, 6S9
laparotomy in, mortality from, 656
methods of giving aid to
battl.-fi.-M in. 659
ambulance stations, 661
T92
INDEX
Gunshot wounds received in land warfare,
methods of giving aid to wound-
ed on battlefield in, dressing
stations, 660
field hospitals, 661
regimental aid, 659
occlusive dressing in, 656
oxid of zinc plaster for holding dress-
ings in, 660
probing for bullet in, 655
X-ray for locating bullet in, 655
received in naval warfare, 674
amputations in, 677
treatment of, 677
shock in, 677, 678
nature of, 676, 679
treatment of, in engagement, 675, 678
conditions hampering, 674
following engagement, 679
transportation of wounded following, 679
Gwathmey method of merging nitrous oxid
with ether anesthesia, 104
Hacker's operation in plastic surgery of
cheeks, 509
Hagedorn's method of paring and suture in
correction of harelip, 466
double, 466
modification of, 466
Hahn's operation in plastic surgery of
cheeks, 509
Halsted's aluminum bands for treatment of
aneurysm of abdominal aorta,
384
of common carotid, 386
of external iliac tract, 391
Hand, anatomy of, 634
fracture of bones of, 725
circular plaster dressing for, 725, 726
perineural infiltration anesthesia of, 64
preparation of, in surgical technic, 16
suppurative diseases of, 637
tendon sheaths of, acute suppurative in-
flammation of, 641
complications of, 642
operative treatment of, anesthetic in,
643
incisions in, 642
site of original inoculation in, 641
stages of, treatment of, 641
diseases of, 639
gonococcal inflammation of, 640
treatment of, 640
inflammation of, acute, 639
treatment of, 639
chronic, C39
plastic type of, 639
treatment of, 639
suppurative diseases of, 637
syphilis of, 640
tuberculosis of, 640
operative treatment of, 641
Hand bowl stand, 43
Handley's operation for establishing arti-
ficial channels for lymph drain-
age, 330
in ascites, 332
in edema of face, 332
Handley 's operation for establishing arti-
ficial channels for lymph drain-
age in edema of lower extrem-
ities, 332
of upper extremities, 331
indications 'for, 330
Harelip, 456
general considerations of, 456
treatment of, 460
age at which to operate in, 460
operations in, 460
after-treatment in, 464
anesthetic in, 461
complications of, 465
for complicated harelip with protrud-
ing premaxillary process, 464
by excision of wedge from nasal
septum, 464
by simple fracture, 464
for double harelip, 464
for simple unilateral harelip, 461
for single complete harelip, 463
instruments in, 461
position of patient in, 461
results of, 467
varieties of, 457
bilateral, complicated, 458
simple, 458
median, 457
unilateral, simple, 457
with fissure of bony parts, 458
Hasner's method for plastic restoration «
lower eyelid, 519
Hayden Derby ejectors for aspiration, 2DO
Head, aspiration in, during operations, 236
postoperative use of, 240
bullet wounds of, 666
non-penetrating, 666, 667
penetrating, 667
infected and complicated, 668
removal of bullet in, 667
infiltration anesthesia for operations on, 55
Heart, chronic valvular disease of, and op
eration, 190
congenital affections of, and operations,
191
dilatation of, a centra-indication to opera
tion, 191
diseases of, contra-indicating operation,
190
hypertrophy of, a centra-indication to op-
eration, 191
neuroses of, and operation, 191
wounds of, and operation, 191
Heat, for sterilization, 3
Helbing's modification of Langenbeck's
method of uranoplasty, 475
Hemophilia, a centra-indication to operation,
192
Hemorrhoids, infiltration anesthesia for, 59,
60
Hemostasis in operative technic, 28
blood transfusion for loss of blood in, 30
bone bleeding in, 29
chemicals in, 29
compression of artery through intramuscu-
lar incision in, 31
Esmarch bandage in, application of, 30
INDEX
Hemostasis in operative technic, ligating of
blood-vessels in, 29
ligating of blood-vessels of pedicles in, 29
normal salt solution injections for loss of
blood in, 30
sequestration anemia in, 30
speed in, 30
Hernia, operation for, in obesity, 182
Hernia cerebri, in bullet wounds of the head,
668
Hernia of muscles, operative treatment of.
613
Hesse and Schaak's suture method of treat-
ment of varicose veins, 324
Hewitt's method of blood transfusion, 339
Hip, bur.sae about, diseases of, 633
congenital dislocation of, plaster-of-Paris
spica for, 749
application of, 749
in bilateral cases, 750
in unilateral cases, 750
dislocation of, 755
dorsal or posterior, reduction of, by
Allis' method, 756
by Bigelow's method, 756
by Stimson's method, 755
inward or anterior, reduction of, by
Allis' direct method, 756
by Allis' indirect method, 756
by Bigelow's method, 756, 757
plaster-of-Paris spica for, 712
application of, 712, 713
Hip joint, infected wounds of, treatment of,
665, 666
Hirudin, use of, as an anticoagulant for
transfusion apparatus, 363. See
also Satterlee and Hooker's
methods of indirect blood trans-
fusion with use of paraffin and
hirudin.
Hodgen's splint in treatment of fractures of
neck of femur, 726
application of, 726
preparation of, 725
Hodgkin's disease, operations and, 191
radium therapy of, 770
vaccine, therapy of, 210
Hoepfner's modification of Payr's invagina-
tion method of end-to-end ar-
terial anastomosis, 264, 272, 273
Holocain in local anesthesia, 51
Hornets, stings of, treatment of wounds due
to, 686
Horsley's technic of end-to-end arterial anas-
tomosis, 271
tension suture holder, 271
Hot air in sterilization, 3
Hot water to check bleeding in capillaries, 327
Hotchkiss's operation in plastic surgery of
cheeks, 511
"Housemaid's knee," 631
Humerus, fracture of epiphysis of upper end
of, 714
plaster-of-Paris dressing for, 715
reduction in, 714
fracture of lower end of, 717
epiphyseal, 720
of external condyle, 720
1 1 "mortis, fracture of lower end of, of uiter
nal eondyle, :
moulded Hplmtn in. 719
of internal epieoadyle, 719
supraron.l
I'i"' -wing in, 718
plaster of Paris splint* 719
T- or Y shaped, 720
moulded MjilinU in, 720
fracture of shaft of, 716
plaster of Paris dressing for, 716, 717
re.lm-tion Of, 718
fracture of surgical neck of, 715
plaM -IK dressing 716
reduction of,
Unmoral theory of immunity, 197
H.v.lati.l disease of muscles, 620
BydroearbOH |>rothcsi«. in treatment of facial
•trinities, 515
preparation of paraffin in, 515
syringes in,
terhnii- of operation in, 516
treatment following operation in, 516
Hydrogen perozid to check bleeding in capil-
laries
Hydrophobia, treatment of wounds caused by
animals having, 688. See also
Rabies.
Hygroma, 631
treatment of, 631
Hyperemia, production of, by continuous as
pi ration, 246
Hyperplasia. Weigert 's theory of, 197
Hypodermic syringes, 14
Hypodermoc lysis for shock, 677
Iliac arteries, aneurysm of external tra
operative treatment of, 391
aneurysm of internal branches of, operative
treatment of, 392
extirpation in. ::HL'. 393
common, ligation of, in continuity, 431
anatomy of, 431
operation in, 432
extraperitoneal, 433
transperitoneal.
results of operation in, 434
external, libation of. in continuity. 438
anatomy of, 438
operation in, 438
extraperitoneal, 438
transperitoneal. 438
results of operation in, 438
internal, libation of. in continuity, 434
anatomy of. •
operation in.
i Its of operation in, 435
Illuminating gas poisoning, 702
Immunity.
acquire.!
active, 196
definition of. 196
passive,
blood t' >». 225
definition of, !!»•"•
duration of. l!»7
exhaustion theory o-
humoral theory of, 197
794
INDEX
Immunity, natural, 195
definition of, 195
phagocyte theory of, 197
side-chain theory of Ehrlich in, 197
theories of, 197
time required for production of, 197
to bacteria, 200
bacteriolysis in, 201
phagocytosis in, 200, 201
to toxins, 199
toxin injected in small quantities confer-
ring, 199
Impregnated gauze for dressings, 10
Incision method of treatment of varicose
veins, 323
Incisions in operative technic, 28
Infection, surgical, 1
agents of, 2
methods of prevention and counteraction
of, 2
by fractional sterilization, 3
by germicidal agents, 3
alcohol, 4
bichlorid of mercury, 4
carbolic acid, 4
chemicals, 3
formaldehyd gas, 5
iodin, 4
iodoform, 4
potassium permanganate, 4
heat, 3
boiling, 3
cautery, 3
hot air, 3
live steam, 3
by mechanical means of sterilization, 3
sources of, 2
Infiltration anesthesia, 52
apparatus for, 52
for celiotomy, 57
for hemorrhoids, 59, 60
for operations about head and face, 55
for operations in fingers, 60
on inguinal and femoral hernia, hydro-
cele of the cord, and gland of
the groin, 58
on knee, 59, 60
on neck and throat, minor, 56
on toes, 60
for reduction of fractures of long bones,
60
for thoracotomy, 56
for thyroidectomy, 56
for tracheotomy, 56
general technic of, 53
into brachial plexus, 62
intraneural, 61
perineural, 63
technic of, 63, 64
preferred technic of, for special groups of
operations, 53
extensive operations on acutely inflamed
areas, 55
major operations on non-inflamed areas,
54
minor operations on inflamed areas, 53
minor operations on non-inflamed areas,
53
Influenza, vaccine therapy of, 210
Infusion, intravenous, 296
amount of fluid in, 297
contra-indications for, 298
indications for, 297
method of, 298
pressure of fluid in, 297
solutions in, 296
temperature of fluid in, 297
time of infusion in, 297
Inguinal hernia, infiltration anesthesia for
57, 58
Injection treatment of vascular nevi, 329
Injuries. See under separate parts.
mechanical, treatment of, 703
Innominate artery, aneurysm of, treatment
of, 385
complications in, 386
distal ligation in, 386
wiring with electrolysis in, 386
ligation of, in continuity, 403
anatomy of, 403
operation in, 404
first method of, 404
second method of, 404
third method of, 404
results of operation in, 404
Insect bites and stings, treatment of wounds
due to, 686
Instruments for end-to-end arterial anastomo-
sis, 263
for operations on blood vessels, 253, 254
in operative technic, 35
artery clamps, 35
forceps, 36
knives, 35
probes, 37
retractors, 37
scissors, 35
in surgical technic, 14
selection of, 14
sterilization of, 15
Interrupted plaster dressings for fractures,
712
Insufflation, pharyngeal, in artificial respira-
tion, 130
Insufflation ether anesthesia, apparatus for,
97
accessories, 99
air compressor, 97
ether vaporizer, 98
filter and humidor, 97
intubating catheter, 98
safety valve, 98
intratracheal, 91. See also under Ether
anesthesia.
pharyngeal, 95. See also' under Ether an-
esthesia.
Insufflation nitrous oxid-oxygen anesthesia,
121
Intestine, diseases of, contra-indicating op-
erations, 188
Intra-abdominal affections, aspiration in,
during operation, 238
Intratracheal insufflation method of adminis-
tration in ether anesthesia, 91.
See also under Ether anesthesia,
in nitrous oxid-oxygen anesthesia, 121
INDEX
7:'.-.
Intravenous infusion. See Infusion, intrave-
nous.
Intravenous injections, 319
technic of, 295, 296
Intravenous saline infusion for shock, 677
lodin for amputations through infected tis-
sues, 664
for dressing of gunshot wounds in war-
fare, 655, 659
for skin sterilization in operations, 147
dangers of, 148
drawbacks of, 148
modifications of, 148
precautions in, 148
for treatment of shell wounds, 673
Irrigating stand, 43
Israel's operation in plastic surgery of
cheeks, 508, 509
Itching conditions, radium therapy for, 771
Jackets, plaster. See Plaster-of -Paris jackets.
Jaesche's modification of Dieff enbach 'a
method of restoration of lower
lip in operation for epithelioma,
502
Jaundice, a centra-indication to operation.
188
Jaw, gunshot wounds of, 668
lower, dislocation of, 752
reduction of, 752
after-care in, 752, 753
Jeger's clamp for isolating parts of two
blood vessels in side-to-side an-
astomosis, 291
holder for Payr's rings for end-to-end
anastomosis, 265
modification of Payr's magnesium cylinder
for end-to-end anastomosis of
deeply placed arteries, 265
suture method of treatment of varicose
veins, 324
technic of end-to-end anastomosis in veins,
288
technic of end-to-end arterial anastomosis,
270, 271
technic of end-to-side anastomosis in veins,
290
technic of end-to-side arterio venous anasto-
mosis, 277
tension suture holder, 272
Jochmann's tuberculins, 216
Joints, gunshot wounds of, inflicted, 665
wounds caused by bullets lodged in or near,
666
Joseph's method of operation for malforma-
tion of the lobule of the ear, 504
Kangaroo tendon for suturing, 8
Keen's ligation of abdominal aorta for
aneurysm, 383
for resection of cervical nerves for relief
of spasmodic torticollis, 534
Kelly instrument table, 42, 43
Keloids, radium therapy of, 765
Kenyon's method for aspiration in treatment
of pneumothorax, 241-244
Keratoses, senile and seborrhoic, radium
therapy of, 764
Kidney, diseaaes of, contra indications to op-
eration,
Kimpton'H iiii-t)io<i of blood transfusion with
paraffin coated mrrnfarlcn, 342
method of indirect blood tran«fu«iun. 312
Knee, bursa* about, diaeasea of 633
infiltration anesthesia for operations on,
59, 60
Knee joint, Charcot 'a, resection in, in srphili
fck j'.-.t,
dislocation of.
r.-.I.M-ti.Mi r.n.i iM,.I.,,!.1ii«ti«m of, 757
infected wounds of, treatment off 665
Knife, use of, in operative technic, 35
Koch's banllcn cmulKioti J15
old tuberculin
tuberculin rt- I:.) or new tubercu-
lin, 216
Kolle's method of operation for abnormal
enlargement of the auricle, 505
for malposition of auricle, 506, 507
Kb'nig's method of paring and suture in cor-
rection of harelip, 466
Kraske's operation in plastic surgery of the
cheeks, Gersunj's modification
of, 512
Krogius's subcutaneous ligature for large
angiomata of scalp, 329
Kromayer light in treatment of "port wine
marks," 330
Kutner's solution for infusion, 297
Lamb's-wool dressings, 10
Lambert, Alexander. <»n handling of patient
with delirium tremens* 161
Lambert's method of treating delirium tre-
mens, 166
Laminae, removal of. See Laminectomy.
Laminectomy, unilateral. 602
advantages and limitations of, 608
anatomical features in, 603
indications for, 602
instruments for, 605
technic of, 606
Landnmnn's tuberculol, 217
Lane's methods of operation for cleft palate,
485
for broad cleft involving almost entire
palate, 487
for extreme width of cleft. 489
v. Langenbeck's method of uranoplasty at
modified l,y H,.|l,
pedunculated flap method for plastic restor-
ation of eyelid, 520
Laparotomy for gunshot wounds in civil
practice, 656
in warfare, mortality from, 656
Larynx, diseases of, and anesthetic in opera-
tions, 189
gunshot wounds of, 669
Leg, fractures of. Sec under Fractures,
gunshot wounds of, 671
ischemic contracture of muscles of, 616
causes of, 616
results of, 616
treatment of, 616-618
rupture of muscles of, operative
of, 613
796
INDEX
Lerde's operation in plastic surgery of
cheeks, 509-511
Lespinasse and Eisenstaedt 's method of end-
to-end anastomosis of blood-ves-
sels, 266, 267
of side-to-side arteriovenous anastomosis,
278
Leukemia a centra-indication to operation,
191
Leukocytes, phagocytic properties of, in im-
munity, 197
Leukoplakia, radium therapy for, 771
Lexer's operation for Dupuytren's contrac-
ture, 646
in plastic surgery of cheeks, 509, 514
Ligation of arteries in continuity, 399. See
also under Arteries,
force applied in, 400
force necessary to rupture coats in, 401
indications for, 399
instruments for, 399
knot in, 400
ligature material for, 399
opening of sheath of vessel and passing
aneurysm needle in, 402
recognition of artery in, 401
results of, 401
Ligation in treatment of aneurysm, 365. See
also under Aneurysm.
of abdominal aorta, 383
of common carotid, distal, 386
double, 386
proximal, 386
of external iliac tract, 391
of innominate artery, 386
distal, 385
internal iliac branches, 392, 393
of subclavian artery, 389
of thoracic aorta, 382
in treatment of angiomata of scalp, 329
lateral, in veins, to restore circulation, 286
to check bleeding in veins, 286
Ligation en masse to check bleeding in capil-
laries, 328
Light rays, burns due to, 700
Lime and soda method of skin sterilization
for operations, 149
Lindemann's method of blood transfusion,
341
of indirect blood transfusion, 312-315
Lip, lower, epitheliomata of, operations for,
495
removal of epithelioma in, 495
removal of glands in, 495
restoration of lip in, 496
Dowd's method of, 501
Estlander's method of, 502
Jaesche's modification of Dieff en-
bach's method in, 502
Malgaigne's method of, 503
Morestin's method of, 498
for very extensive loss of sub-
stance of the two lips and
part of cheek, 500
Sedillot's method of, 503
Syme's method of, 502
technic of operation in, 496
suturing in, 497
Lip, lower, epitheliomata of, radium therapy
of, 767
operations for removal of non-malignant
growths of, 494
anesthetic in, 494
position in, 494
technic of, 494
double triangle method in, 495
plastic surgery of, 503
Lipomata of muscles, 622
Liquid air in freezing of nevi, 328
Liver, diseases of, contra-indicating opera-
tions, 188
gunshot wounds of, 670
Lobar pneumonia. See Pneumonia, lobar.
Locke's fluid, for infusion, 297
Lockjaw. See Tetanus.
Locomotor ataxia and spasticity, 530
Lotheissen's operation for Dupuytren's con-
tracture, 646
Lower extremities, edema of, Handley's op-
eration to establish artificial
channels for lymph drainage in,
332
Lower, Eichard, blood transfusion operation
of, 337, 338
Lumbar puncture in cerebrospinal meningitis,
210
in epidemic cerebrospinal meningitis, 157
Lung, abscess of, a surgical complication of
lobar pneumonia, 164
and operation, 189
gangrene of, and operations, 189
gunshot wounds of, 669
signs and symptoms of, 669
treatment in, 669
Lung-motor for artificial respiration, 131
Lupus of mucous membrane, radium therapy
for, 770
Lupus vulgaris, radium therapy of, 770
Lymph node affections, complicating scarlet
fever, 155
Lymphadenitis in erysipelas, 160
Lymphangitis complicating acute suppurative
inflammation of tendon sheaths
of hand, 642
treatment of, 689
Lymphatics, operation on, 330
Handley's, for establishing artificial
channels for lymph drainage,
330
in affections of face, 332
in affections of lower extremities,
332
in affections of upper extremities, 331
in ascites, 332
indications for, 330
Madura foot, treatment of, 697
Magnesium sulphate, subdural injections of,
in treatment of tetanus, 694
Malgaigne's method of paring and suture in
correction of harelip, 466
of restoration of lower lip in operation for
epithelioma, 503
Mallein in diagnosis of glanders, 208
Mammary artery, internal ligation of, in con-
tinuity, 419
INDEX
797
Mammary artery, internal ligation of, in con-
tinuity, anatomy of, 419
operation in, 419,. 420
Mamourian's method of excision for vari-
cose veins, 322
Markoe operating table, 40, 42
Mastoid region, aspiration during operation
in, 237
Matas endo-aneurysmorrhaphy and aneurys-
moplasty operations, 370
on use of tourniquet and elastic bandage
to check bleeding, 256
Maxillary occlusion, cicatricial, Gussen-
bauer 's autoplastic operation
for, 513
Mayo's method of excision for varicose veins.
321
McBride's method of treating delirium tre-
mens, 167
McGrath's method of indirect blood trans-
fusion, 315
Measles, complications of, 156
Median nerve, injuries to, 559
just above elbow, 559
treatment of, 559
just above wrist, 559
Median and ulnar nerves, injuries affecting,
559
Mediastinum, affections of, and operation,
190
Medullary anesthesia, 64
agents employed in, 67
apparatus for, 66
limitations of, 66
physiology of, 65
circulation in, 65
respiration in, 65
skin in, 66
uterus in, 66
preparation of anesthetic agent in, 66
preparation of patient in, 68
technic of, 68
Meloplasty. See Cheeks, plastic surgery of.
Meltzer method of intratracheal insufflation
in ether anesthesia, 91
pharyngeal tube for artificial respiration,
130
Meningitis, cerebrospinal. See Cerebrospinal
meningitis.
Mercury bichlorid, for sterilization in aseptic
surgical technic, 4
Mercury bichlorid poisoning, 184
operation contra-indicated in, 185
stripping of capsule of kidney in, 184,
185
symptoms of, 185
Metastatic glands, extirpation of, 767
in cancer, radium therapy for, 769
Metchnikoff, phagocyte theory of, to explain
immunity, 197
Meyers, Hans, theory of general anesthesia
of, 72
Michael 's clips for suturing, 33
"Miner's elbow, " 631
Mixed vaccines, 205
Moleskin adhesive plaster, 12
Moore-Corradi method of wiring in treat-
ment of aneurysm, 369
Morestin's method of restoration of lower
lip in operation for epithelioma,
for ven .- low of »u balance of
the two lips and {.art of
Moritz's method of blood transfusion, 340
Moro's tuberculin diagnostic test, 221
Morphin, as adjunct in ether anesthesia, 102
dosage of.
habitual use of, 168
contra- indication to operations, 168
symptoms of, 168
treatment of, 169
Morphin sulphate, hypodermic injection of,
for shock, 677
Mosquito bites, treatment of wounds due to,
8M
Moss dressings, 10
Moulded plaster splints for fractures, 700
application of, 710
preparation of, 709
Mouth, diseases of, contra indicating opera-
tions, 187
Mouth obstruction to respiration in anes-
thesia, l
Mouth and pharynx, aspiration in, during
operation, 237
postoperative use of, 241
Mouse-toothed forceps, 36
Mucous membranes, epitheliomata of, radium
therapy for, 766
lupus of, radium therapy for, 770
Mull bandages, 1 1
Mumps, surgical complications of,
Murphy's end -to t-n.l method of arteriorenoos
anastomosis. I
invagination methods of end-to-end arterial
anastomosis, 263,
early method, 263
recent method, 264
Muscle fibers, split, sutures for, 32
Muscle plastics in region of cheeks, Lexer
method of, 514
Muscles, 613
actinomycosis of, 620
atrophy of, 615
treatment of, t?l.~»
contracture of, ischemic, 616
causes of, 616
results of, 616
trvittmont of, 616618
degeneration of, til~>
treatment of, 615
diseases of, 61~>
hernia of, operative treatment of, 613
hydatid disease of, 620
inflammation of, 618
troatnu-nt of, 619
injuries of, 613
subcutaneous treatment of, 613
of arm an«l leg. rupture of. operative treat
UMMlt Of, 613
ossification of.
clinical forms of, 621, 622
etiology of, 622
treatment of, 622
paralysis of, 626
798
INDEX
Muscles, paralysis of, due to ischemic contrac-
ture of distant muscles, 616
treatment of, 617, 618
transplantation of tendons in treatment
of, 627
rupture of, in arm and leg, operative treat-
ment of, 613
subcutaneous, operative treatment of,
615
suture for, 32
spasticity in, treatment of, 528
by extraspinal operations, 529
alcohol injections into nerves in,
529
nerve resection in, 529
by intraspinal operations, 530
Foerster's operation in, 530
dangers and difficulties of, 533
indications for, 533
results of, 532
technic of, 531
syphilis of, 620
trichiniasis in, 621
etiology of, 621
symptoms of, 621
treatment of, 621
tuberculosis of, 619
treatment of, 619
Beck's bismuth subnitrate and vase-
lin injection in, 620
operative, 620
varieties of, 619
tumors of, 622
treatment of, 622
Musculospiral nerve, injuries to, 556
exploration in, 556
operative treatment of, 557
prognosis of, 556
Myositis, acute parenchymatous, 619
diffuse syphilitic, 621
simple, 618
suppurative, 618
Myxomata of muscles, 622
Nasal obstruction to respiration in anesthesia,
135
Naval warfare, wounds in. See under Gun-
shot wounds.
Neck, gunshot wounds of, 669
inoperable cancer of, radium therapy of,
769
Neck and throat, infiltration anesthesia for
minor operations on, 56
Needling in treatment of aneurysm, 369. See
also Aneurysm.
Neoplasms, malignant, radium therapy for,
766
Nephritis, acute, contra-indicating operation,
192
chronic, contra-indicating operation, 193
complicating scarlet fever, 156
Nephrotomy position in operations, 42
Nerve anastomosis, 538
Nerve avulsion, 536
Nerve bridging, 540
by nerve transplantations, 540
by tubulization, 541
by use of a vein, 541
Nerve crossing, 540
Nerve lesions in anesthesia, 141
prophylaxis in, 141, 142
Nerve resection for relief of spasticity, 529
Nerve sheaths, tumors of, 563
treatment of, 564
Nerves, cranial, disturbances of, 564
eighth, 600
operative treatment for, 600
eleventh, operative treatment of, 601
anatomical considerations in, 601
indications of, 601
technic of, 602
fifth (trigeminal), 564
alcohol injections into nerve trunks in
treatment of, 569
advantages of, 569
anesthesia in, 570
contra-indications for, 570
disadvantages of, 569
instruments for, 570
results of, 574
solution for, 570
technic of operation for, 570
general considerations of, 570
on inferior maxillary nerve, 573
on superior maxillary nerve, 572
anatomical considerations of, 564
inferior maxillary division, 565
ophthalmic division, 565
superior maxillary division, 565
indications for treatment of, 565
intracranial operation on Gasserian gan-
glion for, 574
advantages of, 582
anatomical considerations of, 575
indications for, 575
results of, 583
technic of, 576
posterior root section by infratem-
poral route in (Gushing opera-
tion), 580
sensory root division by autriculo-
temporal route in (Spiller-
Frazier method), 578
care of eyes in, 579
medical treatment for, 565
peripheral operation for, 566
on inferior dental branch, 568
on superior maxillary branch, 567
on supra-orbital branch, 566
results of, 569
resection of nerve trunks at their exit
from base of skull in treatment
of, 569
seventh, operative treatment in, 583
anatomical considerations in, 583
for facial paralysis, 586
anastomosis of peripheral portion of
facial nerve with a neighboring
motor nerve, 586
choice of motor nerve in, 587
methods of, 587
postoperative exercises in, 595
technic of, 587
in facio-hypoglossal anastomosis.
587
(1) incision, 588
INDEX
Nerves, cranial, seventh, operative treatment
in, for facial paralysis, technic
of, in facio-hypoglossal anas-
tomosis :
(2) isolation and section of
facial nerve, 588
(3) exposure of hypoglossal
nerve, 590
(4) implantation, 591
(5) closure of wound, 591
(6) postoperative course, 592
(7) results, 592
in facio-spinal accessory anas-
tomosis, 595
time of operation in, 586
lesions causing, 586
for facial spasm, 584
alcohol injection in, 585
section of facial nerve and anasto-
mosis with a motor nerve in, 585
for neuralgia of sensory portion, 597
by division of motor seventh, pars
intermedia and eighth, 597
results, of, 599
technic of, 597
indications for, 583
tenth, operative treatment of, 600
Nerves, gunshot wounds of, 662
treatment of, 662
Nerves of brachial plexus, lesions of, 545
below the clavicle, 555
in adults, exploratory operation in, 551
in infants, early operation in, 549
nature of, 546
operative treatment of, 551
postoperative treatment of, 555
treatment for, preceding operation, 549
Nerves, peripheral, neuralgias of, 526
posterior root section in treatment of, 526
dangers of, 528
results of, 528
technic of, 526
Nerves, peripheral, operations on, 525
anatomical considerations in, 525
for relief of neuralgias, 526
posterior root section in, 526
dangers of, 528
results of, 528
technic of, 526
for relief of pain, 526
due to traumatism and inflammation, 526
for relief of paralysis, 535
general considerations in, 542
nerve avulsion, 536
neurectasy, 536
neurectomy, 536
neurolysis, 542
neuroplasty, 538
bone "resection in, 541
choice of operation in, 541
nerve anastomosis in, 538
nerve bridging in, 540
by nerve transplantations, 540
by tubulization, 541
by use of a vein, 541
nerve crossing in, 540
neurorrhaphy, 536
after-treatment of, 538
Nerves, peripheral, operations on, for relief
of paralysis, neurorrhaphy, gen
eral principle* of,
lateral tension method of, 537
.,.,.:
through UM,| through method of, 536
neurotomy, 536
for relief of spasm, ollis, 5SS
posterior root section, 535
resection of cervical nerves, 534
for relief of spasticitj, 528
extraspin;i MI in, 529
alcohol ii.
nerve re* 529
intraspinal operations in, 530
Foerster's operation, 530
dangers and difficulties of, 533
itionM for.
results of, 532
technic of.
for repair of injuries, 542
causes of failure in, 545
deformity an-t resulting paralysis In, 544
in brachial plexus, 545
below the clavicle, 555
in adults, exploratory, 551
in infants, early, 549
nature of, 546
operative technic in, 551
postoperative treat "55
treatment for, preceding operation, 549
in cauda equina, 560
anatomical considerations in, 560
causes of, 560
results of, 561
treatment of, 561
in great sciatic nerve, 562
in median nerve, 559
just above elbow, 559
treatment of, 559
just above wrist, 559
in median and ulnar nerves, 559
in muBculospiral nerve, 556
exploration in, 556
operative treatment of, 557
prognosis of, 556
in suprascapular nerve, 555
in ulnar nerve, 557
at elbow, 558
etiology of, 558
symptoms of, 558
treatment in. 558
just above wrist, 557
treatment in, 558
reaction of degeneration in, 543
results of, 545
return of function following, 545
for tumors, 563
indications for, 525
Nerves, peripheral, pain due to tranmstiSM
and inflammation of, 526
medicinal and local treatment of, 526
operative treatment of, 526
technic of, 526
Nerves, suprascapular, injuries to, 555
treatment of, 555
Nervous system, central contra- indicating op-
erations, 193
800
INDEX
Neuralgias of peripheral nerves, 526
posterior root section in treatment of,
526
dangers of, 528
results of, 528
technic of, 526
of sensory portion of seventh nerve, oper-
ative treatment for, 597
by division of motor seventh, pars in-
termedia and eighth, 597
results of, 599
technic of, 597
discussion of, 598
radium therapy for, 771
Neurectasy, 536
Neurectomy, 536
Neurofibromata, 563
Neurolysis, 542
Neuromata, 563
false, 563
treatment of, 563, 564
true, 563
Neuroplasty, 538
bone resection in, 541
choice of operation in, 541
nerve anastomosis in, 538
nerve bridging in, 540
by nerve transplantations, 540
by tubulization, 541
by use of a vein, 541
nerve crossing in, 540
Neurorrhaphy, 536
after-treatment of, 538
general principles of, 537
lateral tension method of, 537
secondary, 538
through-and-through method of, 536
Neurotomy, 536
Nevi, vascular, operations on capillaries for
treatment of, 328. See also un-
der Capillaries.
New growths. See Neoplasms.
Nitrous oxid anesthesia, 110
adjuvants in, 123
alkaloidal narcosis, 124
technic of, 124, 125
ether anesthesia, 123
technic of, 124
postoperative narcosis, 125
administration of nitrous oxid in, 118
of nitrous oxid-oxygen mixtures, 118
advantages and limitations of, 122
apparatus for, 115
for control of gases, 116
measuring, 117
non-measuring, 116
for gas supply, 116
inhaler in, 115
general considerations of, 118, 119
methods of delivery of, 119
by Connell method, 121
by continuous flow method ( Booth -
by), 120
by insufflation, 121
partial, 121, 122
by interrupted flow or rebreathing
method (Gatch), 120
of nitrous oxid undiluted, 118
Nitrous oxid anesthesia, as adjunct in ether
anesthesia, 103
technic of, 103, 104
physiological action of, 111
with nitrous oxid-oxygen mixture, 112,
113
zones in, 113-115
with undiluted nitrous oxid, 111
overdose in, 111, 112
Nitrous oxid-oxygen anesthesia, administra-
tion of gases in, 118
general consideration of, 118, 119
methods of delivery in, 119
by Connell method, 121
by continuous flow method (Boothby),
120
by insufflation, 121
partial, 121, 122
by interrupted flow or rebreathed
method (Gatch), 120
advantages and limitations of, 122
apparatus for, 115
for control of gases, 116
measuring, 117
non-measuring, 116
for gas supply, 116
inhaler, 115
as adjunct in ether anesthesia, 104
physiological action of, 112, 113
zones in, 113-115
Nose and its sinuses, preparation of, preced-
ing operation, 145
Novocain in local anesthesia, 50
in spinal anesthesia, 67
Oakum dressings, 10
Obesity, centra-indication to operation, 182
operation for hernia in, 182
O 'Day's technic of end-to-end arterial anas-
tomosis, 272
Olecranon bursa, diseases of, 633
Olecranon process, fracture of, 720
moulded plaster splint for, 721
reduction of, 720
Open wounds. See Wounds, open.
Operating theater, 37
cleanliness in, 39
furniture in, 39-43
Bentley Squier's portable table in, 42,
43
hand bowl stand in, 43
irrigating stand in, 43
Kelly instrument table in, 42, 43
Markoe operating table in, 40, 42
light in, 38
secondary rooms, accessible, in, 39
ventilation in, 39
Operation, eontra-indications to, 151
acute polyarticular rheumatism, 184
affections of the mediastinum, 190
alcoholism, 164
surgical complications of, 166
treatment of, preceding operation, 164-
166
treatment of delirium tremens in,
166
Lambert's method of, 166
McBride's method of, 167
Operation, contraindications to, anemia, 1"1.
chronic simple, l.'ii.'
shock in, I.") I
bichlorid of mercury |><
catarrh, chronic. I v»
chicken |.o\, I.', I
cocain, habitual use of, 17o
symptoms of, 170, 171
congenital affections of the heart, 191
cory/.a, 1 s'.»
diabetes mellitus, 174
dirt in, I?:.
prognosis of, 180
surgical complications of, 174
diabetic gangrene in, amputation
for, 180-182
diphtheria, 156
diseases of arteries, 191
of bladder, 193
of bronchi, 189
of central nervous system, 193
of esophagus, 188
of heart, 190
of intestine, 188
of kidney, 192
of larynx, 189
of liver, 188
of lung, 189
of mouth, 187
of pancreas, 188
of peritoneum, 189
of pharynx, 187
of pleura, 189, 190
of spleen, 192
of stomach, 188
of suprarenal bodies, 192
of thymus, 192
of thyroid, 192
of tonsils, 187
enteroptosis, 188
epidemic cerebrospinal meningitis, 157
lumbar puncture in, 157
erysipelas, 158
surgical complications of, 158
abscesses, 158
delirium tremens, 161
gangrene of skin, 160
lymphadenitis, 160
phlebitis, 160
pneumonia and empyema, 160
exophthalmic goiter, 192
gout, 184
Hodgkin's disease, 191
leukemia, 191
lobar pneumonia, 163
surgical complications of, 163
abscess of lung, 164
empyema, 163
measles, 156
mumps, 157
neuroses of heart, 191
obesity, 182
opium and morphin, use of, 168
symptoms of, 168
treatment of, 169
pericarditis, plastic, 190
with effusion, 190
52
Operations, contra indications to, phosphorus
185
paeuoKM
purptira and hi mophilia, 192
ri. -\
•
Mir,
196
arthriti.s. 156
lymph node affection*, 155
par 156
p,
sen i
>kin .! LSI-use*, 194
small pox,
status lymphatic,,*. n,i. 192
nal appearances in, 161
other characteristics of, 162
syphilis, 17i'
surgiral complications of, 173
treatment in. 17U
tetanus.
tropical diseases, 193
taberealoais, 186
anesthetic to be used in operations in,
186.
typhoid J-
sur;_ ;li«ations of, 152, 153
.t.- abdominal conditions of, 158
perforation.
typhoid gangrene, 153, 154
typhus 1'.
sur_ plications of, 154
whooping rough,
wounds of heart, 191
preparation of patient for, 143
mental, 1 » ::
physical, lit
diet in. 1 I.',
digestive organs in, 145
drugs in.
ear sterilization in, 150
eye sterilization in.
genito- urinary tract in.
nose and its sinu.M
.1 sterilization in. 150
skin sterilization in. 146 et tcq.
alcohol other bi.-hlond method in,
dangers of, '
drawbacks of.
mo 149
precautions in.
aseptic Mowing. 150
hen/in method in.
carbon tetraehlorid in, 150
iodin method in. 147
dangers of, M*
drawbacks of.
. 148
variations of, 148
lime and soda method ii
picri. acid in. 150
thymol in, 150
teeth in, 1H
throat in. 144
802
INDEX
Operation, centra-indications to, preparation
of patient for, physical, vaginal
sterilization in, 150
washing of stomach in, cases requiring,
146
prophylactic vaccination preceding, 204
Operative technic, 27
bone operations in, 31, 32
closure of wounds in, 32
Michael's clips in, 33
subcuticular suture in, 34
sutures in, 32
drainage in, 34
dressings in, 34
hemostasis in, 28
blood transfusion for loss of blood in, 30
bone bleeding in, 29
chemicals in, 29
compression of artery through intramus-
cular incision in, 31
Esmarch bandage in, application of, 30
ligating of blood-vessels in, 29
ligating of blood-vessels of pedicles in,
29
normal salt solution injections for loss
of blood in, 30
sequestration anemia in, 30
speed in, 30
incisions in, 28
instruments in, 35
artery clamps, 35
forceps, 36
knives, 35
probes, 37
retractors, 37
scissors, 35
operating theater in, 37
cleanliness in, 39
furniture in, 39-43
Bentley-Squier 'a portable table in, 42,
43
hand bowl stand in, 43
irrigating stand in, 43
Kelly instrument table in, 42, 43
Markoe operating table in, 40, 42
light in, 38
secondary rooms, accessible, in, 39
ventilation in, 39
position and arrangement of patient in, 43
celiotomy position in, 40
nephrotomy position in, 42
Rose position in, 41, 42, 44
Trendelenburg position in, 41, 42, 44
speed vs. accuracy in, 27
surgeon's dress in, 44-46
trauma to tissues in, 31
Opium, habitual use of, 168
contra-indication to operations, 168
symptoms of, 168
treatment of, 169
Opsonins, 200
Osmosis, local anesthesia by, 51
Ossification of muscles. See Muscles, ossifi-
cation of.
Osteomyelitis, vaccine therapy of, 210
Osteosarcoma, radium therapy in, 769
Otitis media complicating epidemic cerebro-
spinal meningitis, 157
Otitis media, complicating measles, 157
complicating scarlet fever, 155
vaccine therapy of, 210
Otoplasty. See Ear, plastic operations of.
Pagenstecher 's thread for suturing, 8
Pain due to traumatism and inflammation of
peripheral nerves, 526
medicinal and local treatment of, 526
operative treatment of, 526
technic of, 526
Palate, cleft. See Cleft palate.
Pancreas, diseases of, and anesthetic in op-
eration, 188
Papillomata, of lower lip, operation for ex-
cision of, 494
radium therapy of, 764
Paraffin, use of, as an anticoagulant for trans-
fusion apparatus, 342. See also
Satterlee and Hooker's methods
of indirect blood transfusion
with use of paraffin and hirudin.
Paralysis, anesthesia, 556
brachial birth, Erb 's type of. See Brachial
plexus lesions.
due to injuries of brachial plexus, 545.
See also Brachial plexus le-
sions.
of cauda equina, 561
of great sciatic nerve, 562
of median nerve, 559
of median and ulnar nerves, 559
of musculospiral nerve, 556
of suprascapular nerve, 555
of ulnar nerve, 557
facial. See Facial paralysis.
of muscle groups due to ischemic contrae-
ture of distant muscles, 616
treatment of, 617, 618
of muscles, transplantation of tendons in
treatment of, 627
operations on peripheral nerves for relief
of, 535
general considerations in, 542
nerve avulsion, 536
neurectasy, 536
neurectomy, 536
neurolysis, 542
neuroplasty, 538
bone resection in, 541
choice of operation in, 541
nerve anastomosis in, 538
nerve bridging in, 540
by nerve transplantations, 540
by tubulization, 541
by use of a vein, 541
nerve crossing in, 540
neurorrhaphy, 536
after-treatment of, 538
general principles of, 537
lateral tension method of, 537
secondary, 538
through-and-through method of, 536
neurotomy, 536
Saturday-night, 556
traumatic, Erb's. See Brachial plexus le-
sions.
Volkmann's ischemic, 559
IXDKX
803
I'nrkhill's method of operation for abnormal
enlar^nnciit of tin- aurid.-, ,r)05
Paronychia complicating warl.-t fever, 156
Parotid gland, inoperable sarcoma of, radium
therapy for, 769
Pasteur, exhaustion theory of, to explain im-
munity, 197
Patella, fracture of, 734
plaster-of-Paris dressing for, 734-736
Payr's invagination method of end-to-end ar-
terial anastomosis, 264, 272, 273
rings for end-to-end anastomosis of arter-
ies, 264
"Peri-arthritis humeroscapularis, " 632
Pericarditis, plastic, a contra-indication to
operation, 190
with effusion, 190
Peripheral nerves, neuralgias of, 526
operations on, 525
anatomical considerations of, 525
for relief of neuralgias, 520
posterior root section in, 526
dangers of, 528
results of, 528
technic of, 526
for relief of pain, 526
due to traumatism and inflammation,
526
technic of, 526
for relief of paralysis, 535
general considerations in, 542
nerve avulsion, 536
neurectasy, 536
neurectomy, 536
neurolysis, 542
neuroplasty, 538
bone resection in, 541
choice of operation in, 541
nerve anastomosis in, 538
nerve bridging in, 540
by nerve transplantations, 540
by tubulization, 541
by use of a vein, 541
nerve crossing in, 540
neurorrhaphy, 536
after- treatment of, 538
general principles of, 537
lateral tension method of, 537
secondary, 538
through-and-through method of, 536
neurotomy, 536
for relief of spasmodic torticollis, 533
posterior root section, 535
resection of cervical nerves, 534
for relief of spasticity, 528
extraspinal operations in, 529
alcohol injection in, 529
nerve resection in, 529
intraspinal operations in, 530
Foerster's operation, 530
dangers and difficulties of, 533
indications for, 533
results of, 532
technic of, 531
for repair of injuries, 542
causes of failure in, 545
deformity and resulting paralysis in,
544
Peripheral nerves, neuralgia* of, operations
on, for repair of injuries in
brachial pl«»xu-
below the da
in adults, exploratory, 551
in infants, early, 549
nature of, 546
operative U-< ,51
postoperative treatment in, 556
treatment for, preceding operation,
in cauda equina, 560
anatomical considerations in, 560
WMM • •!'. NO
results of, 561
treatment of, 561
in great sciatic nerve, 561
in median nerve, 550
just above elbow, 550
just above wrist, 550
in median and ulnar nerves, 669
in inn-Mill...). iral nerve, 556
exploration in, 556
operative treatment in, 55?
prognosis of, 556
in suprascapular nerve, 555
in ulnar nerve, 557
at elbow, 558
just above wrist, 557
reaction of degeneration in, 548
results of, 545
n*t urn of function following. 545
for tumors, 563
indications for, 525
pain due to traumatism and inflammation
of, 526
medicinal and local treatment of, 516
operative treatment of, 526
technic of, 526
Periosteum, sutures for, 32
Peritoneum, diseases of, operations in, 180
Peritonitis complicating scarlet fever, 156
Peroneal artery, ligation of, in continuity,
445
anatomy of, 445
operation of, 445
in lower third, 445
in upper third, 445
Phagocytosis, 200, 201
Phagolysis, 200
Pharyngeal insufflation in artificial
tion, 130
method of administering ether for
thesia, 95. See also
Kther anesthesia.
method of administering nitrous oxid oxy-
gen mixture for •iiertiMJi, 121
Pharyngeal obstruction to respiration in an-
esthesia.
Pharyngitis, contra indicating operation,
187
Pharynx, acute infectious phlegmon of. con-
tra indicating operation. 187
cancer of. radium theraj
diseases of, contra indicating operations,
187
ulceration of, contra-indication to
tion. 187
804
INDEX
Phlebitis in erysipelas, 160
infective, operative treatment of, 327
Phlegmon, acute infectious of pharynx, con-
tra-indication to operation, 187
Phosphorus poisoning, 185
Picric acid solution in burns of second de-
gree, 698
of third degree, 699
in skin sterilization for operations, 150
von Pirquet's diagnostic tuberculin reaction,
221
Pistols, automatic, experiments in wounds
made by various types of, 649
United States cavalry, effect of, 654
Plaster, adhesive, 12
moleskin, 12
zinc oxid, 12
Plaster-of-Paris dressings, 11, 707
for club-foot, 751
for Colle 's fracture, 724
moulded plaster splints for, 724, 725
reduction in, 724
for congenital dislocation of hip (spica),
749
application of, 749
in bilateral cases, 750
in unilateral cases, 750
for flat-foot, 752
for fracture of bones of foot, 741
of bones of hand, 725
circular plaster dressing for, 725, 726
of coronoid process, 721
of femur, lower end of, 733
epiphyseal, 734
intercondyloid, 733
of either condyle, 733
neck of, 726
extension and counter-extension in
(Hodgin's splint), 726
application of, 726
preparation of, 725
reduction and retention in (Whit-
man's method), 729
in cases with impaction, 729
in cases without impaction, 729-
731
shaft of, 731
Buck's extension with Volkmann
sliding rest in, 731, 732
in young children, 733.
long plaster spica for, 731
reduction of, 731
subtrochanteric, 731
supracondyloid, 733
long plaster spica in, 733
of fibula alone, 740
of humerus, epiphysis of upper end of.
714
application of, 715
reduction in, 714
lower end of, 717
epiphyseal, 720
of external condyle, 720
of internal condyle, 719
moulded splints in, 719
of internal epicondyle, 719
supracondyloid, 718
plaster-of-Paris dressing in, 718
Plaster-of-Paris dressings for fracture of
humerus, lower end of, supra-
condyloid, plaster - of - Paris
splints in, 718, 719
T- or Y-shaped, 720
moulded splints in, 720
shaft of, 716
application of, 716, 717
reduction in, 716
surgical neck of, 715
application of, 715, 716
reduction in, 715
of olecranon process, 720
application of, 721
reduction in, 720
of radius, of head and neck, 722
shaft of, 723
moulded plaster splints for, 724
reduction in, 723, 724
of radius and ulna, 722
moulded plaster splints for, 723
reduction in, 722
of tibia alone, 736
of tibia and fibula, 736
in cases with difficulty in retaining of
fragments in position, 737
with swelling and displacement,
736
without displacement, 736
of patella, 734-736
of ulna, shaft of, 723
moulded plaster splints for, 723
reduction in, 723
of vertebrae, 749
for Pott's fracture, 740
general principles in application of, 708
materials necessary for, 708
preparation for plaster work in, 709
preparation of, 707
removal of, 713
removal of plaster from hands following
application of, 714
varieties of, 709
circular plaster dressings, 710
application of, 710, 711
fenestrated plaster dressings, 711
interrupted plaster dressings, 712
jackets, 742. See also under Plaster-of-
Paris jackets.
moulded plaster splints, 709
application of, 710
preparation of, 709
spica for hip, 712
application of, 712, 713
Plaster-of-Paris jackets, 742
application of, with patient in dorsal posi-
tion, 745
with patient in prone position, 744
with patient standing, 742-744
Calot, 747
removable, 748
Plastic surgery, general principles of, 451
methods used in, 452
causes of failure in, 456
gliding flaps in, 452
with rotation, 453
granulation method in, 453
pedunculated flaps in, 453
INDEX
Plastic surgery, method-
trillion in, I.VJ
transplantation of
of cheeks, 507, 8et alto
of Heft paint. . , ,ii.s,, r|«ft palate.
of oar, fin J. >
«»f harelip. ll:ir.-li|..
of lower lip. N, , ,//,,/,/• Lip. louer.
of upper li|»,
skin ^raftiny; in, l.'iti
Pleura, disea^,.. ,,t. an«l operations, 180
Plexiform inMir«iiiiat:i.
PneimioeoccuB infections, serum therapy of,
212
vaccine therapy of, 212
Pneumonia, a contra indication to operations.
189
complicating erysipelas, 160
lol.ar. Complicating measles, l.'.i'.
contra indication to operations, 163
surgical complications of, 163
abscess of lung, 164
empyema, 163
Pneumothorax, Kenyon's method of aspira-
tion in treatment of, _' U L' f I
Poisoned weapons, treatment of wounds due
to, 688
Polymyositis hemorrhagica, 619
Polyvalent vaccines, 205
Popliteal artery, aneurysm of, operative
treatment of, 393-395
ligation of, in continuity, anatomy of,
441
operation in, 442
in lower part of popliteal space, 1 1
in upper part of popliteal space, 1 J -
results of operation in, 443
Popliteal bursae, diseases of, 633
"Port wine marks," Kromayer light in
treatment of, 330
Postural compression to check bleeding in
arteries, 255
in veins, 286
Potassium iodid in treatment of actinomyco-
sis, 696
Pott's fracture, plaster-of -Paris dressing for,
740
Pregnancy, defensive ferments in body in,
226, 227
Prepatellar bursa, diseases of, 633
Pressure for production of local anesthesia,
48
Pressure methods, differential, in anesthesia,
128
negative pressure in Sauerbruch chamber
in, 129
positive pressure by face mask in, 129
positive pressure by intratracheal insuffla-
tion in, 130
positive pressure by pharyngeal insuffla-
tion in, 130
Probes, use of, in operative techni-
Probing for bullet in gunshot wounds in
warfare, 655
Prophylactic vaccination. See Vaccination,
prophylactic.
Prostate, inoperable sarcoma of, radium
therapy for, 769
I'M. lie artery, Internal, ligation of, in eon-
' tit.
Pulmonary <«l«ma in aiMwtiieaia
Pulmotor for 11 130
Pump* for n»|. .,• surfwj,
ejector, 280
firat UM» of, 232
operated by fluid or vnj.or. 230
Purpura, a contra indication to operation,
Purw tmall angiomaU of
•ralp, 329
Putrefa, t treatment of, «M
Pyemia, treatment of, 001
. uoun.ln tafeetni by,
treatment of, 080
Pyorrhea alveolarU, vaccino therapy of, 211
(^u in in and urea hydroehlorate in local tmm
theaia, 51
». diagnosis in.
•
administration of viru» in, 213
preparation of
serum therap
Radial art >n of, in continuity, 425
anatomy of, 425
operation in.
in hand.
in lower third, 426
in upper third, 420
in wi
Radio activity, nature of, 781, 702
Radiocarpal .joint, dish-
back war- i
forward.
Hadio-ulnar joint, lower, dislocation of.
backward, 757
forward, 757
Radium, action of rays of, on living eeUa>
703
activity of, 7«!
Alpha rays of.
Beta rays of,
burns of, 701
dosage of.
filtration of.
Mima rays of, 702
history of, 761
rence and production of
radiation of, 701
therapeutic u*e of. in *urgorv. 703. 8*e
oho under Radium therapy.
Radium therapy, danger* of e«ten«r* appli-
of angioraata, 705
of blaM
of cancer, ii.
inoperable
metastatic glandular involvoroent in,
:••.'
of breast, 708
806
INDEX
Eadium therapy, of cancer, inoperable, of
cervix, 768
of esophagus, 769
of groin, 769
of neck, 769
of rectum, 768
of stomach, 769
of uterus, 768
of or near blood-vessels, 769
of or near viscera, 769
of tongue, 767
of tonsil and pharynx, 767
Kadium therapy of chronic ulcerations, 771
of cicatrices, 765
of epitheliomata, cutaneous, 766
indurated, 766
superficial, 766
of lower lip, 767
of mucous membranes, 766
of epulis, 769
of exophthalmic goiter, 770
of fibromata, 764
of interstitial variety, 764
of Hodgkin's disease, 770
of inoperable lesions, 767
of keloids, 765
of leukoplakia, 771
of lupus of mucous membrane, 770
of lupus vulgaris, 770
of malignant neoplasms, 766
of neuralgic and itching conditions, 771
of osteosarcoma, inoperable, 769
of papillomata, 764
of sarcoma, inoperable, 769
of femur, 769
of parotid gland, 769
of prostate, 769
of tonsil, 769
of senile and seborrhoic keratoses, 764
of tuberculous glands, 770
of tuberculous nodules, 770
of tuberculous sinuses, 770
of tuberculous ulcers, 770
of warts, 764
of X-ray keratoses and ulcerations,
764
Kadius, Colle's fracture in, 724
moulded plaster splints for, 724, 725
reduction of, 724
fracture of head and neck of, 722
moulded splint for, 722
fracture of shaft of, 723
moulded plaster splints for, 724
reduction of, 723, 724
Eadius and ulna, fracture of, 722
moulded plaster splints for, 723
reduction of, 722
Raynaud's disease, arteriovenous anastomosis
in, 275. See also under Arter-
ies.
Keceptors in side-chain theory, 198
overproduction of, 198
Rectum, inoperable cancer of, radium therapy
for, 768
sterilization of, in preparation for opera-
tions, 150
Refrigeration method of production of local
anesthesia, 48
Refrigeration method of production of local
anesthesia, indications and limi-
tations of, 48
technic of, 48
Regimental aid to wounded on battlefield,
659
Regional anesthesia, by injection into medul-
lary canal, 64
agents employed in, 67
apparatus for, 66
limitations of, 66
physiology of, 65
circulation in, 65
respiration in, 65
skin in, 66
uterus in, 66
preparation of anesthetic agent in, 66
preparation of patient in, 68
technic of, 68
by intra-arterial injection, 70
technic of, 70
by intraneural infiltration, 61
by intravenous injection, 69
technic of, 70
by perineural infiltration, 63
technic of, 63, 64
Reindfleisch and Friedel's spiral incision for
varicose veins, 323
Renal arteries, aneurysm of, 385
Respiration, artificial, 130
by intratracheal insufflation, 130
by lung-motor, 131
by pharyngeal insufflation, 130
by pulmotor, 130
obstruction to, danger in anesthesia, 135
bronchial, 137
glottal, 136
mouth, 135
nasal, 135
pharyngeal, 135
tracheal, 136
Respiratory failure in anesthesia, 138
etiology of, 138
symptoms of, 138
treatment of, 139
Retractors, use of, in operative technic, 37
Retropharyngeal abscess, anesthetic in opera-
tion in, 187
Revedin's method of skin-grafting, 522
Rheumatic fever, acute, vaccine and serum
treatment in, 213
Rheumatism, acute polyarticular, treatment
of, 184
Rickets, treatment of, 182
Riedinger's experiments with pointed bullet
of modern warfare, 652-654
Rifle bullets, military pointed, 652
French, 653
German, 652
Riedinger's experiments with, 652-654
wounds produced by, 651-653
in Balkan war, 654, 658
wounds due to, 661. See also under Gun-
shot wounds.
Ringer's Fluid, for infusion, 296
Risley and Irving 's method of blood trans-
fusion with paraffin-coated re-
ceptacles, 342
Robert's method of operation for cleft pal-
ate, 490
Rose position in operations, 41, 42, 44
Rubber gloves in surgical techni- . 17
putting on of, 18
sterilization of, 18
use of, arguments for, 18, 20
Rubber tissue drains, 14
Rubber tubes for drainage of wounds, i:»
von Ruck's tuberculin, 216
Saline solution, normal, for infusion, 296
injections of, for shock following hemor-
rhage, 30
Salomoni 's method of end-to-end suture of
arteries, 265, 266
Sarcomata, inoperable, radium therapy of,
769
of femur, 769
of parotid gland, 769
of prostate, 769
of tonsil, 769
of muscles, 622
"Saturday-night" paralysis, 556
Satterlee and Hooker's methods of indirect
blood transfusion with use of
paraffin and hirudin, 316, 337
history of transfusion experiments under-
lying, 337
defibrinated blood in, 341
early apparatus in, 337
later apparatus in, 339
paraffin methods in, 342
recent syringe methods in, 340
operation with hirudin-coated pipets in,
353
preparation of pipets with hirudin coat-
ing in, 354
operation with paraffin-coated pipets in,
345
apparatus in, 346
instruments in, 345
preparation of pipets with paraffin coat-
ing in, 352
technic of, 347
theoretical considerations and principles
underlying, 342
Sayre dressing in fracture of clavicle, 758
Scarification in treatment of nevi, 329
Scarlatina. See Scarlet fever.
Scarlet fever, surgical complications of, 155
albuminuria, 156
arthritis, 156
lymph node affections, 155
nephritis, 156
otitis media, 156
paronychia, 156
peritonitis, 156
vaccine and serum therapy in. 2
Schwarz and McNeil complement-fixation teat
for gonococcus infections, 208,
209
Sciatic artery, aneurysm of. See under
Aneurysm of internal branches
of iliac artery,
ligation of, in continuity, 437
anatomy of, 437
operation in, 437
Bcfeftli
t, mat, injuries to, 568
Scissors, use of, in operative
Hcopolamin as adju:
188
Scorpions, treatment of wounds due to, 887
blood transfusion apparatus, 338
il hernia, infiltration iissthiria for, 58
Scurvy, a Cation to operations, 183
treatment of, 183
Sedillot's method of restoration of lower lip
MM
operation for repair of defects of «PPar
N&L804
Senile and seborrhoie keratoses,
therapy of, 764
Sensitised vaccines, 204
Septicemta, treatment of, 691
Hepticopyemia, treatment of, 691
Sequestration anemia for limiting of
rhage in operations, 80
Serous membranes, absorption of ether by,
188
Serum sickness, 288
methods of injections to avoid, 224
symptoms of, 883
theory of, 223, 224
Serum therapy, 224
administration of serum in, 888
in anthrax, 695
in man, 206
in bubonic plague, 212
in cerebrospinal meningitis, 211
in • holera, prophylactic, 808
in .liphtheria, 207
dosage of antitoxin in, 207
in dysentery, 207
against Flexner- Harris type,
against Shiga type, 207, 808
in erysipelas, 208
in exophthalmic goiter, 208
in glanders, 208
in K'onococeal infections, 212
in gonorrhea, 210
in pneumococcus infections, 212
in rabies.
in rheumatic fever, scute, 213
in scarlet fexer, 213
in tet:irn;-.
in treatment of wounds in blood infections,
888
Sheaths, tendon. See Tendon sheaths.
Shells in land warfare, structure of, 671
wounds produced by, 673
first aid packet for, 673
treatment of. 673
Shiga bacillus. See
Shock, following be
fusion for, 30
normal saline solution injections for, 30
from severe wounds, treatment of, 667,
8§j
in operations complicated by anemia, 151
surgical, in anesthesia, 140
etiology of. 140
treatment of. 141
Shot in land warfare, structure of, 671
Shot, case, in land warfare, structure of, 671
888
808
INDEX
Shoulder, dislocation of, 753
reduction of, by manipulation (Kocher's
method), 753
by traction (Stimson's method), 753, 754
treatment following, 754
Shrapnel in land warfare, 671
structure of, 672
wounds produced by, 673
treatment of, 673
Side-chain theory of immunity, 197
amboceptor and complement combination
in, 199
antibodies in, 198
body cell in, 197
chemical nature of, 198
functions of, 197
nutritive, 197
physiological, 197
side chains, hap tines or receptors in, 198
(1) antitoxin molecule in, 198
(2) agglutinin in, 199
(3) amboceptor in, 198
complement in, 199
haptophore group in, 199
zymophore group in, 199
overproduction of receptors in, 198
toxin molecule in, 198
haptophore group in, 198
toxophore group in, 198
Silicate of soda bandages, 12
Silk for suturing, 8
Silkworm-gut for suturing, 8
Silver wire for suturing, 8
Skin, diseases of, contra-indicating opera-
tions, 193
gangrene of, complicating erysipelas, 160
sterilization of, for operations, 146 et seq.
alcohol-ether-bichlorid method in, 149
dangers of, 149
drawbacks of, 149
modifications of, 149
precautions in, 149
aseptic coating following, 150
benzin method in, 149
carbon tetrachlorid in, 150
iodin method in, 147
dangers of, 148
drawbacks of, 148
modifications of, 148
precautions in, 148
lime and soda method in, 149
picric acid in, 150
thymol in, 150
Skin-grafting, 520
in plastic surgery, 456
instruments for, 520
preparation of surface from which grafts
are to be cut in, 520
preparation of surface to be grafted in,
521
Revedin 'B method of, 522
technic of operation in, 521
Wolf's method of, 522
Woodbury's method of, 522
Skin grafts, transplanting of, in operations
for Dupuytren 's contracture,
645
Small-pox, surgical complications of, 154
Smoler's clamp in treatment of common
carotid aneurysm, 387
Snake bites, treatment of, 687
constitutional treatment, 687
local measures, 687
Sodium bicarbonate for burns, 698
Soft tissues, gunshot wounds of, 662
Spasm, facial. See Facial spasm.
Spasmodic torticollis, operative treatment in,
533
posterior root section in, 535
resection of cervical nerves in, 534
Spasticity and locomotor ataxia, 530
Spasticity in muscles, temporary relief of,
by intraspinal injection of local
anesthetic, 530
treatment of, 528
by extraspinal operations, 529
alcohol injection into nerves in, 529
nerve resection in, 529
by intraspinal operations, 530
Foerster's operation in, 530
dangers and difficulties of, 533
indications for, 533
results of, 532
technic of, 531
Spengler's tuberculins, 217
Spica, plaster-of-Paris, for congenital dislo-
cation of hip, 749
application of, 749
in bilateral cases, 750
in unilateral cases, 750
for hip, 712, 726
application of, 712, 713
Spiders, treatment of wounds due to, 687
Spiller-Frazier method of sensory root di-
vision of Gasserian ganglion, by
antriculotemporal route, for dis-
turbances of fifth (trigeminal)
cranial nerve, 578
Spinal anesthesia, 64
agents employed in, 67
apparatus for, 66
limitations of, 66
physiology of, 65
circulation in, 65
respiration in, 65
skin in, 66
uterus in, 66
preparation of anesthetic agent in, 66
preparation of patient in, 68
technic of, 68
Spinal cord, aspiration in, during operation,
237
Spine, gunshot wounds of, 670
lateral curvature of, plaster-of-Paris jacket
for, 742
tuberculosis of, plaster-of-Paris jacket for,
742
Spitz bullets, in modern warfare, 652
Eiedinger's experiments with, 652-654
wounds produced by, 653
in Balkan war, 654, 658
Spleen, diseases of, and operations, 192
gunshot wounds of, 670
Splints, moulded plaster, for fractures, 709
application of, 710
preparation of, 709
IXDKX
Sponges for dressing of wounds, 10
Sprengel pump, 130
Standardisation of vaccines, 203
Status lymphaticus, a contr.-i indication to op-
erations, l«:i, II»L>
external appearances in. l«il
other charaeteri-tic., ,,f, 102
Steam, live, in sterili/ati.
Steam sterilizer, 22-25
Sterilization, autoclave in, 22-25
by germicidal agents, .'{
chemicals, 3
alcohol, 4
bichlorid of mercury, 4
carbolic acid, 4
formaldehyd gas, 5
iodin, 4
iodoform, 4
potassium permanganate, 4
heat, 3
boiling, 3
cautery, 3
hot air, 3
live steam, 3
by mechanical means in surgical technic, 3
fractional, in operative technic, 3
of dressings, 8
cotton, 10
gauze, 9
of hands in surgical technic, 17
of instruments, 15
of rubber gloves, 18
of skin of patient in surgical operations,
21
of suture material, 25
aluminum alloy, 8
catgut, 6
chromic method of, 7
cumol method of, 6
iodin method of, 7
kangaroo tendon, 8
Pagenstecher 's thread, 8
silk, 8
silkworm-gut, 8
silver wire, 8
of water, 25
Sterilizer, for water, 25
steam, 22-25
Stewart's clamp for isolating portion of lu-
men of blood-vessel, 261
Stock vaccines, 204, 205
Stokes' apparatus for transporting wounded
from warships, 679
shell wound dressing in naval warfare,
673
Stomach, aspiration in. during operatioi
diseases of, contra-indicating operations,
188
inoperable cancer of, radium therapy for,
769
washing of, preceding operation, cases re-
quiring, 1-Hi
Stovain for local anesthesia. ~»1
for spinal anesthesia, i>7
Strychnin sulphate, hypodermic injections of,
for shock. r>77
Subclavian artery, aiieurysm of, 389
medical treatment of; 389
Subclavian artery, aneuryun of, operative
treatment of, 380
;s9
ligati
•MtMQ ..i. i . ,
operation m nn.t |*ortion of,
remit* of, 416
operation in third or second portion of,
417
resulta of
Subcutaneous wounds, 682
Suh'l«-M..i.| buna, 632
acute inflammation of, 632
treatment of,
tuberculosis of, 632
treatment of,
Suction ii. surgery, 229
continuous, advantage of, 235
application pf (totef IN ration, 236
for production of l.*|--r.-mi:i. -»',
in
! Maddrr and dneta, 238
urinary tract, 238
in hra.i.
in intra abdominal ron.litkma, 288
in nia.stoi.l region, 237
in mouth and pharynx, 237
in spinal cord, 237
in stomach, 238
in thorax
|io>tiip.-r:it i'..-. 180
apparatus for, 239, 240
in abdomen, 244
in hra.!.
in mouth and pharynx, I'll
in thorax. Ull
Mil's method of, 243-244
producing of, 229
care and cleaning of apparatus in. 232
connections between anetkw pump and
wound in.
first use of pump* in, 238
in private houses, 231
pumps in, 229
•tor,
mechanical, 229
operated by fluid or vapor, 230
tips or Aozzlea in, 282
double tube, 233
for mouth and pharynx, 235
for use as retractors, 235
MiiK'te tube, i
Sunburn, 700
Supra-orbital artery, ligation of, in
unit..
anatomy of, •
•aeration in, 41.1
SiBJIii I glands, diaeam of, and
ttoM, M
Bupraaeapular urim to, 555
treatment of, 555
n's dress in o|H-r:ition», 44-46
Surgical :ini-stlie>i:i. 1 7
general nature ut. 17
liM-al. nat
Surgical intr.-ti..n. >• • It.t.-otion, nrgicaL
810
INDEX
Surgical shock in anesthesia, 140
etiology of, 140
treatment of, 141
Surgical technic, aseptic. See Aseptic surgi-
cal technic.
Suture, intrasaccular, in treatment of
aneurysm of abdominal aorta,
384
lateral parietal, plication of aorta by, in
treatment of aneurysm of ab-
dominal aorta, 385
subcuticular, 34
Suture material, 5
aluminum alloys, 8
catgut, 6
preparation of, 6
by chromic acid method, 7
by cumol method, 6
by iodin method, 7
kangaroo tendon, 8
Michael's clamps, 33
Pagenstecher 's thread, 8
silk, 8
silkworm-gut, 8
silver wire, 8
Suture method of treatment for varicose
veins, 324
Sutures and tension, in plastic surgery, 452
Suturing of arteries to restore circulation,
259
of veins to restore circulation, 287
Syme's method of restoration of lower lip in
operation for epithelioma, 502
Syphilis, aneurysm and, 173
contra-indicating operations, 172
surgical complications of, 173
treatment in, 172
of muscles, 620
treatment of, 696
Syphilitic myositis, diffuse, 621
Syphilitic tenosynovitis of hand, 640
Syringes, aspirating, 14
hypodermic, 14
Szymanowski 's operation for repair of de-
fects of upper lip, 503, 504
Tabetics, perforative appendicitis in, 173
Tarantulas, treatment of wounds due to,
687
Taylor's keyphotone, 744
Teeth, preparation of, preceding operation,
144
Tendon sheaths, diseases of, 639
of hand, 634
acute inflammation of, 639
treatment of, 639
acute suppurative inflammation of, 641
operative treatment of, anesthetic in,
643
incisions in, 642
site of original inoculation in, 641
stages of, treatment of, 641
' anatomical considerations of, 634
chronic inflammation of, 639
plastic type of, 639
treatment of, 639
complications of, 642
diseases of, 639
Tendon sheaths, diseases of, of hand, gonococ-
cal inflammation of, 640
treatment of, 640
suppurative diseases of, 637
syphilis of, 640
tuberculosis of, 640
operative treatment of, 640, 641
Tendons, 622
dislocation of, 623
treatment of, 623
conservative, 623
operative, 623
ganglion in, 629
clinical nature of, 629
treatment of, 629
non-operative, 629
operative, 630
gunshot wounds of, 662
treatment of, 662
injuries to, 622
subcutaneous, 622
lengthening of, by tenotomy, 627
rupture of, 623
treatment of, 623
shortening of, 628
structure of, 622
tenotomy for lengthening of, 627
thickening and nodulation of, 628
treatment of, 628
transplantation of, 626
foreign substances used in, 627
wounds of, 623
nature of, 623
treatment of, 624
after-care following suture in, G26
primary suture in, 624
secondary suture in, 626
Tenosynovitis, chronic, 639
plastic type of, 639
treatment of, 639
crepitans, 639
of hand, acute, 639
treatment of, 639
gonorrheal, 640
treatment of, 640
syphilitic, 640
tuberculous, 640
operative treatment of, 640, 641
Tenotomy, 627
for lengthening of tendons, 627
Testes, gunshot wounds of, 671
Tetanus, causes of, 173
treatment of, 173
prophylactic use of antitoxin in, 213
administration of, 214
treatment of, 693
by tetanus antitoxin injections, 693
intracerebral, 694
intraneural, 694
intraspinal and intravenous, 693
carbolic acid in, 694
chloretone in, 694
local, for suspicious wounds, 695
magnesium sulphate by subdural injec-
tions in, 694
Tetanus antitoxin, in powdered form, for
tetanus wounds, 695
in treatment of tetanus, 693
INDEX
811
Tetanus antitoxin, in treatment of tetanus,
by intracerelu.il mi.«-tioim, 694
by intraneural in i< < tmns. (394
by intniHpinal ami intravenous injec-
tions, 693
prophylactic use of, against tetanus, 213
administration of, 214
Theater, operating. See Operating theater.
Thoracic aneurysm,
free fascial transplants in, 385
ligature of thoracic aorta in treatment of,
382
plication by lateral parietal suture in, 385
strips of aorta used in, 385
wiring with electrolysis for saccular form
of, 380
complications in, 381
results of, 381
Thorax, aspiration in, during operation, 237
postoperative use of, 241
Kenyon's method of, 242-244
gunshot wounds of, 669
Throat, preparation of, preceding operation,
144
Thrombi, venous, operations to prevent infec-
tion from, 326
Thrombo-arteritis, arteriovenous anastomosis
for removal of obstruction in,
275. See also under Arteries.
Thrombosis, in arteries, arterial section in,
283, 285
Thumb, dislocation of, 755
reduction of, 755
Thymol in skin sterilization for operations,
150
Thymus, diseases of, and operations, 192
Thyroid, diseases of, and operation, 192
Thyroidectomy, infiltration anesthesia for,
56
Tibia, fractures of, plaster-of -Paris dressings
for, 736
Tibia and fibula, fractures of, 736
plaster-of -Paris dressings in cases of, with
difficulty in retaining of frag-
ments in position, 737
with swelling and displacement, 736
without displacement, 736
Tibial artery, anterior, ligation of, in con-
tinuity, 445
anatomy of, 445
operation in, 446
in lower third, 447
in upper third, 446
posterior, ligation of, in continuity, 443
anatomy of, 443
operation in, 444
behind the medial malleolus, 444
in middle of leg, 444
Tic doloureux, intracranial operation on Gas-
serian ganglion of fifth cranial
nerve for, 574
advantages of, 582
anatomical considerations in, 575
indications for, 575
results of, 583
technic of, 576
posterior root section by infratemporal
route in (Gushing method), 580
therapy for,
• •loureux.intracranial operation on Gas-
mnglion of fifth cranial
root division by aarieolotas*
poral route in (SpUler-Praaior
method), 578
care of eyea in, 579
Ticks, bites of, treatment of wounds doe to,
Tinnitus aurium, treatment of, by operation
tfhth cranial nerve, 600
Tissues, trauma to, in operations,
Toes, infiltration aneatbeaia for
on, 60
Tongue, cancer of, radium therapy for, 767
Tonsil, cancer of, radium therapy for, 767
diseases of, a contra indication to
turns, 187
inoperable sarcoma of,
769 •
Torrey's antigonococcic serum, 210
Torsion to check bleeding in veina, 286
Torticollis, spasmodic, operative treatment of,
posterior root section in, 535
resection of cervical aervea in, 584
Tourniquet to check bleeding in arteries, 256
elastic, 256
massage and elevation in use of, 256, 157
pneumatic constrictor as, 257
Toxin molerul,- in -xle-chain theory, 196
Toxin-antitoxin compound, 200
chemical nature of, 200
effect of beat on, 200
Toxins, bacterial, extracellular, 199
intra.rllular, 199
immunity to, 199
Toxoid, definition of, 200
Trachea and larynx, gunshot wounds of, 669
Trachea! obstruction to respiration in
thesia, 136
Tracheotomy, infiltration aaesthesii for, 56
Transfusion of blood. Se
for immunization. 225
Transplantations, nerve, in
of arteries, 285
of tendons, 626
foreign substances used in, 627
of •• irainage of cavities, eta, 295
to reestablish circulation, 291
materials in, 291
methods in, 291
operative technic in, 298
results in, 293-295
in animals, 295
Trendelenburg method of excision for vari-
eon veins, 321
Trendelenburg position in operations, 41, 42,
Trichiniasis, 621
etiology of, 621
symptoms of, 621
treatment of, 621
Trigeminal nerve. See Cranial
turbancea of, fifth.
Trigger finger, 628
ocain in local anesthesia, 51
in spinal anesthesia, 67
812
INDEX
Tropical diseases, a contra indication to op-
eration, !!>.'»
Trowel retractor of Child, 'M
Tubercle, anatomical, treatment of, 696
Tubercula dolorosa, 563
Tuberculin. See Tuberculin therapy,
diagnostic use of, 221
c.-ilmette's conjunctival reaction in, 221
Moro test in, 221
von Pirquet's reaction in, 221
Tuberculin therapy, 215
experimental observations in, 217
method of treatment in, 219, 220
preparation of tuberculins for use in, 219
dosage in, 218
results of, 220
site of injection in, 220
tuberculin reaction in, 217, 218
varieties of tuberculin in, 215
Beraneck's tuberculin, 216
Denys' bouillon filtrate (B. F.), 216
.lorhmann's tuberculins, 216
Koch's bacillen-emulsion (B. E.), 215
Knrh's old tuberculin (O. T.), 216
Koch's tuberculin residue (T. E.) or
new tuberculin, 216
Landmann's tuberculol, 217
von Ruck's tuberculin, 216
Spengler's tuberculins, 217
Tuberculosis, a centra-indication to opera-
tions, 186
anesthetic to be used in operations in, 186,
187
of bursffi, 632
of muscles, 619
treatment of, 619
Beck's bismuth subnitrate and vaselin
injection in, 620
operative, 620
varieties of, 619
of spine, plaster-of-Paris jacket for, 742
treatment of wounds due to, 696
Tuberculous glands, radium therapy of, 770
Tuberculous nodules, radium therapy of, 770
Tuberculous sinuses, radium therapy for, 770
Tuberculous tenosynovitis of hand, 640
operative treatment of, 640, 641
Tuberculous ulcers, radium therapy for, 770
Tubulization in nerve bridging, 541
Tumors of muscles, 622
«»t ner\es. See Neuromata.
Typhoid fever, a centra-indication to opera-
tions, 152
surgical complications of, 152-154
:M -ute abdominal conditions, 153
perforation, 153
typhoid gangrene, 153, 154
prophylactic vaccination against, 214
reaction in, LM.",
vaccine therapy of, 215
Typhoid gangrene, 153, 154
Typhoid perforation, 153
Typhus fever, surgical complications of, 154
Ulcerations, chronic, radium therapy for, 771
Ulna, fracture of shaft of, 723
moulded plaster splints for, 723
reduction of, 723
Ulnar and median nerves, injuries affecting,
559
Ulna and radius, fracture of, 722
moulded plaster splints for, 723
reduction of, 722
Ulnar artery, ligation of, in continuity, 428
anatomy of, 428
operation in, 429
in hand, 430
in juncture of upper and middle thirds,
429
in lower third, 429
in wrist, 429
Ulnar nerve, injuries to, 557
at elbow, 558
etiology of, 558
symptoms of, 558
treatment of, 558
just above wrist, 557
treatment of, 558
Unger's clamps for use in transplantation of
veins, 292, 293
United States cavalry automatic pistol, effect
of, 654
Upper extremities, edema of, Handley's op-
eration for establishing artificial
channels for lymph drainage in,
332
infected wounds in joints of, treatment of,
666
Uranoplasty. See Cleft palate, operations
for.
Uremia, centra-indication to operation, 192
Urethra, gunshot wounds of, 671
Urinary bladder, gunshot wounds of, 670
Uterus, inoperable cancer of, radium therapy
for, 768
Vaccination, dosage in, 203
interval between doses in, 204
prophylactic, against bubonic plague, 212
against cholera, 206
against typhoid fever, 214
reaction in, 215
in cerebrospinal meningitis, 211
preceding operation, 204
treatment of wounds due to, 688
Vaccine therapy in acne, 205
in adenitis, 210
in angina, 210
in anthrax, in animals, 206
in arthritis, 206
in Bacillus aerogenes capsulatus infection,
206
in bubonic plague, 212
in carbuncle, 205
in cerebrospinal meningitis, 211
in chronic furunculosis, 205
in colon bacillus infections, 206
in diphtheria carriers, 207
in dysentery, 207
in erysipelas, 208
in glanders, 208
in gonococcal infections, 212
in gonorrhea, 209
in Hodgkin's disease, 210
in influenza, 210
in localized infections, 210
INDKX
813
Vaccine therapy in osteomyelitis, 210
in otitis media, 210
in pneumococcus infections, 212
in pyorrhea alveolaris, 2 I I
in rabies, 212
in rheumatic fever, acute, 21.:
in scarlet fever, 21.''.
in treatment of wounds in blood infections
692
in typhoid fever, 215
Vaccines, 201
autogenous, 204, 205
use of, in amputations through infected
tissues, 664
dosage of, 203, 204
interval between doses of, 204
mixed, 205
polyvalent, 205
preparation of, 201
estimating number of bacteria in, 202
growing of cultures in, 201, 202
sterilization of, "fractional," 202
prophylactic administration of, preceding
operation, 204
sensitized, 204
standardization of, 203
stock, 204, 205
Vagina, sterilization of, in preparation for
operations, 150
Varicella, a contra indication to operation, 154
surgical complications of, 154
Varicose aneurysm in gunshot wounds of
neck, 669
Varicose veins, operations on veins to remove
cause of circulatory disturbance
due to, 320
choice of method in, 325
excision in, 320
Babcock's method of, 323
circular, 323
inversion method of, 322
Mayo 's method of, 321
spiral, 323
Trendelenburg 's method of, 321
incision in, 323
results of, 326
suture method in, 324
Coenen's method of, 324
Delbet 's technic of, 324
Hesse and Schaak 's technic of, 324
Jeger's technic of, 324
Vein, use of, in nerve bridging, 541
Veins, operations on, 285
anatomical considerations in, 285
for drainage of cavities, etc., 295
transplantation of veins in, 295
to alter blood or circulation for stimula-
tion or medication, 295
blood transfusion in, 299
choice of methods in, 316
contra-indications to, 300
dangers of, 318
agglutination in, 318
air embolism in, 319
alteration of gaseous tension of
blood in, 319
blood embolism in, 319
dilatation of heart, acute, in, 319
Veins, operation* on, to alter blood or circula
• for Mtiinulatioii or m,
t'-M. Mood transfusion in, dan-
ger* of, hemoljrsJi.
tranBitiiHMion of iliiwaae in, 318
!• nt.rinated bl«.
direct tratiaf union in. SOS
artiT method of, SOS
BenheftaVi tub* in. 306
Brewer's tubes in, 308
rel's suture in, 308
<'nl.-'B rannula in, SOS
•s rannula in, 305
-in method of, 800
.ntleroy's tubes in, 309
general management of, 300
amount of Mood to be transfused in,
controlling of inflow of blood in, 301
testt ..nor and
history of.
apparatus used in, early, 337
later, 339
recent, 340
syringe methods of recent times in,
340
indications for, 299
indirect transfusion in, 310
Curtis and David method of. 310
Cooley and Vaughan's method of.
Kimpton's method of, 312
IJndeman'a i
McGrath's met ho.!
Satterlee and Hooker's method of,
316.
operation with hirudin -coated
pipets in, 353
preparation of pipets with
hirudin coating in, 354
operation with paraffin coated
pipet in.
apparatus in, 346
instruments in. 345
preparation of pipeto with par-
affin coating in, 352
technic of.
theoretical considerations and
principles underlying, 342
instruments for. 300
I >:i ratlin methods in
intravenous infusion in. 296
amount of fluid in, 297
c-.ntra indications for, 298
indications for, 297
method of, 298
pressure of fluid in, 297
solutions in. 296
temperature of fluid in. 297
time of infusion in, 297
intravenous injection in, 295, 319
technic of, 296
U9
to check bleeding, 286
bandages and compresses in, 286
cautery in, 286
digital pressure in, 286
814
INDEX
Veins, operations on, to check bleeding, forci-
pressure in, 286
gauze packing in, 286
ligation in, 286
postural compression in, 286
torsion in, 286
to prevent embolic infection, 326
to restore or reestablish circulation, 286
lateral ligation in, 286
suturing of veins in, 287
transplantation of veins in, 291
materials for, 291
methods in, 291
operative technic in, 293
results in, 293-295
in animals, 295
venous anastomosis in, 288
end-to-end, 288
operative technic in, 288
results in, 289
in veins of animals, 289
end-to-side, 289
side-to-side, 290
to remove cause of circulatory disturbance
due to varicose veins, 320
choice of method in, 325
excision in, 320
Babcock's method of, 323
inversion method of, 322
Mayo 's method of, 321
Trendelenburg 's method of, 321
Foster's method of, 323
incision in, 323
circular, 323
spiral, 323
results of, 326
suture method in, 324
Coenen's method of, 324
Delbet 's technic of, 324
Hesse and Schaak's technic of, 324
Jeger's technic of, 324
Venesection, 319
Vertebrae, fractures of, plaster-of-Paris
jacket for, 742
Vertebral artery, ligation of, in continuity,
418
anatomy of, 418
operation in, 419
results of operation in, 419
Viscera, inoperable cancer of or near, radium
therapy for, 769
Volkmann's ischemic contracture of muscles
of arm and leg, 616
causes of, 616
results of, 616
treatment of, 616-618
Volkmann's ischemic paralysis, 559
Volkmann sliding rest in fractures of shaft
of femur, 731, 732
Vomiting in anesthesia, 137
Vulvovaginitis in children, vaccine therapy
of, 209
Warfare, gunshot wounds in. See under
Gunshot wounds.
Warts, radium therapy of, 764
Wasps, stings of, treatment of wounds due
to, 686
Wassermann reaction, principles of, 119, 222,
223
Water,' sterilization of, 25
Weigert's theory to explain hyperplasia,
197
Whitman's method of reduction and reten-
tion in fractures of neck of fe-
mur, 729
in cases with impaction, 729
in cases without impaction, 729-731
Whooping-cough, a contra-indication to op-
erations, 157
Wieting 's method of end-to-side arteriovenous
anastomosis, 276
Wiring in treatment of aneurysm, 369. See
also Aneurysm.
Wiring with electrolysis in aneurysm of ab-
dominal aorta, 384
in innominate aneurysm, 386
in saccular thoracic aneurysm, 380
complications in, 381
results of, 381
Wolf free graft implantation method for
restoration of eyelid, 520
method of skin-grafting, 522
Woodbury's method of skin-grafting, 522
Wounds, classification of, 681
closure of, technic of, 32
sutures in, 32
subcuticular suture in, 33
contused and lacerated, 685
treatment of, 685
due to burns. See Burns,
gunshot. See Gunshot wounds,
of tendons. See Tendons, wounds of.
open, 683
abrasions, 683
contusions and lacerations, 685
incised wounds, 683
linear, 683
punctured, 684
poisoned and infected, 686
due to bacterial invasion, 689
in actinomycosis, 696
in anthrax, 695
in blastomycosis, 697
in blood infections, 691
general treatment in, 691
local treatment in, 691
preventive measures in, 691
specific treatment in, 691
in cellulitis, 690
in diphtheria, 695
in erysipelas, 690
in gaseous or emphysematous cellu-
litis, 690
in glanders, 696
in infections by specific micro-or-
ganisms, 693
in lymphadenitis, 690
in lymphangitis, 689
in madura foot, 697
in putrefactive infections, 692
in pyogenic infections, 689
in syphilis, 696
in tetanus, 693
carbolic acid treatment in, 694
chloretone in, 694
INDEX
815
Wounds, open, poisoned and infected, due to
bacterial invasion in tetanus,
local treatment of suspicious
wounds in, 695
magnesium sulphate by subdural
injections in, 694
tetanus antitoxin injections in,
693
intracerebral, 694
intraneural, 694
intraspinal and intravenous, 693
in tuberculosis, 696
non-bacterial, 686
due to bites of mosquitoes, flies,
ticks, bedbugs, etc., 686
due to definite chemical poison, 686
due to poisoned weapons, 688
due to snake-bites, 687
constitutional treatment, 687
local measures, 687
due to spiders, tarantulas, centipedes
and scorpions, 687
due to stings of bees, wasps and
hornets, 686
due to specific virus, 688
due to hydrophobia, 688
due to vaccination, 688
subcutaneous, 682
treatment of, 682
Wright's method of standardization of vac-
cines, 203
Wrist, dislocations at, 757
of carpal bones, 758
in mediocarpal joint, 758
of semilunar bone, 758
of carpometacarpal joints, 758
of lower radio-ulnar joint, 757
backward, 757
forward, 757
of radiocarpal joint, 757
backward, 757
forward, 757
Wrist-drop in musculospiral paralysis, 556
Wry neck, spasmodic, 533
operative treatment of, 533
posterior root section in, 535
resection of cervical nerves in, 534
X-ray, use of, in locating bullet in gunshot
wounds in warfare, 655
X-ray burns, 700
X-ray keratoses and ulcerations, radium
therapy for, 764
v. Ziemssen's method of blood transfusion,
340
Zinc oxid adhesive plaster, 12
for holding wound dressings, 660
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