(navigation image)
Home American Libraries | Canadian Libraries | Universal Library | Community Texts | Project Gutenberg | Children's Library | Biodiversity Heritage Library | Additional Collections
Search: Advanced Search
Anonymous User (login or join us)
Upload
See other formats

Full text of "Operative therapeusis"

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 



_i v 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 * ^ 6 3 



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.Miplnient 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 
H j : ;.| .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 

fii. 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 ias 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 
le 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<, (I H 
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. 




JT IG< 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 , ml y 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 




PJ O> 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 % P er 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 l 1 /^ 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 22C __ 



180"" 
ISO"" 1 

120 * 
90 m * 

75 
50 mm 
3O mm 



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 



5O m 



ANAESTHETIC EQUILIBRIUM 
g O m 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. 




o mm 

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 RFLEX 

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 



10 4 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 1V 2 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 (N 2 0) 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. 



12 o 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 y 2 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 y 2 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 y 2 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 



13 o 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 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 



13 8 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. 

a ln 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 T 1 /^ 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- antlbodl 6S. 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 , TO , 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 i n - (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 


0000001 to 000001 c c 


1 C C 


T. R. . . 


000001 " 0001 


2 " 


B. E 


000001 " 0001 " 


2 " 


B. F 


00000001 " 0000001 " 


1 " 


Beraneck's 


of A/32 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 
H 2 SO 4 , 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 y 2 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. 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 26 9 

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,,. ,,,,-i f . r ior 
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 
y 2 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 
iy 2 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 y 2 i nc ^ 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 y en > in 1909 > in a P a ~ 
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 w r ound 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 'Crile 7 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: a ln 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 a far 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, a is 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 
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 
e y e ^ 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 

BIBLIOGRAPHY 

AETEEIES 

1. BERNHEIM. Ann. Surg., Feb., 1912, Iv, 195. 

2. . Jour. Am. Med. Assn., 1913, Ix, No. 5, 360. 

3. . Surgery of the Vascular System, 1913, J. B. Lippincott, Phila. 

4. BINNIE. Operative Surgery, 1912, P. Blakiston's Son and Co., Phila. 

5. BUCHANAN. Surg., Gynec. and Obst., Dec., 1912, 648, xv, No. 6. 

6. CARREL. Surg., Gynec. and Obst., 1912, xiv, No. 3, 246. 

7. COENEN. Bruns Beitr. z. klin. Chir., 1911, Ixxv, 313. 

8. DOBROWOLSKAJA. Deutsch. Ztschr. f. Chir., 1912, cxix; Abstract in Surg., 

Gynec. and Obst., 1913, xvi, No. 2, 55 of Int. Abst. of Surg. 

9. GLASSTEIN. Beitr. z. klin. Chir., 1911, 74, 533. 

10. GUTHRIE. Blood Vessel Surgery, 1912, Longmans, Green and Co., 

N. Y. 

11. HALSTED and VAUGHAN. Surg., Gynec. and Obst., 1912, xiv, No. 1,1. 

12. HESSE. Russk. Vrach., 1912, xi, 1789; Abstr. in Surg., Gynec. and 

Obst, 1913, xvi, No. 3, 179 of Int. Abst. of Surg. 

13. HORSLEY. Ann. Surg., 1912, Feb., Iv, 208. 

14. JEGEK. Die Technic der Gefassnaht, 1913, August Hirschwald, Berlin. 

15. KEY. Hygeia, Stockholm, 1913, xxv, 75. Abstract in Surg., Gynec. and 

Obst., 1913, Aug., xvii, 183, of Int. Abst. of Surg. 

16. LEJARS. Bull, et mem. Soc. de chir., 1902, 609. 

17. LESPINASSE and EISENSTAEDT. Surg., Gynec. and Obst., 1911, xii, No. 

5, 477. 

18. MATAS. Keen's Surgery, v, 1909, W. B. Saunders, Phila. 

19. MOSNY and DUMONT. Bull, de 1'Acad. de med., 1911, Ixvi, 358. 

20. MURAD BEY. Deutsch. med. Wchnschr., xxxviii 2 , 1912, 1477. 

21. O'DAY. Northwest Med., 1913, v, 154; Abstract in Surg., Gynec. and 

Obst., 1913, xvii, No. 4, 423. 

22. OPPEL. Arzte Zeit, 1913, xx, 303; Abstract in Surg., Gynec. and 

Obst., 1913, Aug., xvii, 185, of Int. Abst. of Surg. 

23. PERIMOW. Russk. Vrach., 1913, xii, 127; Abstract in Surg., Gynec. 

and Obst., 1913, June, xvi, 532, of Int. Abst. of Surg. 

24. SCHILLER and LOBSTEIN. Deutsch. Ztschr. f. Chir., 1910, 106, s. 487. 

25. STEWART. Ann. Surg., 1907, xlvi, 339. 

CAPILLARIES, VEINS, AND LYMPHATICS 

26. BABCOCK. Jour. Am. Med. Assn., 1910, Iv, 210. 

27. BAKAY. Orvosi hetil., Budapest, 1911, Iv, 703. 



334 OPERATIONS UPON BLOOD VESSELS 

28. BOOTHBY. Ann. Surg., 1912, Ivi, 409. 

29. BREWER. Jour. Am. Med. Assn., 1909, lii, 412. 

30. CASTLE. Jour. Am. Med. Assn., 1911, Ivii, 2123. 

31. COENEN. Verhandl. d. deutsch. Gesellsch. f. Chir., 1911, xl, 246. 

32. COLE. South. Surg. and Gynec. Assn., 1910, Abstract in Surg., Gynec. 

and Obst., Feb., 1911, xii, 2, 188. 

33. CONNELL, KARL. 1ST. Y. City, personal communication. 

34. COOLEY and VAUGHAN. Jour. Am. Med. Assn., 1913, Ix, 435. 

35. CHILE. Hemorrhage and Transfusion, 1909, D. Appleton and Co., N. Y. 

36. CHILE and DOLLEY. Jour. Exper. Med., 1906, 8, 713. 

37. DAVID and CURTIS. Surg., Gynec. and Obst., Oct., 1912, xv, 4, 476. 
38. . Jour. Am. Med. Assn., 1911, Ivi, 35. 

39. . Jour. Am. Med. Assn., 1911, Ivii, 1453. 

40. DELBET. Bull, med., Paris, 1906, xx, 1119. 

41. DORRANCE and GINSBERG. Jour. Am. Med. Assn., 1910, Iv, 569. 

42. DOYEN. Zentralbl. f. Chir., 1909, xxxvi 2 , 1454. 

43. ELSBERG. Jour. Am. Med. Assn., 1909, lii, 887. 

44. ENDERLEN, v. BORST. Miinchen. med. Wchnschr., 1910, 1865. 

45. FAUNTLEROY. Med. Rec., K Y., 1910, Ixxviii, 403. 

46. FOSTER. Surg., Gynec. and Obst., Feb., 1912, xiv, 2, 202. 

47. GEINITZ. Miinchen. med. Wchnschr., 1913, Ix, 1257. 

48. GERRISH. Keen's Surgery, vi, 1913. W. B. Saunders, Phila. 

49. GOECKES. Med. Klin., 1912, s. 105. 

50. GOERLICH. Beitr. z. klin. Chir., 1904, xliv, 278. 

51. HAHN. Med. Rec., N. Y., 1910, Ixxviii, 624. 

52. HANDLEY. Brit. Med. Jour., 1910, I, 825. 

53. HEPBURN. Ann. Surg., 1909, xlix, 115. 

54. HESSE and SCHAACK. Arch. f. klin. Chir., 1911, lix. 

55. . Ann. Surg., 1912, Iv, 170. 

56. . Verhandl. d. deutsch. Gesellsch. f. Chir., 1911, xl, 11 Teil, s. 147. 

57. JEANNEL. French Cong, of Surg., 1910. 

58. JELLETT. Surg., Gynec. and Obst., Aug., 1913, xvii, No. 2, 147. 

59. KATZENSTEIN. Verhandl. d. deutsch. Gesellsch. f. Chir., 1911, xl, I Teil, 

63. 

60. KAYSER. Beitr. z. klin. Chir., 1910, Ixviii, 802. 

61. KEATOR. Am. Jour. Obst., 1912, Ixv, 1003. 

62. KIMPTON. Boston Med. and Surg. Jour., 1913, clxix, Nr. 22, 783. 

63. LILIENTHAL, HOWARD. N. Y. City, personal communication. 

64. LINDEMAN, EDWARD. N. Y. City, personal communication. 

65. . Rep. Ped. Sect., N. Y. Acad. Med., Apr. 10, 1913. 

66. MAMOURIAN. Brit. Med. Jour., 1910, 11, 140. 

67. McCLURE. Bull. Johns Hopkins Hosp., 1909, xx, 110. 

68. McGRATii. Surg., Gynec. and Obst,, March, 1914, xviii, 3, 376. 

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 S 1 /^ 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. 

BIBLIOGRAPHY l 

I. HISTOEICAL REFERENCES 

1. ALBINI. Ore (48), 637. 

2. AVELINQ, J. H. Trans. Obstet. Soc., London, 1864, vi, 126. 

3. . Med. Rec., 1874, ix, 190. 

4. . Boston Med. and Surg. Jour., 1875, xci, 31. 

5. BLUNDELL, J. Researches Physiological and Pathological on Trans- 

fusion of Blood, London, 1814, Coxe and Son. 

6. . Medi.-Chir. Trans., 1818, ix, 56. 

7. . Lancet, 1825, vi, 12 ; 1827-28, 679 ; 1828-29, 321. 

8. BOEHM. Aveling (2), 130. 

9. CASSE, J. Presse medicale beige, 1873, ISTo. 23, 178. 

10. . De la transfusion du sang, Bruxelles, 1874. 

11. CASSELLI. Consideration! sulla transfusione del sangue, e nouve can- 

ello per eseguirla del professore Caselli di Reggio Emilia, Bologna, 
1874. 

12. CHEREAU, A. Union medicale, 1874, 3 ser., xviii, 373, 397. 

13. COLLIE. Esmarch (22), 170, and Ore (48), 676. 

14. COLUSZI. Aveling (2), 130. 

15. COPELLO. Ore (48), 660. 

16. CRILE, G. W. Hemorrhage and Transfusion, D. Appleton and Co., 

1909, 151-158. 

17. CRIPPS, H. Dictionary of Surgery, Lippincott, Phila., 1886, ii, 659- 

660. 

18. DE BELINA, L. Die Transfusion des Blutes in phys. und med. Biezie- 

hung, Heidelberg, 1869. 
19. . Compt. rend. acad. d. sc., Paris, 1869, Ixix, 765. 

20. DENYS, J. B. Philos. Trans., 1667, No. 25, 453 ; 1668, No. 36, 710. 

21. DENTS, J. B., and EMMERETZ, P. Philos. Trans., 1667-68, No. 32, 817. 

22. ESMARCH, F. Handbuch der kriegchirurgischen Technik, Hanover, 

1877, C. Riimpler, 165-172. 

*In Sections V and VI of the Bibliography, except for references cited in the text, 
no literature prior to 1905 is given, as the earlier literature of importance is included in the 
exhaustive bibliography of Morawitz (157) published in that year. 



356 THE TRANSFUSION OF BLOOD 

23. GENDEON. Ore (48), 689. 

24. GESELLIUS, F. Die Transfusion des Blutes, Leipzig, 1873, Franz Wag- 

ner (352 historical references). 

25. GEECCO. Ore (48), 642. 

26. HAMILTON. Aveling (2), 131. 

27. . Hicks (31), 17. 

28. HAEWOOD. Aveling (2), 129. 

29. HASSE, 0. Esmarch (22), 171. 

30. HEWITT, GEAILJ. Trans. Obstet. Soc., London, 1864, vi, 136. 

31. HICKS, J. B. Guy's Hosp. Eeports, 1869, xiv, 1. 

32. HUTEE, C. Arch. f. klin. Chir., 1871, xii, 1. 

33. KING, E. Philos. Trans., 1667, No. 25,449, No. 27,557. 

34. LANDOIS, L. Die Transfusion des Blutes, Leipzig, 1875, F. C. W. Vogel. 

35. LE BLOND. Ore (48), 646. 

36. LE NOEL. Ore (48), 644. 

37. LOWEE, R. Philos. Trans., 1666, No. 20,353; 1667, No. 27,557. 

38. . Tractatus de Corde item de Motu, Colore et Transfusione San- 

guinis, etc., London, 1708. 

39. LUCIANI. Ore (48), 635. 

40. MACDONNELL. Ore (48), 646. 

41. MANZINI and RODOLFI. Esperimenti eseguiti colla trasfusione del 

sangue ai varii pazzi dei manicomii di Brescia, Milano, 1875. 

42. . Ore (48), 216. 

43. MATHIEU. Gaz. d. hop., 1866, xxxix, 527. 

44. . Ore (48), 672. 

45. MONCOQ (de Caen). Gaz. d. hop., 1862, xxxv, 390. 

46. MOESELLI, H. La trasfusione del sangue., Torino, 1876. 

47. . Ore (48), 634. 

48. OEE, P. C. Etudes historiques, physiologiques, et cliniques sur le 

transfusion du sang, deuxieme ed., J. B. Bailliere et Fils, Paris, 1876, 
704 pages. 

49. RALPH, J. Lancet, 1826, x, 280. 

50. ROUSSELL. Jour, de Tanat. et de la physiol., 1867, iv, 552. 

51. SCOTT. Lancet, 1826, x, 221. 

52. TAEDY, C. Aveling (2), 129. 

53. UTEEHAET, C. Berlin, klin. Wchnschr., 1868, 112. 

54. . Esmarch (22), 169. 

55. WALLEE, C. Trans. Obstet. Soc., London, 1869, i, 61. 

56. WEISS. Lancet, 1827-28, i, 662. 

II. ON DEFIBEINATED BLOOD, IN RELATION TO TRANSFUSION 

57. ADDIS, T. Jour. Infect. Dis., 1912, x, 200. 

58. BISCHOFF. Miiller's Arch., 1835, ii, 347, 360; 1838, v, 351. 



BIBLIOGRAPHY 857 

59. CURTIS, V. C., and DAVID, A. II. Surg., Gynec. and Obstct., 1912, xv, 

476. 

60. DIEFFENBACH, J. F. Arch, de med., 1810, 1 ser., xxii, 99. 

61. EDELBERG, M. Arch. f. exper. Path. u. Pharmakol., 1880, xii, 283. 

62. ESMARCH, F. Handbuch der kriegschirurgischen Technic, 1877, 165. 

63. FALTA, W., and FLEMING, G. B. Munchen. med. Wchnschr., 1911, 

Iviii, 2649. 

64. FULD, E. Zentralbl. f. Physiol., 1903, xvii, 529. 

65. GENOU, O. Ann. de PInst. Pasteur, 1901, xv, 232. 

66. GESELLIUS, F. Die transfusion des Blutes, Leipzig, 1873, Franz Wag- 

ner. 

67. HASSE, O. Verhandl. d. deutsch. Gesellsch. f. Chir., Berlin, 1874, iii 2 , 

110, 115. 

68. HUNTER, W. Brit. Med. Jour., 1889, ii, 117, 237, 305. 

69. HURTER, J. Beihefte z. med. Klinik, 1911, vii, 325. 

70. KOHLER, A. Inaug. Diss., Dorpat, 1877. 

71. MOLDOVAN, J. Deutsch. med. Wchnschr., 1910, xxxvi, 2422. 

72. MORAWITZ, P. Ergebn. d. Physiol., 1905, iv, 307. 
73. . Munchen. med. Wchnschr., 1907, liv, 767. 

74. O'CONNOR, J. M. Munchen. med. Wchnschr., 1911, Iviii, 1439. 

75. . Arch. f. exper. Path. u. Pharmakol., 1912, Ixvii, 195. 

76. PIKE, GUTHRIE, and STEWART. Jour. Exper. Med., 1908, x, 371. 

77. PREVOST and DUMAS. Bibliotheque universelle de Geneve, 1821, xvii, 

226. 

78. SCHULTZ, W. Deutsch. Arch. f. klin. Med., 1905, Ixxxiv, 541. 

79. SOLLMANN, T. Am. Jour. Physiol., 1905, xiii, 291. 

80. STEVENS, L. T., and LEE, F. S. Studies fr. Biol. Lab. Johns Hopkins 

Univ., 1884, iii, 99. 

81. STEWART, H. A., and HARVEY, S. C. Jour. Exper. Med., 1912, xvi, 

103. 

82. UTERHART, C. Deutsch. Klin., 1867, xix, 130. 

83. VOGEL, K. M., and McCuRDY, U. F. Arch. Int. Med., 1913, xii, 718. 

III. ON KECENT ADAPTATIONS OF SYRINGE METHODS 

84. COOLEY, T. B., and VAUGHAN, J. W. Jour. Am. Med. Assn., 1913, Ix, 

435. 

85. CROTTI, A. Surg., Gynec. and Obst, 1914, xviii, 236. 

86. FREUND, H. A. Jour. Mich. State Med. Soc., 1913, xii, 459. 

87. LINDEMANN, E. Am. Jour. Dis. Child., 1913, vi, 28. 

88. McGRATH, B. F. Surg., Gynec. and Obst., 1914, xviii, 376. 

89. MORITZ, F. Munchen. med. Wchnschr., 1911, Ivii, 393. 

90. ZIEMSSEN, H. Verhandl. d. Kong. f. inn. Med., No. 11, Leipzig, 1892, 

166. 



358 THE TRANSFUSION OF BLOOD 

91. ZIEMSSEN, H. Deutsch. Arch. f. klin. Med., 1892, 1, 491. 

92. . Miinclien. med. Wchnschr., 1894, xli, 349; 1895, xlii, 301. 

IV. ON TRANSFUSION THROUGH AGENCY OF PARAFFINED RECEPTACLES 

93. BREWER, G. C., and LEGGET. Surg., Gynec. and Obstet., 1909, ix, 293. 

94. CURTIS, V. C., and DAVID, A. H. Jour. Am. Med. Assn., 1911, Ivi, 35 ; 

Ivii, 1453. 
95. . Surg., Gynec. and Obst., 1912, xv, 476. 

96. KIMPTON, A. R. Boston Med. and Surg. Jour., 1913, clxix, 783. 

97. RISLEY, E. H., and IRVING, F. C. Boston Med. and Surg. Jour., 1912, 

clxvi, 956. 

98. SATTERLEE, H. S., and HOOKER, R. S. Arch. Int. Med., 1914, xiii, 51. 

99. . Surg., Gynec. and Obst, 1914, xix, 235. 

100. VINCENT, B. Am. Jour. Dis. Child., 1911, i, 376. 

V. ON THE FACTORS CONCERNED IN THE COAGULATION OF BLOOD 

101. ADDIS, T. Jour. Path, and Bad, 1911, xv, 427. 
102. . Jour. Infect. Dis., 1912, x, 200. 

103. ARTHUS, M., and CHAPIRO, T. Arch, internat. de physiol., 1908, vi, 

298. 

104. ASCHOFF, L. Arch. Int. Med., 1913, xii, 503. 

105. AUSTIN, J. H., and PEPPER, O. H. P. Arch. Int. Med., 1913, xi, 305. 

106. AYNAUD, M. Compt. rend. Soc. de biol., Paris, 1913, Ixxv, 385. 

107. BAYNE-JONES, S. Am. Jour. Physiol., 1912, xxx, 74. 

108. BERNHEIM, B. M. Jour. Am. Med. Assn., 1910, Iv, 283. 

109. BLAIZOT, L. Compt. rend. Soc. de biol., Paris, 1911, Ixx, 560. 

110. BORDET, J. Jour. State Med., London, 1913, xxi, 577. 
111. . Jour. med. de Brux., 1911, xvi, suppl. 102. 

112. BORDET, J., and DELANGE, L. Jour. med. de Brux., 1911, xvi, 165. 

113. . Bull. Soc. d. sc. med. et nat. de Brux., 1911, Ixix, 65. 

114. . Ann. de PInst. Pasteur, 1912, xxvi, 657-737; 1913, xxvii, 341. 

115. CECIL, H. L. Am. Jour. Physiol., 1911, xxix, 156. 

116. CLOWES, C. H. A., and WEST, F. Proc. Soc. Exp. Biol. and Med., K 

Y., 1913-1914, xi, 6. 

117. COHEN, M. S. Arch. Int. Med., 1911, viii, 684, 820 (164 references). 

118. COLLINGWOOD, B. J., and MACMAHON, M. T. Jour. Physiol., 1912, 

xlv, 119. 

119. CRAMER, W., and PRINGLE, H. Quart. Jour. Exper. Physiol., 1913, 

vi,l. 

120. . Jour. Physiol., 1912-1913, Ixv, xi. 

121. DAVIS, D. Am. Jour. Physiol., 1911, xxix, 160. 

122. DE WAELE, H. Ztschr. f. Immunitatsforsch., 1912-1913, xvi, 309, 311. 



BIBLIOGKAPHY 359 

123. DEETJEN, H. Hoppe Seller's Ztschr. f. physiol. Chemie, 1909, Ixiii, 1. 

124. DOCHEZ, A. R. Jour. Exp. Med., 1912, xvi, 693. 

125. DOYON, M. Compt. rend. Soc. de biol., Paris, 1911, Ixxii, 485. 

126. DUCLAUX, J. Compt. rend. Acad. d. sc., Paris, 1912, cliv, 1426. 

127. DUKE, W. W. Jour. Am. Med. Assn., 1910, Iv, 1185. 

128. . Jour. Exper. Med., 1911, xiv, 265. 

129. . Arch. Int. Med., 1912, x, 445 ; 1913, xi, 100. 

130. . Bull. Johns Hopkins Hosp., 1912, xxiii, 145. 

131. EMILE-WEIL, P. Compt. rend. Soc. de biol., Paris, 1906, Ixi, 588. 

132. EMILE-WEIL, P., and BOYE, G. Compt. rend. Soc. de biol., Paris, 1909, 

Ixvii, 428, 454. 

133. FULD, E. Verhandl. d. Berl. med. Gesellsch., 1912, xliii, 2 Teil, 266. 

134. GESSARD, C. Compt. rend. Acad. d. sc., Paris, 1911, cliii, 1241. 

135. . Compt. rend. Acad. d. sc., Paris, 1913, clxvii, 799. 

136. GIRARD, P. Compt. rend. Acad. d. sc., Paris, 1913, clvi, 1401. 

137. GOODPASTURE, E. W. Am. Jour. Physiol., 1914, xxxiii, 70. 

138. GRATIA, A. Jour. med. de Brux., 1913, xviii, 215. 

139. HOWELL, W. H. Am. Jour. Physiol., 1910, xxvi, 453; 1911, xxix, 

187; 1912, xxxi, 1; 1913, xxxii, 264; 1914, xxv, 143. 

140. . Arch. Int. Med., 1914, xiii, 76. 

141. . Cleveland Med. Jour., 1910, Ix, 1, 118. 

142. . Therap. Gazette, 1912, xxxvi, 95. 

143. LE SOURD, L. T., and PAGNIEZ, P. Jour, de phys. et path, gen., 1907, 

ix, 579 ; 1909, xi, 1. 

144. . Compt. rend. Soc. de biol., Paris, 1906, Ixi, 109, 562. 

145. . Compt. rend. Soc. de biol., Paris, 1907, Ixii, 934. 

146. . Compt. rend. Soc. de biol., Paris, 1908, Ixiv, 931. 

Compt. rend. Soc. de biol., Paris, 1908, Ixv, 400. 



148. - . Compt. rend. Soc. de biol., Paris, 1911, Ixxi, 551. 

149. _. Compt. rend. Soc. de biol., Paris, 1913, Ixxiv, 580; 788; 
1259. 

150. LEE, R. D., and VINCENT, B. Arch. Int. Med., 1914, xiii, 398. 

151. LOEB, L. Biochem. Zentralbl., 1907, vi, 889. 

152. . Beitr. z. Chem., Phys. u. Path., 1906, viii, 67; 1907, ix, 185. 

153. MACMAHON, M. Trans. Roy. Acad. Med. Ire., Dublin, 1912, xxx, 501, 

508. 

154. MACRAE, F. W., JR., and SCHNACK, A. G. Am. Jour. Physiol., 1913, 

xxxii, 211. 

155. MEEK, W. J. Am. Jour. Physiol., 1912, xxx, 161. 

156. MELLANBY, J. Jour. Physiol., 1908-1909, xxxviii, 28, 441. 

157. MORAWITZ, P. Ergebn. d. Physiol., 1905, iv, 307. (Contains 490 ref- 

erences.) 

158. . Miinchen. med. Wchnschr., 1907, liv, 767. 

159. - . Handb. d. Biochemie d. Menchen u. d. Tiere, 1908, ii 2 , 40, 70. 



360 THE TRANSFUSION OF BLOOD 

160. MORAWITZ, P. Handbuch. d. biochem. Arbeitsmethoden, E. Abder- 

halden, 1911, v. 223. 

161. MORAWITZ, P., and LOSSEN, J. Deutsch. Arch. f. klin. Med., 1908, 

xciv, 110. 

162. NOLF, P. Acad. roy. de Belg. Bull, de cl. d. sc., Brux., 1906, 58, 71. 

163. . Arch, internal;, de physiol., 1908, vi, 1, 115. 
164. . Rev. gen. d. sc. pures et appliq., 1909, xx, 594. 

165. . Ergebn. d. inn. Med., 1913, x, 275. 

166. PAGNIEZ, P. Presse med., Paris, 1913, xxi, 44. 

167. PEKELHARING, C. A. Biochem. Ztschr., 1908, xi, 1. 

168. PEPPER, O. H. P., and KRUMBHAAR, E. B. Jour. Infect. Dis., 1914, 

xiv, 476. 

169. POLICARD, A. Lyon chirurg., 1911, vi, 448. 

170. REICHERT, E. T. Jour. Exp. Med., 1905, vii, 173. 

171. RETTGER, L. J. Am. Jour. PhysioL, 1909, xxiv, 406. 

172. SAHLI, H. Ztschr. f. klin. Med., 1905, Ivi, 264. 

173. . Deutsch. Arch. f. klin. Med., 1910, xcix, 518. 

174. SCHLESINGER, E. Yerhandl. d. berl. med. Gesellsch., 1912, xliii, 2 

Teil, 273. 

175. VINCI, G., and CHISTONI, A. Arch. ital. de biol., Turin, 1910, liii. 

206. 

176. WEYMOUTH, F. W. Am. Jour. PhysioL, 1913, xxxii, 266. 

177. WHIPPLE, G. H. Arch. Int. Med., 1912, ix, 365; 1913, xii, 637. 

178. . Am. Jour. PhysioL, 1914, xxxiii, 50. 

179. WHIPPLE, G. H., and HTJRWITZ, S. H. Jour. Exp. Med., 1911, xiii, 

136. 

180. ZAK, E. Arch. f. exper. Path. u. PharmakoL, 1912, Ixx, 27; 1913, 

Ixxiv, 1-13. 

181. ZURHELLE, E. Ziegler's Beitr. z. path. Anat, 1910, xlvii, 537. 

VI. ON HIRUDIN 

182. ABEL, J. J., ROWNTREE, L. G., and TURNER, B. B. Jour. Pharm. and 

Exp. Therap., 1914, v, 275. 

183. BARCROFT, J., and MINES, G. R. Jour. PhysioL, 1907-08, xxxvi, 275. 

184. BENCE, J. Zeitschr. f. klin. Med., 1905-06, Iviii, 205. 

185. BODONG, A. tiber Hirudin, Leipzig, 1905, J. B. Hirschfeld. 

186. . Arch. f. exper. Path. u. PharmakoL, 1905, lii, 245. 

187. BURKER, K. Zentralbl. f. PhysioL, 1907, xxi, 655, 659. 

188. . Miinchen. med. Wchnschr., 1908, Iv, 550. 

189. COWIE, D. M. Jour. Med. Res., 1911, xxiv, 497. 

190. DEETJEN, H. Hoppe- Setter's Ztschr. f. physiol. Chemie, 1909, Ixiii, 1. 

191. DETERMANN. Ztschr. f. klin. Med., 1906, lix, 298. 

192. DIENST, A. Zentralbl. f. Gynak., 1909, xxxiii, 1697. 



BIBLIOGRAPHY 361 

193. EMILE-WEIL, P., and BOYE. Compt. rend. Soc. de biol., Paris, 1909, 

Ixvi, 345, 516; Ixvii, 192. 

194. ENGELMANN, F. Zeitsch. f. Geburtsh. u. Gynak, 1911, Ixviii, 640. 

195. ENGELMANN, F., and STADE, C. Miinchen. med. Wchnschr., 1909, Ivi, 

2203. 

196. FRANZ, F. Arch. f. Path. u. Pharmakol., 1902, xlix, 342. 

197. GARIN, CH. Progres med., 1911, 3 ser., xxvii, 629. 

198. HERTZEN, W. E. VON, and OHMAN, K. H. Skandinav. Arch. f. Physiol., 

1908, xx, 1. 

199. HOWELL, W. H. Therap. Gazette, 1912, xxxvi, 95. 

200. KAPOSI, H. Mitt. a. d. Grenzgeb. d. Med. u. Chir., 1904, xiii, 386. 

201. KOHAN, M. Arch. f. exp. Path. u. Pharmakol., 1909, Ixi, 132. 

202. LOEB, L., STRICKLER, A., and TUTTLE, L. Virchow's Arch., 1910, cci, 

11-15. 

203. MELLANBY, J. Jour. Physiol., 1909, xxxviii, 491. 

204. MORAWITZ, P. Ergebn. d. Physiol., 1905, iv, 404-5 (hirudin lit., 317- 

319). 

205. PRINGLE, H., and TAIT. Jour. Physiol., 1911, xlii, xxxix. 

206. PRUSSAK, G. Arch. f. exp. Path. u. Pharmakol., 1909-10, Ixii, 201. 

207. RIEBES, W. Die Wirkung von Blutegelextrakt auf die Gerinbarkeit, 

und die Zellen des Blutes, Leipzig, 1909, Speyer and Kaerner. 

208. RIMANN, H., and WOLF, W. Deutsch. Ztschr. f. Chir., 1909, xcvii, 177. 

209. SATTERLEE, H. S., and HOOKER, R. S. Jour. Am. Med. Assn., 1914, 

Ixii, 1781. 

210. SCHITTENHELM, A., and BODONG, A. Arch. f. Path. u. Pharmakol., 

1906, liv, 217. 

211. SCHWALBE, E. Ziegler's Beitr. z. path. Anat., 1905, vii, Suppl. (Fest- 

schrift fiir Arnold), 65. 

212. SIEVERT, W. Ztschr. f. exper. Path. u. Therap., 1909, vii, 532. 

213. WEIL, E., MOUREQUAND, G., and CHALIER, J. Bull. soc. d. hop. de 

Lyon, 1912, xi, 30. 

214. WELCH, W. H. Heart, 1911, iii, 118. 



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 
pain 7 ' (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.